Critical Functions of Vitamin D

the importance of certain vitamins and minerals in cancer inhibition and better prognosis.

What is Vitamin D?

Vitamin D is technically not a vitamin. It is the name given to a group of fat-soluble prohormones (substances that are precursors to hormones that usually have little hormonal activity by themselves). This supplement must be taken with K2, to direct the calcium it builds into bone only.

Two major forms of vitamin D that are important to humans are vitamin D2, or ergocalciferol, and vitamin D3 or cholecalciferol. Vitamin D2 is made naturally by plants, and vitamin D3 is made naturally by the body when the skin is exposed to ultraviolet radiation (in particular, UVB radiation) in sunlight. Vitamin D2 and vitamin D3 can also be commercially manufactured.

The active form of vitamin D in the body is 1,25-dihydroxyvitamin D. It is involved in a number of processes that are essential for good health, including the following:

• It helps improve muscle strength and immune function.

• It helps reduce inflammation, (critical for Cancer).

• It promotes the absorption of calcium from the small intestine.

• It helps maintain adequate blood levels of the calcium and phosphate needed for bone formation, incorporating minerals to increase strength and density, growth, and repair.

For years, Life Extension has been exploring the potentially devastating consequences of vitamin D deficiency, ranging from cardiovascular disease to cancer. Now in this report, Life Extension magazine examines the link between low levels of plasma vitamin D and autism. At the forefront of this research is Dr. John J. Cannell, executive director of the Vitamin D Council and a forensic psychiatrist at Atascadero State Hospital in California.

The stunning findings suggest that rampant vitamin D deficiency is causally related to brain dysfunction, and may be readily preventable by adequate supplementation.

An epidemic of autism appears to be underway in the United States. According to several respected leaders in child and adult nutrition from across the United States, the current meteoric rise in autism and autism spectrum disorders (ASD) may well be a direct consequence of significant vitamin D deficiencies in pregnant women and their infants.  And evidence points to vitamin D deficiency as the cause of other debilitating brain conditions as well.  This insidious deficiency is readily remedied--yet tragically often missed. 

Read More Here...

Most people get the vitamin D they need through sunlight exposure. It can also be obtained through the diet, but very few foods naturally contain vitamin D. Those that do include fatty fish, fish liver oil, and eggs. 

Most dietary vitamin D comes from fortified foods, such as milk, juices, yogurt, bread, and breakfast cereals. Vitamin D can also be obtained through dietary supplements.

How Vitamin D Reduces the Risk of Cancer

The mechanisms by which vitamin D reduces the risk of cancer are fairly well understood. They include enhancing calcium absorption (in the case of colorectal cancer) [Lamprecht and Lipkin, 2003], inducing cell differentiation, increasing cancer cell apoptosis or death, reducing metastasis and proliferation, and reducing angiogenesis [van den Bemd and Chang, 2002].

In addition, Vitamin D3 down-regulates parathyroid hormone (PTH) [Chapuy et al., 1987]. IGF-I has been implicated in the pathogenesis of human cancer. Since IGF-I stimulates tumor growth and high quantities are a consequence of the standard American diet [Grant, 2002a; 2004], vitamin D can be considered one partial antidote to the American diet.

How Much Vitamin D is needed?

Each person responds differently to UVB exposure and oral intake of vitamin D depending on such factors as skin pigmentation, body mass index (vitamin D is fat soluble), age, condition of digestive tract, other dietary factors, etc.

Dietary vitamin D is insufficient alone to significantly reduce the risk of most cancers since the ingested amounts, up to 200 to 400 I.U. per day, are too low [Grant and Garland, in press]. Evidently, 600 to 1000 I.U per day are required to reduce the risk of vitamin-D-sensitive cancers, except possibly prostate cancer, for which population-average values of serum 25(OH)D are associated with the minimum risk [Tuohimaa et al., 2004; Grant, in press].

The current understanding is that serum 25(OH)D levels should be in the 50 to 70 ng/ml range for cancer prevention and optimal health. The only way to determine one’s 25(OH)D levels is through a blood test.

NOTE: Taking Melatonin supplements allows a reduced dose of Vit. D since they produce a 20 to 100-fold INCREASE in the sensitivity of Breast Cancer cells to Vit. D. This is why periodic blood test to determine Vit. D (25 Hydroxy) level is important.

