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Getsy PM, Davis J, Coffee GA, Lewis THJ, Lewis SJ. Hypercapnic signaling influences hypoxic signaling in the control of breathing in C57BL6 mice. J Appl Physiol (1985) 2023; 134:1188-1206. [PMID: 36892890 PMCID: PMC10151047 DOI: 10.1152/japplphysiol.00548.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/28/2023] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
Interactions between hypoxic and hypercapnic signaling pathways, expressed as ventilatory changes occurring during and following a simultaneous hypoxic-hypercapnic gas challenge (HH-C) have not been determined systematically in mice. This study in unanesthetized male C57BL6 mice addressed the hypothesis that hypoxic (HX) and hypercapnic (HC) signaling events display an array of interactions indicative of coordination by peripheral and central respiratory mechanisms. We evaluated the ventilatory responses elicited by hypoxic (HX-C, 10%, O2, 90% N2), hypercapnic (HC-C, 5% CO2, 21%, O2, 90% N2), and HH-C (10% O2, 5%, CO2, 85% N2) challenges to determine whether ventilatory responses elicited by HH-C were simply additive of responses elicited by HX-C and HC-C, or whether other patterns of interactions existed. Responses elicited by HH-C were additive for tidal volume, minute ventilation and expiratory time, among others. Responses elicited by HH-C were hypoadditive of the HX-C and HC-C responses (i.e., HH-C responses were less than expected by simple addition of HX-C and HC-C responses) for frequency of breathing, inspiratory time and relaxation time, among others. In addition, end-expiratory pause increased during HX-C, but decreased during HC-C and HH-C, therefore showing that HC-C responses influenced the HX-C responses when given simultaneously. Return to room-air responses was additive for tidal volume and minute ventilation, among others, whereas they were hypoadditive for frequency of breathing, inspiratory time, peak inspiratory flow, apneic pause, inspiratory and expiratory drives, and rejection index. These data show that HX-C and HH-C signaling pathways interact with one another in additive and often hypoadditive processes.NEW & NOTEWORTHY We present data showing that the ventilatory responses elicited by a hypoxic gas challenge in male C57BL6 mice are markedly altered by coexposure to hypercapnic gas challenge with hypercapnic responses often dominating the hypoxic responses. These data suggest that hypercapnic signaling processes activated within brainstem regions, such as the retrotrapezoid nuclei, may directly modulate the signaling processes within the nuclei tractus solitarius resulting from hypoxic-induced increase in carotid body chemoreceptor input to these nuclei.
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Affiliation(s)
- Paulina M Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States
| | - Jesse Davis
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States
| | - Gregory A Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States
| | - Tristan H J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States
| | - Stephen J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, Ohio, United States
- Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, Ohio, United States
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2
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Ventilatory responses during and following hypercapnic gas challenge are impaired in male but not female endothelial NOS knock-out mice. Sci Rep 2021; 11:20557. [PMID: 34663876 PMCID: PMC8523677 DOI: 10.1038/s41598-021-99922-5] [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: 03/01/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022] Open
Abstract
The roles of endothelial nitric oxide synthase (eNOS) in the ventilatory responses during and after a hypercapnic gas challenge (HCC, 5% CO2, 21% O2, 74% N2) were assessed in freely-moving female and male wild-type (WT) C57BL6 mice and eNOS knock-out (eNOS-/-) mice of C57BL6 background using whole body plethysmography. HCC elicited an array of ventilatory responses that were similar in male and female WT mice, such as increases in breathing frequency (with falls in inspiratory and expiratory times), and increases in tidal volume, minute ventilation, peak inspiratory and expiratory flows, and inspiratory and expiratory drives. eNOS-/- male mice had smaller increases in minute ventilation, peak inspiratory flow and inspiratory drive, and smaller decreases in inspiratory time than WT males. Ventilatory responses in female eNOS-/- mice were similar to those in female WT mice. The ventilatory excitatory phase upon return to room-air was similar in both male and female WT mice. However, the post-HCC increases in frequency of breathing (with decreases in inspiratory times), and increases in tidal volume, minute ventilation, inspiratory drive (i.e., tidal volume/inspiratory time) and expiratory drive (i.e., tidal volume/expiratory time), and peak inspiratory and expiratory flows in male eNOS-/- mice were smaller than in male WT mice. In contrast, the post-HCC responses in female eNOS-/- mice were equal to those of the female WT mice. These findings provide the first evidence that the loss of eNOS affects the ventilatory responses during and after HCC in male C57BL6 mice, whereas female C57BL6 mice can compensate for the loss of eNOS, at least in respect to triggering ventilatory responses to HCC.
