Reprograming skin fibroblasts into Sertoli cells: a patient-specific tool to understand effects of genetic variants on gonadal development.


Journal

Biology of sex differences
ISSN: 2042-6410
Titre abrégé: Biol Sex Differ
Pays: England
ID NLM: 101548963

Informations de publication

Date de publication:
22 Mar 2024
Historique:
received: 17 02 2023
accepted: 22 02 2024
medline: 23 3 2024
pubmed: 23 3 2024
entrez: 23 3 2024
Statut: epublish

Résumé

Disorders/differences of sex development (DSD) are congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical. With overlapping phenotypes and multiple genes involved, poor diagnostic yields are achieved for many of these conditions. The current DSD diagnostic regimen can be augmented by investigating transcriptome/proteome in vivo, but it is hampered by the unavailability of affected gonadal tissue at the relevant developmental stage. We try to mitigate this limitation by reprogramming readily available skin tissue-derived dermal fibroblasts into Sertoli cells (SC), which could then be deployed for different diagnostic strategies. SCs form the target cell type of choice because they act like an organizing center of embryonic gonadal development and many DSD arise when these developmental processes go awry. We employed a computational predictive algorithm for cell conversions called Mogrify to predict the transcription factors (TFs) required for direct reprogramming of human dermal fibroblasts into SCs. We established trans-differentiation culture conditions where stable transgenic expression of these TFs was achieved in 46, XY adult dermal fibroblasts using lentiviral vectors. The resulting Sertoli like cells (SLCs) were validated for SC phenotype using several approaches. SLCs exhibited Sertoli-like morphological and cellular properties as revealed by morphometry and xCelligence cell behavior assays. They also showed Sertoli-specific expression of molecular markers such as SOX9, PTGDS, BMP4, or DMRT1 as revealed by IF imaging, RNAseq and qPCR. The SLC transcriptome shared about two thirds of its differentially expressed genes with a human adult SC transcriptome and expressed markers typical of embryonic SCs. Notably, SLCs lacked expression of most markers of other gonadal cell types such as Leydig, germ, peritubular myoid or granulosa cells. The trans-differentiation method was applied to a variety of commercially available 46, XY fibroblasts derived from patients with DSD and to a 46, XX cell line. The DSD SLCs displayed altered levels of trans-differentiation in comparison to normal 46, XY-derived SLCs, thus showcasing the robustness of this new trans-differentiation model. Future applications could include using the SLCs to improve definitive diagnosis of DSD in patients with variants of unknown significance. Individuals with disorders/differences of sex development (DSD) frequently do not get a specific genetic diagnostic. A limitation in the field is that the relevant cell types that would be needed to study the molecular events occurring at the time of onset of many DSD are found in the embryonic gonad. This, of course, is not accessible for research or diagnostic purposes. We set out to develop a method for directly transforming more accessible cells, from adult skin, into the cells known to organize the male gonad in the embryo, Sertoli cells. A combination of unique transcription factors was stably integrated into skin fibroblasts, and culture under appropriate conditions allowed differentiation into Sertoli-like cells (SLC), but not other gonadal cell types. The SLCs recapitulated known patterns of gene expression, shape, and behavior of Sertoli cells. The method was also tested on commercially available fibroblasts from a variety of DSD genetic backgrounds. The resulting cells exhibited condition-specific behavior (gene expression, adhesion to substrate, division rate…). This method provides a new tool to study molecular events occurring at the time of onset of DSD in the embryonic gonad, and the impact of patient-specific mutations on those. It could allow identification of new developmental pathways (and, thus, new candidate genes for DSD), as well as a provide models to validate the impact of variants of unknown significance, or to test approaches to correct the genetic anomaly in patient cells.

