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Li Y, Feng Q, Wang L, Gao X, Xi Y, Ye L, Ji J, Yang X, Zhai G. Current targeting strategies and advanced nanoplatforms for atherosclerosis therapy. J Drug Target 2024; 32:128-147. [PMID: 38217526 DOI: 10.1080/1061186x.2023.2300694] [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: 09/16/2023] [Accepted: 12/24/2023] [Indexed: 01/15/2024]
Abstract
Atherosclerosis is one of the major causes of death worldwide, and it is closely related to many cardiovascular diseases, such as stroke, myocardial infraction and angina. Although traditional surgical and pharmacological interventions can effectively retard or slow down the progression of atherosclerosis, it is very difficult to prevent or even reverse this disease. In recent years, with the rapid development of nanotechnology, various nanoagents have been designed and applied to different diseases including atherosclerosis. The unique atherosclerotic microenvironment with signature biological components allows nanoplatforms to distinguish atherosclerotic lesions from normal tissue and to approach plaques specifically. Based on the process of atherosclerotic plaque formation, this review summarises the nanodrug delivery strategies for atherosclerotic therapy, trying to provide help for researchers to understand the existing atherosclerosis management approaches as well as challenges and to reasonably design anti-atherosclerotic nanoplatforms.
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Affiliation(s)
- Yingchao Li
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Qixiang Feng
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Luyue Wang
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Xi Gao
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Yanwei Xi
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Lei Ye
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Jianbo Ji
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Xiaoye Yang
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
| | - Guangxi Zhai
- Department of Pharmaceutics, Shandong University, Jinan, Shandong, P.R. China
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Liang L, Deng Y, Ao Z, Liao C, Tian J, Li C, Yu X. Recent progress in biomimetic nanomedicines based on versatile targeting strategy for atherosclerosis therapy. J Drug Target 2024:1-18. [PMID: 38656224 DOI: 10.1080/1061186x.2024.2347353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/18/2024] [Indexed: 04/26/2024]
Abstract
Atherosclerosis (AS) is considered to be one of the major causes of cardiovascular disease. Its pathological microenvironment is characterised by increased production of reactive oxygen species, lipid oxides, and excessive inflammatory factors, which accumulate at the monolayer endothelial cells in the vascular wall to form AS plaques. Therefore, intervention in the pathological microenvironment would be beneficial in delaying AS. Researchers have designed biomimetic nanomedicines with excellent biocompatibility and the ability to avoid being cleared by the immune system through different therapeutic strategies to achieve better therapeutic effects for the characteristics of AS. Biomimetic nanomedicines can further enhance delivery efficiency and improve treatment efficacy due to their good biocompatibility and ability to evade clearance by the immune system. Biomimetic nanomedicines based on therapeutic strategies such as neutralising inflammatory factors, ROS scavengers, lipid clearance and integration of diagnosis and treatment are versatile approaches for effective treatment of AS. The review firstly summarises the targeting therapeutic strategy of biomimetic nanomedicine for AS in recent 5 years. Biomimetic nanomedicines using cell membranes, proteins, and extracellular vesicles as carriers have been developed for AS.
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Affiliation(s)
- Lijuan Liang
- Department of Pharmacy, Hejiang County People's Hospital, Luzhou, Sichuan, China
| | - Yiping Deng
- Analysis and Testing Center, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
| | - Zuojin Ao
- Analysis and Testing Center, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
| | - Changli Liao
- Science and Technology Department, Southwest Medical University, Luzhou, Sichuan, China
| | - Ji Tian
- Analysis and Testing Center, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
| | - Chunhong Li
- Department of Pharmaceutical Sciences, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
| | - Xin Yu
- Chinese Pharmacy Laboratory, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
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Kamilar E, Bariwal J, Zheng W, Ma H, Liang H. SMALPs Are Not Simply Nanodiscs: The Polymer-to-Lipid Ratios of Fractionated SMALPs Underline Their Heterogeneous Nature. Biomacromolecules 2023; 24:1819-1838. [PMID: 36947865 DOI: 10.1021/acs.biomac.3c00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Amphipathic styrene-maleic acid (SMA) copolymers directly solubilize biomembranes into SMA-lipid particles, or SMALPs, that are often regarded as nanodiscs and hailed as a native membrane platform. The promising outlook of SMALPs inspires the discovery of many SMA-like copolymers that also solubilize biomembranes into putative nanodiscs, but a fundamental question remains on how much the SMALPs or SMALP analogues truly resemble the bilayer structure of nanodiscs. This unfortunate ambiguity undermines the utility of SMA or SMA-like copolymers in membrane biology because the structure and function of many membrane proteins depend critically on their surrounding matrices. Here, we report the structural heterogeneity of SMALPs revealed through fractionating SMALPs comprised of lipids and well-defined SMAs via size-exclusion chromatography followed by quantitative determination of the polymer-to-lipid (P/L) stoichiometric ratios in individual fractions. Through the lens of P/L stoichiometric ratios, different self-assembled polymer-lipid nanostructures are inferred, such as polymer-remodeled liposomes, polymer-encased nanodiscs, polymer-lipid mixed micelles, and lipid-doped polymer micellar aggregates. We attribute the structural heterogeneity of SMALPs to the microstructure variations amongst individual polymer chains that give rise to their polydisperse detergency. As an example, we demonstrate that SMAs with a similar S/MA ratio but different chain sizes participate preferentially in different polymer-lipid nanostructures. We further demonstrate that proteorhodopsin, a light-driven proton pump solubilized within the same SMALPs is distributed amongst different self-assembled nanostructures to display different photocycle kinetics. Our discovery challenges the native nanodisc notion of SMALPs or SMALP analogues and highlights the necessity to separate and identify the structurally dissimilar polymer-lipid particles in membrane biology studies.