References:

1. Chapuy MC, Chapuy P, Meunier PJ. Calcium and vitamin D supplements: effects on calcium metabolism in elderly people. Am J Clin Nutr. 1987;46:324-8.

2. Devesa SS, Grauman DJ, Blot WJ, Pennello GA, Hoover RN, Fraumeni JF Jr., Atlas of Cancer Mortality in the United States, 1950-1994. NIH Publication No. 99-4564, 1999. website (accessed March 3, 2004).

3. Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. J Natl Cancer Inst. 1981;66:1191-308.

4. Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon cancer? Int J Epidemiol. 1980;9:227-31.

5. Garland C, Shekelle RB, Barrett-Connor E, Criqui MH, Rossof AH, Paul O. Dietary vitamin D and calcium and risk of colorectal cancer: a 19-year prospective study in men. Lancet. 1985;1:307-9.

6. Grant WB. An estimate of premature cancer mortality in the United States due to inadequate doses of solar ultraviolet-B radiation, Cancer, 2002b;94:1867-75.

7. Grant WB. A multicountry ecologic study of risk and risk reduction factors for prostate cancer mortality. Eur Urol. 2004;45:371-9.

~ Be Well. ♥

When Supplements Become Dangerous

It's important to remember that Supplements are powerful, which is why we take them of course. But what we don't often think about is their potential interaction with prescription medications we are also taking.  Based on the meds I am taking, my MD probably couldn't tell me what Supplements to avoid, unless they were obvious ones. Do your research!

Supplements can increase the effect of some medications or inhibit the effectiveness of others. They may interact in a way that is less than desirable, so it's important to tell you doctor when you are thinking of adding supplements, and if she/he isn't sure about interactions, turn to the a reliable internet source, or better yet, an Anthroposophic or CAM practitioner.

Below is a list of some common Supplements and possible interactions.

Aloe Vera

Major interaction: Digoxin (Lanoxin)

When taken by mouth, aloe latex is a type of laxative called a stimulant laxative. Stimulant laxatives can decrease potassium levels in the body. Low potassium levels can increase the risk of side effects of digoxin (Lanoxin).

Taken orally, aloe vera may also interact with blood sugar-lowering medicine used to treat Diabetes.

Bitter Orange

This supplement contains chemicals that can speed heart rate and increase blood pressure to dangerous levels.

• There have been reports of fainting, heart attack, and stroke in healthy people after taking bitter orange supplements alone or combined with caffeine. People should avoid taking bitter orange supplements if they have a heart condition or high blood pressure, or if they are taking medications (such as MAO inhibitors), caffeine, or other herbs/supplements that speed up the heart rate.
• Due to lack of safety evidence, pregnant women or nursing mothers should avoid products that contain bitter orange.
• Bitter orange oil used on the skin may increase the risk of sunburn, particularly in light-skinned people

Ginkgo

Ginkgo biloba interactions include bleeding when combined with Warfarin, raised blood pressure when combined with a Thiazide diuretic and coma when combined with the anti-depressant Trazodone (Desyrel, Oleptro, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico, and Mesyre).

Ginseng

Major Interaction: Warfarin (Coumadin)

Warfarin (Coumadin) is used to slow blood clotting

American ginseng has been reported to decrease the effectiveness of Warfarin (Coumadin). Decreasing the effectiveness of warfarin (Coumadin) might increase the risk of clotting. Do not take American ginseng if you take warfarin (Coumadin).

Moderate Interaction: Medications for depression (MAOIs) andAnti-diabetes drugs

American ginseng might stimulate the body. Some medications used for depression can also stimulate the body. Taking American ginseng along with these medications used for depression might cause side effects such as anxiousness, headache, restlessness, and insomnia.  Some of these medications used for depression include phenelzine (Nardil), tranylcypromine (Parnate), and others.

American ginseng might decrease blood sugar. Diabetes medications are also used to lower blood sugar. Taking American ginseng along with diabetes medications might cause your blood sugar to go too low. Monitor your blood sugar closely. Medication dose might need to be changed.  Some medications used for diabetes include glimepiride (Amaryl), glyburide (DiaBeta, Glynase PresTab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), chlorpropamide (Diabinese), glipizide (Glucotrol), tolbutamide (Orinase), and others.

