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Chelluboina B, Cho T, Park JS, Mehta SL, Bathula S, Jeong S, Vemuganti R. Intermittent fasting induced cerebral ischemic tolerance altered gut microbiome and increased levels of short-chain fatty acids to a beneficial phenotype. Neurochem Int 2024; 178:105795. [PMID: 38908519 PMCID: PMC11296926 DOI: 10.1016/j.neuint.2024.105795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/03/2024] [Accepted: 06/19/2024] [Indexed: 06/24/2024]
Abstract
Preconditioning-induced cerebral ischemic tolerance is known to be a beneficial adaptation to protect the brain in an unavoidable event of stroke. We currently demonstrate that a short bout (6 weeks) of intermittent fasting (IF; 15 h fast/day) induces similar ischemic tolerance to that of a longer bout (12 weeks) in adult C57BL/6 male mice subjected to transient middle cerebral artery occlusion (MCAO). In addition, the 6 weeks IF regimen induced ischemic tolerance irrespective of age (3 months or 24 months) and sex. Mice subjected to transient MCAO following IF showed improved motor function recovery (rotarod and beam walk tests) between days 1 and 14 of reperfusion and smaller infarcts (T2-MRI) on day 1 of reperfusion compared with age/sex matched ad libitum (AL) controls. Diet influences the gut microbiome composition and stroke is known to promote gut bacterial dysbiosis. We presently show that IF promotes a beneficial phenotype of gut microbiome following transient MCAO compared with AL cohort. Furthermore, post-stroke levels of short-chain fatty acids (SCFAs), which are known to be neuroprotective, are higher in the fecal samples of the IF cohort compared with the AL cohort. Thus, our studies indicate the efficacy of IF in protecting the brain after stroke, irrespective of age and sex, probably by altering gut microbiome and SCFA production.
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Affiliation(s)
- Bharath Chelluboina
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Tony Cho
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Jin-Soo Park
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Suresh L Mehta
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Soomin Jeong
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA; Neuroscience Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Raghu Vemuganti
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA; Neuroscience Training Program, University of Wisconsin-Madison, Madison, WI, USA; William S. Middleton Veterans Administration Hospital, Madison, WI, USA.
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Chen J, Luo C, Tan D, Li Y. J-shaped associations of pan-immune-inflammation value and systemic inflammation response index with stroke among American adults with hypertension: evidence from NHANES 1999-2020. Front Neurol 2024; 15:1417863. [PMID: 39144717 PMCID: PMC11322096 DOI: 10.3389/fneur.2024.1417863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 07/23/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Stroke, a leading cause of death and disability worldwide, is primarily ischemic and linked to hypertension. Hypertension, characterized by systemic chronic inflammation, significantly increases stroke risk. This study explores the association of novel systemic inflammatory markers (SII, PIV, SIRI) with stroke prevalence in hypertensive U.S. adults using NHANES data. Methods We analyzed data from hypertensive participants in the NHANES 1999-2020 survey, excluding those under 20, pregnant, or with missing data, resulting in 18,360 subjects. Systemic inflammatory markers (SII, PIV, SIRI) were calculated from blood counts. Hypertension and stroke status were determined by self-report and clinical measurements. Covariates included sociodemographic, lifestyle, and medical history factors. Weighted statistical analyses and multivariate logistic regression models were used to explore associations, with adjustments for various covariates. Ethical approval was obtained from the NCHS Ethics Review Board. Results In a cohort of 18,360 hypertensive individuals (mean age 56.652 years), 7.25% had a stroke. Stroke patients were older, had lower PIR, and were more likely to be female, single, less educated, smokers, non-drinkers, physically inactive, and have diabetes and CHD. Multivariate logistic regression showed that SII was not significantly associated with stroke. However, PIV and SIRI were positively associated with stroke prevalence. Each unit increase in lnPIV increased stroke odds by 14% (OR = 1.140, p = 0.0022), and lnSIRI by 20.6% (OR = 1.206, p = 0.0144). RCS analyses confirmed J-shaped associations for lnPIV and lnSIRI with stroke. Stratified analyses identified gender and smoking as significant effect modifiers. Smoking was significantly associated with elevated PIV, SIRI, and SII levels, especially in current smokers. Conclusion Elevated PIV and SIRI levels significantly increase stroke prevalence in hypertensive individuals, notably among males and smokers. A predictive model with PIV, SIRI, and sociodemographic factors offers strong clinical utility.
