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Hydrogen sulfide plays a key role in the inhibitory neurotransmission to the pig intravesical ureter. PLoS One 2014; 9:e113580. [PMID: 25415381 PMCID: PMC4240656 DOI: 10.1371/journal.pone.0113580] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/25/2014] [Indexed: 01/29/2023] Open
Abstract
According to previous observations nitric oxide (NO), as well as an unknown nature mediator are involved in the inhibitory neurotransmission to the intravesical ureter. This study investigates the hydrogen sulfide (H2S) role in the neurogenic relaxation of the pig intravesical ureter. We have performed western blot and immunohistochemistry to study the expression of the H2S synthesis enzymes cystathionine γ-lyase (CSE) and cystathionine β-synthase (CBS), measurement of enzymatic production of H2S and myographic studies for isometric force recording. Immunohistochemical assays showed a high CSE expression in the intravesical ureter muscular layer, as well as a strong CSE-immunoreactivity within nerve fibres distributed along smooth muscle bundles. CBS expression, however, was not consistently observed. On ureteral strips precontracted with thromboxane A2 analogue U46619, electrical field stimulation (EFS) and the H2S donor P-(4-methoxyphenyl)-P-4-morpholinylphosphinodithioic acid (GYY4137) evoked frequency- and concentration-dependent relaxations. CSE inhibition with DL-propargylglycine (PPG) reduced EFS-elicited responses and a combined blockade of both CSE and NO synthase (NOS) with, respectively, PPG and NG-nitro-L-arginine (L-NOARG), greatly reduced such relaxations. Endogenous H2S production rate was reduced by PPG, rescued by addition of GYY4137 and was not changed by L-NOARG. EFS and GYY4137 relaxations were also reduced by capsaicin-sensitive primary afferents (CSPA) desensitization with capsaicin and blockade of ATP-dependent K+ (KATP) channels, transient receptor potential A1 (TRPA1), transient receptor potential vanilloid 1 (TRPV1), vasoactive intestinal peptide/pituitary adenylyl cyclase-activating polypeptide (VIP/PACAP) and calcitonin gene-related peptide (CGRP) receptors with glibenclamide, HC030031, AMG9810, PACAP6–38 and CGRP8–37, respectively. These results suggest that H2S, synthesized by CSE, is involved in the inhibitory neurotransmission to the pig intravesical ureter, through an NO-independent pathway, producing smooth muscle relaxation via KATP channel activation. H2S also promotes the release of inhibitory neuropeptides, as PACAP 38 and/or CGRP from CSPA through TRPA1, TRPV1 and related ion channel activation.
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Martínez-Sáenz A, Recio P, Orensanz LM, Fernandes VS, Martínez MP, Bustamante S, Carballido J, García-Sacristán A, Prieto D, Hernández M. Role of calcitonin gene-related peptide in inhibitory neurotransmission to the pig bladder neck. J Urol 2011; 186:728-35. [PMID: 21683385 DOI: 10.1016/j.juro.2011.03.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Indexed: 12/01/2022]
Abstract
PURPOSE We studied the role of calcitonin gene-related peptide in nonadrenergic, noncholinergic neurotransmission to the pig bladder neck. MATERIALS AND METHODS We used immunohistochemical techniques to determine the distribution of calcitonin gene-related peptide immunoreactive fibers as well as organ baths for isometric force recording. We investigated relaxation due to endogenously released or exogenously applied calcitonin gene-related peptide in urothelium denuded phenylephrine precontracted strips treated with guanethidine, atropine and NG-nitro-L-arginine to block noradrenergic neurotransmission, muscarinic receptors and nitric oxide synthase, respectively. RESULTS Rich calcitonin gene-related peptide immunoreactive innervation was found penetrating through the adventitia and distributed in the suburothelial and muscle layers. Numerous, variable size, varicose calcitonin gene-related peptide immunopositive terminals were seen close below the urothelium. In the muscle layer calcitonin gene-related peptide immunopositive nerves usually appeared as varicose terminals running along muscle fibers. Electrical field stimulation (2 to 16 Hz) and exogenous calcitonin gene-related peptide (0.1 nM to 0.3 μM) evoked frequency and concentration dependent relaxation, respectively. Nerve responses were potentiated by capsaicin, decreased by calcitonin gene-related peptide (8-37) and abolished by tetrodotoxin, capsaicin sensitive primary afferent blockers, calcitonin gene-related peptide receptors and neuronal voltage gated Na+ channels. Calcitonin gene-related peptide-induced relaxation was potentiated by the neuronal voltage gated Ca2+ channels blocker ω-conotoxin-GVIA and decreased by calcitonin gene-related peptide (8-37). Calcitonin gene-related peptide relaxation was not modified by blockade of endopeptidases, nitric oxide synthase, guanylyl cyclase and cyclooxygenase. CONCLUSIONS Results suggest that calcitonin gene-related peptide is involved in the nonadrenergic, noncholinergic inhibitory neurotransmission of the pig bladder neck, producing relaxation through neuronal and muscle calcitonin gene-related peptide receptors. Nitric oxide/cyclic guanosine monophosphate and cyclooxygenase pathways do not seem to be involved in such responses.
