| Literature DB >> 30970259 |
Cyril Planchais1, Ayrin Kök1, Alexia Kanyavuz2, Valérie Lorin1, Timothée Bruel3, Florence Guivel-Benhassine3, Tim Rollenske4, Julie Prigent1, Thierry Hieu1, Thierry Prazuck5, Laurent Lefrou6, Hedda Wardemann4, Olivier Schwartz3, Jordan D Dimitrov2, Laurent Hocqueloux5, Hugo Mouquet7.
Abstract
Mucosal immune responses to HIV-1 involve the recognition of the viral envelope glycoprotein (gp)160 by tissue-resident B cells and subsequent secretion of antibodies. To characterize the B cells "sensing" HIV-1 in the gut of infected individuals, we probed monoclonal antibodies produced from single intestinal B cells binding to recombinant gp140 trimers. A large fraction of mucosal B cell antibodies were polyreactive and showed only low affinity to HIV-1 envelope glycoproteins, particularly the gp41 moiety. A few high-affinity gp140 antibodies were isolated but lacked neutralizing, potent ADCC, and transcytosis-blocking capacities. Instead, they displayed cross-reactivity with defined self-antigens. Specifically, intestinal HIV-1 gp41 antibodies targeting the heptad repeat 2 region (HR2) cluster II cross-reacted with the p38α mitogen-activated protein kinase 14 (MAPK14). Hence, physiologic polyreactivity of intestinal B cells and molecular mimicry-based self-reactivity of HIV-1 antibodies are two independent phenomena, possibly diverting and/or impairing mucosal humoral immunity to HIV-1.Entities:
Keywords: B cells; HIV-1; MAPK14; antibodies; cross-reactivity; intestine; mucosa; polyreactivity
Mesh:
Year: 2019 PMID: 30970259 PMCID: PMC6458971 DOI: 10.1016/j.celrep.2019.03.032
Source DB: PubMed Journal: Cell Rep Impact factor: 9.423
Figure 1Capture of HIV-1 Env-Reactive Mucosal B Cells
(A) Representative ELISA graph showing the reactivity of purified serum IgG (sIgG) from HIV-1-infected individuals (n = 5) against trimeric gp140, gp120, and gp41 proteins. Error bars indicate the SEM of duplicate values. Ctr+, positive control sIgG; pt3, patient 3 (Scheid et al., 2009); Ctr−, negative control sIgG; hd2, healthy donor 2 (Prigent et al., 2016).
(B) Neutralization activity of sIgG from HIV-1-infected donors (n = 5) measured by TZM-bl assay.
(C) Dot plots comparing the percentage of IgA+CD19+ and IgG+CD19+ cells in the IEL, LPL, and peripheral blood mononuclear cell (PBMC) compartments determined by flow cytometry as shown in Figure S1. Median values are indicated below.
(D) Dot plots comparing the distribution of B cell subsets in the IEL, LPL, and PBMC compartments determined by flow cytometry as shown in Figure S1. Percentage of mature naive (MN), resting memory (RM), activated memory (AM), and tissue-like memory (TLM) B cells and antibody-secreting cells (ASC) are shown.
(E) HIV-1 gp140-reactive B cell fluorescence-activated cell sorting (FACS). (Top) Cytograms show the gating strategy used for single-cell sorts of gp140-binding mucosal B cells. An example is given for patient COA21. (Bottom) Dot plots comparing the percentage of gp140-reactive IgA+ and IgG+ CD19+ lymphocytes from the IEL, LPL, and PBMC compartments determined by flow cytometry as shown in Figure S1.
(F) Pie charts show the distribution of single gp140-binding B cells captured by FACS with YU-2 gp140 trimers among IEL and LPL IgA+ and IgG+ B cell populations. The number of B cells captured is indicated in the center of each pie chart.
(G) Representative ELISA graph showing the reactivity of gp140-captured mucosal monoclonal antibodies (mAbs; n = 76) against YU-2 gp140 trimers. Error bars indicate the SEM of duplicate values. Dotted black and green lines represent the positive control 10-1074 and negative control mGO53 IgG antibodies, respectively. The proportion of high affinity anti-gp140 antibodies in each patients’ group is shown below in the pie charts. The total number of tested antibodies is indicated in the center of each pie chart.
See also Figures S1 and S2 and Tables S1 and S2.
