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Sufriyana H, Wu YW, Su ECY. Artificial intelligence-assisted prediction of preeclampsia: Development and external validation of a nationwide health insurance dataset of the BPJS Kesehatan in Indonesia. EBioMedicine 2020; 54:102710. [PMID: 32283530 PMCID: PMC7152721 DOI: 10.1016/j.ebiom.2020.102710] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
Background We developed and validated an artificial intelligence (AI)-assisted prediction of preeclampsia applied to a nationwide health insurance dataset in Indonesia. Methods The BPJS Kesehatan dataset have been preprocessed using a nested case-control design into preeclampsia/eclampsia (n = 3318) and normotensive pregnant women (n = 19,883) from all women with one pregnancy. The dataset provided 95 features consisting of demographic variables and medical histories started from 24 months to event and ended by delivery as the event. Six algorithms were compared by area under the receiver operating characteristics curve (AUROC) with a subgroup analysis by time to the event. We compared our model to similar prediction models from systematically reviewed studies. In addition, we conducted a text mining analysis based on natural language processing techniques to interpret our modeling results. Findings The best model consisted of 17 predictors extracted by a random forest algorithm. Nine∼12 months to the event was the period that had the best AUROC in external validation by either geographical (0.88, 95% confidence interval (CI) 0.88–0.89) or temporal split (0.86, 95% CI 0.85–0.86). We compared this model to prediction models in seven studies from 869 records in PUBMED, EMBASE, and SCOPUS. This model outperformed the previous models in terms of the precision, sensitivity, and specificity in all validation sets. Interpretation Our low-cost model improved preliminary prediction to decide pregnant women that will be predicted by the models with high specificity and advanced predictors. Funding This work was supported by grant no. MOST108-2221-E-038-018 from the Ministry of Science and Technology of Taiwan.
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Affiliation(s)
- Herdiantri Sufriyana
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Department of Medical Physiology, College of Medicine, University of Nahdlatul Ulama Surabaya, Surabaya 60237, Indonesia.
| | - Yu-Wei Wu
- Department of Medical Physiology, College of Medicine, University of Nahdlatul Ulama Surabaya, Surabaya 60237, Indonesia; Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan.
| | - Emily Chia-Yu Su
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan; Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei 11031, Taiwan.
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52
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Yao Z, Long Y, Ye J, Li P, Jiang Y, Chen Y. 16S rRNA Gene-Based Analysis Reveals the Effects of Gestational Diabetes on the Gut Microbiota of Mice During Pregnancy. Indian J Microbiol 2020; 60:239-245. [PMID: 32372772 DOI: 10.1007/s12088-020-00862-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 03/06/2020] [Indexed: 12/15/2022] Open
Abstract
Hyperglycemia is one of the metabolic characteristics of gestational diabetes mellitus (GDM). Considering that GDM is able to cause changes in the gut bacterial community and function in the mother's intestine compared with healthy pregnant women, we aimed to clarify the correlation between hyperglycemia and gut microbiota in a GDM mouse model. Mice were divided into four groups: CE0, GDME0, CE18, and GDME18. C and GDM represent the control (C) and GDM groups, while E0 and E18 represent early or late trimesters of embryo day 0 or 18, respectively. GDM mouse models were created by injecting streptozocin on embryo day 0. The gut microbiota was characterized using the Illumina MiSeq platform targeting the V3-4 region of the 16S rRNA. Operational taxonomic unit analysis revealed a significant difference between CE18 and CE0, in which Akkermansia and Prevotellaceae were more abundant in the early trimester group, CE0. Moreover, the Clostridiales_vadinBB60 group was more abundant, while Parasutterella was much lower in GDME18 than in CE18. The gut microbiota community structure correlated with the GDM state, and LEfSe and molecular ecological network analysis further confirmed these diversities. Our research shows that changes in the community structure of the gut microbiota from the early to late trimester correlate with the GDM state. Changes in the abundance of the probiotic bacteria Akkermansia, Prevotellaceae, and Parasutterella may be involved in the GDM state.
