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Kumar N, Sharma S, Tripathi BN. Pathogenicity and virulence of lumpy skin disease virus: A comprehensive update. Virulence 2025; 16:2495108. [PMID: 40265421 PMCID: PMC12036493 DOI: 10.1080/21505594.2025.2495108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2024] [Revised: 03/11/2025] [Accepted: 04/11/2025] [Indexed: 04/24/2025] Open
Abstract
Lumpy skin disease (LSD), which was confined to the Africa for many decades, has expanded its geographical distribution to numerous countries across Asia and Europe in recent years. The LSD virus (LSDV) is a relatively poorly studied virus. Its 151 Kb genome encodes 156 open reading frames (ORF); however, the exact number of the proteins encoded by the viral genome and their specific functions remain largely unknown. Arthropod vectors primarily transmit the LSDV mechanically, but the precise nature of these vectors in different regions and their role in transmission is not fully understood. Homologous live-attenuated vaccines prepared using LSDV have proven to be highly efficacious compared to heterologous vaccines based on sheep pox virus or goatpox virus, in protecting cattle against LSD. This review offers the latest insights into the molecular biology and transmission of LSDV and discusses the safety and efficacy of available vaccines, along with the challenges faced in controlling and eradicating the disease in endemic regions.
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Affiliation(s)
- Naveen Kumar
- National Centre for Veterinary Type Cultures, ICAR-National Research Centre on Equines, Hisar, India
- ICMR-National Institute of Virology, Pune, India
| | - Shalini Sharma
- Division of Veterinary Physiology and Biochemistry, Sher-e-Kashmir University of Agricultural Sciences and Technology, Jammu, India
| | - Bhupendra N. Tripathi
- National Centre for Veterinary Type Cultures, ICAR-National Research Centre on Equines, Hisar, India
- Division of Veterinary Physiology and Biochemistry, Sher-e-Kashmir University of Agricultural Sciences and Technology, Jammu, India
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Roh T, Seo W, Won M, Yang WS, Sapkota A, Park EJ, Yun SH, Jeon SM, Kim KT, Lee B, Ryu G, Lee SH, Shin JM, Shin HJ, Kim YJ, Lee Y, Chung C, Song IC, Song HK, Jo EK. The inflammasome-activating poxvirus peptide IAMP29 promotes antimicrobial and anticancer responses. Exp Mol Med 2024; 56:2475-2490. [PMID: 39511430 PMCID: PMC11612179 DOI: 10.1038/s12276-024-01339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 11/15/2024] Open
Abstract
Poxviruses are implicated in a variety of infectious diseases; however, little is known about the molecular mechanisms that underlie the immune response during poxvirus infection. We investigated the function and mechanisms of the monkeypox virus envelope protein (A30L) and its core peptide (IAMP29) during the activation of innate immune responses. The A30L protein and its core peptide, IAMP29 (a 29-amino-acid inflammasome-activating peptide encompassing His40 to Asp69 of A30L), strongly activated the nucleotide-binding oligomerization domain, leucine rich repeat and pyrin domain-containing 3 (NLRP3) inflammasome by inducing the production of mitochondrial reactive oxygen species in human monocytes. Specifically, IAMP29 triggered metabolic reprogramming toward glycolysis and interacted with pyruvate kinase M isoforms (PKM1 and PKM2), thus activating the NLRP3 inflammasome and interleukin (IL)-1β production in human monocytes and murine macrophages. In human primary monocyte-derived macrophages, IAMP29-induced inflammasome activation promoted an antimicrobial response to rapidly growing non-tuberculous mycobacteria. Furthermore, IAMP29 exhibited cytotoxic activity against leukemia cells, which was mediated by pyroptosis and apoptosis. These findings provide insights into the immunological function of the poxvirus envelope peptide and suggest its therapeutic potential.