Figure 2Epitopes and Antiviral Activities of Mucosal HIV-1 gp140 Antibodies
(A) Representative ELISA graphs show the binding of mucosal HIV-1-specific antibodies to trimeric gp140, gp120 and gp41 proteins. Error bars indicate the SEM of quadruplicate values. The green dotted line corresponds to the negative control antibody mGO53.
(B) Epitope mapping. (Left) Representative ELISA graph comparing the binding of anti-gp120 antibody 6-104 to wild-type gp120, gp120core, gp120D368R, and gpI420R mutant proteins. Error bars indicate the SEM of quadruplicate values. (Right) Representative ELISA graph shows the reactivity of mucosal anti-gp41 monoclonal antibodies (mAbs) against overlapping peptides covering the extracellular portion of gp41 (gp41EC). The sequence of the peptide recognized by 6-159 is indicated on the top.
(C) Plot shows the neutralization activity of mucosal gp140-specific mAbs as measured in duplicate in two independent in vitro TZM-bl assay experiments (one representative is shown).
(D) Antibody binding to infected target cells. (Left) Graph shows the binding of anti-gp140 IgGs to NL4.3-infected cells, measured as the percentage of IgG+ in Gag+ cells by flow cytometry. (Right) Heat map comparing the percentage of bound, infected cells (n = 9 viruses) by antibodies (at 15 μg/ml) assayed by flow cytometry as shown in Figure S3. 3BNC117 and mGO53 are positive and negative control, respectively.
(E) Bar graphs comparing the ADCC activity of HIV-1 nnAbs and bNAbs (PGT128 and 3BNC117) against target cells infected by selected viruses as measured by flow cytometry. Mean values (dots) ± SEM of three independent experiments performed in duplicate are shown. mGO53 is the non-HIV-1 isotype control.
(F) Bar graph shows the percentage of transcytosis of NLAD8 alone (white, no antibody), in the presence of non-HIV-1 mGO53 control (gray), HIV-1 bNAb 10-1074, and mucosal HIV-1 antibodies expressed as monomeric IgG (blue) and IgA (orange) antibodies. Mean values ± SEM of quadruplicate values from two independent experiments (dots) are shown.
(G) Scatter plot shows the infectivity level of transcytosed NLAD8 viruses derived from the experiments shown in (F) on TZM-bl reporter cells. Antibodies were tested at a final concentration of 66.7 nM. RLU, relative light units. Groups in (F) and (G) were compared to the no-antibody control by the Mann-Whitney test. ns, not significant; ∗∗∗p < 0.001.
(H) Bar graphs show the amount of free viruses captured by mucosal HIV-1 and control antibodies measured by ELISA as p24 content. Mean of quadruplicate values ± SEM are shown.
(I) ELISA graphs show the binding of mucosal HIV-1 and control antibodies to purified human mucin 2. Mean values ± SEM of two independent experiments performed in duplicate are shown.
See also Figure S3.
Figure 3Polyreactivity and Binding to HIV-1 Env Glycoproteins
(A) ELISA graphs show the reactivity of mucosal antibodies isolated from HIV-1-infected individuals (n = 72) against keyhole limpet hemocyanin (KLH), double-stranded DNA (dsDNA), insulin, and lipopolysaccharide (LPS). mGO53 (green lines) and ED38 (dotted lines) are negative and positive control antibodies, respectively. Horizontal lines show cutoff optical density 405 (OD405 nm) for positive reactivity.
(B) Correlation plots comparing the polyreactivity and the reactivity to HIV-1 Env proteins of mucosal antibodies. The y axis indicates the area under the curve (AUC) values of the ELISA binding curves shown in Figure S4A. The x axis indicates cumulative area under the curve (CAUC) values for polyreactivity (polyR) as measured in (A) against all four antigens. Bivariate correlations were estimated with the two-tailed Pearson correlation test. ∗∗∗∗p < 0.0001.
(C) ELISA graphs show the reactivity of IgA+ and IgG+ memory B cell antibodies from healthy individuals hd2 and hd4 (n = 124) (Prigent et al., 2016) against trimeric gp140, gp120, and gp41 proteins. mGO53 (green lines) and ED38 (dotted lines) are negative and positive control antibodies, respectively. Horizontal lines show cutoff OD405 nm for positive reactivity. The proportion of antibodies reactive against each HIV-1 protein is shown in pie charts (right), with the total number of antibodies tested indicated in the center.