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Affiliation(s)
- Ziting Yao
- 1College of Agriculture, Guangxi University, Nanning, 543000 China
| | - Yu Long
- 2Department of Gynecology and Obstetrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021 China
| | - Juan Ye
- 3Guangxi Key Laboratory of Genomic and Personalized Medicine, Guangxi Medical University, Nanning, 530021 China
| | - Pu Li
- PFOMIC Bioinformatics Company, Nanning, 530004 China
| | - Yonghua Jiang
- 3Guangxi Key Laboratory of Genomic and Personalized Medicine, Guangxi Medical University, Nanning, 530021 China
| | - Yanming Chen
- 5School of Electrical Engineering, Guangxi University, Nanning, 543004 China
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53
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Chen X, Li P, Liu M, Zheng H, He Y, Chen MX, Tang W, Yue X, Huang Y, Zhuang L, Wang Z, Zhong M, Ke G, Hu H, Feng Y, Chen Y, Yu Y, Zhou H, Huang L. Gut dysbiosis induces the development of pre-eclampsia through bacterial translocation. Gut 2020; 69:513-522. [PMID: 31900289 DOI: 10.1136/gutjnl-2019-319101] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 12/11/2019] [Accepted: 12/14/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Pre-eclampsia (PE) is one of the malignant metabolic diseases that complicate pregnancy. Gut dysbiosis has been identified for causing metabolic diseases, but the role of gut microbiome in the pathogenesis of PE remains unknown. DESIGN We performed a case-control study to compare the faecal microbiome of PE and normotensive pregnant women by 16S ribosomal RNA (rRNA) sequencing. To address the causative relationship between gut dysbiosis and PE, we used faecal microbiota transplantation (FMT) in an antibiotic-treated mouse model. Finally, we determined the microbiome translocation and immune responses in human and mouse placental samples by 16S rRNA sequencing, quantitative PCR and in situ hybridisation. RESULTS Patients with PE showed reduced bacterial diversity with obvious dysbiosis. Opportunistic pathogens, particularly Fusobacterium and Veillonella, were enriched, whereas beneficial bacteria, including Faecalibacterium and Akkermansia, were markedly depleted in the PE group. The abundances of these discriminative bacteria were correlated with blood pressure (BP), proteinuria, aminotransferase and creatinine levels. On successful colonisation, the gut microbiome from patients with PE triggered a dramatic, increased pregestational BP of recipient mice, which further increased after gestation. In addition, the PE-transplanted group showed increased proteinuria, embryonic resorption and lower fetal and placental weights. Their T regulatory/helper-17 balance in the small intestine and spleen was disturbed with more severe intestinal leakage. In the placenta of both patients with PE and PE-FMT mice, the total bacteria, Fusobacterium, and inflammatory cytokine levels were significantly increased. CONCLUSIONS This study suggests that the gut microbiome of patients with PE is dysbiotic and contributes to disease pathogenesis.
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Affiliation(s)
- Xia Chen
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Pan Li
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Mian Liu
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Huimin Zheng
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Microbiome Research Centre, St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Yan He
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Mu-Xuan Chen
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Wenli Tang
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaojing Yue
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yongxin Huang
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Lingling Zhuang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhijian Wang
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Mei Zhong
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Guibao Ke
- Department of Internal Medicine, Affiliated Hospital, Chengdu University, Chengdu, Sichuan, China
| | - Haoyue Hu
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yinglin Feng
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yun Chen
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Yanhong Yu
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
| | - Hongwei Zhou
- Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Liping Huang
- Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, China
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Ahmadian E, Rahbar Saadat Y, Hosseiniyan Khatibi SM, Nariman-Saleh-Fam Z, Bastami M, Zununi Vahed F, Ardalan M, Zununi Vahed S. Pre-Eclampsia: Microbiota possibly playing a role. Pharmacol Res 2020; 155:104692. [PMID: 32070720 DOI: 10.1016/j.phrs.2020.104692] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/23/2020] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
Abstract
Pre-eclampsia (PE) is a complication of pregnancy that is associated with mortality and morbidity in mothers and fetuses worldwide. Oxygen dysregulation in the placenta, abnormal remodeling of the spiral artery, defective placentation, oxidative stress at the fetal-maternal border, inflammation and angiogenic impairment in the maternal circulation are the main causes of this syndrome. These events result in a systemic and diffuse endothelial cell dysfunction, an essential pathophysiological feature of PE. The impact of bacteria on the multifactorial pathway of PE is the recent focus of scientific inquiry since microbes may cause each of the aforementioned features. Microbes and their derivatives by producing antigens and other inflammatory factors may trigger infection and inflammatory responses. A mother's bacterial communities in the oral cavity, gut, vagina, cervix and uterine along with the placenta and amniotic fluid microbiota may be involved in the development of PE. Here, we review the mechanistic and pathogenic role of bacteria in the development of PE. Then, we highlight the impact of alterations in a set of maternal microbiota (dysbiosis) on the pathogenesis of PE.
