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Xue L, Chen R, Liu Y, Niu P, Zhou J, Liu J, Zhang J, Chen H. Association of maternal blood high-mobility group box 1 levels and adverse pregnancy outcomes: A systematic review and meta-analysis. Reprod Biol 2024; 24:100859. [PMID: 38492434 DOI: 10.1016/j.repbio.2024.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 03/18/2024]
Abstract
Conflicting findings have emerged regarding the levels of high mobility group box 1 (HMGB1) in individuals experiencing adverse pregnancy outcomes. Here we conducted a meta-analysis to assess the association between maternal blood HMGB1 levels and adverse pregnancy outcomes. Utilizing databases such as PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Embase and China National Knowledge Infrastructure (CNKI), a systematic literature search was conducted in January 2024. Eligible literature was screened according to inclusion and exclusion criteria. Quality assessment was evaluated using the Newcastle-Ottawa Scale (NOS). The extracted data were analyzed using Review Manager 5.4 and STATA 12.0 software. 21 observational studies with a total of 2471 participants were included in this meta-analysis. Significantly higher peripheral blood levels of HMGB1 were associated with preeclampsia (PE) (SMD=1.34; 95% CI: 0.72-1.95; P < 0.0001) and gestational diabetes mellitus (GDM) (SMD=1.20; 95% CI: 0.31-2.09; P = 0.009). Additionally, HMGB1 levels in peripheral blood were significantly elevated in patients with unexplained recurrent spontaneous abortion (URSA) than those in pregnancy controls (SMD=4.22; 95% CI: 1.64-6.80; P = 0.001) or non-pregnancy controls (SMD=3.87; 95% CI: 1.81-5.92; P = 0.0002). Interestingly, higher blood HMGB1 levels were observed in women with preterm birth (PTB), however, the results did not reach a statistical difference (SMD=0.54; 95% CI: -0.36-1.44; P = 0.24). In conclusion, overexpressed maternal blood HMGB1 levels were associated with adverse pregnancy outcomes, including PE, GDM and URSA. Further studies should be conducted to validate the efficacy of HMGB1 as a biomarker for assessing the risk of adverse pregnancy outcomes.
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Affiliation(s)
- Liping Xue
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China; School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Ruolin Chen
- College of Letter and Science, University of California Davis, CA, USA
| | - Ying Liu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
| | - Jintuo Zhou
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
| | - Jinhua Liu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China; School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China; School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China.
| | - Huajiao Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China; School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China.
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Arredondo-Damián JG, Martínez-Soto JM, Molina-Pelayo FA, Soto-Guzmán JA, Castro-Sánchez L, López-Soto LF, Candia-Plata MDC. Systematic review and bioinformatics analysis of plasma and serum extracellular vesicles proteome in type 2 diabetes. Heliyon 2024; 10:e25537. [PMID: 38356516 PMCID: PMC10865249 DOI: 10.1016/j.heliyon.2024.e25537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/16/2024] Open
Abstract
Background Type 2 diabetes (T2D) is a complex metabolic ailment marked by a global high prevalence and significant attention in primary healthcare settings due to its elevated morbidity and mortality rates. The pathophysiological mechanisms underlying the onset and progression of this disease remain subjects of ongoing investigation. Recent evidence underscores the pivotal role of the intricate intercellular communication network, wherein cell-derived vesicles, commonly referred to as extracellular vesicles (EVs), emerge as dynamic regulators of diabetes-related complications. Given that the protein cargo carried by EVs is contingent upon the metabolic conditions of the originating cells, particular proteins may serve as informative indicators for the risk of activating or inhibiting signaling pathways crucial to the progression of T2D complications. Methods In this study, we conducted a systematic review to analyze the published evidence on the proteome of EVs from the plasma or serum of patients with T2D, both with and without complications (PROSPERO: CRD42023431464). Results Nine eligible articles were systematically identified from the databases, and the proteins featured in these articles underwent Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. We identified changes in the level of 426 proteins, with CST6, CD55, HBA1, S100A8, and S100A9 reported to have high levels, while FGL1 exhibited low levels. Conclusion These proteins are implicated in pathophysiological mechanisms such as inflammation, complement, and platelet activation, suggesting their potential as risk markers for T2D development and progression. Further studies are required to explore this topic in greater detail.