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Affiliation(s)
- Elizabeth Kamilar
- Department of Cell Physiology & Molecular Biophysics, Center for Membrane Protein Research, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, United States
| | - Jitender Bariwal
- Department of Cell Physiology & Molecular Biophysics, Center for Membrane Protein Research, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, United States
| | - Wan Zheng
- Department of Cell Physiology & Molecular Biophysics, Center for Membrane Protein Research, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, United States
| | - Hairong Ma
- Department of Cell Physiology & Molecular Biophysics, Center for Membrane Protein Research, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, United States
| | - Hongjun Liang
- Department of Cell Physiology & Molecular Biophysics, Center for Membrane Protein Research, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, United States
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Han S, Mei L, Quach T, Porter C, Trevaskis N. Lipophilic Conjugates of Drugs: A Tool to Improve Drug Pharmacokinetic and Therapeutic Profiles. Pharm Res 2021; 38:1497-1518. [PMID: 34463935 DOI: 10.1007/s11095-021-03093-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/05/2021] [Indexed: 01/19/2023]
Abstract
Lipophilic conjugates (LCs) of small molecule drugs have been used widely in clinical and pre-clinical studies to achieve a number of pharmacokinetic and therapeutic benefits. For example, lipophilic derivatives of drugs are employed in several long acting injectable products to provide sustained drug exposure for hormone replacement therapy and to treat conditions such as neuropsychiatric diseases. LCs can also be used to modulate drug metabolism, and to enhance drug permeation across membranes, either by increasing lipophilicity to enhance passive diffusion or by increasing protein-mediated active transport. Furthermore, such conjugation strategies have been employed to promote drug association with endogenous macromolecular carriers (e.g. albumin and lipoproteins), and this in turn results in altered drug distribution and pharmacokinetic profiles, where the changes can be 'general' (e.g. prolonged plasma half-life) or 'specific' (e.g. enhanced delivery to specific tissues in parallel with the macromolecular carriers). Another utility of LCs is to enhance the encapsulation of drugs within engineered nanoscale drug delivery systems, in order to best take advantage of the targeting and pharmacokinetic benefits of nanomedicines. The current review provides a summary of the mechanisms by which lipophilic conjugates, including in combination with delivery vehicles, can be used to control drug delivery, distribution and therapeutic profiles. The article is structured into sections which highlight a specific benefit of LCs and then demonstrate this benefit with case studies. The review attempts to provide a toolbox to assist researchers to design and optimise drug candidates, including consideration of drug-formulation compatibility.
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Affiliation(s)
- Sifei Han
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia.
- Suzhou Institute of Drug Innovation, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Suzhou, Jiangsu, 215123, China.
| | - Lianghe Mei
- Suzhou Institute of Drug Innovation, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Suzhou, Jiangsu, 215123, China
| | - Tim Quach
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- PureTech Health, 6 Tide Street, Boston, MA, 02210, USA
| | - Chris Porter
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Natalie Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia.
