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Theodorou CM, Jackson JE, Stokes SC, Pivetti CD, Kumar P, Paxton ZJ, Matsukuma KE, Yamashiro KJ, Reynaga L, Hyllen AA, de Lorimier AJ, Hassan M, Wang A, Farmer DL, Saadai P. Early investigations into improving bowel and bladder function in fetal ovine myelomeningocele repair. J Pediatr Surg 2022; 57:941-948. [PMID: 35093254 PMCID: PMC10372624 DOI: 10.1016/j.jpedsurg.2021.12.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Fetal myelomeningocele (MMC) repair improves lower extremity motor function. We have previously demonstrated that augmentation of fetal MMC repair with placental mesenchymal stromal cells (PMSCs) seeded on extracellular matrix (PMSC-ECM) further improves motor function in the ovine model. However, little progress has been made in improving bowel and bladder function, with many patients suffering from neurogenic bowel and bladder. We hypothesized that fetal MMC repair with PMSC-ECM would also improve bowel and bladder function. METHODS MMC defects were surgically created in twelve ovine fetuses at median gestational age (GA) 73 days, followed by defect repair at GA101 with PMSC-ECM. Fetuses were delivered at GA141. Primary bladder function outcomes were voiding posture and void volumes. Primary bowel function outcome was anorectal manometry findings including resting anal pressure and presence of rectoanal inhibitory reflex (RAIR). Secondary outcomes were anorectal and bladder detrusor muscle thickness. PMSC-ECM lambs were compared to normal lambs (n = 3). RESULTS Eighty percent of PMSC-ECM lambs displayed normal voiding posture compared to 100% of normal lambs (p = 1). Void volumes were similar (PMSC-ECM 6.1 ml/kg vs. normal 8.8 ml/kg, p = 0.4). Resting mean anal pressures were similar between cohorts (27.0 mmHg PMSC-ECM vs. normal 23.5 mmHg, p = 0.57). RAIR was present in 3/5 PMSC-ECM lambs that underwent anorectal manometry and all normal lambs (p = 0.46). Thicknesses of anal sphincter complex, rectal wall muscles, and bladder detrusor muscles were similar between cohorts. CONCLUSION Ovine fetal MMC repair augmented with PMSC-ECM results in near-normal bowel and bladder function. Further work is needed to evaluate these outcomes in human patients.
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Affiliation(s)
- Christina M Theodorou
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States.
| | - Jordan E Jackson
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Sarah C Stokes
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Christopher D Pivetti
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Zachary J Paxton
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Karen E Matsukuma
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, United States
| | - Kaeli J Yamashiro
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Alicia A Hyllen
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Arthur J de Lorimier
- Department of Pediatrics, Division of Gastroenterology. University of California Davis Medical Center. Sacramento, CA, United States
| | - Maheen Hassan
- Department of Pediatrics, Division of Gastroenterology. University of California Davis Medical Center. Sacramento, CA, United States
| | - Aijun Wang
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA, United States
| | - Diana L Farmer
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
| | - Payam Saadai
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA, United States
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Theodorou CM, Stokes SC, Jackson JE, Pivetti CD, Kumar P, Yamashiro KJ, Paxton ZJ, Reynaga L, Hyllen AA, Wang A, Farmer DL. Efficacy of clinical-grade human placental mesenchymal stromal cells in fetal ovine myelomeningocele repair. J Pediatr Surg 2022; 57:753-758. [PMID: 34217509 PMCID: PMC9365331 DOI: 10.1016/j.jpedsurg.2021.