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Cuevas-Diaz Duran R, Martinez-Ledesma E, Garcia-Garcia M, Bajo Gauzin D, Sarro-Ramírez A, Gonzalez-Carrillo C, Rodríguez-Sardin D, Fuentes A, Cardenas-Lopez A. The Biology and Genomics of Human Hair Follicles: A Focus on Androgenetic Alopecia. Int J Mol Sci 2024; 25:2542. [PMID: 38473791 DOI: 10.3390/ijms25052542] [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: 01/16/2024] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
Androgenetic alopecia is a highly prevalent condition mainly affecting men. This complex trait is related to aging and genetics; however, multiple other factors, for example, lifestyle, are also involved. Despite its prevalence, the underlying biology of androgenetic alopecia remains elusive, and thus advances in its treatment have been hindered. Herein, we review the functional anatomy of hair follicles and the cell signaling events that play a role in follicle cycling. We also discuss the pathology of androgenetic alopecia and the known molecular mechanisms underlying this condition. Additionally, we describe studies comparing the transcriptional differences in hair follicles between balding and non-balding scalp regions. Given the genetic contribution, we also discuss the most significant risk variants found to be associated with androgenetic alopecia. A more comprehensive understanding of this pathology may be generated through using multi-omics approaches.
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Affiliation(s)
- Raquel Cuevas-Diaz Duran
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey 64710, NL, Mexico
- CapilarFix®, Monterrey 66220, NL, Mexico
| | - Emmanuel Martinez-Ledesma
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey 64710, NL, Mexico
- Tecnologico de Monterrey, Institute for Obesity Research, Monterrey 64849, NL, Mexico
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Mustafa AI, Ibrahim SE, Gohary YM, Al-Husseini NF, Fawzy E, El-Shimi OS. Association between angiotensin-converting enzyme gene insertion deletion polymorphism and androgenetic alopecia susceptibility among Egyptian patients: A preliminary case-controlled study. J Cosmet Dermatol 2021; 21:2629-2634. [PMID: 34499796 DOI: 10.1111/jocd.14434] [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: 07/10/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Androgenetic alopecia (AGA) is a prevalent condition with a complex etiopathogenesis. Angiotensin-converting enzyme (ACE) gene located on the chromosome 17q23 contains an insertion (I) and deletion (D) polymorphism in the intron 16. This gene polymorphism plays a role in multiple inflammatory disorders. However, there are no studies investigating its association with AGA susceptibility. OBJECTIVES In this work, we aimed at exploring the association of ACE gene I/D polymorphism in AGA susceptibility in a group of Egyptian patients. METHODS This study included 100 AGA patients, and 100 apparently healthy controls. The ACE gene I/D polymorphism was analyzed by polymerase chain reaction. RESULTS The DD, ID genotypes, and D allele showed higher frequent distribution among studied AGA patients than controls (p < 0.05 each). Positive family history and ACE gene I/D polymorphism were considered AGA susceptibility predictors in both uni- and multivariable analyses [p < 0.05 each (OR (95% CI)] on applying logistic regression analysis for risk factors prediction. CONCLUSIONS This study highlights the possible contribution of the suspected genetic polymorphism as a susceptibility indicator for AGA development in the examined group of patients.
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Affiliation(s)
- Amany Ibrahim Mustafa
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt.,Department of Dermatology, Venereology and Andrology, Faculty of Medicine, October 6 University, Giza Governorate, Egypt
| | - Samah Ezzat Ibrahim
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Yasser Mostafa Gohary
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Beni-Suef University, Beni Suef, Egypt
| | - Naglaa Fathy Al-Husseini
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Eman Fawzy
- Department of Laboratory Medicine, Mansoura Fever Hospital, Mansoura, Egypt
| | - Ola Samir El-Shimi
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
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English R, Ruiz S. Conflicting Reports Regarding the Histopathological Features of Androgenic Alopecia: Are Biopsy Location, Hair Diameter Diversity, and Relative Hair Follicle Miniaturization Partly to Blame? Clin Cosmet Investig Dermatol 2021; 14:357-365. [PMID: 33854354 PMCID: PMC8039045 DOI: 10.2147/ccid.s306157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022]
Abstract
Despite decades of study, debate persists over the role of inflammation, fibrosis, and prostaglandins in the histopathology of androgenic alopecia (AGA). This brief review proposes that inconsistent findings across histological studies are a consequence of three inadequately controlled variables: 1) biopsy location, 2) hair diameter diversity (HDD), and 3) relative hair follicle miniaturization (HFM) within and across subjects. We suggest new methodological considerations to improve AGA histopathological research, as well as a novel classification system to quantify HFM by its stages. Finally, we hypothesize a dynamic relationship between inflammation, fibrosis, and prostaglandin activity dependent on relative HFM.