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Morin EE, Guo Y, He H, Yuan W, Souery WN, Fawaz MV, Chen YE, Schwendeman A. Synergetic Effect of rHDL and LXR Agonist on Reduction of Atherosclerosis in Mice. Front Pharmacol 2021; 11:513031. [PMID: 33390931 PMCID: PMC7772318 DOI: 10.3389/fphar.2020.513031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 10/19/2020] [Indexed: 12/12/2022] Open
Abstract
High-density lipoproteins (HDLs) are unique in that they play an important role in the reverse cholesterol transport process. However, reconstituted HDL (rHDL) infusions have demonstrated limited beneficial effect in clinical practice. This is perhaps a consequence of the limited cholesterol efflux abilities of atheroma macrophages due to decreased expression of cholesterol transporters in advanced atheromas and following rHDL infusion treatment. Thus, we propose that a combination therapy of rHDL and a liver X receptor (LXR) agonist could maximize the therapeutic benefit of rHDL by upregulating ATP-binding cassette transporters A-1 (ABCA1) and ATP-binding cassette transporter G-1 (ABCG1), and enhancing cholesterol efflux to rHDL. In macrophages, rHDL downregulated the expression of ABCA1/G1 in a dose- and rHDL composition-dependent manner. Although LXR agonist, T0901317 (T1317), upregulated the expression of ABCA1 and ABCG1, the drug itself did not have any effect on cholesterol efflux (6.6 ± 0.5%) while the combination of rHDL and T1317 exhibited enhanced cholesterol efflux from [3H]-cholesterol loaded J774A.1 macrophages (23.3 ± 1.3%). Treatment with rHDL + T1317 significantly reduced the area of aortic plaque in ApoE-/- mice compared to PBS treated control animals (24.16 ± 1.42% vs. 31.59 ± 1.93%, p < 0.001), while neither rHDL nor T1317 treatment alone had a significant effect. Together, we show that rHDL paired with an LXR agonist can induce a synergetic effect in reducing atheroma burden. This synergy could lead to lower overall effective dose for both drugs, potentially overcoming the existing barriers in clinical development and renewing pharmaceutical interest in these two drug classes.
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Affiliation(s)
- Emily E Morin
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Yanhong Guo
- Department of Internal Medicine, University of Michigan, NCRC, Ann Arbor, MI, United States
| | - Hongliang He
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Wenmin Yuan
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Whitney N Souery
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Maria V Fawaz
- Department of Medicinal Chemistry, University of Michigan, Ann Arbor, MI, United States
| | - Yuqing Eugene Chen
- Department of Internal Medicine, University of Michigan, NCRC, Ann Arbor, MI, United States
| | - Anna Schwendeman
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, MI, United States.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States
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Pedersbæk D, Kræmer MK, Kempen PJ, Ashley J, Braesch-Andersen S, Andresen TL, Simonsen JB. The Composition of Reconstituted High-Density Lipoproteins (rHDL) Dictates the Degree of rHDL Cargo- and Size-Remodeling via Direct Interactions with Endogenous Lipoproteins. Bioconjug Chem 2019; 30:2634-2646. [PMID: 31487985 DOI: 10.1021/acs.bioconjchem.9b00552] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The application of reconstituted high-density lipoproteins (rHDL) as a drug-carrier has during the past decade been established as a promising approach for effective receptor-mediated drug delivery, and its ability to target tumors has recently been confirmed in a clinical trial. The rHDL mimics the endogenous HDL, which is known to be highly dynamic and undergo extensive enzyme-mediated remodulations. Hence, to reveal the physiological rHDL stability, a thorough characterization of the dynamics of rHDL in biologically relevant environments is needed. We employ a size-exclusion chromatography (SEC) method to evaluate the dynamics of discoidal rHDL in fetal bovine serum (FBS), where we track both the rHDL lipids (by the fluorescence from lipid-conjugated fluorophores) and apoA-I (by human apoA-I ELISA). We show by using lipoprotein depleted FBS and isolated lipoproteins that rHDL lipids can be transferred to endogenous lipoproteins via direct interactions in a nonenzymatic process, resulting in rHDL compositional- and size-remodeling. This type of dynamics could lead to misinterpretations of fluorescence-based rHDL uptake studies due to desorption of labile lipophilic fluorophores or off-target side effects due to desorption of incorporated drugs. Importantly, we show how the degree of rHDL remodeling can be controlled by the compositional design of the rHDL. Understanding the correlation between the molecular properties of the rHDL constituents and their collective dynamics is essential for improving the rHDL-based drug delivery platform. Taken together, our work highlights the need to carefully consider the compositional design of rHDL and test its stability in a biological relevant environment, when developing rHDL for drug delivery purposes.
