Leading in Research

USF neuroscientist probes how different states of tau drive brain cell damage

Research by Laura Blair’s team seeking to untangle tau may lead to targeted treatments for Alzheimer’s, Parkinson’s and other neurodegenerative diseases

Featured in the Research Matters Aug. 2017 Issue

 

Both of USF Health neuroscientist Laura Blair’s grandmothers died from ALS, a debilitating neurodenerative disease that progressively weakens muscles and leads to paralysis.

 

 

Laura Blair, PhD, assistant professor in the Department of Molecular Medicine, at her laboratory in the USF Health Byrd Alzheimer’s Institute

“Seeing that firsthand really put in my heart to do everything I could to help people suffering from these devastating neurodegenerative diseases,” said Blair, PhD, an assistant professor in the Morsani College of Medicine’s Department of Molecular Medicine.

As an USF undergraduate student conducting research in chemist Bill Baker’s laboratory, she had the chance to work at the USF Health Byrd Alzheimer’s Institute with Chad Dickey, PhD, an accomplished and creative NIH-funded neuroscientist who was the first to find that proteins involved in learning and memory were selectively impaired in a mouse model of Alzheimer’s disease.

Blair jumped at the opportunity.  Dr. Dickey’s National Institutes of Health (NIH) work was focusing on defects in the removal of damaged proteins from cells, with promising studies of the key role “chaperone proteins” play in regulating brain cell function in Alzheimer’s disease and other neurodegenerative disorders.

“I was excited to be part of the translational work he was doing – seeking to understand how the cell’s natural defense, these chaperone proteins, might be harnessed to regulate (abnormal) misfolding proteins in order to help fix or prevent neurodegenerative disease,” Dr. Blair said.

That was nine years ago.

Dr. Blair pulls up microscopic images of stained neurons with doctoral student Lindsey Shelton, right. The stain is used to determine if treatments administered to mice —  for instance, overexpressing cochaperone protein Aha1 or human enzyme CyP40 — change how toxic tau becomes to nerve cells.  

COPH sound-icon-png Dr. Laura Blair describes the focus of her laboratory’s research.

Carrying on a scientific legacy

Since then, Dr. Blair received her doctorate in medical sciences at USF in 2014 (she also earned bachelor’s and master’s degrees here) and continued to work in Dr. Dickey’s laboratory as a postdoctoral fellow.  When Dr. Dickey passed away last year at the age 40 following a courageous battle with cancer, Dr. Blair and colleague John Koren, PhD, assumed the leadership of Dickey’s team with heavy hearts. But they push forward with their mentor’s same dedication to seeking answers and sense of urgency to “publish, publish, publish.”

“Chad was always larger than life and one of the biggest influences in my life, so losing him has been surreal,” said Blair, who keeps Dr. Dickey’s nameplate on the office she now occupies. “It’s hard, but we will continue the work he started and carry on his scientific legacy.”

“He was a tremendous mentor who taught all of us how to think about a problem and ways to come up with solutions.” And she said, smiling at the memory of Dr. Dickey’s unrelenting drive to find solutions, “he taught us there’s no sense in waiting until tomorrow for an experiment that could have been started yesterday.”

Dr. Blair with Jeremy Baker, doctoral candidate in the Department of Molecular Medicine who was the lead author for a recent PLOS Biology paper reporting that a human enzyme can reduce neurotoxic amyloids in a mouse model of dementia.

Dr. Blair’s laboratory studies how chaperone proteins drive different states of the tau protein associated with Alzheimer’s disease and more than a dozen other tauopathies, including Parkinson’s disease and traumatic brain injury.  Just as their name suggests, “chaperone” proteins escort other proteins in the cell to the places they need to be, ensure these proteins do not interact with others that could be bad influences, and see to it that proteins degrade, “or are put to bed, so to speak,” when the time is right, Dr. Blair said. Under normal circumstances, chaperone proteins help ensure tau proteins are properly folded to maintain the healthy structure of nerve cells.

Pursuing how chaperones drive different states of tau

In particular, the USF researchers explore how various chaperone proteins interact, for better or worse, with various forms of tau – ranging from soluble tau protein that can spread from one brain cell to another to the aggregated, misfolded species of tau tangles inside brain cells.  (Sticky plaques of B-amyloid protein and toxic tangles of tau protein both accumulate in patients with Alzheimer’s disease, but recent studies suggest that tau deposits may be more closely linked to the actual death of neurons leading to memory loss and dementia.)

“If we can understand which states of tau are worse in terms of driving neurotoxicity,” Dr. Blair said, “maybe we can begin to shift tau into a better state so we can help delay disease progression, if not stop it in its tracks.”

COPH sound-icon-png Dr. Blair comments on differences in Alzheimer’s disease.

 

Dr. Blair and colleague John Koren, PhD, assistant professor (far left), co-manage a research team focusing on how chaperone proteins drive different states of the tau protein associated with Alzheimer’s disease and more than a dozen other tauopathies.

With a support of a new five-year, $1.5-million R01 grant from the National Institute on Aging, Dr. Blair, along with co-principal investigators Paula Bickford, PhD, of the USF Center of Excellence for Aging and Brain Repair, and Vladimir Urvesky of the Department of Molecular Medicine, is looking at a family of energy-independent, small heat shock proteins known to prevent harmful tau aggregation.  In an earlier paper published several years ago in the Journal of Neuroscience, Drs. Blair, Dickey and colleagues reported that high levels of one of these chaperone proteins, Hsp27, reduced tau accumulation in neurons and rescued learning and memory in a mouse model for Alzheimer’s disease.

Dr. Blair is also principal investigator of a second, five-year $1.36-million grant from the National Institute of Mental Health (the continuation of a grant originally awarded to Dr. Dickey) to develop a treatment blocking the effect of a stress-related protein genetically linked to depression, anxiety and other behaviors associated with post-traumatic stress disorder (PTSD). The grant builds upon earlier USF research, showing that as levels of this stress-related protein, known as FKBP51, increase in the brain with age it partners with chaperone protein Hsp90 to make tau more deadly to brain cells involved in memory formation. Using a new mouse model genetically engineered to overexpress FKBP51 and exhibit symptoms like those seen in humans with PTSD, Dr. Blair’s team will test various treatments on mice exposed to early-life environmental stresses.

Dr. Blair and Shelton, lead author of a USF-led paper published this September in Proceedings of the National Academy of Sciences demonstrating that Hsp90 cochaperone Aha1 boosted production of toxic tau aggregates in a mouse model of neurodegenerative disease. 