(D) Same as in (B) but for memory B cell antibodies from healthy individuals.
(E) Dot plot shows the reactivity of intestinal IgA+ and IgG+ plasmablast mAbs from healthy individuals (n = 41) (Benckert et al., 2011) against trimeric gp140, gp120 and gp41 proteins. The y axis indicates the AUC values of the ELISA binding curves shown in Figure S4B. The dotted line represents the positive threshold, and the percentages of binders are indicated below each group.
Mean values from two independent experiments are shown in (A)–(E).
(F) (Left) SPR sensorgrams comparing the binding of selected antibodies (n = 7) to trimeric YU-2 gp140 glycoproteins. The y axis shows the resonance units (RU) obtained at a given time (s, seconds) indicated on the x axis. (Right) Dot plots comparing the relative affinity (KD) and kinetics constants (ka, kd) of selected antibodies to trimeric YU-2 gp140 glycoproteins.
(G) (Top) Cytograms show the binding of selected IgG antibodies to Gag+ YU-2-infected cells. (Bottom). Graph comparing the percentage of antibody binding to YU-2 virions exposed at the surface of infected target cells as measured by flow cytometry. mGO53 is the non-HIV-1 isotype control. Error bars indicate the SEM of triplicate values.
See also Figure S4.
Figure 4Cross-Reactivity of Mucosal HIV-1 Antibodies against Human Self-Antigens
(A) Bar graph shows the polyreactivity levels of mucosal HIV-1 gp140 antibodies as measured in duplicate by ELISA against KLH, dsDNA, insulin, and LPS in Figure S5A. The x axis indicates cumulative AUC (CAUC) values for polyreactivity (polyR).
(B) Antibody binding to HEp-2 cells was assayed by immunofluorescence assay. Ctr+, positive control of the kit. mGO53 and ED38 are negative and positive control antibodies, respectively. The scale bars represent 15 μM.
(C) Frequency histograms show the log10 protein displacement (σ) of the mean fluorescent intensity (MFI) signals for the selected antibodies (n = 9) compared with non-reactive antibody mGO53. The polyreactivity index (PI) corresponds to the Gaussian mean of all array protein displacements.
(D) Representative protein microarray plots show the reactivity profile of mucosal anti-gp140 antibodies against human proteins. For each protein spot, the MFI given by the reference (mGO53) and test are depicted on the y and x axes, respectively. Each dot represents the average of duplicate array proteins. The diagonal lines indicate equal binding for reference and test antibodies. Blue dots indicate immunoreactive proteins with a Z score > 5 that were identified in two independent experiments as shown in Figure S5B.
(E) Representative ELISA graph comparing the reactivity of mucosal anti-gp140 antibodies to purified MAPK14. mGO53 is the negative control (green). Error bars indicate the SEM of duplicate values.
(F) SPR sensorgram showing the binding overtime of 6-195 to purified MAPK14 proteins immobilized on the sensor chip (50 RUs).
See also Figure S5.
Figure 5Binding of HIV-1 gp41 HR2 Antibodies to MAPK14
(A) Representative ELISA graphs show the reactivity of blood anti-gp41 antibodies against overlapping peptides covering the extracellular portion of gp41 (gp41EC). The sequences of the peptides recognized are indicated on the top.
(B) Representative ELISA graphs show the binding of biotinylated mucosal anti-gp41 to YU-2 gp140 in the presence of potential competitor antibodies (blood-derived anti-gp41 IgG). Error bars indicate the SEM of duplicate values.
(C) Protein microarray plots show the reactivity profile of blood anti-gp140 antibodies against human proteins. For each protein spot, the mean fluorescence intensity (MFI) given by the reference (mGO53) and test antibody are depicted on the y and x axes, respectively. Each dot represents the average of duplicate array proteins. The diagonal lines indicate equal binding for reference and test antibodies.
(D) Bar graphs comparing the MFI values (Left) and Z scores (Right) for the binding of the selected anti-gp41 antibodies to MAPK14 immobilized on the protein array.
(E) Representative ELISA graph comparing the reactivity of blood anti-gp140 antibodies to purified MAPK14 proteins. The 6-195 and mGO53 (green) were used as positive and negative control, respectively. Error bars indicate the SEM of duplicate values.