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Affiliation(s)
- Elham Ahmadian
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yalda Rahbar Saadat
- Nutrition Research Center, Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Ziba Nariman-Saleh-Fam
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Milad Bastami
- Department of Medical Genetics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Short-chain fatty acids accompanying changes in the gut microbiome contribute to the development of hypertension in patients with preeclampsia. Clin Sci (Lond) 2020; 134:289-302. [PMID: 31961431 DOI: 10.1042/cs20191253] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 12/15/2022]
Abstract
Preeclampsia (PE) is regarded as a pregnancy-associated hypertension disorder that is related to excessive inflammatory responses. Although the gut microbiota (GM) and short-chain fatty acids (SCFAs) have been related to hypertension, their effects on PE remain unknown. We determined the GM abundance and faecal SCFA levels by 16S ribosomal RNA (rRNA) sequencing and gas chromatography, respectively, using faecal samples from 27 patients with severe PE and 36 healthy, pregnant control subjects. We found that patients with PE had significantly decreased GM diversity and altered GM abundance. At the phylum level, patients with PE exhibited decreased abundance of Firmicutes albeit increased abundance of Proteobacteria; at the genus level, patients with PE had lower abundance of Blautia, Eubacterium_rectale, Eubacterium_hallii, Streptococcus, Bifidobacterium, Collinsella, Alistipes, and Subdoligranulum, albeit higher abundance of Enterobacter and Escherichia_Shigella. The faecal levels of butyric and valeric acids were significantly decreased in patients with PE and significantly correlated with the above-mentioned differential GM abundance. We predicted significantly increased abundance of the lipopolysaccharide (LPS)-synthesis pathway and significantly decreased abundance of the G protein-coupled receptor (GPCR) pathway in patients with PE, based on phylogenetic reconstruction of unobserved states (PICRUSt). Finally, we evaluated the effects of oral butyrate on LPS-induced hypertension in pregnant rats. We found that butyrate significantly reduced the blood pressure (BP) in these rats. In summary, we provide the first evidence linking GM dysbiosis and reduced faecal SCFA to PE and demonstrate that butyrate can directly regulate BP in vivo, suggesting its potential as a therapeutic agent for PE.
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Abstract
PURPOSE OF REVIEW This review will provide an in-depth coverage of the epidemiological and pre-clinical literature surrounding the role of dietary protein in hypertension, with a special emphasis on the history of our work on the Dahl salt-sensitive rat. RECENT FINDINGS Our studies have dedicated much effort into understanding the relationship between dietary protein and its effect on the development of salt-sensitive hypertension and renal injury. Our evidence over the last 15 years have demonstrated that both the source and amount of dietary protein can influence the severity of disease, where we have determined mechanisms related to immunity, the maternal environment during pregnancy, and more recently the gut microbiota, which significantly contribute to these diet-induced effects. Deeper understanding of these dietary protein-related mechanisms may provide insight on the plausibility of dietary modifications as future therapeutic avenues for hypertension and renal disease.
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57
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The Evolving Microbiome from Pregnancy to Early Infancy: A Comprehensive Review. Nutrients 2020; 12:nu12010133. [PMID: 31906588 PMCID: PMC7019214 DOI: 10.3390/nu12010133] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 12/12/2022] Open
Abstract
Pregnancy induces a number of immunological, hormonal, and metabolic changes that are necessary for the mother to adapt her body to this new physiological situation. The microbiome of the mother, the placenta and the fetus influence the fetus growth and undoubtedly plays a major role in the adequate development of the newborn infant. Hence, the microbiome modulates the inflammatory mechanisms related to physiological and pathological processes that are involved in the perinatal progress through different mechanisms. The present review summarizes the actual knowledge related to physiological changes in the microbiota occurring in the mother, the fetus, and the child, both during neonatal period and beyond. In addition, we approach some specific pathological situations during the perinatal periods, as well as the influence of the type of delivery and feeding.