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Affiliation(s)
| | - Sophia Ruiz
- Perfect Hair Health, San Francisco, CA, 94115, USA
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English RS. A hypothetical pathogenesis model for androgenic alopecia: clarifying the dihydrotestosterone paradox and rate-limiting recovery factors. Med Hypotheses 2017; 111:73-81. [PMID: 29407002 DOI: 10.1016/j.mehy.2017.12.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/25/2017] [Accepted: 12/28/2017] [Indexed: 12/30/2022]
Abstract
Androgenic alopecia, also known as pattern hair loss, is a chronic progressive condition that affects 80% of men and 50% of women throughout a lifetime. But despite its prevalence and extensive study, a coherent pathology model describing androgenic alopecia's precursors, biological step-processes, and physiological responses does not yet exist. While consensus is that androgenic alopecia is genetic and androgen-mediated by dihydrotestosterone, questions remain regarding dihydrotestosterone's exact role in androgenic alopecia onset. What causes dihydrotestosterone to increase in androgenic alopecia-prone tissues? By which mechanisms does dihydrotestosterone miniaturize androgenic alopecia-prone hair follicles? Why is dihydrotestosterone also associated with hair growth in secondary body and facial hair? Why does castration (which decreases androgen production by 95%) stop pattern hair loss, but not fully reverse it? Is there a relationship between dihydrotestosterone and tissue remodeling observed alongside androgenic alopecia onset? We review evidence supporting and challenging dihydrotestosterone's causal relationship with androgenic alopecia, then propose an evidence-based pathogenesis model that attempts to answer the above questions, account for additionally-suspected androgenic alopecia mediators, identify rate-limiting recovery factors, and elucidate better treatment targets. The hypothesis argues that: (1) chronic scalp tension transmitted from the galea aponeurotica induces an inflammatory response in androgenic alopecia-prone tissues; (2) dihydrotestosterone increases in androgenic alopecia-prone tissues as part of this inflammatory response; and (3) dihydrotestosterone does not directly miniaturize hair follicles. Rather, dihydrotestosterone is a co-mediator of tissue dermal sheath thickening, perifollicular fibrosis, and calcification - three chronic, progressive conditions concomitant with androgenic alopecia progression. These conditions remodel androgenic alopecia-prone tissues - restricting follicle growth space, oxygen, and nutrient supply - leading to the slow, persistent hair follicle miniaturization characterized in androgenic alopecia. If true, this hypothetical model explains the mechanisms by which dihydrotestosterone miniaturizes androgenic alopecia-prone hair follicles, describes a rationale for androgenic alopecia progression and patterning, makes sense of dihydrotestosterone's paradoxical role in hair loss and hair growth, and identifies targets to further improve androgenic alopecia recovery rates: fibrosis, calcification, and chronic scalp tension.
