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Sawaya AP, Vecin NM, Burgess JL, Ojeh N, DiBartolomeo G, Stone RC, Pastar I, Tomic-Canic M. Calreticulin: a multifunctional protein with potential therapeutic applications for chronic wounds. Front Med (Lausanne) 2023; 10:1207538. [PMID: 37692787 PMCID: PMC10484228 DOI: 10.3389/fmed.2023.1207538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Calreticulin is recognized as a multifunctional protein that serves an essential role in diverse biological processes that include wound healing, modification and folding of proteins, regulation of the secretory pathway, cell motility, cellular metabolism, protein synthesis, regulation of gene expression, cell cycle regulation and apoptosis. Although the role of calreticulin as an endoplasmic reticulum-chaperone protein has been well described, several studies have demonstrated calreticulin to be a highly versatile protein with an essential role during wound healing. These features make it an ideal molecule for treating a complex, multifactorial diseases that require fine tuning, such as chronic wounds. Indeed, topical application of recombinant calreticulin to wounds in multiple models of wound healing has demonstrated remarkable pro-healing effects. Among them include enhanced keratinocyte and fibroblast migration and proliferation, induction of extracellular matrix proteins, recruitment of macrophages along with increased granulation tissue formation, all of which are important functions in promoting wound healing that are deregulated in chronic wounds. Given the high degree of diverse functions and pro-healing effects, application of exogenous calreticulin warrants further investigation as a potential novel therapeutic option for chronic wound patients. Here, we review and highlight the significant effects of topical application of calreticulin on enhancing wound healing and its potential as a novel therapeutic option to shift chronic wounds into healing, acute-like wounds.
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Affiliation(s)
- Andrew P. Sawaya
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Nicole M. Vecin
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jamie L. Burgess
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Nkemcho Ojeh
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados
| | - Gabrielle DiBartolomeo
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rivka C. Stone
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Irena Pastar
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Marjana Tomic-Canic
- Wound Healing and Regenerative Medicine Research Program, Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
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Verma A, Arora A, Bhatt AN, Arya MB, Prasad AK, Parmar VS, Dwarakanath BS. Radiosensitization of calreticulin-overexpressing human glioma cell line by the polyphenolic acetate 7, 8-diacetoxy-4-methylcoumarin. Cancer Rep (Hoboken) 2021; 5:e1326. [PMID: 34472223 PMCID: PMC9780425 DOI: 10.1002/cnr2.1326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/17/2020] [Accepted: 11/16/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Calreticulin (CRT), an endoplasmic reticulum-resident protein generally overexpressed in cancer cells, is associated with radiation resistance. CRT shows higher transacetylase activity, as shown by us earlier, in the presence of the polyphenolic acetates (like 7, 8-diacetoxy-4-methylcoumarin, DAMC) and modifies the activity of a number of proteins, thereby influencing cell signaling. AIM To investigate the relationship between CRT expression and radiation response in a human glioma cell line and to evaluate the radiomodifying effects of DAMC. METHODS AND RESULTS Studies were carried out in an established human glioma cell line (BMG-1) and its isogenic clone overexpressing CRT (CROE, CRT-overexpressing cells) by analyzing clonogenic survival, cell proliferation, micronuclei analysis, and protein levels by Western blotting as parameters of responses. CRT overexpression conferred resistance against radiation-induced cell death in CROE cells (D37 = 7.35 Gy, D10 = 12.6 Gy and D0 = 7.25 Gy) as compared to BMG-1 cells (D37 = 5.70 Gy, D10 = 9.2 Gy and D0 = 5.6 Gy). A lower level of radiation-induced micronuclei formation observed in CROE cells suggested that reduced induction and/or enhanced DNA repair partly contributed to the enhanced radioresistance. Consistent with this suggestion, we noted that CRT-mediated radioresistance was coupled with enhanced grp78 level and reduced P53 activation-mediated prodeath signaling, while no changes were noted in acetylation of histone H4. DAMC-enhanced radiation-induced delayed (secondary) apoptosis, which was higher in CROE cells. CONCLUSION CRT overexpression confers resistance against radiation-induced death of human glioma cells, which can be overcome by the polyphenolic acetate DAMC.
