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Kula H, Ilgen O, Kurt S, Yılmaz F. Patterns of proliferation and fibrosis in a rat model of endometriosis following administration of Allium cepa. Clin Exp Reprod Med 2024; 51:112-119. [PMID: 38263589 PMCID: PMC11140262 DOI: 10.5653/cerm.2023.06261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE Endometriosis is a common gynecological disease among reproductive-age women. Numerous hypotheses exist regarding the pathogenesis of endometriosis. In Turkey, the consumption of Allium cepa (commonly known as the "onion cure") is a popular treatment employed to alleviate a variety of gynecological disorders. METHODS In this study, our objective was to assess the therapeutic mechanisms of the onion bulb A. cepa using an autologous endometriosis model in Sprague-Dawley rats. Previous research has shown that A. cepa possesses anti-inflammatory, antioxidant, and antiapoptotic properties. We evaluated the pathological condition of endometriotic implants by employing hematoxylin-eosin staining and Ki67 immunohistochemistry analysis. Transforming growth factor-beta 1 (TGF-β1) and alpha-smooth muscle actin (α-SMA) have been identified as profibrotic markers that are highly overexpressed in endometriotic tissues relative to eutopic endometrial tissue. Furthermore, TGF-β1 influences the differentiation and progression of endometriosis. To quantify profibrotic activity, we measured TGF-β1 and α-SMA using the immunosorbent assay method. RESULTS Lower histologic evaluation scores for endometriotic implants were observed in the group receiving high-dose A. cepa relative to the other groups. Ki67 expression was reduced following the high-dose A. cepa regimen, which consisted of 30% A. cepa and 70% normal feed. However, no statistically significant differences in TGF-β1 or α-SMA levels were observed among the groups (p=0.7 and p=0.778, respectively). CONCLUSION The findings suggest that A. cepa could serve as a therapeutic agent in endometriosis treatment, as evidenced by the reduction in proliferative potential. Nevertheless, A. cepa was not associated with significantly lower levels of endometriosis-associated TGF-β1 or α-SMA.
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Affiliation(s)
- Hakan Kula
- Department of Obstetrics and Gynecology, Dokuz Eylul University, Izmir, Turkey
| | - Orkun Ilgen
- Department of Obstetrics and Gynecology, Dokuz Eylul University, Izmir, Turkey
| | - Sefa Kurt
- Department of Obstetrics and Gynecology, Dokuz Eylul University, Izmir, Turkey
| | - Filiz Yılmaz
- Department of Histology and Embryology, Hitit University, Corum, Turkey
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2
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Li S, Fan Y, Shu C, Zhou Y, Shu J. Methyl 3,4-dihydroxybenzoate alleviates oxidative damage in granulosa cells by activating Nrf2 antioxidant pathway. J Ovarian Res 2024; 17:87. [PMID: 38664755 PMCID: PMC11044314 DOI: 10.1186/s13048-024-01412-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Oxidative damage induced granulosa cells (GCs) apoptosis was considered as a significant cause of compromised follicle quality, antioxidants therapy has emerged as a potential method for improving endometriosis pregnancy outcomes. Here, we found that GCs from endometriosis patients show increased oxidative stress level. Methyl 3,4-dihydroxybenzoate (MDHB), a small molecule compound that is extracted from natural plants, reversed tert-butyl hydroperoxide (TBHP) induced GCs oxidative damage. Therefore, the aim of this study was to assess the protective effect of MDHB for GCs and its potential mechanisms. TUNEL staining and immunoblotting of cleaved caspase-3/7/9 showed MDHB attenuated TBHP induced GCs apoptosis. Mechanistically, MDHB treatment decreased cellular and mitochondria ROS production, improved the mitochondrial function by rescuing the mitochondrial membrane potential (MMP) and ATP production. Meanwhile, MDHB protein upregulated the expression of vital antioxidant transcriptional factor Nrf2 and antioxidant enzymes SOD1, NQO1 and GCLC to inhibited oxidative stress state, further beneficial to oocytes and embryos quality. Therefore, MDHB may represent a potential drug candidate in protecting granulosa cells in endometriosis, which can improve pregnancy outcomes for endometriosis-associated infertility.
