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Zhang X, Hou J, Zhou G, Wang H, Wu Z. zDHHC3-mediated S-palmitoylation of SLC9A2 regulates apoptosis in kidney clear cell carcinoma. J Cancer Res Clin Oncol 2024; 150:194. [PMID: 38619631 PMCID: PMC11018659 DOI: 10.1007/s00432-024-05737-y] [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: 08/03/2023] [Accepted: 04/01/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE Kidney clear cell carcinoma (KIRC) has a poor prognosis, high morbidity and mortality rates, and high invasion and metastasis rate, and effective therapeutic targets are lacking. zDHHC3 has been implicated in various cancers, but its specific role in KIRC remains unclear. METHODS In this study, we performed a pan-cancer analysis, bioinformatics analysis, and cell experiment to detect the role of zDHHC3 in KIRC. RESULTS zDHHC3 was significantly down-regulated in KIRC, and that its high expression was associated with favorable patient outcomes. We identified 202 hub genes that were most relevant to high zDHHC3 expression and KIRC, and found that they were involved mainly in ion transport and renal cell carcinoma. Among these hub genes, SLC9A2 was identified as a downstream gene of zDHHC3. zDHHC3 suppression led to decreased expression and S-palmitoylation of SLC9A2, which further inhibited the apoptosis of Caki-2 cells. CONCLUSION Our findings suggest that zDHHC3 plays an important role in KIRC, due partly to its regulation of SLC9A2 S-palmitoylation. The targeting of the zDHHC3-SLC9A2 axis may provide a new option for the clinical treatment of KIRC.
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Affiliation(s)
- Xiuyun Zhang
- Department of Pathology, Renmin Hospital of Wuhan University, Wuhan, 430000, China
| | - Junpeng Hou
- Department of Orthopedic Surgery, Zhengzhou Central Hospital Affiliated With Zhengzhou University, Zhengzhou, 450000, China
| | - Guangyuan Zhou
- School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Haixia Wang
- School of Medicine, Shihezi University, Shihezi, 832003, Xinjiang Province, China
| | - Zeang Wu
- First Affiliated Hospital of Shihezi University, Dr. Zeang Wu, 107 North Second Road, Shihezi, 832003, Xinjiang Province, China.
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Al-Shamasi AA, Elkaffash R, Mohamed M, Rayan M, Al-Khater D, Gadeau AP, Ahmed R, Hasan A, Eldassouki H, Yalcin HC, Abdul-Ghani M, Mraiche F. Crosstalk between Sodium-Glucose Cotransporter Inhibitors and Sodium-Hydrogen Exchanger 1 and 3 in Cardiometabolic Diseases. Int J Mol Sci 2021; 22:12677. [PMID: 34884494 PMCID: PMC8657861 DOI: 10.3390/ijms222312677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 12/14/2022] Open
Abstract
Abnormality in glucose homeostasis due to hyperglycemia or insulin resistance is the hallmark of type 2 diabetes mellitus (T2DM). These metabolic abnormalities in T2DM lead to cellular dysfunction and the development of diabetic cardiomyopathy leading to heart failure. New antihyperglycemic agents including glucagon-like peptide-1 receptor agonists and the sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to attenuate endothelial dysfunction at the cellular level. In addition, they improved cardiovascular safety by exhibiting cardioprotective effects. The mechanism by which these drugs exert their cardioprotective effects is unknown, although recent studies have shown that cardiovascular homeostasis occurs through the interplay of the sodium-hydrogen exchangers (NHE), specifically NHE1 and NHE3, with SGLT2i. Another theoretical explanation for the cardioprotective effects of SGLT2i is through natriuresis by the kidney. This theory highlights the possible involvement of renal NHE transporters in the management of heart failure. This review outlines the possible mechanisms responsible for causing diabetic cardiomyopathy and discusses the interaction between NHE and SGLT2i in cardiovascular diseases.
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Affiliation(s)
- Al-Anood Al-Shamasi
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (A.-A.A.-S.); (R.E.); (M.M.); (M.R.); (D.A.-K.)
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Rozina Elkaffash
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (A.-A.A.-S.); (R.E.); (M.M.); (M.R.); (D.A.-K.)
