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Partenope C, Galazzi E, Albanese A, Bellone S, Rabbone I, Persani L. Sex steroid priming in short stature children unresponsive to GH stimulation tests: Why, who, when and how. Front Endocrinol (Lausanne) 2022; 13:1072271. [PMID: 36523598 PMCID: PMC9744763 DOI: 10.3389/fendo.2022.1072271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/14/2022] [Indexed: 11/30/2022] Open
Abstract
Despite decades of experience, the diagnosis of growth hormone deficiency (GHD) remains challenging, especially in peripubertal children. Failure to respond to GH stimulation tests (GHSTs) is needed to confirm GHD, but long-standing controversies regarding the number of tests needed and the interpretation of GH peaks are still a matter of debate worldwide. Diagnostic workup is even more problematic in short children with slow growth and delayed sexual development: they often exhibit low GH peaks under GHST, which often normalize as puberty progresses. Consequently, this transient suboptimal response to GHST may result in GH overtreatment, carrying both health and economic concerns. Considering the complex and bound link between GH axis and sex steroids, the use of sex steroid priming prior to GHST might be helpful in peripubertal setting. However, its use is still controversial. There is no consensus regarding patient selection, timing, dose, and preparation of sex steroids. In this review, we aim to overview the use of sex steroid priming in clinical practice, highlighting the need to develop appropriate guidelines in order to overcome diagnostic pitfalls in peripubertal age.
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Affiliation(s)
- Cristina Partenope
- Division of Pediatrics, Department of Health Science University of Piemonte Orientale, Ospedale Maggiore della Carità, Novara, Italy
- *Correspondence: Cristina Partenope,
| | - Elena Galazzi
- Department of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Assunta Albanese
- Department of Paediatric Endocrinology, St. George’s University Hospital NHS Foundation Trust, London, United Kingdom
| | - Simonetta Bellone
- Division of Pediatrics, Department of Health Science University of Piemonte Orientale, Ospedale Maggiore della Carità, Novara, Italy
| | - Ivana Rabbone
- Division of Pediatrics, Department of Health Science University of Piemonte Orientale, Ospedale Maggiore della Carità, Novara, Italy
| | - Luca Persani
- Department of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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SOCS2 Inhibits Mitochondrial Fatty Acid Oxidation via Suppressing LepR/JAK2/AMPK Signaling Pathway in Mouse Adipocytes. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:3742542. [PMID: 32733634 PMCID: PMC7376435 DOI: 10.1155/2020/3742542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 12/22/2022]
Abstract
Suppressor of cytokine signaling 2 (SOCS2) plays an important role in fat deposition, skeletal muscle, central nervous system development, and mitochondria biogenesis. Nevertheless, the regulatory mechanisms of SOCS2 on mitochondrial fatty acid oxidation (FAO) remain unclear. Leptin could inhibit food intake and increase thermogenesis through leptin receptor (LepR), which was present in the hypothalamus and certain peripheral organs, including adipose tissue. With strong interest, we focused on the connection between leptin and SOCS2 and their effect on FAO in adipocytes. In our study, we found that the mRNA level of SOCS2 and the protein levels of PGC-1α, CPT-1b, FAT, and p-ACC were elevated by leptin in the inguinal adipose tissue of mice. On the contrary, the protein levels of FABP4, FATP1, and FAS were declined. The genes related to fatty acid oxidation such as PGC-1α, NRF-1, TFAM, CPT-1b, AOX1, COX2, and UCP2 were attenuated by SOCS2, but elevated by leptin. Moreover, fatty acid oxidation enzyme MCAD, LCAD, and Cyt C levels were reduced in response to SOCS2. These reductions correspond well with the reduced release of free fatty acid and the reduction of mitochondrial complexes I and III by SOCS2. Furthermore, JAK2/AMPK pathway-specific inhibitors could block the mitochondrial FAO; hence, this pathway was implied to have a potential impact on FAO. Together, these studies suggested that SOCS2 had a negative effect on mitochondrial fatty acid oxidation, and the LepR/JAK2/AMPK pathway played a crucial role in this process.