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Affiliation(s)
- Shishi Li
- Department of Reproductive Endocrinology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310000, People's Republic of China
| | - Yuhang Fan
- Department of Reproductive Endocrinology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310000, People's Republic of China
| | - Chongyi Shu
- Department of Reproductive Endocrinology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310000, People's Republic of China
| | - Yier Zhou
- Department of Reproductive Endocrinology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310000, People's Republic of China
| | - Jing Shu
- Department of Reproductive Endocrinology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310000, People's Republic of China.
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D’Amico R, Impellizzeri D, Cordaro M, Siracusa R, Interdonato L, Crupi R, Gugliandolo E, Macrì F, Di Paola D, Peritore AF, Fusco R, Cuzzocrea S, Di Paola R. Regulation of Apoptosis and Oxidative Stress by Oral Boswellia Serrata Gum Resin Extract in a Rat Model of Endometriosis. Int J Mol Sci 2022; 23:ijms232315348. [PMID: 36499679 PMCID: PMC9736785 DOI: 10.3390/ijms232315348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022] Open
Abstract
Endometriosis (EMS) is a gynecological disease characterized by inflammation, oxidative stress, and apoptosis dysregulation. This study aims to evaluate the effect of Boswellia serrata gum resin extract (BS) on the endometriotic lesions in a rat model of endometriosis. We divided female rats into three groups, including Sham, EMS, EMS + BS. In the EMS and EMS + BS groups, pathology was induced and after 7 days by the abdominal high-frequency ultrasound (hfUS) analysis the presence of the endometriotic lesions was confirmed. Subsequently, the EMS + BS group was administered with BS (100 mg/Kg) daily for another 7 days. At the end of the experiment, the hfUS analysis was repeated and the animals were sacrificed to evaluate the size and histoarchitecture of the endometriotic implants. Pelvic ultrasound showed increased size of the endometriotic lesions in the Endo group, while BS administration reduced the lesion size. The macroscopic analysis confirmed the reduced area and volume of the endometriotic lesions of the EMS + BS group. The histological analysis showed reduced characteristic of ectopic stroma and glands in the animals treated with BS. Western blot analyses were conducted to evaluate the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway. BS increases the expression of Nfr2 in the nucleus and the expression of its downstream antioxidant proteins NQO-1 and HO-1. Moreover, it reduced lipid peroxidation and increased glutathione (GSH) levels, and glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities. BS administration also restored the impaired apoptotic pathway in the lesions by reducing Bcl-2 expression and increasing Bax and cleaved caspase 9 levels. The BS apoptotic effect was also confirmed by the cleavage of PARP, another specific marker of apoptosis, and by the TUNEL assay. Our results show that BS administration resulted in an effective and coordinated suppression of Endo owing to its antioxidant and antiapoptotic activities.
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Affiliation(s)
- Ramona D’Amico
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Daniela Impellizzeri
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Marika Cordaro
- Department of Biomedical, Dental and Morphological and Functional Imaging, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| | - Rosalba Siracusa
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Livia Interdonato
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Rosalia Crupi
- Department of Veterinary Sciences, University of Messina, Viale Annunzita, 98168 Messina, Italy
| | - Enrico Gugliandolo
- Department of Veterinary Sciences, University of Messina, Viale Annunzita, 98168 Messina, Italy
| | - Francesco Macrì
- Department of Veterinary Sciences, University of Messina, Viale Annunzita, 98168 Messina, Italy
| | - Davide Di Paola
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Alessio Filippo Peritore
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Roberta Fusco
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
- Correspondence:
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, n 31, 98166 Messina, Italy
| | - Rosanna Di Paola
- Department of Veterinary Sciences, University of Messina, Viale Annunzita, 98168 Messina, Italy
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Mirzaei N, Jahanian Sadatmahalleh S, Rouholamin S, Nasiri M. A randomized trial assessing the efficacy of Silymarin on endometrioma-related manifestations. Sci Rep 2022; 12:17549. [PMID: 36266431 PMCID: PMC9584967 DOI: 10.1038/s41598-022-22073-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/10/2022] [Indexed: 01/13/2023] Open
Abstract
To study the effect of silymarin on the Interleukin-6 (IL-6) level, size of endometrioma lesion, pain, sexual function, and Quality of Life (QoL) in women diagnosed with endometriosis. This randomized, double-blind placebo-controlled clinical trial was performed on 70 women with endometriosis which was divided into two groups of intervention and control. The intervention was 140 mg silymarin (or matching placebo) administered twice daily for 12 weeks. The volume of endometrioma lesions, the level of IL-6 concentration in serum, pain, sexual function, and QoL were analyzed before and after the intervention. The means of endometrioma volume (P = 0.04), IL-6 (P = 0.002), and pain (P < 0.001) were reduced significantly in the silymarin group after intervention. However, the QoL and female sexual function did not improve substantially in the two groups (P > 0.05). Silymarin significantly reduced interleukin-6 levels, sizes of endometrioma lesions, and pain-related symptoms. The trial has been registered in the Iranian Registry of Clinical Trials (IRCT20150905023897N5) on 4th February 2020 (04/02/2020) ( https://en.irct.ir/trial/42215 ) and the date of initial participant enrollment was 2nd March 2020 (02/03/2020).
