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Lichtwald A, Ittermann T, Friedrich N, Lange AE, Winter T, Kolbe C, Allenberg H, Nauck M, Heckmann M. Impact of Maternal Pre-Pregnancy Underweight on Cord Blood Metabolome: An Analysis of the Population-Based Survey of Neonates in Pomerania (SNiP). Int J Mol Sci 2024; 25:7552. [PMID: 39062795 PMCID: PMC11276627 DOI: 10.3390/ijms25147552] [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: 05/24/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Intrauterine growth restriction leads to an altered lipid and amino acid profile in the cord blood at the end of pregnancy. Pre-pregnancy underweight is an early risk factor for impaired fetal growth. The aim of this study was to investigate whether a pre-pregnancy body mass index (ppBMI) of <18.5 kg/m2, as early as at the beginning of pregnancy, is associated with changes in the umbilical cord metabolome. In a sample of the Survey of Neonates in Pomerania (SNIP) birth cohort, the cord blood metabolome of n = 240 newborns of mothers with a ppBMI of <18.5 kg/m2 with n = 208 controls (ppBMI of 18.5-24.9 kg/m2) was measured by NMR spectrometry. A maternal ppBMI of <18.5 kg/m2 was associated with increased concentrations of HDL4 cholesterol, HDL4 phospholipids, VLDL5 cholesterol, HDL 2, and HDL4 Apo-A1, as well as decreased VLDL triglycerides and HDL2 free cholesterol. A ppBMI of <18.5 kg/m2 combined with poor intrauterine growth (a gestational weight gain (GWG) < 25th percentile) was associated with decreased concentrations of total cholesterol; cholesterol transporting lipoproteins (LDL4, LDL6, LDL free cholesterol, and HDL2 free cholesterol); LDL4 Apo-B; total Apo-A2; and HDL3 Apo-A2. In conclusion, maternal underweight at the beginning of pregnancy already results in metabolic changes in the lipid profile in the cord blood, but the pattern changes when poor GWG is followed by pre-pregnancy underweight.
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Affiliation(s)
- Alexander Lichtwald
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, 17475 Greifswald, Germany; (A.E.L.); (H.A.)
| | - Till Ittermann
- Institute for Community Medicine, Division SHIP—Clinical Epidemiological Research, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Nele Friedrich
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (N.F.); (T.W.); (M.N.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 17475 Greifswald, Germany
| | - Anja Erika Lange
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, 17475 Greifswald, Germany; (A.E.L.); (H.A.)
| | - Theresa Winter
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (N.F.); (T.W.); (M.N.)
| | - Claudia Kolbe
- Department of Gynecology and Obstetrics, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Heike Allenberg
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, 17475 Greifswald, Germany; (A.E.L.); (H.A.)
| | - Matthias Nauck
- Institute for Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (N.F.); (T.W.); (M.N.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 17475 Greifswald, Germany
| | - Matthias Heckmann
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, 17475 Greifswald, Germany; (A.E.L.); (H.A.)
- German Centre for Child and Adolescent Health (DZKL), Partner Site Greifswald/Rostock, 17475 Greifswald, Germany
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Waldrop SW, Niemiec S, Wood C, Gyllenhammer LE, Jansson T, Friedman JE, Tryggestad JB, Borengasser SJ, Davidson EJ, Yang IV, Kechris K, Dabelea D, Boyle KE. Cord blood DNA methylation of immune and lipid metabolism genes is associated with maternal triglycerides and child adiposity. Obesity (Silver Spring) 2024; 32:187-199. [PMID: 37869908 PMCID: PMC10872762 DOI: 10.1002/oby.23915] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE Fetal exposures may impact offspring epigenetic signatures and adiposity. The authors hypothesized that maternal metabolic traits associate with cord blood DNA methylation, which, in turn, associates with child adiposity. METHODS Fasting serum was obtained in 588 pregnant women (27-34 weeks' gestation), and insulin, glucose, high-density lipoprotein cholesterol, triglycerides, and free fatty acids were measured. Cord blood DNA methylation and child adiposity were measured at birth, 4-6 months, and 4-6 years. The association of maternal metabolic traits with DNA methylation (429,246 CpGs) for differentially methylated probes (DMPs) and regions (DMRs) was tested. The association of the first principal component of each DMR with child adiposity was tested, and mediation analysis was performed. RESULTS Maternal triglycerides were associated with the most DMPs and DMRs of all traits tested (261 and 198, respectively, false discovery rate < 0.05). DMRs were near genes involved in immune function and lipid metabolism. Triglyceride-associated CpGs were associated with child adiposity at 4-6 months (32 CpGs) and 4-6 years (2 CpGs). One, near CD226, was observed at both timepoints, mediating 10% and 22% of the relationship between maternal triglycerides and child adiposity at 4-6 months and 4-6 years, respectively. CONCLUSIONS DNA methylation may play a role in the association of maternal triglycerides and child adiposity.