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Affiliation(s)
- Taylor Roh
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Wonhyoung Seo
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Minho Won
- Department of Biochemistry, Chungnam National University College of Natural Sciences, Daejeon, Republic of Korea
| | - Woo Seok Yang
- Department of Life Sciences, Korea University, Seoul, Republic of Korea
| | - Asmita Sapkota
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Eun-Jin Park
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Sung-Ho Yun
- Bio-Chemical Analysis Team, Korea Basic Science Institute, Cheongju, Republic of Korea
| | - Sang Min Jeon
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Kyung Tae Kim
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Bomi Lee
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Gyoungah Ryu
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Sang-Hee Lee
- Center for Research Equipment, Korea Basic Science Institute, Cheongju, Republic of Korea
| | - Jung-Min Shin
- Department of Dermatology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Hyo Jung Shin
- Department of Anatomy and Cell Biology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Brain Research Institute, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Young Jae Kim
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Young Lee
- Department of Dermatology, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Chaeuk Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Ik-Chan Song
- Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Hyun Kyu Song
- Department of Life Sciences, Korea University, Seoul, Republic of Korea
| | - Eun-Kyeong Jo
- Department of Microbiology, Chungnam National University College of Medicine, Daejeon, Republic of Korea.
- Infection Control Convergence Research Center, Chungnam National University College of Medicine, Daejeon, Republic of Korea.
- Department of Medical Science, Chungnam National University College of Medicine, Daejeon, Republic of Korea.
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Fang D, Liu Y, Dou D, Su B. The unique immune evasion mechanisms of the mpox virus and their implication for developing new vaccines and immunotherapies. Virol Sin 2024; 39:709-718. [PMID: 39181538 PMCID: PMC11738799 DOI: 10.1016/j.virs.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 08/20/2024] [Indexed: 08/27/2024] Open
Abstract
Mpox is an infectious and contagious zoonotic disease caused by the mpox virus (MPXV), which belongs to the genus Orthopoxvirus. Since 2022, MPXV has posed a significant threat to global public health. The emergence of thousands of cases across the Western Hemisphere prompted the World Health Organization to declare an emergency. The extensive coevolutionary history of poxviruses with humans has enabled these viruses to develop sophisticated mechanisms to counter the human immune system. Specifically, MPXV employs unique immune evasion strategies against a wide range of immunological elements, presenting a considerable challenge for treatment, especially following the discontinuation of routine smallpox vaccination among the general population. In this review, we start by discussing the entry of the mpox virus and the onset of early infection, followed by an introduction to the mechanisms by which the mpox virus can evade the innate and adaptive immune responses. Two caspase-1 inhibitory proteins and a PKR escape-related protein have been identified as phylogenomic hubs involved in modulating the immune environment during the MPXV infection. With respect to adaptive immunity, mpox viruses exhibit unique and exceptional T-cell inhibition capabilities, thereby comprehensively remodeling the host immune environment. The viral envelope also poses challenges for the neutralizing effects of antibodies and the complement system. The unique immune evasion mechanisms employed by MPXV make novel multi-epitope and nucleic acid-based vaccines highly promising research directions worth investigating. Finally, we briefly discuss the impact of MPXV infection on immunosuppressed patients and the current status of MPXV vaccine development. This review may provide valuable information for the development of new immunological treatments for mpox.
