Associations of the Gut Microbiome With Treatment Resistance in Schizophrenia

From BugSigDB
Reviewed Marked as Reviewed by Svetlana up on 2024-7-16
study design
Citation
PMID PubMed identifier for scientific articles.
DOI Digital object identifier for electronic documents.
URI
Authors
Vasileva SS, Yang Y, Baker A, Siskind D, Gratten J, Eyles D
Journal
JAMA psychiatry
Year
2024
IMPORTANCE: There is growing interest in the role of gut microbiome composition in schizophrenia. However, lifestyle factors are often neglected, and few studies have investigated microbiome composition in treatment-resistant schizophrenia. OBJECTIVE: To explore associations between the gut microbiome and schizophrenia diagnosis, treatment resistance, clozapine response, and treatment-related adverse effects while adjusting for demographic and lifestyle factors. DESIGN, SETTING, AND PARTICIPANTS: In this case-control study of adults aged 20 to 63 years, stool samples and data on demographic characteristics, lifestyle, and medication use were collected and gut microbiome measures obtained using shotgun metagenomics. Participants with a schizophrenia diagnosis were referred through psychiatric inpatient units and outpatient clinics. Data were collected for 4 distinct groups: control individuals without a psychiatric diagnosis (past or present), individuals with treatment-responsive schizophrenia taking nonclozapine antipsychotic medications, clozapine-responsive individuals with treatment-resistant schizophrenia, and clozapine-nonresponsive individuals with treatment-resistant schizophrenia. Participants were recruited between November 2020 and November 2021. Control individuals were recruited in parallel through posters and online advertisements and matched for age, sex, and body mass index (BMI) to the individuals with schizophrenia. Participants were excluded if taking antibiotics in the past 2 months, if unable to communicate in English or otherwise follow study instructions, were pregnant or planning to become pregnant, or had any concomitant disease or condition making them unsuited to the study per investigator assessment. Data were analyzed from January 2022 to March 2023. MAIN OUTCOMES AND MEASURES: Omics relationship matrices, α and β diversity, and relative abundance of microbiome features. RESULTS: Data were collected for 97 individuals (71 [74%] male; mean [SD] age, 40.4 [10.3] years; mean [SD] BMI, 32.8 [7.4], calculated as weight in kilograms divided by height in meters squared). Significant microbiome associations with schizophrenia were observed at multiple taxonomic and functional levels (eg, common species: b2, 30%; SE, 13%; adjusted P = .002) and treatment resistance (eg, common species: b2, 27%; SE, 16%; adjusted P = .03). In contrast, limited evidence was found for microbiome associations with clozapine response, constipation, or metabolic syndrome. Significantly decreased microbial richness was found in individuals with schizophrenia compared to control individuals (t95 = 4.25; P < .001; mean [SD] for control individuals, 151.8 [32.31]; mean [SD] for individuals with schizophrenia, 117.00 [36.2]; 95% CI, 18.6-51.0), which remained significant after a covariate and multiple comparison correction. However, limited evidence was found for differences in β diversity (weighted UniFrac) for schizophrenia diagnosis (permutational multivariate analysis of variance [PERMANOVA]: R2, 0.03; P = .02), treatment resistance (R2, 0.02; P = .18), or clozapine response (R2, 0.04; P = .08). Multiple differentially abundant bacterial species (19) and metabolic pathways (162) were found in individuals with schizophrenia, which were primarily associated with treatment resistance and clozapine exposure. CONCLUSIONS AND RELEVANCE: The findings in this study are consistent with the idea that clozapine induces alterations to gut microbiome composition, although the possibility that preexisting microbiome differences contribute to treatment resistance cannot be ruled out. These findings suggest that prior reports of microbiome alterations in individuals with chronic schizophrenia may be due to medication or lifestyle factors and that future studies should incorporate these variables in their design and interpretation.