(F) Affinity of anti-gp41 antibodies to MAPK14. (Left) Representative SPR curves comparing the binding overtime of selected anti-gp41 IgGs (at 250 nM) to purified MAPK14 immobilized on the sensor chip (250 RUs). (Right) Dot plots comparing the relative affinity (KD) of anti-gp41 antibodies to MAPK14. No binding could be detected (ND) for the following antibodies: 5-25, 10-137, 10-437, and 10-1304.
See also Figure S6.
Figure 6Interactions of Anti-HR2 Cluster II Antibodies with MAPK14
(A) Representative ELISA graph shows the binding of biotinylated anti-cluster II D50 antibody to MN gp41 in the presence of potential competitor antibodies (anti-gp41HR2 IgGs). mGO53 is the negative control (green).
(B) Representative ELISA graph shows the binding of murine (D50) and human (167-D IV, 98-6, and 5F3) anti-cluster II antibodies to purified MAPK14. mGO53 is the negative control (green).
(C) Surface representations show the electrostatic potentials of the gp41 cluster II (residues 642–664) (deposited in the Protein Data Base under PDB: 1ENV) calculated with PyMOL, colored blue (positive electrostatic potential) to red (negative electrostatic potential).
(D) Representative ELISA graph shows the area under the curves of OD405 nm values (AUC) for the binding of the selected IgG antibodies to purified MAPK14 in presence of increasing salt concentration.
(E) (Top) Amino acid sequence alignment of the gp41 region spanning residues 642–665. Amino acid variations are shown in red. (Bottom) Heat map comparing the mean AUC values for the ELISA binding of anti-gp41 and control antibodies to the selected HIV-1 Env strains (n = 8) as measured in Figure S7. Color intensity is proportional to the reactivity level, with darker-blue colors indicating high binding, whereas light colors show moderate binding (white, no binding).
(F) Diagram shows the sequence alignment (Top) based on the structural superposition (Bottom) between a gp41HR2 cluster II peptide (red, from PDB: 1ENV) and MAPK14 (blue, PDB: 5ETI).
(G) ELISA graph comparing the binding of mutated anti-gp41 antibodies (black straight lines) and their germline counterparts (red dotted lines) to trimeric YU-2 gp140, gp41, and MAPK14.
Error bars in (A), (B), (D), and (G) indicate the SEM of duplicate values. See also Figure S7.
| REAGENT or RESOURCE | SOURCE | IDENTIFIER |
|---|---|---|
| Human monoclonal IgG PGT128 | N/A | |
| Human monoclonal IgG 10-1074 | N/A | |
| Human monoclonal IgG 3BNC117 | N/A | |
| Human monoclonal IgG 5-25 | N/A | |
| Human monoclonal IgG 6-161 | N/A | |
| Human monoclonal IgG 6-161 GL | This paper | N/A |
| Human monoclonal IgG 10-137 | N/A | |
| Human monoclonal IgG 10-325 | N/A | |
| Human monoclonal IgG 10-437 | N/A | |
| Human monoclonal IgG 10-647 | N/A | |
| Human monoclonal IgG 10-679 | N/A | |
| Human monoclonal IgG 10-1304 | N/A | |
| Human monoclonal IgG 10-1487 | N/A | |
| Human monoclonal IgG/IgA 6-195 | This paper | N/A |
| Human monoclonal IgG 6-195 GL | This paper | N/A |
| Human monoclonal IgG 64-i109 | This paper | N/A |
| Human monoclonal IgG 64-i109 GL | This paper | N/A |
| Human monoclonal IgG 18-295 | This paper | N/A |
| Human monoclonal IgG ED38 | N/A | |
| Human monoclonal IgG mGO53 | N/A | |
