1
|
Skurlova M, Holubova K, Kleteckova L, Kozak T, Kubova H, Horacek J, Vales K. Chemobrain in blood cancers: How chemotherapeutics interfere with the brain's structure and functionality, immune system, and metabolic functions. Med Res Rev 2024; 44:5-22. [PMID: 37265248 DOI: 10.1002/med.21977] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 09/29/2022] [Revised: 03/28/2023] [Accepted: 04/30/2023] [Indexed: 06/03/2023]
Abstract
Cancer treatment brings about a phenomenon not fully clarified yet, termed chemobrain. Its strong negative impact on patients' well-being makes it a trending topic in current research, interconnecting many disciplines from clinical oncology to neuroscience. Clinical and animal studies have often reported elevated concentrations of proinflammatory cytokines in various types of blood cancers. This inflammatory burst could be the background for chemotherapy-induced cognitive deficit in patients with blood cancers. Cancer environment is a dynamic interacting system. The review puts into close relationship the inflammatory dysbalance and oxidative/nitrosative stress with disruption of the blood-brain barrier (BBB). The BBB breakdown leads to neuroinflammation, followed by neurotoxicity and neurodegeneration. High levels of intracellular reactive oxygen species (ROS) induce the progression of cancer resulting in increased mutagenesis, conversion of protooncogenes to oncogenes, and inactivation of tumor suppression genes to trigger cancer cell growth. These cell alterations may change brain functionality, as well as morphology. Multidrug chemotherapy is not without consequences to healthy tissue and could even be toxic. Specific treatment impacts brain function and morphology, functions of the immune system, and metabolism in a unique mixture. In general, a chemo-drug's effects on cognition in cancer are not direct and/or in-direct, usually a combination of effects is more probable. Last but not least, chemotherapy strongly impacts the immune system and could contribute to BBB disruption. This review points out inflammation as a possible mechanism of brain damage during blood cancers and discusses chemotherapy-induced cognitive impairment.
Collapse
Affiliation(s)
- M Skurlova
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - K Holubova
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - L Kleteckova
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - T Kozak
- Department of Developmental Epileptology, Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic
| | - H Kubova
- Department of Internal Medicine and Hematology, Faculty Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - J Horacek
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| | - K Vales
- Department of Experimental Psychopharmacology, National Institute of Mental Health, Klecany, Czech Republic
| |
Collapse
|
2
|
Hanna DMF, Youshia J, Fahmy SF, George MY. Nose to brain delivery of naringin-loaded chitosan nanoparticles for potential use in oxaliplatin-induced chemobrain in rats: impact on oxidative stress, cGAS/STING and HMGB1/RAGE/TLR2/MYD88 inflammatory axes. Expert Opin Drug Deliv 2023; 20:1859-1873. [PMID: 37357778 DOI: 10.1080/17425247.2023.2228685] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Received: 01/17/2023] [Accepted: 05/26/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Oxaliplatin induces chemobrain in cancer patients/survivors. Nutraceutical naringin has antioxidant and anti-inflammatory properties with low oral bioavailability. Our aim was to formulate naringin in chitosan nanoparticles for nose to brain delivery and assess its neuroprotective effect against oxaliplatin-induced chemobrain in rats. METHODS Naringin chitosan nanoparticles were prepared by ionic gelation. Rats were administered oral naringin (80 mg/kg), intranasal naringin (0.3 mg/kg) or intranasal naringin-loaded chitosan nanoparticles (0.3 mg/kg). Naringin's neuroprotective efficacy was assessed based on behavioral tests, histopathology, and measuring oxidative stress and inflammatory markers. RESULTS Selected nanoparticles formulation showed drug loading of 5%, size of 150 nm and were cationic. Intranasal naringin administration enhanced memory function, inhibited hippocampal acetylcholinesterase activity, and corrected oxaliplatin-induced histological changes. Moreover, it reduced malondialdehyde and elevated reduced glutathione hippocampal levels. Furthermore, it decreased levels of inflammatory markers: NF-kB and TNF-α by 1.25-fold. Upstream to this inflammatory status, intranasal naringin downregulated the hippocampal protein levels of two pathways: cGAS/STING and HMGB1/RAGE/TLR2/MYD88. CONCLUSION Intranasal naringin-loaded chitosan nanoparticles showed superior amelioration of oxaliplatin-induced chemobrain in rats at a dose 267-fold lower to that administered orally. The potential involvement of cGAS/STING and HMGB1/RAGE/TLR2/MYD88 pathways in the mechanistic process of either oxaliplatin-induced chemobrain or naringin-mediated neuroprotection was evidenced.