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Baby SM, Discala JF, Gruber R, Getsy PM, Cheng F, Damron DS, Lewis SJ. Tempol Reverses the Negative Effects of Morphine on Arterial Blood-Gas Chemistry and Tissue Oxygen Saturation in Freely-Moving Rats. Front Pharmacol 2021; 12:749084. [PMID: 34630119 PMCID: PMC8493249 DOI: 10.3389/fphar.2021.749084] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022] Open
Abstract
We have reported that pretreatment with the clinically approved superoxide dismutase mimetic, Tempol (4-hydroxy-2,2,6,6-tetramethylpiperidine-N-oxyl), blunts the cardiorespiratory depressant responses elicited by a subsequent injection of fentanyl, in halothane-anesthetized rats. The objective of the present study was to determine whether Tempol is able to reverse the effects of morphine on arterial blood-gas (ABG) chemistry in freely-moving Sprague Dawley rats. The intravenous injection of morphine (10 mg/kg) elicited substantial decreases in pH, pO2 and sO2 that were accompanied by substantial increases in pCO2 and Alveolar-arterial gradient, which results in diminished gas-exchange within the lungs. Intravenous injection of a 60 mg/kg dose of Tempol 15 min after the injection of morphine caused minor improvements in pO2 and pCO2 but not in other ABG parameters. In contrast, the 100 mg/kg dose of Tempol caused an immediate and sustained reversal of the negative effects of morphine on arterial blood pH, pCO2, pO2, sO2 and Alveolar-arterial gradient. In other rats, we used pulse oximetry to determine that the 100 mg/kg dose of Tempol, but not the 60 mg/kg dose elicited a rapid and sustained reversal of the negative effects of morphine (10 mg/kg, IV) on tissue O2 saturation (SpO2). The injection of morphine caused a relatively minor fall in mean arterial blood pressure that was somewhat exacerbated by Tempol. These findings demonstrate that Tempol can reverse the negative effects of morphine on ABG chemistry in freely-moving rats paving the way of structure-activity and mechanisms of action studies with the host of Tempol analogues that are commercially available.
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Affiliation(s)
| | | | - Ryan Gruber
- Galleon Pharmaceuticals Inc, Horsham, PA, United states
| | - Paulina M Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United states
| | - Feixiong Cheng
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United states
| | - Derek S Damron
- Department of Biological Sciences, School of Biomedical Sciences, Kent State University, Kent, OH, United states
| | - Stephen J Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United states.,Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United states
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Getsy PM, Sundararajan S, May WJ, von Schill GC, McLaughlin DK, Palmer LA, Lewis SJ. Short-term facilitation of breathing upon cessation of hypoxic challenge is impaired in male but not female endothelial NOS knock-out mice. Sci Rep 2021; 11:18346. [PMID: 34526532 PMCID: PMC8443732 DOI: 10.1038/s41598-021-97322-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023] Open
Abstract
Decreases in arterial blood oxygen stimulate increases in minute ventilation via activation of peripheral and central respiratory structures. This study evaluates the role of endothelial nitric oxide synthase (eNOS) in the expression of the ventilatory responses during and following a hypoxic gas challenge (HXC, 10% O2, 90% N2) in freely moving male and female wild-type (WT) C57BL6 and eNOS knock-out (eNOS-/-) mice. Exposure to HXC caused an array of responses (of similar magnitude and duration) in both male and female WT mice such as, rapid increases in frequency of breathing, tidal volume, minute ventilation and peak inspiratory and expiratory flows, that were subject to pronounced roll-off. The responses to HXC in male eNOS-/- mice were similar to male WT mice. In contrast, several of the ventilatory responses in female eNOS-/- mice (e.g., frequency of breathing, and expiratory drive) were greater compared to female WT mice. Upon return to room-air, male and female WT mice showed similar excitatory ventilatory responses (i.e., short-term potentiation phase). These responses were markedly reduced in male eNOS-/- mice, whereas female eNOS-/- mice displayed robust post-HXC responses that were similar to those in female WT mice. Our data demonstrates that eNOS plays important roles in (1) ventilatory responses to HXC in female compared to male C57BL6 mice; and (2) expression of post-HXC responses in male, but not female C57BL6 mice. These data support existing evidence that sex, and the functional roles of specific proteins (e.g., eNOS) have profound influences on ventilatory processes, including the responses to HXC.