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Affiliation(s)
- Dennis Pedersbæk
- Technical University of Denmark , Department of Health Technology , 2800 Kongens Lyngby , Denmark
| | - Martin Kisha Kræmer
- Technical University of Denmark , Department of Health Technology , 2800 Kongens Lyngby , Denmark
| | - Paul Joseph Kempen
- Technical University of Denmark , Department of Health Technology , 2800 Kongens Lyngby , Denmark
| | - Jon Ashley
- Technical University of Denmark , Department of Health Technology , 2800 Kongens Lyngby , Denmark
| | | | - Thomas L Andresen
- Technical University of Denmark , Department of Health Technology , 2800 Kongens Lyngby , Denmark
| | - Jens B Simonsen
- Technical University of Denmark , Department of Health Technology , 2800 Kongens Lyngby , Denmark
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7
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Jiang C, Zhao Y, Yang Y, He J, Zhang W, Liu J. Evaluation of the Combined Effect of Recombinant High-Density Lipoprotein Carrier and the Encapsulated Lovastatin in RAW264.7 Macrophage Cells Based on the Median-Effect Principle. Mol Pharm 2018; 15:1017-1027. [DOI: 10.1021/acs.molpharmaceut.7b00923] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Cuiping Jiang
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210008, PR China
| | - Yi Zhao
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210008, PR China
| | - Yun Yang
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210008, PR China
| | - Jianhua He
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210008, PR China
| | - Wenli Zhang
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210008, PR China
| | - Jianping Liu
- Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210008, PR China
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8
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Wang W, Chen K, Su Y, Zhang J, Li M, Zhou J. Lysosome-Independent Intracellular Drug/Gene Codelivery by Lipoprotein-Derived Nanovector for Synergistic Apoptosis-Inducing Cancer-Targeted Therapy. Biomacromolecules 2018; 19:438-448. [DOI: 10.1021/acs.biomac.7b01549] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Wei Wang
- State Key Laboratory of Natural
Medicines, Department of Pharmaceutics, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Kerong Chen
- State Key Laboratory of Natural
Medicines, Department of Pharmaceutics, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Yujie Su
- State Key Laboratory of Natural
Medicines, Department of Pharmaceutics, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Jielei Zhang
- State Key Laboratory of Natural
Medicines, Department of Pharmaceutics, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Min Li
- State Key Laboratory of Natural
Medicines, Department of Pharmaceutics, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
| | - Jianping Zhou
- State Key Laboratory of Natural
Medicines, Department of Pharmaceutics, China Pharmaceutical University, 24 Tongjiaxiang, Nanjing 210009, China
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Mahmoudi M, Yu M, Serpooshan V, Wu JC, Langer R, Lee RT, Karp JM, Farokhzad OC. Multiscale technologies for treatment of ischemic cardiomyopathy. NATURE NANOTECHNOLOGY 2017; 12:845-855. [PMID: 28875984 PMCID: PMC5717755 DOI: 10.1038/nnano.2017.167] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 07/13/2017] [Indexed: 05/02/2023]
Abstract
The adult mammalian heart possesses only limited capacity for innate regeneration and the response to severe injury is dominated by the formation of scar tissue. Current therapy to replace damaged cardiac tissue is limited to cardiac transplantation and thus many patients suffer progressive decay in the heart's pumping capacity to the point of heart failure. Nanostructured systems have the potential to revolutionize both preventive and therapeutic approaches for treating cardiovascular disease. Here, we outline recent advancements in nanotechnology that could be exploited to overcome the major obstacles in the prevention of and therapy for heart disease. We also discuss emerging trends in nanotechnology affecting the cardiovascular field that may offer new hope for patients suffering massive heart attacks.
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Affiliation(s)
- Morteza Mahmoudi
- Center for Nanomedicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Nanotechnology Research Center, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 13169-43551, Iran
| | - Mikyung Yu
- Center for Nanomedicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Vahid Serpooshan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Joseph C. Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California 94305, USA
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California 94305, USA
- Institute of Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Robert Langer
- The David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Richard T. Lee
- Department of Stem Cell and Regenerative Biology, Harvard University, Harvard Stem Cell Institute, Cambridge, Massachusetts 02138, USA
- Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Cambridge, Massachusetts 02138, USA
| | - Jeffrey M. Karp
- Center for Nanomedicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts 02139, USA
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Harvard Stem Cell Institute, Cambridge, Massachusetts 02138, USA
| | - Omid C. Farokhzad
- Center for Nanomedicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
- Nanotechnology Research Center, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 13169-43551, Iran
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