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Affiliation(s)
- Negin Mirzaei
- grid.412266.50000 0001 1781 3962Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Jalal Al-Ahmad Highway, Nasr Bridge, Tehran, 14115-111 Iran
| | - Shahideh Jahanian Sadatmahalleh
- grid.412266.50000 0001 1781 3962Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Jalal Al-Ahmad Highway, Nasr Bridge, Tehran, 14115-111 Iran
| | - Safoura Rouholamin
- grid.411036.10000 0001 1498 685XDepartment of Obstetrics and Gynecology, Faculty of Medical Sciences, Isfahan University of Medical Sciences, Hezar-Jerib Ave., Isfahan, 81746 73461 Iran
| | - Malihe Nasiri
- grid.411600.2Department of Basic Sciences, Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Effectiveness of Gamma Oryzanol on prevention of surgical induced endometriosis development in rat model. Sci Rep 2022; 12:2816. [PMID: 35181729 PMCID: PMC8857219 DOI: 10.1038/s41598-022-06883-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/07/2022] [Indexed: 01/18/2023] Open
Abstract
Infertility is believed to be triggered by endometriosis whose pathophysiology and the etiology is still unknown. Certain genes play pivotal roles in pathogenesis of endometriosis. Natural products and plants are used as important sources for production of new drugs. The current study assesses the effects of gamma-oryzanol (GO) in a rat model with surgically induced endometriosis. The experimental endometriosis was induced in 24 wistar rats, and the animals were subsequently subdivided into endometriosis-sole (endom group), 3000 and 6000 µg/kg GO (GO-3000 and GO-6000) and Vit C groups. The protein levels of estrogen receptor-alpha (ER-α), Steroidogenic factor 1 (SF1), Sirtuin 1 (SIRT1), heme oxygenase 1 (HO1), light chain 3 (LC3B) and Beclin1 (BECN1) were assessed. TUNEL staining was used for detecting the apoptosis rate. The results revealed that protein levels of SF1, HO1, and total LC3B significantly (P < 0.05) decreased in GO-6000-treated groups compared to endom group. Moreover, the protein level of BECN1 and SIRT-1 significantly (P < 0.05) increased in GO-6000-treated groups compared to endom group. GO treatment did not imply any significant difference (P > 0.05) concerning the protein levels of ER-α. The TUNEL staining results showed higher TUNEL-positive cells reactions in the rats treated with GO-6000 and Vit C. Thus, GO is involved in improving condition rats involved with endometriosis through modulation in the protein levels of some molecules and also induction of apoptosis.
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Farahani ZK, Taherianfard M, Naderi MM, Ferrero H. Possible therapeutic effect of royal jelly on endometriotic lesion size, pain sensitivity, and neurotrophic factors in a rat model of endometriosis. Physiol Rep 2021; 9:e15117. [PMID: 34806344 PMCID: PMC8606856 DOI: 10.14814/phy2.15117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 01/07/2023] Open
Abstract
Endometriosis is the abnormal growth of endometrial tissue. The goals of the study are: (1) Is any correlation between endometriosis pain and neurotrophins in the serum, dorsal root ganglion (DRG), and peritoneal fluid (PF) in rat models of experimental endometriosis?, (2) Possible therapeutic effects of royal jelly (RJ) on pain scores, size of endometriotic lesion, and neurotrophic factors. Forty-eight Sprague Dawley female rats weighing 205.023 ± 21.54 g were maintained in a standard condition. The rats were randomly divided into one of the six groups: Control (no intervention), Sham-1 (remove of uterine horn), RJ (administration of 200 mg/kg/day RJ for 21 days), Endometriosis (induction of endometriosis), Treatment (induction of endometriosis+administration of 200 mg/kg/day RJ for 21 days), and Sham-2 (induction of endometriosis+administration of water). Formalin test performed for pain evaluation. The levels of Brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), substance P, and calcitonin gene-related peptide (CGRP) were measured by enzyme-linked immunosorbent assay. The mean pain scores in all three phases of the formalin test were significantly increased by endometriosis induction (p < 0.05). The concentrations of BDNF, NGF, and CGRP in DRG of the endometriosis group were significantly higher than these factors in the Control, Sham-1, and RJ groups (p < 0.05). RJ could significantly (p < 0.001) decrease the mean lesion size and the mean pain score in the late phase (p < 0.05). The present results determine that endometriosis pain may be related to nervous system neurotrophic factors. Treatment with RJ could decrease the size of endometriosis lesions as well as pain scores. The findings may shed light on other complementary and alternative remedies for endometriosis.