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Affiliation(s)
- Ana Martínez-Sáenz
- Departamento de Fisiología, Facultad de Farmacia, Universidad Complutense de Madrid, and Departamento de Investigación, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Bustamante Alarma S, Carballido Rodríguez J. La urodinámica “In vitro”. Actas Urol Esp 2008; 32:169-71. [DOI: 10.1016/s0210-4806(08)73808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Revisión de estudios funcionales en experimentación básica en urología. Actas Urol Esp 2008; 32:390-5. [DOI: 10.1016/s0210-4806(08)73852-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Hernández M, Barahona MV, Recio P, Benedito S, Martínez AC, Rivera L, García-Sacristán A, Prieto D, Orensanz LM. Neuronal and smooth muscle receptors involved in the PACAP- and VIP-induced relaxations of the pig urinary bladder neck. Br J Pharmacol 2006; 149:100-9. [PMID: 16847435 PMCID: PMC1629402 DOI: 10.1038/sj.bjp.0706832] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND PURPOSE As pituitary adenylate cyclase-activating polypeptide 38 (PACAP 38)- and vasoactive intestinal peptide (VIP) are widely distributed in the urinary tract, the current study investigated the receptors and mechanisms involved in relaxations induced by these peptides in the pig bladder neck. EXPERIMENTAL APPROACH Urothelium-denuded strips were suspended in organ baths for isometric force recordings and the relaxations to VIP and PACAP analogues were investigated. KEY RESULTS VIP, PACAP 38, PACAP 27 and [Ala(11,22,28)]-VIP produced similar relaxations. Inhibition of neuronal voltage-gated Ca(2+) channels reduced relaxations to PACAP 38 and increased those induced by VIP. Blockade of capsaicin-sensitive primary afferents (CSPA), nitric oxide (NO)-synthase or guanylate cyclase reduced the PACAP 38 relaxations but failed to modify the VIP responses. Inhibition of VIP/PACAP receptors and of voltage-gated K(+) channels reduced PACAP 38 and VIP relaxations, which were not modified by the K(+) channel blockers iberiotoxin, charybdotoxin, apamin or glibenclamide. The phosphodiesterase 4 inhibitor rolipram and the adenylate cyclase activator forskolin produced potent relaxations. Blockade of protein kinase A (PKA) reduced PACAP 38- and VIP-induced relaxations. CONCLUSIONS AND IMPLICATIONS PACAP 38 and VIP relax the pig urinary bladder neck through muscle VPAC(2) receptors linked to the cAMP-PKA pathway and involve activation of voltage-gated K(+) channels. Facilitatory PAC(1) receptors located at CSPA and coupled to NO release, and inhibitory VPAC receptors at motor endings are also involved in the relaxations to PACAP 38 and VIP, respectively. VIP/PACAP receptor antagonists could be useful in the therapy of urinary incontinence produced by intrinsic sphincter deficiency.
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Affiliation(s)
- M Hernández
- Departamento de Fisiología, Fisiología Animal, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain.