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Wang J, Gu X, Yang J, Wei Y, Zhao Y. Gut Microbiota Dysbiosis and Increased Plasma LPS and TMAO Levels in Patients With Preeclampsia. Front Cell Infect Microbiol 2019; 9:409. [PMID: 31850241 PMCID: PMC6901393 DOI: 10.3389/fcimb.2019.00409] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Objective: To characterize the gut microbiota in patients with preeclampsia (PE) compared with healthy controls. Methods: We analyzed and compared the microbiota communities in the feces of 48 PE patients with 48 age-, gestational weeks-, and pre-pregnancy body mass index-matched healthy controls using 16S rRNA gene sequencing, and also we tested fecal and plasma lipopolysaccharide (LPS) and plasma trimethylamine-N-oxide (TMAO) concentration levels in the two groups. Results: Compared with the control group, microbial alpha diversity was lower in the PE group, but there was no statistically significant difference between the two groups. At the phylum level, Firmicutes (51.64% PE vs. 59.62% Control, P < 0.05), Bacteroidetes (40.51% PE vs. 34.81% Control, P< 0.05), Proteobacteria (4.51% PE vs. 2.56% Control, P < 0.05), and Actinobacteria (2.90% PE vs. 1.77% Control, P < 0.05), exhibited significant differences between the PE group and the control group. LEfSe analysis found 17 differentially abundant taxa between the two groups. PICRUSt analysis found that in the KEGG pathways, the microbial gene functions related to LPS biosynthesis were higher in the fecal microbiome of the PE group. The fecal and plasma LPS concentrations and plasma TMAO concentrations of PE patients were higher than those of the healthy controls. Conclusion: PE patients had gut microbiota dysbiosis and increased plasma LPS and TMAO levels, which will lead to a better understanding of the relationship between the gut microbiota and PE.
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Affiliation(s)
- Jing Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xunke Gu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Jing Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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de Brito Alves JL, de Oliveira Y, Carvalho NNC, Cavalcante RGS, Pereira Lira MM, Nascimento LCPD, Magnani M, Vidal H, Braga VDA, de Souza EL. Gut microbiota and probiotic intervention as a promising therapeutic for pregnant women with cardiometabolic disorders: Present and future directions. Pharmacol Res 2019; 145:104252. [PMID: 31054952 DOI: 10.1016/j.phrs.2019.104252] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/10/2019] [Accepted: 04/30/2019] [Indexed: 12/12/2022]
Abstract
Maternal cardiometabolic disorders, such as gestational diabetes mellitus, pre-eclampsia, obesity, and dyslipidemia, are the most common conditions that predispose offspring to risk for future cardiometabolic diseases, needing appropriate therapeutic approach. The implications of microbiota in the pathophysiology of maternal cardiometabolic disorders are progressively emerging and probiotics may be a simple and safe therapeutic strategy for maternal cardiometabolic management. In this review, we argue the importance of cardiometabolic dysfunction during pregnancy and/or lactation on the offspring risk for cardiometabolic disease in later life. In addition, we comprehensively discuss the microbial diversity observed in maternal cardiometabolic disorders and we present the main findings on probiotic intervention as a potential strategy for management of maternal cardiometabolic disorders. Current data reveal that gut microbiota may be transmitted from mother to offspring. Whether targeting microbiota with probiotic intervention during the periconceptional period prevents or delays the onset of cardiometabolic disorders in adult offspring should be tested in future clinical trials.
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Affiliation(s)
- José Luiz de Brito Alves
- Department of Nutrition, Health Sciences Center, Federal University of Paraíba, João Pessoa, Brazil.