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Affiliation(s)
- Paulina M. Getsy
- grid.67105.350000 0001 2164 3847Department of Pediatrics, Biomedical Research Building BRB 319, Case Western Reserve University, 10900 Euclid Avenue Mail Stop 1714, Cleveland, OH 44106-1714 USA ,grid.67105.350000 0001 2164 3847Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH USA
| | - Sripriya Sundararajan
- grid.27755.320000 0000 9136 933XPediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.411024.20000 0001 2175 4264Present Address: Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Walter J. May
- grid.27755.320000 0000 9136 933XPediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Graham C. von Schill
- grid.27755.320000 0000 9136 933XPediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Dylan K. McLaughlin
- grid.27755.320000 0000 9136 933XPediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Lisa A. Palmer
- grid.27755.320000 0000 9136 933XPediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Stephen J. Lewis
- grid.67105.350000 0001 2164 3847Department of Pediatrics, Biomedical Research Building BRB 319, Case Western Reserve University, 10900 Euclid Avenue Mail Stop 1714, Cleveland, OH 44106-1714 USA ,grid.67105.350000 0001 2164 3847Department of Pharmacology, Case Western Reserve University, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH USA
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Getsy PM, Sundararajan S, Lewis SJ. Carotid sinus nerve transection abolishes the facilitation of breathing that occurs upon cessation of a hypercapnic gas challenge in male mice. J Appl Physiol (1985) 2021; 131:821-835. [PMID: 34236243 DOI: 10.1152/japplphysiol.01031.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Arterial pCO2 elevations increase minute ventilation via activation of chemosensors within the carotid body (CB) and brainstem. Although the roles of CB chemoafferents in the hypercapnic (HC) ventilatory response have been investigated, there are no studies reporting the role of these chemoafferents in the ventilatory responses to a HC challenge or the responses that occur upon return to room air, in freely moving mice. This study found that an HC challenge (5% CO2, 21% O2, 74% N2 for 15 min) elicited an array of responses, including increases in frequency of breathing (accompanied by decreases in inspiratory and expiratory times), and increases in tidal volume, minute ventilation, peak inspiratory and expiratory flows, and inspiratory and expiratory drives in sham-operated (SHAM) adult male C57BL6 mice, and that return to room air elicited a brief excitatory phase followed by gradual recovery of all parameters toward baseline values over a 15-min period. The array of ventilatory responses to the HC challenge in mice with bilateral carotid sinus nerve transection (CSNX) performed 7 days previously occurred more slowly but reached similar maxima as SHAM mice. A major finding was responses upon return to room air were dramatically lower in CSNX mice than SHAM mice, and the parameters returned to baseline values within 1-2 min in CSNX mice, whereas it took much longer in SHAM mice. These findings are the first evidence that CB chemoafferents play a key role in initiating the ventilatory responses to HC challenge in C57BL6 mice and are essential for the expression of post-HC ventilatory responses.NEW & NOTEWORTHY This study presents the first evidence that carotid body chemoafferents play a key role in initiating the ventilatory responses, such as increases in frequency of breathing, tidal volume, and minute ventilation that occur in response to a hypercapnic gas challenge in freely moving C57BL6 mice. Our study also demonstrates for the first time that these chemoafferents are essential for the expression of the ventilatory responses that occur upon return to room air in these mice.
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Affiliation(s)
- Paulina M Getsy
- Department of Pediatrics, Case Western University, Cleveland, Ohio
| | - Sripriya Sundararajan
- Pediatric Respiratory Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Stephen J Lewis
- Department of Pediatrics, Case Western University, Cleveland, Ohio.,Department of Pharmacology, Case Western University, Cleveland, Ohio
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Getsy PM, Coffee GA, Hsieh YH, Lewis SJ. Loss of Cervical Sympathetic Chain Input to the Superior Cervical Ganglia Affects the Ventilatory Responses to Hypoxic Challenge in Freely-Moving C57BL6 Mice. Front Physiol 2021; 12:619688. [PMID: 33967819 PMCID: PMC8100345 DOI: 10.3389/fphys.2021.619688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/30/2021] [Indexed: 11/13/2022] Open
Abstract
The cervical sympathetic chain (CSC) innervates post-ganglionic sympathetic neurons within the ipsilateral superior cervical ganglion (SCG) of all mammalian species studied to date. The post-ganglionic neurons within the SCG project to a wide variety of structures, including the brain (parenchyma and cerebral arteries), upper airway (e.g., nasopharynx and tongue) and submandibular glands. The SCG also sends post-ganglionic fibers to the carotid body (e.g., chemosensitive glomus cells and microcirculation), however, the function of these connections are not established in the mouse. In addition, nothing is known about the functional importance of the CSC-SCG complex (including input to the carotid body) in the mouse. The objective of this study was to determine the effects of bilateral transection of the CSC on the ventilatory responses [e.g., increases in frequency of breathing (Freq), tidal volume (TV) and minute ventilation (MV)] that occur during and following exposure to a hypoxic gas challenge (10% O2 and 90% N2) in freely-moving sham-operated (SHAM) adult male C57BL6 mice, and in mice in which both CSC were transected (CSCX). Resting ventilatory parameters (19 directly recorded or calculated parameters) were similar in the SHAM and CSCX mice. There were numerous important differences in the responses of CSCX and SHAM mice to the hypoxic challenge. For example, the increases in Freq (and associated decreases in inspiratory and expiratory times, end expiratory pause, and relaxation time), and the increases in MV, expiratory drive, and expiratory flow at 50% exhaled TV (EF50) occurred more quickly in the CSCX mice than in the SHAM mice, although the overall responses were similar in both groups. Moreover, the initial and total increases in peak inspiratory flow were higher in the CSCX mice. Additionally, the overall increases in TV during the latter half of the hypoxic challenge were greater in the CSCX mice. The ventilatory responses that occurred upon return to room-air were essentially similar in the SHAM and CSCX mice. Overall, this novel data suggest that the CSC may normally provide inhibitory input to peripheral (e.g., carotid bodies) and central (e.g., brainstem) structures that are involved in the ventilatory responses to hypoxic gas challenge in C57BL6 mice.