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Sellers DJ, Chapple CR, W Hay DP, Chess-Williams R. Depressed contractile responses to neurokinin A in idiopathic but not neurogenic overactive human detrusor muscle. Eur Urol 2006; 49:510-8. [PMID: 16420969 DOI: 10.1016/j.eururo.2005.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2005] [Revised: 11/05/2005] [Accepted: 11/21/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The role of tachykinins such as neurokinin A in regulating bladder function is unclear, but NK2 receptors seem to mediate contraction in the human bladder and it has been suggested that these peptides may have a role in the pathophysiology of bladder dysfunction. The present study investigates neurokinin receptor-mediated contractility of detrusor muscle in the idiopathic overactive and neurogenic overactive bladder and investigates the neurokinin receptor subtypes involved. METHODS Human bladder was obtained from patients undergoing cystectomy (normal) or clam cystoplasty (idiopathic overactive) and from patients with spinal injuries (neurogenic overactive). Strips of isolated detrusor muscle were mounted in physiological Krebs-bicarbonate solution and cumulative concentration-response curves to 1 nM to 300 microM neurokinin A (NKA) were obtained in the absence and presence of neurokinin receptor antagonists, either the NK2 receptor-selective antagonist SR 48968 or the NK3 receptor-selective antagonist SB 223412. RESULTS NKA evoked concentration-dependent contraction of normal, idiopathic, and neurogenic overactive detrusor strips. In idiopathic overactive detrusor muscle, NKA-induced contraction was significantly reduced relative to normal detrusor (0.031 +/- 0.005 mg/g, n = 11 versus 0.193 +/- 0.039 mg/g, n = 7). Sensitivity to the peptide was also significantly (p < 0.01) reduced in idiopathic overactive detrusor, with mean pEC50 values (concentration producing 50% maximal response) of 6.62+/-0.16 (n = 11) compared to 7.47+/-0.19 (n = 7) in normal detrusor. In contrast, NKA-induced responses of neurogenic overactive detrusor were similar to those in normal detrusor, with a mean maximum contraction of 0.199 +/- 0.036 mg/g (n = 10) and mean pEC50 value of 7.85+/-0.16 (n = 10). NKA curves in all groups were shifted to the right by the NK2 receptor-selective antagonist SR 48968 with high affinity, pK(B) values being similar in normal, idiopathic, and neurogenic overactive detrusor (8.85 + 0.08, n = 14; 8.97 +/- 0.13, n = 12; 8.73 +/- 0.12, n = 8, respectively). In contrast the NK3 receptor-selective antagonist SB 223412 had a minimal effect on NKA responses and affinity values were low (pK(B) 5.81 +/- 0.11, n = 12 in normal; 5.75 +/- 0.08, n = 12 in idiopathic overactive, and 5.77 +/- 0.13, n = 11 in neurogenic overactive). CONCLUSION These data indicate that NKA-induced responses are impaired in detrusor muscle from idiopathic overactive human bladder, but not in detrusor muscle from neurogenic overactive bladder. The NK2 receptor subtype appears to mediate NKA responses in the normal, idiopathic overactive, and neurogenic overactive detrusor. This is important evidence suggesting a difference between the bladder pathophysiology observed in idiopathic versus neurogenic overactive detrusor.
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Affiliation(s)
- Donna J Sellers
- Biomedical Research Centre, Sheffield Hallam University, Sheffield S1 1WB, UK.
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Hernández M, Barahona MV, Recio P, Bustamante S, Benedito S, Rivera L, García-Sacristán A, Prieto D, Orensanz LM. PACAP 38 is involved in the non-adrenergic non-cholinergic inhibitory neurotransmission in the pig urinary bladder neck. Neurourol Urodyn 2006; 25:490-7. [PMID: 16721838 DOI: 10.1002/nau.20287] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIMS To investigate the role played by pituitary adenylate cyclase activating polypeptide 38 (PACAP 38) in the non-adrenergic non-cholinergic (NANC) neurotransmission of the pig urinary bladder neck. METHODS Urothelium-denuded bladder neck strips were dissected and mounted in organ baths containing a physiological saline solution (PSS) at 37 degrees C and gassed with 5% CO(2) and 95% O(2), for isometric force recording. The relaxations to transmural nerve stimulation (EFS) or PACAP 38 were performed on strips precontracted with 1 microM phenylephrine (PhE). EFS experiments were carried out in the absence and the presence of guanethidine (10 microM), atropine (0.1 microM), and N(G)-nitro-L-arginine (L-NOARG, 100 microM), to block noradrenergic neurotransmission, muscarinic receptors, and nitric oxide (NO) synthase, respectively. RESULTS EFS (2-16 Hz, 1 ms duration, 20 sec trains, 75 mA current output) evoked frequency-dependent relaxations which were reduced by the VIP/PACAP receptor antagonist PACAP (6-38) (3 microM), and by the neurotoxin of the capsaicin-sensitive primary afferents capsaicin (10 microM), and abolished by the neuronal voltage-activated Na(+) channel blocker tetrodotoxin (TTX, 1 microM). The vasoactive intestinal peptide (VIP) receptor antagonist [Lys(1), Pro(2,5), Arg(3,4), Tyr(6)]-VIP (3 microM) failed to modify the EFS-induced relaxations. PACAP 38 (1 nM-1 microM) induced concentration-dependent relaxations which were reduced by PACAP (6-38), TTX and by the neuronal voltage-gated Ca(2+) channel inhibitor omega-conotoxin GVIA (omega-CgTX, 1 microM). CONCLUSIONS The results suggest that PACAP 38, mainly released from capsaicin-sensitive primary afferents, is involved in the NANC inhibitory neurotransmission of the pig urinary bladder neck, producing relaxation through neuronal and muscle VIP/PACAP receptor activation.