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Affiliation(s)
- Amit Verma
- Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Majumdar MargDelhiIndia,Present address:
PACT & Health LLC, BranfordConnecticut, 06405‐2546USA
| | - Aastha Arora
- Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Majumdar MargDelhiIndia
| | - Anant N Bhatt
- Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Majumdar MargDelhiIndia
| | | | - Ashok K Prasad
- Bioorganic Laboratory, Department of ChemistryUniversity of DelhiDelhiIndia
| | - Virinder S Parmar
- Bioorganic Laboratory, Department of ChemistryUniversity of DelhiDelhiIndia,Department of Chemistry and Environmental ScienceMedgar Evers College, The City University of New YorkBrooklynNew York
| | - Bilikere S Dwarakanath
- Institute of Nuclear Medicine and Allied Sciences, Brig. S. K. Majumdar MargDelhiIndia,Central Research FacilitySri Ramachandra Institute of Higher Education and ResearchChennaiIndia
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Esteves AM, Papaevangelou E, Dasgupta P, Galustian C. Combination of Interleukin-15 With a STING Agonist, ADU-S100 Analog: A Potential Immunotherapy for Prostate Cancer. Front Oncol 2021; 11:621550. [PMID: 33777767 PMCID: PMC7988118 DOI: 10.3389/fonc.2021.621550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
Prostate cancer is the second most commonly diagnosed cancer in men with mortality rates, overtaking those for breast cancer in the last 2 years in the UK. Despite advances in prostate cancer treatments, over 25% of men do not survive over 5 years with advanced disease. Due to the success of immunotherapies in treating other cancers, this treatment modality has been investigated for Prostate cancer, however, the sole FDA approved immunotherapy so far (Provenge™) only extends life by a few months. Therefore, finding immunotherapeutic agents to treat prostate cancer is of major interest. Our group has previously shown that Interleukin-15 (IL-15), unlike other therapeutic cytokines such as IL-2 and IL-12, can stimulate expansion and activity of CD8 T cells and NK cells in vitro when they are exposed to prostate cancer cells, while studies in mice have shown a 50% reduction in tumor size with no apparent toxicity. In this study, we aim to examine potencies of IL-15 in combination with a cyclic dinucleotide (CDN) that activates the Stimulator of Interferon-Gene (STING) receptor. Selected CDNs (also known as STING agonists) have previously been shown to activate both T cells and dendritic cells through STING. We hypothesize that the combination of STING agonists and IL-15 can additively increase NK and T cell activity as they act to increase type I interferons (IFNs) through STING activation and IFN-γ through IL-15. In prostate cancer-lymphocyte co-cultures we now show that combination of IL-15 and the STING agonist ADU-S100 analog induces a marked killing of cancer cells above that seen with IL-15 or ADU-S100 alone. We show that this is related to a potent activation of NK cells resulting in increased perforin and CD69 expression, and up to a 13-fold increase in IFNγ secretion in the co-cultures. NK cells are responsible for killing of the cancer cells, as shown by a lack of cytotoxicity in NK depleted lymphocyte-tumor cell co-cultures, or in co-cultures of B and T cells with tumor cells. In summary, we propose that the combination of IL-15 and the sting agonist ADU-S100 analog may be potently effective in treatment of prostate cancer.
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Affiliation(s)
- Ana M Esteves
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, United Kingdom
| | - Efthymia Papaevangelou
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, United Kingdom
| | - Prokar Dasgupta
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, United Kingdom.,Urology Centre, Guy's Hospital, London, United Kingdom
| | - Christine Galustian
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, United Kingdom
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Holmström MO, Hasselbalch HC, Andersen MH. Cancer Immune Therapy for Philadelphia Chromosome-Negative Chronic Myeloproliferative Neoplasms. Cancers (Basel) 2020; 12:E1763. [PMID: 32630667 PMCID: PMC7407874 DOI: 10.3390/cancers12071763] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/19/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023] Open
Abstract
Philadelphia chromosome-negative chronic myeloproliferative neoplasms (MPN) are neoplastic diseases of the hematopoietic stem cells in the bone marrow. MPN are characterized by chronic inflammation and immune dysregulation. Of interest, the potent immunostimulatory cytokine interferon-α has been used to treat MPN for decades. A deeper understanding of the anti-cancer immune response and of the different immune regulatory mechanisms in patients with MPN has paved the way for an increased perception of the potential of cancer immunotherapy in MPN. Therapeutic vaccination targeting the driver mutations in MPN is one recently described potential new treatment modality. Furthermore, T cells can directly react against regulatory immune cells because they recognize proteins like arginase and programmed death ligand 1 (PD-L1). Therapeutic vaccination with arginase or PD-L1 therefore offers a novel way to directly affect immune inhibitory pathways, potentially altering tolerance to tumor antigens like mutant CALR and mutant JAK2. Other therapeutic options that could be used in concert with therapeutic cancer vaccines are immune checkpoint-blocking antibodies and interferon-α. For more advanced MPN, adoptive cellular therapy is a potential option that needs more preclinical investigation. In this review, we summarize current knowledge about the immune system in MPN and discuss the many opportunities for anti-cancer immunotherapy in patients with MPN.