| | - Yohanna de Oliveira
- Department of Nutrition, Health Sciences Center, Federal University of Paraíba, João Pessoa, Brazil
| | | | | | | | | | - Marciane Magnani
- Department of Food Engineering, Technology Center, Federal University of Paraiba, Joao Pessoa, Brazil
| | - Hubert Vidal
- Univ-Lyon, CarMeN(Cardio, Metabolism,Diabetes and Nutrition) Laboratory, INSERM U1060, INRA U1397, Université Claude Bernard Lyon 1, INSA Lyon, Oullins, France
| | - Valdir de Andrade Braga
- Department of Biotechnology, Biotechnology Center, Federal University of Paraíba, João Pessoa, PB, Brazil
| | - Evandro Leite de Souza
- Department of Nutrition, Health Sciences Center, Federal University of Paraíba, João Pessoa, Brazil
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Lv LJ, Li SH, Li SC, Zhong ZC, Duan HL, Tian C, Li H, He W, Chen MC, He TW, Wang YN, Zhou X, Yao L, Yin AH. Early-Onset Preeclampsia Is Associated With Gut Microbial Alterations in Antepartum and Postpartum Women. Front Cell Infect Microbiol 2019; 9:224. [PMID: 31297341 PMCID: PMC6608563 DOI: 10.3389/fcimb.2019.00224] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Imbalances in gut microbiota composition are linked to hypertension, host metabolic abnormalities, systemic inflammation, and other conditions. In the present study, we examined the changes of gut microbiota in women with early-onset preeclampsia (PE) and in normotensive, uncomplicated pregnant women during late pregnancy and at 1 and 6 weeks postpartum. Methods: Gut microbiota profiles of women with PE and healthy pregnant women in the third trimester and at 1 and 6 weeks postpartum were assessed by 16S rRNA gene amplicon sequencing. Plasma levels of interleukin-6 (IL-6), intestinal fatty acid-binding protein (I-FABP), zonulin, and lipopolysaccharide (LPS) were measured in the third trimesters. Results: At the genus level, 8 bacterial genera were significantly enriched in the antepartum samples of PE patients compared to healthy controls, of which Blautia, Ruminococcus2, Bilophila, and Fusobacterium represented the major variances in PE microbiomes. Conversely, 5 genera, including Faecalibacterium, Gemmiger, Akkermansia, Dialister, and Methanobrevibacter, were significantly depleted in antepartum PE samples. Maternal blood pressure and liver enzyme levels were positively correlated to the PE-enriched genera such as Anaerococcus, Ruminococcus2, Oribacterium, and Bilophila, while the fetal features (e.g., Apgar score and newborn birth weight) were positively correlated with PE-depleted genera and negatively correlated with PE-enriched genera. Moreover, maternal blood IL-6 level was positively associated with gut Bilophila and Oribacterium, whereas LPS level was negatively associated with Akkermansia. In terms of postpartum women, both the gut microbial composition and the PE-associated microbial alterations were highly consistent with those of the antepartum women. Conclusion: PE diagnosed in the third trimester of pregnancy is associated with a disrupted gut microbiota composition compared with uncomplicated pregnant women, which are associated with maternal clinical features (blood pressure level and liver dysfunction) and newborn birth weight. Moreover, these antepartum alterations in gut microbiota persisted 6 weeks postpartum.
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Affiliation(s)
- Li-Juan Lv
- The First Affiliated Hospital of Jinan University, Guangzhou, China.,Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | | | | | - Zhi-Cheng Zhong
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hong-Li Duan
- Department of Obstetrics, Guangdong Women and Children Hospital, Guangzhou, China
| | | | - Hui Li
- Department of Obstetrics, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wei He
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Min-Chai Chen
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Tian-Wen He
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Yu-Nan Wang
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xin Zhou
- Tianjin Key Laboratory of Cardiovascular Remodeling and Target Organ Injury, Pingjin Hospital Heart Center, Tianjin, China
| | - Lena Yao
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Ai-Hua Yin
- Medical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
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Beale AL, Kaye DM, Marques FZ. The role of the gut microbiome in sex differences in arterial pressure. Biol Sex Differ 2019; 10:22. [PMID: 31023366 PMCID: PMC6485140 DOI: 10.1186/s13293-019-0236-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/08/2019] [Indexed: 01/22/2023] Open
Abstract
There has been intense interest in the role of the gut microbiome in human health and a broad range of diseases in recent years. In the context of cardiovascular disease, gut dysbiosis (defined as a change in the gut microbiome and the gut-epithelial barrier) has been linked to disturbances in blood pressure (BP) regulation. These findings build upon our understanding of the complex pathophysiology of essential hypertension. There are clear sex differences in the epidemiology of hypertension, with distinct trends in BP across the life-course in men and women. To date, a role for the gut microbiome in contributing to the sex differences in BP is yet to be clearly established. The purpose of this review is to summarise the current literature regarding how the gut microbiome differs between men and women and to investigate whether sex-determined differences in the gut microbiome influence the response to factors such as diet, obesity and inflammation. Finally, we will explore evidence for the possible interaction between sex-specific factors, including sex hormones and pregnancy, with the gut in the context of hypertension pathophysiology.
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Affiliation(s)
- Anna L Beale
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia.,Central Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia.,Heart Centre, Alfred Hospital, Melbourne, Australia
| | - David M Kaye
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia.,Central Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia.,Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Francine Z Marques
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia. .,School of Biological Sciences, Faculty of Science, Monash University, Melbourne, Australia.
