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Santana-Sánchez P, Vaquero-García R, Legorreta-Haquet MV, Chávez-Sánchez L, Chávez-Rueda AK. Hormones and B-cell development in health and autoimmunity. Front Immunol 2024; 15:1385501. [PMID: 38680484 PMCID: PMC11045971 DOI: 10.3389/fimmu.2024.1385501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/29/2024] [Indexed: 05/01/2024] Open
Abstract
The development of B cells into antibody-secreting plasma cells is central to the adaptive immune system as they induce protective and specific antibody responses against invading pathogens. Various studies have shown that, during this process, hormones can play important roles in the lymphopoiesis, activation, proliferation, and differentiation of B cells, and depending on the signal given by the receptor of each hormone, they can have a positive or negative effect. In autoimmune diseases, hormonal deregulation has been reported to be related to the survival, activation and/or differentiation of autoreactive clones of B cells, thus promoting the development of autoimmunity. Clinical manifestations of autoimmune diseases have been associated with estrogens, prolactin (PRL), and growth hormone (GH) levels. However, androgens, such as testosterone and progesterone (P4), could have a protective effect. The objective of this review is to highlight the links between different hormones and the immune response mediated by B cells in the etiopathogenesis of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and multiple sclerosis (MS). The data collected provide insights into the role of hormones in the cellular, molecular and/or epigenetic mechanisms that modulate the B-cell response in health and disease.
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Affiliation(s)
| | | | | | | | - Adriana Karina Chávez-Rueda
- Unidad de Investigación Médica en Inmunología, Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México (CDMX), Mexico
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2
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Abe J, Jafarpour S, Vu MH, O'Brien D, Boyd NK, Vogel BN, Nguyen L, Paulsen KC, Saucier LE, Ahsan N, Mitchell WG, Santoro JD. Impact of endocrine dysregulation on disability and non-motor symptoms in pediatric onset multiple sclerosis. Front Neurol 2023; 14:1304610. [PMID: 38130835 PMCID: PMC10733457 DOI: 10.3389/fneur.2023.1304610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Background Pediatric onset multiple sclerosis (POMS) commonly occurs at the time of various endocrine changes. Evaluation of the impact of endocrine status on disease severity in POMS has not been previously explored. Objective This study sought to evaluate if sex and stress hormones in children with POMS impact motor and non-motor diseases severity. Methods A single-center case control study was performed. Individuals with POMS were compared to individuals without neurologic disease. Each individual had three blood draws assessing stress and sex hormones between 07:00 and 09:00. Measures of fatigue (Epworth sleepiness scale), depression (PHQ-9), and quality of life (PedsQL) assessed at each visit. Results Forty individuals with POMS and 40 controls were enrolled. Individuals with POMS had lower free testosterone (p = 0.003), cortisol (p < 0.001), and ACTH (p < 0.001) and had higher progesterone (p = 0.025) levels than controls. Relapses and EDSS were not impacted by endocrine variables. The POMS cohort had a significantly higher Epworth score (p < 0.001), PHQ-9 score (p < 0.001), and lower PQL score (p < 0.001) than controls. Non-motor measures were not associated with endocrine status. Conclusion Free testosterone, cortisol, ACTH, and progesterone were abnormal in children with POMS although there was no association between endocrine status and markers of disease severity or non-motor symptoms of MS.
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Affiliation(s)
- Justin Abe
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, United States
| | - Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - My H. Vu
- Biostatistics and Data Management Core, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Devon O'Brien
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Natalie K. Boyd
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Benjamin N. Vogel
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Lina Nguyen
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Kelli C. Paulsen
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Laura E. Saucier
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Nusrat Ahsan
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Wendy G. Mitchell
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Jonathan D. Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, United States
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3
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Abstract
Oestrogens and their receptors contribute broadly to physiology and diseases. In premenopausal women, endogenous oestrogens protect against cardiovascular, metabolic and neurological diseases and are involved in hormone-sensitive cancers such as breast cancer. Oestrogens and oestrogen mimetics mediate their effects via the cytosolic and nuclear receptors oestrogen receptor-α (ERα) and oestrogen receptor-β (ERβ) and membrane subpopulations as well as the 7-transmembrane G protein-coupled oestrogen receptor (GPER). GPER, which dates back more than 450 million years in evolution, mediates both rapid signalling and transcriptional regulation. Oestrogen mimetics (such as phytooestrogens and xenooestrogens including endocrine disruptors) and licensed drugs such as selective oestrogen receptor modulators (SERMs) and downregulators (SERDs) also modulate oestrogen receptor activity in both health and disease. Following up on our previous Review of 2011, we herein summarize the progress made in the field of GPER research over the past decade. We will review molecular, cellular and pharmacological aspects of GPER signalling and function, its contribution to physiology, health and disease, and the potential of GPER to serve as a therapeutic target and prognostic indicator of numerous diseases. We also discuss the first clinical trial evaluating a GPER-selective drug and the opportunity of repurposing licensed drugs for the targeting of GPER in clinical medicine.