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Affiliation(s)
- Morten Orebo Holmström
- National Center for Cancer Immune Therapy, Department of Oncology, Herlev University Hospital, DK-2730 Herlev, Denmark;
| | | | - Mads Hald Andersen
- National Center for Cancer Immune Therapy, Department of Oncology, Herlev University Hospital, DK-2730 Herlev, Denmark;
- Department of Immunology and Microbiology, University of Copenhagen, DK-2200 Copenhagen N, Denmark
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Mannan-Binding Lectin Regulates Inflammatory Cytokine Production, Proliferation, and Cytotoxicity of Human Peripheral Natural Killer Cells. Mediators Inflamm 2019; 2019:6738286. [PMID: 31915415 PMCID: PMC6930792 DOI: 10.1155/2019/6738286] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/07/2019] [Accepted: 11/25/2019] [Indexed: 12/31/2022] Open
Abstract
Natural killer (NK) cells represent the founding members of innate lymphoid cells (ILC) and play critical roles in inflammation and the immune response. NK cell effector functions are regulated and fine-tuned by various immune modulators. Mannan (or mannose)-binding lectin (MBL), a soluble C-type lectin, is traditionally recognized as an initiator of the complement pathway. Recently, it is also considered as an immunomodulator by its interaction with kinds of immune cells. However, the effect of MBL on NK cell function remains unexplored. In this study, we found that human plasma MBL could interact directly with peripheral NK cells partially via its collagen-like region (CLR). This MBL binding markedly suppressed the interleukin-2- (IL-2-) induced inflammatory cytokine tumor necrosis factor-alpha (TNF-α) and interferon-gamma (IFN-γ) production but increased the IL-10 production in NK cells. In addition, the expression of activation surface markers such as CD25 and CD69 declined after MBL treatment. Also, MBL impaired the proliferation and lymphokine-activated killing (LAK) of NK cells. Moreover, we demonstrated that MBL inhibited IL-2-induced signal transducers and activators of transcription 5 (STAT5) activation in NK cells. In conclusion, we have uncovered a far unknown regulatory role of MBL on NK cells, a new clue that could be important in the immunomodulatory networks of immune responses.
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Fukuda N, Senga Y, Honda S. Anxa2
‐ and
Ctsd
‐knockout CHO cell lines to diminish the risk of contamination with host cell proteins. Biotechnol Prog 2019; 35:e2820. [DOI: 10.1002/btpr.2820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/08/2019] [Accepted: 04/09/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Nobuo Fukuda
- Biomedical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST) Ibaraki Japan
| | - Yukako Senga
- Biomedical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST) Ibaraki Japan
| | - Shinya Honda
- Biomedical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST) Ibaraki Japan
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Araki M, Komatsu N. Novel molecular mechanism of cellular transformation by a mutant molecular chaperone in myeloproliferative neoplasms. Cancer Sci 2017; 108:1907-1912. [PMID: 28741795 PMCID: PMC5623763 DOI: 10.1111/cas.13327] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 07/19/2017] [Indexed: 12/03/2022] Open
Abstract
Deregulation of the cytokine‐receptor signaling pathway plays a significant role in tumorigenesis. Such deregulation is frequently caused by alterations in the genes involved in the signaling pathway. At the end of 2013, recurrent somatic mutations in the calreticulin (CALR) gene that encodes a molecular chaperone were identified in a subset of patients with Philadelphia‐chromosome negative myeloproliferative neoplasms (MPN). The present review focuses on the role of CALR mutations in the oncogenic transformations observed in MPN. All the CALR mutations were found to generate a + 1 frameshift in the reading frame on exon 9, which encodes the carboxy (C)‐terminus end of CALR, and thus conferred a common mutant‐specific sequence in all the CALR mutants. The mutant CALR (but not the wild‐type) constitutively activates the thrombopoietin (TPO) receptor, myeloproliferative leukemia protein (MPL), even in the absence of TPO to induce cellular transformation. Preferential interaction between the mutant CALR and MPL is achieved by a presumptive conformational change induced by the mutant‐specific C‐terminus domain, which allows N‐domain binding to MPL. Even though mutant CALR is expressed on the cell surface and is secreted out of cells, it only presents autocrine capacity for MPL activation. These findings define a novel molecular mechanism by which the mutant molecular chaperone constitutively activates the cytokine receptor to induce cellular transformation.
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Affiliation(s)
- Marito Araki
- Department of Transfusion Medicine and Stem Cell Regulation, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Tabasum S, Noreen A, Kanwal A, Zuber M, Anjum MN, Zia KM. Glycoproteins functionalized natural and synthetic polymers for prospective biomedical applications: A review. Int J Biol Macromol 2017; 98:748-776. [PMID: 28111295 DOI: 10.1016/j.ijbiomac.2017.01.078] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 01/05/2017] [Accepted: 01/16/2017] [Indexed: 02/06/2023]
Abstract
Glycoproteins have multidimensional properties such as biodegradability, biocompatibility, non-toxicity, antimicrobial and adsorption properties; therefore, they have wide range of applications. They are blended with different polymers such as chitosan, carboxymethyl cellulose (CMC), polyvinyl pyrrolidone (PVP), polycaprolactone (PCL), heparin, polystyrene fluorescent nanoparticles (PS-NPs) and carboxyl pullulan (PC) to improve their properties like thermal stability, mechanical properties, resistance to pH, chemical stability and toughness. Considering the versatile charateristics of glycoprotein based polymers, this review sheds light on synthesis and characterization of blends and composites of glycoproteins, with natural and synthetic polymers and their potential applications in biomedical field such as drug delivery system, insulin delivery, antimicrobial wound dressing uses, targeting of cancer cells, development of anticancer vaccines, development of new biopolymers, glycoproteome research, food product and detection of dengue glycoproteins. All the technical scientific issues have been addressed; highlighting the recent advancement.
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Affiliation(s)
- Shazia Tabasum
- Institute of Chemistry, Government College University, Faisalabad 38030, Pakistan
| | - Aqdas Noreen
- Institute of Chemistry, Government College University, Faisalabad 38030, Pakistan
| | - Arooj Kanwal
- Institute of Chemistry, Government College University, Faisalabad 38030, Pakistan
| | - Mohammad Zuber
- Institute of Chemistry, Government College University, Faisalabad 38030, Pakistan
| | | | - Khalid Mahmood Zia
- Institute of Chemistry, Government College University, Faisalabad 38030, Pakistan.
