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Lu F, Verleg SMNE, Groven RVM, Poeze M, van Griensven M, Blokhuis TJ. Is there a role for N1-N2 neutrophil phenotypes in bone regeneration? A systematic review. Bone 2024; 181:117021. [PMID: 38253189 DOI: 10.1016/j.bone.2024.117021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/02/2024] [Accepted: 01/17/2024] [Indexed: 01/24/2024]
Abstract
PURPOSE This review aims to provide an overview of the multiple functions of neutrophils, with the recognition of the inflammatory (N1) and regenerative (N2) phenotypes, in relation to fracture healing. METHODS A literature search was performed using the PubMed database. The quality of the articles was evaluated using critical appraisal checklists. RESULTS Thirty one studies were included in this review. These studies consistently support that neutrophils exert both beneficial and detrimental effects on bone regeneration, influenced by Tumor Necrosis Factor-α (TNF-α), Interleukin 8 (IL-8), mast cells, and macrophages. The N2 phenotype has recently emerged as one promoter of bone healing. The N1 phenotype has progressively been connected with inflammatory neutrophils during fracture healing. CONCLUSIONS This review has pinpointed various aspects and mechanisms of neutrophil influence on bone healing. The recognition of N1 and N2 neutrophil phenotypes potentially shed new light on the dynamic shifts taking place within the Fracture Hematoma (FH).
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Affiliation(s)
- Fangzhou Lu
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands; Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - Samai M N E Verleg
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands; Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - Rald V M Groven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands; Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - Martijn Poeze
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
| | - Martijn van Griensven
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Taco J Blokhuis
- Division of Trauma Surgery, Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands.
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Capobianco CA, Hankenson KD, Knights AJ. Temporal dynamics of immune-stromal cell interactions in fracture healing. Front Immunol 2024; 15:1352819. [PMID: 38455063 PMCID: PMC10917940 DOI: 10.3389/fimmu.2024.1352819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Bone fracture repair is a complex, multi-step process that involves communication between immune and stromal cells to coordinate the repair and regeneration of damaged tissue. In the US, 10% of all bone fractures do not heal properly without intervention, resulting in non-union. Complications from non-union fractures are physically and financially debilitating. We now appreciate the important role that immune cells play in tissue repair, and the necessity of the inflammatory response in initiating healing after skeletal trauma. The temporal dynamics of immune and stromal cell populations have been well characterized across the stages of fracture healing. Recent studies have begun to untangle the intricate mechanisms driving the immune response during normal or atypical, delayed healing. Various in vivo models of fracture healing, including genetic knockouts, as well as in vitro models of the fracture callus, have been implemented to enable experimental manipulation of the heterogeneous cellular environment. The goals of this review are to (1): summarize our current understanding of immune cell involvement in fracture healing (2); describe state-of-the art approaches to study inflammatory cells in fracture healing, including computational and in vitro models; and (3) identify gaps in our knowledge concerning immune-stromal crosstalk during bone healing.
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Affiliation(s)
- Christina A. Capobianco
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Kurt D. Hankenson
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Alexander J. Knights
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, United States
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Jo S, Lee SH, Jeon C, Jo HR, You YJ, Lee JK, Sung IH, Kim TH, Lee CH. Myosin heavy chain 2 (MYH2) expression in hypertrophic chondrocytes of soft callus provokes endochondral bone formation in fracture. Life Sci 2023; 334:122204. [PMID: 37871676 DOI: 10.1016/j.lfs.2023.122204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/08/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
AIMS Muscle-bone interactions during fracture healing are rarely known. Here we investigated the presence and significance of myosin heavy chain 2 (MYH2), a component of myosin derived from muscles, in fracture healing. MAIN METHODS We collected five hematoma and seven soft callus tissues from patients with distal radius fractures patients, randomly selected three of them, and performed a liquid chromatography-mass spectrometry (LC-MS) proteomics analysis. Proteomic results were validated by histological observation, immunohistochemistry, and immunofluorescence for MYH2 expression. These findings were further confirmed in a murine femoral fracture model in vivo and investigated using various methods in vitro. KEY FINDINGS The LC-MS proteomics analysis showed that MYH proteins were enriched in human soft calluses compared to hematoma. Notably, MYH2 protein is upregulated as high rank in each soft callus. The histological examination showed that MYH2 expression was elevated in hypertrophic chondrocytes within the human soft callus. Consistent with human data, Myh2 were significantly co-localized with Sox9 in hypertrophic chondrocytes of murine femoral fracture, in comparison to pre-hypertrophic and proliferating chondrocytes. Soluble MYH2 protein treatment increased MMP13 and RUNX2 expression in chondrocytes. In soluble MYH2 treatment, proliferation of chondrocytes was not altered, but the osteogenic and chondrogenic features of chondrocytes increased and decreased during differentiation, respectively. SIGNIFICANCE These findings indicate the potential of soluble MYH2 protein as a promising therapeutic strategy for promoting endochondral bone formation in chondrocytes following fracture.
