[Show abstract][Hide abstract] ABSTRACT: The use of tumour-associated antigens for cancer immunotherapy studies is exacerbated by tolerance to these self-antigens. Tolerance may be broken by using ex vivo monocyte-derived dendritic cells (DCs) pulsed with self-antigens. Targeting tumour-associated antigens directly to DCs in vivo is an alternative and simpler strategy. The identification of cell surface receptors on DCs, and targeting antigens to DC receptors, has become a popular approach for inducing effective immune responses against cancer antigens. Many years ago, we demonstrated that targeting the mannose receptor on macrophages using the carbohydrate mannan to DCs led to appropriate immune responses and tumour protection in animal models. We conducted Phase I, I/II and II, clinical trials demonstrating the effectiveness of oxidised mannan-MUC1 in patients with adenocarcinomas. Here we summarise DC targeting approaches and their efficacy in human clinical trials.
[Show abstract][Hide abstract] ABSTRACT: The predominant proteins of the CNS are myelin basic protein, proteolipid protein (PLP) and myelin oligodendrocyte glycoprotein. PLP139-151 is one of the major encephalitogenic epitopes of PLP. The epitope PLP139-151 binds to MHC class II (I-A(s)) of SJL/J mice and induces Th1 responses.
[Show abstract][Hide abstract] ABSTRACT: Mucin 1 antigen, highly expressed by epithelial ovarian cancer (EOC), is a potential target for immunotherapy. A previous successful phase 1 trial was conducted in patients with adenocarcinoma who were injected with Cvac, autologous monocyte-derived dendritic cells (DCs) incubated with mannosylated mucin 1 protein (M-FP). The present study was a phase 2 trial of Cvac in patients with advanced EOC.
Journal for immunotherapy of cancer. 01/2014; 2:16.
[Show abstract][Hide abstract] ABSTRACT: Little is known of the impact of Fc receptor (FcR) polymorphism in macaques on the binding of human (hu)IgG, and nothing is known of this interaction in the pig-tailed macaque (Macaca nemestrina), which is used in preclinical evaluation of vaccines and therapeutic Abs. We defined the sequence and huIgG binding characteristics of the M. nemestrina activating FcγRIIa (mnFcγRIIa) and inhibitory FcγRIIb (mnFcγRIIb) and predicted their structures using the huIgGFc/huFcγRIIa crystal structure. Large differences were observed in the binding of huIgG by mnFcγRIIa and mnFcγRIIb compared with their human FcR counterparts. MnFcγRIIa has markedly impaired binding of huIgG1 and huIgG2 immune complexes compared with huFcγRIIa (His(131)). In contrast, mnFcγRIIb has enhanced binding of huIgG1 and broader specificity, as, unlike huFcγRIIb, it avidly binds IgG2. Mutagenesis and molecular modeling of mnFcγRIIa showed that Pro(159) and Tyr(160) impair the critical FG loop interaction with huIgG. The enhanced binding of huIgG1 and huIgG2 by mnFcγRIIb was shown to be dependent on His(131) and Met(132). Significantly, both His(131) and Met(132) are conserved across FcγRIIb of rhesus and cynomolgus macaques. We identified functionally significant polymorphism of mnFcγRIIa wherein proline at position 131, also an important polymorphic site in huFcγRIIa, almost abolished binding of huIgG2 and huIgG1 and reduced binding of huIgG3 compared with mnFcγRIIa His(131). These marked interspecies differences in IgG binding between human and macaque FcRs and polymorphisms within species have implications for preclinical evaluation of Abs and vaccines in macaques.