Sections du résumé

BACKGROUND BACKGROUND
Disorders/differences of sex development (DSD) are congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical. With overlapping phenotypes and multiple genes involved, poor diagnostic yields are achieved for many of these conditions. The current DSD diagnostic regimen can be augmented by investigating transcriptome/proteome in vivo, but it is hampered by the unavailability of affected gonadal tissue at the relevant developmental stage. We try to mitigate this limitation by reprogramming readily available skin tissue-derived dermal fibroblasts into Sertoli cells (SC), which could then be deployed for different diagnostic strategies. SCs form the target cell type of choice because they act like an organizing center of embryonic gonadal development and many DSD arise when these developmental processes go awry.
METHODS METHODS
We employed a computational predictive algorithm for cell conversions called Mogrify to predict the transcription factors (TFs) required for direct reprogramming of human dermal fibroblasts into SCs. We established trans-differentiation culture conditions where stable transgenic expression of these TFs was achieved in 46, XY adult dermal fibroblasts using lentiviral vectors. The resulting Sertoli like cells (SLCs) were validated for SC phenotype using several approaches.
RESULTS RESULTS
SLCs exhibited Sertoli-like morphological and cellular properties as revealed by morphometry and xCelligence cell behavior assays. They also showed Sertoli-specific expression of molecular markers such as SOX9, PTGDS, BMP4, or DMRT1 as revealed by IF imaging, RNAseq and qPCR. The SLC transcriptome shared about two thirds of its differentially expressed genes with a human adult SC transcriptome and expressed markers typical of embryonic SCs. Notably, SLCs lacked expression of most markers of other gonadal cell types such as Leydig, germ, peritubular myoid or granulosa cells.
CONCLUSIONS CONCLUSIONS
The trans-differentiation method was applied to a variety of commercially available 46, XY fibroblasts derived from patients with DSD and to a 46, XX cell line. The DSD SLCs displayed altered levels of trans-differentiation in comparison to normal 46, XY-derived SLCs, thus showcasing the robustness of this new trans-differentiation model. Future applications could include using the SLCs to improve definitive diagnosis of DSD in patients with variants of unknown significance.
Individuals with disorders/differences of sex development (DSD) frequently do not get a specific genetic diagnostic. A limitation in the field is that the relevant cell types that would be needed to study the molecular events occurring at the time of onset of many DSD are found in the embryonic gonad. This, of course, is not accessible for research or diagnostic purposes. We set out to develop a method for directly transforming more accessible cells, from adult skin, into the cells known to organize the male gonad in the embryo, Sertoli cells. A combination of unique transcription factors was stably integrated into skin fibroblasts, and culture under appropriate conditions allowed differentiation into Sertoli-like cells (SLC), but not other gonadal cell types. The SLCs recapitulated known patterns of gene expression, shape, and behavior of Sertoli cells. The method was also tested on commercially available fibroblasts from a variety of DSD genetic backgrounds. The resulting cells exhibited condition-specific behavior (gene expression, adhesion to substrate, division rate…). This method provides a new tool to study molecular events occurring at the time of onset of DSD in the embryonic gonad, and the impact of patient-specific mutations on those. It could allow identification of new developmental pathways (and, thus, new candidate genes for DSD), as well as a provide models to validate the impact of variants of unknown significance, or to test approaches to correct the genetic anomaly in patient cells.

Autres résumés

Type: plain-language-summary (eng)
Individuals with disorders/differences of sex development (DSD) frequently do not get a specific genetic diagnostic. A limitation in the field is that the relevant cell types that would be needed to study the molecular events occurring at the time of onset of many DSD are found in the embryonic gonad. This, of course, is not accessible for research or diagnostic purposes. We set out to develop a method for directly transforming more accessible cells, from adult skin, into the cells known to organize the male gonad in the embryo, Sertoli cells. A combination of unique transcription factors was stably integrated into skin fibroblasts, and culture under appropriate conditions allowed differentiation into Sertoli-like cells (SLC), but not other gonadal cell types. The SLCs recapitulated known patterns of gene expression, shape, and behavior of Sertoli cells. The method was also tested on commercially available fibroblasts from a variety of DSD genetic backgrounds. The resulting cells exhibited condition-specific behavior (gene expression, adhesion to substrate, division rate…). This method provides a new tool to study molecular events occurring at the time of onset of DSD in the embryonic gonad, and the impact of patient-specific mutations on those. It could allow identification of new developmental pathways (and, thus, new candidate genes for DSD), as well as a provide models to validate the impact of variants of unknown significance, or to test approaches to correct the genetic anomaly in patient cells.