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Bolamperti S, Guidobono F, Rubinacci A, Villa I. The Role of Growth Hormone in Mesenchymal Stem Cell Commitment. Int J Mol Sci 2019; 20:ijms20215264. [PMID: 31652811 PMCID: PMC6862273 DOI: 10.3390/ijms20215264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/16/2022] Open
Abstract
Growth hormone (GH) is best known for its prominent role in promoting prepubertal growth and in regulating body composition and metabolism during adulthood. In recent years, the possible role of GH in the modulation of mesenchymal stem cell (MSC) commitment has gained interest. MSCs, characterized by active self-renewal and differentiation potential, express GH receptors. In MSCs derived from different adult tissues, GH induces an inhibition of adipogenic differentiation and favors MSC differentiation towards osteogenesis. This activity of GH indicates that regulation of body composition by GH has already started in the tissue progenitor cells. These findings have fostered research on possible uses of MSCs treated with GH in those pathologies, where a lack of or delays in bone repair occur. After an overview of GH activities, this review will focus on the research that has characterized GH’s effects on MSCs and on preliminary studies on the possible application of GH in bone regenerative medicine.
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Affiliation(s)
- Simona Bolamperti
- Bone Metabolism Unit, Division of Genetics & Cell Biology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy.
| | - Francesca Guidobono
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20129 Milan, Italy.
| | - Alessandro Rubinacci
- Bone Metabolism Unit, Division of Genetics & Cell Biology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy.
| | - Isabella Villa
- Bone Metabolism Unit, Division of Genetics & Cell Biology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy.
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Walugembe M, Bertolini F, Dematawewa CMB, Reis MP, Elbeltagy AR, Schmidt CJ, Lamont SJ, Rothschild MF. Detection of Selection Signatures Among Brazilian, Sri Lankan, and Egyptian Chicken Populations Under Different Environmental Conditions. Front Genet 2019; 9:737. [PMID: 30693019 PMCID: PMC6339939 DOI: 10.3389/fgene.2018.00737] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 12/22/2018] [Indexed: 12/12/2022] Open
Abstract
Extreme environmental conditions are a major challenge in livestock production. Changes in climate, particularly those that contribute to weather extremes like drought or excessive humidity, may result in reduced performance and reproduction and could compromise the animal's immune function. Animal survival within extreme environmental conditions could be in response to natural selection and to artificial selection for production traits that over time together may leave selection signatures in the genome. The aim of this study was to identify selection signatures that may be involved in the adaptation of indigenous chickens from two different climatic regions (Sri Lanka = Tropical; Egypt = Arid) and in non-indigenous chickens that derived from human migration events to the generally tropical State of São Paulo, Brazil. To do so, analyses were conducted using fixation index (Fst) and hapFLK analyses. Chickens from Brazil (n = 156), Sri Lanka (n = 92), and Egypt (n = 96) were genotyped using the Affymetrix Axiom®600k Chicken Genotyping Array. Pairwise Fst analyses among countries did not detect major regions of divergence between chickens from Sri Lanka and Brazil, with ecotypes/breeds from Brazil appearing to be genetically related to Asian-Indian (Sri Lanka) ecotypes. However, several differences were detected in comparisons of Egyptian with either Sri Lankan or Brazilian populations, and common regions of difference on chromosomes 2, 3 and 8 were detected. The hapFLK analyses for the three separate countries suggested unique regions that are potentially under selection on chromosome 1 for all three countries, on chromosome 4 for Sri Lankan, and on chromosomes 3, 5, and 11 for the Egyptian populations. Some of identified regions under selection with hapFLK analyses contained genes such as TLR3, SOCS2, EOMES, and NFAT5 whose biological functions could provide insights in understanding adaptation mechanisms in response to arid and tropical environments.