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Affiliation(s)
- Sungsin Jo
- Hanyang University Institute for Rheumatology Research (HYIRR), Hanyang University, Seoul 04763, Republic of Korea
| | - Seung Hoon Lee
- Hanyang University Institute for Rheumatology Research (HYIRR), Hanyang University, Seoul 04763, Republic of Korea
| | - Chanhyeok Jeon
- Hanyang University Institute for Rheumatology Research (HYIRR), Hanyang University, Seoul 04763, Republic of Korea; Department of Translational Medicine, Graduate School of Biomedical Science and Engineering, Hanyang University, Seoul 04763, Republic of Korea
| | - Hye-Ryeong Jo
- Hanyang University Institute for Rheumatology Research (HYIRR), Hanyang University, Seoul 04763, Republic of Korea
| | - Yong Jin You
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Jin Kyu Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Il-Hoon Sung
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Tae-Hwan Kim
- Hanyang University Institute for Rheumatology Research (HYIRR), Hanyang University, Seoul 04763, Republic of Korea; Department of Translational Medicine, Graduate School of Biomedical Science and Engineering, Hanyang University, Seoul 04763, Republic of Korea; Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul 04763, Republic of Korea
| | - Chang-Hun Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul 04763, Republic of Korea.
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Fouladseresht H, Ghamar Talepoor A, Eskandari N, Norouzian M, Ghezelbash B, Beyranvand MR, Nejadghaderi SA, Carson-Chahhoud K, Kolahi AA, Safiri S. Potential Immune Indicators for Predicting the Prognosis of COVID-19 and Trauma: Similarities and Disparities. Front Immunol 2022; 12:785946. [PMID: 35126355 PMCID: PMC8815083 DOI: 10.3389/fimmu.2021.785946] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/17/2021] [Indexed: 12/15/2022] Open
Abstract
Although cellular and molecular mediators of the immune system have the potential to be prognostic indicators of disease outcomes, temporal interference between diseases might affect the immune mediators, and make them difficult to predict disease complications. Today one of the most important challenges is predicting the prognosis of COVID-19 in the context of other inflammatory diseases such as traumatic injuries. Many diseases with inflammatory properties are usually polyphasic and the kinetics of inflammatory mediators in various inflammatory diseases might be different. To find the most appropriate evaluation time of immune mediators to accurately predict COVID-19 prognosis in the trauma environment, researchers must investigate and compare cellular and molecular alterations based on their kinetics after the start of COVID-19 symptoms and traumatic injuries. The current review aimed to investigate the similarities and differences of common inflammatory mediators (C-reactive protein, procalcitonin, ferritin, and serum amyloid A), cytokine/chemokine levels (IFNs, IL-1, IL-6, TNF-α, IL-10, and IL-4), and immune cell subtypes (neutrophil, monocyte, Th1, Th2, Th17, Treg and CTL) based on the kinetics between patients with COVID-19 and trauma. The mediators may help us to accurately predict the severity of COVID-19 complications and follow up subsequent clinical interventions. These findings could potentially help in a better understanding of COVID-19 and trauma pathogenesis.