Identifiants

pubmed: 38520033
doi: 10.1186/s13293-024-00599-y
pii: 10.1186/s13293-024-00599-y
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

24

Subventions

Organisme : National Institute of Child Health and Human Development
ID : Disorders/Differences of Sex Development (DSD) - Translational Research Network (R01HD093450)
Organisme : Children's National Hospital
ID : Core funding
Organisme : National Health and Medical Research Council
ID : 2002426
Organisme : National Health and Medical Research Council
ID : APP1154870

Informations de copyright

© 2024. The Author(s).

Références

Hughes IA, Houk C, Ahmed SF, Lee PA. Consensus statement on management of intersex disorders. Arch Dis Child. 2006;91:554–63.
doi: 10.1136/adc.2006.098319 pubmed: 16624884 pmcid: 2082839
Lee PA, Houk CP, Ahmed SF, Hughes IA, International Consensus Conference on Intersex organized by the Lawson Wilkins Pediatric Endocrine S, the European Society for Paediatric E Consensus statement on management of intersex disorders. International Consensus Conference on Intersex. Pediatrics. 2006;118(2):e488–500.
Délot EC, Papp JC, Délot EC, Fox M, Grody W, Lee H, et al. Genetics of disorders of sex development: the DSD-TRN experience. Endocrinol Metab Clin N Am. 2017;46(2):519–37.
doi: 10.1016/j.ecl.2017.01.015
Hutson JM, Grover SR, O’Connell M, Pennell SD. Malformation syndromes associated with disorders of sex development. Nat Rev Endocrinol. 2014;10(8):476–87.
doi: 10.1038/nrendo.2014.83 pubmed: 24913517
Baetens D, Stoop H, Peelman F, Todeschini AL, Rosseel T, Coppieters F, et al. NR5A1 is a novel disease gene for 46, XX testicular and ovotesticular disorders of sex development. Genet Med. 2016;4(19):367.
Délot EC, Vilain E. Towards improved genetic diagnosis of human differences of sex development. Nat Rev Genet. 2021;22(9):588–602.
doi: 10.1038/s41576-021-00365-5 pubmed: 34083777 pmcid: 10598994
Parivesh A, Barseghyan H, Délot E, Vilain E. Translating genomics to the clinical diagnosis of disorders/differences of sex development. Curr Top Dev Biol. 2019;134:317–75. https://doi.org/10.1016/bs.ctdb.2019.01.005 .
doi: 10.1016/bs.ctdb.2019.01.005 pubmed: 30999980 pmcid: 7382024
León NY, Reyes AP, Harley VR. A clinical algorithm to diagnose differences of sex development. Lancet Diabetes Endocrinol. 2019;7(7):560–74.
doi: 10.1016/S2213-8587(18)30339-5 pubmed: 30803928
Barseghyan H, Délot EC, Vilain E. New technologies to uncover the molecular basis of disorders of sex development. Mol Cell Endocrinol. 2018;468(January):60–9.
doi: 10.1016/j.mce.2018.04.003 pubmed: 29655603 pmcid: 7249677
Croft B, Ayers K, Sinclair A, Ohnesorg T. Review disorders of sex development: the evolving role of genomics in diagnosis and gene discovery. Birth Defects Res C Embryo Today. 2016;108(4):337–50.
doi: 10.1002/bdrc.21148 pubmed: 28033663
Délot E, Vilain E. Chapter 17: Differences of sex development. In: J. F. Strauss, R. L. Barbieri, A. Dokras, C. J. Williams & S. Zev Williams editors. Ninth edition of Yen & Jaffe’s Reproductive Endocrinology. Physiology, Pathophysiology, and Clinical management. Elsevier. 
Hamanaka K, Miyatake S, Koshimizu E, Tsurusaki Y, Mitsuhashi S, Iwama K, et al. RNA sequencing solved the most common but unrecognized NEB pathogenic variant in Japanese nemaline myopathy. Genet Med. 2019;21(7):1629–38.
doi: 10.1038/s41436-018-0360-6 pubmed: 30467404