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Affiliation(s)
- Muhammed Walugembe
- Department of Animal Science, Iowa State University, Ames, IA, United States
| | - Francesca Bertolini
- Department of Animal Science, Iowa State University, Ames, IA, United States
| | | | - Matheus P Reis
- Department of Animal Science, College of Agricultural and Veterinary Sciences, São Paulo State University, Jaboticabal, Brazil
| | - Ahmed R Elbeltagy
- Department of Animal Biotechnology, Animal Production Research Institute, Giza, Egypt
| | - Carl J Schmidt
- Animal and Food Sciences, University of Delaware, Newark, DE, United States
| | - Susan J Lamont
- Department of Animal Science, Iowa State University, Ames, IA, United States
| | - Max F Rothschild
- Department of Animal Science, Iowa State University, Ames, IA, United States
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Bolamperti S, Signo M, Spinello A, Moro G, Fraschini G, Guidobono F, Rubinacci A, Villa I. GH prevents adipogenic differentiation of mesenchymal stromal stem cells derived from human trabecular bone via canonical Wnt signaling. Bone 2018; 112:136-144. [PMID: 29694926 DOI: 10.1016/j.bone.2018.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
The imbalance between osteogenesis and adipogenesis, which naturally accompanies bone marrow senescence, may contribute to the development of bone-associated diseases, like osteoporosis. In the present study, using primary human mesenchymal stromal cells (hMSCs) isolated from trabecular bone, we assessed the possible effect of GH on hMSC differentiation potential into adipocytes. GH (5 ng/ml) significantly inhibited the lipid accumulation in hMSCs cultured for 14 days in lipogenic medium. GH decreased the expression of the adipogenic genes, CCAAT/enhancer-binding protein alpha (C/EBPα) and adiponectin (ADN) as well as the expression of two lipogenesis-related enzymes, lipoprotein lipase (LPL) and acethylCoA carboxylase (ACACA). In parallel, GH induced an increase in the gene expression and protein levels of osterix (OSX) and osteoprotegerin (OPG). These effects were ascribed to enhanced Wnt signaling as GH significantly reduced Wnt inhibitors, Dickkopf 1 (DKK1) and the secreted frizzled protein 2 (SFRP2), and increased the expression of an activator of Wnt, Wnt3. Accordingly, the expression of β-catenin and its nuclear levels were raised. Wnt involvement in GH anti-adipogenic effect was further confirmed by the silencing of β-catenin. In silenced hMSC, both the inhibitory effect of GH on the expression of the adipogenic genes, ADN and C/EBPα and the lipogenesis enzymes LPL and ACACA, were prevented together with the stimulatory effect of GH on the osteogenic genes OSX and OPG. The present study supports the hypothesis that when GH secretion declines as in aging, the fat in the bone-marrow cavities increases and the osteogenic capacity of the MSC pool is reduced due to a decrease in Wnt signaling.
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Affiliation(s)
- Simona Bolamperti
- Bone Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
| | - Michela Signo
- Bone Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
| | - Alice Spinello
- Bone Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
| | - GianLuigi Moro
- Orthopaedic Unit, Dept of Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Gianfranco Fraschini
- Orthopaedic Unit, Dept of Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Guidobono
- Bone Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Rubinacci
- Bone Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
| | - Isabella Villa
- Bone Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy.
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Birzniece V, Ho KKY. Sex steroids and the GH axis: Implications for the management of hypopituitarism. Best Pract Res Clin Endocrinol Metab 2017; 31:59-69. [PMID: 28477733 DOI: 10.1016/j.beem.2017.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Growth hormone (GH) regulates somatic growth, substrate metabolism and body composition. Sex hormones exert profound effect on the secretion and action of GH. Estrogens stimulate the secretion of GH, but inhibit the action of GH on the liver, an effect that occurs when administered orally. Estrogens suppress GH receptor signaling by stimulating the expression proteins that inhibit cytokine receptor signaling. This effect of estrogens is avoided when physiological doses of estrogens are administered via a non-oral route. Estrogen-like compounds, such as selective estrogen receptor modulators, possess dual properties of inhibiting the secretion as well as the action of GH. In contrast, androgens stimulate GH secretion, driving IGF-1 production. In the periphery, androgens enhance the action of GH. The differential effects of estrogens and androgens influence the dose of GH replacement in patients with hypopituitarism on concomitant treatment with sex steroids. Where possible, a non-oral route of estrogen replacement is recommended for optimizing cost-benefit of GH replacement in women with GH deficiency. Adequate androgen replacement in conjunction with GH replacement is required to achieve the full anabolic effect in men with hypopituitarism.