The ultimate goal of all this tau regulation research is to discover and commercialize targeted treatments that work, whether that’s drugs that inhibit or activate chaperone proteins, or gene therapies, or a combination. Currently no FDA-approved medications for Alzheimer’s disease specifically target beta amyloid or tau; they only help improve symptoms for some patients for a limited time.

A single-bullet therapeutic approach to a disease like Alzheimer’s that affects diffuse areas of the brain is unlikely, Dr. Blair said. “The multi-treatment option is probably going to be the most effective, but it’s difficult to address that until we have individual treatments moving forward.”

“Working toward treatments to help slow and prevent these devastating neurodegenerative diseases is what keeps our laboratory so motivated and determined.”

COPH sound-icon-png On working in a building that bridges research and clinical care

 

Slides, containing stained nerve cells from mouse brain tissue, are used by the researchers to evaluate neuronal health following various treatments.

Identifying potential treatments for neurodegenerative diseases

Building on Dr. Dickey’s work with chaperone proteins, the USF researchers continue to make significant progress in identifying potential targets to help slow or prevent neurodegenerative disease progression.

The team recently identified cochaperone protein Aha1, which binds to and stimulates the activity of heat shock protein Hsp90, as one promising therapeutic target.  Hsp90 regulates the folding, degradation and accumulation of tau. In a study published this September in  Proceedings of the National Academy of Sciences, the researchers demonstrated that Hsp90 cochaperone Aha1 boosted production of toxic tau aggregates in a mouse model of neurodegenerative disease and led to neuron loss and memory impairment.

The researchers also found that inhibiting Aha1 prevented the dramatic accumulation of tau in cultured cells. “We think Aha1 inhibitors offer promise for effects similar to Hsp90 inhibitors with less side effects,” Dr. Blair said.

Dr. Blair and Shelton work at an automated stereotactic injector station. The equipment helps the researchers determine the effects of gene therapy in the brain.

This June, in the journal PLoS Biology, Dr. Blair (principal investigator), Jeremy Baker (lead author) and colleagues reported for the first time that a naturally-occurring human enzyme – called cyclophilin 40 or CyP40 – could break apart clumps of tau in a mouse model of dementia. The USF led study found that CyP40 reduced the amount of aggregated tau, converting it into a more soluble and less toxic form of amyloid. In a mouse model of an Alzheimer’s-like disease, experimental expression of CyP40 preserved brain neurons and rescued cognitive deficits. The same enzyme also disaggregated alpha-synuclein, an aggregate associated with Parkinson’s disease.

Exactly how CyP40 can untangle clumps of tau and alpha-synuclein is not yet clear, but, Blair said “our finding suggests that CyP40, or one of the more than 40 other proteins with similar activity, may have a role to play in treating neurodegenerative diseases.”

Dr. Blair points to the hippocampus on the map of a mouse brain. An area critical for learning and memory, the hippocampus is especially vulnerable to damage at early stages of Alzheimer’s disease.

COPH sound-icon-png What Dr. Blair hopes she can impart to students as a mentor

 

Some things you might not know about Dr. Blair:

  • Blair and her husband Tom belong to a local swing dancing community, where they enjoy dancing the Lindy Hop and Balboa to ‘40s jazz.
  • Blair is a mother to 7-year-old Oliver, and a stepmother to 17-year-old Laney, who is a high school senior. They also have two dogs, a Shih Tzu named Oreo and a Shih Tzu-Yorkshire terrier mix named Pumpkin.
  • Participating in the Great American Teach-in two years ago, Dr. Blair spoke to her son’s kindergarten class about her career as a neuroscientist, including working on brain teaser puzzles and discussing a video of a preclinical neurobehavioral test with the young students. But, she said, the kids were particularly impressed with the squishy plastic “stress-reliever brains” she brought along.

Research associate Leo Breydo loads protein into a gel.

Cultured cells are harvested for analysis.

-Photos by Sandra C. Roa and Eric Younghans, University Communications and Marketing

 


Genetics research may help tailor more precise therapies for asthma, heart failure

Studies led by USF’s Dr. Stephen Liggett shed light on genetic variability of adrenergic receptors and how they might best be used to treat disease

Featured in the Research Matters Jan. 2018 Issue

 

Dr. Stephen Liggett, who leads the research enterprise for the Morasani College of Medicine and for USF Health, also oversees a genomics laboratory working on NIH-funded studies. Behind him is a radioligand binding machine used to determine the number of receptors in each cell.

While significant progress has been made managing asthma over the last two decades, about half of all asthmatics achieve optimal control of this chronic inflammatory disease using currently available medications.  Similarly, only about 50 percent of patients with congestive heart failure, which occurs when the heart is too weak to pump enough blood to meet the body’s needs, have an average life expectancy of more than five years.

More still needs to be  known at the molecular level about these common diseases to identify potential new targets for drug therapies, said Stephen B. Liggett, MD, associate vice president for research at USF Health, vice dean for research at the Morsani College of Medicine, and professor of internal medicine and molecular pharmacology and physiology.

What ties these two diseases together are the receptors on cardiac muscle and on smooth muscle of the airways. Dr. Liggett’s laboratory helps shed light on the genetic variability of adrenergic receptors and on how these receptors can best be used for treatment. The genetic studies have been particularly useful in developing the concept of pharmacogenetics, a tailoring of therapy based on an individual’s genetic makeup, for heart failure and asthma.

“Twenty years ago we had a handful of medicines for high blood pressure, and today we don’t use any of them. Now, we have a whole new group of more effective (antihypertensive) drugs with much fewer side effects,” he said.  “And, I’m sure that one day, we’ll have more tools in our toolbox to better treat heart failure and asthma – drugs that work better for subgroups of people as defined by their genetic makeup and environmental exposures.”

COPH sound-icon-png Dr. Liggett comments on some of his laboratory’s contributions to the field over his career.

 

Mining a “superfamily” of receptors for better drug targets

Dr. Liggett leads a USF team that studies the genetic, molecular biology, structure and function of G-coupled protein receptors, or GPCRs, the largest family of human proteins.  More than 800 GPCRs have been discovered within cell membranes in the human body, Dr. Liggett said, and one or more of these receptors plays a role in virtually everything the body does, including controlling thoughts in the brain, sight and smell, uterine contraction and relaxation, blood pressure, cardiac, lung and kidney function, to name just a few.