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Stoll G, Iribarren K, Michels J, Leary A, Zitvogel L, Cremer I, Kroemer G. Calreticulin expression: Interaction with the immune infiltrate and impact on survival in patients with ovarian and non-small cell lung cancer. Oncoimmunology 2016; 5:e1177692. [PMID: 27622029 DOI: 10.1080/2162402x.2016.1177692] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022] Open
Abstract
Loss of expression of calreticulin (CALR) has been detected by immunohistochemistry in a fraction of non-small cell lung cancers (NSCLC) and has been demonstrated to have a major negative prognostic impact on overall patient survival. Here, we analyzed the impact of CALR expression levels detected by microarray finding a positive correlation between CALR and the expression of a metagene indicating the presence of cytotoxic T lymphocytes (CTL) in NSCLC and ovarian cancer. In addition, we detected a positive correlation with a metagene suggestive of activated dendritic cell (aDC) infiltration in ovarian cancer. Combination of two parameters (CALR + DC (dendritic cell) in NSCL and CALR + aDC in ovarian cancer) or three parameters (CALR + CTL + DC in NSCL and CALR + CTL + aDC in ovarian cancer) had a significant impact on overall patient survival in NSCL (Adenoconsortium) and ovarian cancer (TCGA collection), allowing the stratification of patients in high-risk and low-risk groups. In addition, CALR and aDC alone have a significant impact on overall survival in ovarian cancer. In contrast, in mammary, colorectal and prostate cancer, CALR had no impact on patient survival if analyzed alone or in combination with the immune infiltrate. In addition, CALR correlates with CTL infiltrate in three cancer types (colorectal, breast, ovarian). Altogether, these results support the contention that, at least in some cancers, loss of CALR expression may negatively affect immunosurveillance, thereby reducing patient survival.
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Affiliation(s)
- Gautier Stoll
- Equipe 11 labellisée Ligue contre le Cancer, Center de Recherche des Cordeliers, INSERM U 1138, 15 rue de l'Ecole de Médecine, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, Paris, France; Université Pierre et Marie Curie, 15 rue de l'Ecole de Médecine, Paris, France
| | - Kristina Iribarren
- Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, Paris, France; Université Pierre et Marie Curie, 15 rue de l'Ecole de Médecine, Paris, France; Laboratory "Cancer, Immune control and escape," Center de Recherche des Cordeliers, INSERM U 1138, 15 rue de l'Ecole de Médecine, Paris, France; Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, Villejuif, France
| | - Judith Michels
- Department of Medical Oncology, Gustave Roussy Cancer Campus (GRCC) , 114 rue Edouard Vaillant , Villejuif, France
| | - Alexandra Leary
- Department of Medical Oncology, Gustave Roussy Cancer Campus (GRCC), 114 rue Edouard Vaillant, Villejuif, France; Laboratory 'Predictive Biomarkers and New Therapeutic Strategies in Oncology' INSERM U981, Gustave Roussy Cancer Campus, 114 rue Edouard Vaillant, Villejuif, France
| | - Laurence Zitvogel
- Université Paris Sud, Université Paris Saclay, Kremlin Bicêtre, France; Institut National de la Santé Et de la Recherche Medicale (INSERM), U1015, GRCC, Villejuif, France; Center of Clinical Investigations in Biotherapies of Cancer (CICBT) 507, Villejuif, France
| | - Isabelle Cremer
- Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, Paris, France; Université Pierre et Marie Curie, 15 rue de l'Ecole de Médecine, Paris, France; Laboratory "Cancer, Immune control and escape," Center de Recherche des Cordeliers, INSERM U 1138, 15 rue de l'Ecole de Médecine, Paris, France
| | - Guido Kroemer
- Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, Paris, France; Université Pierre et Marie Curie, 15 rue de l'Ecole de Médecine, Paris, France; Metabolomics and Cell Biology Platforms, Gustave Roussy Comprehensive Cancer Institute, Villejuif, France; Pôle de Biologie, Hôpital Européen Georges Pompidou, AP-HP, Paris, France; Karolinska Institute, Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
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Eggleton P, Bremer E, Dudek E, Michalak M. Calreticulin, a therapeutic target? Expert Opin Ther Targets 2016; 20:1137-47. [DOI: 10.1517/14728222.2016.1164695] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Chen Q, Fang X, Jiang C, Yao N, Fang X. Thrombospondin promoted anti-tumor of adenovirus-mediated calreticulin in breast cancer: Relationship with anti-CD47. Biomed Pharmacother 2015. [PMID: 26211590 DOI: 10.1016/j.biopha.2015.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Calreticulin (CRT) protein has multifaceted role in carcinogenesis, however its role in breast cancer remains unidentified. In this study, we attempted to evaluate the effect of overexpressed CRT on breast cancer cells viability and proliferation. METHODS Levels of mRNA and protein expression for CRT and CD47 in cells were determined by Quantitative RT-PCR analysis and Western blot, respectively. Cells apoptosis was evaluated using Annexin V-FITC assay with flow cytometry. Cell viability was assessed using MTT assay. Cell migration and autophagy were also evaluated. RESULTS In breast cancer cells of MCF-7 and MDA-MB-231, both CRT and CD47 expression were enhanced, compared with that in normal breast cells of MCF-10A. Overexpression of CRT by MCF-7 and MDA-MB-231 cells transfected with significantly suppressed cell migration, viability as well as promote cell apoptosis while exerted no effected on cell autophagy. Interestingly, combining of thrombospondin (TSP) and overexpression of CRT significantly induced cell autophagy and inhibited tumor growth in MCF-7 cells xenograft. In result of chip assay, we observed that TSP treatment promoted interaction of TSP with CRT and CD47. CONCLUSION TSP promoted anti-tumor of adenovirus-mediated CRT via forming complexes with CRT and CD47 in breast cancer.