Collapse
Affiliation(s)
- Diana M F Hanna
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - John Youshia
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Sarah Farid Fahmy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Mina Y George
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| |
Collapse
|
3
|
Ntagwabira F, Trujillo M, McElroy T, Brown T, Simmons P, Sykes D, Allen AR. Piperlongumine as a Neuro-Protectant in Chemotherapy Induced Cognitive Impairment. Int J Mol Sci 2022; 23:2008. [PMID: 35216124 PMCID: PMC8880369 DOI: 10.3390/ijms23042008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022] Open
Abstract
Advances in the early diagnosis and treatment have led to increases in breast cancer survivorship. Survivors report cognitive impairment symptoms such as loss of concentration and learning and memory deficits which significantly reduce the patient's quality of life. Additional therapies are needed to prevent these side effects and, the precise mechanisms of action responsible are not fully elucidated. However, increasing evidence points toward the use of neuroprotective compounds with antioxidants and anti-inflammatory properties as tools for conserving learning and memory. Here, we examine the ability of piperlongumine (PL), an alkaloid known to have anti-inflammatory and antioxidant effects, to play a neuroprotective role in 16-week-old female C57BL/6J mice treated with a common breast cancer regimen of doxorubicin, cyclophosphamide, and docetaxel (TAC). During social memory testing, TAC-treated mice exhibited impairment, while TAC/PL co-treated mice did not exhibit measurable social memory deficits. Proteomics analysis showed ERK1/2 signaling is involved in TAC and TAC/PL co-treatment. Reduced Nrf2 mRNA expression was also observed. mRNA levels of Gria2 were increased in TAC treated mice and reduced in TAC/PL co-treated mice. In this study, PL protects against social memory impairment when co-administered with TAC via multifactorial mechanisms involving oxidative stress and synaptic plasticity.
Collapse
Affiliation(s)
- Fabio Ntagwabira
- Division of Radiation Health, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA; (F.N.); (M.T.); (T.M.); (T.B.); (P.S.)
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
- Neurobiology & Developmental Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
| | - Madison Trujillo
- Division of Radiation Health, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA; (F.N.); (M.T.); (T.M.); (T.B.); (P.S.)
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
- Neurobiology & Developmental Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
| | - Taylor McElroy
- Division of Radiation Health, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA; (F.N.); (M.T.); (T.M.); (T.B.); (P.S.)
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
- Neurobiology & Developmental Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
| | - Taurean Brown
- Division of Radiation Health, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA; (F.N.); (M.T.); (T.M.); (T.B.); (P.S.)
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
- Neurobiology & Developmental Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
| | - Pilar Simmons
- Division of Radiation Health, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA; (F.N.); (M.T.); (T.M.); (T.B.); (P.S.)
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
| | | | - Antiño R. Allen
- Division of Radiation Health, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA; (F.N.); (M.T.); (T.M.); (T.B.); (P.S.)