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Affiliation(s)
- Zahra K. Farahani
- Physiology Division of Basic Sciences DepartmentSchool of Veterinary MedicineShiraz UniversityShirazIran
- Maternal, Fetal, and Neonatal Research CenterTehran University of Medical SciencesTehranIran
| | - Mahnaz Taherianfard
- Physiology Division of Basic Sciences DepartmentSchool of Veterinary MedicineShiraz UniversityShirazIran
| | - Mohamad Mehdi Naderi
- Reproductive Biotechnology Research CenterAvicenna Research InstituteACECRTehranIran
| | - Hortensia Ferrero
- Institute of Treatment and Diagnosis of Uterine DiseasesIVI FoundationValenciaSpain
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Balasubramanian V, Saravanan R, Joseph LD, Dev B, Gouthaman S, Srinivasan B, Dharmarajan A, Rayala SK, Venkatraman G. Molecular dysregulations underlying the pathogenesis of endometriosis. Cell Signal 2021; 88:110139. [PMID: 34464692 DOI: 10.1016/j.cellsig.2021.110139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 01/07/2023]
Abstract
Endometriosis is a crippling disease characterized by the presence of endometrium-like tissue or scar outside the uterine cavity, commonly confined to the peritoneal and serosal surfaces of the pelvic organs. 10-15% of women in reproductive age are estimated to be affected by endometriosis. Most of these patients present with infertility and suffer from pelvic pain. The benign disease rarely progresses to malignancy. Regardless of its high prevalence, the pathogenesis of the disease is not fully understood. Treatment options for endometriosis are limited and are often based on a symptomatic approach. The unavailability of proper diagnostic approaches, fewer therapeutic options, and sparse understanding of molecular alterations are responsible for the continued disease burden. Exploring the molecular elements causing the pathogenesis of endometriosis may lead to a number of breakthroughs in the treatment of the illness, such as the discovery of new biomarkers for diagnosis and therapeutic targets that can be a guide to better prognosis and reduced recurrence. The goal of this review is to provide the reader a critical understanding of the disease by summarizing the genetic, immunological, hormonal, and epigenetic deregulations that support the molecular basis for development of endometriotic cyst, with a special focus on the study models needed to analyze these changes in the endometriotic microenvironment.
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Affiliation(s)
- Vaishnavi Balasubramanian
- Department of Human Genetics, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Roshni Saravanan
- Department of Human Genetics, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Leena Dennis Joseph
- Department of Pathology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Bhawna Dev
- Department of Radiology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Shanmugasundaram Gouthaman
- Department of Surgical Oncology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Bhuvana Srinivasan
- Department of Obstetrics and Gynecology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Arun Dharmarajan
- Department of Biomedical Sciences, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Suresh Kumar Rayala
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, Tamil Nadu, India
| | - Ganesh Venkatraman
- Department of Human Genetics, Faculty of Biomedical Sciences, Technology and Research, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
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Bartiromo L, Schimberni M, Villanacci R, Ottolina J, Dolci C, Salmeri N, Viganò P, Candiani M. Endometriosis and Phytoestrogens: Friends or Foes? A Systematic Review. Nutrients 2021; 13:nu13082532. [PMID: 34444692 PMCID: PMC8398277 DOI: 10.3390/nu13082532] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 12/17/2022] Open
Abstract
The aim of this systematic review was to provide comprehensive and available data on the possible role of phytoestrogens (PE) for the treatment of endometriosis. We conducted an advanced, systematic search of online medical databases PubMed and Medline. Only full-length manuscripts written in English up to September 2020 were considered. A total of 60 studies were included in the systematic review. According to in vitro findings, 19 out of 22 studies reported the ability of PE in inducing anti-proliferative, anti-inflammatory and proapoptotic effects on cultured cells. Various mechanisms have been proposed to explain this in vitro action including the alteration of cell cycle proteins, the activation/inactivation of regulatory pathways, and modification of radical oxidative species levels. Thirty-eight articles on the effects of phytoestrogens on the development of endometriotic lesions in in vivo experimental animal models of endometriosis have been included. In line with in vitro findings, results also derived from animal models of endometriosis generally supported a beneficial effect of the compounds in reducing lesion growth and development. Finally, only seven studies investigated the effects of phytoestrogens intake on endometriosis in humans. The huge amount of in vitro and in vivo animal findings did not correspond to a consistent literature in the women affected. Therefore, whether the experimental findings can be translated in women is currently unknown.