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Meram Mohamed
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (A.-A.A.-S.); (R.E.); (M.M.); (M.R.); (D.A.-K.)
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Menatallah Rayan
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (A.-A.A.-S.); (R.E.); (M.M.); (M.R.); (D.A.-K.)
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Dhabya Al-Khater
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (A.-A.A.-S.); (R.E.); (M.M.); (M.R.); (D.A.-K.)
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Alain-Pierre Gadeau
- INSERM, Biology of Cardiovascular Disease, University of Bordeaux, U1034 Pessac, France;
| | - Rashid Ahmed
- Department of Mechanical and Chemical Engineering, College of Engineering, Qatar University, Doha P.O. Box 2713, Qatar; (R.A.); (A.H.)
- Biomedical Research Centre (BRC), Qatar University, Doha P.O. Box 2713, Qatar;
| | - Anwarul Hasan
- Department of Mechanical and Chemical Engineering, College of Engineering, Qatar University, Doha P.O. Box 2713, Qatar; (R.A.); (A.H.)
- Biomedical Research Centre (BRC), Qatar University, Doha P.O. Box 2713, Qatar;
| | - Hussein Eldassouki
- College of Kinesiology, University of Saskatchewan, Saskatoon, SK S7N 5B5, Canada;
| | | | - Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center at San Antonio, Floyd Curl Drive, San Antonio, TX 7703, USA;
| | - Fatima Mraiche
- Department of Pharmaceutical Sciences, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar; (A.-A.A.-S.); (R.E.); (M.M.); (M.R.); (D.A.-K.)
- Biomedical and Pharmaceutical Research Unit, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
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Xi D, Li Y, Yan J, Li Y, Wang X, Cao B. Small RNA coaR contributes to intestinal colonization in Vibrio cholerae via the two-component system EnvZ/OmpR. Environ Microbiol 2020; 22:4231-4243. [PMID: 31868254 DOI: 10.1111/1462-2920.14906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
Vibrio cholerae is a waterborne bacterium responsible for worldwide outbreaks of acute and fatal cholera. Recently, small regulatory RNAs (sRNAs) have become increasingly recognized as important regulators of virulence gene expression in response to environmental signals. In this study, we determined that two-component system EnvZ/OmpR was required for intestinal colonization in V. cholerae O1 EI Tor strain E12382. Analysis of the characteristics of OmpR revealed a potential binding site in the intergenic region between vc1470 and vc1471, and qRT-PCR showed that expression of the intergenic region increased 5.3-fold in the small intestine compared to LB medium. Race and northern blot assays were performed and demonstrated a new sRNA, coaR (cholerae osmolarity and acidity related regulatory RNA). A ΔcoaR mutant showed a deficient colonization ability in small intestine with CI of 0.15. We identified a target of coaR, tcpI, a negative regulator of the major pilin subunit of TcpA. The ΔtcpI mutant has an increased colonization with CI of 3.16. The expression of coaR increased 2.8-fold and 3.3-fold under relative acidic and hypertonic condition. In summary, coaR was induced under the condition of high osmolarity and acid stress via EnvZ/OmpR and explained that tcpI relieves pH-mediated repression of toxin co-regulated pilus synthesis.
