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Yuan JH, Estacion M, Mis MA, Tanaka BS, Schulman BR, Chen L, Liu S, Dib-Hajj FB, Dib-Hajj SD, Waxman SG. KCNQ variants and pain modulation: a missense variant in Kv7.3 contributes to pain resilience. Brain Commun 2021; 3:fcab212. [PMID: 34557669 PMCID: PMC8454204 DOI: 10.1093/braincomms/fcab212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/13/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
There is a pressing need for understanding of factors that confer resilience to pain. Gain-of-function mutations in sodium channel Nav1.7 produce hyperexcitability of dorsal root ganglion neurons underlying inherited erythromelalgia, a human genetic model of neuropathic pain. While most individuals with erythromelalgia experience excruciating pain, occasional outliers report more moderate pain. These differences in pain profiles in blood-related erythromelalgia subjects carrying the same pain-causative Nav1.7 mutation and markedly different pain experience provide a unique opportunity to investigate potential genetic factors that contribute to inter-individual variability in pain. We studied a patient with inherited erythromelalgia and a Nav1.7 mutation (c.4345T>G, p. F1449V) with severe pain as is characteristic of most inherited erythromelalgia patients, and her mother who carries the same Nav1.7 mutation with a milder pain phenotype. Detailed six-week daily pain diaries of pain episodes confirmed their distinct pain profiles. Electrophysiological studies on subject-specific induced pluripotent stem cell-derived sensory neurons from each of these patients showed that the excitability of these cells paralleled their pain phenotype. Whole-exome sequencing identified a missense variant (c.2263C>T, p. D755N) in KCNQ3 (Kv7.3) in the pain resilient mother. Voltage-clamp recordings showed that co-expression of Kv7.2-wild type (WT)/Kv7.3-D755N channels produced larger M-currents than that of Kv7.2-WT/Kv7.3-WT. The difference in excitability of the patient-specific induced pluripotent stem cell-derived sensory neurons was mimicked by modulating M-current levels using the dynamic clamp and a model of the mutant Kv7.2-WT/Kv7.3-D755N channels. These results show that a 'pain-in-a-dish' model can be used to explicate genetic contributors to pain, and confirm that KCNQ variants can confer pain resilience via an effect on peripheral sensory neurons.
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Affiliation(s)
- Jun-Hui Yuan
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Mark Estacion
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Malgorzata A Mis
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Brian S Tanaka
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Betsy R Schulman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Lubin Chen
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Shujun Liu
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Fadia B Dib-Hajj
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Sulayman D Dib-Hajj
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Stephen G Waxman
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT 06520, USA
- Center for Rehabilitation Research, VA Connecticut Healthcare System, West Haven, CT 06516, USA
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Akin EJ, Higerd GP, Mis MA, Tanaka BS, Adi T, Liu S, Dib-Hajj FB, Waxman SG, Dib-Hajj SD. Building sensory axons: Delivery and distribution of Na V1.7 channels and effects of inflammatory mediators. Sci Adv 2019; 5:eaax4755. [PMID: 31681845 PMCID: PMC6810356 DOI: 10.1126/sciadv.aax4755] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/13/2019] [Indexed: 05/12/2023]
Abstract
Sodium channel NaV1.7 controls firing of nociceptors, and its role in human pain has been validated by genetic and functional studies. However, little is known about NaV1.7 trafficking or membrane distribution along sensory axons, which can be a meter or more in length. We show here with single-molecule resolution the first live visualization of NaV1.7 channels in dorsal root ganglia neurons, including long-distance microtubule-dependent vesicular transport in Rab6A-containing vesicles. We demonstrate nanoclusters that contain a median of 12.5 channels at the plasma membrane on axon termini. We also demonstrate that inflammatory mediators trigger an increase in the number of NaV1.7-carrying vesicles per axon, a threefold increase in the median number of NaV1.7 channels per vesicle and a ~50% increase in forward velocity. This remarkable enhancement of NaV1.7 vesicular trafficking and surface delivery under conditions that mimic a disease state provides new insights into the contribution of NaV1.7 to inflammatory pain.
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Affiliation(s)
- Elizabeth J. Akin
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Grant P. Higerd
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
- MD-PhD Program, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Malgorzata A. Mis
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Brian S. Tanaka
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Talia Adi
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Shujun Liu
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Fadia B. Dib-Hajj
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Stephen G. Waxman
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
- Corresponding author. (S.D.D.-H.); (S.G.W.)
| | - Sulayman D. Dib-Hajj
- Department of Neurology, Yale University, New Haven, CT 06510, USA
- Center for Neuroscience and Regeneration Research, Yale University, New Haven, CT 06510, USA
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA
- Corresponding author. (S.D.D.-H.); (S.G.W.)