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Affiliation(s)
- Ludovica Bartiromo
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
| | - Matteo Schimberni
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
| | - Roberta Villanacci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
| | - Jessica Ottolina
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
| | - Carolina Dolci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
| | - Noemi Salmeri
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
| | - Paola Viganò
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-02-550-343-02
| | - Massimo Candiani
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (L.B.); (M.S.); (R.V.); (J.O.); (C.D.); (N.S.); (M.C.)
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Talebi H, Farahpour MR, Hamishehkar H. The effectiveness of Rutin for prevention of surgical induced endometriosis development in a rat model. Sci Rep 2021; 11:7180. [PMID: 33785814 PMCID: PMC8010059 DOI: 10.1038/s41598-021-86586-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
Apoptosis and antioxidant mechanisms are pathways for the treatment of endometriosis (Endo). Rutin (Rtn) is an antioxidant flavonol that induces apoptosis. This study, for first time, was conducted to evaluate the effects of rutin on Endo through apoptosis and antioxidant mechanisms. The experimental Endo was induced in 24 rats and then the animals were subdivided into Endo-sole, 3000 and 6000 µg/kg rutin (Rtn-3000 and Rtn-6000) and vitamin C groups. After 4 weeks, the expression of Bcl2, Bax, anti Pro Caspase-9, cleaved Caspase-9, pro PARP, pro Cleaved PARP, Pro PARP, pro mTOR and mTOR were assessed by western blotting technique. The protein concentrations of malondialdehyde (MDA), total antioxidant capacity, and super oxide dismutase and gutathione peroxidase were also evaluated. TUNEL staining was also used for the detection of apoptosis. Caspase-9 and concentration of antioxidants were higher in the treated groups compared to Endo-sole group (P < 0.05). The results also showed that rutin decreased the expression of Bcl2 and MDA concentration (P < 0.05). The results for TUNEL staining showed that the animals treated with Rtn-6000 and vitamin C showed higher apoptosis. Rutin induces apoptosis by the expression of Bcl-2, Bax and caspase and also antioxidant activity by increasing antioxidants concentrations.
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Affiliation(s)
- Hatef Talebi
- Department of Basic Sciences, Faculty of Veterinary Medicine, Urmia Branch, Islamic Azad University, Urmia, Iran
| | - Mohammad Reza Farahpour
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Urmia Branch, Islamic Azad University, Urmia, Iran.