Kernohan KD, Frésard L, Zappala Z, Hartley T, Smith KS, Wagner J, et al. Whole-transcriptome sequencing in blood provides a diagnosis of spinal muscular atrophy with progressive myoclonic epilepsy. Hum Mutat. 2017;38(6):611–4.
doi: 10.1002/humu.23211 pubmed: 28251733 pmcid: 5889109
Kremer LS, Bader DM, Mertes C, Kopajtich R, Pichler G, Iuso A, et al. Genetic diagnosis of Mendelian disorders via RNA sequencing. Nat Commun. 2017;8(1):1–11.
doi: 10.1038/ncomms15824
Cummings BB, Marshall JL, Tukiainen T, Lek M, Donkervoort S, Foley AR, et al. Improving genetic diagnosis in Mendelian disease with transcriptome sequencing. Sci Transl Med. 2017;9(386):eaal5209. https://doi.org/10.1126/scitranslmed.aal5209 .
doi: 10.1126/scitranslmed.aal5209 pubmed: 28424332 pmcid: 5548421
Lecluze E, Rolland AD, Filis P, Evrard B, Leverrier-Penna S, Ben MM, et al. Dynamics of the transcriptional landscape during human fetal testis and ovary development. Hum Reprod. 2020;35(5):1099–119.
doi: 10.1093/humrep/deaa041 pubmed: 32412604
Ross AJ, Capel B. Signaling at the crossroads of gonad development. Trends Endocrinol Metab. 2005;16(1):19–25.
doi: 10.1016/j.tem.2004.11.004 pubmed: 15620545
Sekido R, Bar I, Narváez V, Penny G, Lovell-Badge R. SOX9 is up-regulated by the transient expression of SRY specifically in Sertoli cell precursors. Dev Biol. 2004;274(2):271–9.
doi: 10.1016/j.ydbio.2004.07.011 pubmed: 15385158
Svingen T, Koopman P. Building the mammalian testis: origins, differentiation, and assembly of the component cell populations. Genes Dev. 2013;27(22):2409–26.
doi: 10.1101/gad.228080.113 pubmed: 24240231 pmcid: 3841730
Mackay S. Gonadal development in mammals at the cellular and molecular levels. Int Rev Cytol. 2000;200:47–99.
doi: 10.1016/S0074-7696(00)00002-4 pubmed: 10965466
McLaren A. Germ and somatic cell lineages in the developing gonad. Mol Cell Endocrinol. 2000;163(1–2):3–9.
doi: 10.1016/S0303-7207(99)00234-8 pubmed: 10963867
Cool J, Capel B. Mixed signals: development of the testis. Semin Reprod Med. 2009;27:5–13.
doi: 10.1055/s-0028-1108005 pubmed: 19197800
Tevosian SG, Albrecht KH, Crispino JD, Fujiwara Y, Eicher EM, Orkin SH. Gonadal differentiation, sex determination and normal Sry expression in mice require direct interaction between transcription partners GATA4 and FOG2. Development. 2002;129(19):4627–34.
doi: 10.1242/dev.129.19.4627 pubmed: 12223418
Wilhelm D, Englert C. The Wilms tumor suppressor WT1 regulates early gonad development by activation of Sf1. Genes Dev. 2002;16(14):1839–51. https://doi.org/10.1101/gad.220102 .
doi: 10.1101/gad.220102 pubmed: 12130543 pmcid: 186395
Hanley NA, Ball SG, Clement-Jones M, Hagan DM, Strachan T, Lindsay S, et al. Expression of steroidogenic factor 1 and Wilms’ tumour 1 during early human gonadal development and sex determination. 1999. www.elsevier.com/locate/modo . Accessed 8 Dec 2020.
Tarulli GA, Stanton PG, Meachem SJ. Is the adult sertoli cell terminally differentiated? Biol Reprod. 2012;87(1):1–11.
doi: 10.1095/biolreprod.111.095091
Sharpe RM, McKinnell C, Kivlin C, Fisher JS. Proliferation and functional maturation of Sertoli cells, and their relevance to disorders of testis function in adulthood. Reproduction. 2003;125(6):769–84.
doi: 10.1530/rep.0.1250769 pubmed: 12773099
Sekido R, Lovell-Badge R. Genetic control of testis development. Sex Dev. 2013;7(1–3):21–32.
doi: 10.1159/000342221 pubmed: 22964823