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
- Neurobiology & Developmental Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR 72205, USA
| |
Collapse
|
4
|
Rummel NG, Chaiswing L, Bondada S, St Clair DK, Butterfield DA. Chemotherapy-induced cognitive impairment: focus on the intersection of oxidative stress and TNFα. Cell Mol Life Sci 2021; 78:6533-6540. [PMID: 34424346 PMCID: PMC10561769 DOI: 10.1007/s00018-021-03925-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/27/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
Chemotherapy-induced cognitive impairment (CICI) has been observed in a large fraction of cancer survivors. Although many of the chemotherapeutic drugs do not cross the blood-brain barrier, following treatment, the structure and function of the brain are altered and cognitive dysfunction occurs in a significant number of cancer survivors. The means by which CICI occurs is becoming better understood, but there still remain unsolved questions of the mechanisms involved. The hypotheses to explain CICI are numerous. More than 50% of FDA-approved cancer chemotherapy agents are associated with reactive oxygen species (ROS) that lead to oxidative stress and activate a myriad of pathways as well as inhibit pathways necessary for proper brain function. Oxidative stress triggers the activation of different proteins, one in particular is tumor necrosis factor alpha (TNFα). Following treatment with various chemotherapy agents, this pro-inflammatory cytokine binds to its receptors at the blood-brain barrier and translocates to the parenchyma via receptor-mediated endocytosis. Once in brain, TNFα initiates pathways that may eventually lead to neuronal death and ultimately cognitive impairment. TNFα activation of the c-jun N-terminal kinases (JNK) and Janus kinase-signal transducer and activator of transcription (JAK/STAT) pathways may contribute to both memory decline and loss of higher executive functions reported in patients after chemotherapy treatment. Chemotherapy also affects the brain's antioxidant capacity, allowing for accumulation of ROS. This review expands on these topics to provide insights into the possible mechanisms by which the intersection of oxidative stress and TNFΑ are involved in chemotherapy-induced cognitive impairment.
Collapse
Affiliation(s)
- Nicole G Rummel
- Department of Chemistry, University of Kentucky, Lexington, KY, 40506, USA
- Markey Cancer Center, University of Kentucky, Lexington, KY, 40536, USA
| | - Luksana Chaiswing
- Markey Cancer Center, University of Kentucky, Lexington, KY, 40536, USA
- Department of Toxicology and Cancer Biology, University of Kentucky, Lexington, KY, 40536, USA
| | - Subbarao Bondada
- Markey Cancer Center, University of Kentucky, Lexington, KY, 40536, USA
- Department of Microbiology, Immunology and Molecular Genetics, University of Kentucky, Lexington, KY, 40536, USA
| | - Daret K St Clair
- Markey Cancer Center, University of Kentucky, Lexington, KY, 40536, USA
- Department of Toxicology and Cancer Biology, University of Kentucky, Lexington, KY, 40536, USA
| | - D Allan Butterfield
- Department of Chemistry, University of Kentucky, Lexington, KY, 40506, USA.
- Markey Cancer Center, University of Kentucky, Lexington, KY, 40536, USA.
| |
Collapse
|
5
|
Ongnok B, Khuanjing T, Chunchai T, Pantiya P, Kerdphoo S, Arunsak B, Nawara W, Jaiwongkam T, Apaijai N, Chattipakorn N, Chattipakorn SC. Donepezil Protects Against Doxorubicin-Induced Chemobrain in Rats via Attenuation of Inflammation and Oxidative Stress Without Interfering With Doxorubicin Efficacy. Neurotherapeutics 2021; 18:2107-2125. [PMID: 34312765 PMCID: PMC8608968 DOI: 10.1007/s13311-021-01092-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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] [Accepted: 07/10/2021] [Indexed: 02/08/2023] Open
Abstract
Although doxorubicin (Dox) is an effective chemotherapy medication used extensively in the treatment of breast cancer, it frequently causes debilitating neurological deficits known as chemobrain. Donepezil (DPZ), an acetylcholinesterase inhibitor, provides therapeutic benefits in various neuropathological conditions. However, comprehensive mechanistic insights regarding the neuroprotection of DPZ on cognition and brain pathologies in a Dox-induced chemobrain model remain obscure. Here, we demonstrated that Dox-treated rats manifested conspicuous cognitive deficits and developed chemobrain pathologies as indicated by brain inflammatory and oxidative insults, glial activation, defective mitochondrial homeostasis, increased potential lesions associated with Alzheimer's disease, disrupted neurogenesis, loss of dendritic spines, and ultimately neuronal death through both apoptosis and necroptosis. Intervention with DPZ co-treatment completely restored cognitive function by attenuating these pathological conditions induced by DOX. We also confirmed that DPZ treatment does not affect the anti-cancer efficacy of Dox in breast cancer cells. Together, our findings suggest that DPZ treatment confers potential neuroprotection against Dox-induced chemobrain.
