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Jin C, Cherian RM, Liu J, Playà-Albinyana H, Galli C, Karlsson NG, Breimer ME, Holgersson J. Identification by mass spectrometry and immunoblotting of xenogeneic antigens in the N- and O-glycomes of porcine, bovine and equine heart tissues. Glycoconj J 2020; 37:485-498. [PMID: 32542517 PMCID: PMC7329767 DOI: 10.1007/s10719-020-09931-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/06/2020] [Accepted: 06/04/2020] [Indexed: 12/11/2022]
Abstract
Animal bioprosthetic heart valves (BHV) are used to replace defective valves in patients with valvular heart disease. Especially young BHV recipients may experience a structural valve deterioration caused by an immune reaction in which α-Gal and Neu5Gc are potential target antigens. The expression of these and other carbohydrate antigens in animal tissues used for production of BHV was explored. Protein lysates of porcine aortic and pulmonary valves, and porcine, bovine and equine pericardia were analyzed by Western blotting using anti-carbohydrate antibodies and lectins. N-glycans were released by PNGase F digestion and O-glycans by β-elimination. Released oligosaccharides were analyzed by liquid chromatography – tandem mass spectrometry. In total, 102 N-glycans and 40 O-glycans were identified in animal heart tissue lysates. The N- and O-glycan patterns were different between species. α-Gal and Neu5Gc were identified on both N- and O-linked glycans, N,N´-diacetyllactosamine (LacdiNAc) on N-glycans only and sulfated O-glycans. The relative amounts of α-Gal-containing N-glycans were higher in bovine compared to equine and porcine pericardia. In contrast to the restricted number of proteins carrying α-Gal and LacdiNAc, the distribution of proteins carrying Neu5Gc-determinants varied between species and between different tissues of the same species. Porcine pericardium carried the highest level of Neu5Gc-sialylated O-glycans, and bovine pericardium the highest level of Neu5Gc-sialylated N-glycans. The identified N- and O-linked glycans, some of which may be immunogenic and remain in BHVs manufactured for clinical use, could direct future genetic engineering to prevent glycan expression rendering the donor tissues less immunogenic in humans.
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Affiliation(s)
- Chunsheng Jin
- Department of Medical Biochemistry, Institute of Biomedicine Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Reeja Maria Cherian
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Jining Liu
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Heribert Playà-Albinyana
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Biochemistry and Biotechnology, Faculty of Chemistry, Rovira i Virgili University, Tarragona, Spain
| | - Cesare Galli
- Avantea Laboratory of Reproductive Technologies, Cremona, Italy.,Avantea Foundation, Cremona, Italy
| | - Niclas G Karlsson
- Department of Medical Biochemistry, Institute of Biomedicine Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael E Breimer
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Jan Holgersson
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Recombinant Mucin-Type Fusion Proteins with a Galα1,3Gal Substitution as Clostridium difficile Toxin A Inhibitors. Infect Immun 2016; 84:2842-52. [PMID: 27456831 DOI: 10.1128/iai.00341-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/18/2016] [Indexed: 02/04/2023] Open
Abstract
The capability of a recombinant mucin-like fusion protein, P-selectin glycoprotein ligand-1/mouse IgG2b (PSGL-1/mIgG2b), carrying Galα1,3Galβ1,4GlcNAc determinants to bind and inhibit Clostridium difficile toxin A (TcdA) was investigated. The fusion protein, produced by a glyco-engineered stable CHO-K1 cell line and designated C-PGC2, was purified by affinity and gel filtration chromatography from large-scale cultures. Liquid chromatography-mass spectrometry was used to characterize O-glycans released by reductive β-elimination, and new diagnostic ions to distinguish Galα1,3Gal- from Galα1,4Gal-terminated O-glycans were identified. The C-PGC2 cell line, which was 20-fold more sensitive to TcdA than the wild-type CHO-K1, is proposed as a novel cell-based model for TcdA cytotoxicity and neutralization assays. The C-PGC2-produced fusion protein could competitively inhibit TcdA binding to rabbit erythrocytes, making it a high-efficiency inhibitor of the hemagglutination property of TcdA. The fusion protein also exhibited a moderate capability for neutralization of TcdA cytotoxicity in both C-PGC2 and CHO-K1 cells, the former with and the latter without cell surface Galα1,3Galβ1,4GlcNAc sequences. Future studies in animal models of C. difficile infection will reveal its TcdA-inhibitory effect and therapeutic potential in C. difficile-associated diseases.