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Affiliation(s)
- Eric R Prossnitz
- Department of Internal Medicine, Division of Molecular Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
- Center of Biomedical Research Excellence in Autophagy, Inflammation and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
- University of New Mexico Comprehensive Cancer Center, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | - Matthias Barton
- Molecular Internal Medicine, University of Zürich, Zürich, Switzerland.
- Andreas Grüntzig Foundation, Zürich, Switzerland.
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4
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Boziki M, Theotokis P, Kesidou E, Karafoulidou E, Konstantinou C, Michailidou I, Bahar Y, Altintas A, Grigoriadis N. Sex, aging and immunity in multiple sclerosis and experimental autoimmune encephalomyelitis: An intriguing interaction. Front Neurol 2023; 13:1104552. [PMID: 36698908 PMCID: PMC9869255 DOI: 10.3389/fneur.2022.1104552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) with a profound neurodegenerative component early in the disease pathogenesis. Age is a factor with a well-described effect on the primary disease phenotype, namely, the relapsing-remitting vs. the primary progressive disease. Moreover, aging is a prominent factor contributing to the transition from relapsing-remitting MS (RRMS) to secondary progressive disease. However, sex also seems to, at least in part, dictate disease phenotype and evolution, as evidenced in humans and in animal models of the disease. Sex-specific gene expression profiles have recently elucidated an association with differential immunological signatures in the context of experimental disease. This review aims to summarize current knowledge stemming from experimental autoimmune encephalomyelitis (EAE) models regarding the effects of sex, either independently or as a factor combined with aging, on disease phenotype, with relevance to the immune system and the CNS.
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Affiliation(s)
- Marina Boziki
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Paschalis Theotokis
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Kesidou
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Karafoulidou
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrystalla Konstantinou
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Iliana Michailidou
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Ayse Altintas
- School of Medicine, Koç University, Istanbul, Turkey
| | - Nikolaos Grigoriadis
- Laboratory of Experimental Neurology and Neuroimmunology and Multiple Sclerosis Center, 2nd Neurological University Department, AHEPA General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece,*Correspondence: Nikolaos Grigoriadis ✉
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5
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McCombe PA, Greer JM. Effects of biological sex and pregnancy in experimental autoimmune encephalomyelitis: It's complicated. Front Immunol 2022; 13:1059833. [PMID: 36518769 PMCID: PMC9742606 DOI: 10.3389/fimmu.2022.1059833] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/03/2022] [Indexed: 11/29/2022] Open
Abstract
Experimental autoimmune encephalomyelitis (EAE) can be induced in many animal strains by inoculation with central nervous system antigens and adjuvant or by the passive transfer of lymphocytes reactive with these antigens and is widely used as an animal model for multiple sclerosis (MS). There are reports that female sex and pregnancy affect EAE. Here we review the effects of biological sex and the effects of pregnancy on the clinical features (including disease susceptibility) and pathophysiology of EAE. We also review reports of the possible mechanisms underlying these differences. These include sex-related differences in the immune system and in the central nervous system, the effects of hormones and the sex chromosomes and molecules unique to pregnancy. We also review sex differences in the response to factors that can modify the course of EAE. Our conclusion is that the effects of biological sex in EAE vary amongst animal models and should not be widely extrapolated. In EAE, it is therefore essential that studies looking at the effects of biological sex or pregnancy give full information about the model that is used (i.e. animal strain, sex, the inducing antigen, timing of EAE induction in relation to pregnancy, etc.). In addition, it would be preferable if more than one EAE model were used, to show if any observed effects are generalizable. This is clearly a field that requires further work. However, understanding of the mechanisms of sex differences could lead to greater understanding of EAE, and suggest possible therapies for MS.