Experiment 1


Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/06/27

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus, Scholastica

Subjects

Location of subjects
Australia
Host species Species from which microbiome was sampled. Contact us to have more species added.
Homo sapiens
Body site Anatomical site where microbial samples were extracted from according to the Uber Anatomy Ontology
Feces Cow dung,Cow pat,Droppings,Dung,Excrement,Excreta,Faeces,Fecal material,Fecal matter,Fewmet,Frass,Guano,Matières fécales@fr,Merde@fr,Ordure,Partie de la merde@fr,Piece of shit,Porción de mierda@es,Portion of dung,Portion of excrement,Portion of faeces,Portion of fecal material,Portion of fecal matter,Portion of feces,Portion of guano,Portion of scat,Portionem cacas,Scat,Spoor,Spraint,Stool,Teil der fäkalien@de,Feces,feces
Condition The experimental condition / phenotype studied according to the Experimental Factor Ontology
Schizophrenia [X]Schizophrenia, unspecified,[X]Schizophrenia, unspecified (disorder),Dementia Praecox,Disorder, Schizophrenic,Disorders, Schizophrenic,Other specified types of schizophrenia,Other specified types of schizophrenia, chronic state,Other specified types of schizophrenia, chronic state with acute exacerbation,Other specified types of schizophrenia, in remission,Other specified types of schizophrenia, subchronic state,Other specified types of schizophrenia, subchronic state with acute exacerbation,Other specified types of schizophrenia, unspecified state,SCHIZO NEC-CHR/EXACERB,SCHIZO NEC-SUBCHR/EXACER,SCHIZO NOS-CHR/EXACERB,SCHIZO NOS-SUBCHR/EXACER,schizoaffective disorder,schizophrenia,schizophrenia (disease),Schizophrenia (disorder),SCHIZOPHRENIA NEC-CHR,SCHIZOPHRENIA NEC-REMISS,SCHIZOPHRENIA NEC-SUBCHR,SCHIZOPHRENIA NEC-UNSPEC,Schizophrenia NOS,Schizophrenia NOS (disorder),SCHIZOPHRENIA NOS-UNSPEC,schizophrenia with or without an affective disorder,Schizophrenia, NOS,schizophrenia-1,Schizophrenias,SCHIZOPHRENIC DIS,Schizophrenic Disorder,Schizophrenic Disorders,Schizophrenic disorders (disorder),SCZD,Unspecified schizophrenia,Unspecified schizophrenia (disorder),Unspecified schizophrenia, chronic state with acute exacerbation,Unspecified schizophrenia, subchronic state with acute exacerbation,Unspecified schizophrenia, unspecified state,Schizophrenia
Group 0 name Corresponds to the control (unexposed) group for case-control studies
control individuals without a psychiatric diagnosis (past or present)
Group 1 name Corresponds to the case (exposed) group for case-control studies
SCZ: individuals with a psychiatric diagnosis of schizophrenia
Group 1 definition Diagnostic criteria applied to define the specific condition / phenotype represented in the case (exposed) group
Participants with a schizophrenia diagnosis categorized as follows: 1. AAP: individuals with treatment-responsive schizophrenia taking atypical antipsychotics (not clozapine) with a total Positive and Negative Symptom Scale (PANSS) score of 60 or low. 2. CR: individuals with treatment-resistant schizophrenia who were clozapine responsive total PANSS score ≤60). 3. CNR: individuals with treatment-resistant schizophrenia who were clozapine nonresponsive (total PANSS score >60).
Group 0 sample size Number of subjects in the control (unexposed) group
25
Group 1 sample size Number of subjects in the case (exposed) group
72
Antibiotics exclusion Number of days without antibiotics usage (if applicable) and other antibiotics-related criteria used to exclude participants (if any)
2 months

Lab analysis

Sequencing type
WMS
16S variable region One or more hypervariable region(s) of the bacterial 16S gene
Not specified
Sequencing platform Manufacturer and experimental platform used for quantifying microbial abundance
Illumina

Statistical Analysis

Data transformation Data transformation applied to microbial abundance measurements prior to differential abundance testing (if any).
centered log-ratio
Statistical test
ANCOM
Significance threshold p-value or FDR threshold used for differential abundance testing (if any)
.05
MHT correction Have statistical tests be corrected for multiple hypothesis testing (MHT)?
Yes
Matched on Factors on which subjects have been matched on in a case-control study
age, body mass index, sex
Confounders controlled for Confounding factors that have been accounted for by stratification or model adjustment
age, body mass index, sex