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/11/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND While fetal repair of myelomeningocele (MMC) revolutionized management, many children are still unable to walk independently. Preclinical studies demonstrated that research-grade placental mesenchymal stromal cells (PMSCs) prevent paralysis in fetal ovine MMC, however this had not been replicated with clinical-grade cells that could be used in an upcoming human clinical trial. We tested clinical-grade PMSCs seeded on an extracellular matrix (PMSC-ECM) in the gold standard fetal ovine model of MMC. METHODS Thirty-five ovine fetuses underwent MMC defect creation at a median of 76 days gestational age, and defect repair at 101 days gestational age with application of clinical-grade PMSC-ECM (3 × 105 cells/cm2, n = 12 fetuses), research-grade PMSC-ECM (3 × 105 cells/cm2, three cell lines with n = 6 (Group 1), n = 6 (Group 2), and n = 3 (Group 3) fetuses, respectively) or ECM without PMSCs (n = 8 fetuses). Three normal lambs underwent no surgical interventions. The primary outcome was motor function measured by the Sheep Locomotor Rating scale (SLR, range 0: complete paralysis to 15: normal ambulation) at 24 h of life. Correlation of lumbar spine large neuron density with SLR was evaluated. RESULTS Clinical-grade PMSC-ECM lambs had significantly better motor function than ECM-only lambs (SLR 14.5 vs. 6.5, p = 0.04) and were similar to normal lambs (14.5 vs. 15, p = 0.2) and research-grade PMSC-ECM lambs (Group 1: 14.5 vs. 15, p = 0.63; Group 2: 14.5 vs. 14.5, p = 0.86; Group 3: 14.5 vs. 15, p = 0.50). Lumbar spine large neuron density was strongly correlated with motor function (r = 0.753, p<0.001). CONCLUSIONS Clinical-grade placental mesenchymal stromal cells seeded on an extracellular matrix rescued ambulation in a fetal ovine myelomeningocele model. Lumbar spine large neuron density correlated with motor function, suggesting a neuroprotective effect of the PMSC-ECM in prevention of paralysis. A first-in-human clinical trial of PMSCs in human fetal myelomeningocele repair is underway.
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Affiliation(s)
- Christina M. Theodorou
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA,Corresponding author information: Christina Theodorou, Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, , Phone: 916-453-2080
| | - Sarah C. Stokes
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Jordan E. Jackson
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Christopher D. Pivetti
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Kaeli J. Yamashiro
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Zachary J. Paxton
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Alicia A. Hyllen
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Aijun Wang
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Diana L. Farmer
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
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Stokes SC, Theodorou CM, Jackson JE, Pivetti C, Kumar P, Yamashiro KJ, Paxton ZJ, Reynaga L, Hyllen A, Wang A, Farmer DL. Long-term safety evaluation of placental mesenchymal stromal cells for in utero repair of myelomeningocele in a novel ovine model. J Pediatr Surg 2022; 57:18-25. [PMID: 34657738 PMCID: PMC9415987 DOI: 10.1016/j.jpedsurg.2021.09.021] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Augmentation of in utero myelomeningocele repair with human placental mesenchymal stromal cells seeded onto extracellular matrix (PMSC-ECM) improves motor outcomes in an ovine myelomeningocele model. This study evaluated the safety of PMSC-ECM application directly onto the fetal spinal cord in preparation for a clinical trial. METHODS Laminectomy of L5-L6 with PMSC-ECM placement directly onto the spinal cord was performed in five fetal lambs at gestational age (GA) 100-106 days. Lambs and ewes were monitored for three months following delivery. Lambs underwent magnetic resonance imaging (MRI) of the brain and spine at birth and at three months. All organs from lambs and uteri from ewes underwent histologic evaluation. Lamb spinal cords and brains and ewe placentas were evaluated for persistence of PMSCs by polymerase chain reaction for presence of human DNA. RESULTS MRIs demonstrated no evidence of abnormal tissue growth or spinal cord tethering. Histological analysis demonstrated no evidence of abnormal tissue growth or treatment related adverse effects. No human DNA was identified in evaluated tissues. CONCLUSION There was no evidence of abnormal tissue growth or PMSC persistence at three months following in utero application of PMSC-ECM to the spinal cord. This supports proceeding with clinical trials of PMSC-ECM for in utero myelomeningocele repair. LEVEL OF EVIDENCE N/A TYPE OF STUDY: Basic science.