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Liu Z, Niu X, Wang J. Naringenin as a natural immunomodulator against T cell-mediated autoimmune diseases: literature review and network-based pharmacology study. Crit Rev Food Sci Nutr 2022; 63:11026-11043. [PMID: 35776085 DOI: 10.1080/10408398.2022.2092054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
T cells, especially CD4+ T helper (Th) cells, play a vital role in the pathogenesis of specific autoimmune diseases. Naringenin, a citrus flavonoid, exhibits anti-inflammatory, anti-oxidant, and antitumor properties, which have been verified in animal autoimmune disease models. However, naringenin's possible effects and molecular mechanisms in T cell-mediated autoimmune diseases are unclear. This review summarizes the findings of previous studies and predicts the target of naringenin in T cell-mediated autoimmune disorders such as multiple sclerosis, inflammatory bowel disease, and rheumatoid arthritis through network pharmacology analysis. We performed DAVID enrichment analysis, protein-protein interaction analysis, and molecular docking to predict the positive effect of naringenin on T cell-mediated autoimmune disorders. Sixteen common genes were screened, among which the core genes were PTGS2, ESR1, CAT, CASP3, MAPK1, and AKT1. The possible molecular mechanism relates to HIF-1, estrogen, TNF, and NF-κB signaling pathways. Our findings have significance for future naringenin treatment of T cell-mediated autoimmune diseases.
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Affiliation(s)
- Zejin Liu
- Infection and Immunity Institute and Translational Medical Center of Huaihe Hospital, Henan University, Kaifeng, China
| | - Xinli Niu
- School of Life Sciences, Henan University, Kaifeng, China
| | - Junpeng Wang
- Infection and Immunity Institute and Translational Medical Center of Huaihe Hospital, Henan University, Kaifeng, China
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7
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Aldhahri RS, Alghamdi BS, Alzahrani NA, Bahaidrah KA, Alsufiani HM, Mansouri RA, Ashraf GM. Biochanin A Improves Memory Decline and Brain Pathology in Cuprizone-Induced Mouse Model of Multiple Sclerosis. Behav Sci (Basel) 2022; 12:70. [PMID: 35323389 PMCID: PMC8945046 DOI: 10.3390/bs12030070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 12/30/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterized by the demyelination of nerves, neural degeneration, and axonal loss. Cognitive impairment, including memory decline, is a significant feature in MS affecting up to 70% of patients. Thereby, it substantially impacts patients’ quality of life. Biochanin A (BCA) is an o-methylated isoflavone with a wide variety of pharmacological activities, including antioxidant, anti-inflammatory, and neuroprotective activities. Thus, this study aimed to investigate the possible protective effects of BCA on memory decline in the cuprizone (CPZ) model of MS. Thirty Swiss albino male mice (SWR/J) were randomly divided into three groups (n = 10): control (normal chow + i.p. 1:9 mixture of DMSO and PBS), CPZ (0.2% w/w of CPZ mixed into chow + i.p. 1:9 mixture of DMSO and PBS), and CPZ + BCA (0.2% w/w of CPZ mixed into chow + i.p. 40 mg/kg of BCA). At the last week of the study (week 5), a series of behavioral tasks were performed. A grip strength test was performed to assess muscle weakness while Y-maze, novel object recognition task (NORT), and novel arm discrimination task (NADT) were performed to assess memory. Additionally, histological examination of the hippocampus and the prefrontal cortex (PFC) were conducted. BCA administration caused a significant increase in the grip strength compared with the CPZ group. Additionally, BCA significantly improved the mice’s spatial memory in the Y-maze and recognition memory in the NORT and the NADT compared with the CPZ group. Moreover, BCA mitigated neuronal damage in the PFC and the hippocampus after five weeks of administration. In conclusion, our data demonstrates the possible protective effect of BCA against memory deterioration in mice fed with CPZ for five weeks.
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8
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Xiang W, Xie C, Guan Y. The identification, development and therapeutic potential of IL-10-producing regulatory B cells in multiple sclerosis. J Neuroimmunol 2021; 354:577520. [PMID: 33684831 DOI: 10.1016/j.jneuroim.2021.577520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022]
Abstract
Regulatory B cells are a rare B-cell subset widely known to exert their immunosuppressive function via the production of interleukin-10 (IL-10) and other mechanisms. B10 cells are a special subset of regulatory B cells with immunoregulatory function that is fully attributed to IL-10. Their unique roles in the animal model of multiple sclerosis (MS) have been described, as well as their relevance in MS patients. This review specifically focuses on the identification and development of B10 cells, the signals that promote IL-10 production in B cells, the roles of B10 cells in MS, and the potential and major challenges of the application of B10-based therapies for MS.