Alpha Diversity

Shannon Estimator of species richness and species evenness: more weight on species richness
unchanged
Simpson Estimator of species richness and species evenness: more weight on species evenness
unchanged
Richness Number of species
decreased

Signature 4

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/06/29

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and SCZ group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: increased abundance in SCZ: individuals with a psychiatric diagnosis of schizophrenia

NCBI Quality ControlLinks
Anaerotruncus colihominis
Blautia producta
Eggerthella lenta
Escherichia coli
Gordonibacter urolithinfaciens
Hungatella effluvii
Faecalicatena gnavusFaecalicatena gnavus
Flavonifractor sp000508885Flavonifractor sp000508885
Lawsonibacter sp900066825Lawsonibacter sp900066825
Clostridium M bolteaeClostridium M bolteae
Streptococcus parasanguinis BStreptococcus parasanguinis B
Absiella innocuumAbsiella innocuum
Clostridium M MIC9612Clostridium M MIC9612
Tyzzerella sp000411335Tyzzerella sp000411335
Clostridium M clostridioformeClostridium M clostridioforme

Revision editor(s): Jacob A. De Jesus

Signature 5

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/06/29

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and SCZ group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: decreased abundance in SCZ: individuals with a psychiatric diagnosis of schizophrenia

NCBI Quality ControlLinks
Romboutsia timonensis
ER4 sp000765235ER4 sp000765235
KLE1615 sp900066985KLE1615 sp900066985
Oscillibacter sp001916835Oscillibacter sp001916835

Revision editor(s): Jacob A. De Jesus

Experiment 2


Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus, Scholastica

Differences from previous experiment shown

Subjects

Condition The experimental condition / phenotype studied according to the Experimental Factor Ontology
Response to antipsychotic drug response to antipsychotic treatment,Response to antipsychotic drug,response to antipsychotic drug
Group 0 name Corresponds to the control (unexposed) group for case-control studies
control individuals without a psychiatric diagnosis of schizophrenia
Group 1 name Corresponds to the case (exposed) group for case-control studies
AAP: individuals with treatment-responsive schizophrenia taking atypical antipsychotics (not clozapine)
Group 1 definition Diagnostic criteria applied to define the specific condition / phenotype represented in the case (exposed) group
AAP: individuals with treatment-responsive schizophrenia taking atypical antipsychotics (not clozapine) with a total Positive and Negative Symptom Scale (PANSS) score of 60 or low.
Group 1 sample size Number of subjects in the case (exposed) group
24

Lab analysis

Statistical Analysis

Alpha Diversity

Shannon Estimator of species richness and species evenness: more weight on species richness
unchanged
Simpson Estimator of species richness and species evenness: more weight on species evenness
unchanged
Richness Number of species
decreased

Signature 1

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and AAP group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: decreased abundance in AAP: individuals with treatment-responsive schizophrenia taking atypical antipsychotics (not clozapine)

NCBI Quality ControlLinks
ER4 sp900317525ER4 sp900317525

Revision editor(s): Jacob A. De Jesus

Experiment 3


Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/06/29

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus, Scholastica

Differences from previous experiment shown

Subjects

Condition The experimental condition / phenotype studied according to the Experimental Factor Ontology
Treatment refractory schizophrenia refractory schizophrenia,treatment resistant schizophrenia,treatment-refractory schizophrenia,TRS,Treatment refractory schizophrenia,treatment refractory schizophrenia
Group 0 name Corresponds to the control (unexposed) group for case-control studies
AAP: individuals with treatment-responsive schizophrenia taking atypical antipsychotics (not clozapine)
Group 1 name Corresponds to the case (exposed) group for case-control studies
TRS: individuals with treatment-resistant schizophrenia taking clozapine
Group 1 definition Diagnostic criteria applied to define the specific condition / phenotype represented in the case (exposed) group
Participants with treatment-resistant schizophrenia categorized as follows: 1. CR: individuals with treatment-resistant schizophrenia who were clozapine responsive total PANSS score ≤60). 2. CNR: individuals with treatment-resistant schizophrenia who were clozapine nonresponsive (total PANSS score >60).
Group 0 sample size Number of subjects in the control (unexposed) group
24
Group 1 sample size Number of subjects in the case (exposed) group
48