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Affiliation(s)
- Vita Birzniece
- School of Medicine, Western Sydney University, Penrith, NSW 2751, Australia; Garvan Institute of Medical Research, Sydney, NSW 2010, Australia; School of Medicine, University of New South Wales, NSW 2052, Australia.
| | - Ken K Y Ho
- Garvan Institute of Medical Research, Sydney, NSW 2010, Australia; Centres for Health Research, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD 4102, Australia
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Zhu B, Dai L, Yu Y, Wang D, Peng T, Liu C. A Role of Suppressor of Cytokine Signaling 2 in the Regulation of Ecdysteroid Signaling Pathway in Procambarus clarkii. ACTA ACUST UNITED AC 2016; 325:441-52. [PMID: 27461053 DOI: 10.1002/jez.2029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 12/29/2022]
Abstract
A suppressor of cytokine signaling 2 (SOCS-2) homolog was identified from the red crayfish Procambarus clarkii. Phylogenic analysis showed that P. clarkii SOCS-2 (Pc-SOCS-2) was very similar to that of invertebrates. The sequence contains a central SH2 domain, a conserved SOCS box, and a variable N-terminal domain. Real-time polymerase chain reaction showed that Pc-SOCS-2 mRNA level was higher in muscle and heart than in the other tissues examined. A 40-kDa recombinant protein was successfully expressed and purified from Escherichia coli cells as confirmed by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and Western blotting. Pc-SOCS-2 was significantly downregulated in the hepatopancreas after 20-hydroxyecdysone injection. Knockdown of Pc-SOCS-2 gene by small interfering RNA transfection in the hepatopancreas increased the expression levels of 20-hydroxyecdysone-responsive genes at 48 hr. Taken together, these results suggest that Pc-SOCS-2 is a negative regulator of ecdysteroid signaling transduction.
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Affiliation(s)
- Baojian Zhu
- College of Life Sciences, Anhui Agricultural University, Hefei, 230036, People's Republic of China.
| | - Lishang Dai
- College of Life Sciences, Anhui Agricultural University, Hefei, 230036, People's Republic of China
| | - Yingying Yu
- College of Life Sciences, Anhui Agricultural University, Hefei, 230036, People's Republic of China
| | - Daojun Wang
- College of Life Sciences, Anhui Agricultural University, Hefei, 230036, People's Republic of China
| | - Tao Peng
- College of Life Sciences, Anhui Agricultural University, Hefei, 230036, People's Republic of China
| | - Chaoliang Liu
- College of Life Sciences, Anhui Agricultural University, Hefei, 230036, People's Republic of China
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Carson JA, Manolagas SC. Effects of sex steroids on bones and muscles: Similarities, parallels, and putative interactions in health and disease. Bone 2015; 80:67-78. [PMID: 26453497 PMCID: PMC4600533 DOI: 10.1016/j.bone.2015.04.015] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/23/2015] [Accepted: 04/07/2015] [Indexed: 12/31/2022]
Abstract
Estrogens and androgens influence the growth and maintenance of bones and muscles and are responsible for their sexual dimorphism. A decline in their circulating levels leads to loss of mass and functional integrity in both tissues. In the article, we highlight the similarities of the molecular and cellular mechanisms of action of sex steroids in the two tissues; the commonality of a critical role of mechanical forces on tissue mass and function; emerging evidence for an interplay between mechanical forces and hormonal and growth factor signals in both bones and muscles; as well as the current state of evidence for or against a cross-talk between muscles and bone. In addition, we review evidence for the parallels in the development of osteoporosis and sarcopenia with advancing age and the potential common mechanisms responsible for the age-dependent involution of these two tissues. Lastly, we discuss the striking difference in the availability of several drug therapies for the prevention and treatment of osteoporosis, as compared to none for sarcopenia. This article is part of a Special Issue entitled "Muscle Bone Interactions".
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Affiliation(s)
- James A Carson
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208 USA
| | - Stavros C Manolagas
- Division of Endocrinology and Metabolism, Center for Osteoporosis and Metabolic Bone Diseases, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, Little Rock, AR, USA.