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Affiliation(s)
- Stephanie W. Waldrop
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Sierra Niemiec
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Cheyret Wood
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Lauren E. Gyllenhammer
- Department of Pediatrics, University of California, Irvine, School of Medicine, Irvine, CA, USA
| | - Thomas Jansson
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jacob E. Friedman
- Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jeanie B. Tryggestad
- Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sarah J. Borengasser
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Elizabeth J. Davidson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Ivana V. Yang
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- The Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Aurora, CO USA
| | - Katerina Kechris
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- The Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Aurora, CO USA
| | - Dana Dabelea
- The Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Aurora, CO USA
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Kristen E. Boyle
- Section of Nutrition, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- The Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Aurora, CO USA
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Sharma S, Bhonde R. Dilemma of Epigenetic Changes Causing or Reducing Metabolic Disorders in Offsprings of Obese Mothers. Horm Metab Res 2023; 55:665-676. [PMID: 37813098 DOI: 10.1055/a-2159-9128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Maternal obesity is associated with fetal complications predisposing later to the development of metabolic syndrome during childhood and adult stages. High-fat diet seems to influence individuals and their subsequent generations in mediating weight gain, insulin resistance, obesity, high cholesterol, diabetes, and cardiovascular disorder. Research evidence strongly suggests that epigenetic alteration is the major contributor to the development of metabolic syndrome through DNA methylation, histone modifications, and microRNA expression. In this review, we have discussed the outcome of recent studies on the adverse and beneficial effects of nutrients and vitamins through epigenetics during pregnancy. We have further discussed about the miRNAs altered during maternal obesity. Identification of new epigenetic modifiers such as mesenchymal stem cells condition media (MSCs-CM)/exosomes for accelerating the reversal of epigenetic abnormalities for the development of new treatments is yet another aspect of the present review.
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Affiliation(s)
- Shikha Sharma
- Institute for Stem Cell Science and Regenerative Medicine, Bangalore, India
| | - Ramesh Bhonde
- Stem Cells and Regenerative Medicine, Dr. D. Y. Patil Vidyapeeth Pune (Deemed University), Pune, India
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Thangaraj SV, Kachman M, Halloran KM, Sinclair KD, Lea R, Bellingham M, Evans NP, Padmanabhan V. Developmental programming: Preconceptional and gestational exposure of sheep to a real-life environmental chemical mixture alters maternal metabolome in a fetal sex-specific manner. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 864:161054. [PMID: 36565874 PMCID: PMC10322214 DOI: 10.1016/j.scitotenv.2022.161054] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 05/21/2023]
Abstract
BACKGROUND Everyday, humans are exposed to a mixture of environmental chemicals some of which have endocrine and/or metabolism disrupting actions which may contribute to non-communicable diseases. The adverse health impacts of real-world chemical exposure, characterized by chronic low doses of a mixture of chemicals, are only recently emerging. Biosolids derived from human waste represent the environmental chemical mixtures humans are exposed to in real life. Prior studies in sheep have shown aberrant reproductive and metabolic phenotypes in offspring after maternal biosolids exposure. OBJECTIVE To determine if exposure to biosolids perturbs the maternal metabolic milieu of pregnant ewes, in a fetal sex-specific manner. METHODS Ewes were grazed on inorganic fertilizer (Control) or biosolids-treated pastures (BTP) from before mating and throughout gestation. Plasma from pregnant ewes (Control n = 15, BTP n = 15) obtained mid-gestation were analyzed by untargeted metabolomics. Metabolites were identified using Agilent MassHunter. Multivariate analyses were done using MetaboAnalyst 5.0 and confirmed using SIMCA. RESULTS Univariate and multivariate analysis of 2301 annotated metabolites identified 193 differentially abundant metabolites (DM) between control and BTP sheep. The DM primarily belonged to the super-class of lipids and organic acids. 15-HeTrE, oleamide, methionine, CAR(3:0(OH)) and pyroglutamic acid were the top DM and have been implicated in the regulation of fetal growth and development. Fetal sex further exacerbated differences in metabolite profiles in the BTP group. The organic acids class of metabolites was abundant in animals with male fetuses. Prenol lipid, sphingolipid, glycerolipid, alkaloid, polyketide and benzenoid classes showed fetal sex-specific responses to biosolids. DISCUSSION Our study illustrates that exposure to biosolids significantly alters the maternal metabolome in a fetal sex-specific manner. The altered metabolite profile indicates perturbations to fatty acid, arginine, branched chain amino acid and one‑carbon metabolism. These factors are consistent with, and likely contribute to, the adverse phenotypic outcomes reported in the offspring.