The Journal of Immunology 12/2013; · 5.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Targeting antigens to dendritic cell receptors has recently become a popular approach to inducing effective immune responses against cancer antigens. Almost 20 years ago, however, we demonstrated that targeting the mannose receptor on macrophages and dendritic cells leads to strong cellular immune responses. We conducted numerous human clinical trials demonstrating the effectiveness of oxidized mannan-MUC1 (M-FP) in MUC1(+) adenocarcinoma patients. In one trial, the 5-8-year follow-up of breast cancer patients vaccinated with M-FP was published previously; we now report here the 12-15-year follow-up. Details regarding the preparation of the vaccine, inclusion and exclusion criteria, immunotherapy and follow-up schedule, were published previously. Results: The follow-up at 12-15 years showed that the recurrence rate in patients receiving placebo was 60% (nine of 15). In those receiving immunotherapy (M-FP), the rate was 12.5% (two of 16). The time of recurrence in the placebo group ranged from 7 to 180 months (mean: 65.8 months) and in the two patients of the vaccine group, the recurrence appeared at 95 and 141 months (mean: 118 months) after surgery. These findings are statistically significant (p = 0.02 for survival and p = 0.009 for percentage of patients cancer-free). All patients injected with M-FP showed no evidence of toxic effects or signs of autoimmunity during the 12-15-year follow-up. Discussion: The preliminary evidence indicates that M-FP is beneficial in the overall survival of early-stage breast cancer patients. This long-term clinical follow-up of patients strongly supports the necessity for a large Phase III study of direct M-FP injection in early-stage breast cancer patients, to evaluate immunotherapy as an adjuvant treatment for breast cancer.
[Show abstract][Hide abstract] ABSTRACT: Previous studies on the role of the tetraspanin CD37 in cellular immunity appear contradictory. In vitro approaches indicate a negative regulatory role, whereas in vivo studies suggest that CD37 is necessary for optimal cellular responses. To resolve this discrepancy, we studied the adaptive cellular immune responses of CD37(-/-) mice to intradermal challenge with either tumors or model antigens and found that CD37 is essential for optimal cell-mediated immunity. We provide evidence that an increased susceptibility to tumors observed in CD37(-/-) mice coincides with a striking failure to induce antigen-specific IFN-γ-secreting T cells. We also show that CD37 ablation impairs several aspects of DC function including: in vivo migration from skin to draining lymph nodes; chemotactic migration; integrin-mediated adhesion under flow; the ability to spread and form actin protrusions and in vivo priming of adoptively transferred naïve T cells. In addition, multiphoton microscopy-based assessment of dermal DC migration demonstrated a reduced rate of migration and increased randomness of DC migration in CD37(-/-) mice. Together, these studies are consistent with a model in which the cellular defect that underlies poor cellular immune induction in CD37(-/-) mice is impaired DC migration.
European Journal of Immunology 02/2013; · 4.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The direct or indirect targeting of antibody Fc receptors (FcRs) presents unique opportunities and interesting challenges for the treatment of inflammatory diseases, cancer and infection. Biological responses induced via the Fc portions of antibodies are powerful, complex and unusual, and comprise both activating and inhibitory effects. These properties can be exploited in the engineering of therapeutic monoclonal antibodies to improve their activity in vivo. FcRs have also emerged as key participants in the pathogenesis of several important autoimmune diseases, including systemic lupus erythematosus and rheumatoid arthritis. Therapeutic approaches based on antagonizing FcR function with small molecules or biological drugs such as monoclonal antibodies and recombinant soluble FcR ectodomains have gained momentum. This Review addresses various strategies to manipulate FcR function to overcome immune complex-mediated inflammatory diseases, and considers approaches to improve antibody-based anticancer therapies.
dressNature Reviews Drug Discovery 04/2012; 11(4):311-31. · 37.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cytoplasmic delivery and cross-presentation of proteins and peptides is necessary for processing and presentation of antigens for the generation of cytotoxic T cells. We previously described the use of the 16 amino acid peptide penetratin from the Drosophila Antennapedia homeodomain (penetratin, Antp) to transport cytotoxic T lymphocyte epitopes derived from ovalbumin (OVA) or the Mucin-1 tumor-associated antigen into cells. We have now shown that penetratin covalently conjugated to OVA protein and linked in tandem to CD4(+) and/or CD8(+) T-cell epitopes from OVA-stimulated T cells in vitro (B3Z T-cell hybridoma and OT-I and OT-II T cells). The induction of these responses was directly mediated by the penetratin peptide as linking a nonspecific 16-mer peptide to OVA or mixing did not induce CD8(+) or CD4(+) T-cell responses in vitro. Furthermore, interferon (IFN)-γ-secreting CD4(+) and CD8(+) T cells were induced which suppressed B16.OVA tumor growth in C57BL/6 mice. Tumor protection was mediated by a CD8(+) T-cell-dependent mechanism and did not require CD4(+) help to protect mice 7 days after a boost immunization. Alternatively, 40 days after a boost immunization, the presence of CD4(+) help enhanced antigen-specific IFN-γ-secreting CD8(+) T cells and tumor protection in mice challenged with B16.OVA. Long-term CD8 responses were equally enhanced by antigen-specific and universal CD4 help. In addition, immunization with AntpOVA significantly delayed growth of B16.OVA tumors in mice in a tumor therapy model.