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Affiliation(s)
- Dong Fang
- Department of Health Sciences, National Natural Science Foundation of China, Beijing, 100085, China
| | - Yan Liu
- Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Dou Dou
- Department of Health Sciences, National Natural Science Foundation of China, Beijing, 100085, China
| | - Bin Su
- Department of Health Sciences, National Natural Science Foundation of China, Beijing, 100085, China; Beijing Key Laboratory for HIV/AIDS Research, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China; Central Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
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Doan TA, Forward TS, Schafer JB, Lucas ED, Fleming I, Uecker-Martin A, Ayala E, Guthmiller JJ, Hesselberth JR, Morrison TE, Tamburini BAJ. Immunization-induced antigen archiving enhances local memory CD8+ T cell responses following an unrelated viral infection. NPJ Vaccines 2024; 9:66. [PMID: 38514656 PMCID: PMC10957963 DOI: 10.1038/s41541-024-00856-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
Antigens from viruses or immunizations can persist or are archived in lymph node stromal cells such as lymphatic endothelial cells (LEC) and fibroblastic reticular cells (FRC). Here, we find that, during the time frame of antigen archiving, LEC apoptosis caused by a second, but unrelated, innate immune stimulus such as vaccina viral infection or CpG DNA administration resulted in cross-presentation of archived antigens and boosted memory CD8 + T cells specific to the archived antigen. In contrast to "bystander" activation associated with unrelated infections, the memory CD8 + T cells specific to the archived antigen from the immunization were significantly higher than memory CD8 + T cells of a different antigen specificity. Finally, the boosted memory CD8 + T cells resulted in increased protection against Listeria monocytogenes expressing the antigen from the immunization, but only for the duration that the antigen was archived. These findings outline an important mechanism by which lymph node stromal cell archived antigens, in addition to bystander activation, can augment memory CD8 + T cell responses during repeated inflammatory insults.
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Affiliation(s)
- Thu A Doan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
- Immunology Graduate Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tadg S Forward
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Johnathon B Schafer
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Erin D Lucas
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
- Immunology Graduate Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ira Fleming
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Aspen Uecker-Martin
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edgardo Ayala
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jenna J Guthmiller
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jay R Hesselberth
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thomas E Morrison
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Beth A Jirón Tamburini
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
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Zeng GG, Jiang WL, Yu J, Nie GY, Lu YR, Xiao CK, Wang C, Zheng K. The Potential Relationship Between Cardiovascular Diseases and Monkeypox. Curr Probl Cardiol 2024; 49:102116. [PMID: 37802168 DOI: 10.1016/j.cpcardiol.2023.102116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
Mpox, a novel epidemic disease, has broken out the period of coronavirus disease 2019 since May 2022, which was caused by the mpox virus. Up to 12 September 2023, there are more than 90,439 confirmed mpox cases in over 115 countries all over the world. Moreover, the outbreak of mpox in 2022 was verified to be Clade II rather than Clade I. Highlighting the significance of this finding, a growing body of literature suggests that mpox may lead to a series of cardiovascular complications, including myocarditis and pericarditis. It is indeed crucial to acquire more knowledge about mpox from a perspective from the clinical cardiologist. In this review, we would discuss the epidemiological characteristics and primary treatments of mpox to attempt to provide a framework for cardiovascular physicians.
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Affiliation(s)
- Guang-Gui Zeng
- Department of Clinical Laboratory, Hengyang Central Hospital, Hengyang, Hunan, China; Institute of Pathogenic Biology, Hengyang Medical College, University of South China, Hengyang, Hunan, China; Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, 2020 Grade Excellent Doctor Class of Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Wan-Li Jiang
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, 2020 Grade Excellent Doctor Class of Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Jiang Yu
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, 2020 Grade Excellent Doctor Class of Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Gui-Ying Nie
- Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, 2020 Grade Excellent Doctor Class of Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Yu-Ru Lu
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chang-Kai Xiao
- Department of Urology, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, Hunan, China
| | - Chuan Wang
- Institute of Pathogenic Biology, Hengyang Medical College, University of South China, Hengyang, Hunan, China.
| | - Kang Zheng
- Department of Clinical Laboratory, Hengyang Central Hospital, Hengyang, Hunan, China.
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Souza ARV, Brinkmann A, Esparza J, Nitsche A, Damaso CR. Gene duplication, gene loss, and recombination events with variola virus shaped the complex evolutionary path of historical American horsepox-based smallpox vaccines. mBio 2023; 14:e0188723. [PMID: 37729584 PMCID: PMC10653919 DOI: 10.1128/mbio.01887-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/28/2023] [Indexed: 09/22/2023] Open
Abstract
IMPORTANCE Modern smallpox vaccines, such as those used against mpox, are made from vaccinia viruses, but it is still unknown whether cowpox, horsepox, or vaccinia viruses were used in the early 20th century or earlier. The mystery began to be solved when the genomes of six historical smallpox vaccines used in the United States from 1850 to 1902 were determined. Our work analyzed in detail the genomes of these six historical vaccines, revealing a complex genomic structure. Historical vaccines are highly similar to horsepox in the core of their genomes, but some are closer to the structure of vaccinia virus at the ends of the genome. One of the vaccines is a recombinant virus with parts of variola virus recombined into its genome. Our data add valuable information for understanding the evolutionary path of current smallpox vaccines and the genetic makeup of the potentially extinct group of horsepox viruses.
