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Zhu H, Auten RL, Whorton AR, Mason SN, Bock CB, Kucera GT, Kelleher ZT, Vose AT, McMahon TJ. Endothelial LAT1 (SLC7A5) Mediates S-Nitrosothiol Import and Modulates Respiratory Sequelae of Red Blood Cell Transfusion In Vivo. Thromb Haemost 2024; 124:656-668. [PMID: 38519039 PMCID: PMC11199053 DOI: 10.1055/s-0044-1782182] [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: 03/15/2023] [Accepted: 01/03/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Increased adhesivity of red blood cells (RBCs) to endothelial cells (ECs) may contribute to organ dysfunction in malaria, sickle cell disease, and diabetes. RBCs normally export nitric oxide (NO)-derived vascular signals, facilitating blood flow. S-nitrosothiols (SNOs) are thiol adducts formed in RBCs from precursor NO upon the oxygenation-linked allosteric transition in hemoglobin. RBCs export these vasoregulatory SNOs on demand, thereby regulating regional blood flow and preventing RBC-EC adhesion, and the large (system L) neutral amino acid transporter 1 (LAT1; SLC7A5) appears to mediate SNO export by RBCs. METHODS To determine the role of LAT1-mediated SNO import by ECs generally and of LAT1-mediated SNO import by ECs in RBC SNO-dependent modulation of RBC sequestration and blood oxygenation in vivo, we engineered LAT1fl/fl; Cdh5-Cre+ mice, in which the putative SNO transporter LAT1 can be inducibly depleted (knocked down, KD) specifically in ECs ("LAT1ECKD"). RESULTS We show that LAT1 in mouse lung ECs mediates cellular SNO uptake. ECs from LAT1ECKD mice (tamoxifen-induced LAT1fl/fl; Cdh5-Cre+) import SNOs poorly ex vivo compared with ECs from wild-type (tamoxifen-treated LAT1fl/fl; Cdh5-Cre-) mice. In vivo, endothelial depletion of LAT1 increased RBC sequestration in the lung and decreased blood oxygenation after RBC transfusion. CONCLUSION This is the first study showing a role for SNO transport by LAT1 in ECs in a genetic mouse model. We provide the first direct evidence for the coordination of RBC SNO export with EC SNO import via LAT1. SNO flux via LAT1 modulates RBC-EC sequestration in lungs after transfusion, and its disruption impairs blood oxygenation by the lung.
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Affiliation(s)
- Hongmei Zhu
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
- Durham VA Health Care System, Durham North Carolina, United States
| | - Richard L. Auten
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States
| | - Augustus Richard Whorton
- Department of Pharmacology, Duke University Medical Center, Durham, North Carolina, United States
| | - Stanley Nicholas Mason
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States
| | - Cheryl B. Bock
- Rodent Cancer Models Shared Resource, Duke University Medical Center, Durham, North Carolina, United States
| | - Gary T. Kucera
- Rodent Cancer Models Shared Resource, Duke University Medical Center, Durham, North Carolina, United States
| | - Zachary T. Kelleher
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
| | - Aaron T. Vose
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
- Durham VA Health Care System, Durham North Carolina, United States
| | - Tim J. McMahon
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, United States
- Durham VA Health Care System, Durham North Carolina, United States
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2
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Abstract
Nonhuman primates are critically important animal models in which to study complex human diseases, understand biological functions, and address the safety of new diagnostics and therapies proposed for human use. They have genetic, physiologic, immunologic, and developmental similarities when compared to humans and therefore provide important preclinical models of human health and disease. This review highlights select research areas that demonstrate the importance of nonhuman primates in translational research. These include pregnancy and developmental disorders, infectious diseases, gene therapy, somatic cell genome editing, and applications of in vivo imaging. The power of the immune system and our increasing understanding of the role it plays in acute and chronic illnesses are being leveraged to produce new treatments for a range of medical conditions. Given the importance of the human immune system in health and disease, detailed study of the immune system of nonhuman primates is essential to advance preclinical translational research. The need for nonhuman primates continues to remain a high priority, which has been acutely evident during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) global pandemic. Nonhuman primates will continue to address key questions and provide predictive models to identify the safety and efficiency of new diagnostics and therapies for human use across the lifespan.