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Chen H, Li J, Li N, Liu H, Tang J. Increased circulating trimethylamine N-oxide plays a contributory role in the development of endothelial dysfunction and hypertension in the RUPP rat model of preeclampsia. Hypertens Pregnancy 2019; 38:96-104. [PMID: 30821524 DOI: 10.1080/10641955.2019.1584630] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We examined whether trimethylamine-N-oxide (TMAO) plays a role in endothelial dysfunction and hypertension in the reduced uterine perfusion pressure (RUPP) rat model of preeclampsia (PE). Methods: Normal pregnant rats and RUPP rats were treated without or with 3,3-Dimethyl-1-butanol (DMB, a TMAO inhibitor) from gestational day 14. Results: On day 19 of gestation, RUPP rats had higher plasma TMAO, impaired vasodilation and hypertension, decreased interleukin (IL)-10, increased superoxide production and proinflammatory cytokines in the aorta. All of which were reversed by DMD. Conclusion: Increased circulating TMAO downregulates IL-10 and promotes vascular inflammation and oxidative stress, contributing to endothelial dysfunction and hypertension in PE.
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Affiliation(s)
- Hui Chen
- a Department of Obstetrics , Affiliated Hospital of Jining Medical University , Jining , Shandong , China
| | - Jiabao Li
- b College of Clinical Medicine , Jining Medical University , Jining , Shandong , China
| | - Ning Li
- c College of Public Health , Jining Medical University , Jining , Shandong , China
| | - Hongsheng Liu
- d Cardiac Intensive Care Unit , Affiliated Hospital of Jining Medical University , Jining , Shandong , China
| | - Jiyun Tang
- a Department of Obstetrics , Affiliated Hospital of Jining Medical University , Jining , Shandong , China
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Ponzo V, Fedele D, Goitre I, Leone F, Lezo A, Monzeglio C, Finocchiaro C, Ghigo E, Bo S. Diet-Gut Microbiota Interactions and Gestational Diabetes Mellitus (GDM). Nutrients 2019; 11:E330. [PMID: 30717458 PMCID: PMC6413040 DOI: 10.3390/nu11020330] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 02/07/2023] Open
Abstract
Medical nutritional therapy is the first-line approach in managing gestational diabetes mellitus (GDM). Diet is also a powerful modulator of the gut microbiota, whose impact on insulin resistance and the inflammatory response in the host are well known. Changes in the gut microbiota composition have been described in pregnancies either before the onset of GDM or after its diagnosis. The possible modulation of the gut microbiota by dietary interventions in pregnancy is a topic of emerging interest, in consideration of the potential effects on maternal and consequently neonatal health. To date, very few data from observational studies are available about the associations between diet and the gut microbiota in pregnancy complicated by GDM. In this review, we analyzed the available data and discussed the current knowledge about diet manipulation in order to shape the gut microbiota in pregnancy.
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Affiliation(s)
- Valentina Ponzo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Debora Fedele
- Dietetic and Clinical Nutrition Unit, S. Giovanni Battista Hospital, Città della Salute e della Scienza, 10126 Turin, Italy.
| | - Ilaria Goitre
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, 10126 Turin, Italy.
| | - Antonela Lezo
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, 10126 Turin, Italy.
| | - Clara Monzeglio
- Gynecology and Obstetrics Unit, S. Anna Hospital, Città della Salute e della Scienza, 10126 Turin, Italy.
| | - Concetta Finocchiaro
- Dietetic and Clinical Nutrition Unit, S. Giovanni Battista Hospital, Città della Salute e della Scienza, 10126 Turin, Italy.
| | - Ezio Ghigo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
| | - Simona Bo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy.
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Through the Microbial Looking Glass: Premature Labor, Preeclampsia, and Gestational Diabetes: A Scoping Review. J Perinat Neonatal Nurs 2019; 33:35-51. [PMID: 30676461 PMCID: PMC6349420 DOI: 10.1097/jpn.0000000000000375] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The influence of microbial factors on adverse perinatal outcomes has become the focal point of recent investigations, with particular interest in the role of the microbiome and probiotic interventions. The purpose of this scoping review was to identify and critique the most recent evidence about these factors as they relate to pregnancies complicated by preeclampsia (PEC), preterm birth (PTB), and gestational diabetes mellitus (GDM). Four databases (PubMed, EMBASE, Web of Science, and Cochrane) were searched for articles published in English in the last 10 years with the concepts of the microbiome, probiotics, and PEC, PTB, or GDM. Forty-nine articles were eligible for full-text review. Five articles were excluded, leaving 44 articles that met all the eligibility criteria. The relationships between the microbiome and the risk for PEC, PTB, and GDM are not fully elucidated, although probiotic interventions seem beneficial in decreasing PEC and GDM risk. Probiotic interventions targeting bacterial vaginosis and elimination of infection in women at risk for PTB appear to be beneficial. More research is needed to understand the contributions of the microbiome to adverse perinatal outcomes. Probiotic interventions appear to be effective in reducing risk for select outcomes.