| Mouse monoclonal IgG D50 | Cat#11393 | |
| Human monoclonal IgG/IgA 6-159 | This paper | N/A |
| Human monoclonal IgG 6-104 | This paper | N/A |
| Human monoclonal IgG 558-2 | N/A | |
| Human monoclonal IgG DH308 | N/A | |
| Human monoclonal IgG DH307 | N/A | |
| Human monoclonal IgG 167-D IV | Cat#11681 | |
| Human monoclonal IgG 98-6 | Cat#1240 | |
| Human monoclonal IgG 5F3 | Cat#6882 | |
| Mouse anti-human CD38-APC (HIT2) | BD biosciences | Cat#555462 |
| Mouse anti-human CD21 BV421 (B-ly4) | BD biosciences | Cat#562966 |
| Mouse anti-human CD27 PE-CF594 (M-T271) | BD biosciences | Cat#562297 |
| Mouse anti-human CD19 Alexa Fluor 700 (HIB19) | BD biosciences | Cat#557921 |
| Mouse anti-human CD24 PE-Cy7 (ML5) | BD biosciences | Cat#561646 |
| Mouse anti-human CD10 BV650 (HI10a) | BD biosciences | Cat#563734 |
| Mouse anti-human IgD APC-H7 (IA6-2) | BD biosciences | Cat#561305 |
| Mouse anti-human IgM BV605 (G20-127) | BD biosciences | Cat#562977 |
| Mouse anti-human IgG BV786 (G18-145) | BD biosciences | Cat#564230 |
| Mouse anti-human CD138 BV711 (MI15) | BD biosciences | Cat#563184 |
| Mouse anti-human IgA FITC (IS11-8E10) | Miltenyi Biotec | Cat#130-113-475 |
| Goat anti-human IgG Alexa Fluor 647 | Life technologies | Cat#A-21445 |
| Peroxidase AffiniPure Goat Anti-Human IgG, Fcγ fragment specific | Jackson ImmunoReseach | Cat#109-035-098 |
| Peroxidase AffiniPure Goat Anti-Human IgA/IgG/IgM (H+L) | Jackson ImmunoReseach | Cat#109-035-064 |
| Blood human monoclonal IgGs from healthy individuals (hd2 & hd4) | N/A | |
| Intestinal human monoclonal IgGs from healthy individuals (e.g., HD1a361 and HD2a57) | N/A | |
| NEB 10-beta Competent | New England Biolabs | C3019H |
| Lab adapted HIV-1 virus (NLAD8) | NIH AIDS Reagent Program | Cat#11346 |
| Lab adapted HIV-1 virus (NL4.3) | NIH AIDS Reagent Program | Cat#7407 |
| Lab adapted HIV-1 virus (YU-2) | NIH AIDS Reagent Program | Cat#1350 |
| Transmitted/founder HIV-1 virus (WITO) | NIH AIDS Reagent Program | Cat#11739 |
| Transmitted/founder HIV-1 virus (CH058) | NIH AIDS Reagent Program | Cat#11856 |
| Transmitted/founder HIV-1 virus (CH077) | NIH AIDS Reagent Program | Cat#11742 |
| Transmitted/founder HIV-1 virus (CH0106) | NIH AIDS Reagent Program | Cat#11743 |
| Transmitted/founder HIV-1 virus (REJO) | NIH AIDS Reagent Program | Cat#11746 |
| Transmitted/founder HIV-1 virus (RHPA) | NIH AIDS Reagent Program | Cat#11744 |
| Colorectal biopsies from HIV-1+ individuals | Centre Hospitalier Regional d’Orléans, France | N/A |
| Peripheral blood mononuclear cells (PBMCs) & sera from HIV-1+ individuals | Centre Hospitalier Regional d’Orléans, France | N/A |
| AviTagged clade B YU-2 gp140 trimers | N/A | |
| YU-2 gp120 | N/A | |
| YU-2 gp120D368R | N/A | |
| YU-2 gp120I420R | N/A | |
| Clade B HXBc2 gp120core proteins | N/A | |
| Clade B MN gp41 protein | NIH AIDS Reagent Program | Cat#12027 |
| Clade B SF162 trimeric gp140 | NIH AIDS Reagent Program | Cat#12026 |
| Clade D UG021 trimeric gp140 | NIH AIDS Reagent Program | Cat#12065 |
| Clade A UG037 trimeric gp140 | NIH AIDS Reagent Program | Cat#12063 |
| Clade F BR029 trimeric gp140 | NIH AIDS Reagent Program | Cat#12066 |
| Clade C/B’ CN54 trimeric gp140 | NIH AIDS Reagent Program | Cat#12064 |