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Affiliation(s)
- Sarah C Stokes
- Division of Pediatric General, Thoracic and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA.
| | - Christina M Theodorou
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Jordan E Jackson
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Christopher Pivetti
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Kaeli J Yamashiro
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Zachary J Paxton
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Alicia Hyllen
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA
| | - Aijun Wang
- Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA.,Shriners Hospital for Children Northern California, 3425 Stockton Blvd, Sacramento, CA 95817, USA
| | - Diana L Farmer
- Division of Pediatric General, Thoracic, and Fetal Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA.,Surgical Bioengineering Laboratory, University of California Davis, Sacramento, CA 95817, USA.,Shriners Hospital for Children Northern California, 3425 Stockton Blvd, Sacramento, CA 95817, USA
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Jackson JE, Pivetti C, Stokes SC, Theodorou CM, Kumar P, Paxton ZJ, Hyllen A, Reynaga L, Wang A, Farmer DL. Placental Mesenchymal Stromal Cells: Preclinical Safety Evaluation for Fetal Myelomeningocele Repair. J Surg Res 2021; 267:660-668. [PMID: 34273796 PMCID: PMC9365330 DOI: 10.1016/j.jss.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/01/2021] [Accepted: 06/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Myelomeningocele (MMC) is the congenital failure of neural tube closure in utero, for which the standard of care is prenatal surgical repair. We developed clinical-grade placental mesenchymal stromal cells seeded on a dural extracellular matrix (PMSC-ECM), which have been shown to improve motor outcomes in preclinical ovine models. To evaluate the long-term safety of this product prior to use in a clinical trial, we conducted safety testing in a murine model. METHODS Clinical grade PMSCs obtained from donor human placentas were seeded onto a 6 mm diameter ECM at a density of 3 × 105 cells/cm2. Immunodeficient mice were randomized to receive either an ECM only or PMSC-ECM administered into a subcutaneous pocket. Mice were monitored for tumor formation until two study endpoints: 4 wk and 6 mo. Pathology and histology on all tissues was performed to evaluate for tumors. Quantitative polymerase chain reaction (qPCR) was performed to evaluate for the presence of human DNA, which would indicate persistence of PMSCs. RESULTS Fifty-four mice were included; 13 received ECM only and 14 received PMSC-ECM in both the 4-wk and 6-mo groups. No mice had gross or microscopic evidence of tumor development. A nodular focus of mature fibrous connective tissue was identified at the subcutaneous implantation pocket in the majority of mice with no significant difference between ECM only and PMSC-ECM groups (P = 0.32 at 4 wk, P > 0.99 at 6 mo). Additionally, no human DNA was detected by qPCR in any mice at either time point. CONCLUSIONS Subcutaneous implantation of the PMSC-ECM product did not result in tumor formation and we found no evidence that PMSCs persisted. These results support the safety of the PMSC-ECM product for use in a Phase 1/2a human clinical trial evaluating fetal MMC repair augmented with PMSC-ECM.
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Affiliation(s)
- Jordan E Jackson
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, Sacramento, California; Department of Surgery, University of California Davis, Sacramento, California.