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Affiliation(s)
- Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, University of California, Davis, California, USA;
- California National Primate Research Center, University of California, Davis, California, USA
| | - Stephen C Noctor
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, California, USA;
| | - Dennis J Hartigan-O'Connor
- California National Primate Research Center, University of California, Davis, California, USA
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, California, USA;
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3
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Wang L, Zhong WH, Liu DY, Shen HQ, He ZJ. Metabolic analysis of infants with bronchopulmonary dysplasia under early nutrition therapy: An observational cohort study. Exp Biol Med (Maywood) 2021; 247:470-479. [PMID: 34894806 DOI: 10.1177/15353702211060513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To assess the amino acid and fatty acid metabolite patterns between infants with and without bronchopulmonary dysplasia in different nutritional stages after birth and identify metabolic indicators of bronchopulmonary dysplasia. This was an observational cohort of preterm infants born at a gestational age ≤32 + 6 weeks and with a body weight ≤2000 g. Amino acid and carnitine profiles were measured in dried blood spots (DBSs) during the early nutrition transitional phase using tandem mass spectrometry. Bronchopulmonary dysplasia was defined as oxygen dependence at 36 weeks of postmenstrual age or 28 days after birth. Metabolomic analysis was employed to define metabolites with significant differences, map significant metabolites into pathways, and identify metabolic indicators of bronchopulmonary dysplasia. We evaluated 45 neonates with and 40 without bronchopulmonary dysplasia. Four amino acids and three carnitines showed differences between the groups. Three carnitines (C0, C2, and C6:1) were high in the bronchopulmonary dysplasia group mostly; conversely, all four amino acids (threonine, arginine, methionine, and glutamine (Gln)) were low in the bronchopulmonary dysplasia group. Pathway analysis of these metabolites revealed two pathways with significant changes (p < 0.05). ROC analysis showed Gln/C6:1 at total parenteral nutrition phase had both 80% sensitivity and specificity for predicting the development of bronchopulmonary dysplasia, with an area under the curve of 0.81 (95% confidence interval 0.71-0.89). Amino acid and fatty acid metabolite profiles changed in infants with bronchopulmonary dysplasia after birth during the nutrition transitional period, suggesting that metabolic dysregulation may participate in the development of bronchopulmonary dysplasia. Our findings demonstrate that metabolic indicators are promising for forecasting the occurrence of bronchopulmonary dysplasia among preterm neonates.
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Affiliation(s)
- Li Wang
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai 200092, China
| | - Wen Hua Zhong
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai 200092, China.,Department of Neonatology, Jiaxing Maternity and Child Health Care Hospital, Jiaxing 314001, China
| | - Dan Yang Liu
- Department of Neonatology, Jingan District Zhabei Central Hospital, Shanghai 200070, China
| | - Hai Qing Shen
- Department of Neonatology, International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai 200030, China *These authors have contributed equally to this work
| | - Zhen Juan He
- Department of Neonatology, Xinhua Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai 200092, China
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4
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Yue L, Lu X, Dennery PA, Yao H. Metabolic dysregulation in bronchopulmonary dysplasia: Implications for identification of biomarkers and therapeutic approaches. Redox Biol 2021; 48:102104. [PMID: 34417157 PMCID: PMC8710987 DOI: 10.1016/j.redox.2021.102104] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/03/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in premature infants. Accumulating evidence shows that dysregulated metabolism of glucose, lipids and amino acids are observed in premature infants. Animal and cell studies demonstrate that abnormal metabolism of these substrates results in apoptosis, inflammation, reduced migration, abnormal proliferation or senescence in response to hyperoxic exposure, and that rectifying metabolic dysfunction attenuates neonatal hyperoxia-induced alveolar simplification and vascular dysgenesis in the lung. BPD is often associated with several comorbidities, including pulmonary hypertension and neurodevelopmental abnormalities, which significantly increase the morbidity and mortality of this disease. Here, we discuss recent progress on dysregulated metabolism of glucose, lipids and amino acids in premature infants with BPD and in related in vivo and in vitro models. These findings suggest that metabolic dysregulation may serve as a biomarker of BPD and plays important roles in the pathogenesis of this disease. We also highlight that targeting metabolic pathways could be employed in the prevention and treatment of BPD.
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Affiliation(s)
- Li Yue
- Department of Orthopedics, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Xuexin Lu
- Department of Pediatrics, Ascension St. John Hospital, Detroit, MI, USA
| | - Phyllis A Dennery
- Department of Molecular Biology, Cell Biology & Biochemistry, Division of Biology and Medicine, Brown University, Providence, RI, USA; Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hongwei Yao
- Department of Molecular Biology, Cell Biology & Biochemistry, Division of Biology and Medicine, Brown University, Providence, RI, USA.