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Affiliation(s)
- Qifeng Chen
- Department of General Surgery, 117th Hospital of PLA, No. 14, Road Lingyin, District Xihu, 310013 Hangzhou, PR China.
| | - Xiaoming Fang
- Department of General Surgery, 117th Hospital of PLA, No. 14, Road Lingyin, District Xihu, 310013 Hangzhou, PR China
| | - Chaohui Jiang
- Department of General Surgery, 117th Hospital of PLA, No. 14, Road Lingyin, District Xihu, 310013 Hangzhou, PR China
| | - Ning Yao
- Department of General Surgery, 117th Hospital of PLA, No. 14, Road Lingyin, District Xihu, 310013 Hangzhou, PR China
| | - Xudong Fang
- Department of General Surgery, 117th Hospital of PLA, No. 14, Road Lingyin, District Xihu, 310013 Hangzhou, PR China
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Rangel-Colmenero BR, Gomez-Gutierrez JG, Villatoro-Hernández J, Zavala-Flores LM, Quistián-Martínez D, Rojas-Martínez A, Arce-Mendoza AY, Guzmán-López S, Montes-de-Oca-Luna R, Saucedo-Cárdenas O. Enhancement of Ad-CRT/E7-mediated antitumor effect by preimmunization with L. lactis expressing HPV-16 E7. Viral Immunol 2014; 27:463-7. [PMID: 25216057 DOI: 10.1089/vim.2014.0055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Although current polyvalent vaccines can prevent development of cervical cancer, they cannot be used to treat patients who already have the disease. Adenovirus expressing calreticulin-E7 (Ad-CRT-E7) has shown promising results in the cervical cancer murine model. We also demonstrated that immunization with Lactococcus lactis encoding HPV-16 E7 (Ll-E7) anchored to its surface induces significant HPV-16 E7-specific immune response. Here, we assessed the combination of both approaches in the treatment of a cervical cancer animal model. Intranasal preimmunization of Ll-E7, followed by a single Ad-CRT/E7 application, induced ∼80% of tumor suppression in comparison with controls. Mice treated with a combination of Ll-E7 and Ad-CRT/E7 resulted in a 70% survival rate 300 days post-treatment, whereas 100% of the mice in the control groups died by 50 days. Significant CD8+ cytotoxic T-lymphocytes infiltration was detected in the tumors of mice treated with Ll-E7+Ad-CRT/E7. Tumors with regression showed a greater number of positive cells for in situ TUNEL staining than controls. Our results suggest that preimmunization with Ll-E7 enhances the Ad-CRT/E7-mediated antitumor effect. This treatment provides an enormous advantage over repeated applications of Ad-CRT/E7 by maintaining the effectiveness of the three-dose application of Ad-CRT/E7, but avoiding the high systemic toxicities associated with such repeat treatments.
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Affiliation(s)
- Blanca R Rangel-Colmenero
- 1 División de Genética, Centro de Investigación Biomédica del Noreste, Instituto Mexicano del Seguro Social (IMSS) , Monterrey, Mexico
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Ní Fhlathartaigh M, McMahon J, Reynolds R, Connolly D, Higgins E, Counihan T, FitzGerald U. Calreticulin and other components of endoplasmic reticulum stress in rat and human inflammatory demyelination. Acta Neuropathol Commun 2013; 1:37. [PMID: 24252779 PMCID: PMC3893522 DOI: 10.1186/2051-5960-1-37] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 06/28/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Calreticulin (CRT) is a chaperone protein, which aids correct folding of glycosylated proteins in the endoplasmic reticulum (ER). Under conditions of ER stress, CRT is upregulated and may be displayed on the surface of cells or be secreted. This 'ecto-CRT' may activate the innate immune response or it may aid clearance of apoptotic cells. Our and other studies have demonstrated upregulation of ER stress markers CHOP, BiP, ATF4, XBP1 and phosphorylated e-IF2 alpha (p-eIF2 alpha) in biopsy and post-mortem human multiple sclerosis (MS) samples. We extend this work by analysing changes in expression of CRT, BiP, CHOP, XBP1 and p-eIF2 alpha in a rat model of inflammatory demyelination. Demyelination was induced in the spinal cord by intradermal injection of recombinant mouse MOG mixed with incomplete Freund's adjuvant (IFA) at the base of the tail. Tissue samples were analysed by semi-quantitative scoring of immunohistochemically stained frozen tissue sections. Data generated following sampling of tissue from animals with spinal cord lesions, was compared to that obtained using tissue derived from IFA- or saline-injected controls. CRT present in rat serum and in a cohort of human serum derived from 14 multiple sclerosis patients and 11 healthy controls was measured by ELISA. RESULTS Stained tissue scores revealed significantly (p<0.05) increased amounts of CRT, CHOP and p-eIF2 alpha in the lesion, lesion edge and normal-appearing white matter when compared to controls. CHOP and p-eIF2 alpha were also significantly raised in regions of grey matter and the central canal (p<0.05). Immunofluorescent dual-label staining confirmed expression of these markers in astrocytes, microglia or neurons. Dual staining of rat and human spinal cord lesions with Oil Red O and CRT antibody showed co-localisation of CRT with the rim of myelin fragments. ELISA testing of sera from control and EAE rats demonstrated significant down-regulation (p<0.05) of CRT in the serum of EAE animals, compared to saline and IFA controls. This contrasted with significantly increased amounts of CRT detected in the sera of MS patients (p<0.05), compared to controls. CONCLUSION This data highlights the potential importance of CRT and other ER stress proteins in inflammatory demyelination.