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An J, Dėdinaitė A, Nilsson A, Holgersson J, Claesson PM. Comparison of a Brush-with-Anchor and a Train-of-Brushes Mucin on Poly(methyl methacrylate) Surfaces: Adsorption, Surface Forces, and Friction. Biomacromolecules 2014; 15:1515-25. [DOI: 10.1021/bm500173s] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Junxue An
- School
of Chemical Science and Engineering, Department of Chemistry, Division
of Surface and Corrosion Science, KTH Royal Institute of Technology, Drottning Kristinas väg 51, SE-100 44 Stockholm, Sweden
| | - Andra Dėdinaitė
- School
of Chemical Science and Engineering, Department of Chemistry, Division
of Surface and Corrosion Science, KTH Royal Institute of Technology, Drottning Kristinas väg 51, SE-100 44 Stockholm, Sweden
- Chemistry,
Materials and Surfaces, SP Technical Research Institute of Sweden, P. O. Box 5607, SE-114 86 Stockholm, Sweden
| | - Anki Nilsson
- Recopharma
AB, Arvid Wallgrens backe 20, 413 46 Gothenburg, Sweden
| | - Jan Holgersson
- Department
of Clinical Chemistry and Transfusion Medicine, The Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Vita stråket
13, SE-413 45 Gothenburg, Sweden
| | - Per M. Claesson
- School
of Chemical Science and Engineering, Department of Chemistry, Division
of Surface and Corrosion Science, KTH Royal Institute of Technology, Drottning Kristinas väg 51, SE-100 44 Stockholm, Sweden
- Chemistry,
Materials and Surfaces, SP Technical Research Institute of Sweden, P. O. Box 5607, SE-114 86 Stockholm, Sweden
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Maria Cherian R, Gaunitz S, Nilsson A, Liu J, Karlsson NG, Holgersson J. Shiga-like toxin binds with high avidity to multivalent O-linked blood group P1 determinants on mucin-type fusion proteins. Glycobiology 2013; 24:26-38. [DOI: 10.1093/glycob/cwt086] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Gustafsson A, Holgersson J. A new generation of carbohydrate-based therapeutics: recombinant mucin-type fusion proteins as versatile inhibitors of protein-carbohydrate interactions. Expert Opin Drug Discov 2013; 1:161-78. [PMID: 23495799 DOI: 10.1517/17460441.1.2.161] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cell surface carbohydrates are essential for a multitude of biomedically important interactions that take place at the cell surface. Carbohydrate-binding proteins are, therefore, significant targets for the development of carbohydrate-based inhibitors. Due to their multivalent character, monovalent low-molecular-weight sugar homologues or analogues are usually poor inhibitors of these interactions. Recent advances in organic and chemoenzymatic synthesis of carbohydrates will undoubtedly increase the pace by which new multivalent carbohydrate-based drugs are developed. Knowledge gained on the glycosyltransferases that are involved in glycan biosynthesis can be used to engineer host cells for recombinant production of proteins with tailored glycan substitution. In particular, recombinant mucin-type proteins can serve as natural scaffolds for multivalent presentation of therapeutic carbohydrate determinants.
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Affiliation(s)
- Anki Gustafsson
- Karolinska Institute, Karolinska University Hospital, Division of Clinical Immunology, F-79, S-141 86 Stockholm, Sweden.