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Affiliation(s)
- Daoyi Xi
- TEDA Institute of Biological Sciences and Biotechnology, Nankai University, Tianjin, 300457, China.,Key Laboratory of Molecular Microbiology and Technology of the Ministry of Education, Nankai University, Tianjin, 300457, China.,Tianjin Research Center for Functional Genomics and Biochips, TEDA College, Nankai University, Tianjin, 300457, China.,Tianjin Key Laboratory of Microbial Functional Genomics, TEDA College, Nankai University, Tianjin, 300457, China
| | - Yujia Li
- TEDA Institute of Biological Sciences and Biotechnology, Nankai University, Tianjin, 300457, China.,Key Laboratory of Molecular Microbiology and Technology of the Ministry of Education, Nankai University, Tianjin, 300457, China.,Tianjin Research Center for Functional Genomics and Biochips, TEDA College, Nankai University, Tianjin, 300457, China.,Tianjin Key Laboratory of Microbial Functional Genomics, TEDA College, Nankai University, Tianjin, 300457, China
| | - Junxiang Yan
- TEDA Institute of Biological Sciences and Biotechnology, Nankai University, Tianjin, 300457, China.,Key Laboratory of Molecular Microbiology and Technology of the Ministry of Education, Nankai University, Tianjin, 300457, China.,Tianjin Research Center for Functional Genomics and Biochips, TEDA College, Nankai University, Tianjin, 300457, China.,Tianjin Key Laboratory of Microbial Functional Genomics, TEDA College, Nankai University, Tianjin, 300457, China
| | - Yuehua Li
- TEDA Institute of Biological Sciences and Biotechnology, Nankai University, Tianjin, 300457, China.,Key Laboratory of Molecular Microbiology and Technology of the Ministry of Education, Nankai University, Tianjin, 300457, China.,Tianjin Research Center for Functional Genomics and Biochips, TEDA College, Nankai University, Tianjin, 300457, China.,Tianjin Key Laboratory of Microbial Functional Genomics, TEDA College, Nankai University, Tianjin, 300457, China
| | - Xiaochen Wang
- TEDA Institute of Biological Sciences and Biotechnology, Nankai University, Tianjin, 300457, China.,Key Laboratory of Molecular Microbiology and Technology of the Ministry of Education, Nankai University, Tianjin, 300457, China.,Tianjin Research Center for Functional Genomics and Biochips, TEDA College, Nankai University, Tianjin, 300457, China.,Tianjin Key Laboratory of Microbial Functional Genomics, TEDA College, Nankai University, Tianjin, 300457, China
| | - Boyang Cao
- TEDA Institute of Biological Sciences and Biotechnology, Nankai University, Tianjin, 300457, China.,Key Laboratory of Molecular Microbiology and Technology of the Ministry of Education, Nankai University, Tianjin, 300457, China.,Tianjin Research Center for Functional Genomics and Biochips, TEDA College, Nankai University, Tianjin, 300457, China.,Tianjin Key Laboratory of Microbial Functional Genomics, TEDA College, Nankai University, Tianjin, 300457, China
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Deficient Active Transport Activity in Healing Mucosa After Mild Gastric Epithelial Damage. Dig Dis Sci 2020; 65:119-131. [PMID: 31515722 PMCID: PMC7950857 DOI: 10.1007/s10620-019-05825-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peptic ulcers recur, suggesting that ulcer healing may leave tissue predisposed to subsequent damage. In mice, we have identified that the regenerated epithelium found after ulcer healing will remain abnormal for months after healing. AIM To determine whether healed gastric mucosa has altered epithelial function, as measured by electrophysiologic parameters. METHOD Ulcers were induced in mouse gastric corpus by serosal local application of acetic acid. Thirty days or 8 months after ulcer induction, tissue was mounted in an Ussing chamber. Transepithelial electrophysiologic parameters (short-circuit current, Isc. resistance, R) were compared between the regenerated healed ulcer region and the non-ulcerated contralateral region, in response to luminal hyperosmolar NaCl challenge (0.5 M). RESULTS In unperturbed stomach, luminal application of hyperosmolar NaCl transiently dropped Isc followed by gradual recovery over 2 h. Compared to the starting baseline Isc, percent Isc recovery was reduced in 30-day healing mucosa, but not at 8 months. Prior to NaCl challenge, a lower baseline Isc was observed in trefoil factor 2 (TFF2) knockout (KO) versus wild type (WT), with no Isc recovery in either non-ulcerated or healing mucosa of KO. Inhibiting Na/H exchanger (NHE) transport in WT mucosa inhibited Isc recovery in response to luminal challenge. NHE2-KO baseline Isc was reduced versus NHE2-WT. In murine gastric organoids, NHE inhibition slowed recovery of intracellular pH and delayed the repair of photic induced damage. CONCLUSION Healing gastric mucosa has deficient electrophysiological recovery in response to hypertonic NaCl. TFF2 and NHE2 contribute to Isc regulation, and the recovery and healing of transepithelial function.