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Zhao R, Feng D, Zhuang G, Liu Y, Chi S, Zhang J, Zhou X, Zhang W, Wang H. Protein kinase CK2 participates in estrogen-mediated endothelial progenitor cell homing to endometriotic lesions through stromal cells in a stromal cell-derived factor-1- CXCR4-dependent manner. Fertil Steril 2021; 113:1067-1079.e5. [PMID: 32386617 DOI: 10.1016/j.fertnstert.2019.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 12/19/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To explore the possible mechanism of protein kinase CK2, which participates in estrogen recruitment of endothelial progenitor cells (EPCs), and its role in the angiogenesis of endometriosis lesions. DESIGN Laboratory study. SETTING University. ANIMAL(S) BALB/c mice. INTERVENTION(S) Exposure of human endometrial stromal cells (HESCs) to estrogen and CK2 inhibitor CX-4945 and endometrial stromal cells transfected with the protein kinase CK2 vector (HESC-CK2). Endometriosis models were induced by allogeneic mice transplantation of the endometrium into dorsal skinfold chambers. The mice received an IP injection of 50 mg/kg emodin per day or were treated with 100 μg/kg estrogen by SC injection once a week. MAIN OUTCOME MEASURE(S) The concentration of cytokines in cells was measured with ELISA. The migration of EPCs was examined using the scratch assay method and Transwell, a capillary tube-formation assay to determine EPC tube-forming capacity, and protein and mRNA expression with Western blot and polymerase chain reaction analyses, respectively. RESULT(S) Protein kinase CK2 participates in estrogen-mediated EPC homing to endometriotic lesions through stromal cells in a stromal cell-derived factor-1 (SDF-1)-CXCR4-dependent manner. Conditioned medium from endometrial stromal cells that were stably transfected with the protein kinase CK2 vector (HESC-CK2) or pretreated with estrogen significantly enhanced the migration and recruitment of EPCs. In contrast, conditioned medium from HESCs that were treated with CX-4945, a selective inhibitor of CK2, inhibited the mobility and viability of EPCs. Furthermore, CK2 overexpression significantly upregulated SDF-1 expression and secretion in endometrial stromal cells by activating the AKT/mTOR pathway. Moreover, treatment with the SDF-1 receptor CXCR4-specific inhibitor AMD3100 completely reversed the CK2-enhanced migration of EPCs. CONCLUSION(S) This study demonstrates that CK2 participates in estrogen-mediated EPC homing to endometriotic lesions through stromal cells in an SDF-1-CXCR4-dependent manner and may be a therapeutic target.
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Affiliation(s)
- Rong Zhao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Dilu Feng
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Guobin Zhuang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yan Liu
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Shuqi Chi
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Jun Zhang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xing Zhou
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Wei Zhang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China
| | - Hongbo Wang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huang Zhong University of Science and Technology, Wuhan, People's Republic of China.
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11
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Maharani M, Lajuna L, Yuniwati C, Sabrida O, Sutrisno S. Phytochemical characteristics from Phaleria macrocarpa and its inhibitory activity on the peritoneal damage of endometriosis. J Ayurveda Integr Med 2020; 12:229-233. [PMID: 33288353 PMCID: PMC8185966 DOI: 10.1016/j.jaim.2020.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/22/2022] Open
Abstract
Background Endometriois represents a gynecological disease that still becomes an issue in community. Phaleria macrocarpa is a plant native to Indonesia that contains an antioxidant substance, which may serve as apoptotic modulator and useful for angiogenesis. Objective This study aims to evaluate the effects of flavonoid isolates from P. macrocarpa (PM) on the development of granulomas, apoptosis, proliferation, and angiogenesis of the disease. Material and methods Total thirty mice (Mus musculus) were categorized into six groups, including the normal group (without any treatment), EMT (endometriosis) group, and EMT group treated with PM flavonoid isolates. Identification of the active compounds of P. macrocarpa was done using LC-HRMS. Measurement of granuloma scores and vascular density was done histologically. Apoptosis and proliferation analysis was performed by immunohistochemical techniques. Results There was an increase in granulomas, proliferation, and apoptosis in the peritoneal tissues of the endometriosis model. This change can be normalized by extract of P. macrocarpa. Conclusion We concluded that the flavonoid isolates from P. macrocarpa can suppress the growth of endometriosis lesions through normalization of proliferation and apoptosis. Thus, the P. macrocarpa flavonoid can be used as an alternative to inhibit the development of endometriosis.
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Affiliation(s)
- Maharani Maharani
- Department of Midwifery, Polytechnic of Health-Ministry of Health, Aceh Besar, Aceh, Indonesia.