Immunology and Cell Biology 03/2011; 89(8):904-13. · 4.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cell penetrating peptides (CPP) represent a novel approach to facilitate cytoplasmic delivery of macromolecules. The DNA binding domain of Drosophila Antennapedia contains 60 amino acids and consists of 3 α-helices, with internalizing activity mapped to a 16-amino acid peptide penetratin (Antp) within the third α-helix. Here, we report on the use of penetratin to deliver a multiple antigen peptide (MAP) incorporating the immunodominant CD8 epitope of ovalbumin, SIINFEKL (MAPOVACD8). We demonstrate that penetratin linked to the MAPOVACD8 construct either by a disulfide (SS) or thioether (SC) linkage promotes the uptake, cross presentation and subsequent in vivo proliferation and generation of OVACD8 (SIINFEKL)-specific T cells. The MAPOVACD8 construct without penetratin is not presented by MHC class I molecules nor does it generate an in vivo IFN-γ response in C57BL/6 mice. Moreover, we clearly define the uptake and intracellular processing pathways of AntpMAPOVACD8 SS and SC revealing the majority of AntpMAPOVACD8 is taken up by DC via an endocytic, proteasome and tapasin independent mechanism. We also show that the uptake mechanism of AntpMAPOVACD8 is dose dependent and uptake or intracellular processing is not altered by the type of chemical linkage.
Biochimica et Biophysica Acta 12/2010; 1798(12):2286-95. · 4.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Reactive oxygen species (ROS) have been implicated in various physiological activities. However, their role in dendritic cell (DC) activation and generation has not been investigated. Using the bone marrow-derived GM-CSF-induced ex vivo DC model, we characterize how induction of ROS correlates with inflammatory DC functionality and expansion. We describe that the functionality of GM-CSF-induced DCs is distinct in two developmental stages. Whereas division of DC-committed hematopoietic progenitor cells (HPCs) neared completion by day 6, the level of ROS soared after day 4. Day 3 ROS(lo) DCs were highly responsive to TLR stimuli such as LPS and zymosan by rapid upregulation of CD80, CD86, and MHC class II, in contrast to the low response of day 6 ROS(hi) DCs. ROS(hi) DCs could not initiate and sustain a significant level of NF-kappaB phosphorylation in response to LPS and zymosan, although demonstrating hyperactivation of p38 MAPK by LPS, in a fashion disparate to ROS(lo) DCs. ROS(lo) DCs stimulated a higher level of allogeneic and OVA-specific T cell proliferative responses, although ROS(hi) DCs were much more proficient in processing OVA. In response to pathogenic stimuli, ROS(hi) DCs also demonstrated rapid cellular adhesion and H(2)O(2) release, indicating their role in immediate microbial targeting. Moreover, HPC expansion and DC generation were dependent on the surge of ROS in an NADPH oxidase-independent manner. These findings point to the potential role of cellular ROS in mediating functionality and development of DCs from HPCs during inflammation.