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Affiliation(s)
- Medardo Hernández
- Departamento de Fisiología (Fisiología Animal), Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain.
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Barthó L, Benkó R, Patacchini R, Pethö G, Holzer-Petsche U, Holzer P, Lázár Z, Undi S, Illényi L, Antal A, Horváth OP. Effects of capsaicin on visceral smooth muscle: a valuable tool for sensory neurotransmitter identification. Eur J Pharmacol 2005; 500:143-57. [PMID: 15464028 DOI: 10.1016/j.ejphar.2004.07.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2004] [Indexed: 11/27/2022]
Abstract
Studying the visceral effects of the sensory stimulant capsaicin is a useful and relatively simple tool of neurotransmitter identification and has been used for this purpose for approximately 25 years in the authors' and other laboratories. We believe that conclusions drawn from experiments on visceral preparations may have an impact on studies dealing with the central endings of primary afferent neurons, i.e. research on nociception at the spinal level. The present review concentrates on the effects of capsaicin--through the transient receptor potential vanilloid receptor type 1 (TRPV1) receptor--on innervated gastrointestinal, respiratory and genitourinary smooth muscle preparations. Tachykinins and calcitonin gene-related peptide (CGRP) are the most widely accepted transmitters to mediate "local efferent" effects of capsaicin-sensitive nerves in tissues taken from animals. Studies more and more frequently indicate a supra-additive interaction of various types of tachykinin receptors (tachykinin NK(1), NK(2), NK(3) receptors) in the excitatory effects of capsaicin. There is also evidence for a mediating role of ATP, acting on P(2) purinoceptors. Non-specific inhibitory actions of capsaicin-like drugs have to be taken into consideration while designing experiments with these drugs. Results obtained on human tissues may be sharply different from those of animal preparations. Capsaicin potently inhibits tone and movements of human intestinal preparations, an effect mediated by nitric oxide (NO) and/or vasoactive intestinal polypeptide.
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Affiliation(s)
- Lorand Barthó
- Department of Pharmacology and Pharmacotherapy, Division of Pharmacodynamics, University Medical School of Pécs, Pécs, Hungary.
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Hernández M, Barahona MV, Recio P, Rivera L, Benedito S, Martínez AC, García-Sacristán A, Orensanz LM, Prieto D. Heterogeneity of neuronal and smooth muscle receptors involved in the VIP- and PACAP-induced relaxations of the pig intravesical ureter. Br J Pharmacol 2003; 141:123-31. [PMID: 14662737 PMCID: PMC1574168 DOI: 10.1038/sj.bjp.0705582] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
1. The mechanisms and receptors involved in the vasoactive intestinal peptide (VIP)- and pituitary adenylate cyclase-activating polypeptide (PACAP)-induced relaxations of the pig intravesical ureter were investigated. 2. VIP, PACAP 38 and PACAP 27 concentration-dependently relaxed U46619-contracted ureteral strips with a similar potency. [Ala(11,22,28)]-VIP, a VPAC(1) agonist, showed inconsistent relaxations. 3. The neuronal voltage-gated Ca(2+) channel inhibitor, omega-conotoxin GVIA (omega-CgTX, 1 microm), reduced the VIP relaxations. Urothelium removal or blockade of capsaicin-sensitive primary afferents, nitric oxide (NO) synthase and guanylate cyclase with capsaicin (10 microm), N(G)-nitro-l-arginine (l-NOARG, 100 microm) and 1H-[1,2,4]-oxadiazolo[4,3-a]quinoxalin-1-one (ODQ, 5 microm), respectively, did not change the VIP relaxations. However, the PACAP 38 relaxations were reduced by omega-CgTX, capsaicin, l-NOARG and ODQ. 4. The VIP and VIP/PACAP receptor antagonists, [Lys(1), Pro(2,5), Arg(3,4), Tyr(6)]-VIP (1 microm) and PACAP (6-38) (0.4 microm), inhibited VIP and VIP and PACAP 38, respectively, relaxations. 5. The nonselective and large-conductance Ca(2)-activated K(+) channel blockers, tetraethylammonium (3 mm) and charybdotoxin (0.1 microm), respectively, and neuropeptide Y (0.1 microm) did not modify the VIP relaxations. The small-conductance Ca(2)-activated K(+) channel blocker apamin (1 microm) did not change the PACAP 27 relaxations. 6. The cAMP-dependent protein kinase A (PKA) blocker, 8-(4-chlorophenylthio)adenosine-3',5'-cyclic monophosphorothioate (Rp-8-CPT-cAMPS, 100 microm), reduced VIP relaxations. The phosphodiesterase 4 inhibitor rolipram and the adenylate cyclase activator forskolin relaxed ureteral preparations. The rolipram relaxations were reduced by Rp-8-CPT-cAMPS. Forskolin (30 nm) evoked a potentiation of VIP relaxations. 7. These results suggest that VIP and PACAP relax the pig ureter through smooth muscle receptors, probably of the VPAC(2) subtype, linked to a cAMP-PKA pathway. Neuronal VPAC receptors localized at motor nerves and PAC(1) receptors placed at sensory nerves and coupled to NO release, seem also to be involved in the VIP and PACAP 38 relaxations.