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65
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Effects of bifidobacteria-produced exopolysaccharides on human gut microbiota in vitro. Appl Microbiol Biotechnol 2018; 103:1693-1702. [DOI: 10.1007/s00253-018-9572-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 12/30/2022]
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Wen Y, Peng L, Xu R, Zang N, Huang Q, Zhong M. Maternal serum trimethylamine-N-oxide is significantly increased in cases with established preeclampsia. Pregnancy Hypertens 2018; 15:114-117. [PMID: 30825906 DOI: 10.1016/j.preghy.2018.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/22/2018] [Accepted: 12/10/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE To compare the levels of trimethylamine-N-oxide (TMAO) in sera of normal and preeclamptic pregnancies and to explore whether serum TMAO level was associated with the severity of preeclampsia. MATERIALS AND METHODS Eighty-six pregnant women in the third trimester were enrolled in this case control study. Levels of TMAO were quantified by a novel liquid chromatography/tandem mass spectrometry-based method in fasting serum samples from 43 preeclamptic women and 43 normotensive controls. Clinical characteristics, serum biomarkers of inflammation (IL-1β) and biomarkers of endothelial dysfunction (sVCAM-1, sFlt-1) were assessed. RESULTS TMAO levels were significantly higher in women with preeclampsia than those with normal pregnancy. The serum levels of TMAO were positively correlated with systolic blood pressure (r = 0.602, P < 0.001), urinary protein levels (r = 0.557, P < 0.001) and the serum levels of IL-1β (r = 0.633, P < 0.001), sVCAM-1 (r = 0.719, P < 0.001) as well as sFlt-1 (r = 0.763, P < 0.001) in patients with PE. CONCLUSIONS Elevated TMAO levels are associated with higher risk of preeclampsia and correlate with increased systemic inflammation and endothelial dysfunction. Further validation of these findings with more robust multicenter prospective and longitudinal characterization of maternal serum TMAO in pregnancy may be carried out in subsequent investigations to determine its suitability as a predictive biomarker for preeclampsia.
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Affiliation(s)
- Yuwen Wen
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China; First School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Linrui Peng
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China; First School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Ruoting Xu
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China; First School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, China; Division of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Nailiang Zang
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Qitao Huang
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China.
| | - Mei Zhong
- Division of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China
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67
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Zhang J, Wang G, Liu J, Gao L, Liu M, Wang C, Chuai M, Bao Y, Li G, Li R, Zhang Y, Yang X. Gut microbiota‐derived endotoxin enhanced the incidence of cardia bifida during cardiogenesis. J Cell Physiol 2018; 233:9271-9283. [DOI: 10.1002/jcp.26175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Jing Zhang
- Division of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical CollegeJinan UniversityGuangzhouChina
| | - Guang Wang
- Division of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical CollegeJinan UniversityGuangzhouChina
| | - Jia Liu
- The First Affiliate Hospital of Jinan UniversityGuangzhouChina
| | - Lin‐rui Gao
- Division of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical CollegeJinan UniversityGuangzhouChina
| | - Meng Liu
- Division of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical CollegeJinan UniversityGuangzhouChina
| | - Chao‐jie Wang
- Division of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical CollegeJinan UniversityGuangzhouChina
| | - Manli Chuai
- Division of Cell and Developmental BiologyUniversity of DundeeDundeeUK
| | - Yongping Bao
- Norwich Medical SchoolUniversity of East AngliaNorwichNorfolkUK
| | - Ge Li
- Guangdong Laboratory Animals Monitoring InstituteGuangdong Provincial Key Laboratory of Laboratory AnimalsGuangzhouGuangdongChina
| | - Rui‐man Li
- The First Affiliate Hospital of Jinan UniversityGuangzhouChina
| | - Yu Zhang
- Guangdong Laboratory Animals Monitoring InstituteGuangdong Provincial Key Laboratory of Laboratory AnimalsGuangzhouGuangdongChina
| | - Xuesong Yang
- Division of Histology and Embryology, Key Laboratory for Regenerative Medicine of the Ministry of Education, Medical CollegeJinan UniversityGuangzhouChina