The Journal of Immunology 02/2010; 184(6):2863-72. · 5.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Parallel to attenuated and subunit vaccines, DNA vaccines require adjuvant signals in addition to antigen presentation for the induction of adaptive immune responses. As opposed to common beliefs, increasing evidence is showing that Toll-like receptor 9 activation by CpG motifs present in DNA vaccines are not vital for the induction of immune responses in vivo. Investigations on the signaling pathways of the adjuvant effect mediated by DNA vaccines have revealed other important mediators. DNA-dependent activator of interferon regulatory factors (DAI) and absent in melanoma (AIM)2 were recently identified as cytosolic DNA sensors that respond with the release of type I interferon and proinflammatory cytokines. Both are distinct molecules with different signaling pathways. AIM2 acts through inflammasomes to activate caspase-1, whilst DAI activates the transcription factors, NF-kappaB and interferon regulatory factor 3. Most significantly, the noncanonical IkappaB kinase, TANK-binding kinase-1, was identified as the essential signaling component in DNA vaccines that is responsible for the generation of immune responses. This review provides an update on the cellular detection and the subsequent signaling pathways mediated by DNA vaccines.
Expert Review of Vaccines 10/2009; 8(9):1161-70. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent years have seen a surge in interest in cell-penetrating peptides (CPP) as an efficient means for delivering therapeutic targets into cellular compartments. The cell membrane is impermeable to hydrophilic substances yet linking to CPP can facilitate delivery into cells. Thus the unique translocatory property of CPP ensures they remain an attractive carrier, with the capacity to deliver cargoes in an efficient manner having applications in drug delivery, gene transfer and DNA vaccination. Fundamental for an effective vaccine is the delivery of antigen epitopes to antigen-presenting cells, ensuing processing and presentation and induction of an immune response. Vaccination with proteins or synthetic peptides incorporating CTL epitopes have proven limited due to the failure for exogenous antigens to be presented efficiently to T cells. Linking of antigens to CPP overcomes such obstacles by facilitating cellular uptake, processing and presentation of exogenous antigen for the induction of potent immune responses. This review will encompass the various strategies for the delivery of whole proteins, T cell epitopes and preclinical studies utilizing CPP for cancer vaccines.
Biochimica et Biophysica Acta 09/2009; 1805(1):25-34. · 4.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Receptor mediated gene delivery is an attractive non-viral method for targeting genetic material to specific cell types. We have previously utilized oxidized (OMPLL) and reduced mannan poly-L-lysine (RMPLL) to target DNA vaccines to antigen presenting cells and demonstrated that it could induce far stronger immune responses in mice compared to naked DNA immunization. In this study, we describe the immune enhancing attributes of mannan-PLL mediated DNA vaccination at the molecular level. Several attributes observed in similar gene delivery conjugates, such as entry via the endocytic pathway, low toxicity, protection from nucleases and compaction of particle size, were also evident here. In addition, OMPLL and RMPLL conjugates had profound effects on the antigen presentation functions of dendritic cells and macrophages, through the stimulation of cytokine production and maturation of dendritic cells. Interestingly, we demonstrate that OMPLL-DNA and RMPLL-DNA are able to mediate dendritic cell activation via toll-like receptor 2 as opposed to mannan alone which mediates via toll-like receptor 4. Overall, this report leads to greater understanding of how oxidized and reduced mannan mediated gene delivery could augment immune responses to DNA vaccination and provide insights into ways of further improving its immunogenicity.
[Show abstract][Hide abstract] ABSTRACT: The interaction of immune complexes with the human Fc receptor, FcgammaRIIa, initiates the release of inflammatory mediators and is implicated in the pathogenesis of human autoimmune diseases, including rheumatoid arthritis and systemic lupus erythematosus, so this FcR is a potential target for therapy. We have used the three-dimensional structure of an FcgammaRIIa dimer to design small molecule inhibitors, modeled on a distinct groove and pocket created by receptor dimerization, adjacent to the ligand-binding sites. These small chemical entities (SCEs) blocked immune complex-induced platelet activation and aggregation and tumor necrosis factor secretion from macrophages in a human cell line and transgenic mouse macrophages. The SCE appeared specific for FcgammaRIIa, as they inhibited only immune complex-induced responses and had no effect on responses to stimuli unrelated to FcR, for example platelet stimulation with arachidonic acid. In vivo testing of the SCE in FcgammaRIIa transgenic mice showed that they inhibited the development and stopped the progression of collagen-induced arthritis (CIA). The SCEs were more potent than methotrexate and anti-CD3 in sustained suppression of CIA. Thus, in vitro and in vivo activity of these SCE FcgammaRIIa receptor antagonists demonstrated their potential as anti-inflammatory agents for autoimmune diseases involving immune complexes.