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Affiliation(s)
- Weiwei Xiang
- Department of Neurology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 160 Pujian Rd, Shanghai 200127, China
| | - Chong Xie
- Department of Neurology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 160 Pujian Rd, Shanghai 200127, China
| | - Yangtai Guan
- Department of Neurology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 160 Pujian Rd, Shanghai 200127, China.
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9
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Abstract
Regulatory T cells (Treg) play an indispensable role in maintaining the body's immune nonresponse to self-antigens and suppressing the body's unwarranted and potentially harmful immune responses. Their absence, reduction, dysfunction, transformation, and instability can lead to numerous autoimmune diseases. There are several distinct subtypes of the Treg cells, although they share certain biological characteristics and have unique phenotypes with different regulatory functions, as well as mechanistic abilities. In this book chapter, we introduce the latest advances in Treg cell subtypes pertaining to classification, phenotype, biological characteristics, and mechanisms. We also highlight the relationship between Treg cells and various diseases, including autoimmune, infectious, as well as tumors and organ transplants.
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Affiliation(s)
- Yang Du
- Department of Pathology and Physiopathology, Guilin Medical University, Guilin, Guangxi, China.,Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, Guangxi, China
| | - Qiannan Fang
- Department of Clinical Immunology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Song-Guo Zheng
- Department of Internal Medicine, Ohio State University College of Medicine and Wexner Medical Center, Columbus, OH, USA.
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10
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Monteiro C, Kasahara T, Sacramento PM, Dias A, Leite S, Silva VG, Gupta S, Agrawal A, Bento CAM. Human pregnancy levels of estrogen and progesterone contribute to humoral immunity by activating T FH /B cell axis. Eur J Immunol 2020; 51:167-179. [PMID: 33012073 DOI: 10.1002/eji.202048658] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/13/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022]
Abstract
Circulating TFH (cTFH ) cells express CXCR5, PD-1, and, when activated, ICOS, and release IL-21. According to the production of IFN-γ, IL-4, and IL-17 and expression of FoxP3, these cells are also classified as cTFH 1, cTFH 2, cTFH 17, and cTFR cells, respectively. This CD4+ T-cell subset is pivotal to efficient humoral immunity, and pregnancy appears to favor IgG production. Here, not only pregnancy amplified the in vivo production of anti-HBsAg IgG in HBV immunized women, but the frequency of cTFH cells was directly correlated with estradiol levels. In vitro, pregnancy-related dose of 17-β-estradiol (E2) directly increased the percentage of different cTFH subsets. While E2 and progesterone (P4) increased the proportion of differentiated TFH cells derived from naïve CD4+ T-cells, only E2 amplified the release of IL-21 in those cell cultures. In addition, E2 and P4 increased the proportion of memory B cells and plasma cells, respectively. In SEB-activated B/TFH cell co-cultures, E2, in the presence of P4, increased the production of total IgG. Finally, among the hormones, P4 was stronger in upregulating the percentage of IL-10+ TFR cells. Collectively, our findings suggested that E2 and P4 cooperate in the humoral immune response by favoring the expansion of different cTFH and B cell subsets.
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Affiliation(s)
- Clarice Monteiro
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.,Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Taissa Kasahara
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.,Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Priscila M Sacramento
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aleida Dias
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.,Post-graduate Program in Microbiology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone Leite
- Fernando Figueiras Institute, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Vander G Silva
- Fernando Figueiras Institute, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Sudhir Gupta
- Department of Medicine, University of California, Irvine, CA, USA
| | - Anshu Agrawal
- Department of Medicine, University of California, Irvine, CA, USA
| | - Cleonice A M Bento
- Department of Microbiology and Parasitology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.,Fernando Figueiras Institute, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
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11
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Abstract
Sex-related differences in the occurrence of autoimmune diseases is well documented, with females showing a greater propensity to develop these diseases than their male counterparts. Sex hormones, namely dihydrotestosterone and estrogens, have been shown to ameliorate the severity of inflammatory diseases. Immunologically, the beneficial effects of sex hormones have been ascribed to the suppression of effector lymphocyte responses accompanied by immune deviation from pro-inflammatory to anti-inflammatory cytokine production. In this review, we present our view of the mechanisms of sex hormones that contribute to their ability to suppress autoimmune responses with an emphasis on the pathogenesis of experimental autoimmune encephalomyelitis.