| | - Lia Lajuna
- Department of Midwifery, Polytechnic of Health-Ministry of Health, Aceh Besar, Aceh, Indonesia
| | - Cut Yuniwati
- Department of Midwifery, Polytechnic of Health-Ministry of Health, Aceh Besar, Aceh, Indonesia
| | - Oktalia Sabrida
- Department of Midwifery, Polytechnic of Health-Ministry of Health, Aceh Besar, Aceh, Indonesia
| | - Sutrisno Sutrisno
- Division of Fertility, Endocrinology, and Reproduction, Department of Obstetrics and Gynecology, Saiful Anwar General Hospital, Universitas of Brawijaya, Malang, East Java, Indonesia
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12
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Meresman GF, Götte M, Laschke MW. Plants as source of new therapies for endometriosis: a review of preclinical and clinical studies. Hum Reprod Update 2020; 27:367-392. [PMID: 33124671 DOI: 10.1093/humupd/dmaa039] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Given the disadvantages and limitations of current endometriosis therapy, there is a progressive increase in studies focusing on plant-derived agents as a natural treatment option with the intention of achieving high efficiency, avoiding adverse effects and preserving the chance for successful pregnancy. The heterogeneity of these studies in terms of evaluated agents, applied approaches and outcomes illustrates the need for an up-to-date summary and critical view on this rapidly growing field in endometriosis research. OBJECTIVE AND RATIONALE This review provides a comprehensive overview of plant-derived agents and natural treatment strategies that are under preclinical or clinical investigation and critically evaluates their potential for future endometriosis therapy. SEARCH METHODS An English language PubMed literature search was performed using variations of the terms 'endometriosis', 'natural therapy', 'herb/herbal', 'plant', 'flavonoid', 'polyphenol', 'phytochemical', 'bioactive', 'Kampo' and 'Chinese medicine'. It included both animal and human studies. Moreover, the Clinicaltrials.gov database was searched with the term 'endometriosis' for clinical trials on plant-derived agents. No restriction was set for the publication date. OUTCOMES Natural therapies can be assigned to three categories: (i) herbal extracts, (ii) specific plant-derived bioactive compounds and (iii) Chinese herbal medicine (CHM). Agents of the first category have been shown to exert anti-proliferative, anti-inflammatory, anti-angiogenic and anti-oxidant effects on endometrial cells and endometriotic lesions. However, the existing evidence supporting their use in endometriosis therapy is quite limited. The most studied specific plant-derived bioactive compounds are resveratrol, epigallocatechin-3-gallate, curcumin, puerarin, ginsenosides, xanthohumol, 4-hydroxybenzyl alcohol, quercetin, apigenin, carnosic acid, rosmarinic acid, wogonin, baicalein, parthenolide, andrographolide and cannabinoids, with solid evidence about their inhibitory activity in experimental endometriosis models. Their mechanisms of action include pleiotropic effects on known signalling effectors: oestrogen receptor-α, cyclooxygenase-2, interleukin-1 and -6, tumour necrosis factor-α, intercellular adhesion molecule-1, vascular endothelial growth factor, nuclear factor-kappa B, matrix metalloproteinases as well as reactive oxygen species (ROS) and apoptosis-related proteins. Numerous studies suggest that treatment with CHM is a good choice for endometriosis management. Even under clinical conditions, this approach has already been shown to decrease the size of endometriotic lesions, alleviate chronic pelvic pain and reduce postoperative recurrence rates. WIDER IMPLICATIONS The necessity to manage endometriosis as a chronic disease highlights the importance of identifying novel and affordable long-term safety therapeutics. For this purpose, natural plant-derived agents represent promising candidates. Many of these agents exhibit a pleiotropic action profile, which simultaneously inhibits fundamental processes in the pathogenesis of endometriosis, such as proliferation, inflammation, ROS formation and angiogenesis. Hence, their inclusion into multimodal treatment concepts may essentially contribute to increase the therapeutic efficiency and reduce the side effects of future endometriosis therapy.
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Affiliation(s)
- Gabriela F Meresman
- Institute of Biology and Experimental Medicine (IBYME-CONICET), C1428ADN Buenos Aires, Argentina
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, 48149 Münster, Germany
| | - Matthias W Laschke
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Germany
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13
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Auriemma RS, Del Vecchio G, Scairati R, Pirchio R, Liccardi A, Verde N, de Angelis C, Menafra D, Pivonello C, Conforti A, Alviggi C, Pivonello R, Colao A. The Interplay Between Prolactin and Reproductive System: Focus on Uterine Pathophysiology. Front Endocrinol (Lausanne) 2020; 11:594370. [PMID: 33162942 PMCID: PMC7581729 DOI: 10.3389/fendo.2020.594370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/23/2020] [Indexed: 12/24/2022] Open
Abstract
Over the last years, increasing evidence has focused on crucial pathogenetic role of PRL on malignant, premalignant and benign uterine diseases. Studies in animals and humans have documented that PRL receptors (PRL-Rs) are widely expressed on uterine cells and that PRL is directly synthesized by the endometrium under the stimulatory action of progesterone. Uterine PRL secretion is finely modulated by autocrine/paracrine mechanisms which do not depend on the same control factors implied in the regulation of PRL secretion from pituitary. On the other hand, PRL is synthesized also in the myometrium and directly promotes uterine smooth muscle cell growth and proliferation. Therefore, PRL and PRL-Rs appear to play an important role for the activation of signaling pathways involved in uterine cancers and preneoplastic lesions. Circulating PRL levels are reportedly increased in patients with cervical or endometrial cancers, as well as uterine premalignant lesions, and might be used as discriminative biomarker in patients with uterine cancers. Similarly, increased PRL levels have been implicated in the endometriosis-induced infertility, albeit a clear a causative role for PRL in the pathogenesis of endometriosis is yet to be demonstrated. This evidence has suggested the potential application of dopamine agonists in the therapeutic algorithm of women with malignant, premalignant and benign uterine lesions. This review focuses on the role of PRL as tumorigenic factor for uterus and the outcome of medical treatment with dopamine agonists in patients with malignant and benign uterine disease.