Immunology and Cell Biology 12/2008; 87(1):3-12. · 4.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: C-type lectin receptors (CLRs) are a class of pathogen-recognition receptors that are actively investigated in the field of vaccine delivery. Many of their properties have functions linked to the immune system. These receptors are expressed abundantly on antigen-presenting cells and are considered to be the sentinels of immune surveillance owing to their endocytic nature and the ability to recognize a diverse range of pathogens through recognition of pathogen-associated molecular patterns. CLRs are also involved in the processes of antigen presentation mediated through the induction of dendritic cell maturation and cytokine production. These properties engender CLRs to be ideal for vaccine targeting. Conversely, CLRs also function to recognize glycosylated self-antigens to induce homeostatic control and tolerance. In this review, we will describe the various preclinical/clinical vaccination strategies to target antigens and plasmid DNA to this diverse class of receptors.
Expert Review of Vaccines 10/2008; 7(7):1005-18. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Previous studies have demonstrated that the antitumor effect of melphalan can be increased by the administration of the vasodilator hydralazine. This potentiation is due to the induction of hypoxia, which is known to potentiate melphalan cytotoxicity. In this study we investigated whether the same potentiation by hydralazine could be achieved using N-acetylmelphalan–antibody conjugates. In a murine thymoma model, the administration of 250 μg of hydralazine 1 h after the injection of free drug resulted in a significant reduction in tumor growth compared to free drug alone. The same dosage schedule did not result in any significant potentiation of the antitumor activity of N-acetylmelphalan–antibody conjugates, although significant potentiation of conjugate action was observed when hydralazine was given 24 h later. This increased antitumor efficacy did not appear to be due to a synergistic effect, as no potentiation of either free drug or conjugate by hydralazine was observed in vitro. As free drug is known to be cleared rapidly whereas drug conjugates in this model are known to reach maximal tumor concentration 24 h after injection, the potentiation by hydralazine observed 1 h after free drug administration and 24 h after conjugate injection may require the presence of drug at the tumor site when vasodilation occurs. Although the mechanism(s) of hydralazine potentiation of N-acetylmelphalan–antibody conjugate action is unclear, it may be possible to increase the antitumor efficacy of these conjugates in the clinic by the use of hydralazine.
Drug Delivery 09/2008; 1(1):61-67. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Drug–antibody conjugates are undergoing close scrutiny as new antitumor agents because they confer increased drug specificity, producing higher accumulation in the tumor and less systemic toxicity than free drug. Consequently this has led to the use of drugs more toxic than those that can normally be used. How-ever, contrary to these conclusions immunoconjugates containing aminopterin (AMN), while having potent antitumor activity, are more toxic than free drug. AMN, a more toxic analog of the folic acid antagonist methotrexate (MTX), was coupled to the anti-Ly-2.1 antibody and the in vivo activity of the conjugate was tested against the Ly-2.1+ murine thymoma ITT(1)75NS E3 (E3). The aminopterin conjugates had molar ratios of 4–6 residues of AMN per MoAb molecule and retained 50% of the original antibody activity. A single dose of 75 μg AMN-anti-Ly-2.1 inhibited tumor growth by 30% and injection of 105 μg AMN–MoAb conjugate, in three doses, caused 63% tumor growth inhibition. Considerably higher doses of free AMN are required to produce similar tumor inhibition. Injection of 90 μg AMN-anti-Ly-2.1 or 900 μg free AMN produced signs of toxicity or death in the mice. Hematological examination revealed severe depletions in white blood cell (control, 7.71 × 103/μl; AMN, 3.39 × 103/μl; and AMN-anti-Ly-2.1, 1.29 × 103/μl and platelet (control, 501.6 × 103/μl; AMN, 234.7 × 103/μl; and AMN-anti-Ly-2.1, 157.1 × 103/μl) numbers for free and conjugated forms of AMN. Histological and hematological examinations indicate that there are similar sites of toxicity after AMN and AMN–MoAb conjugate treatment. The studies showed that the AMN–anti-Ly-2.1 conjugate is a potent antitumor agent and is capable of reducing the growth of subcutaneous tumors.