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Affiliation(s)
- Ninaad Lasrado
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE, 68583, USA
| | - Ting Jia
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE, 68583, USA
| | | | - Rodrigo Franco
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE, 68583, USA
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Jay Reddy
- School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE, 68583, USA.
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12
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Abstract
Multiple sclerosis (MS) is the most common chronic inflammatory and neurodegenerative disease of the central nervous system (CNS). An interesting feature that this debilitating disease shares with many other inflammatory disorders is that susceptibility is higher in females than in males, with the risk of MS being three times higher in women compared to men. Nonetheless, while men have a decreased risk of developing MS, many studies suggest that males have a worse clinical outcome. MS exhibits an apparent sexual dimorphism in both the immune response and the pathophysiology of the CNS damage, ultimately affecting disease susceptibility and progression differently. Overall, women are predisposed to higher rates of inflammatory relapses than men, but men are more likely to manifest signs of disease progression and worse CNS damage. The observed sexual dimorphism in MS may be due to sex hormones and sex chromosomes, acting in parallel or combination. In this review, we outline current knowledge on the sexual dimorphism in MS and discuss the interplay of sex chromosomes, sex hormones, and the immune system in driving MS disease susceptibility and progression.
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Affiliation(s)
- Francesca Gilli
- Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Krista D DiSano
- Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Andrew R Pachner
- Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
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Huang N, Chi H, Qiao J. Role of Regulatory T Cells in Regulating Fetal-Maternal Immune Tolerance in Healthy Pregnancies and Reproductive Diseases. Front Immunol 2020; 11:1023. [PMID: 32676072 PMCID: PMC7333773 DOI: 10.3389/fimmu.2020.01023] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022] Open
Abstract
Regulatory T cells (Tregs) are a specialized subset of T lymphocytes that function as suppressive immune cells and inhibit various elements of immune response in vitro and in vivo. While there are constraints on the number or function of Tregs which can be exploited to evoke an effective anti-tumor response, sufficient expansion of Tregs is essential for successful organ transplantation and for promoting tolerance of self and foreign antigens. The immune-suppressive property of Tregs equips this T lymphocyte subpopulation with a pivotal role in the establishment and maintenance of maternal tolerance to fetal alloantigens, which is necessary for successful pregnancy. Elevation in the level of pregnancy-related hormones including estrogen, progesterone and human chorionic gonadotropin promotes the recruitment and expansion of Tregs, directly implicating these cells in the regulation of fetal-maternal immune tolerance. Current studies have provided evidence that a defect in the number or function of Tregs contributes to the etiology of several reproductive diseases, such as recurrent spontaneous abortion, endometriosis, and pre-eclampsia. In this review, we provide insight into the underlying mechanism through which Tregs contribute to pregnancy-related immune tolerance and demonstrate the association between deficiencies in Tregs and the development of reproductive diseases.
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Affiliation(s)
- Ning Huang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Hongbin Chi
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Khayambashi S, Salter A, Tyry T, Cutter GR, Fox RJ, Marrie RA. Gender identity and sexual orientation affect health care satisfaction, but not utilization, in persons with Multiple Sclerosis. Mult Scler Relat Disord 2020; 37:101440. [DOI: 10.1016/j.msard.2019.101440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
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15
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Seifert HA, Gerstner G, Kent G, Vandenbark AA, Offner H. Estrogen-induced compensatory mechanisms protect IL-10-deficient mice from developing EAE. J Neuroinflammation 2019; 16:195. [PMID: 31665042 PMCID: PMC6821034 DOI: 10.1186/s12974-019-1588-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/12/2019] [Indexed: 02/08/2023] Open
Abstract
Background IL-10 knockout (KO) mice are protected from experimental autoimmune encephalomyelitis (EAE) with low-dose estrogen (E2) treatment similar to wild-type (WT) mice. Previous studies have demonstrated a decrease in tumor necrosis factor in all E2-treated groups, which led to the protection of the mice. Methods This study used IL-10 KO mice and WT mice treated either with E2 or sham pellets 7 days prior to induction of EAE. Mice were observed for 21 days post-immunization. The spleen, inguinal lymph nodes, and brain were evaluated by flow cytometry. Spinal cords were evaluated using a cytokine/chemokine array, RT-PCR, and histology. Results This study demonstrates that E2 treatment induced three heightened regulatory mechanisms that potentially protect IL-10 KO mice from EAE: (1) an increase in programmed death-ligands 1 and 2 on monocytes and macrophages in the periphery and within the CNS; (2) an increase in CD73 in the inflamed CNS, which can increase the production of the anti-inflammatory molecule adenosine; and (3) a decrease in CD4+CD25+FoxP3+ regulatory T cells in the spleen. Together, these factors comprise an alternative compensatory mechanism that significantly downregulates key pro-inflammatory cytokine, chemokine, and chemokine receptor genes which are enhanced in the spinal cord of IL-10 KO mice. This group of E2-treated mice remained asymptomatic after EAE challenge similar to E2-treated WT mice, despite their having more T and B lymphocytes in the brain, and modestly increased demyelination in the spinal cord. Conclusion These results indicate that previously unrecognized compensatory mechanisms of EAE protection are stimulated by E2 in the absence of IL-10, which can provide disease protection comparable to the IL-10-dependent effects induced by E2 in WT mice.