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Mis MA, Rogers MF, Jeffries AR, Wilbrey AL, Chen L, Yang Y, Dib-Hajj S, Waxman SG, Stevens EB, Randall AD. Differential aging-related changes in neurophysiology and gene expression in IB4-positive and IB4-negative nociceptive neurons. Aging Cell 2018; 17:e12795. [PMID: 29943484 PMCID: PMC6052481 DOI: 10.1111/acel.12795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 04/25/2018] [Accepted: 05/28/2018] [Indexed: 12/16/2022] Open
Abstract
Despite pain prevalence altering with age, the effects of aging on the properties of nociceptors are not well understood. Nociceptors, whose somas are located in dorsal root ganglia, are frequently divided into two groups based on their ability to bind isolectin B4 (IB4). Here, using cultured neurons from 1‐, 3‐, 5‐, 8‐, 12‐, and 18‐month‐old mice, we investigate age‐dependent changes in IB4‐positive and IB4‐negative neurons. Current‐clamp experiments at physiological temperature revealed nonlinear changes in firing frequency of IB4‐positive, but not IB4‐negative neurons, with a peak at 8 months. This was likely due to the presence of proexcitatory conductances activated at depolarized membrane potentials and significantly higher input resistances found in IB4‐positive neurons from 8‐month‐old mice. Repetitive firing in nociceptors is driven primarily by the TTX‐resistant sodium current, and indeed, IB4‐positive neurons from 8‐month‐old mice were found to receive larger contributions from the TTX‐resistant window current around the resting membrane potential. To further address the mechanisms behind these differences, we performed RNA‐seq experiments on IB4‐positive and IB4‐negative neurons from 1‐, 8‐, and 18‐month‐old mice. We found a larger number of genes significantly affected by age within the IB4‐positive than IB4‐negative neurons from 8‐month‐old mice, including known determinants of nociceptor excitability. The above pronounced age‐dependent changes at the cellular and molecular levels in IB4‐positive neurons point to potential mechanisms behind the reported increase in pain sensitivity in middle‐aged rodents and humans, and highlight the possibility of targeting a particular group of neurons in the development of age‐tailored pain treatments.
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Affiliation(s)
- Malgorzata A. Mis
- School of Physiology, Pharmacology, and Neuroscience; University of Bristol; Bristol UK
| | - Mark F. Rogers
- Intelligent Systems Laboratory; University of Bristol; Bristol UK
| | - Aaron R. Jeffries
- University of Exeter Medical School; University of Exeter; Exeter UK
| | | | - Lubin Chen
- Department of Neurology and Center for Neuroscience and Regeneration Research; Yale University School of Medicine; New Haven Connecticut USA
- Rehabilitation Research Center; Veterans Administration Connecticut Healthcare System; West Haven Connecticut USA
| | - Yang Yang
- Department of Medicinal Chemistry and Molecular Pharmacology; Purdue University College of Pharmacy and Purdue Institute for Integrative Neuroscience; West Lafayette Indiana USA
| | - Sulayman Dib-Hajj
- Department of Neurology and Center for Neuroscience and Regeneration Research; Yale University School of Medicine; New Haven Connecticut USA
- Rehabilitation Research Center; Veterans Administration Connecticut Healthcare System; West Haven Connecticut USA
| | - Stephen G. Waxman
- Department of Neurology and Center for Neuroscience and Regeneration Research; Yale University School of Medicine; New Haven Connecticut USA
- Rehabilitation Research Center; Veterans Administration Connecticut Healthcare System; West Haven Connecticut USA
| | | | - Andrew D. Randall
- School of Physiology, Pharmacology, and Neuroscience; University of Bristol; Bristol UK
- Institute of Biomedical and Clinical Sciences; University of Exeter Medical School; Hatherly Laboratories; University of Exeter; Exeter UK
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Huang J, Mis MA, Tanaka B, Adi T, Estacion M, Liu S, Walker S, Dib-Hajj SD, Waxman SG. Atypical changes in DRG neuron excitability and complex pain phenotype associated with a Na v1.7 mutation that massively hyperpolarizes activation. Sci Rep 2018; 8:1811. [PMID: 29379075 PMCID: PMC5788866 DOI: 10.1038/s41598-018-20221-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/16/2018] [Indexed: 02/06/2023] Open
Abstract
Sodium channel Nav1.7 plays a central role in pain-signaling: gain-of-function Nav1.7 mutations usually cause severe pain and loss-of-function mutations produce insensitivity to pain. The Nav1.7 I234T gain-of-function mutation, however, is linked to a dual clinical presentation of episodic pain, together with absence of pain following fractures, and corneal anesthesia. How a Nav1.7 mutation that produces gain-of-function at the channel level causes clinical loss-of-function has remained enigmatic. We show by current-clamp that expression of I234T in dorsal root ganglion (DRG) neurons produces a range of membrane depolarizations including a massive shift to >−40 mV that reduces excitability in a small number of neurons. Dynamic-clamp permitted us to mimic the heterozygous condition via replacement of 50% endogenous wild-type Nav1.7 channels by I234T, and confirmed that the I234T conductance could drastically depolarize DRG neurons, resulting in loss of excitability. We conclude that attenuation of pain sensation by I234T is caused by massively depolarized membrane potential of some DRG neurons which is partly due to enhanced overlap between activation and fast-inactivation, impairing their ability to fire. Our results demonstrate how a Nav1.7 mutation that produces channel gain-of-function can contribute to a dual clinical presentation that includes loss of pain sensation at the clinical level.