Consequently, malfunctions of GPCR signaling pathways are implicated in many chronic diseases including asthma and cardiovascular diseases.  Already this “superfamily” of receptors accounts for nearly half the targets of all prescribed drugs. But, a deeper understanding of the dynamics of the GPCR signaling network and how it maintains a healthy cell or responds to pathogens could lead to the design of drugs that more precisely target diseases with greater effectiveness and fewer side effects.

Dr. Liggett began his work with GPCRs in 1988 as a Howard Hughes Institute postdoctoral research fellow in the Duke University Medical Center laboratory of mentor Robert Lefkowitz, MD. Dr. Lefkowitz was awarded the 2012 Nobel Prize in Chemistry with Brian Kobilka, MD, for groundbreaking discoveries revealing the inner workings of GPCRs.

Building upon his interest and advanced training in pulmonary and critical care medicine, Dr. Liggett began early in his career to concentrate on one of the classes of GPCRs known as adrenergic receptors, which are stimulated by the hormone epinephrine and the neurotransmitter noepinephrine. They are involved in increasing the rate and force of contraction of the heart, as well as constriction and dilation of blood vessels throughout the body and of airways in the lung. For the last 28 years, he has been continuously funded by the National Institutes of Health (NIH) to study the molecular basis of beta-adrenergic receptors in asthma.

Biological scientist Ashley Goss

Dr. Liggett is the principal investigator of a four-year, $1.12-million R01 grant from the NIH’s National Heart, Blood and Lung Institute (NHBLI) that seeks to understand how beta-adrenergic signaling is regulated to influence the development and treatment of asthma. Over his career, he has also been awarded millions of dollars in NIH funding to explore the role of genetic variations of GPCRs in heart failure, including whether those variations may alter how effectively drugs work in individual patients.

Bitter taste receptors in a new place

Dr. Liggett is also currently a project principal investigator for a five-year, $2-million NHBLI P01 grant examining how airway smooth muscle bitter taste receptors might be applied as new treatments for asthma and chronic obstructive pulmonary disease.

Using a genomics-based method that Dr. Liggett pioneered, his team had previously identified bitter taste receptors, initially thought only to exist on the tongue, deep inside the lung at the airway smooth muscle and demonstrated they act to open the airway. “When activated, they appear far superior to the beta-agonists commonly prescribed to patients to open their airways during an asthma attack,” said Dr. Liggett, who published the discovery and the need for alternatives to current bronchodilators in Nature Medicine and other journals.

Overall, discoveries emerging from Dr. Liggett’s research have yielded more than 250 peer-reviewed papers, many highly cited and appearing in top journals such as Nature Medicine, Science, Proceedings of the National Academy of Sciences, and the New England Journal of Medicine. His work has been cited by other papers more than 26,000 times. He also holds 18 patents detailing potential new targets for drug therapy or genetic variations of known drug targets and how they might be used to predict response to medications and customize treatment.

COPH sound-icon-png The serendipity of finding bitter taste receptors on smooth airway muscle in the lungs

 

Laboratory assistant Hiwot Zewdie

Among some of his laboratory’s major findings:

– While at the University of Maryland, Dr. Liggett’s team worked with colleagues at the University of Wisconsin-Madison to sequence for the first time the entire genomes (more than 100 different strains) of all known rhinoviruses, a frequent cause of respiratory infections including the common cold. The groundbreaking work, published on the cover of Science, provided a powerful framework for large-scale, genome-based epidemiological studies and the design of antiviral agents or vaccines to combat rhinoviruses. “I originally suggested sequencing 10 strains, and then my collaborator asked why not do them all,” he said. “This made the difference between a mediocre proof-of-concept paper and a full article in Science. I learned that it is important to think big if you want to make a real difference”

–  Discovered and characterized genetic variations that may predict which patients with congestive heart failure respond best to a life-saving beta-blocker drug.  These landmark studies occurred over several years and were published in Nature Medicine twice, and the Proceedings of the National Academy of Sciences three times. “This is a good example of the progression of an idea over time, where every year or so an unexpected turn of events occurred, and new insight was gained,” he said.

– While at the University of Cincinnati, Dr. Liggett, working with colleagues at Washington University and Thomas Jefferson University, found that a genetic variation of an enzyme, which inhibits beta-adrenergic receptor signaling, confers “genetic beta-blockade” in cardiac muscle and protects against early death in African Americans with heart failure.  The findings, published in Nature Medicine, provided insight into individual variations in disease outcomes. Another key study from Cincinnati revealed that a certain combination of genetic variants within a single gene conferred low vs. excellent responses to inhaled beta-agonists in treating asthma. These combinations, called haplotypes, had never been identified in GPCRs. The work was published in Proceedings of the National Academy of Sciences.

Dr. Liggett’s groundbreaking research sequencing all known human rhinoviruses, a frequent cause of respiratory infections, was featured on the April 3, 2009 cover of the journal Science.

Advancing outside his field of study

Dr. Liggett joined USF Health in 2012 from the University of Maryland School of Medicine in Baltimore, where he was associate dean for interdisciplinary research and professor of medicine and physiology. He received his MD degree at the University of Miami and completed both a residency in internal medicine and fellowship in pulmonary diseases and critical care medicine at Washington University School of Medicine and Barnes Hospital in St. Louis, MO.

Within two years, he advanced from a postdoctoral research fellowship in Dr. Lefkowitz’s laboratory at Duke to tenured associate professor and director of pulmonary and critical care medicine at the University of Cincinnati College of Medicine.  By the time he left Cincinnati for the University of Maryland in 2005, he held an endowed chair in medicine and directed the university’s Cardiopulmonary Research Center.

Though he had no significant wet-lab experience, Dr. Liggett was fascinated by the emerging science called “molecular biology” and was undeterred from branching into a field of study in which he had no formal training.

He secured a position as assistant professor at Duke following his fellowship there, and figured out how to sequence adrenergic receptor genes from a patient’s blood. While routine now, such genetic testing had not been done previously.  He unexpectedly kept finding multiple variations (called polymorphisms or mutations) in genes coding for the same receptors, so he sought out the advice of some classic geneticists.  At the time, Dr. Liggett said, their traditional thought was modeled after diseases like cystic fibrosis — if a person had the genetic mutation they developed the disease, if the mutation was absent they did not.

