Name: phenotypic and functional analysis of activated regulatory t cells isolated from chronic lymphocytic choriomeningitis virus-infected mice
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Description: Watch this Scientific Journal Video about Phenotypic and Functional Analysis of Activated Regulatory T Cells Isolated from Chronic Lymphocytic Choriomeningitis Virus-infected Mice at JoVE.com

This work was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2015R1A6A3A01020610 to HJP) and a grant from the Korean Health Technology R&amp;D Project, Ministry for Health, Welfare and Family Affairs, Republic of Korea (HI15C0493 to SJH).

In dieser Studie wurden die Mäuse in einem spezifischen Pathogen freie Einrichtung des Yonsei Laboratory Animal Research Center of Yonsei University gehalten. mit von der International genehmigten Protokollen Animal Care und Use Committee des Yonsei Laboratory Animal Research Center an der Yonsei University Alle Tierversuche wurden in Übereinstimmung mit den koreanischen Food and Drug Administration Richtlinien durchgeführt. 1. Herstellung der Lösungen <ol><li> Bereiten 2% RPMI-Medium ...

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Obwohl nur eine kleine Anzahl von T reg Zellen in Mäusen und Menschen vorhanden sind , ist es wichtig , ihre Funktion zu verstehen , wie sie die Immunantwort bei der Regulierung und Aufrechterhaltung der Immuntoleranz eine wichtige Rolle spielen. Die Anzahl und die unterdrückenden Funktionen von T reg Zellen erhöht sich während einer chronischen Virusinfektion 15-20 sowie Krebsprogression 13,14. Dies ist wahrscheinlich aufgrund der fortgesetzten Antigen-Stimulation. Zur Au...

Regulatorische T (T reg) Zellen exprimieren forkhead box P3 (Foxp3) als Transkriptionsfaktor für ihre Entwicklung und Funktion 1. Zusätzlich exprimieren T reg Zellen verschiedene andere Moleküle wie CD25 2, Lymphozytenaktivierung Gen 3 (LAG-3) 3, Glucocorticoid-induzierter Tumor necrosis factor receptor 4 und zytotoxische T-Lymphozyten assoziiertes Protein 4 (CTLA-4) 5 auf ihrer Oberfläche oder intrazelluläre Region. Während einer chronischen Infektion mit verschiedenen Arten von Krankheitserregern wie Viren 6,7, Bakterien 8,9 und Parasiten 10-12, oder im Verlauf der Krebsentwicklung 13,14 geworden T reg Zellen in aktivierten Zellen differenziert, verbesserte Unterdrückungsfunktion anzeigt Targeting - Effektor CD4 + und CD8 + T - Zellen. Eine Reihe von Arbeiten haben vorgeschlagen , dass erweitert und aktivierten T - reg - Zellen auf die Beeinträchtigung der CD8 + T - Zell - respons beitragene während Freund Retrovirus (FV) Infektion 15-17. FV-induzierte T - Zellen hemmen reg IFN-γ oder Granzym B Expression und zytotoxische Reaktivität von CD8 + T - Zellen 15-17. Darüber hinaus wurde in einem Herpes simplex - Virus - Infektionsmodell berichtet geführt , die Depletion von CD4 + CD25 + T - Zellen in reg Expansion der virusspezifischen CD8 + T - Zellen und schwere Gewebeschäden durch Infiltration von immunopathogenen CD4 + T - Zellen 18-20. Mäuse chronisch mit dem 13 - Stamm von lymphatischer choriomeningitis Virusklon infiziert (LCMV CL13) 21-24 haben den Phänotyp und die Funktion der Effektor - T - Zellen (T eff) und T reg Zellen während der chronischen Virusinfektion weit verbreitet zu charakterisieren. Während persistent LCMV - Infektion, Virus-spezifischen T - Zellen eff schrittweise ihre Effektor - Funktion verlieren und erschöpft T (T exh) Zellen werden. Auf der anderen Seite, Treg Zellen verstärken ihre Fähigkeit , 25 Virus-spezifischen T - Zell - Antwort zu unterdrücken. Die Abnahme der Funktionsfähigkeit der T eff Zellen kann durch verschiedene Faktoren wie Aufregulation von inhibitorischen Rezeptoren auf T eff Zellen veränderte Funktion von Antigen-präsentierenden Zellen, die Herstellung von immunregulatorischen Zytokine und erhöhter Frequenz oder verstärkte Funktion von T reg erklärt Zellen 26. Unter den Faktoren , die bei T - Zell - Unterdrückung, den programmierten Zelltod - Protein-1 (PD-1) exprimierenden T exh Zellen und T - reg - Zellen wurden als Kennzeichen der Antigen Persistenz und unterdrückende Umwelt weit betrachtet. Vor kurzem wurde berichtet , dass die Blockade des PD-1 - Weg und Ablation von T reg Zellen verbesserte T - Zell - Funktion führen und Viruslast während LCMV chronischen Infektion 27 verringert. Darüber hinaus werden T reg Zellen während einer chronischen Infektion von Mäusen mit LCMV aktiviert 23,25 </sup&gt; und ihre unterdrückende Funktion 25 verstärkt. PD-1 ist stark auf T - Zellen exprimiert reg sowie T exh Zellen und der Grad der PD-1 durch T - Zellen exprimiert reg korreliert mit der Stärke ihrer suppressive Funktion T - Zell - Proliferation 25 zu hemmen. Hier beschreiben wir ein Verfahren mit den Merkmalen von aktivierten T - reg - Zellen von Mäusen , infiziert mit LCMV CL13 und ruhenden T reg Zellen isoliert aus naiven Mäusen isoliert zu vergleichen. Weiterhin erläutern wir eine Reihe von Prozessen aktiviert T reg Zellen zu trennen und ihre ex vivo Phänotyp zu untersuchen, sowie ihre suppressive Aktivität in vitro zu messen.