Kava

In March 2002, the U.S. Food and Drug Administration (FDA) issued an advisory to consumers of the potential risk of severe liver injuryfrom the use of dietary supplements containing kava (also known as kava kava or Piper methysticum). Reports from health authorities in Germany, Switzerland, France, Canada, and the United Kingdom have linked kava use to at least 25 cases of liver toxicity, including hepatitis, cirrhosis, and liver failure, prompting some of these countries to remove kava from the market.

Avoid driving and operating heavy machinery while taking kava because the herb has been reported to cause drowsiness.

Licorice Root

• People with heart disease or high blood pressure should be cautious about using licorice.
• When taken in large amounts, licorice can affect the body’s levels of a hormone called cortisol and related steroid drugs, such as prednisone.
• Pregnant women should avoid using licorice as a supplement or consuming large amounts of licorice as food, as some research suggests it could increase the risk of preterm labor.

Melatonin

Major Interaction:Sedative medications (CNS depressants)

Melatonin might cause sleepiness and drowsiness. Medications that cause sleepiness are called sedatives. Taking melatonin along with sedative medications might cause too much sleepiness. Some sedative medications include clonazepam (Klonopin), lorazepam (Ativan), phenobarbital (Donnatal), zolpidem (Ambien), and others.

Moderate Interaction:

Birth control pills (Contraceptive drugs)

The body makes melatonin. Birth control pills seem to increase how much melatonin the body makes. Taking melatonin along with birth control pills might cause too much melatonin to be in the body. Some birth control pills include ethinyl estradiol and levonorgestrel (Triphasil), ethinyl estradiol and norethindrone (Ortho-Novum 1/35, Ortho-Novum 7/7/7), and others.

Caffeine

Caffeine might decrease melatonin levels in the body. Taking melatonin along with caffeine might decrease the effectiveness of melatonin supplements.

Fluvoxamine (Luvox)

Taking fluvoxamine (Luvox) can increase the amount of melatonin that the body absorbs. Taking melatonin along with fluvoxamine (Luvox) might increase the effects and side effects of melatonin.

Medications for diabetes (Antidiabetes drugs)

Melatonin might increase blood sugar. Diabetes medications are used to lower blood sugar. By increasing blood sugar, melatonin might decrease the effectiveness of diabetes medications.  Some medications used for diabetes include glimepiride (Amaryl), glyburide (DiaBeta, Glynase PresTab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), chlorpropamide (Diabinese), glipizide (Glucotrol), tolbutamide (Orinase), and others.

Medications that decrease the immune system (Immunosuppressants)

Melatonin might increase the immune system. Taking melatonin along with medications that decrease the immune system might decrease the effectiveness of medications that decrease the immune system.   Some medications that decrease the immune system include azathioprine (Imuran), basiliximab (Simulect), cyclosporine (Neoral, Sandimmune), daclizumab (Zenapax), muromonab-CD3 (OKT3, Orthoclone OKT3), mycophenolate (CellCept)...

Medications that slow blood clotting (Anticoagulant / Antiplatelet drugs)

Melatonin might slow blood clotting. Taking melatonin along with medications that also slow clotting might increase the chances of bruising and bleeding.

For Full list Click Here.

St. John's Wort

• Research has shown that St. John’s wort interacts with many medications in ways that can interfere with their intended effects. Examples of medications that can be affected include:
  • Antidepressants
  • Birth control pills
  • Cyclosporine, which prevents the body from rejecting transplanted organs
  • Digoxin, a heart medication
  • Indinavir and possibly other drugs used to control HIV infection
  • Irinotecan and possibly other drugs used to treat cancer
  • Seizure-control drugs, such as phenytoin and phenobarbital
  • Warfarin and related anticoagulants.

Taking St. John’s wort with certain antidepressants may lead to increased serotonin-related side effects, which may be potentially serious.

For more Info Click Here.

Vitamin K

Warfarin (Coumadin) interacts with VITAMIN K: Vitamin K is used by the body to help blood clot. Warfarin (Coumadin) is used to slow blood clotting. By helping the blood clot, vitamin K might decrease the effectiveness of warfarin (Coumadin). Be sure to have your blood checked regularly. The dose of your warfarin (Coumadin) might need to be changed.