“There was no consideration for common genetic variants and how they might affect disease risk, progression, or response to treatment. It simply was not in their thought process,” Dr. Liggett said. He was told “it’s probably nothing and don’t quit your day job.” He did not take their advice.

COPH sound-icon-png Some advice Dr. Liggett would give to emerging young scientists

 

Assistant professor Donghwa Kim, PhD

Instead, he returned to the laboratory to sequence and clone receptors from many different populations with asthma and heart failure, showing that the receptor genes did indeed differ from one individual to another, generally with several common “versions.” His team also created “humanized” mice expressing the human genes for asthma and heart failure so they could begin to understand the physiology of the receptors. They began to find that some genetic alterations increased receptor function, some decreased the drug’s affinity to bind (responsiveness) to a receptor, and still others altered how the receptor was regulated.  And, through NIH-supported clinical trials, the researchers correlated outcomes observed in patients undergoing drug therapies with the genetic variations uncovered in the laboratory.

“If there’s a lesson to be learned here by young investigators, I’d say it’s that you can collect information from experts in the field, but you need to use your gut to ultimately decide on whether to pursue a line of research or not,” Dr. Liggett said.

Personalized medicine challenge: Common diseases, multiple genetic variations

Realizing personalized medicine’s full potential will require a better understanding of how environmental variables – including diet, exercise, the gastrointestinal microbiome (gut bacteria) and toxin exposure – combine with genetic variations to affect disease and its treatment, he said. “Personalized medicine faces its greatest challenges in the common diseases like asthma, atherosclerotic heart disease and heart failure, because they involve multiple variations in multiple genes that interact with the environment to give you a disease – and also provide a set-up for unique ways to treat the disease.”

Biological scientist Maria Castano

Dr. Liggett was one of the first physicians recruited for what would become the USF Health Heart Institute.  He recalls that he still had the letter of offer in his pocket when he stood before the Hillsborough County Commission in 2012 to help USF Health leadership pitch the need for a cardiovascular institute to include a focus on genomics-based personalized medicine.  The county joined the state in funding the project, and Dr. Liggett was instrumental in the early planning stages of the Heart Institute before the arrival of its founding director Dr. Samuel Wickline.  The institute is now under construction in downtown Tampa as part of the new Morsani College of Medicine facility, a key anchor of Water Street Tampa. Already, 21 of the 31 institute’s biomedical scientists who will investigate the root causes of heart and vascular diseases with the aim of finding new ways to detect, treat and prevent them, have been recruited.

“There’s an excitement here and philosophy of excellence that’s rewarding to see,” Dr. Liggett said. “We have a strategic plan in place, including moving ahead to expand research in cardiovascular disease, infectious disease and the microbiome, and the neurosciences. Our departments are recruiting at a good pace, and the faculty we’re bringing in all have NIH funding and are highly collaborative.”

Dr. Liggett is an elected fellow of the American Association for the Advancement of Science – one of only five Morsani College of Medicine faculty members to receive that prestigious honor.  He is also an elected Fellow of the National Academy of Inventors and the American College of Chest Physicians. Last year, he was one of 30 scientists nationwide selected to join The Research Exemplar Project – recognition of his outstanding reputation as a leader whose high-impact, federally-funded research yields novel and reproducible results.

Over his career, he has served on several NIH study sections and on the editorial board of high-impact journals relevant to fundamental biochemistry as well as heart and lung diseases.  He is currently editor-in-chief of the Journal of Personalized Medicine.

COPH sound-icon-png The potential of new treatments for asthma and heart failure

 

Dr. Liggett holds 18 patents detailing potential new targets for drug therapy or genetic variations of known drug targets, which might be used to predict response to medications and customize treatment.

Some things you may not know about Dr. Liggett:

  • He has asthma, which helps motivate his research toward finding better treatments for this common lung disease affecting one in 12 people in the United States.
  • Restores vintage cars, primarily DeLoreans. Although he recently finished bringing a funky lime green 1974 Volkswagen Thing back to life, and over the holidays restored a 1973 VW camper. 
  • Lives with wife Julie on the beach in Treasure Island, where they enjoy surfing, paddle boarding, and photography.
  • Has three children – Elliott, an engineer at NASA’s Jet Propulsion Laboratory at Cal Tech in Pasadena, CA; Grace, who recently completed her master’s degree in public health at USF; and Mara, an undergraduate student studying social work at Florida Atlantic University, and two step-children — Madison, an undergraduate at the University of Florida, and Tripp, a senior at St. Petersburg Catholic High School. He also has three grandchildren, ages 2 to 9.

– Written by Anne Delotto Baier, photos by Sandra C. Roa, and audio clips by Eric Younghans, University Communications and Marketing

 

 

Dr. Mack Wu studies molecular control of ischemia-reperfusion injury, leaky gut

Featured in the Research Matters July 2017 Issue

 

USF Health researcher Mack Wu, MD, studies what happens when the microvascular endothelial barrier controlling blood-tissue exchange is compromised during ischemia-reperfusion injury, a condition that can lead to irreversible tissue damage. He also investigates the molecular control of gut permeability, also known as “leaky gut,” in tissue injuries caused by trauma and severe burns.

His group’s work has broad implications for a variety of conditions including stroke, heart attack, thrombosis, sepsis, trauma or other inflammatory diseases associated with microvascular injury.

Mack Wu, MD, is a professor of surgery and molecular medicine at USF Health Morsani College of Medicine and a research physiologist at James A. Haley Veterans’ Hospital. On the monitor next to him are images of microvessels in the small intestine injected with fluorescent dye.

The closely connected endothelial cells lining the interior of blood vessel walls play a critical role in limiting the how much fluid, proteins and small molecules cross the wall of the tiny blood vessels, or microvessels. However when this protective endothelial barrier is damaged, excessive amounts of blood fluid, proteins and molecules leak outside the microvessels into nearby body tissue – a process known as microvascular hyperpermeability. If this breech of endothelial barrier is associated with a body-wide inflammatory response, it can trigger a chain of events leading to edema (swelling), shock from severe blood and fluid loss (hypovolemic shock), and ultimately multiple organ failure.

 

Pinpointing Potential Solutions For Ischemia-Reperfusion Injury

Previous research by Dr. Wu’s laboratory and other groups discovered that ischemia-reperfusion injury can cause endothelial barrier damage leading to vascular hyperpermeability, or abnormally leaky blood vessels.