<table border="0" cellpadding="0" cellspacing="0" width="976">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:383px;">FITC Rat Anti-Mouse CD4</td>
			<td style="width:67px;">RM4-5</td>
			<td style="width:173px;">BD Biosciences</td>
			<td style="width:104px;">553047</td>
			<td style="width:249px;">Please determine appropriate concentration. In this protocol, this reagent was diluted 100X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Cytofix/Cytoperm</td>
			<td></td>
			<td>BD Biosciences</td>
			<td>554714</td>
			<td>Use this reagent for cell surface staining.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">U-Bottom Tissue Culture Plates</td>
			<td></td>
			<td>BD Biosciences</td>
			<td>353077</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Fixation buffer</td>
			<td></td>
			<td>BD Biosciences</td>
			<td align="right">554655</td>
			<td>Use this reagent for cell surface staining.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">FITC Rat Anti-Mouse CD25</td>
			<td>7D4</td>
			<td>BD Biosciences</td>
			<td>553072</td>
			<td>Please determine appropriate concentration. In this protocol, this reagent was diluted 100X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Cell strainer, 70mm</td>
			<td></td>
			<td>BD Biosciences</td>
			<td>352350</td>
			<td>Use this strainer for grinding the whole spleen.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Cell strainer, 40mm</td>
			<td></td>
			<td>BD Biosciences</td>
			<td>352340</td>
			<td>Use this strainer for filtering the cells before column enrichment.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Brilliant Violet 421 Anti-mouse CD279 (PD-1)</td>
			<td>29F.1A12</td>
			<td>BioLegend</td>
			<td>135217</td>
			<td>Please determine appropriate concentration. In this protocol, this reagent was diluted 100X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Brilliant Violet 605 Anti-Mouse CD4</td>
			<td>RM4-5</td>
			<td>Biolegend</td>
			<td align="right">100547</td>
			<td>Please determine appropriate concentration. In this protocol, this reagent was diluted 100X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">APC Anti-Mouse/Rat Foxp3&#160;</td>
			<td>FJK-16s</td>
			<td>eBioscience</td>
			<td>17-5773</td>
			<td>Please determine appropriate concentration. In this protocol, this reagent was diluted 100X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Foxp3 / Transcription Factor Staining Buffer Set</td>
			<td></td>
			<td>eBioscience</td>
			<td>00-5223</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">PerCP-Cyanine5.5 Anti-Mouse CD8a</td>
			<td>53-6.7</td>
			<td>eBiosicence</td>
			<td>45-0081</td>
			<td>Please determine appropriate concentration. In this protocol, this reagent was diluted 100X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Mouse IFN-gamma Platinum ELISA</td>
			<td></td>
			<td>eBiosicence</td>
			<td>BMS606</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">RPMI 1640</td>
			<td></td>
			<td>GE Life Sciences</td>
			<td>SH30027</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">PBS (1X)</td>
			<td></td>
			<td>GE Life Sciences</td>
			<td>SH30256</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">ACK Lysing Buffer</td>
			<td></td>
			<td>Gibco</td>
			<td>A10492-01</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">L-Glutamine, 200mM solution</td>
			<td></td>
			<td>Gibco&#160;</td>
			<td>25030</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Penicillin-Streptomycin, 10,000U/mL</td>
			<td></td>
			<td>Gibco&#160;</td>
			<td>10378-016</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">LIVE/DEAD Fixable Near-IR Dead Cell Stain Kit</td>
			<td></td>
			<td>Life technologies</td>
			<td>L-34975</td>
			<td>Please determine appropriate concentration. In this protocol, this reagent was diluted 500X in FACS buffer.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">CD8a+ T Cell Isolation Kit, mouse</td>
			<td></td>
			<td>Miltenyibiotec</td>
			<td>130-104-075</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">CD4+CD25+ Regulatory T Cell Isolation Kit, mouse</td>
			<td></td>
			<td>Miltenyibiotec</td>
			<td>130-091-041</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">MACS Separation Columns, LD columns</td>
			<td></td>
			<td>Miltenyibiotec</td>
			<td>130-042-901</td>
			<td>Use this column for Treg cell isolation</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">MACS Separation Columns, LS columns</td>
			<td></td>
			<td>Miltenyibiotec</td>
			<td>130-042-401</td>
			<td>Use this column for CD8+ T cell and Treg cell isolation</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">EDTA, 0.5M (pH 8.0)</td>
			<td></td>
			<td>Promega</td>
			<td>V4231</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">2-Mercaptoethanol</td>
			<td></td>
			<td>Sigma Life Science</td>
			<td>M7522</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Fetal Bovine Serum</td>
			<td></td>
			<td>Thermo Fisher Scientific</td>
			<td>SH30919.03</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">CellTrace Violet Cell Proliferation Kit</td>
			<td></td>
			<td>Thermo Fisher Scientific</td>
			<td>C34557</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">BD Canto II flowcytometer</td>
			<td></td>
			<td>BD Biosciences</td>
			<td></td>
			<td>Flow cytometer*</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Flowjo</td>
			<td></td>
			<td>TreeStar</td>
			<td></td>
			<td>Flow cytometry software&#8224;</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Hematocytomer</td>
			<td></td>
			<td>Marienfeld superior</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