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Affiliation(s)
- Hilary A Seifert
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.,Neuroimmunology Research, VA Portland Health Care System, R&D-31, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Grant Gerstner
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.,Neuroimmunology Research, VA Portland Health Care System, R&D-31, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Gail Kent
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.,Neuroimmunology Research, VA Portland Health Care System, R&D-31, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Arthur A Vandenbark
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.,Neuroimmunology Research, VA Portland Health Care System, R&D-31, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, OR, USA
| | - Halina Offner
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA. .,Neuroimmunology Research, VA Portland Health Care System, R&D-31, 3710 SW US Veterans Hospital Rd., Portland, OR, 97239, USA. .,Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA.
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16
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Liu H, Qiu F, Wang Y, Zeng Q, Liu C, Chen Y, Liang CL, Zhang Q, Han L, Dai Z. CD8+CD122+PD-1+ Tregs Synergize With Costimulatory Blockade of CD40/CD154, but Not B7/CD28, to Prolong Murine Allograft Survival. Front Immunol 2019; 10:306. [PMID: 30863408 PMCID: PMC6399415 DOI: 10.3389/fimmu.2019.00306] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/06/2019] [Indexed: 01/22/2023] Open
Abstract
A transplanted organ is always rejected in the absence of any immunosuppressive treatment due to vigorous alloimmunity. However, continuously global immunosuppression with a conventional immunosuppressant may result in severe side effects, including nephrotoxicity, tumors and infections. Tregs have been widely used to inhibit allograft rejection, especially in animal models. However, it's well accepted that administration of Tregs alone is not satisfactory in immune-competent wild-type animals. Therefore, it's imperative to promote Treg therapies under the cover of other approaches, including costimulatory blockade. In the present study, we demonstrated that administration of in vitro-expanded CD8+CD122+PD-1+ Tregs synergized with costimulatory blockade of CD40/CD154, but not B7/CD28, to prolong skin allograft survival in wild-type mice and to reduce cellular infiltration in skin allografts as well. Treg treatment and blockade of CD40/CD154, but not B7/CD28, also exhibited an additive effect on suppression of T cell proliferation in vitro and pro-inflammatory cytokine expression in skin allografts. Importantly, blocking B7/CD28, but not CD40/CD154, costimulation decreased the number of transferred CD8+CD122+PD-1+ Tregs and their expression of IL-10 in recipient mice. Furthermore, it's B7/CD28, but not CD40/CD154, costimulatory blockade that dramatically reduced IL-10 production by CD8+CD122+PD-1+ Tregs in vitro, suggesting that B7/CD28, but not CD40/CD154, costimulation is critical for their production of IL-10. Indeed, infusion of IL-10-deficient CD8+CD122+PD-1+ Tregs failed to synergize with anti-CD154 Ab treatment to further prolong allograft survival. Our data may explain why blocking B7/CD28 costimulatory pathway does not boost IL-10-dependent Treg suppression of alloimmunity. Thus, these findings could be implicated in clinical organ transplantation.