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Affiliation(s)
| | | | - Dianhui Tan
- Department of Neurosurgery, the First Affiliated Hospital of Shantou University Medical College, Shantou, China
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Zhou C, Qiu SW, Wang FM, Liu YC, Hu W, Yang ML, Liu WH, Li H. Gasdermin D could be lost in the brain parenchyma infarct core and a pyroptosis-autophagy inhibition effect of Jie-Du-Huo-Xue decoction after stroke. Front Pharmacol 2024; 15:1449452. [PMID: 39139639 PMCID: PMC11320715 DOI: 10.3389/fphar.2024.1449452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 07/15/2024] [Indexed: 08/15/2024] Open
Abstract
Background The Chinese ethnic medicine Jie-Du-Huo-Xue Decoction (JDHXD) is used to alleviate neuroinflammation in cerebral ischemia (CI). Our previous studies have confirmed that JDHXD can inhibit microglial pyroptosis in CI. However, the pharmacological mechanism of JDHXD in alleviating neuroinflammation and pyroptosis needs to be further elucidated. New research points out that there is an interaction between autophagy and inflammasome NLRP3, and autophagy can help clear NLRP3. The NLRP3 is a key initiator of pyroptosis and autophagy. The effect of JDHXD promoting autophagy to clear NLRP3 to inhibit pyroptosis on cerebral ischemia-reperfusion inflammatory injury is currently unknown. We speculate that JDHXD can inhibit pyroptosis in CI by promoting autophagy to clear NLRP3. Methods Chemical characterization of JDHXD was performed using LC-MS. Model of middle cerebral artery occlusion/reperfusion (MCAO/R) was established in SD rats. Neurological deficits, neuron damage, and cerebral infarct volume were evaluated. Western Blot and immunofluorescence were used to detect neuronal pyroptosis and autophagy. Results 30 possible substance metabolites in JDHXD medicated serum were analyzed by LC-MS (Composite Score > 0.98). Furthermore, JDHXD protects rat neurological function and cerebral infarct size after CI. JDHXD inhibited the expression of pyroptosis and autophagy after CI. Our western blot and immunofluorescence results showed that JDHXD treatment can reduce the expression of autophagy-related factors ULK1, beclin1, and LC3-Ⅱ. The expression of NLRP3 protein was lower in the JDHXD group than in the I/R group. Compared with the I/R group, the expressions of pyroptosis-related factors caspase-1 P 10, GSDMD-NT, IL-18, and IL-1β decreased in the JDHXD group. Furthermore, we observed an unexpected result: immunofluorescence demonstrated that Gasdermin D (GSDMD) was significantly absent in the infarct core, and highly expressed in the peri-infarct and contralateral cerebral hemispheres. This finding challenges the prevailing view that GSDMD is elevated in the ischemic cerebral hemisphere. Conclusion JDHXD inhibited pyroptosis and autophagy after MCAO/R. JDHXD suppressed pyroptosis and autophagy by inhibiting NLRP3, thereby alleviating CI. In addition, we present a different observation from previous studies that the expression of GSDMD in the infarct core was lower than that in the peri-infarct and contralateral non-ischemic hemispheres on day 3 of CI.
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Affiliation(s)
- Chang Zhou
- Hunan University of Chinese Medicine, Changsha, Hunan, China
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Changsha, Hunan, China
| | - Shi-wei Qiu
- Hunan University of Chinese Medicine, Changsha, Hunan, China
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Feng-ming Wang
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Yu-chen Liu
- Hunan University of Chinese Medicine, Changsha, Hunan, China
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Wei Hu
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Mei-lan Yang
- Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Wang-hua Liu
- Hunan University of Chinese Medicine, Changsha, Hunan, China
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Key Laboratory of TCM Heart and Lung Syndrome Differentiation & Medicated Diet and Dietotherapy, University of Chinese Medicine, Changsha, Hunan, China
- Hunan Engineering Technology Research Center for Medicinal and Functional Food, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Hua Li
- Hunan University of Chinese Medicine, Changsha, Hunan, China
- Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
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Ma X, Xia J, Yuan J, Meng X, Chen H, Li X. Blockade of exosome release alleviates the hypersensitive reaction by influencing the T helper cell population in cow's milk allergic mice. Food Funct 2024; 15:3050-3059. [PMID: 38414407 DOI: 10.1039/d3fo05336a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
The aim of this work was to evaluate the ameliorative effects of exosome biogenesis in cow's milk allergy (CMA) response. In this context, BALB/c mice were systemically sensitized with cow's milk proteins plus an aluminum adjuvant to induce CMA. The inhibitor GW4869 of exosome biogenesis was added before sensitization and then the anaphylactic reactions were evaluated both in vivo (clinical score and body temperature) and in vitro (serum histamine, allergen-specific antibodies, cytokines by ELISA and cell analysis by flow cytometry) to explore the role of exosomes in the development of CMA. Nanoparticle tracking analysis (NTA) and transmission electron microscopy (TEM) showed that the size distribution and morphology of CMA-derived exosomes were not changed after GW4869 preconditioning, and the concentration of exosomes was much lower than that of the CMA group. In the GW4869 group, inhibition of release of exosomes modulated the induction of T helper 2 cell (Th2)-related substances, with a decrease in histamine and allergen-specific immunoglobulin (Ig) E, and the expression of Th1, Th2, and Th17 cells all decreased as well. Moreover, the experimental data were integrated by means of principal component analysis (PCA) to give an overview that the percentage of Th cells and concentrations of cytokines were more influenced by GW4869 treatment. These data for the first time demonstrated that exosomes are involved in the development of CMA and the blockade of exosome release with GW4869 suppressed the IgE-mediated immune response in CMA.