Lab analysis

Statistical Analysis

Alpha Diversity

Shannon Estimator of species richness and species evenness: more weight on species richness
unchanged
Simpson Estimator of species richness and species evenness: more weight on species evenness
unchanged
Richness Number of species
unchanged

Signature 1

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/01

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for AAP and TRS group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: increased abundance in TRS: individuals with treatment-resistant schizophrenia taking clozapine

NCBI Quality ControlLinks
Eggerthella lenta
Eisenbergiella tayi
Hungatella effluvii
Ruthenibacterium lactatiformans
Faecalicatena gnavusFaecalicatena gnavus
Negativibacillus sp000435195Negativibacillus sp000435195
Tyzzerella sp000411335Tyzzerella sp000411335
Absiella innocuumAbsiella innocuum
Lachnospiraceae MIC9747Lachnospiraceae MIC9747
Clostridium Q symbiosumClostridium Q symbiosum
QAND01 MIC7514QAND01 MIC7514

Revision editor(s): Jacob A. De Jesus

Signature 2

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/01

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for AAP and TRS group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: decreased abundance in TRS: individuals with treatment-resistant schizophrenia taking clozapine

NCBI Quality ControlLinks
Faecalibacterium MIC7145Faecalibacterium MIC7145
Faecalibacterium prausnitzii DFaecalibacterium prausnitzii D

Revision editor(s): Jacob A. De Jesus

Experiment 4


Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus, Scholastica

Differences from previous experiment shown

Subjects

Group 0 name Corresponds to the control (unexposed) group for case-control studies
control individuals without a psychiatric diagnosis of schizophrenia
Group 1 definition Diagnostic criteria applied to define the specific condition / phenotype represented in the case (exposed) group
Participants with treatment-resistant schizophrenia categorized as follows: 1. CR: individuals with treatment-resistant schizophrenia who were clozapine responsive total PANSS score ≤60). 2. CNR: individuals with treatment-resistant schizophrenia who were clozapine nonresponsive (total PANSS score >60).
Group 0 sample size Number of subjects in the control (unexposed) group
25

Lab analysis

Statistical Analysis

Signature 1

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and TRS group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: increased abundance in TRS: individuals with treatment-resistant schizophrenia taking clozapine

NCBI Quality ControlLinks
Anaerotruncus colihominis
Eggerthella lenta
Escherichia coli
Gordonibacter urolithinfaciens
Hungatella effluvii
Ruthenibacterium lactatiformans
Faecalicatena gnavusFaecalicatena gnavus
Flavonifractor sp000508885Flavonifractor sp000508885
Clostridium M bolteaeClostridium M bolteae
Lawsonibacter sp900066825Lawsonibacter sp900066825
Absiella innocuumAbsiella innocuum
Tyzzerella sp000411335Tyzzerella sp000411335
Clostridium M MIC9612Clostridium M MIC9612
Streptococcus parasanguinis BStreptococcus parasanguinis B
Clostridium M clostridioformeClostridium M clostridioforme

Revision editor(s): Jacob A. De Jesus

Signature 2

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and TRS group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: decreased abundance in TRS: individuals with treatment-resistant schizophrenia taking clozapine

NCBI Quality ControlLinks
Romboutsia timonensis
ER4 sp000765235ER4 sp000765235
Faecalibacterium MIC7145Faecalibacterium MIC7145
Acetatifactor sp900066365Acetatifactor sp900066365
KLE1615 sp900066985KLE1615 sp900066985
Faecalibacterium prausnitzii DFaecalibacterium prausnitzii D
Oscillibacter sp001916835Oscillibacter sp001916835
GCA 900066135 MIC6659GCA 900066135 MIC6659
UBA7182 MIC8422UBA7182 MIC8422

Revision editor(s): Jacob A. De Jesus

Experiment 5


Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus, Scholastica

Differences from previous experiment shown

Subjects

Condition The experimental condition / phenotype studied according to the Experimental Factor Ontology
Response to clozapine Response to clozapine,response to clozapine
Group 1 name Corresponds to the case (exposed) group for case-control studies
CR: individuals with treatment-resistant schizophrenia responsive to clozapine
Group 1 definition Diagnostic criteria applied to define the specific condition / phenotype represented in the case (exposed) group
CR: individuals with treatment-resistant schizophrenia who were clozapine responsive (total PANSS score ≤60).
Group 1 sample size Number of subjects in the case (exposed) group
26