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Affiliation(s)
- Huazhen Liu
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Feifei Qiu
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Yuanzhong Wang
- Department of Cancer Biology, Beckman Research Institute of City of Hope, Duarte, CA, United States
| | - Qiaohuang Zeng
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Cuihua Liu
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Yuchao Chen
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Chun-Ling Liang
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Qunfang Zhang
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Ling Han
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Zhenhua Dai
- Section of Immunology and Joint Immunology Program, Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
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17
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Sena A, Macedo A, Ferret-Sena V, Capela C, Pedrosa R. Serum Lipoprotein Profile Is Associated With Protective Effects of Oral Contraceptive Use on Multiple Sclerosis Severity: A Cross-Sectional Study. Front Neurol 2019; 10:60. [PMID: 30787904 PMCID: PMC6373519 DOI: 10.3389/fneur.2019.00060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/17/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The mechanisms underlying the influence of sex hormones in multiple sclerosis (MS) are uncertain. Sex steroids interact with cholesterol metabolism and the serum lipid profile has been associated with the severity of the disease. We hypothesized that the putative associations between lipoprotein metabolism and MS could be modulated by sex steroids exposure. The aim of this study was to investigate whether oral contraceptives (OC) use changes the lipoprotein profile associated with disability in patients with multiple sclerosis. Methods: Clinical data was collected from 133 relapsing-remitting multiple sclerosis (RRMS) women with a mean of 6.5 years of disease duration and prior to the start of disease-modifying therapies. Patients who were using OC after disease onset (DO) (OC+, n = 57) were compared to those who never used OC or discontinued its intake before DO (OC-, n = 76). In both cohorts of subjects, the associations between the apolipoprotein E (ApoE) polymorphism, and plasma lipid levels, and the annualized relapse rate (RR), the Expanded Disability Status Score (EDSS), and the Multiple Sclerosis Severity Score (MSSS) were evaluated using a hierarchic multiple regression analysis after adjustment for confounders. Results: Low density lipoprotein (LDL) levels were associated with higher EDSS (p = 0.010) and MSSS (p = 0.024) in the whole studied cohort. In E3/E3 phenotype carriers (73.7%), EDSS and MSSS were lower in OC+ in comparison with OC- subgroup of patients (p < 0.01). LDL and total cholesterol were associated with EDSS (p = 0.005 and p = 0.043, respectively), and LDL and the triglyceride/high density lipoprotein ratio with MSSS (p = 0.011 and p = 0.048, respectively) in OC+ patients. In OC- subgroup of patients, ApoE levels were associated with EDSS (p = 0.012) and MSSS (p = 0.031). No significant interactions between the lipid variables or OC use and RR were observed. Conclusions: Serum lipid profile is associated with protective effects of OC use on disability of RRMS patients. Lipoprotein metabolism may be involved in the modulatory effects of sex steroids on the severity of the disease.
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Affiliation(s)
- Armando Sena
- Centro de Investigação Multidisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Caparica, Portugal.,Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.,Departamento de Neurociências, Serviço de Neurologia, Centro Hospitalar de Lisboa-Central, Lisbon, Portugal
| | - Ana Macedo
- Keypoint, Consultora Científica, Algés, Portugal.,Departamento de Ciências Biomédicas e Medicina (DCBM), Universidade do Algarve, Faro, Portugal
| | - Véronique Ferret-Sena
- Centro de Investigação Multidisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Caparica, Portugal
| | - Carlos Capela
- Departamento de Neurociências, Serviço de Neurologia, Centro Hospitalar de Lisboa-Central, Lisbon, Portugal
| | - Rui Pedrosa
- Departamento de Neurociências, Serviço de Neurologia, Centro Hospitalar de Lisboa-Central, Lisbon, Portugal
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18
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Ohgomori T, Jinno S. Cuprizone-induced demyelination in the mouse hippocampus is alleviated by phytoestrogen genistein. Toxicol Appl Pharmacol 2019; 363:98-110. [DOI: 10.1016/j.taap.2018.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/28/2022]
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19
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Thompson KK, Nissen JC, Pretory A, Tsirka SE. Tuftsin Combines With Remyelinating Therapy and Improves Outcomes in Models of CNS Demyelinating Disease. Front Immunol 2018; 9:2784. [PMID: 30555470 PMCID: PMC6283261 DOI: 10.3389/fimmu.2018.02784] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022] Open
Abstract
Though promoting remyelination in multiple sclerosis (MS) has emerged as a promising therapeutic strategy, it does not address inflammatory signals that continue to induce neuronal damage and inhibit effectiveness of repair mechanisms. Our lab has previously characterized the immunomodulatory tetrapeptide, tuftsin, which induces an anti-inflammatory shift in microglia and macrophages. This targeted anti-inflammatory agent improves physical deficits in experimental autoimmune encephalomyelitis (EAE), an animal model of MS. Here, we sought to determine whether tuftsin is also effective in combination with benztropine, an FDA-approved drug that stimulates remyelination, in both EAE and in the cuprizone model of demyelination. We show that combining these two agents to promote anti-inflammatory and remyelinating mechanisms alleviates symptoms in EAE and lessens pathological hallmarks in both MS models. Importantly, tuftsin is required to transform the inflammatory CNS environment normally present in EAE/MS into one of an anti-inflammatory nature, and benztropine is required in the cuprizone model to improve remyelination. Our data further support tuftsin's beneficial immunomodulatory activity in the context of EAE, and show that when studying remyelination in the absence of an autoimmune insult, tuftsin still activated microglia toward an anti-inflammatory fate, but benztropine was necessary for significant repair of the damaged myelin. Overall, tuftsin effectively combined with benztropine to significantly improve MS-like pathologies in both models.