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Affiliation(s)
- Xin Ma
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, China.
- School of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi Province Key Laboratory of Food Allergy, Nanchang University, Nanchang, 330047, China
| | - Jiaheng Xia
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, China.
- Jiangxi Province Key Laboratory of Edible and Medicinal Resources Exploitation, Nanchang University, Nanchang, 330047, China
- School of Resource and Environmental and Chemical Engineering, Nanchang University, Nanchang, 330047, China
| | - Jin Yuan
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, China.
- School of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi Province Key Laboratory of Food Allergy, Nanchang University, Nanchang, 330047, China
| | - Xuanyi Meng
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, China.
- School of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi Province Key Laboratory of Food Allergy, Nanchang University, Nanchang, 330047, China
- Sino-German Joint Research Institute (Jiangxi-OAI), Nanchang University, Nanchang 330047, China
| | - Hongbing Chen
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, China.
- School of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi Province Key Laboratory of Food Allergy, Nanchang University, Nanchang, 330047, China
- Sino-German Joint Research Institute (Jiangxi-OAI), Nanchang University, Nanchang 330047, China
| | - Xin Li
- State Key Laboratory of Food Science and Resources, Nanchang University, Nanchang 330047, China.
- School of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi Province Key Laboratory of Food Allergy, Nanchang University, Nanchang, 330047, China
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Raffaele S, Thougaard E, Laursen CCH, Gao H, Andersen KM, Nielsen PV, Ortí-Casañ N, Blichfeldt-Eckhardt M, Koch S, Deb-Chatterji M, Magnus T, Stubbe J, Madsen K, Meyer M, Degn M, Eisel ULM, Wlodarczyk A, Fumagalli M, Clausen BH, Brambilla R, Lambertsen KL. Microglial TNFR2 signaling regulates the inflammatory response after CNS injury in a sex-specific fashion. Brain Behav Immun 2024; 116:269-285. [PMID: 38142915 DOI: 10.1016/j.bbi.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023] Open
Abstract
Microglia, the resident immune cells of the central nervous system (CNS), play a major role in damage progression and tissue remodeling after acute CNS injury, including ischemic stroke (IS) and spinal cord injury (SCI). Understanding the molecular mechanisms regulating microglial responses to injury may thus reveal novel therapeutic targets to promote CNS repair. Here, we investigated the role of microglial tumor necrosis factor receptor 2 (TNFR2), a transmembrane receptor previously associated with pro-survival and neuroprotective responses, in shaping the neuroinflammatory environment after CNS injury. By inducing experimental IS and SCI in Cx3cr1CreER:Tnfrsf1bfl/fl mice, selectively lacking TNFR2 in microglia, and corresponding Tnfrsf1bfl/fl littermate controls, we found that ablation of microglial TNFR2 significantly reduces lesion size and pro-inflammatory cytokine levels, and favors infiltration of leukocytes after injury. Interestingly, these effects were paralleled by opposite sex-specific modifications of microglial reactivity, which was found to be limited in female TNFR2-ablated mice compared to controls, whereas it was enhanced in males. In addition, we show that TNFR2 protein levels in the cerebrospinal fluid (CSF) of human subjects affected by IS and SCI, as well as healthy donors, significantly correlate with disease stage and severity, representing a valuable tool to monitor the inflammatory response after acute CNS injury. Hence, these results advance our understanding of the mechanisms regulating microglia reactivity after acute CNS injury, aiding the development of sex- and microglia-specific, personalized neuroregenerative strategies.