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Vanderschueren D, Laurent MR, Claessens F, Gielen E, Lagerquist MK, Vandenput L, Börjesson AE, Ohlsson C. Sex steroid actions in male bone. Endocr Rev 2014; 35:906-60. [PMID: 25202834 PMCID: PMC4234776 DOI: 10.1210/er.2014-1024] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Sex steroids are chief regulators of gender differences in the skeleton, and male gender is one of the strongest protective factors against osteoporotic fractures. This advantage in bone strength relies mainly on greater cortical bone expansion during pubertal peak bone mass acquisition and superior skeletal maintenance during aging. During both these phases, estrogens acting via estrogen receptor-α in osteoblast lineage cells are crucial for male cortical and trabecular bone, as evident from conditional genetic mouse models, epidemiological studies, rare genetic conditions, genome-wide meta-analyses, and recent interventional trials. Genetic mouse models have also demonstrated a direct role for androgens independent of aromatization on trabecular bone via the androgen receptor in osteoblasts and osteocytes, although the target cell for their key effects on periosteal bone formation remains elusive. Low serum estradiol predicts incident fractures, but the highest risk occurs in men with additionally low T and high SHBG. Still, the possible clinical utility of serum sex steroids for fracture prediction is unknown. It is likely that sex steroid actions on male bone metabolism rely also on extraskeletal mechanisms and cross talk with other signaling pathways. We propose that estrogens influence fracture risk in aging men via direct effects on bone, whereas androgens exert an additional antifracture effect mainly via extraskeletal parameters such as muscle mass and propensity to fall. Given the demographic trends of increased longevity and consequent rise of osteoporosis, an increased understanding of how sex steroids influence male bone health remains a high research priority.
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Affiliation(s)
- Dirk Vanderschueren
- Clinical and Experimental Endocrinology (D.V.) and Gerontology and Geriatrics (M.R.L., E.G.), Department of Clinical and Experimental Medicine; Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine (M.R.L., F.C.); and Centre for Metabolic Bone Diseases (D.V., M.R.L., E.G.), KU Leuven, B-3000 Leuven, Belgium; and Center for Bone and Arthritis Research (M.K.L., L.V., A.E.B., C.O.), Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden
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Abstract
Mouse models with cell-specific deletion of the estrogen receptor (ER) α, the androgen receptor (AR) or the receptor activator of nuclear factor κB ligand (RANKL), as well as cascade-selective estrogenic compounds have provided novel insights into the function and signalling of ERα and AR. The studies reveal that the effects of estrogens on trabecular versus cortical bone mass are mediated by direct effects on osteoclasts and osteoblasts, respectively. The protection of cortical bone mass by estrogens is mediated via ERα, using a non-nucleus-initiated mechanism. By contrast, the AR of mature osteoblasts is indispensable for the maintenance of trabecular bone mass in male mammals, but not required for the anabolic effects of androgens on cortical bone. Most unexpectedly, and independently of estrogens, ERα in osteoblast progenitors stimulates Wnt signalling and periosteal bone accrual in response to mechanical strain. RANKL expression in B lymphocytes, but not T lymphocytes, contributes to the loss of trabecular bone caused by estrogen deficiency. In this Review, we summarize this evidence and discuss its implications for understanding the regulation of trabecular and cortical bone mass; the integration of hormonal and mechanical signals; the relative importance of estrogens versus androgens in the male skeleton; and, finally, the pathogenesis and treatment of osteoporosis.
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Affiliation(s)
- Stavros C Manolagas
- Division of Endocrinology and Metabolism, Centre for Osteoporosis and Metabolic Bone Diseases, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, 4301 West Markham, Little Rock, AR 72205-7199, USA
| | - Charles A O'Brien
- Division of Endocrinology and Metabolism, Centre for Osteoporosis and Metabolic Bone Diseases, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, 4301 West Markham, Little Rock, AR 72205-7199, USA
| | - Maria Almeida
- Division of Endocrinology and Metabolism, Centre for Osteoporosis and Metabolic Bone Diseases, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, 4301 West Markham, Little Rock, AR 72205-7199, USA
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