Drug Delivery 09/2008; 1(1):27-33. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The evidence that dendritic cell (DC) subsets produce differential cytokines in response to specific TLR stimulation is robust. However, the role of TLR stimulation in Ag presentation and phenotypic maturation among DC subsets is not clear. Through the adjuvanticity of a novel mannosylated Ag, mannosylated dendrimer OVA (MDO), as a pathogen-associated molecular pattern Ag, we characterized the functionality of GM-CSF/IL-4-cultured bone marrow DC and Flt3 ligand (Flt3-L) DC subsets by Ag presentation and maturation assays. It was demonstrated that both bone marrow DCs and Flt3-L DCs bound, processed, and presented MDO effectively. However, while Flt3-L CD24(high) (conventional CD8(+) equivalent) and CD11b(high) (CD8(-) equivalent) DCs were adept at MDO processing by MHC class I and II pathways, respectively, CD45RA(+) plasmacytoid DCs presented MDO poorly to T cells. Successful MDO presentation was largely dependent on competent TLR4 for Ag localization and morphological/phenotypic maturation of DC subsets, despite the indirect interaction of MDO with TLR4. Furthermore, Toll/IL-1 receptor-domain-containing adaptor-inducing IFN-beta, but not MyD88, as a TLR4 signaling modulator was indispensable for MDO-induced DC maturation and Ag presentation. Taken together, our findings suggest that DC subsets differentially respond to a pathogen-associated molecular pattern-associated Ag depending on the intrinsic programming and TLRs expressed. Optimal functionality of DC subsets in Ag presentation necessitates concomitant TLR signaling critical for efficient Ag localization and processing.
The Journal of Immunology 09/2008; 181(4):2455-64. · 5.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: DNA immunization is an attractive form of vaccination, which has shown promising results only in small animal models. There is a need to develop efficient gene delivery systems. We previously demonstrated that oxidized (OM) and reduced mannan (RM) complexed to ovalbumin DNA via poly-l-lysine (PLL), were able to generate potent immune responses in mice. Herein, we further investigated the suitability of OMPLL and RMPLL as carriers for mucin 1 (MUC1) DNA vaccination for cancer immunotherapy. Studies presented here showed that immune responses in C57BL/6 mice induced by OMPLL-MUC1 DNA and RMPLL-MUC1 DNA immunization were more immunogenic compared to MUC1 DNA alone. Moreover, tumor protection was evident at a dose as low as 0.5 microg. In addition, strong T cell responses were induced in HLA-A2 transgenic and human MUC1 transgenic mice. These results demonstrate the potential of OM and RM as efficient non-viral gene delivery carriers for DNA vaccines for use in cancer immunotherapy.
[Show abstract][Hide abstract] ABSTRACT: Antigen mannosylation has been shown to be an effective approach to potentiate antigen immunogenicity, due to the enhanced antigen uptake and presentation by APC. To overcome disadvantages associated with conventional methods used to mannosylate antigens, we have developed a novel mannose-based antigen delivery system that utilizes a polyamidoamine (PAMAM) dendrimer. It is demonstrated that mannosylated dendrimer ovalbumin (MDO) is a potent immune inducer. With a strong binding avidity to DC, MDO potently induced OVA-specific T cell response in vitro. It was found that the immunogenicity of MDO was due not only to enhanced antigen presentation, but also to induction of DC maturation. Mice immunized with MDO generated strong OVA-specific CD4(+)/CD8(+) T cell and antibody responses. MDO also targeted lymph node DC to cross-present OVA, leading to OTI CD8(+) T cell proliferation. Moreover, upon challenge with B16-OVA tumor cells, tumors in mice pre-immunized with MDO either did not grow or displayed a much more delayed onset, and had slower kinetics of growth than those of OVA-immunized mice. This mannose-based antigen delivery system was applied here for the first time to the immunization study. With several advantages and exceptional adjuvanticity, we propose mannosylated dendrimer as a potential vaccine carrier.
European Journal of Immunology 03/2008; 38(2):424-36. · 4.52 Impact Factor