Ischemia-reperfusion injury is typically associated with conditions like organ transplantation, stroke, heart attack, or cardiopulmonary bypass where blood supply to a vital organ is temporarily cut off (ischemia), resulting in oxygen deprivation. For instance, a period of ischemia occurs while a donor organ is transported to a recipient in the operating room, or when a clot interrupts blood circulation to the brain. When blood supply is re-established with new blood returned to the previously oxygen-deprived area (reperfusion), tissue injury can worsen because the reperfusion itself causes inflammation and oxidative damage rather than restoring normal function. It its severest form, ischemia-reperfusion injury can result in multiple organ failure, or even death.

“I believe endothelial barrier injury is one of the key elements of ischemia-reperfusion injury, so my group is trying to find out which molecule is ultimately responsible for the endothelial barrier damage,” said Dr. Wu, a professor of surgery and molecular medicine at USF Health Morsani College of Medicine and a research physiologist at James A. Haley Veterans’ Hospital.

Dr. Wu with some members of his laboratory team. From left, Rebecca Eitnier, research assistant; Shimin Zhang, Department of Molecular Medicine graduate student; Ricci Haines, research associate; and Fang Wang, research assistant.

 

With the support of a $1.49-million, four-year R01 grant from the National Heart, Lung and Blood Institute, Dr. Wu’s team is zeroing in on a molecule known as focal adhesion kinase, or FAK, an enzyme that may play a role in weakening the microvascular endothelial barrier during ischemia-reperfusion injury.   Using cell models and a newly developed mouse model in which the endothelial-specific gene for FAK is knocked out, the USF researchers are testing whether selectively inhibiting FAK activity can rescue the endothelial barrier from such injury.

The work is critical because no FDA-approved treatment exists to prevent tissue damage following reperfusion. Identifying a new mechanism for the injury would provide potential targets for drug development, Dr. Wu said. So for instance, he said, after an initial stroke a new intravenously administered drug selectively targeting endothelial cells in the brain’s microvessels might stop further harmful swelling of the brain caused by stroke.

 

Defining Molecular Control Of “Leaky Gut” In Severe Burn Trauma

A second grant from the U.S. Department of Veterans Affairs funds Dr. Wu’s studies to define the underlying molecular mechanisms of leaky guts induced by traumatic injury associated with thermal (fire, scald or chemical) burns.  Massive burn trauma is a significant cause of injury and death in American soldiers. With a $960,000 VA Merit Award, Dr. Wu focuses on how intestinal epithelial barrier damage happens during severe burns, with the aim of developing targeted therapies to prevent posttraumatic complications.  In particular, he is working to determine the pathways by which the protein palmitoylation in gut epithelial cells are stimulated by burn injury.

Epithelial cells line the interior of the small intestines, and after severe burn injury, this protective epithelial barrier commonly breaks down, causing bacteria and toxins to flow from the intestine into the circulating blood.  The result of this abnormal epithelial permeability, or “leaky gut,” can be deadly if sepsis ensues – a bacterial infection in the bloodstream sets up a body-wide inflammatory response leading to multiple organ failure.

While the role gut barrier failure plays in posttraumatic complications is well recognized, its cellular and molecular mechanisms remain poorly understood.  Currently, pushing IV fluids to help prevent hypovolemic shock and administering antibiotics and anti-inflammatories are the only therapies, mostly supportive, Dr. Wu said.

“More effective early therapeutic interventions to prevent leaky gut and systemic inflammatory response will be key to preventing sepsis,” he added, whether in soldiers with trauma or VA patients with inflammatory bowel diseases.

 

From Industry To Academia

Dr. Wu joined USF Health and the Haley VA Hospital in 2011.  He came from Sacramento, Calif, where he was an associate professor of surgery at the University of California at Davis School of Medicine and a research physiologist at Sacramento VA Medical Center.   Previously, Dr. Wu was a faculty member in the Department of Medical Physiology at Texas A&M University Health Science Center. He screened pharmaceutical compounds as a toxicologist in a biotechnology laboratory before joining Texas A&M, moving from industry to academia in 1995.

Dr. Wu received his MD degree from Second Military Hospital in Shanghai, China, and conducted an internship at Shanghai Second Hospital.

One of his earliest and most highly cited studies, published in the American Journal of Physiology (1996), was first to report nitric oxide’s role in contributing to cardiovascular injury. The study showed an increase in nitric oxide induces vascular endothelial growth factor (VEGF) to promote leakage in tiny coronary veins.

Another more recent study in Shock (2012) provided direct evidence that thermal burn injury causes intestinal barrier disruption and inflammation characterized by intestinal mucosal permeability (leakage) and an infiltration of immune system cells known as neutrophils.

 

Something You May Not Know About Dr. Wu:

He loves deep-sea fishing. Dr. Wu has fished for sharks off the Golf coast of Texas, rockfish off the Pacific coast of California, and grouper off the west coast of Florida.

Dr. Wu is a member of the USF Health Heart Institute. His team’s work has broad implications for a variety of conditions including stroke, heart attack, thrombosis, sepsis, trauma or other inflammatory diseases associated with microvascular injury.

 

– Written by Anne Delotto Baier, photos by Eric Younghans, USF Health Communications and Marketing

 

USF researcher studies irregular cardiac electrical signals

Featured in the Research Matters April 2017 Issue

 

Seeking to understand how the heart short circuits, Sami Noujaim looks for new drugs to fix atrial fibrillation

Within the last three years, USF biomedical scientist Sami Noujaim, PhD, lost his older brother to sudden cardiac death and his 80-year-old father was diagnosed with atrial fibrillation.

The experiences gave Dr. Noujaim a new appreciation for his research on understanding how normal and abnormal electrical impulses are generated in the heart. The Cardiac Electrophysiology Research Laboratory he directs focuses on finding more effective drugs to treat atrial fibrillation, the most common irregular heart rhythm and a condition for which prevalence rises markedly after age 65.

Sami Noujaim, PhD, directs the Cardiac Electrophysiology Research Laboratory in the USF Health Department of Molecular Pharmacology and Physiology.

 

“When life throws something like that at you, the work you do takes on a more personal tone, a sense of mission.  I realized that neither myself nor my loved ones are immune from the cardiovascular diseases I’m studying,” said Dr. Noujaim, an assistant professor in the Morsani College of Medicine’s Department of Molecular Pharmacology and Physiology. “We are all at risk.”

COPH sound-icon-png Dr. Sami Noujaim describes the focus of his laboratory’s research.