Collapse
Affiliation(s)
- Benjamin Ongnok
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Thawatchai Khuanjing
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Titikorn Chunchai
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Patcharapong Pantiya
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Sasiwan Kerdphoo
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Busarin Arunsak
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Wichwara Nawara
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Thidarat Jaiwongkam
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Nattayaporn Apaijai
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, 50200, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Neuroelectrophysiology Unit, Chiang Mai University, 50200, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, 50200, Chiang Mai, Thailand.
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, 50200, Chiang Mai, Thailand.
| |
Collapse
|
6
|
English K, Shepherd A, Uzor NE, Trinh R, Kavelaars A, Heijnen CJ. Astrocytes rescue neuronal health after cisplatin treatment through mitochondrial transfer. Acta Neuropathol Commun 2020; 8:36. [PMID: 32197663 PMCID: PMC7082981 DOI: 10.1186/s40478-020-00897-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/13/2020] [Indexed: 12/28/2022] Open
Abstract
Neurodegenerative disorders, including chemotherapy-induced cognitive impairment, are associated with neuronal mitochondrial dysfunction. Cisplatin, a commonly used chemotherapeutic, induces neuronal mitochondrial dysfunction in vivo and in vitro. Astrocytes are key players in supporting neuronal development, synaptogenesis, axonal growth, metabolism and, potentially mitochondrial health. We tested the hypothesis that astrocytes transfer healthy mitochondria to neurons after cisplatin treatment to restore neuronal health.We used an in vitro system in which astrocytes containing mito-mCherry-labeled mitochondria were co-cultured with primary cortical neurons damaged by cisplatin. Culture of primary cortical neurons with cisplatin reduced neuronal survival and depolarized neuronal mitochondrial membrane potential. Cisplatin induced abnormalities in neuronal calcium dynamics that were characterized by increased resting calcium levels, reduced calcium responses to stimulation with KCl, and slower calcium clearance. The same dose of cisplatin that caused neuronal damage did not affect astrocyte survival or astrocytic mitochondrial respiration. Co-culture of cisplatin-treated neurons with astrocytes increased neuronal survival, restored neuronal mitochondrial membrane potential, and normalized neuronal calcium dynamics especially in neurons that had received mitochondria from astrocytes which underlines the importance of mitochondrial transfer. These beneficial effects of astrocytes were associated with transfer of mitochondria from astrocytes to cisplatin-treated neurons. We show that siRNA-mediated knockdown of the Rho-GTPase Miro-1 in astrocytes reduced mitochondrial transfer from astrocytes to neurons and prevented the normalization of neuronal calcium dynamics.In conclusion, we showed that transfer of mitochondria from astrocytes to neurons rescues neurons from the damage induced by cisplatin treatment. Astrocytes are far more resistant to cisplatin than cortical neurons. We propose that transfer of functional mitochondria from astrocytes to neurons is an important repair mechanism to protect the vulnerable cortical neurons against the toxic effects of cisplatin.
Collapse
Affiliation(s)
- Krystal English
- Division of Internal Medicine, Department of Symptom Research, Laboratories of Neuroimmunology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030 USA
| | - Andrew Shepherd
- Division of Internal Medicine, Department of Symptom Research, Laboratories of Neuroimmunology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030 USA
| | - Ndidi-Ese Uzor
- Department of Neurobiology & Anatomy, The University of Texas McGovern Medical School, Houston, TX 77030 USA
- Department of Neurology, The University of Texas McGovern Medical School, Houston, TX 77030 USA
| | - Ronnie Trinh
- Division of Internal Medicine, Department of Symptom Research, Laboratories of Neuroimmunology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030 USA
| | - Annemieke Kavelaars
- Division of Internal Medicine, Department of Symptom Research, Laboratories of Neuroimmunology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030 USA
| | - Cobi J. Heijnen
- Division of Internal Medicine, Department of Symptom Research, Laboratories of Neuroimmunology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030 USA
| |
Collapse
|