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Affiliation(s)
- Hamed Fouladseresht
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atefe Ghamar Talepoor
- Department of Immunology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nahid Eskandari
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marzieh Norouzian
- Department of Laboratory Sciences, School of Allied Medical Sciences, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Behrooz Ghezelbash
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Reza Beyranvand
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- *Correspondence: Mohammad Reza Beyranvand,
| | - Seyed Aria Nejadghaderi
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Kristin Carson-Chahhoud
- Australian Centre for Precision Health, Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
- School of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Safiri
- Social Determinants of Health Research Center, Department of Community Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Ehnert S, Relja B, Schmidt-Bleek K, Fischer V, Ignatius A, Linnemann C, Rinderknecht H, Huber-Lang M, Kalbitz M, Histing T, Nussler AK. Effects of immune cells on mesenchymal stem cells during fracture healing. World J Stem Cells 2021; 13:1667-1695. [PMID: 34909117 PMCID: PMC8641016 DOI: 10.4252/wjsc.v13.i11.1667] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/31/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023] Open
Abstract
In vertebrates, bone is considered an osteoimmune system which encompasses functions of a locomotive organ, a mineral reservoir, a hormonal organ, a stem cell pool and a cradle for immune cells. This osteoimmune system is based on cooperatively acting bone and immune cells, cohabitating within the bone marrow. They are highly interdependent, a fact that is confounded by shared progenitors, mediators, and signaling pathways. Successful fracture healing requires the participation of all the precursors, immune and bone cells found in the osteoimmune system. Recent evidence demonstrated that changes of the immune cell composition and function may negatively influence bone healing. In this review, first the interplay between different immune cell types and osteoprogenitor cells will be elaborated more closely. The separate paragraphs focus on the specific cell types, starting with the cells of the innate immune response followed by cells of the adaptive immune response, and the complement system as mediator between them. Finally, a brief overview on the challenges of preclinical testing of immune-based therapeutic strategies to support fracture healing will be given.
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Affiliation(s)
- Sabrina Ehnert
- Siegfried Weller Research Institute at the BG Trauma Center Tübingen, Department of Trauma and Reconstructive Surgery, University of Tübingen, Tübingen 72076, Germany
| | - Borna Relja
- Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto-von-Guericke University, Magdeburg 39120, Germany
| | - Katharina Schmidt-Bleek
- Julius Wolff Institute and Berlin Institute of Health Center of Regenerative Therapies, Charité - University Medicine Berlin, Berlin 13353, Germany
| | - Verena Fischer
- Institute of Orthopedic Research and Biomechanics, Ulm University Medical Center, Ulm 89091, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Ulm University Medical Center, Ulm 89091, Germany
| | - Caren Linnemann
- Siegfried Weller Research Institute at the BG Trauma Center Tübingen, Department of Trauma and Reconstructive Surgery, University of Tübingen, Tübingen 72076, Germany
| | - Helen Rinderknecht
- Siegfried Weller Research Institute at the BG Trauma Center Tübingen, Department of Trauma and Reconstructive Surgery, University of Tübingen, Tübingen 72076, Germany
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma-Immunology (ITI), University Hospital Ulm, Ulm 89091, Germany
| | - Miriam Kalbitz
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen 91054, Germany
| | - Tina Histing
- Siegfried Weller Research Institute at the BG Trauma Center Tübingen, Department of Trauma and Reconstructive Surgery, University of Tübingen, Tübingen 72076, Germany
| | - Andreas K Nussler
- Siegfried Weller Research Institute at the BG Trauma Center Tübingen, Department of Trauma and Reconstructive Surgery, University of Tübingen, Tübingen 72076, Germany
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6
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Teuben MPJ, Hofman M, Greven J, Shehu A, Teuber H, Pfeifer R, Pape HC, Hildebrand F. Altered cell surface receptor dynamics and circulatory occurrence of neutrophils in a small animal fracture model. Pathol Res Pract 2020; 216:153108. [PMID: 32853946 DOI: 10.1016/j.prp.2020.153108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Excessive activation of the immune response after femoral fractures and fracture fixation is potentially associated with the development of systemic and local complications, particularly in multiple trauma patients. A dysregulated function of neutrophils, the most prevailing immune cells in circulation, has been discussed as a central pathophysiological background for these unfavourable post-traumatic courses. Our aim was to investigate alterations in activity and functionality as expressed by the cell surface receptor dynamics of circulatory neutrophils after femoral fracture and intramedullary stabilization. MATERIAL AND METHODS After intramedullary stabilization, an isolated femur fracture was induced in 18 Sprague-Dawley rats. Animals were terminated at different time points, i.e. after 3 (n = 5, group 3d), 7 (n = 5, group 7d) and 14 (n = 5, Group 14d) days and grouped accordingly. Additionally, baseline measurements were performed in one control animal per study group (n = 3) after anaesthesia induction and termination, without prior intramedullary nailing and fracture induction. The numbers and cell surface expression of CD11b, CD11a, CD62 L, and CD49d of circulating neutrophils were compared between groups. RESULTS Neutrophil numbers were significantly reduced at 3 days compared with baseline measurements (1.2 × 105 vs. 6.3 × 105 cells/mL, p < 0.01). By day 7, neutrophil counts significantly increased back to homeostatic levels (p < 0.05). At day 3, CD11b-expression was significantly reduced, whereas CD11a-expression was increased compared with the baseline measurements (p < 0.05). At day 7, the circulatory neutrophil pool exhibited a unique CD11bhigh/CD11ahigh-neutrophil subset showing a significantly increased co-expression of CD49d. The expression of CD62 L did not change significantly throughout the experiment compared with baseline measurements. CONCLUSIONS This descriptive small animal fracture study is the first to show that an intramedullary stabilized femur fracture is associated with a temporary reduction in circulatory neutrophil count and concurrent changes in circulatory neutrophil function. Moreover, we demonstrated that the restoration to homeostatic neutrophil activation status occurs concomitantly with the appearance of a novel neutrophil subtype (CD11bhigh/CD11ahigh) in circulation. Our fundamental new findings of the changes in circulatory neutrophil count and functionality after trauma form an excellent basis for future studies to further elucidate the role of neutrophils as activators and regulators of different post-traumatic processes, potentially resulting in local (e.g., fracture healing disturbances) or systemic (e.g., MODS) complications. This might result in the development of specific therapies to reduce adverse outcomes after trauma.