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Affiliation(s)
- Kaitlyn K Thompson
- Program in Molecular and Cellular Pharmacology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY, United States
| | - Jillian C Nissen
- Program in Molecular and Cellular Pharmacology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY, United States.,Department of Biological Sciences, State University of New York, College at Old Westbury, Old Westbury, NY, United States
| | - Amanda Pretory
- Program in Molecular and Cellular Pharmacology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY, United States
| | - Stella E Tsirka
- Program in Molecular and Cellular Pharmacology, Department of Pharmacological Sciences, Stony Brook University, Stony Brook, NY, United States
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20
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Abstract
Women have stronger immune responses to infections and vaccination than men. Paradoxically, the stronger immune response comes at a steep price, which is the high incidence of autoimmune diseases in women. The reasons why women have stronger immunity and higher incidence of autoimmunity are not clear. Besides gender, sex hormones contribute to the development and activity of the immune system, accounting for differences in gender-related immune responses. Both innate and adaptive immune systems bear receptors for sex hormones and respond to hormonal cues. This review focuses on the role of sex hormones particularly estrogen, in the adaptive immune response, in health, and autoimmune disease with an emphasis on systemic lupus erythematosus.
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Affiliation(s)
- Vaishali R Moulton
- Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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21
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Seifert HA, Vandenbark AA, Offner H. Regulatory B cells in experimental stroke. Immunology 2018; 154:169-177. [PMID: 29313944 DOI: 10.1111/imm.12887] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 12/21/2017] [Accepted: 12/28/2017] [Indexed: 12/30/2022] Open
Abstract
Current treatment options for human stroke are limited mainly to the modestly effective infusion of tissue plasminogen activator (tPA), with additional improvement of functional independence and higher rates of angiographic revascularization observed after mechanical thrombectomy. However, new therapeutic strategies that address post-stroke immune-mediated inflammatory responses are urgently needed. Recent studies in experimental stroke have firmly implicated immune mechanisms in the propagation and partial resolution of central nervous system damage after the ischaemic event. A new-found anti-inflammatory role for regulatory B (Breg) cells in autoimmune diseases sparked interest in these cells as potential immunomodulators in stroke. Subsequent studies identified interleukin-10 as a common regulatory cytokine among all five of the currently recognized Breg cell subsets, several of which can be found in the affected brain hemisphere after induction of experimental stroke in mice. Transfer of enriched Breg cell subpopulations into both B-cell-depleted and wild-type mice confirmed their potent immunosuppressive activities in vivo, including recruitment and potentiation of regulatory T cells. Moreover, Breg cell therapy strongly reduced stroke volumes and treatment outcomes in ischaemic mice even when administered 24 hr after induction of experimental stroke, a treatment window far exceeding that of tPA. These striking results suggest that transfer of enriched Breg cell populations could have therapeutic value in human stroke, although considerable clinical challenges remain.
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Affiliation(s)
- Hilary A Seifert
- Neuroimmunology Research, VA Portland Health Care System, Portland, OR, USA.,Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Arthur A Vandenbark
- Neuroimmunology Research, VA Portland Health Care System, Portland, OR, USA.,Department of Neurology, Oregon Health & Science University, Portland, OR, USA.,Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, OR, USA
| | - Halina Offner
- Neuroimmunology Research, VA Portland Health Care System, Portland, OR, USA.,Department of Neurology, Oregon Health & Science University, Portland, OR, USA.,Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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