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Affiliation(s)
| | | | | | | | - Luis Castro-Sánchez
- University Center for Biomedical Research, University of Colima, Colima, Colima, Mexico
- CONAHCYT-University of Colima, Colima, Colima, Mexico
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Coste K, Bruet S, Chollat-Namy C, Filhol O, Cochet C, Gallot D, Marceau G, Blanchon L, Sapin V, Belville C. Characterization of RAGE and CK2 Expressions in Human Fetal Membranes. Int J Mol Sci 2023; 24:ijms24044074. [PMID: 36835482 PMCID: PMC9966553 DOI: 10.3390/ijms24044074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
At the feto-maternal interface, fetal membranes (FM) play a crucial role throughout pregnancy. FM rupture at term implicates different sterile inflammation mechanisms including pathways activated by the transmembrane glycoprotein receptor for advanced glycation end-products (RAGE) belonging to the immunoglobulin superfamily. As the protein kinase CK2 is also implicated in the inflammation process, we aimed to characterize the expressions of RAGE and the protein kinase CK2 as a candidate regulator of RAGE expression. The amnion and choriodecidua were collected from FM explants and/or primary amniotic epithelial cells throughout pregnancy and at term in spontaneous labor (TIL) or term without labor (TNL). The mRNA and protein expressions of RAGE and the CK2α, CK2α', and CK2β subunits were investigated using reverse transcription quantitative polymerase chain reaction and Western blot assays. Their cellular localizations were determined with microscopic analyses, and the CK2 activity level was measured. RAGE and the CK2α, CK2α', and CK2β subunits were expressed in both FM layers throughout pregnancy. At term, RAGE was overexpressed in the amnion from the TNL samples, whereas the CK2 subunits were expressed at the same level in the different groups (amnion/choriodecidua/amniocytes, TIL/TNL), without modification of the CK2 activity level and immunolocalization. This work paves the way for future experiments regarding the regulation of RAGE expression by CK2 phosphorylation.
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Affiliation(s)
- Karen Coste
- iGReD, Team “Translational Approach to Epithelial Injury and Repair”, UMR6293 CNRS-U1103 INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
- CHU Clermont-Ferrand, Neonatal Intensive Care Department, F-63000 Clermont-Ferrand, France
| | - Shaam Bruet
- CHU Clermont-Ferrand, Neonatal Intensive Care Department, F-63000 Clermont-Ferrand, France
| | - Caroline Chollat-Namy
- CHU Clermont-Ferrand, Neonatal Intensive Care Department, F-63000 Clermont-Ferrand, France
| | - Odile Filhol
- INSERM, CEA, UMR Biosanté, U1292, University Grenoble Alpes, F-38000 Grenoble, France
| | - Claude Cochet
- INSERM, CEA, UMR Biosanté, U1292, University Grenoble Alpes, F-38000 Grenoble, France
| | - Denis Gallot
- iGReD, Team “Translational Approach to Epithelial Injury and Repair”, UMR6293 CNRS-U1103 INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
- CHU Clermont-Ferrand, Obstetrics and Gynecology Department, F-63000 Clermont-Ferrand, France
| | - Geoffroy Marceau
- iGReD, Team “Translational Approach to Epithelial Injury and Repair”, UMR6293 CNRS-U1103 INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
- CHU Clermont-Ferrand, Biochemistry and Molecular Genetic Department, F-63000 Clermont-Ferrand, France
| | - Loïc Blanchon
- iGReD, Team “Translational Approach to Epithelial Injury and Repair”, UMR6293 CNRS-U1103 INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Vincent Sapin
- iGReD, Team “Translational Approach to Epithelial Injury and Repair”, UMR6293 CNRS-U1103 INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
- CHU Clermont-Ferrand, Biochemistry and Molecular Genetic Department, F-63000 Clermont-Ferrand, France
| | - Corinne Belville
- iGReD, Team “Translational Approach to Epithelial Injury and Repair”, UMR6293 CNRS-U1103 INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
- Correspondence: ; Tel.: +33-4-7317-8174
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Romani R, Talesa VN, Antognelli C. The Glyoxalase System Is a Novel Cargo of Amniotic Fluid Stem-Cell-Derived Extracellular Vesicles. Antioxidants (Basel) 2022; 11:antiox11081524. [PMID: 36009243 PMCID: PMC9405222 DOI: 10.3390/antiox11081524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 11/26/2022] Open
Abstract
The glyoxalase system is a ubiquitous cellular metabolic pathway whose main physiological role is the removal of methylglyoxal (MG). MG, a glycolysis byproduct formed by the spontaneous degradation of triosephosphates glyceraldehyde-3-phosphate (GA3P) and dihydroxyacetonephosphate (DHAP), is an arginine-directed glycating agent and precursor of the major advanced glycation end product arginine-derived, hydroimidazolone (MG-H1). Extracellular vesicles (EVs) are a heterogeneous family of lipid-bilayer-vesicular structures released by virtually all living cells, involved in cell-to-cell communication, specifically by transporting biomolecules to recipient cells, driving distinct biological responses. Emerging evidence suggests that included in the EVs cargo there are different metabolic enzymes. Specifically, recent research has pointed out that EVs derived from human amniotic fluid stem cell (HASC-EVs) contain glycolytic pay-off phase enzymes, such as glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Since GAPDH catalyzes the sixth step of glycolysis using as a substrate GA3P, from which MG spontaneously origins, we wanted to investigate whether MG-derived MG-H1, as well as glyoxalases, could be novel molecule cargo in these EVs. By using immunoassays and spectrophotometric methods, we found, for the first time ever, that HASC-EVs contain functional glyoxalases and MG-H1, pioneering research to novel and exciting roles of these eclectic proteins, bringing them to the limelight once more.