phenotypic and functional analysis of activated regulatory t cells isolated from chronic lymphocytic choriomeningitis virus-infected mice

Regulatory T (T reg) Zellen, die Foxp3 als Transkriptionsfaktor exprimieren, sind Untergruppen von CD4 + T - Zellen. T reg - Zellen spielen eine entscheidende Rolle bei der Immuntoleranz und Homöostase Wartung durch die Immunantwort regulieren. Die primäre Rolle der T reg Zellen ist , die Proliferation von Effektor - T (T eff) Zellen und die Produktion von Zytokinen wie IFN-γ, TNF-α und IL-2 zu unterdrücken. Es wurde gezeigt , dass T reg Zellen die Fähigkeit , die Funktion von T - Zellen zu hemmen eff während persistent Pathogen - Infektion und der Entwicklung von Krebs verbessert. Um die Funktion von T reg Zellen unter ruhenden oder entzündeten Bedingungen, die eine Vielzahl von in - vitro - Unterdrückung Tests unter Verwendung von Maus oder humanen T - reg - Zellen klären entwickelt worden. Das Hauptziel dieser Studie ist es, ein Verfahren zu entwickeln , um die Unterschiede im Phänotyp und unterdrückende Funktion zwischen ruhenden und aktivierten T reg zu vergleichenZellen. Um aktivierten T - reg - Zellen wurden die Mäuse infiziert mit lymphatischer choriomeningitis Virus (LCMV) Klon 13 (CL13), eine chronische Belastung von LCMV isolieren. T reg Zellen aus der Milz von LCMV CL13-infizierten Mäusen isoliert zeigten sowohl die aktivierten Phänotyp und verbesserte suppressive Aktivität gegenüber T - Zellen aus naiven reg Mäusen isoliert ruht. Hier beschreiben wir die Basisprotokoll für ex vivo - Phänotyp - Analyse aktivierten T - reg - Zellen unterscheiden von T reg ruhenden Zellen. Weiterhin beschreiben wir ein Protokoll für die Messung der suppressive Aktivität von vollständig aktivierten T reg Zellen.

Wir erzeugten Mäuse mit persistenten Virusinfektion , indem sie mit 2 × 10 6 pfu von LCMV CL13 intravenös injiziert wird . Um die phänotypische Veränderungen in T reg Zellen und T conv Zellen während der chronischen Virusinfektion, Milzlymphozyten erhalten von naiven und infizierten Mäusen wurden gefärbt mit verschiedenen Antikörpern und analysiert mittels Durchflusszytometrie untersucht. CD4 + T conv (1A, o...