Searching For Noninvasive Solutions To Atrial Fibrillation

Atrial fibrillation is a problem with the cardiac electrical circuitry that controls the rate and rhythm of the heartbeat. The condition affects about 9 percent of the U.S. population age 65 or older, according to the Centers for Disease Control and Prevention, and can lead to potentially deadly complications such as stroke and heart failure. While signs of atrial fibrillation may include heart palpitations, fatigue, lightheadedness, dizziness and shortness of breath, some people experience no noticeable symptoms.

Treatment and management options include lifestyle changes, medications to help control heart rate and rhythm and reduce the risk of blood clots, controlled electrical shock (cardioversion to reset heart rhythm), invasive procedures (catheter ablation) and surgical implantation of pacemakers.  However, a major challenge is that atrial fibrillation frequently recurs after normal heart rhythm (sinus rhythm) is restored.

“The existing treatments can be good, but there is a lot of room for improvement, so we are focusing on contributing to noninvasive treatment options,” Dr. Noujaim said. “If we could help physicians get patients with atrial fibrillation to long-term normal sinus rhythm, and perhaps increase the ability to take them off blood thinners, it would be a significant improvement.”

Dr. Noujaim’s laboratory uses specialized equipment to measure the electrical activity of heart muscle cells and image what he describes as “atrial fibrillation in a dish.”

 

Closing In On A Pathway Linking Aging And Afib

Dr. Noujaim currently works with colleagues at USF and other institutions, including Tufts University, the University of Michigan, and Northeastern University, to investigate how age-related changes in specific potassium ion channels known as GIRK may trigger a cascade of molecular events leading to atrial fibrillation. His research, supported by a five-year $2.14 million RO1 grant from the National Heart, Lung and Blood Institute employs techniques including structural biology, molecular simulations, and cellular and whole organ electrophysiology.

The researchers hypothesize that in aging-associated atrial fibrillation, the condition may arise when a biochemical pathway controlling the GIRK postassium channels begins behaving abnormally, in part because of structural and metabolic cardiovascular changes that occur with aging.  High blood pressure, diabetes, and coronary artery disease– among the most common risk factors for atrial fibrillation – become more common as people grow older.

At USF, Dr. Noujaim collaborates with Javier Cuevas, PhD, in Molecular Pharmacology and Physiology, Michael Teng, PhD, in Molecular Medicine and in Allergy and Immunology, and Juan Del Valle, PhD, in Chemistry to investigate ways to target and block the GIRK potassium channels using pharmacological approaches that rely on immunology and chemistry.

Mohammed Alhadidy (left), a biomedical graduate student, and Bojjibabu Chidipi, PhD, a postdoctoral scholar in Molecular Pharmacology and Physiology, record the electrical signals from several cells using a multichannel automated patch clamp.

 

The significance of investigating the relationship between aging and atrial fibrillation.

 

Designing A “Perfect Plug” Using An Antimalarial Drug Model

“Right now, we are trying to design a perfect plug using the antimalarial drug chloroquine as a model,” Dr. Noujaim said, “We have evidence that if we block that specific type of potassium channels we will be able to stop atrial fibrillation or at least reduce its occurrence.”

Earlier work by Dr. Noujaim and others, including a study reported in the journal FASEB, demonstrated that the antimalarial drug chloroquine was effective in blocking the GIRK potassium channels and suggested a new path for discovering antiarrhythmic drugs.

Dr. Noujaim continues using cellular and animal models to pinpoint how and where the chloroquine molecule interacts with the potassium channel – with the aim of discovering a “plug” that works even better than the antimalarial drug. At the same time, he has reached out to USF Health Department of Cardiovascular Sciences to begin applying the laboratory findings to the clinic.

Working with cardiologists Bengt Herweg, MD, and Dany Sayad, MD, Dr. Noujaim recently gained approval for a pilot study to enroll 40 adults without heart damage whose atrial fibrillation has persisted more than one week and less one year. The team will test the effectiveness of chloroquine in restoring and maintaining normal heart rhythm in patients with atrial fibrillation.

The laboratory uses techniques including structural biology, molecular simulations, and cellular and whole organ electrophysiology to conduct its NIH-funded research.

 

Collaborating With Clinicians On New Treatment Options

Dr. Sayad, initially surprised at Dr. Noujaim’s proposal to try chloroquine, said the strength of the preclinical data convinced him of the antimalarial drug’s potential as another antiarrhythmic option. “Treating atrial fibrillation can be especially challenging in older patients, who experience a higher recurrence of atrial fibrillation (following cardioversion) and more failure on drugs used to regulate heart rhythm,” he said.

Clinicians help biomedical scientists like Dr. Noujaim frame and focus their studies to make the research more relevant to challenges faced in treating patients, such as maintaining sinus rhythm once a normal heartbeat has been restored.

“It does not mean that the fundamental, basic science questions are not important,” Dr. Noujaim said. “To the contrary, those questions are at the heart of every single experiment we do; however, we must always think about the big picture and why we are asking those questions. And that always goes back to the clinic.”

In previous electrophysiology experiments, Dr. Noujaim and colleagues helped better define the contribution of the nervous system within the heart, otherwise known as the intrinsic cardiac ganglia, to normal and abnormal heart rhythm. Using both mouse models and patients with atrial fibrillation, the study shed light on how nerves emerging from these cardiac ganglia regulate activity of the sinus node, the heart’s natural pacemaker.  The study appeared in Cardiovascular Research in 2013.

Dr. Noujaim with members of his research team, from left, Bojjibabu Chidipi, Mohammed Alhadidy and laboratory manager Michelle Reiser.

 

Dr. Noujaim comments on the importance of a clinical perspective to frame biomedical research. 

Impressed By USF’s Biomedical Research Opportunities

Dr. Noujaim came to USF in 2015 from the Molecular Cardiology Research Institute at Tufts University School of Medicine. He received his PhD in pharmacology, with distinction, from SUNY Upstate Medical University in Syracuse, NY, followed by a year of postdoctoral training there.  He then completed a three-year postdoctoral fellowship, supported by the American Heart Association, and the National Institutes of Health, at the Center for Arrhythmia Research, University of Michigan, in Ann Arbor, MI.

Dr. Noujaim said he was attracted to USF by the opportunity to be part of an emerging preeminent university committed to establishing a cardiovascular institute bridging top biomedical research and clinical care.