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Kurashima CK, Ng PK, Kendal-Wright CE. RAGE against the Machine: Can Increasing Our Understanding of RAGE Help Us to Battle SARS-CoV-2 Infection in Pregnancy? Int J Mol Sci 2022; 23:6359. [PMID: 35742804 PMCID: PMC9224312 DOI: 10.3390/ijms23126359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 12/05/2022] Open
Abstract
The receptor of advanced glycation end products (RAGE) is a receptor that is thought to be a key driver of inflammation in pregnancy, SARS-CoV-2, and also in the comorbidities that are known to aggravate these afflictions. In addition to this, vulnerable populations are particularly susceptible to the negative health outcomes when these afflictions are experienced in concert. RAGE binds a number of ligands produced by tissue damage and cellular stress, and its activation triggers the proinflammatory transcription factor Nuclear Factor Kappa B (NF-κB), with the subsequent generation of key proinflammatory cytokines. While this is important for fetal membrane weakening, RAGE is also activated at the end of pregnancy in the uterus, placenta, and cervix. The comorbidities of hypertension, cardiovascular disease, diabetes, and obesity are known to lead to poor pregnancy outcomes, and particularly in populations such as Native Hawaiians and Pacific Islanders. They have also been linked to RAGE activation when individuals are infected with SARS-CoV-2. Therefore, we propose that increasing our understanding of this receptor system will help us to understand how these various afflictions converge, how forms of RAGE could be used as a biomarker, and if its manipulation could be used to develop future therapeutic targets to help those at risk.
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Affiliation(s)
- Courtney K. Kurashima
- School of Natural Sciences and Mathematics, Chaminade University of Honolulu, Honolulu, HI 96816, USA; (C.K.K.); (P.K.N.)
| | - Po’okela K. Ng
- School of Natural Sciences and Mathematics, Chaminade University of Honolulu, Honolulu, HI 96816, USA; (C.K.K.); (P.K.N.)
| | - Claire E. Kendal-Wright
- School of Natural Sciences and Mathematics, Chaminade University of Honolulu, Honolulu, HI 96816, USA; (C.K.K.); (P.K.N.)
- Department of Obstetrics, Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI 96813, USA
- Department of Anatomy, Biochemistry and Physiology, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI 96813, USA
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6
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Wu YY, Li XF, Wu S, Niu XN, Yin SQ, Huang C, Li J. Role of the S100 protein family in rheumatoid arthritis. Arthritis Res Ther 2022; 24:35. [PMID: 35101111 PMCID: PMC8802512 DOI: 10.1186/s13075-022-02727-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/16/2022] [Indexed: 12/14/2022] Open
Abstract
Rheumatoid arthritis is a chronic systemic autoimmune disease characterized by synovial hyperplasia, inflammatory cell infiltration, and proliferation of inflammatory tissue (angiogranuloma). The destruction of joints and surrounding tissues eventually causes joint deformities and dysfunction or even loss. The S100 protein family is one of the biggest subtribes in the calcium-binding protein family and has more than 20 members. The overexpression of most S100 proteins in rheumatoid arthritis is closely related to its pathogenesis. This paper reviews the relationship between S100 proteins and the occurrence and development of rheumatoid arthritis. It will provide insights into the development of new clinical diagnostic markers and therapeutic targets for rheumatoid arthritis.