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Zamanian M, Veerakumarasivam A, Abdullah S, Rosli R. Calreticulin and cancer. Pathol Oncol Res 2013; 19:149-54. [PMID: 23392843 DOI: 10.1007/s12253-012-9600-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/21/2012] [Indexed: 01/05/2023]
Abstract
Calreticulin (CRT) as a multi-functional endoplasmic reticulum protein is involved in a spectrum of cellular processes which ranges from calcium homeostasis and chaperoning to cell adhesion and finally malignant formation and progression. Previous studies have shown a contributing role for CRT in a range of different cancers. This present review will focus on the possible roles of CRT in the progression of malignant proliferation and the mechanisms involved in its contribution to cancer invasion.
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Affiliation(s)
- Mohammadreza Zamanian
- Genetic Medicine Research Center, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
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Qiu X, Hong C, Zhong Z, Li Y, Zhang T, Bao W, Xiong S, Gao XM. Modulation of cellular immunity by antibodies against calreticulin. Eur J Immunol 2012; 42:2419-30. [PMID: 22685035 DOI: 10.1002/eji.201142320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 05/02/2012] [Accepted: 05/30/2012] [Indexed: 12/26/2022]
Abstract
Although caltreticulin (CRT) is mainly a residential ER protein, it is also expressed on the membrane surface of various types of cells exhibiting multiple functions. We report here that intraperitoneal administration of a soluble recombinant CRT fragment (rCRT/39-272) led to a substantial decrease in delayed type hypersensitivity (DTH) responses in BALB/c mice and EAE in C57BL/6 mice. In the recall response against keyhole limpet hemocyanin (KLH) in vitro, draining lymph node cells from the rCRT/39-272-treated mice produced less IFN-γ but more IL-4 as compared with the cells from the control group. The immunomodulating effect of intraperitoneally administered rCRT/39-272 was attributed to anti-CRT Abs thereby induced, because, in passive transfer experiments, the CRT-specific antiserum could suppress DTH in BALB/c mice. B-cell-deficient μMT mice were not susceptible to rCRT/39-272-mediated DTH suppression. Furthermore, CRT appears on the surface of murine T cells soon after activation and remains detectable (at relatively low level) by flow cytometry for approximately 5 days in vitro. Anti-CRT Abs were able to inhibit AKT phosphorylation, proliferation, and cytokine production by activated murine T cells. We propose that cell surface CRT could play a role in the function of effector T cells and may be considered a target for immunological manipulation.
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Affiliation(s)
- Xiang Qiu
- Department of Immunology, Peking University Health Science Center, Beijing, China
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16
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Erić-Nikolić A, Milovanović Z, Sánchez D, Pekáriková A, Džodić R, Matić IZ, Tučková L, Jevrić M, Buta M, Rašković S, Juranić Z. Overexpression of calreticulin in malignant and benign breast tumors: relationship with humoral immunity. Oncology 2012; 82:48-55. [PMID: 22310016 DOI: 10.1159/000335267] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 11/16/2011] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Calreticulin is a multicompartmental protein which regulates many important cellular responses. The aim of this study was to elucidate whether the intensity and location of calreticulin overexpression in tumor cells are related to the elevated humoral immunity to calreticulin in patients with benign or malignant breast disease. METHODS This study involved 27 patients with benign and 58 patients with malignant breast tumors before surgical resection and 38 healthy volunteers. Cytoplasmatic or membranous calreticulin overexpression in malignant or benign cells in paraffin-embedded tissues was determined using immunohistochemistry. Levels of the serum anti-calreticulin autoantibodies were detected by ELISA. RESULTS Statistically significant differences between serum levels of IgA of anti-calreticulin antibodies in controls and patients with breast tumors, and between controls and patients with nonmalignant breast diseases were found, but no statistically significant differences were found between levels of serum IgG anti-calreticulin antibodies. Humoral immunity to calreticulin developed against cytoplasmatic and co-localized membranous calreticulin was not correlated to the intensity of its overexpression and was present even in the absence of its membranous localization. CONCLUSIONS The degree of calreticulin overexpression in lobular breast carcinoma is lower than in ductal breast carcinoma. Elevated concentrations of anti-calreticulin IgA antibodies were present more frequently in patients with metastasis in locoregional lymph nodes in comparison to anti-calreticulin IgG antibodies.