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Pedersen SF, Counillon L. The SLC9A-C Mammalian Na +/H + Exchanger Family: Molecules, Mechanisms, and Physiology. Physiol Rev 2019; 99:2015-2113. [PMID: 31507243 DOI: 10.1152/physrev.00028.2018] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Na+/H+ exchangers play pivotal roles in the control of cell and tissue pH by mediating the electroneutral exchange of Na+ and H+ across cellular membranes. They belong to an ancient family of highly evolutionarily conserved proteins, and they play essential physiological roles in all phyla. In this review, we focus on the mammalian Na+/H+ exchangers (NHEs), the solute carrier (SLC) 9 family. This family of electroneutral transporters constitutes three branches: SLC9A, -B, and -C. Within these, each isoform exhibits distinct tissue expression profiles, regulation, and physiological roles. Some of these transporters are highly studied, with hundreds of original articles, and some are still only rudimentarily understood. In this review, we present and discuss the pioneering original work as well as the current state-of-the-art research on mammalian NHEs. We aim to provide the reader with a comprehensive view of core knowledge and recent insights into each family member, from gene organization over protein structure and regulation to physiological and pathophysiological roles. Particular attention is given to the integrated physiology of NHEs in the main organ systems. We provide several novel analyses and useful overviews, and we pinpoint main remaining enigmas, which we hope will inspire novel research on these highly versatile proteins.
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Affiliation(s)
- S F Pedersen
- Section for Cell Biology and Physiology, Department of Biology, University of Copenhagen, Copenhagen, Denmark; and Université Côte d'Azur, CNRS, Laboratoire de Physiomédecine Moléculaire, LP2M, France, and Laboratories of Excellence Ion Channel Science and Therapeutics, Nice, France
| | - L Counillon
- Section for Cell Biology and Physiology, Department of Biology, University of Copenhagen, Copenhagen, Denmark; and Université Côte d'Azur, CNRS, Laboratoire de Physiomédecine Moléculaire, LP2M, France, and Laboratories of Excellence Ion Channel Science and Therapeutics, Nice, France
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6
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Flinck M, Kramer SH, Schnipper J, Andersen AP, Pedersen SF. The acid-base transport proteins NHE1 and NBCn1 regulate cell cycle progression in human breast cancer cells. Cell Cycle 2018; 17:1056-1067. [PMID: 29895196 DOI: 10.1080/15384101.2018.1464850] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Precise acid-base homeostasis is essential for maintaining normal cell proliferation and growth. Conversely, dysregulated acid-base homeostasis, with increased acid extrusion and marked extracellular acidification, is an enabling feature of solid tumors, yet the mechanisms through which intra- and extracellular pH (pHi, pHe) impact proliferation and growth are incompletely understood. The aim of this study was to determine the impact of pH, and specifically of the Na+/H+ exchanger NHE1 and Na+, HCO3- transporter NBCn1, on cell cycle progression and its regulators in human breast cancer cells. Reduction of pHe to 6.5, a common condition in tumors, significantly delayed cell cycle progression in MCF-7 human breast cancer cells. The NHE1 protein level peaked in S phase and that of NBCn1 in G2/M. Steady state pHi changed through the cell cycle, from 7.1 in early S phase to 6.8 in G2, recovering again in M phase. This pattern, as well as net acid extrusion capacity, was dependent on NHE1 and NBCn1. Accordingly, knockdown of either NHE1 or NBCn1 reduced proliferation, prolonged cell cycle progression in a manner involving S phase prolongation and delayed G2/M transition, and altered the expression pattern and phosphorylation of cell cycle regulatory proteins. Our work demonstrates, for the first time, that both NHE1 and NBCn1 regulate cell cycle progression in breast cancer cells, and we propose that this involves cell cycle phase-specific pHi regulation by the two transporters.