Yohimbe

• Yohimbe has been associated with high blood pressure, increased heart rate, headache, anxiety, dizziness, nausea, vomiting, tremors, and sleeplessness. Yohimbe can be dangerous if taken in large doses or for long periods of time.
• People should not combine yohimbe with MAO inhibitors as effects may be additive. Yohimbe should be used with caution when taken with medicines for high blood pressure, tricyclic antidepressants, or phenothiazines (a group of medicines used mostly for mental health conditions such as schizophrenia).
• People with kidney problems and people with psychiatric conditions should not use yohimbe.
• Women who are pregnant or breastfeeding should not take yohimbe.

Zinc

FDA notified consumers and healthcare professionals to discontinue use of three Zicam Nasal Gel/Nasal Swab products sold over-the-counter as cold remedies because they are associated with the loss of sense of smell that may be long-lasting or permanent. The FDA has received more than 130 reports of loss of sense of smell associated with the use of the three Zicam products.  In these reports, many people who experienced a loss of smell said the condition occurred with the first dose; others reported a loss of the sense of smell after multiple uses of the products.

Conversely, if you are taking any of the following drugs, see cautions below.

Aspirin

Aspirin DEPLETES Folic Acid, zinc, potassium, vitamin C and iron. Avoid higher doses of the following if you take Aspirin. Vitamin E,. Bromelain, Garlic, Ginger, Magnesium, Ginkgo, all which act as blood thinners and thus could cause bleeding.

Ativan

Avoid any herbs that act as a sedative, like Kava Kava, Lemon Balm, Calif. Poppy, St. John's Wort or Valerian.  Exception: Melatonin.

Lisinopril

This also DEPLETES Zinc, which could lead to an increase in blood Copper levels and foster cancer angiogenesis and progression. Zinc supplements are encouraged if taking this medicine.

Lovastatin

Statins DEPLETE CoQ10, a nutrient needed for healthy muscle, heart and brain function. AVOID Red Yeast supplements with this drug.

Take Fiber supplements 1 - 2 hours away from this med to avoid reducing its absorption.

Niacin taken in large doses with this drug has been reported to cause potentially serious muscle disorders. Bu taking a low dose (500mg) actually enhances the effectiveness of the Statin drug. IT may also be beneficial to take Vitamin E with this drug to prevent the possibility of oxidative damage to LDL cholesterol.

Nadolol

DEPLETES CoQ10. Supplementation is recommended.

In the News: Integrative Medicine: Antioxidants and Chemotherapy

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Antioxidants and Chemotherapy

By Drs. Kay judge and Maxine Barish-Wreden

Published: Thursday, May. 31, 2012

Inflammation, and the use of antioxidants to put out inflammatory fires, is a hot topic these days. What do we mean by inflammation?

Inflammation is a natural and necessary response in the body whenever we are accosted by harmful germs or when we injure ourselves. When this occurs, our immune system steps in to fight foreign invaders and to bring our body back into balance so that we can heal.

Inflammatory chemicals are produced during this process, which can be harmful to our tissues, but antioxidants in our foods, such as vitamins C and E, help to quell this response and restore order to our tissues.

Inflammation can run amok, however, and cause persistent damage to healthy tissue, especially if we smoke or if we are overweight or obese. Chemotherapy drugs that are used to treat cancer also produce severe inflammation in the body, and this particular inflammatory response helps to kill off cancer cells. But it also harms healthy tissue in the process.

Many oncologists have been fearful of having their patients take any antioxidants during chemotherapy for fear that antioxidants might reduce the effectiveness of the chemo.

In a recent article in the journal Alternative and Complementary Therapies, Dr. Keith Block, a renowned integrative cancer specialist affiliated with the University of Illinois, discussed his review of more than 2,300 studies on the use of antioxidants during chemotherapy, and his report is very reassuring.

In summary, antioxidants often help to reduce side effects from chemotherapy, and this may allow patients to complete their full course of medication without interruption, which itself leads to better outcomes. Certain antioxidants also enhance the effectiveness of chemotherapy, reduce long-term toxicity and improve survival.