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Affiliation(s)
- Stefano Raffaele
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark; Department of Pharmacological and Biomolecular Sciences "Rodolfo Paoletti", Università degli Studi di Milano, 20133 Milan, Italy
| | - Estrid Thougaard
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark
| | - Cathrine C H Laursen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark; BRIDGE-Brain Research Inter Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark
| | - Han Gao
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, 510630 Guangzhou, China; Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, 510630 Guangzhou, China
| | - Katrine M Andersen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark
| | - Pernille V Nielsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark
| | - Natalia Ortí-Casañ
- Department of Molecular Neurobiology, Groningen Institute for Evolutionary Life Sciences, University of Groningen, Groningen 9713 AV, Netherlands
| | - Morten Blichfeldt-Eckhardt
- Department of Anaesthesiology, Vejle Hospital, 7100 Vejle, Denmark; Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark
| | - Simon Koch
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Tim Magnus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jane Stubbe
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark
| | - Kirsten Madsen
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark
| | - Morten Meyer
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark; BRIDGE-Brain Research Inter Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark; Department of Neurology, Odense University Hospital, 5000 Odense C, Denmark
| | | | - Ulrich L M Eisel
- Department of Molecular Neurobiology, Groningen Institute for Evolutionary Life Sciences, University of Groningen, Groningen 9713 AV, Netherlands
| | - Agnieszka Wlodarczyk
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark; BRIDGE-Brain Research Inter Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark
| | - Marta Fumagalli
- Department of Pharmacological and Biomolecular Sciences "Rodolfo Paoletti", Università degli Studi di Milano, 20133 Milan, Italy
| | - Bettina H Clausen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark; BRIDGE-Brain Research Inter Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark
| | - Roberta Brambilla
- BRIDGE-Brain Research Inter Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark; The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami FL, USA.
| | - Kate L Lambertsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5230 Odense M, Denmark; BRIDGE-Brain Research Inter Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, 5230 Odense M, Denmark; Department of Neurology, Odense University Hospital, 5000 Odense C, Denmark.
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Kang S, Lee J, Choi S, Nesbitt J, Min PH, Trushina E, Choi DS. Moderate ethanol exposure reduces astrocyte-induced neuroinflammatorysignaling and cognitive decline in presymptomatic APP/PS1 mice. RESEARCH SQUARE 2023:rs.3.rs-3627637. [PMID: 38077051 PMCID: PMC10705690 DOI: 10.21203/rs.3.rs-3627637/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Background Alcohol use disorder (AUD) has been associated with the development of neurodegenerative diseases, including Alzheimer's disease (AD). However, recent studies demonstrate that moderate alcohol consumption may be protective against dementia and cognitive decline. Methods We examined astrocyte function, low-density lipoprotein (LDL) receptor-related protein 1 (LRP1), and the NF-κB p65 and IKK-α/β signaling pathways in modulating neuroinflammation and amyloid beta (Aβ) deposition. We assessed apolipoprotein E (ApoE) in the mouse brain using IHC and ELISA in response to moderate ethanol exposure (MEE). First, to confirm the intracerebral distribution of ApoE, we co-stained with GFAP, a marker for astrocytes that biosynthesize ApoE. We sought to investigate whether the ethanol-induced upregulation of LRP1 could potentially inhibit the activity of IL-1β and TNF-α induced IKK-α/β towards NF-κB p65, resulting in a reduction of pro-inflammatory cytokines. To evaluate the actual Aβ load in the brains of APP/PS1 mice, we performed with a specific antibody Aβ (Thioflavin S) on both air- and ethanol-exposed groups, subsequently analyzing Aβ levels. We also measured glucose uptake activity using 18F-FDG in APP/PS1 mice. Finally, we investigated whether MEE induced cognitive and memory changes using the Y maze, noble objective recognition (NOR) test, and Morris water maze (MWM). Results Our findings demonstrate that MEE reduced astrocytic glial fibrillary acidic protein (GFAP) and ApoE levels in the cortex and hippocampus in presymptomatic APP/PS1 mice. Interestingly, increased LRP1 protein expression is accompanied by dampening the IKK-α/β-NF-κB p65 pathway, resulting in decreased IL-1β and TNF-α levels in male mice. Notably, female mice show reduced anti-inflammatory cytokines, IL-4, and IL-10 levels without altering IL-1β and TNF-α concentrations. In both males and females, Aβ plaques, a hallmark of AD, were reduced in the cortex and hippocampus of ethanol-exposed presymptomatic APP/PS1 mice. Consistently, MEE increased fluorodeoxyglucose (FDG)-positron emission tomography (PET)-based brain activities and normalized cognitive and memory deficits in the APP/PS1 mice. Conclusions Our findings suggest that MEE may benefit AD pathology via modulating LRP1 expression, potentially reducing neuroinflammation and attenuating Aβ deposition. Our study implies that reduced astrocyte derived ApoE and LDL cholesterol levels are critical for attenuating AD pathology.
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Affiliation(s)
| | - Jeyeon Lee
- Mayo Clinic College of Medicine, and Science
| | - Sun Choi
- Mayo Clinic College of Medicine, and Science
| | | | - Paul H Min
- Mayo Clinic College of Medicine, and Science
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