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5
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Yang K, He S, Dong W. Gut microbiota and bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:2460-2470. [PMID: 34077996 DOI: 10.1002/ppul.25508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/02/2021] [Accepted: 05/16/2021] [Indexed: 12/20/2022]
Abstract
Bronchopulmonary dysplasia is a relatively common and severe complication of prematurity, and its pathogenesis remains ambiguous. Revolutionary advances in microbiological analysis techniques, together with the growing sophistication of the gut-lung axis hypothesis, have resulted in more studies linking gut microbiota dysbiosis to the occurrence and development of bronchopulmonary dysplasia. The present article builds on current findings to examine the intrinsic associations between gut microbiota and bronchopulmonary dysplasia. Gut microbiota dysbiosis may insult the intestinal barrier, triggering inflammation, metabolic disturbances, and malnutrition, consequences of which might impact bronchopulmonary dysplasia by altering the gut-lung axis. By evaluating the potential mechanisms, new therapeutic targets and potential therapeutic modalities for bronchopulmonary dysplasia can be identified from a microecological perspective.
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Affiliation(s)
- Kun Yang
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shasha He
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenbin Dong
- Department of Pediatrics, Division of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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6
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Tiono J, Surate Solaligue DE, Mižíková I, Nardiello C, Vadász I, Böttcher-Friebertshäuser E, Ehrhardt H, Herold S, Seeger W, Morty RE. Mouse genetic background impacts susceptibility to hyperoxia-driven perturbations to lung maturation. Pediatr Pulmonol 2019; 54:1060-1077. [PMID: 30848059 DOI: 10.1002/ppul.24304] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND The laboratory mouse is widely used in preclinical models of bronchopulmonary dysplasia, where lung alveolarization is stunted by exposure of pups to hyperoxia. Whether the diverse genetic backgrounds of different inbred mouse strains impacts lung development in newborn mice exposed to hyperoxia has not been systematically assessed. METHODS Hyperoxia (85% O2 , 14 days)-induced perturbations to lung alveolarization were assessed by design-based stereology in C57BL/6J, BALB/cJ, FVB/NJ, C3H/HeJ, and DBA/2J inbred mouse strains. The expression of components of the lung antioxidant machinery was assessed by real-time reverse transcriptase polymerase chain reaction and immunoblot. RESULTS Hyperoxia-reduced lung alveolar density in all five mouse strains to different degrees (C57BL/6J, 64.8%; FVB/NJ, 47.4%; BALB/cJ, 46.4%; DBA/2J, 45.9%; and C3H/HeJ, 35.9%). Hyperoxia caused a 94.5% increase in mean linear intercept in the C57BL/6J strain, whilst the C3H/HeJ strain was the least affected (31.6% increase). In contrast, hyperoxia caused a 65.4% increase in septal thickness in the FVB/NJ strain, where the C57BL/6J strain was the least affected (30.3% increase). The expression of components of the lung antioxidant machinery in response to hyperoxia was strain dependent, with the C57BL/6J strain exhibiting the most dramatic engagement. Baseline expression levels of components of the lung antioxidant systems were different in the five mouse strains studied, under both normoxic and hyperoxic conditions. CONCLUSION The genetic background of laboratory mouse strains dramatically influenced the response of the developing lung to hyperoxic insult. This might be explained, at least in part, by differences in how antioxidant systems are engaged by different mouse strains after hyperoxia exposure.
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Affiliation(s)
- Jennifer Tiono
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, member of the German Center for Lung Research (DZL), Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | - David E Surate Solaligue
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, member of the German Center for Lung Research (DZL), Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | - Ivana Mižíková
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, member of the German Center for Lung Research (DZL), Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | - Claudio Nardiello
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, member of the German Center for Lung Research (DZL), Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | - István Vadász
- Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | | | - Harald Ehrhardt
- Division of General Pediatrics and Neonatology, University Children's Hospital Giessen, Justus Liebig, University, Giessen, Germany
| | - Susanne Herold
- Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, member of the German Center for Lung Research (DZL), Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
| | - Rory E Morty
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, member of the German Center for Lung Research (DZL), Bad Nauheim, Germany.,Department of Internal Medicine (Pulmonology), Universities of Giessen and Marburg Lung Center, member of The German Center for Lung Research (DZL), Giessen, Germany
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7
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Zhao H, Dennery PA, Yao H. Metabolic reprogramming in the pathogenesis of chronic lung diseases, including BPD, COPD, and pulmonary fibrosis. Am J Physiol Lung Cell Mol Physiol 2018; 314:L544-L554. [PMID: 29351437 DOI: 10.1152/ajplung.00521.2017] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The metabolism of nutrient substrates, including glucose, glutamine, and fatty acids, provides acetyl-CoA for the tricarboxylic acid cycle to generate energy, as well as metabolites for the biosynthesis of biomolecules, including nucleotides, proteins, and lipids. It has been shown that metabolism of glucose, fatty acid, and glutamine plays important roles in modulating cellular proliferation, differentiation, apoptosis, autophagy, senescence, and inflammatory responses. All of these cellular processes contribute to the pathogenesis of chronic lung diseases, including bronchopulmonary dysplasia, chronic obstructive pulmonary disease, and pulmonary fibrosis. Recent studies demonstrate that metabolic reprogramming occurs in patients with and animal models of chronic lung diseases, suggesting that metabolic dysregulation may participate in the pathogenesis and progression of these diseases. In this review, we briefly discuss the catabolic pathways for glucose, glutamine, and fatty acids, and focus on how metabolic reprogramming of these pathways impacts cellular functions and leads to the development of these chronic lung diseases. We also highlight how targeting metabolic pathways can be utilized in the prevention and treatment of these diseases.