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Affiliation(s)
- Yuan-Yuan Wu
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China
| | - Xiao-Feng Li
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China.,Postdoctoral Station of Clinical Medicine of Anhui Medical University, Hefei, Anhui, China
| | - Sha Wu
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China
| | - Xue-Ni Niu
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China
| | - Su-Qin Yin
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China
| | - Cheng Huang
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China.
| | - Jun Li
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, Hefei, 230032, China.
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7
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Choltus H, Lavergne M, De Sousa Do Outeiro C, Coste K, Belville C, Blanchon L, Sapin V. Pathophysiological Implication of Pattern Recognition Receptors in Fetal Membranes Rupture: RAGE and NLRP Inflammasome. Biomedicines 2021; 9:biomedicines9091123. [PMID: 34572309 PMCID: PMC8466405 DOI: 10.3390/biomedicines9091123] [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: 07/30/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 12/28/2022] Open
Abstract
Preterm prelabor ruptures of fetal membranes (pPROM) are a pregnancy complication responsible for 30% of all preterm births. This pathology currently appears more as a consequence of early and uncontrolled process runaway activation, which is usually implicated in the physiologic rupture at term: inflammation. This phenomenon can be septic but also sterile. In this latter case, the inflammation depends on some specific molecules called “alarmins” or “damage-associated molecular patterns” (DAMPs) that are recognized by pattern recognition receptors (PRRs), leading to a microbial-free inflammatory response. Recent data clarify how this activation works and which receptor translates this inflammatory signaling into fetal membranes (FM) to manage a successful rupture after 37 weeks of gestation. In this context, this review focused on two PRRs: the receptor for advanced glycation end-products (RAGE) and the NLRP7 inflammasome.
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Affiliation(s)
- Helena Choltus
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
| | - Marilyne Lavergne
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
| | - Coraline De Sousa Do Outeiro
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
| | - Karen Coste
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
| | - Corinne Belville
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
| | - Loïc Blanchon
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
| | - Vincent Sapin
- CNRS, INSERM, GReD, Université Clermont Auvergne, 63000 Clermont-Ferrand, France; (H.C.); (M.L.); (C.D.S.D.O.); (K.C.); (C.B.); (L.B.)
- CHU de Clermont-Ferrand, Biochemistry and Molecular Genetic Department, 63000 Clermont-Ferrand, France
- Correspondence: ; Tel.: +33-473-178-174
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8
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Saito Reis CA, Padron JG, Norman Ing ND, Kendal-Wright CE. High-mobility group box 1 is a driver of inflammation throughout pregnancy. Am J Reprod Immunol 2020; 85:e13328. [PMID: 32851715 DOI: 10.1111/aji.13328] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/10/2020] [Accepted: 08/18/2020] [Indexed: 12/15/2022] Open
Abstract
A proinflammatory response driven by high-mobility group box 1 (HMGB1) is important for the success of both the early stages of pregnancy and parturition initiation. However, the tight regulation of HMGB1 within these two stages is critical, as increased HMGB1 can manifest into pregnancy-related pathologies. Although during the early stages of pregnancy HMGB1 is critical for the development and implantation of the embryo, and uterine decidualization, high levels within the uterine cavity have been linked to pregnancy failure. In addition, chronic inflammation, resultant from increased HMGB1 within the maternal circulation and gestational tissues, also increases the risk for preterm labor, preterm birth, or infant mortality. Due to the link between HMGB1 and several pregnancy pathologies, the possibility of leveraging HMGB1 as a biomarker has been assessed. However, data are limited that demonstrate how known HMGB1 inhibitors could reduce inflammation within pregnancy. Thus, further research is warranted to improve our understanding of the potential of HMGB1 as a therapeutic target to reduce inflammation within pregnancy. This review aims to describe what is understood about the role of HMGB1 that drives inflammation throughout pregnancy and highlight its potential as a biomarker and therapeutic target within this context.
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Affiliation(s)
- Chelsea A Saito Reis
- Natural Science and Mathematics, Chaminade University of Honolulu, Honolulu, HI, USA
| | - Justin G Padron
- Anatomy, Biochemistry and Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoā, Honolulu, HI, USA
| | - Nainoa D Norman Ing
- Natural Science and Mathematics, Chaminade University of Honolulu, Honolulu, HI, USA
| | - Claire E Kendal-Wright
- Natural Science and Mathematics, Chaminade University of Honolulu, Honolulu, HI, USA.,Anatomy, Biochemistry and Physiology, John A. Burns School of Medicine, University of Hawai'i at Manoā, Honolulu, HI, USA.,Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'I at Manoā, Honolulu, HI, USA
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