Lab analysis

Statistical Analysis

Alpha Diversity

Shannon Estimator of species richness and species evenness: more weight on species richness
unchanged
Simpson Estimator of species richness and species evenness: more weight on species evenness
unchanged
Richness Number of species
decreased

Signature 1

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and CR group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: increased abundance in CR: individuals with treatment-resistant schizophrenia responsive to clozapine

NCBI Quality ControlLinks
Eggerthella lenta
Hungatella effluvii
Faecalicatena gnavusFaecalicatena gnavus
Flavonifractor sp000508885Flavonifractor sp000508885
Lawsonibacter sp900066825Lawsonibacter sp900066825

Revision editor(s): Jacob A. De Jesus

Signature 2

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for control individuals and CR group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: decreased abundance in CR: individuals with treatment-resistant schizophrenia responsive to clozapine

NCBI Quality ControlLinks
Romboutsia timonensis
ER4 sp000765235ER4 sp000765235
KLE1615 sp900066985KLE1615 sp900066985
Oscillibacter sp001916835Oscillibacter sp001916835
Acetatifactor sp900066365Acetatifactor sp900066365
Faecalibacterium MIC7145Faecalibacterium MIC7145
Agathobacter faecisAgathobacter faecis
Faecalibacterium prausnitzii DFaecalibacterium prausnitzii D
Ruminococcus D bicirculansRuminococcus D bicirculans
ER4 sp900317525ER4 sp900317525
GCA 900066135 MIC6659GCA 900066135 MIC6659
UBA7182 MIC8422UBA7182 MIC8422

Revision editor(s): Jacob A. De Jesus

Experiment 6


Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus, Scholastica

Differences from previous experiment shown

Subjects

Condition The experimental condition / phenotype studied according to the Experimental Factor Ontology
Treatment refractory schizophrenia refractory schizophrenia,treatment resistant schizophrenia,treatment-refractory schizophrenia,TRS,Treatment refractory schizophrenia,treatment refractory schizophrenia
Group 1 name Corresponds to the case (exposed) group for case-control studies
CNR: individuals with treatment-resistant schizophrenia nonresponsive to clozapine
Group 1 definition Diagnostic criteria applied to define the specific condition / phenotype represented in the case (exposed) group
CNR: individuals with treatment-resistant schizophrenia who were clozapine nonresponsive (total PANSS score >60).
Group 1 sample size Number of subjects in the case (exposed) group
22

Lab analysis

Statistical Analysis

Alpha Diversity

Shannon Estimator of species richness and species evenness: more weight on species richness
unchanged
Simpson Estimator of species richness and species evenness: more weight on species evenness
unchanged
Richness Number of species
unchanged

Signature 1

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for CR and CNR group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: increased abundance in CNR: individuals with treatment-resistant schizophrenia nonresponsive to clozapine

NCBI Quality ControlLinks
Ruthenibacterium lactatiformans
Faecalicatena gnavusFaecalicatena gnavus
CAG 83 sp000431575CAG 83 sp000431575

Revision editor(s): Jacob A. De Jesus

Signature 2

Reviewed Marked as Reviewed by Svetlana up on 2024-7-16

Curated date: 2024/07/04

Curator: Jacob A. De Jesus

Revision editor(s): Jacob A. De Jesus

Source: Figure 3

Description: Differentially abundant species identified for CR and CNR group comparisons. Analyses were performed using ANCOM-BC, adjusting for age, sex, and body mass index.

Abundance in Group 1: decreased abundance in CNR: individuals with treatment-resistant schizophrenia nonresponsive to clozapine

NCBI Quality ControlLinks
Romboutsia timonensis
Faecalibacterium MIC7145Faecalibacterium MIC7145
ER4 sp000765235ER4 sp000765235
Faecalibacterium prausnitzii DFaecalibacterium prausnitzii D
UBA7182 MIC8422UBA7182 MIC8422
Gemmiger MIC9530Gemmiger MIC9530
GCA 900066135 MIC6659GCA 900066135 MIC6659

Revision editor(s): Jacob A. De Jesus