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Affiliation(s)
- Haifeng Zhao
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University , Providence, Rhode Island.,Department of Nutrition and Food Hygiene, School of Public Health, Shanxi Medical University , Taiyuan, Shanxi , China
| | - Phyllis A Dennery
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University , Providence, Rhode Island.,Department of Pediatrics, Warren Alpert Medical School of Brown University , Providence, Rhode Island
| | - Hongwei Yao
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University , Providence, Rhode Island
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8
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Surate Solaligue DE, Rodríguez-Castillo JA, Ahlbrecht K, Morty RE. Recent advances in our understanding of the mechanisms of late lung development and bronchopulmonary dysplasia. Am J Physiol Lung Cell Mol Physiol 2017; 313:L1101-L1153. [PMID: 28971976 DOI: 10.1152/ajplung.00343.2017] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/21/2017] [Accepted: 09/23/2017] [Indexed: 02/08/2023] Open
Abstract
The objective of lung development is to generate an organ of gas exchange that provides both a thin gas diffusion barrier and a large gas diffusion surface area, which concomitantly generates a steep gas diffusion concentration gradient. As such, the lung is perfectly structured to undertake the function of gas exchange: a large number of small alveoli provide extensive surface area within the limited volume of the lung, and a delicate alveolo-capillary barrier brings circulating blood into close proximity to the inspired air. Efficient movement of inspired air and circulating blood through the conducting airways and conducting vessels, respectively, generates steep oxygen and carbon dioxide concentration gradients across the alveolo-capillary barrier, providing ideal conditions for effective diffusion of both gases during breathing. The development of the gas exchange apparatus of the lung occurs during the second phase of lung development-namely, late lung development-which includes the canalicular, saccular, and alveolar stages of lung development. It is during these stages of lung development that preterm-born infants are delivered, when the lung is not yet competent for effective gas exchange. These infants may develop bronchopulmonary dysplasia (BPD), a syndrome complicated by disturbances to the development of the alveoli and the pulmonary vasculature. It is the objective of this review to update the reader about recent developments that further our understanding of the mechanisms of lung alveolarization and vascularization and the pathogenesis of BPD and other neonatal lung diseases that feature lung hypoplasia.
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Affiliation(s)
- David E Surate Solaligue
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany; and.,Department of Internal Medicine (Pulmonology), University of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
| | - José Alberto Rodríguez-Castillo
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany; and.,Department of Internal Medicine (Pulmonology), University of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
| | - Katrin Ahlbrecht
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany; and.,Department of Internal Medicine (Pulmonology), University of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
| | - Rory E Morty
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany; and .,Department of Internal Medicine (Pulmonology), University of Giessen and Marburg Lung Center, German Center for Lung Research, Giessen, Germany
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Auten R, Ren C, Yilmaz O, Noah TL. Pediatric pulmonology year in review 2016: Part 2. Pediatr Pulmonol 2017; 52:1219-1225. [PMID: 28440920 PMCID: PMC7167696 DOI: 10.1002/ppul.23719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 04/03/2017] [Indexed: 12/14/2022]
Abstract
Pediatric Pulmonology continues to publish research and clinical topics related to the entire range of children's respiratory disorders. As we have done annually in recent years, we here summarize some of the past year's publications in our major topic areas, as well as selected literature in these areas from other core journals relevant to our discipline. This review (Part 2) covers selected articles on neonatology, asthma, physiology and lung function testing, and infectious diseases.
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Affiliation(s)
| | - Clement Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ozge Yilmaz
- Pediatric Allergy and Pulmonology, Celal Bayar University Department of Pediatrics, Manisa, Turkey
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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