“The opportunities that the University of South Florida is providing for scientists are equal or greater than those at any other major academic medical center,” he said.  “It was also striking to me that, in a place the size of USF, the USF Health leadership is so actively engaged in research, with their own laboratories and grants. That’s not what you would see in a lot of places, and as a biomedical scientist it makes me feel that the leadership here really values research.”

Dr. Noujaim is passionate about the cardiovascular research his laboratory conducts, which he says has taken on a greater sense of mission since his own family’s experience with sudden cardiac death and atrial fibrillation. 

 

COPH sound-icon-png His take on the benefit of brainstorming with scientists in other disciplines.

  • Born in Lebanon, he moved to the United States after graduating from high school.
  • He routinely swims laps in an indoor pool.
  • He enjoys experimenting with cooking, specializing in inventing new dishes by combining ingredients he finds in his refrigerator. “I’ve discovered by trial and error that no matter how bad what I cook really is, adding a tablespoon of soy sauce makes it alright,” he said.
  • His first scientific experiment as a college student volunteering in Boston’s Beth Israel Deaconess Medical Center laboratory was unforgettable. He fainted while his blood was being drawn so he could use it to help study blood platelet activation and aggregation. Click on video below to find out more.

– Written by Anne Delotto Baier, Photos by Sandra C. Roa and Eric Younghans

 

 

 

 

Pioneering nanotechnology research has applications for cardiovascular disease

The USF Health Heart Institute’s new leader Dr. Samuel Wickline arrives with an impressive NIH portfolio and strong track record of entrepreneurial research.

Featured in the Research Matters January 2017 Issue

 

The founding director of the USF Health Heart Institute has a passion for innovation, translational medicine and entrepreneurship.

Samuel A. Wickline, MD, has parlayed his expertise in harnessing nanotechnology for molecular imaging and targeted treatments into an impressive $1-million portfolio of National Institutes of Health awards, multiple patents and four start-up biotechnology companies.

“We’ve developed nanostructures that can carry drugs or exist as therapeutic agents themselves against various types of inflammatory diseases, including, cancer, cardiovascular disease, arthritis and even infectious diseases like HIV,” said Dr. Wickline, who arrived at USF Health last month from the Washington University School of Medicine in St. Louis.

 

 

 

 

COPH sound-icon-png  Dr. Samuel Wickline talks about his vision for the USF Health Heart Institute.

 

At Washington University, Dr. Wickline, a cardiologist, most recently was J. Russell Hornsby Professor in Biomedical Sciences and a professor of medicine with additional appointments in biomedical engineering, physics, and cell biology and physiology.

“I like the challenge of building things,” he said.

In St. Louis, he built a 29-year career as an accomplished physician-scientist keenly interested in translating basic science discoveries into practical applications to benefit patients. He served as chief of cardiology at Jewish Hospital, developed one of the first cardiac MRI training and research programs in the country, helped establish Washington University’s first graduate program in biomedical engineering, and led a university consortium that works with academic and industry partners to develop medical applications for nanotechnology.

At USF, there will be no shortage of challenging opportunities to build.

 

 

Building the USF Health Heart Institute

 

A major part of Dr. Wickline’s new job is helping to design, build and equip the Heart Institute. Most importantly, he will staff the state-of-the-art facility with a critical interdisciplinary mix of top biomedical scientists (including immunologists, molecular biologists, cell physiologists and genomics experts), who investigate the root causes of heart and vascular disease with the aim of finding new ways to detect, treat and prevent them. The Heart Institute will be co-located with new Morsani College of Medicine in downtown Tampa; construction on the combined facility is expected to begin later this year.

“I have been impressed by the energy and commitment here at the University of South Florida to invest substantial resources in a heart institute,” Dr. Wickline said. “I believe we have a lot to offer in terms of bench-to-bedside research that could solve some of the major cardiovascular problems” like atherosclerosis or heart failure.

“We want to put together a program that supplies the appropriate core facilities to attract the best and brightest researchers to this cardiovascular institute.”

Cardiovascular disease is the leading cause of death in the United States and worldwide, so exploring potential new treatment options is critical. One of the Heart Institute’s driving themes will be advancing concepts and findings that prove promising in the laboratory into projects commercialized for clinical use, Dr. Wickline said.

“Our goal is to make a difference in the lives of patients,” he said. “Innovation is not just about having a new idea, it’s about having a useful idea.”

Dr. Wickline also serves as associate dean for cardiovascular research and a professor of cardiovascular sciences at the Morsani College of Medicine. He holds the Tampa General Endowed Chair for Cardiovascular Research created last year with a gift from USF’s primary teaching hospital.

With Washington University colleague Hua Pan, PhD, a biomedical engineer and expert in molecular biology, Dr. Wickline is re-building his group at USF. Dr. Pan was recently recruited to USF as an assistant professor of medicine to continue her collaborations with Dr. Wickline.

 

 

COPH sound-icon-png  An example of Dr. Wickline’s group using nanotechnology to help combat atherosclerosis.

 

 

Dr. Wickline’s lab focuses on building nanoparticles to deliver drugs or other therapeutic agents to specific cell types, or targets.

Designing nanoparticles to “kill the messenger”

 

Dr. Wickline’s lab focuses on building nanoparticles – shaped like spheres or plates, but 10 to 50 times smaller than a red blood cell – to deliver drugs or other therapeutic agents through the bloodstream to specific cell types, or targets. These tiny carrier systems can effectively deliver a sizeable dosage directly to a targeted tissue, yet only require small amounts of the treatment in the circulation to reduce the risk of harmful side effects.

Some types of nanoparticles can carry image-enhancing agents that allow researchers to quantify where the illuminated particles travel, serving as beacons to specific molecules of interest, and enabling one to determine whether a therapeutic agent has penetrated its targeted site, Dr. Wickline said.

Dr. Wickline also is known for designing nanoparticles derived from a component of bee venom called melittin. While bee venom itself is toxic, Dr. Wickline’s laboratory has detoxified the molecule and modified its structure to produce a formula that allows the nanoparticles to carry small interfering (siRNA), also known as “silencing RNA,” or other types of synthetic DNA or RNA strand.

Among other functions, siRNA can be used to inhibit the genes that lead to the production of toxic proteins. Many in the nanotechnology research and development community are working to make siRNA treatment feasible as what Dr. Wickline calls “a message killer,” but the challenges have been daunting.