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Affiliation(s)
- Jianying Huang
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Malgorzata A Mis
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Brian Tanaka
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Talia Adi
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Mark Estacion
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Shujun Liu
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Suellen Walker
- Developmental Neurosciences Program, Department of Anaesthesia and Pain Medicine, UCL Great Ormond Street Hospital, London, WC1N 1EH, UK
| | - Sulayman D Dib-Hajj
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510.,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516
| | - Stephen G Waxman
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, USA, 06510. .,Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA, 06516.
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5
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Alexandrou AJ, Brown AR, Chapman ML, Estacion M, Turner J, Mis MA, Wilbrey A, Payne EC, Gutteridge A, Cox PJ, Doyle R, Printzenhoff D, Lin Z, Marron BE, West C, Swain NA, Storer RI, Stupple PA, Castle NA, Hounshell JA, Rivara M, Randall A, Dib-Hajj SD, Krafte D, Waxman SG, Patel MK, Butt RP, Stevens EB. Subtype-Selective Small Molecule Inhibitors Reveal a Fundamental Role for Nav1.7 in Nociceptor Electrogenesis, Axonal Conduction and Presynaptic Release. PLoS One 2016; 11:e0152405. [PMID: 27050761 PMCID: PMC4822888 DOI: 10.1371/journal.pone.0152405] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/14/2016] [Indexed: 01/08/2023] Open
Abstract
Human genetic studies show that the voltage gated sodium channel 1.7 (Nav1.7) is a key molecular determinant of pain sensation. However, defining the Nav1.7 contribution to nociceptive signalling has been hampered by a lack of selective inhibitors. Here we report two potent and selective arylsulfonamide Nav1.7 inhibitors; PF-05198007 and PF-05089771, which we have used to directly interrogate Nav1.7’s role in nociceptor physiology. We report that Nav1.7 is the predominant functional TTX-sensitive Nav in mouse and human nociceptors and contributes to the initiation and the upstroke phase of the nociceptor action potential. Moreover, we confirm a role for Nav1.7 in influencing synaptic transmission in the dorsal horn of the spinal cord as well as peripheral neuropeptide release in the skin. These findings demonstrate multiple contributions of Nav1.7 to nociceptor signalling and shed new light on the relative functional contribution of this channel to peripheral and central noxious signal transmission.
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Affiliation(s)
- Aristos J. Alexandrou
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Adam R. Brown
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Mark L. Chapman
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - Mark Estacion
- Center for Neuroscience & Regeneration Research, Yale Medical School and Veterans Affairs Hospital, West Haven, CT, 06516, United States of America
| | - Jamie Turner
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Malgorzata A. Mis
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Anna Wilbrey
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Elizabeth C. Payne
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Alex Gutteridge
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Peter J. Cox
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Rachel Doyle
- Pfizer Global R&D, Ramsgate Road, Sandwich, Kent, CT13 9NJ, United Kingdom
| | - David Printzenhoff
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - Zhixin Lin
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - Brian E. Marron
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - Christopher West
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - Nigel A. Swain
- Worldwide Medicinal Chemistry, Pfizer Neusentis, The Portway Building, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - R. Ian Storer
- Worldwide Medicinal Chemistry, Pfizer Neusentis, The Portway Building, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Paul A. Stupple
- Worldwide Medicinal Chemistry, Pfizer Neusentis, The Portway Building, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
| | - Neil A. Castle
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - James A. Hounshell
- Dept. Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, 22911, United States of America
| | - Mirko Rivara
- Dept. Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, 22911, United States of America
| | - Andrew Randall
- Medical School, Hatherly Building, University of Exeter, Prince of Wales Road, Exeter, EX4 4PS, United Kingdom
| | - Sulayman D. Dib-Hajj
- Center for Neuroscience & Regeneration Research, Yale Medical School and Veterans Affairs Hospital, West Haven, CT, 06516, United States of America
| | - Douglas Krafte
- Pfizer Neusentis, 4222 Emperor Boulevard, Durham, North Carolina, 27703, United States of America
| | - Stephen G. Waxman
- Center for Neuroscience & Regeneration Research, Yale Medical School and Veterans Affairs Hospital, West Haven, CT, 06516, United States of America
| | - Manoj K. Patel
- Dept. Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, 22911, United States of America
| | - Richard P. Butt
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
- * E-mail: (EBS); (RPB)
| | - Edward B. Stevens
- Pfizer Neusentis, The Portway Buiding, Granta Park, Great Abington, Cambridge, CB21 6GS, United Kingdom
- * E-mail: (EBS); (RPB)
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