Watch this Scientific Journal Video about Phenotypic and Functional Analysis of Activated Regulatory T Cells Isolated from Chronic Lymphocytic Choriomeningitis Virus-infected Mice at JoVE.com

Phenotypic and Functional Analysis of Activated Regulatory T Cells Isolated from Chronic Lymphocytic Choriomeningitis Virus-infected Mice

Here, we describe a protocol to analyze the phenotype of regulatory T (Treg) cells isolated from na&#239;ve and chronic lymphocytic choriomeningitis virus-infected mice. In addition, we provide a process to evaluate the suppressive activity of the Treg cells.

Die phänotypische und funktionale Analyse von aktivierten regulatorischen T-Zellen isoliert von chronischer lymphatischer Choriomeningitisvirus-infizierte Mäuse

Regulatory T (Treg) cells, which express Foxp3 as a transcription factor, are subsets of CD4+ T cells. Treg cells play crucial roles in immune tolerance ...

The overall goal of this procedure is to evaluate the in vitro suppressive function of regulatory T cells, isolated from chronic virus infected mice. This method can help answer questions about the phenotype and in vitro suppressive function of activated regulatory T cells during a chronic virus infection. This technique can evaluate the direct effect of regulatory T cells on the individual with a positive response to T cells in vitro.This is a great advantage of this technique. Begin by transferring five times ten to the fifth total splenic lymphocytes in 50 microliters of facs buffer into each well of a new U bottom 96 well plate, followed by 150 microliters of facs buffer. Centrifuge the plate and discard the supernatant.Then agitate the cell pellets and wash the cells two more times in 200 microliters of facs buffer per well. After the second wash, resuspend the pellets in 50 microliters of antibody cocktail per well, for 20 minutes in the dark at four degrees Celsius. Then wash the cells two times in facs buffer, and decant the supernatant.Next, fix the cells for 20 minutes in the dark at four degrees Celsius with 100 microliters of fixation buffer, followed by two washes with permeabilization wash buffer. After the second wash, resuspend the cells in 50 microliters of anti-FOXP3 antibody. To prepare the anti CD3 CD28 coated beads, transfer the appropriate volume of magnetic beads into a 15 milliliter tube, and add an equal volume of PPS.Gently mix the solution by pipetting, and centrifuge the magnetic beads. At the end of the wash, discard the supernatant, and dilute the beads in 50 microliters of complete medium per well. Next, seed 50 microliters of one times ten to the fifth CD4 positive CD25 positive regulatory T cells per well in a 96 well U bottom plate, followed by 50 microliters of one times ten to the fifth CD8 positive responder T cells per well.When all of the cells have been plated, add 50 microliters of the diluted anti CD3 CD28 coated beads to each well, and add up to 50 microliters of medium to bring the total volume of each well up to 200 microliters. Then cover the plate with foil and place it at 37 degrees Celsius in a carbon dioxide incubator for 72 hours. To analyze the CD8 positive T cell cytokine production, after three days of culture, transfer the supernatants into another 96 well plate and analyze the supernatants by ELISA, according to the manufacturer's instructions.To analyze the proliferation of the CD8 positive T cells, wash the plate of cells with facs buffer three times. Then resuspend the pellets in 50 microliters of an appropriate antibody cocktail against proliferated CD8 positive T cells for 20 minutes in the dark at four degrees Celsius. At the end of the incubation, wash the cells two times in facs buffer and fix them for 20 minutes in the dark at four degrees Celsius with 100 microliters of fixation buffer.Finally, wash the cells two more times in facs buffer and resuspend the pellets in 200 microliters of facs buffer. Then measure the percentage of phylate dilabelled CD8 positive T cell proliferation by flow cytometry. In splenic lymphocytes obtained from naive and infected mice, PD-1 is specifically up regulated in both conventional FOXP3 negative CD4 positive and FOXP3 negative CD8 positive cells of LCMV clone 13 infected mice.The frequency of FOXP3 positive CD4 positive regulatory T cells is two times higher in LCMV clone 13 infected mice than in naive mice, with most of the FOXP3 positive CD4 positive cells also displaying an activated PD-1 high phenotype. CD8 positive responder T cells can be separated successfully without significant contamination by other immune cells. After regulatory T cell isolation, a dominant population of CD25 positive CD4 positive T cells with more than 80 percent purity can be obtained.The stimulation of isolated regulatory and responder T cells by anti CD3 CD28 coated beads results in the inhibition of CD8 positive responder T cells in a dose dependent manner. Indeed, when CD8 positive responder T cells are co-cultured with chronic regulatory T cells at a one to one ratio, the CD8 positive responder T cell proliferation is significantly inhibited. Interferon gamma production by CD8 positive responder cells is also significantly inhibited when CD8 positive responder T cells are co-cultured with activated regulatory T cells from chronically infected mice, compared to co-culture with resting regulatory T cells from naive mice.We have found this technique can be completed in 80 hours if it is performed properly. While you are attempting this procedure, it is important to remember to use freshly isolated regulatory T cells immediately after their isolation. After this development, this technique paved the way for researchers in the field of medicine to explore the function of regulatory T cells in a chronic inflammatory disease.After watching this video, you should have a good understanding of how to set up an in vitro regulatory T cell suppression procedure, using a regulatory and responder T cell co-culture system.