Not a single study reviewed by Block showed any evidence of antioxidants interfering with the effectiveness of chemotherapy. In fact, a recent article looking at the impact of antioxidants in Chinese women undergoing treatment for invasive breast cancer found that use of antioxidant vitamin supplements in the first six months after diagnosis resulted in a reduced risk of both mortality and cancer recurrence.

Other studies have suggested survival benefit in certain cancers when patients take melatonin, as well as reduced toxicity from chemo with the use of glutathione and coenzyme Q10 among others.

So, if you are affected by cancer, what should you be thinking about to protect yourself during and after chemotherapy? First and foremost, begin by eating a super-healthful, plant-based diet that is loaded with dark-colored fruits and veggies so that you maximize your intake of antioxidants from your food, which is the most powerful way to get them.

You can also consider supplementing your diet with some of the more powerful antioxidants, such as fish oil, coenzyme Q10, vitamin C, vitamin E and selenium, though we recommend that you meet with an integrative cancer specialist first so that you can determine which supplements are ideal for you, given your particular tumor as well as your treatment regimen.

And for those of you who have been affected by cancer, either because you or a loved one have faced this disease, there is a conference coming to Sacramento in September that you should know about. It's titled "Cancer as a Turning Point, From Surviving to Thriving," and it is a gathering of some of the best and most inspiring experts in this business.

Cancer as a Turning Point is sponsored by the non-profit organization Healing Journeys, whose vision is that everyone touched by cancer or any life-altering condition be empowered to move from surviving to thriving. This conference is usually offered in two cities across the country every year.  The conference is free to all attendees, though donations are greatly appreciated to offset the cost, and donations are also tax-deductible. For more information, and to register, go to www.healingjourneys.org.

And for more information on an integrative approach to cancer treatment, look at Block's 2009 book "Life Over Cancer" (Bantam, $28, 608 pages) or Alschuler's gem that she co-wrote with Karolyn Gazella, "The Definitive Guide to Cancer: An Integrative Approach to Prevention, Treatment, and Healing" (Celestial Arts, $25, 496 pages), now in its third edition.

~ Be Well! ♥

Things You Didn't Know about Melatonin, but Should!

I was surprised when 4 of the 5 nationally recognized CAM specialists I consulted with asked me to take high doses of Melatonin (15 - 18 mg) as part of my supplement regimen. You have to build the dose gradually, starting with 2 mg /night. I didn't have problems with sleep then, but was educated as to why this was an important addition for cancer prevention.  There is little reason not to add Melatonin to your diet.  It has been shown to be safe up to those levels.  The only caution is if you are also taking sedative medications like clonazepam (Klonopin), lorazepam (Ativan), phenobarbital (Donnatal), zolpidem (Ambien). For other mild drug interactions, click here.

What is Melatonin?

The hormone melatonin, is found in a great variety of organisms.  Melatonin is produced in humans by the pineal gland.  The plant derived form, phytomelatonin, is sold as a dietary supplement in the United States and is used by some CAM practitioners in the treatment of cancer patients.

Long known for its ability to regulate the body`s natural circadian rhythms, melatonin is rapidly emerging as a powerful agent in the fight against brain aging and neurologic deterioration. Melatonin effectively protects both lipids and proteins from free radical damage as it easily crosses the blood-brain barrier. The production of melatonin decreases with age and oxidation slowly diminishes the normal electrical communication patterns seen in a healthy brain.

The result of a study published in the Behavioral and Brain Functionsjournal found that patients suffering from neurologic disorders such as Parkinson`s and Alzheimer`s disease were deficient in circulating levels of melatonin.

What does it Do?

Circadian organization of the host-cancer balance is important to cancer prevention, screening, diagnosis, and treatment.

Both melatonin and chronotherapy have been studied for many years but, despite largely positive findings, have not been brought into mainstream cancer therapy.

All living organisms are organized in biological time, and melatonin, a hormone secreted mainly by the pineal gland, is an important part of this scheme. In the human light-dark cycle, melatonin peaks every 24 hours, between 2 a.m. and 3 a.m.

The light-dark cycle helps synchronize the activity of the central biological clock. It is also a new member of an expanding group of regulatory factors that control cell  proliferation and loss, and is the only known chronobiotic hormonal regulator of neoplastic cell growth (a cell that is part of tumor).