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MESH Headings
- 15-Hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5,13-dienoic Acid/pharmacology
- Animals
- Apamin/pharmacology
- Capsaicin/pharmacology
- Charybdotoxin/administration & dosage
- Colforsin/pharmacology
- Cyclic AMP/analogs & derivatives
- Cyclic AMP/pharmacology
- Dose-Response Relationship, Drug
- Drug Synergism
- Female
- Guanylate Cyclase/pharmacology
- Male
- Muscle, Smooth/drug effects
- Muscle, Smooth/physiology
- NG-Nitroarginine Methyl Ester/pharmacology
- Neurons, Afferent/drug effects
- Neurons, Afferent/physiology
- Neuropeptide Y/physiology
- Neuropeptides/antagonists & inhibitors
- Neuropeptides/pharmacology
- Nitric Oxide Synthase/pharmacology
- Oxadiazoles/pharmacology
- Peptide Fragments/antagonists & inhibitors
- Peptide Fragments/pharmacology
- Pituitary Adenylate Cyclase-Activating Polypeptide
- Potassium Channels, Calcium-Activated/physiology
- Quinoxalines/pharmacology
- Receptors, Calcitonin Gene-Related Peptide
- Receptors, Peptide/antagonists & inhibitors
- Receptors, Peptide/drug effects
- Receptors, Vasoactive Intestinal Peptide/physiology
- Rolipram/antagonists & inhibitors
- Rolipram/pharmacology
- Sensory Receptor Cells/physiology
- Swine
- Tetraethylammonium/administration & dosage
- Ureter/cytology
- Ureter/drug effects
- Ureter/injuries
- Vasoactive Intestinal Peptide/antagonists & inhibitors
- Vasoactive Intestinal Peptide/pharmacology
- omega-Conotoxin GVIA/pharmacology
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Affiliation(s)
- Medardo Hernández
- Departamento de Fisiología, Facultad de Farmacia, UCM, 28040-Madrid, Spain.
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Templeman L, Sellers DJ, Chapple CR, Rosario DJ, Hay DPW, Chess-Williams R. Investigation of neurokinin-2 and -3 receptors in the human and pig bladder. BJU Int 2003; 92:787-92. [PMID: 14616468 DOI: 10.1046/j.1464-410x.2003.04458.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the role of neurokinin (NK)-2 and -3 receptors in mediating the contraction of detrusor muscle strips from human and pig, to determine whether the pig is a good model for the study of tachykinin receptors in the human bladder, as the biological actions of tachykinins, e.g. substance P and NKA are mediated via three distinct receptor subtypes, NK-1, -2 and -3. MATERIALS AND METHODS Strips of detrusor muscle were obtained from the bladder dome and neck of female pigs and from patients undergoing cystectomy. Cumulative concentration-response curves to NKA were obtained in the absence and presence of either the NK-2 receptor-selective antagonist SR48968 or the NK-3 receptor-selective antagonist SB223412. RESULTS NKA produced concentration-dependent contractions in the human and pig detrusor muscle; the curves were shifted to the right by SR48968, with high affinity (pKB 8.9, 8.3 and 8.0 in the human, pig dome and pig neck, respectively), whereas SB223412 had a minimal effect (pKB 5.8, 5.8 and 6.3, respectively). CONCLUSION These data confirm that the NK-2 receptor subtype mediates NKA-induced contraction of the human and pig detrusor muscle. The NK-3 receptor appears to have no role in detrusor contraction of either species. The results also provide evidence that the NK-2 receptor in human and pig are the same, and the latter may be an appropriate species to study tachykinin-induced contractions in human bladder.
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Affiliation(s)
- L Templeman
- Department of Biomedical Science, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
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