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Skoog EC, Sjöling Å, Navabi N, Holgersson J, Lundin SB, Lindén SK. Human gastric mucins differently regulate Helicobacter pylori proliferation, gene expression and interactions with host cells. PLoS One 2012; 7:e36378. [PMID: 22563496 PMCID: PMC3341350 DOI: 10.1371/journal.pone.0036378] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 04/02/2012] [Indexed: 12/13/2022] Open
Abstract
Helicobacter pylori colonizes the mucus niche of the gastric mucosa and is a risk factor for gastritis, ulcers and cancer. The main components of the mucus layer are heavily glycosylated mucins, to which H. pylori can adhere. Mucin glycosylation differs between individuals and changes during disease. Here we have examined the H. pylori response to purified mucins from a range of tumor and normal human gastric tissue samples. Our results demonstrate that mucins from different individuals differ in how they modulate both proliferation and gene expression of H. pylori. The mucin effect on proliferation varied significantly between samples, and ranged from stimulatory to inhibitory, depending on the type of mucins and the ability of the mucins to bind to H. pylori. Tumor-derived mucins and mucins from the surface mucosa had potential to stimulate proliferation, while gland-derived mucins tended to inhibit proliferation and mucins from healthy uninfected individuals showed little effect. Artificial glycoconjugates containing H. pylori ligands also modulated H. pylori proliferation, albeit to a lesser degree than human mucins. Expression of genes important for the pathogenicity of H. pylori (babA, sabA, cagA, flaA and ureA) appeared co-regulated in response to mucins. The addition of mucins to co-cultures of H. pylori and gastric epithelial cells protected the viability of the cells and modulated the cytokine production in a manner that differed between individuals, was partially dependent of adhesion of H. pylori to the gastric cells, but also revealed that other mucin factors in addition to adhesion are important for H. pylori-induced host signaling. The combined data reveal host-specific effects on proliferation, gene expression and virulence of H. pylori due to the gastric mucin environment, demonstrating a dynamic interplay between the bacterium and its host.
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Affiliation(s)
- Emma C. Skoog
- Mucosal Immunobiology and Vaccine Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Biomedical Chemistry and Cell Biology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Åsa Sjöling
- Mucosal Immunobiology and Vaccine Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Microbiology and Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nazanin Navabi
- Mucosal Immunobiology and Vaccine Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Biomedical Chemistry and Cell Biology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Holgersson
- Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Samuel B. Lundin
- Mucosal Immunobiology and Vaccine Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Microbiology and Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sara K. Lindén
- Mucosal Immunobiology and Vaccine Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Biomedical Chemistry and Cell Biology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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Diswall M, Gustafsson A, Holgersson J, Sandrin MS, Breimer ME. Antigen-binding specificity of anti-αGal reagents determined by solid-phase glycolipid-binding assays. A complete lack of αGal glycolipid reactivity in α1,3GalT-KO pig small intestine. Xenotransplantation 2011; 18:28-39. [PMID: 21342285 DOI: 10.1111/j.1399-3089.2011.00623.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND αGal-specific lectins, monoclonal and polyclonal antibodies (Abs) are widely used in xenotransplantation research. Immunological assays such as immunohistochemistry, flow cytometry, Western blot and thin layer chromatography are often the only applicable characterization procedures when limited amount of tissue is available and biochemical characterization is impossible. Hence, detailed knowledge of the Ab/lectin carbohydrate-binding specificity is essential. METHODS The binding specificity of human blood group AB serum, three different affinity-purified human polyclonal anti-Gal Ab batches, and two anti-Gal mAb clones (TH5 and 15.101) as well as Griffonia simplicifolia isolectin B4 and Marasmius oreades agglutinin were examined for reactivity with glycolipid fractions isolated from human and pig (wild-type and α1,3GalT-KO) tissues using thin layer chromatogram and microtiter well binding assays. RESULTS All anti-Gal-specific reagents reacted with the pentaglycosylceramide Galα1,3nLc4, and several 6-12 sugar compounds in wild-type pig kidneys. However, their staining intensity with different αGal antigens varied considerably. Some, but not all, anti-Gal reagents cross-reacted with a pure iGb3 glycolipid reference compound. No reactivity with glycolipids isolated from α1,3GalT-KO pig small intestine or human tissues was found, confirming the specificity of the anti-Gal reagents in those tissues for α1,3Gal-epitopes produced by the α1,3GalT (GGTA1). CONCLUSIONS Different anti-Gal reagents vary in their carbohydrate epitope specificity. Mono-/polyclonal Abs and lectins have different carbohydrate epitope fine specificity toward pig glycolipids as well as purified Galα1,3nLc4, and iGb3. Despite the difference in αGal specificity, all reagents were completely non-reactive with glycolipids isolated from α1,3GalT-KO pig small intestine.