| Clade C ZM96 trimeric gp140 | N/A | |
| Consensus clade B 15-mer overlapping peptide library | NIH AIDS Reagent Program | Cat#9480 |
| This paper | N/A | |
| Human recombinant MAPK14 (p38 α) | BPS Bioscience | Cat#40070 |
| Recombinant human mucin 2 | MyBioSource | Cat#MBS958652 |
| Purified double stranded (ds)-DNA | Sigma-Aldrich | Cat#D1501 |
| Purified Hemocyanin - Keyhole Limpet (KLH) | Sigma-Aldrich | Cat#H8283 |
| Purified Lipopolysaccharides (LPS) | Sigma-Aldrich | Cat#L2637 |
| Purified Insulin | Sigma-Aldrich | Cat#I9278 |
| FITC-labeled DEAE-dextran | Molecular Probes | Cat#95648 |
| Peroxidase-conjugated streptavidin | BD Biosciences | Cat#554066 |
| Polyethylenimine | Polysciences | 23966-2 |
| LIVE∕DEAD fixable aqua dead cell stain kit | Thermo Fisher Scientific | Cat#L34957 |
| SuperScript IV reverse transcriptase | Thermo Fisher Scientific | Cat#18091200 |
| ReadiUse ABTS Substrate Solution | Euromedex | Cat#11001-AAT |
| Streptavidin R-PE conjugate | Thermo Fisher Scientific | Cat#SA10041 |
| EZ-Link Sulfo-NHS-LC-Biotinylation kit | Thermo Fisher Scientific | Cat#21435 |
| BirA biotin-protein ligase bulk reaction kit | Avidity, LLC | Cat#bulk BirA |
| HIV-1 p24 Antigen Capture Assay | Advanced Bioscience Laboratories Inc | Cat#5421 |
| Amine Coupling Kit | Biacore, GE Healthcare | Cat# BR100050 |
| ANA HEp-2 AeskuSlides® | Aesku.Diagnostics | Cat#51.100 |
| FUGENE-6 transfection reagent | Promega | Cat# E2691 |
| TZM-bl cells | NIH AIDS Reagent Program | Cat# 8129 |
| Epithelial monolayer-forming human endometrial carcinoma type A HEC-1A cells | ATCC® | Cat# HTB-112 |
| Freestyle 293-F cells | Thermo Fisher Scientific | Cat#R79007 |
| CEM.NKR CCR5+ cells | NIH AIDS Reagent Program | Cat#4376 |
| IgH PCR primers | N/A | |
| IgK PCR primers | N/A | |
| IgL PCR primers | N/A | |
| pSG3ΔEnv vector | NIH AIDS Reagent Program | Cat#11051 |
| pcDNA3.1/Zeo(+) expression vector | Thermo Fisher Scientific | Cat#V86020 |
| HIV-1 Env Expression Vector (Bal.26) | NIH AIDS Reagent Program | Cat#11446 |
| HIV-1 Env Expression Vector (6535.3) | NIH AIDS Reagent Program | Cat#11017 |
| HIV-1 Env Expression Vector (YU-2) | NIH AIDS Reagent Program | Cat#12133 |
| HIV-1 Env Expression Vector (SC422661.8) | NIH AIDS Reagent Program | Cat# 11058 |
| HIV-1 Env Expression Vector (PVO.4) | NIH AIDS Reagent Program | Cat# 11022 |
| GraphPad Prism software (v6.0a) | GraphPad Prism Inc. | |
| FlowJo software (v10.3) | FlowJo LLC | |
| BIAevaluation software (v4.1.1) | Biacore, GE Healthcare | |
| UCSF Chimera software (v1.9) | ||
| ZEN imaging software (Zen 2.0 blue version) | Zeiss | |
| Spotxel® software | SICASYS Software GmbH | |
| ProtoArray® Prospector software (v5.2.3) | Thermo Fisher Scientific | |
| GenePix Pro 6.0 software | Molecular Devices | |
| CM5 chips | Biacore, Inc. | BR-1000-12 |
| Peptide M-coupled agarose beads | Invivogen | Cat#gel-pdm-5 |
| Protein G Sepharose 4 fast flow beads | GE Healthcare | Cat#17061805 |
| HisPur Cobalt agarose beads | Thermo Fisher Scientific | Cat#25228 |
| ProtoArray Human Protein Microarrays | Thermo Fisher Scientific | Cat#PAH0525101 |
| Superdex® 200 increase 10/300 GL column | GE Healthcare | Cat#GE28-9909-44 |