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17
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Gold LI, Eggleton P, Sweetwyne MT, Van Duyn LB, Greives MR, Naylor SM, Michalak M, Murphy-Ullrich JE. Calreticulin: non-endoplasmic reticulum functions in physiology and disease. FASEB J 2009; 24:665-83. [PMID: 19940256 DOI: 10.1096/fj.09-145482] [Citation(s) in RCA: 299] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Calreticulin (CRT), when localized to the endoplasmic reticulum (ER), has important functions in directing proper conformation of proteins and glycoproteins, as well as in homeostatic control of cytosolic and ER calcium levels. There is also steadily accumulating evidence for diverse roles for CRT localized outside the ER, including data suggesting important roles for CRT localized to the outer cell surface of a variety of cell types, in the cytosol, and in the extracellular matrix (ECM). Furthermore, the addition of exogenous CRT rescues numerous CRT-driven functions, such as adhesion, migration, phagocytosis, and immunoregulatory functions of CRT-null cells. Recent studies show that topically applied CRT has diverse and profound biological effects that enhance cutaneous wound healing in animal models. This evidence for extracellular bioactivities of CRT has provided new insights into this classically ER-resident protein, despite a lack of knowledge of how CRT exits from the ER to the cell surface or how it is released into the extracellular milieu. Nonetheless, it has become clear that CRT is a multicompartmental protein that regulates a wide array of cellular responses important in physiological and pathological processes, such as wound healing, the immune response, fibrosis, and cancer.-Gold, L. I., Eggleton, P., Sweetwyne, M. T., Van Duyn, L. B., Greives, M. R., Naylor, S.-M., Michalak, M., Murphy-Ullrich, J. E. Calreticulin: non-endoplamic reticulum functions in physiology and disease.
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Affiliation(s)
- Leslie I Gold
- Departments of Medicine and Pathology, New York, University School of Medicine, 550 First Ave., NB16S13 New York, NY 10016 USA.
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Michalak M, Groenendyk J, Szabo E, Gold L, Opas M. Calreticulin, a multi-process calcium-buffering chaperone of the endoplasmic reticulum. Biochem J 2009; 417:651-666. [DOI: 10.1042/bj20081847] [Citation(s) in RCA: 532] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Calreticulin is an ER (endoplasmic reticulum) luminal Ca2+-buffering chaperone. The protein is involved in regulation of intracellular Ca2+ homoeostasis and ER Ca2+ capacity. The protein impacts on store-operated Ca2+ influx and influences Ca2+-dependent transcriptional pathways during embryonic development. Calreticulin is also involved in the folding of newly synthesized proteins and glycoproteins and, together with calnexin (an integral ER membrane chaperone similar to calreticulin) and ERp57 [ER protein of 57 kDa; a PDI (protein disulfide-isomerase)-like ER-resident protein], constitutes the ‘calreticulin/calnexin cycle’ that is responsible for folding and quality control of newly synthesized glycoproteins. In recent years, calreticulin has been implicated to play a role in many biological systems, including functions inside and outside the ER, indicating that the protein is a multi-process molecule. Regulation of Ca2+ homoeostasis and ER Ca2+ buffering by calreticulin might be the key to explain its multi-process property.
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Affiliation(s)
- Marek Michalak
- Department of Biochemistry, University of Alberta, Edmonton, Alberta, Canada, T6G 2H7
| | - Jody Groenendyk
- Department of Biochemistry, University of Alberta, Edmonton, Alberta, Canada, T6G 2H7
| | - Eva Szabo
- Laboratory of Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada, M5S 1A8
| | - Leslie I. Gold
- Departments of Medicine and Pathology, New York University School of Medicine, New York, NY 10016, U.S.A
| | - Michal Opas
- Laboratory of Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada, M5S 1A8
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Erić A, Juranić Z, Milovanović Z, Marković I, Inić M, Stanojević-Bakić N, Vojinović-Golubović V. Effects of humoral immunity and calreticulin overexpression on postoperative course in breast cancer. Pathol Oncol Res 2008; 15:89-90. [PMID: 18925427 DOI: 10.1007/s12253-008-9112-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 10/07/2008] [Indexed: 11/25/2022]
Abstract
The aim was to investigate whether the humoral immunity and overexpression of calreticulin in tumor tissue determined before surgery, correlate with incidence of metastases in breast cancer patients within two years after operation. Before operation, their humoral immunity and overexpression of caleticulin and Her-2/neu in tumor tissue were analyzed by immunohystochemistry. In 23 patients with metastases in regionally lymph nodes, seven had Her-2/neu overexpression. Among those seven patients, three developed distant metastasis (two women one year and in one woman two years after surgery) and all of them showed the presence of stromal IgG immunoreactivity and overexpression of calreticulin in their tumors tissue. Preliminary data showed that serum IgG immunoreactivity to tumor stroma in combination with overexpression of calreticulin in tumor cells correlate with postoperative appearance of metastases, particularly in the group of patients with Her-2/neu overexpressed tumors and metastases in axillary lymph nodes.