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Affiliation(s)
- Mette Diswall
- Department of Surgery, Sahlgrenska Academy at Gothenburg University, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Fischer-Lougheed J, Gregory C, White Z, Shulkin I, Gunthart M, Kearns-Jonker M. Identification of an anti-idiotypic antibody that defines a B-cell subset(s) producing xenoantibodies in primates. Immunology 2007; 123:390-7. [PMID: 17916162 DOI: 10.1111/j.1365-2567.2007.02704.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Synthetic anti-idiotypic antibodies represent a potentially valuable tool for the isolation and characterization of B cells that produce xenoantibodies. An anti-idiotypic antibody that binds to a subset of B cells producing antibodies encoded by the variable-region heavy chain 3 (V(H)3) germline genes DP35 [immunoglobulin variable-region heavy chain 3-11 (IGHV3-11)], DP-53 and DP-54 plus a small number of V(H)4 gene-encoded antibodies in humans has recently been identified. These germline progenitors also encode xenoantibodies in humans. We tested whether the small, clearly defined group of B cells identified with this anti-idiotypic antibody produce xenoantibodies in non-human primates mounting active immune responses to porcine xenografts. Peripheral blood B cells were sorted by flow cytometry on the basis of phenotype, and cDNA libraries were prepared from each of these sorted groups of cells. Immunoglobulin V(H) gene libraries were prepared from the sorted cells, and the V(H) genes expressed in each of the sorted groups were identified by nucleic acid sequencing. Our results indicate that xenoantibody-producing peripheral blood B cells, defined on the basis of binding to fluorescein isothiocyanate (FITC)-conjugated galactose alpha(1,3) galactose-bovine serum albumin (Gal-BSA) and the anti-idiotypic antibody 2G10, used the IGHV3-11 germline gene to encode xenoantibodies and were phenotypically CD11b+ (Mac-1+) and CD5-. This novel reagent may be used in numerous applications including definition of xenoantibody-producing B-cell subsets in humans and non-human primates and immunosuppression by depletion of B cells producing anti-Gal xenoantibodies.
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Affiliation(s)
- Jacqueline Fischer-Lougheed
- Department of Cardiothoracic Surgery, Saban Research Institute of the Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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9
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Holgersson J, Löfling J. Glycosyltransferases involved in type 1 chain and Lewis antigen biosynthesis exhibit glycan and core chain specificity. Glycobiology 2006; 16:584-93. [PMID: 16484342 DOI: 10.1093/glycob/cwj090] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Sialyl Lewis A (SLe(a)), Lewis A (Le(a)), and Lewis B (Le(b)) have been studied in many different biological contexts, for example in microbial adhesion and cancer. Their biosynthesis is complex and involves beta1,3-galactosyltransferases (beta3Gal-Ts) and a combined action of alpha2- and/or alpha4-fucosyltransferases (Fuc-Ts). Further, O-glycans with different core structures have been identified, and the ability of beta3Gal-Ts and Fuc-Ts to use these as substrates has not been resolved. Therefore, to examine the in vivo specificity of enzymes involved in SLe(a), Le(a), and Le(b) synthesis, we have transiently transfected CHO-K1 cells with relevant human glycosyltransferases and, on secreted reporter proteins, detected the resulting Lewis antigens on N- and O-linked glycans using western blotting and Le-specific antibodies. beta3Gal-T1, -T2, and -T5 could synthesize type 1 chains on N-linked glycans, but only beta3Gal-T5 worked on O-linked glycans. The latter enzyme could use both core 2 and core 3 precursor structures. Furthermore, the specificity of FUT5 and FUT3 in Le(a) and Le(b) synthesis was different, with FUT5 fucosylating H type 1 only on core 2, but FUT3 fucosylating H type 1 much more efficient on core 3 than on core 2. Finally, FUT1 and FUT2 were both found to direct alpha2-fucosylation on type 1 chains on both N- and O-linked structures. This knowledge enables us to engineer recombinant glycoproteins with glycan- and core chain-specific Lewis antigen substitution. Such tools will be important for investigations on the fine carbohydrate specificity of Le(b)-binding lectins, such as Helicobacter pylori adhesins and DC-SIGN, and may also prove useful as therapeutics.