Research

JoVE Journal

Immunology and Infection

Generation of Induced Regulatory T Cells from Primary Human Na&iuml;ve and Memory T Cells

Generation of Induced Regulatory T Cells from Primary Human Na&#239;ve and Memory T Cells

Generation der induzierte regulatorische T-Zellen aus primären humanen naiven und Gedächtnis-T-Zellen

The development and maintenance of immunosuppressive CD4+ regulatory T cells (Tregs) contribute to the peripheral tolerance needed to remain in ...

Forschung

Immunologie und Infektion

New Tools to Expand Regulatory T Cells from HIV-1-infected Individuals

Neue Tools erweitern regulatorischen T-Zellen von HIV-1-infizierten Personen

CD4+ Regulatory T cells (Tregs) are potent immune modulators and serve an important function in human immune homeostasis. Depletion of Tregs has led to ...

Lymphocyte Isolation from Human Skin for Phenotypic Analysis and Ex Vivo Cell Culture

Lymphocyte Isolation from Human Skin for Phenotypic Analysis and Ex Vivo Cell Culture

Lymphocyte Isolierung von menschlicher Haut für phänotypische Analyse und<em&gt; Ex Vivo</em&gt; Zellkultur

Human skin has an important barrier function and contains various immune cells that contribute to tissue homeostasis and protection from pathogens. As the ...

Determination of Biofilm Initiation on Virus-infected Cells by Bacteria and Fungi

Bestimmung von Biofilm Initiation auf Virus-infizierte Zellen durch Bakterien und Fungi

The study of polymicrobial interactions across the taxonomic kingdoms that include fungi, bacteria and virus have not been previously examined with ...

Functional Characterization of Regulatory Macrophages That Inhibit Graft-reactive Immunity

Funktionelle Charakterisierung von regulatorischen Makrophagen, die eine pfropfreaktive Immunität hemmen

Macrophage accumulation in transplanted organs has long been recognized as a feature of allograft rejection1. Immunogenic monocytes infiltrate the ...

Development of Stem Cell-derived Antigen-specific Regulatory T Cells Against Autoimmunity

Entwicklung von Stammzellen abgeleiteten Antigen-spezifische regulatorische T-Zellen gegen Autoimmunität

Autoimmune diseases arise due to the loss of immunological self-tolerance. Regulatory T cells (Tregs) are important mediators of immunologic ...

In Vitro Differentiation of Human CD4+FOXP3+ Induced Regulatory T Cells (iTregs) from Na&#239;ve CD4+ T Cells Using a TGF-&#946;-containing Protocol

In vitro Differenzierung von humanen CD4 + FOXP3 + Induced regulatorischer T - Zellen (iTregs) von Naïve CD4 + T - Zellen unter Verwendung eines TGF-β-enthaltende Protokoll

Regulatory T cells (Tregs) are an integral part of peripheral tolerance, suppressing immune reactions against self-structures and thus preventing ...

Single-cell Quantitation of mRNA and Surface Protein Expression in Simian Immunodeficiency Virus-infected CD4+ T Cells Isolated from Rhesus macaques

Single-cell Quantitation of mRNA and Surface Protein Expression in Simian Immunodeficiency Virus-infected CD4+ T Cells Isolated from Rhesus macaques

Einzellige Quantifizierung der mRNA und Oberfläche Protein-Expression in Simian Immunodeficiency Virus-infizierten CD4+ T Zellen isoliert von Rhesus-Makaken

Single-cell analysis is an important tool for dissecting heterogeneous populations of cells. The identification and isolation of rare cells can be ...

In Vivo Augmentation of Gut-Homing Regulatory T Cell Induction

In Vivo Augmentation der Gut-Homing Regulatory T Cell Induction

Inflammatory bowel disease (IBD) is an inflammatory chronic disease in the gastrointestinal tract (GUT). In the United States, there are approximately 1.4 ...