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Michel L, Reygagne P, Benech P, Jean-Louis F, Scalvino S, Ly Ka So S, Hamidou Z, Bianovici S, Pouch J, Ducos B, Bonnet M, Bensussan A, Patatian A, Lati E, Wdzieczak-Bakala J, Choulot JC, Loing E, Hocquaux M. Study of gene expression alteration in male androgenetic alopecia: evidence of predominant molecular signalling pathways. Br J Dermatol 2017; 177:1322-1336. [PMID: 28403520 DOI: 10.1111/bjd.15577] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Male androgenetic alopecia (AGA) is the most common form of hair loss in men. It is characterized by a distinct pattern of progressive hair loss starting from the frontal area and the vertex of the scalp. Although several genetic risk loci have been identified, relevant genes for AGA remain to be defined. OBJECTIVES To identify biomarkers associated with AGA. METHODS Molecular biomarkers associated with premature AGA were identified through gene expression analysis using cDNA generated from scalp vertex biopsies of hairless or bald men with premature AGA, and healthy volunteers. RESULTS This monocentric study reveals that genes encoding mast cell granule enzymes, inflammatory mediators and immunoglobulin-associated immune mediators were significantly overexpressed in AGA. In contrast, underexpressed genes appear to be associated with the Wnt/β-catenin and bone morphogenic protein/transforming growth factor-β signalling pathways. Although involvement of these pathways in hair follicle regeneration is well described, functional interpretation of the transcriptomic data highlights different events that account for their inhibition. In particular, one of these events depends on the dysregulated expression of proopiomelanocortin, as confirmed by polymerase chain reaction and immunohistochemistry. In addition, lower expression of CYP27B1 in patients with AGA supports the notion that changes in vitamin D metabolism contributes to hair loss. CONCLUSIONS This study provides compelling evidence for distinct molecular events contributing to alopecia that may pave the way for new therapeutic approaches.
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Affiliation(s)
- L Michel
- Inserm UMR976, Skin Research Institute, F-75475, Paris, France.,University Paris Diderot, Sorbonne Paris-Cité, Hôpital Saint-Louis, F-75475, Paris, France
| | - P Reygagne
- Centre Sabouraud, F-75475, Paris, France
| | - P Benech
- NICN UMR 7259 CNRS Faculté de Médecine, 13344, Marseille, France.,GENEX, 91160, Longjumeau, France
| | - F Jean-Louis
- Inserm UMR976, Skin Research Institute, F-75475, Paris, France.,University Paris Diderot, Sorbonne Paris-Cité, Hôpital Saint-Louis, F-75475, Paris, France
| | - S Scalvino
- Laboratoire BIO-EC, 91160, Longjumeau, France
| | - S Ly Ka So
- Inserm UMR976, Skin Research Institute, F-75475, Paris, France
| | - Z Hamidou
- Centre Sabouraud, F-75475, Paris, France
| | | | - J Pouch
- Plateforme de qPCR à Haut Débit Genomic Paris Centre, IBENS, 75005, Paris, France
| | - B Ducos
- Plateforme de qPCR à Haut Débit Genomic Paris Centre, IBENS, 75005, Paris, France.,Laboratoire de Physique Statistique, École Normale Supérieure, PSL Research University, University Paris Diderot, Sorbonne Paris-Cité, CNRS, 75005, Paris, France
| | - M Bonnet
- Inserm UMR976, Skin Research Institute, F-75475, Paris, France
| | - A Bensussan
- Inserm UMR976, Skin Research Institute, F-75475, Paris, France.,University Paris Diderot, Sorbonne Paris-Cité, Hôpital Saint-Louis, F-75475, Paris, France
| | | | - E Lati
- GENEX, 91160, Longjumeau, France.,Laboratoire BIO-EC, 91160, Longjumeau, France
| | | | | | - E Loing
- IEB-Lucas Meyer Cosmetics, 31520, Ramonville, France
| | - M Hocquaux
- IEB-Lucas Meyer Cosmetics, 31520, Ramonville, France
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Rossi A, Fortuna MC, Pranteda G, Garelli V, Di Nunno D, Mari E, Calvieri S, Carlesimo M. Klinische, histologische und trichoskopische Korrelate bei Erkrankungen der Kopfhaut. ACTA ACUST UNITED AC 2016. [DOI: 10.1159/000442453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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8
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Almodovar-Real A, Diaz-Martinez M, Ruiz-Villaverde R, Naranjo-Sintes R. Mast Cells and Scarring Alopecia: Is There a Clear Pathophysiological Relationship? ACTAS DERMO-SIFILIOGRAFICAS 2015. [DOI: 10.1016/j.adengl.2015.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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9
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Almodovar-Real A, Diaz-Martinez MA, Ruiz-Villaverde R, Naranjo-Sintes R. Mast cells and scarring alopecia: Is there a clear pathophysiological relationship? ACTAS DERMO-SIFILIOGRAFICAS 2015; 106:854-7. [PMID: 26358499 DOI: 10.1016/j.ad.2015.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/12/2015] [Accepted: 03/19/2015] [Indexed: 02/07/2023] Open
Affiliation(s)
- A Almodovar-Real
- Unidad de Gestión Clínica de Dermatología Médico Quirúrgica y Venereología, Hospital Universitario San Cecilio, Granada, España.