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Affiliation(s)
- Jan Holgersson
- Division of Clinical Immunology, Karolinska Institutet, Karolinska University Hospital, Huddinge, S-141 86 Stockholm, Sweden
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Holgersson J, Gustafsson A, Breimer ME. Characteristics of protein-carbohydrate interactions as a basis for developing novel carbohydrate-based antirejection therapies. Immunol Cell Biol 2005; 83:694-708. [PMID: 16266322 DOI: 10.1111/j.1440-1711.2005.01373.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The relative shortage of human organs for transplantation is today the major barrier to a broader use of transplantation as a means of treating patients with end-stage organ failure. This barrier could be partly overcome by an increased use of blood group ABO-incompatible live donors, and such trials are currently underway at several transplant centres. If xenotransplantation can be used clinically in the future, the human organ shortage will, in principle, be eradicated. In both these cases, carbohydrate antigens and the corresponding anti-carbohydrate antibodies are the major primary immunological barriers to overcome. Refined carbohydrate-based therapeutics may permit an increased number of ABO-incompatible transplantations to be carried out, and may remove the initial barriers to clinical xenotransplantation. Here, we will discuss the chemical characteristics of protein-carbohydrate interactions and outline carbohydrate-based antirejection therapies as used today in experimental as well as in clinical settings. Novel mucin-based adsorbers of natural anti-carbohydrate antibodies will also be described.
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Affiliation(s)
- Jan Holgersson
- Division of Clinical Immunology, Karolinska Institute, Karolinska University Hospital at Huddinge, Stockholm, Sweden
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Liu J, Gustafsson A, Breimer ME, Kussak A, Holgersson J. Anti-pig antibody adsorption efficacy of {alpha}-Gal carrying recombinant P-selectin glycoprotein ligand-1/immunoglobulin chimeras increases with core 2 {beta}1, 6-N-acetylglucosaminyltransferase expression. Glycobiology 2004; 15:571-83. [PMID: 15625182 DOI: 10.1093/glycob/cwi037] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We have previously described the construction of a P-selectin glycoprotein ligand-1-mouse immunoglobulin Fc fusion protein, which when transiently coexpressed with the porcine alpha1,3 galactosyltransferase in COS cells becomes a very efficient adsorber of xenoreactive, anti-pig antibodies. To relate the adsorption capacity with the glycan expression of individual fusion proteins produced in different cell lines, stable CHO-K1, COS, and 293T cells producing this fusion protein have been engineered. On alpha1,3 galactosyltransferase coexpression, high-affinity adsorbers were produced by both COS and 293T cells, whereas an adsorber of lower affinity was derived from CHO-K1 cells. Stable coexpression of a core 2 beta1,6 N-acetylglucosaminyltransferase in CHO-K1 cells led to increased alpha-Gal epitope density and improved anti-pig antibody adsorption efficacy. ESI-MS/MS of O-glycans released from PSGL-1/mIgG(2b) produced in an alpha1,3 galactosyl- and core 2 beta1,6 N-acetylglucosaminyltransferase expressing CHO-K1 cell clone revealed a number of structures with carbohydrate sequences consistent with terminal Gal-Gal. In contrast, no O-glycan structures with terminal Gal-Gal were identified on the fusion protein when expressed alone or in combination with the alpha1,3 galactosyltransferase in CHO-K1 cells. In conclusion, the density of alpha-Gal epitopes on PSGL-1/mIgG(2b) was dependent on the expression of O-linked glycans with core 2 structures and lactosamine extensions. The structural complexity of the terminal Gal-Gal expressing O-glycans with both neutral as well as sialic acid-containing structures is likely to contribute to the high adsorption efficacy.
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Affiliation(s)
- Jining Liu
- Division of Clinical Immunology, Karolinska Institutet, Karolinska University Hospital, S-141 86 Stockholm, Sweden
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