At physiological concentrations, melatonin suppresses cell growth and multiplication and inhibits cancer cell proliferation in vitro through specific cell-cycle effects. At pharmacological concentrations, melatonin suppresses cancer cell growth and multiplication.

Unique Property of this Antioxidant

The Blood-Brain Barrier is a mechanism that controls the passage of substances from the blood into the cerobrospinal fluid and thus into the brain and spinal cord. The blood-brain barrier (BBB) lets essential metabolites, such as oxygen and glucose, pass from the blood to the brain and central nervous system (CNS) but blocks most molecules that are more massive than about 500 daltons. This means that everything from hormones and neurotransmitters to viruses and bacteria are refused access to the brain by the BBB. It also means that many drugs, which would otherwise be capable of treating disorders of the CNS, are denied access to the very regions where they would be affective.

Key functions of the BBB are:

• Protecting the brain from "foreign substances" (such as viruses and bacteria) in the blood that could injure the brain
• Shielding the brain from hormones and neurotransmitters in the rest of the body
• Maintaining a constant environment (homeostasis) for the brain

Melatonin is an antioxidant that can easily cross cell membranes and the blood–brain barrier.^reference

Melatonin is a direct scavenger of OH, O₂⁻, and NO.^[5] Unlike other antioxidants, melatonin does not undergo redox cycling, the ability of a molecule to undergo reduction and oxidation repeatedly. Redox cycling may allow other antioxidants (such as vitamin C) to act as pro-oxidants, counterintuitively promoting free radical formation. Melatonin, on the other hand, once oxidized, cannot be reduced to its former state because it forms several stable end-products upon reacting with free radicals. Therefore, it has been referred to as a terminal (or suicidal) antioxidant.

Melatonin Shown to Lower Cancer Risk by 34%

Melatonin has been shown to be effective in the fight against many cancer lines including those affecting the liver, breast, prostate, lung and brain. Melatonin is a powerful and versatile antioxidant that is naturally secreted by the pineal gland at night during total darkness. The natural nutrient can scavenge the most dangerous free radicals that are known to result in genetic deletions that dramatically increase the risk of many cancers.

The result of a meta-analysis of ten studies released in the Journal of Pineal Research demonstrated that melatonin is able to lower the risk of many cancer lines by up to 34%. Researchers found that this protection resulted across all dosage ranges and there were no adverse effects reported. The lead author concluded, "The substantial reduction in risk of death, low adverse events reported and low costs related to this intervention suggest great potential for melatonin in treating cancer."

Read more  here.

Research

Researchers at Harvard evaluated 147 people with invasive breast cancer and 291 without cancer as part of the Nurses Health Study. They took a morning urine sample and measured melatonin levels via a melatonin by-product called 6-sulphatoxymelatonin. The researchers found women with the highest melatonin had the lowest risk of cancer.

Spanish researchers evaluated melatonin supplements as a treatment for rats with advanced and untreated breast tumors. Melatonin given daily significantly increased survival in animals. The researchers concluded that the results strongly suggest that melatonin is beneficial during advanced breast cancer, because it increases survival time.

Additional Reading:

1. Mills E, Wu P, Seely D, Guyatt G. Melatonin in the treatment of cancer: a systematic review of randomized controlled trials and meta-analysis. J Pineal Res. 2005 Nov:39(4):360-6.
2. Saez MC, Barriga C, Garcia JJ, Rodriguez AB, Masot J, Duran E, Ortega E. Melatonin increases the survival time of animals with untreated mammary tumours: Neuroendocrine stabilization. Mol Cell Biochem. 2005:278(1-2):15-20.
3. Markesbery W: Oxidative stress hypothesis in Alzheimer's disease. Free Radic Biol Med 1997, 23:134-147. PubMed Abstract.
4. Reiter RJ: Oxidative damage in the central nervous system: protection by melatonin. Prog Neurobiol 1998, 56:359-384. PubMed Abstract
5. Poeggeler B, Saarela S, Reiter RJ, Tan DX, Chen LD, Manchester LC, Barlow-Walden LR (November 1994). "Melatonin--a highly potent endogenous radical scavenger and electron donor: new aspects of the oxidation chemistry of this indole accessed in vitro". Ann. N. Y. Acad. Sci. 738: 419–20. DOI:10.1111/j.1749-6632.1994.tb21831.x. PMID 7832450.