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Affiliation(s)
- Paulina M Getsy
- Department of Pediatrics, Division of Pulmonology, Allergy and Immunology, Case Western Reserve University, Cleveland, OH, United States.,The Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH, United States
| | - Gregory A Coffee
- Department of Pediatrics, Division of Pulmonology, Allergy and Immunology, Case Western Reserve University, Cleveland, OH, United States
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Stephen J Lewis
- Department of Pediatrics, Division of Pulmonology, Allergy and Immunology, Case Western Reserve University, Cleveland, OH, United States.,Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
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7
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Caballero-Eraso C, Shin MK, Pho H, Kim LJ, Pichard LE, Wu ZJ, Gu C, Berger S, Pham L, Yeung HYB, Shirahata M, Schwartz AR, Tang WYW, Sham JSK, Polotsky VY. Leptin acts in the carotid bodies to increase minute ventilation during wakefulness and sleep and augment the hypoxic ventilatory response. J Physiol 2018; 597:151-172. [PMID: 30285278 DOI: 10.1113/jp276900] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/03/2018] [Indexed: 01/10/2023] Open
Abstract
KEY POINTS Leptin is a potent respiratory stimulant. A long functional isoform of leptin receptor, LepRb , was detected in the carotid body (CB), a key peripheral hypoxia sensor. However, the effect of leptin on minute ventilation (VE ) and the hypoxic ventilatory response (HVR) has not been sufficiently studied. We report that LepRb is present in approximately 74% of the CB glomus cells. Leptin increased carotid sinus nerve activity at baseline and in response to hypoxia in vivo. Subcutaneous infusion of leptin increased VE and HVR in C57BL/6J mice and this effect was abolished by CB denervation. Expression of LepRb in the carotid bodies of LepRb deficient obese db/db mice increased VE during wakefulness and sleep and augmented the HVR. We conclude that leptin acts on LepRb in the CBs to stimulate breathing and HVR, which may protect against sleep disordered breathing in obesity. ABSTRACT Leptin is a potent respiratory stimulant. The carotid bodies (CB) express the long functional isoform of leptin receptor, LepRb , but the role of leptin in CB has not been fully elucidated. The objectives of the current study were (1) to examine the effect of subcutaneous leptin infusion on minute ventilation (VE ) and the hypoxic ventilatory response to 10% O2 (HVR) in C57BL/6J mice before and after CB denervation; (2) to express LepRb in CB of LepRb -deficient obese db/db mice and examine its effects on breathing during sleep and wakefulness and on HVR. We found that leptin enhanced carotid sinus nerve activity at baseline and in response to 10% O2 in vivo. In C57BL/6J mice, leptin increased VE from 1.1 to 1.5 mL/min/g during normoxia (P < 0.01) and from 3.6 to 4.7 mL/min/g during hypoxia (P < 0.001), augmenting HVR from 0.23 to 0.31 mL/min/g/Δ F I O 2 (P < 0.001). The effects of leptin on VE and HVR were abolished by CB denervation. In db/db mice, LepRb expression in CB increased VE from 1.1 to 1.3 mL/min/g during normoxia (P < 0.05) and from 2.8 to 3.2 mL/min/g during hypoxia (P < 0.02), increasing HVR. Compared to control db/db mice, LepRb transfected mice showed significantly higher VE throughout non-rapid eye movement (20.1 vs. -27.7 mL/min respectively, P < 0.05) and rapid eye movement sleep (16.5 vs 23.4 mL/min, P < 0.05). We conclude that leptin acts in CB to augment VE and HVR, which may protect against sleep disordered breathing in obesity.
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Affiliation(s)
- Candela Caballero-Eraso
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Mi-Kyung Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lenise J Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis E Pichard
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zhi-Juan Wu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chenjuan Gu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Slava Berger
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Luu Pham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ho-Yee Bonnie Yeung
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Machiko Shirahata
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wan-Yee Winnie Tang
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James S K Sham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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