| | - Christopher Pivetti
- Department of Surgery, University of California Davis, Sacramento, California
| | - Sarah C Stokes
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, Sacramento, California; Department of Surgery, University of California Davis, Sacramento, California
| | - Christina M Theodorou
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, Sacramento, California; Department of Surgery, University of California Davis, Sacramento, California
| | - Priyadarsini Kumar
- Department of Surgery, University of California Davis, Sacramento, California
| | - Zachary J Paxton
- Department of Surgery, University of California Davis, Sacramento, California
| | - Alicia Hyllen
- Department of Surgery, University of California Davis, Sacramento, California
| | - Lizette Reynaga
- Department of Surgery, University of California Davis, Sacramento, California
| | - Aijun Wang
- Department of Surgery, University of California Davis, Sacramento, California
| | - Diana L Farmer
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, Sacramento, California; Department of Surgery, University of California Davis, Sacramento, California
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Gao K, Kumar P, Cortez-Toledo E, Hao D, Reynaga L, Rose M, Wang C, Farmer D, Nolta J, Zhou J, Zhou P, Wang A. Potential long-term treatment of hemophilia A by neonatal co-transplantation of cord blood-derived endothelial colony-forming cells and placental mesenchymal stromal cells. Stem Cell Res Ther 2019; 10:34. [PMID: 30670078 PMCID: PMC6341603 DOI: 10.1186/s13287-019-1138-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 09/07/2018] [Revised: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 01/02/2023] Open
Abstract
Background Hemophilia A (HA) is an X-linked recessive disorder caused by mutations in the Factor VIII (FVIII) gene leading to deficient blood coagulation. As a monogenic disorder, HA is an ideal target for cell-based gene therapy, but successful treatment has been hampered by insufficient engraftment of potential therapeutic cells. Methods In this study, we sought to determine whether co-transplantation of endothelial colony-forming cells (ECFCs) and placenta-derived mesenchymal stromal cells (PMSCs) can achieve long-term engraftment and FVIII expression. ECFCs and PMSCs were transduced with a B domain deleted factor VIII (BDD-FVIII) expressing lentiviral vector and luciferase, green fluorescent protein or Td-Tomato containing lentiviral tracking vectors. They were transplanted intramuscularly into neonatal or adult immunodeficient mice. Results In vivo bioluminescence imaging showed that the ECFC only and the co-transplantation groups but not the PMSCs only group achieved long-term engraftment for at least 26 weeks, and the co-transplantation group showed a higher engraftment than the ECFC only group at 16 and 20 weeks post-transplantation. In addition, cell transplantation at the neonatal age achieved higher engraftment than at the adult age. Immunohistochemical analyses further showed that the engrafted ECFCs expressed FVIII, maintained endothelial phenotype, and generated functional vasculature. Next, co-transplantation of ECFCs and PMSCs into F8 knock-out HA mice reduced the blood loss volume from 562.13 ± 19.84 μl to 155.78 ± 44.93 μl in a tail-clip assay. Conclusions This work demonstrated that co-transplantation of ECFCs with PMSCs at the neonatal age is a potential strategy to achieve stable, long-term engraftment, and thus holds great promise for cell-based treatment of HA. Electronic supplementary material The online version of this article (10.1186/s13287-019-1138-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kewa Gao
- Department of Burns and Plastic Surgery, The Third Xiangya Hospital of Central South University, Changsha, Hunan, 410013, People's Republic of China.,Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA.,Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Northern California, Sacramento, CA, 95817, USA
| | - Elizabeth Cortez-Toledo
- Department of Internal Medicine, Stem Cell Program and Institute for Regenerative Cures, University of California Davis, Sacramento, CA, 95817, USA
| | - Dake Hao
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA.,Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Northern California, Sacramento, CA, 95817, USA
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA
| | - Melanie Rose
- Department of Internal Medicine, Stem Cell Program and Institute for Regenerative Cures, University of California Davis, Sacramento, CA, 95817, USA
| | - Chuwang Wang
- Department of Burns and Plastic Surgery, The Third Xiangya Hospital of Central South University, Changsha, Hunan, 410013, People's Republic of China.,Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA
| | - Diana Farmer
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA.,Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Northern California, Sacramento, CA, 95817, USA
| | - Jan Nolta
- Department of Internal Medicine, Stem Cell Program and Institute for Regenerative Cures, University of California Davis, Sacramento, CA, 95817, USA
| | - Jianda Zhou
- Department of Burns and Plastic Surgery, The Third Xiangya Hospital of Central South University, Changsha, Hunan, 410013, People's Republic of China.
| | - Ping Zhou
- Department of Internal Medicine, Stem Cell Program and Institute for Regenerative Cures, University of California Davis, Sacramento, CA, 95817, USA.
| | - Aijun Wang
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA, 95817, USA. .,Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Northern California, Sacramento, CA, 95817, USA. .,Department of Biomedical Engineering, University of California Davis, Davis, CA, 95616, USA.
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