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Affiliation(s)
- Renata S. Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Guendalina Del Vecchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Roberta Scairati
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Alessia Liccardi
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Nunzia Verde
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, Naples, Italy
| | - Cristina de Angelis
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, Naples, Italy
| | - Davide Menafra
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, Naples, Italy
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14
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Belkacemi L, Darmani NA. Dopamine receptors in emesis: Molecular mechanisms and potential therapeutic function. Pharmacol Res 2020; 161:105124. [PMID: 32814171 DOI: 10.1016/j.phrs.2020.105124] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/20/2020] [Accepted: 08/05/2020] [Indexed: 12/19/2022]
Abstract
Dopamine is a member of the catecholamine family and is associated with multiple physiological functions. Together with its five receptor subtypes, dopamine is closely linked to neurological disorders such as schizophrenia, Parkinson's disease, depression, attention deficit-hyperactivity, and restless leg syndrome. Unfortunately, several dopamine receptor-based agonists used to treat some of these diseases cause nausea and vomiting as impending side-effects. The high degree of cross interactions of dopamine receptor ligands with many other targets including G-protein coupled receptors, transporters, enzymes, and ion-channels, add to the complexity of discovering new targets for the treatment of nausea and vomiting. Using activation status of signaling cascades as mechanism-based biomarkers to foresee drug sensitivity combined with the development of dopamine receptor-based biased agonists may hold great promise and seems as the next step in drug development for the treatment of such multifactorial diseases. In this review, we update the present knowledge on dopamine and dopamine receptors and their potential roles in nausea and vomiting. The pre- and clinical evidence provided in this review supports the implication of both dopamine and dopamine receptor agonists in the incidence of emesis. Besides the conventional dopaminergic antiemetic drugs, potential novel antiemetic targeting emetic protein signaling cascades may offer superior selectivity profile and potency.
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Affiliation(s)
- Louiza Belkacemi
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, 91766, USA
| | - Nissar A Darmani
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, 91766, USA.
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15
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Sieberg CB, Lunde CE, Borsook D. Endometriosis and pain in the adolescent- striking early to limit suffering: A narrative review. Neurosci Biobehav Rev 2019; 108:866-876. [PMID: 31862211 DOI: 10.1016/j.neubiorev.2019.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 12/17/2022]
Abstract
Endometriosis, a condition in which uterine tissue grows outside the uterus, is a debilitating disease, affecting millions of women and costing the United States approximately $78 billion annually in pain- related disability. It is also the leading cause of chronic pelvic pain (CPP), which is often unresponsive to existing treatments. Adolescent women with the disease are at particular risk as there are often significant diagnostic delays, which in turn can exacerbate pain. Research and treatment guidelines for adolescents with endometriosis are largely based on studies for adult women due to the limited number of studies focusing on adolescents. The current paper critically reviews the literature as it pertains to endometriosis pathophysiology, mechanisms contributing to CPP, and treatment implications and recommendations with a focus on gaps related to adolescents.
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Affiliation(s)
- Christine B Sieberg
- Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, USA; Biobehavioral Pediatric Pain Lab, Department of Psychiatry, Boston Children's Hospital, USA; Department of Psychiatry, Harvard Medical School, USA; Department of Anesthesiology, Harvard Medical School, USA.
| | - Claire E Lunde
- Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, USA; Biobehavioral Pediatric Pain Lab, Department of Psychiatry, Boston Children's Hospital, USA; Nuffield Department of Women's and Reproductive Health, Medical Sciences Division, University of Oxford, UK
| | - David Borsook
- Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, USA; Department of Anesthesiology, Harvard Medical School, USA
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