Cameron FJ, Sinclair AH. Mutations in SRY and SOX9: testis-determining genes. Hum Mutat. 1997;9:388–95.
doi: 10.1002/(SICI)1098-1004(1997)9:5<388::AID-HUMU2>3.0.CO;2-0 pubmed: 9143916
Wagner T, Wirth J, Meyer J, Zabel B, Held M, Zimmer J, et al. Autosomal sex reversal and campomelic dysplasia are caused by mutations in and around the SRY-related gene SOX9. Cell. 1994;79(6):1111–20.
doi: 10.1016/0092-8674(94)90041-8 pubmed: 8001137
Croft B, Ohnesorg T, Hewitt J, Bowles J, Quinn A, Tan J, et al. Human sex reversal is caused by duplication or deletion of core enhancers upstream of SOX9. Nat Commun. 2018;9(1):1–10. https://doi.org/10.1038/s41467-018-07784-9 .
doi: 10.1038/s41467-018-07784-9
Knower KC, Kelly S, Harley VR. Turning on the male–SRY, SOX9 and sex determination in mammals. Cytogenet Genome Res. 2003;101(3–4):185–98. https://doi.org/10.1159/000074336 .
doi: 10.1159/000074336 pubmed: 14684982
Rodríguez Gutiérrez D, Eid W, Biason-Lauber A. A human gonadal cell model from induced pluripotent stem cells. Front Genet. 2018;9(October):1–14. https://doi.org/10.3389/fgene.2018.00498/full .
doi: 10.3389/fgene.2018.00498/full
Knarston IM, Pachernegg S, Robevska G, Ghobrial I, Er PX, Georges E, et al. An in vitro differentiation protocol for human embryonic bipotential gonad and testis cell development. Stem Cell Rep. 2020;15(6):1377–91. https://doi.org/10.1016/j.stemcr.2020.10.009 .
doi: 10.1016/j.stemcr.2020.10.009
Buganim Y, Itskovich E, Chiang HY, Cheng AW, Ganz K, Sarkar S, et al. Direct reprogramming of fibroblasts into embryonic sertoli-like cells by defined factors. Cell Stem Cell. 2012;11:373–86.
doi: 10.1016/j.stem.2012.07.019 pubmed: 22958931 pmcid: 3438668
Liang J, Wang N, He J, Du J, Guo Y, Li L, et al. Induction of sertoli-like cells from human fibroblasts by nr5a1 and gata4. Elife. 2019;8:1–27.
doi: 10.7554/eLife.48767
Rackham OJL, Firas J, Fang H, Oates ME, Holmes ML, Knaupp AS, et al. A predictive computational framework for direct reprogramming between human cell types. Nat Genet. 2016;48(3):331–5. https://doi.org/10.1038/ng.3487 .
doi: 10.1038/ng.3487 pubmed: 26780608
Ewels P, Magnusson M, Lundin S, Käller M. MultiQC: summarize analysis results for multiple tools and samples in a single report. Bioinformatics. 2016;32(19):3047–8.
doi: 10.1093/bioinformatics/btw354 pubmed: 27312411 pmcid: 5039924
Dobin A, Davis CA, Schlesinger F, Drenkow J, Zaleski C, Jha S, et al. STAR: ultrafast universal RNA-seq aligner. Bioinformatics. 2013;29(1):15.
doi: 10.1093/bioinformatics/bts635 pubmed: 23104886
Li B, Dewey CN. RSEM: Accurate transcript quantification from RNA-Seq data with or without a reference genome. BMC Bioinform. 2011;12(1):1–16.
doi: 10.1186/1471-2105-12-323
Soneson C, Love MI, Robinson MD, Floor SN. Differential analyses for RNA-seq: transcript-level estimates improve gene-level inferences. F1000Research. 2016;4:1521.
doi: 10.12688/f1000research.7563.2 pmcid: 4712774
Love MI, Huber W, Anders S. Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2. Genome Biol. 2014;15(12):1–21.
doi: 10.1186/s13059-014-0550-8
Raudvere U, Kolberg L, Kuzmin I, Arak T, Adler P, Peterson H, et al. g:Profiler: a web server for functional enrichment analysis and conversions of gene lists (2019 update). Nucleic Acids Res. 2019;47(W1):W191–8.
doi: 10.1093/nar/gkz369 pubmed: 31066453 pmcid: 6602461