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Affiliation(s)
- Aline R. V. Souza
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Annika Brinkmann
- Centre for Biological Threats and Special Pathogens 1 – Highly Pathogenic Viruses & German Consultant Laboratory for Poxviruses & WHO Collaborating Centre for Emerging Infections and Biological Threats, Robert Koch Institute, Berlin, Germany
| | - José Esparza
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Andreas Nitsche
- Centre for Biological Threats and Special Pathogens 1 – Highly Pathogenic Viruses & German Consultant Laboratory for Poxviruses & WHO Collaborating Centre for Emerging Infections and Biological Threats, Robert Koch Institute, Berlin, Germany
| | - Clarissa R. Damaso
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Andrei G, Snoeck R. Differences in pathogenicity among the mpox virus clades: impact on drug discovery and vaccine development. Trends Pharmacol Sci 2023; 44:719-739. [PMID: 37673695 DOI: 10.1016/j.tips.2023.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 09/08/2023]
Abstract
Since May 2022, mpox virus (MPXV) has attracted considerable attention due to a multi-country outbreak. Marked differences in epidemiology, transmission, and pathology between the 2022 global mpox outbreak (clade IIb) and classical mpox disease, endemic in Africa (clades I and IIa) have been highlighted. MPXV genome analysis has identified the genomic changes characterizing clade IIb and the drivers of MPXV rapid evolution. Although mpox cases have largely declined, MPXV cryptic transmission and microevolution continues, which may lead to an MPXV of unpredictable pathogenicity. Vaccines and antivirals developed against variola virus, the agent that caused the extinguished plague smallpox, have been used to contain the 2022 mpox outbreak. In this review article, recent findings on MPXV origin and evolution and relevant models able to recapitulate differences in MPXV pathogenicity, which are important for drug and vaccine development, are discussed.
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Affiliation(s)
- Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium.
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
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Tamburini B, Doan T, Forward T, Lucas E, Fleming I, Uecker-Martin A, Hesselberth J, Morrison T. Vaccine-induced antigen archiving enhances local memory CD8+ T cell responses following an unrelated viral infection. RESEARCH SQUARE 2023:rs.3.rs-3307809. [PMID: 37841845 PMCID: PMC10571600 DOI: 10.21203/rs.3.rs-3307809/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Viral and vaccine antigens persist or are archived in lymph node stromal cells (LNSC) such as lymphatic endothelial cells (LEC) and fibroblastic reticular cells (FRC). Here, we find that, during the time frame of antigen archiving, LEC apoptosis caused by a second, but unrelated, innate immune stimulus such as vaccina viral infection or CpG DNA administration boosted memory CD8+ T cells specific to the archived antigen. In contrast to "bystander" activation associated with unrelated infections, the memory CD8+ T cells specific to the vaccine archived antigen were significantly higher than memory CD8+ T cells of a different antigen specificity. Finally, the boosted memory CD8+ T cells resulted in increased protection against Listeria monocytogenes expressing the vaccine antigen, but only for the duration that the vaccine antigen was archived. These findings outline a novel mechanism by which LNSC archived antigens, in addition to bystander activation, can augment memory CD8+ T cell responses during repeated inflammatory insults.
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Affiliation(s)
| | - Thu Doan
- University of Colorado Anschutz Medical Campus
| | | | - Erin Lucas
- University of Colorado Anschutz Medical Campus
| | - Ira Fleming
- University of Colorado Anschutz Medical Campus
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