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Crusell MKW, Hansen TH, Nielsen T, Allin KH, Rühlemann MC, Damm P, Vestergaard H, Rørbye C, Jørgensen NR, Christiansen OB, Heinsen FA, Franke A, Hansen T, Lauenborg J, Pedersen O. Gestational diabetes is associated with change in the gut microbiota composition in third trimester of pregnancy and postpartum. MICROBIOME 2018; 6:89. [PMID: 29764499 PMCID: PMC5952429 DOI: 10.1186/s40168-018-0472-x] [Citation(s) in RCA: 252] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 03/26/2018] [Indexed: 05/22/2023]
Abstract
BACKGROUND Imbalances of gut microbiota composition are linked to a range of metabolic perturbations. In the present study, we examined the gut microbiota of women with gestational diabetes mellitus (GDM) and normoglycaemic pregnant women in late pregnancy and about 8 months postpartum. METHODS Gut microbiota profiles of women with GDM (n = 50) and healthy (n = 157) pregnant women in the third trimester and 8 months postpartum were assessed by 16S rRNA gene amplicon sequencing of the V1-V2 region. Insulin and glucose homeostasis were evaluated by a 75 g 2-h oral glucose tolerance test during and after pregnancy. RESULTS Gut microbiota of women with GDM was aberrant at multiple levels, including phylum and genus levels, compared with normoglycaemic pregnant women. Actinobacteria at phylum level and Collinsella, Rothia and Desulfovibrio at genus level had a higher abundance in the GDM cohort. Difference in abundance of 17 species-level operational taxonomic units (OTUs) during pregnancy was associated with GDM. After adjustment for pre-pregnancy body mass index (BMI), 5 of the 17 OTUs showed differential abundance in the GDM cohort compared with the normoglycaemic pregnant women with enrichment of species annotated to Faecalibacterium and Anaerotruncus and depletion of species annotated to Clostridium (sensu stricto) and to Veillonella. OTUs assigned to Akkermansia were associated with lower insulin sensitivity while Christensenella OTUs were associated with higher fasting plasma glucose concentration. OTU richness and Shannon index decreased from late pregnancy to postpartum regardless of metabolic status. About 8 months after delivery, the microbiota of women with previous GDM was still characterised by an aberrant composition. Thirteen OTUs were differentially abundant in women with previous GDM compared with women with previous normoglycaemic pregnancy. CONCLUSION GDM diagnosed in the third trimester of pregnancy is associated with a disrupted gut microbiota composition compared with normoglycaemic pregnant women, and 8 months after pregnancy, differences in the gut microbiota signatures are still detectable. The gut microbiota composition of women with GDM, both during and after pregnancy, resembles the aberrant microbiota composition reported in non-pregnant individuals with type 2 diabetes and associated intermediary metabolic traits.
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Affiliation(s)
- Mie Korslund Wiinblad Crusell
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Tue Haldor Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Trine Nielsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Kristine Højgaard Allin
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
- Department of Clinical Epidemiology, Bispebjerg and Frederiksberg Hospital, Hovedvejen 5, Nordre Fasanvej 57, 2000 Frederiksberg, Copenhagen Denmark
| | - Malte C. Rühlemann
- Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Straße 12, 24105 Kiel, Germany
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Department of Obstetrics, Rigshospitalet University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamdsvej 3B, 2200 Copenhagen N, Denmark
| | - Henrik Vestergaard
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820 Gentofte, Denmark
| | - Christina Rørbye
- Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Kettegaards Allé 30, 2650 Hvidovre, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 9 A, 3. sal, 5000 Odense, Denmark
| | - Ole Bjarne Christiansen
- Department of Obstetrics and Gynaecology, Rigshospitalet University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- Fertility Clinic 4071, Rigshospitalet University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade, 9000 Aalborg, Denmark
| | - Femke-Anouska Heinsen
- Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Straße 12, 24105 Kiel, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, University Hospital Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Straße 12, 24105 Kiel, Germany
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Jeannet Lauenborg
- Department of Obstetrics and Gynaecology, Herlev University Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Section for Metabolic Genetics, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
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