| | - M A Diaz-Martinez
- Unidad de Gestión Clínica de Dermatología Médico Quirúrgica y Venereología, Hospital Universitario San Cecilio, Granada, España
| | - R Ruiz-Villaverde
- Unidad de Gestión Clínica de Dermatología Médico Quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, España
| | - R Naranjo-Sintes
- Unidad de Gestión Clínica de Dermatología Médico Quirúrgica y Venereología, Hospital Universitario San Cecilio, Granada, España
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Rossi A, Fortuna MC, Pranteda G, Garelli V, Di Nunno D, Mari E, Calvieri S, Carlesimo M. Clinical, Histological and Trichoscopic Correlations in Scalp Disorders. Dermatology 2015; 231:201-8. [DOI: 10.1159/000430909] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/21/2015] [Indexed: 11/19/2022] Open
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11
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Monteiro C, Dourado M, Matos M, Duarte I, Lamas S, Galhardo V, Lima D. Critical care and survival of fragile animals: The case of Prrxl1 knockout mice. Appl Anim Behav Sci 2014. [DOI: 10.1016/j.applanim.2014.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Kibar M, Aktan S, Bilgin M. Scalp dermatoscopic findings in androgenetic alopecia and their relations with disease severity. Ann Dermatol 2014; 26:478-84. [PMID: 25143677 PMCID: PMC4135103 DOI: 10.5021/ad.2014.26.4.478] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 09/09/2013] [Accepted: 09/14/2013] [Indexed: 11/17/2022] Open
Abstract
Background Clinicians are searching for new methods to diagnose and predict the course of androgenetic alopecia noninvasively. Objective Our aim is to evaluate trichoscopic findings and their relations with disease severity in androgenetic alopecia. Methods The videodermatoscopic findings of 143 female and 63 male patients with androgenetic alopecia were compared with each other, with those of healthy subjects (n=100), and with those of patients with other nonscarring alopecias (n=208). Mann-Whitney U-test, χ2 analyses, and logistic regression analysis were used for statistical analysis. Results No statistically significant relation was found between trichoscopic findings and severity in male androgenetic alopecia (MAGA) on the basis of the modified Hamilton Norwood scale (among 7 degrees); however, multihair follicular unit and perifollicular pigmentation were related to low severity whereas white dots, honeycomb pattern pigmentation, and brown dots were related to high severity. On the other hand, according to the Ludwig classification, arborizing red lines were related to low severity and brown dots were related to high severity, whereas there was no difference in stages between the Ebling and Olsen classifications in female androgenetic alopecia (FAGA). In the characteristic trichoscopic findings in this study, perifollicular pigmentation was found as a normal feature of the scalp, whereas multihair follicular unit and honeycomb pigment pattern, which were previously considered as normal features, were observed to be related to androgenetic alopecia. Conclusion No relation was found between MAGA severity and trichoscopic findings, as well as between FAGA severity according to different disease severity classifications and trichoscopic findings.