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Affiliation(s)
- Aleksandra Erić
- Institute of Oncology and Radiology of Serbia, Pasterova 14, 11 000, Belgrade, Serbia.
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Affiliation(s)
- Nigel J Waterhouse
- Cancer Cell Death Laboratory, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, Melbourne, Victoria 8006, Australia.
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Lettau M, Schmidt H, Kabelitz D, Janssen O. Secretory lysosomes and their cargo in T and NK cells. Immunol Lett 2006; 108:10-9. [PMID: 17097742 DOI: 10.1016/j.imlet.2006.10.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Accepted: 10/10/2006] [Indexed: 11/22/2022]
Abstract
Secretory lysosomes are specialized organelles that combine catabolic functions of conventional lysosomes with an inducible secretory potential. They are present in various hematopoietic cell types commonly characterized by the need for rapid mobilization and secretion of effector proteins. As an example, the cytotoxic effector function of T cells and natural killer cells strictly depends on the activation-dependent mobilization of such vesicles to the cytotoxic immunological synapse. This review focuses on some molecules that have been identified as cargo of secretory lysosomes and which play a major role in effector function of CTL and NK cells. We also briefly point to the fact that the dysregulation of formation and transport of secretory vesicles is causative for severe immunodeficiencies and autoimmunity observed in patients and also in mice that have been used as representative model systems to analyze the pathophysiological relevance of secretory vesicles in vivo.
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Affiliation(s)
- Marcus Lettau
- Institute of Immunology, Medical Center Schleswig-Holstein Campus Kiel, Michaelisstr. 5, D-24105 Kiel, Germany
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Sipione S, Simmen KC, Lord SJ, Motyka B, Ewen C, Shostak I, Rayat GR, Dufour JM, Korbutt GS, Rajotte RV, Bleackley RC. Identification of a Novel Human Granzyme B Inhibitor Secreted by Cultured Sertoli Cells. THE JOURNAL OF IMMUNOLOGY 2006; 177:5051-8. [PMID: 17015688 DOI: 10.4049/jimmunol.177.8.5051] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sertoli cells have long since been recognized for their ability to suppress the immune system and protect themselves as well as other cell types from harmful immune reaction. However, the exact mechanism or product produced by Sertoli cells that affords this immunoprotection has never been fully elucidated. We examined the effect of mouse Sertoli cell-conditioned medium on human granzyme B-mediated killing and found that there was an inhibitory effect. We subsequently found that a factor secreted by Sertoli cells inhibited killing through the inhibition of granzyme B enzymatic activity. SDS-PAGE analysis revealed that this factor formed an SDS-insoluble complex with granzyme B. Immunoprecipitation and mass spectroscopic analysis of the complex identified a proteinase inhibitor, serpina3n, as a novel inhibitor of human granzyme B. We cloned serpina3n cDNA, expressed it in Jurkat cells, and confirmed its inhibitory action on granzyme B activity. Our studies have led to the discovery of a new inhibitor of granzyme B and have uncovered a new mechanism used by Sertoli cells for immunoprotection.
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Affiliation(s)
- Simonetta Sipione
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Lominadze G, Powell DW, Luerman GC, Link AJ, Ward RA, McLeish KR. Proteomic Analysis of Human Neutrophil Granules. Mol Cell Proteomics 2005; 4:1503-21. [PMID: 15985654 DOI: 10.1074/mcp.m500143-mcp200] [Citation(s) in RCA: 250] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Stimulated exocytosis of intracellular granules plays a critical role in conversion of inactive, circulating neutrophils to fully activated cells capable of chemotaxis, phagocytosis, and bacterial killing. The functional changes induced by exocytosis of each of the granule subsets, gelatinase (tertiary) granules, specific (secondary) granules, and azurophil (primary) granules, are poorly defined. To improve the understanding of the role of exocytosis of these granule subsets, a proteomic analysis of the azurophil, specific, and gelatinase granules from human neutrophils was performed. Two different methods for granule protein identification were applied. First, two-dimensional (2D) gel electrophoresis followed by MALDI-TOF MS analysis of peptides obtained by in-gel trypsin digestion of proteins was performed. Second, peptides from tryptic digests of granule membrane proteins were separated by two-dimensional microcapillary chromatography using strong cation exchange and reverse phase microcapillary high pressure liquid chromatography and analyzed with electrospray ionization tandem mass spectrometry (2D HLPC ESI-MS/MS). Our analysis identified 286 proteins on the three granule subsets, 87 of which were identified by MALDI MS and 247 were identified by 2D HPLC ESI-MS/MS. The increased sensitivity of 2D HPLC ESI-MS/MS, however, resulted in identification of over 500 proteins from subcellular organelles contaminating isolated granules. Defining the proteome of neutrophil granule subsets provides a basis for understanding the role of exocytosis in neutrophil biology. Additionally, the described methods may be applied to mobilizable compartments of other secretory cells.
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Affiliation(s)
- George Lominadze
- Department of Medicine, University of Louisville and the Veterans Affairs Medical Center, Louisville, Kentucky 40202, USA
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