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Affiliation(s)
- Mette Flinck
- a Section for Cell Biology and Physiology, Department of Biology , University of Copenhagen , Copenhagen Ø , Denmark
| | - Signe Hoejland Kramer
- a Section for Cell Biology and Physiology, Department of Biology , University of Copenhagen , Copenhagen Ø , Denmark
| | - Julie Schnipper
- a Section for Cell Biology and Physiology, Department of Biology , University of Copenhagen , Copenhagen Ø , Denmark
| | - Anne Poder Andersen
- a Section for Cell Biology and Physiology, Department of Biology , University of Copenhagen , Copenhagen Ø , Denmark
| | - Stine Falsig Pedersen
- a Section for Cell Biology and Physiology, Department of Biology , University of Copenhagen , Copenhagen Ø , Denmark
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7
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Walker NM, Liu J, Stein SR, Stefanski CD, Strubberg AM, Clarke LL. Cellular chloride and bicarbonate retention alters intracellular pH regulation in Cftr KO crypt epithelium. Am J Physiol Gastrointest Liver Physiol 2016; 310:G70-80. [PMID: 26542396 PMCID: PMC4719062 DOI: 10.1152/ajpgi.00236.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/29/2015] [Indexed: 01/31/2023]
Abstract
Cystic fibrosis (CF) is caused by mutations in the CF transmembrane conductance regulator (CFTR), an anion channel providing a major pathway for Cl(-) and HCO3 (-) efflux across the apical membrane of the epithelium. In the intestine, CF manifests as obstructive syndromes, dysbiosis, inflammation, and an increased risk for gastrointestinal cancer. Cftr knockout (KO) mice recapitulate CF intestinal disease, including intestinal hyperproliferation. Previous studies using Cftr KO intestinal organoids (enteroids) indicate that crypt epithelium maintains an alkaline intracellular pH (pHi). We hypothesized that Cftr has a cell-autonomous role in downregulating pHi that is incompletely compensated by acid-base regulation in its absence. Here, 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein microfluorimetry of enteroids showed that Cftr KO crypt epithelium sustains an alkaline pHi and resistance to cell acidification relative to wild-type. Quantitative real-time PCR revealed that Cftr KO enteroids exhibit downregulated transcription of base (HCO3 (-))-loading proteins and upregulation of the basolateral membrane HCO3 (-)-unloader anion exchanger 2 (Ae2). Although Cftr KO crypt epithelium had increased Ae2 expression and Ae2-mediated Cl(-)/HCO3 (-) exchange with maximized gradients, it also had increased intracellular Cl(-) concentration relative to wild-type. Pharmacological reduction of intracellular Cl(-) concentration in Cftr KO crypt epithelium normalized pHi, which was largely Ae2-dependent. We conclude that Cftr KO crypt epithelium maintains an alkaline pHi as a consequence of losing both Cl(-) and HCO3 (-) efflux, which impairs pHi regulation by Ae2. Retention of Cl(-) and an alkaline pHi in crypt epithelium may alter several cellular processes in the proliferative compartment of Cftr KO intestine.
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Affiliation(s)
- Nancy M. Walker
- 1Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and
| | - Jinghua Liu
- 1Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and
| | - Sydney R. Stein
- 1Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and
| | - Casey D. Stefanski
- 1Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and ,2Department of Biomedical Sciences, University of Missouri, Columbia, Missouri
| | - Ashlee M. Strubberg
- 1Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and ,2Department of Biomedical Sciences, University of Missouri, Columbia, Missouri
| | - Lane L. Clarke
- 1Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and ,2Department of Biomedical Sciences, University of Missouri, Columbia, Missouri
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Kawada N, Isaka Y, Rakugi H, Moriyama T. SCAD syndrome: A vicious cycle of kidney stones, CKD, and AciDosis. World J Clin Urol 2014; 3:113-118. [DOI: 10.5410/wjcu.v3.i2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 05/23/2014] [Accepted: 06/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cumulative evidence has shown that kidney stone formers are at high risk for developing end-stage renal disease (ESRD) and cardiovascular disease. The aim of this mini-review is to summarize the present knowledge about the close relationships among kidney stone formation, chronic kidney disease (CKD), and plasma and urine acidosis (SCAD). Part of the cause of the positive relationships between higher risk of developing ESRD and cardiovascular diseases in stone formers may be explained by inflammation and cell death due to the components of kidney stones. In CKD patients, acidic urine and loss of anti-crystallization factors may cause stone formation. Acidosis can promote tissue inflammation and may affect vascular tone. Correction of plasma and urine acidosis may improve renal and cardiovascular outcome of stone formers and CKD patients. More intensive and long-term interventions, which include correction of plasma and urine pH in patients with reduced renal function and correction of urine pH in patients with normal renal function, may be considered in treating patients with SCAD syndrome.
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