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Affiliation(s)
- Michel P J Teuben
- Department of Traumatology and Harald Tscherne Research Laboratory, University Hospital Zurich, Raemistraße 10, 8032, Zurich, Switzerland.
| | - Martijn Hofman
- Department of Orthopaedic Trauma and Reconstructive Surgery, University of Aachen Medical Center, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Johannes Greven
- Department of Orthopaedic Trauma and Reconstructive Surgery, University of Aachen Medical Center, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Alba Shehu
- Department of Orthopaedic Trauma and Reconstructive Surgery, University of Aachen Medical Center, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Henrik Teuber
- Department of Traumatology and Harald Tscherne Research Laboratory, University Hospital Zurich, Raemistraße 10, 8032, Zurich, Switzerland.
| | - Roman Pfeifer
- Department of Traumatology and Harald Tscherne Research Laboratory, University Hospital Zurich, Raemistraße 10, 8032, Zurich, Switzerland.
| | - Hans-Christoph Pape
- Department of Traumatology and Harald Tscherne Research Laboratory, University Hospital Zurich, Raemistraße 10, 8032, Zurich, Switzerland.
| | - Frank Hildebrand
- Department of Orthopaedic Trauma and Reconstructive Surgery, University of Aachen Medical Center, Pauwelsstraße 30, 52074, Aachen, Germany.
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Mortaz E, Zadian SS, Shahir M, Folkerts G, Garssen J, Mumby S, Adcock IM. Does Neutrophil Phenotype Predict the Survival of Trauma Patients? Front Immunol 2019; 10:2122. [PMID: 31552051 PMCID: PMC6743367 DOI: 10.3389/fimmu.2019.02122] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022] Open
Abstract
According to the World Health Organization (WHO), trauma is responsible for 10% of deaths and 16% of disabilities worldwide. This is considerably higher than those for malaria, tuberculosis, and HIV/AIDS combined. While the human suffering and death caused by injury is well-recognized, injury has a significant medical care cost. Better prediction of the state of trauma patients in the days immediately after trauma may reduce costs. Traumatic injuries to multiple organs can cause dysfunction in all systems of the body especially the immune system placing patients at high risk of infections and inflammatory complications which are often fatal. Neutrophils are the most abundant leukocyte in the human circulation and are crucial for the prevention of microbial disease. Significant changes in neutrophil functions such as enhanced chemotaxis, Neutrophil extracellular trap (NET)-induced cell death (NETosis), and phagocytosis occur early after injury followed by prolonged functional defects such as phagocytosis, killing mechanisms, and receptor expression. Analysis of these changes may improve the prediction of the patient's condition over time. We provide a comprehensive and up-to-date review of the literature investigating the effect of trauma on neutrophil phenotype with an underlying goal of using this knowledge to examine the predictive potential of neutrophil alterations on secondary complications in patients with traumatic injuries. We conclude that alterations in neutrophil surface markers and functions may be potential biomarkers that predict the outcome of trauma patients.
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Affiliation(s)
- Esmaeil Mortaz
- Department of Immunology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Sajjad Zadian
- Department of Immunology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehri Shahir
- Department of Immunology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gert Folkerts
- Division of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Johan Garssen
- Division of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Nutricia Research Centre for Specialized Nutrition, Utrecht, Netherlands
| | - Sharon Mumby
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ian M Adcock
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
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