“The big challenge in the field of siRNA, and many companies have failed at this, is how to get the nanostructure to the cells so that the siRNA can do what it’s supposed – hit its target and kill the messenger — without being destroyed along the way, or having harmful side effects,” Dr. Wickline said. “We figured out how to engineer into a simple peptide all of the complex functionality that allows that to happen.”

 

 

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COPH sound-icon-png  Dr. Wickline comments on how being a physician adds perspective to the science he conducts.

 

 

Different targets, same delivery vehicle

 

In a recent series of experiments in mice, Dr. Wickline and colleagues have shown that silencing RNA messages delivered by nanoparticle to a specific type of immune cell known as a macrophage – a “big eater” of fat – actually shrinks plaques that accumulate inside the walls of the arteries during atherosclerosis, one of the main causes of cardiovascular disease. The build-up of atherosclerotic plaques with fat-laden macrophages narrows, weakens and hardens arteries, eventually reducing the amount of oxygen-rich blood delivered to vital organs.

This type of plaque-inhibiting nanotherapy could be useful in aggressive forms of atherosclerosis where patients have intractable chest pain or after an acute heart attack or stroke to prevent a secondary cardiac event, Dr. Wickline said.

In another study, Washington University School of Medicine researchers investigated the potential of the siRNA nanoparticle designed by co-investigators Dr. Pan and Dr. Wickline in treating the inflammation that may lead to osteoarthritis, a degenerative joint disease that is a major cause of disability in the aging population. The nanoparticles — injected directly into injured joints in mice to suppress the activity of the molecule NF-κB — reduced local inflammation immediately following injury and reduced the destruction of cartilage. The findings were reported September 2016 in the Proceedings of the National Academy of Sciences.

Previously, Dr. Wickline said, the Washington University group had shown that nanoparticles delivered through the bloodstream inhibited inflammation in a mouse model of rheumatoid arthritis. And, another laboratory at the University of Kentucky is studying whether locally injected siRNA nanoparticles can quell the bacterial inflammation that can lead to a serious gum disease known as periodontitis. Other collaborating labs are using these nanoparticles in pancreatic, colon, and ovarian cancers with good effects.

“The specific targets in these cases may be different, but the nice thing about this kind of delivery system for RNA interference is that the delivery agent itself, the nanostructures, are the same,” Dr. Wickline said. “All we have to do is change out a little bit of the genetic material that targets the messages and we’re set up to go after another disease. So it’s completely modular and nontoxic.”

The St. Louis-based biotechnology company Trasir Therapeutics is developing these peptide-based nanocarriers for silencing RNA to treat diseases with multiple mechanisms of inflammation. Dr. Wickline co-founded the company in 2014 and continues to serve as its chief scientific officer.

Dr. Wicklne: “Innovation is not just about having a new idea, it’s about having a useful idea.”

 

COPH sound-icon-png  Inhibiting chronic inflammation without getting rid of beneficial immune responses.

 

 

Calming the destructive cycle of inflammation

 

Dr. Wickline’s work is supported by several NIH RO1 grants, including one from the National Heart, Lung and Blood Institute to develop and test nanotherapies seeking to interrupt inflammatory signaling molecules and reduce the likelihood of thrombosis in acute cardiovascular syndromes.

In essence, Dr. Wickline said, he is interested in suppressing chronic inflammation, without disrupting the beneficial functions of surveillance by which the immune system recognizes and destroys invading pathogens or potential cancer cells.

“If you can inhibit the ongoing inflammation associated with (inappropriate) immune system response, you inhibit the positive feedback cycle of more inflammation, more plaques, more damage and more danger,” he said. “If you can cool off inflammation by using a message killer that says (to macrophages) ‘don’t come here, don’t eat fat, don’t make a blood clot’ – that’s what we think could be a game changer.”

Another NIH grant has funded collaborative work to develop an image-based nanoparticle that detects where in a compromised blood vessel too much blood clotting (hypercoagulation) occurs, and delivers potent anti-clotting agent only to that site. Formation of abnormal blood clots can trigger a heart attack when a clot blocks an artery that leads to heart muscle, or a stroke when a clot obstructs an artery supplying blood to the brain.

Because this site-specific nanotherapy targets only areas of active clotting, it may provide a safer, more effective approach against cardiac conditions like atrial fibrillation and acute heart attack than existing anticoagulant drugs such as warfarin and newer blood thinners like Xarelto® (rivaroxoban) or Eliquis® (apixiban), all which work systemically and come with raised risk for serious bleeding, Dr. Wickline said.

In a study published last year in the journal Arteriosclerosis, Thrombosis, and Vascular Biology, Dr. Wickline and colleagues found that nanoparticles delivering a potent inhibitor of thrombin, a coagulant protein in blood that plays a role in inflammation, not only reduced clotting risk but also rapidly healed blood vessel endothelial barriers damaged during plaque growth.

The preclinical work showed the experimental treatment “is actually an anti-atherosclerotic drug as well as an anti-clotting drug, so there are many potential applications,” Dr. Wickline said.

Dr. Wickline received his MD degree from the University of Hawaii School of Medicine. He completed a residency in internal medicine, followed by clinical and research fellowships in cardiology at Barnes Hospital and Washington University, where he joined the medical school faculty in 1987.

He has authored more than 300 peer-reviewed papers and holds numerous U.S. patents. Dr. Wickline is a fellow of the American College of Cardiology and the American Heart Association, and a 2014 recipient of the Washington University Chancellor’s Award for Innovation and Entrepreneurship.

 

 

Some things you may not know about Dr. Wickline

  • His first scientific experiment was conducted at age 21, before entering medical school, when he worked in a research laboratory in Hawaii run by a cardiovascular surgeon interested in techniques to best support the heart during cardiopulmonary bypass surgery. Dr. Wickline figured out why one particular way of perfusing blood through the heart pump machine could dangerously compromise oxygenated blood flow to the brain. The results were published in the Annals of Thoracic Surgery. One of Dr. Wickline’s first studies in medical school, published in the prestigious journal Circulation, described a method for determining the size of a heart attack by recording electrical signals, called vector cardiograms.
  • He grew up in St. Petersburg, Fla., and did some trick water skiing as a teen. “I learned how to ski backwards.” After being “landlocked” in Missouri for 37 years following medical school in Hawaii, he said he’s glad for the opportunity to get back to get back to the beach and water sports.
  • He likes to play the ukulele.

 

– Story by Anne Delotto Baier, photos and video by Sandra C. Roa

 

 

 

 

 

 

 

 

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