Jameson SA, Natarajan A, Cool J, DeFalco T, Maatouk DM, Mork L, et al. Temporal transcriptional profiling of somatic and germ cells reveals biased lineage priming of sexual fate in the fetal mouse gonad. PLoS Genet. 2012;8(3): e1002575. https://doi.org/10.1371/journal.pgen.1002575 .
doi: 10.1371/journal.pgen.1002575 pubmed: 22438826 pmcid: 3305395
Zhao L, Wang C, Lehman ML, He M, An J, Svingen T, et al. Transcriptomic analysis of mRNA expression and alternative splicing during mouse sex determination. Mol Cell Endocrinol. 2018;15(478):84–96.
doi: 10.1016/j.mce.2018.07.010
Buonocore F, Achermann JC. Human sex development: targeted technologies to improve diagnosis. Genome Biol. 2016;17(1):257.
doi: 10.1186/s13059-016-1128-4 pubmed: 27978845 pmcid: 5159992
Lakpour M, Aghajanpour S, Koruji M, Shahverdi A, Sadighi-Gilani M, Sabbaghian M, et al. Isolation, culture and characterization of human sertoli cells by flow cytometry: development of procedure. J Reprod Infertil. 2017;18(2):213–7.
pubmed: 28868245 pmcid: 5565911
Wen L, Yuan Q, Sun M, Niu M, Wang H, Fu H, et al. Generation and characteristics of human Sertoli cell line immortalized by overexpression of human telomerase. Oncotarget. 2017;8(10):16553–70.
doi: 10.18632/oncotarget.14985 pubmed: 28152522 pmcid: 5369984
Shlush E, Maghen L, Swanson S, Kenigsberg S, Moskovtsev S, Barretto T, et al. In vitro generation of Sertoli-like and haploid spermatid-like cells from human umbilical cord perivascular cells. Stem Cell Res Ther. 2017;8(1):1–16.
doi: 10.1186/s13287-017-0491-8
Chui K, Trivedi A, Cheng CY, Cherbavaz DB, Dazin PF, Huynh ALT, et al. Characterization and functionality of proliferative human sertoli cells. Cell Transplant. 2011;20(5):619–35.
doi: 10.3727/096368910X536563 pubmed: 21054948
Bucay N, Yebra M, Cirulli V, Afrikanova I, Kaido T, Hayek A, et al. A novel approach for the derivation of putative primordial germ cells and sertoli cells from human embryonic stem cells. Stem Cells. 2008;27:68–77.
doi: 10.1634/stemcells.2007-1018
Ono M, Harley VR. Disorders of sex development: new genes, new concepts. Nat Rev Endocrinol. 2013;9(2):79–91. https://doi.org/10.1038/nrendo.2012.235 .
doi: 10.1038/nrendo.2012.235 pubmed: 23296159
Alessio ACD, Fan ZP, Wert KJ, Baranov P, Cohen MA, Saini JS, et al. A systematic approach to identify candidate transcription factors that control cell identity. Stem Cell Rep. 2015;5(5):763–75. https://doi.org/10.1016/j.stemcr.2015.09.016 .
doi: 10.1016/j.stemcr.2015.09.016
Morris SA, Cahan P, Li H, Zhao AM, San Roman AK, Shivdasani RA, et al. Dissecting engineered cell types and enhancing cell fate conversion via Cellnet. Cell. 2014;158(4):889–902.
doi: 10.1016/j.cell.2014.07.021 pubmed: 25126792 pmcid: 4291075

Auteurs

Abhinav Parivesh (A)

Center for Genetic Medicine Research, Children's National Hospital, Washington D.C., 20010, USA.

Emmanuèle Délot (E)

Center for Genetic Medicine Research, Children's National Hospital, Washington D.C., 20010, USA.

Alejandra Reyes (A)

Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, 3168, Australia.

Janelle Ryan (J)

Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, 3168, Australia.

Surajit Bhattacharya (S)

Center for Genetic Medicine Research, Children's National Hospital, Washington D.C., 20010, USA.

Vincent Harley (V)

Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, 3168, Australia.

Eric Vilain (E)

Institute for Clinical and Translational Science, University of California, Irvine, CA, USA. evilain@hs.uci.edu.

Classifications MeSH