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Affiliation(s)
- Melike Kibar
- Department of Dermatology, Beypazarı Public Hospital, Ankara, Turkey
| | - Sebnem Aktan
- Department of Dermatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Muzaffer Bilgin
- Department of Biostatistics, Eskişehir Osmangazi University School of Medicine, Eskişehir, Turkey
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Larson AR, Zhan Q, Johnson E, Fragoso AC, Wan M, Murphy GF. A prostaglandind-synthase-positive mast cell gradient characterizes scalp patterning. J Cutan Pathol 2014; 41:364-9. [DOI: 10.1111/cup.12286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/09/2013] [Accepted: 12/16/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Allison R. Larson
- Department of Dermatology; Brigham and Women's Hospital; Boston MA USA
| | - Qian Zhan
- Program in Dermatopathology, Department of Pathology; Brigham and Women's Hospital; Boston MA USA
| | - Elisha Johnson
- Department of Pathology; Brigham and Women's Hospital; Boston MA USA
| | - Ana Carolina Fragoso
- Program in Dermatopathology, Department of Pathology; Brigham and Women's Hospital; Boston MA USA
| | - Marilyn Wan
- Program in Dermatopathology, Department of Pathology; Brigham and Women's Hospital; Boston MA USA
| | - George F. Murphy
- Program in Dermatopathology, Department of Pathology; Brigham and Women's Hospital; Boston MA USA
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Kim HM, Lim YY, Kim MY, Son IP, Kim DH, Park SR, Seo SK, Lee MS, Mun SK, Kim CW, Kim BJ. Inhibitory effect of tianeptine on catagen induction in alopecia areata-like lesions induced by ultrasonic wave stress in mice. Clin Exp Dermatol 2013; 38:758-67. [PMID: 23581888 DOI: 10.1111/ced.12047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Alopecia areata (AA) is characterized by rapid and complete hair loss in one or multiple areas of the scalp. Stress is an important triggering factor in AA. AIM To identify the inhibitory effect of tianeptine on catagen induction in C57BL/6 mice with AA-like lesions induced by ultrasonic wave stress (UWS). METHODS The mice were divided into four groups. Group 1 received oral tianeptine before and after UWS; group 2 received oral tianeptine only after UWS; group 3 was given UWS treatment only; and group 4 (negative control group) was not given any treatment. Phototrichigraphy and dermatoscopy were used for assessment. Histological analysis was performed using haematoxylin and eosin, toluidine blue, Masson trichrome and Verhoeff-van Gieson stains. Immunohistochemical analysis was also performed. The level of apoptosis and expression of neuropeptides in the skin were assessed by terminal deoxynucleotidyl transferase dUTP nick end labelling and immunofluorescence assays. RESULTS Mice in group 1 had an increased rate of hair growth and greater hair-shaft thickness compared with mice in groups 2 and 3. In addition, mice in group 1 had a higher number of anagen hair follicles, increased synthesis of collagen and elastic fibres, decreased mast-cell degranulation, reduction in cell apoptosis in hair follicles, and recovery of vitamin D receptor expression. Expression of neuropeptides (substance P, calcitonin gene-related peptide) was not altered. CONCLUSIONS Tianeptine might play a role in suppressing catagen induction in a stress-induced AA mouse model.
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Affiliation(s)
- H M Kim
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
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Vanderford DA, Greer PK, Sharp JM, Chichlowski M, Rouse DC, Selim MA, Hale LP. Alopecia in IL-10-deficient mouse pups is c-kit-dependent and can be triggered by iron deficiency. Exp Dermatol 2010; 19:518-26. [PMID: 20100190 DOI: 10.1111/j.1600-0625.2009.01032.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hair loss (alopecia) can result from a variety of metabolic, endocrine, immunologic, and environmental causes. This investigation was undertaken to determine the mechanisms underlying the sporadic development of alopecia in litters from C57BL/6 interleukin-10-deficient (Il10(-/-)) mice. All pups in affected litters demonstrated alopecia by postnatal days 17-19, with hair loss from their trunks but not from their head, base of tail, or feet. Histopathology revealed distorted hair follicles containing broken hair shafts and prominent dermal infiltrates containing increased numbers of activated mast cells. Hair re-growth began soon after weaning, suggesting that the alopecia was triggered by factors transmitted during lactation. Milk from Il10(-/-) dams induced macrophage secretion of pro-inflammatory cytokines in vitro regardless of whether or not their pups developed alopecia. Feeding dams a diet containing 3-6 ppm iron increased the percentage of litters with alopecia to 100% for pups with mast cells, with 0% alopecia in mast cell-deficient pups. When dams were fed a diet containing 131 ppm iron, significantly lower haemoglobin and hematocrit values were observed in pups from litters with alopecia (71%; 5 of 7 litters) compared to litters without alopecia. Genetic or pharmacologic inhibition of c-kit that resulted in depletion of mast cells in pups prevented hair loss in at-risk litters. These studies demonstrate that maternal iron-restricted diets enhance the incidence of alopecia in IL-10-deficient mouse pups and suggest mast cells as potential effector cells. Further studies are indicated to further explore the mechanisms involved and to determine how mast cells may contribute to alopecia in humans.
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Affiliation(s)
- Deborah A Vanderford
- Office of Animal Welfare Assurance, Duke University Medical Center, Durham, NC, USA
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