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Affiliation(s)
- S V Thangaraj
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - M Kachman
- MM BRCF Metabolomics Core, University of Michigan, Ann Arbor, MI, USA
| | - K M Halloran
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - K D Sinclair
- University of Nottingham, Sutton Bonington Campus, Loughborough, UK
| | - R Lea
- University of Nottingham, Sutton Bonington Campus, Loughborough, UK
| | - M Bellingham
- School of Biodiversity One Health and Veterinary Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - N P Evans
- School of Biodiversity One Health and Veterinary Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - V Padmanabhan
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
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Suhre K, Zaghlool S. Connecting the epigenome, metabolome and proteome for a deeper understanding of disease. J Intern Med 2021; 290:527-548. [PMID: 33904619 DOI: 10.1111/joim.13306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/26/2022]
Abstract
Epigenome-wide association studies (EWAS) identify genes that are dysregulated by the studied clinical endpoints, thereby indicating potential new diagnostic biomarkers, drug targets and therapy options. Combining EWAS with deep molecular phenotyping, such as approaches enabled by metabolomics and proteomics, allows further probing of the underlying disease-associated pathways. For instance, methylation of the TXNIP gene is associated robustly with prevalent type 2 diabetes and further with metabolites that are short-term markers of glycaemic control. These associations reflect TXNIP's function as a glucose uptake regulator by interaction with the major glucose transporter GLUT1 and suggest that TXNIP methylation can be used as a read-out for the organism's exposure to glucose stress. Another case is the association between DNA methylation of the AHRR and F2RL3 genes with smoking and a protein that is involved in the reprogramming of the bronchial epithelium. These examples show that associations between DNA methylation and intermediate molecular traits can open new windows into how the body copes with physiological challenges. This knowledge, if carefully interpreted, may indicate novel therapy options and, together with monitoring of the methylation state of specific methylation sites, may in the future allow the early diagnosis of impending disease. It is essential for medical practitioners to recognize the potential that this field holds in translating basic research findings to clinical practice. In this review, we present recent advances in the field of EWAS with metabolomics and proteomics and discuss both the potential and the challenges of translating epigenetic associations, with deep molecular phenotypes, to biomedical applications.
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Affiliation(s)
- K Suhre
- From the, Bioinformatics Core, Weill Cornell Medicine-Qatar, Education City, Doha, Qatar.,Department of Biophysics and Physiology, Weill Cornell Medicine, New York, USA
| | - S Zaghlool
- From the, Bioinformatics Core, Weill Cornell Medicine-Qatar, Education City, Doha, Qatar.,Department of Biophysics and Physiology, Weill Cornell Medicine, New York, USA
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LaBarre JL, McCabe CF, Jones TR, Song PX, Domino SE, Treadwell MC, Dolinoy DC, Padmanabhan V, Burant CF, Goodrich JM. Maternal lipodome across pregnancy is associated with the neonatal DNA methylome. Epigenomics 2020; 12:2077-2092. [PMID: 33290095 DOI: 10.2217/epi-2020-0234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Aim: To classify the association between the maternal lipidome and DNA methylation in cord blood leukocytes. Materials & methods: Untargeted lipidomics was performed on first trimester maternal plasma (M1) and delivery maternal plasma (M3) in 100 mothers from the Michigan Mother-Infant Pairs cohort. Cord blood leukocyte DNA methylation was profiled using the Infinium EPIC bead array and empirical Bayes modeling identified differential DNA methylation related to maternal lipid groups. Results: M3-saturated lysophosphatidylcholine was associated with 45 differentially methylated loci and M3-saturated lysophosphatidylethanolamine was associated with 18 differentially methylated loci. Biological pathways enriched among differentially methylated loci by M3 saturated lysophosphatidylcholines were related to cell proliferation and growth. Conclusion: The maternal lipidome may be influential in establishing the infant epigenome.
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Affiliation(s)
- Jennifer L LaBarre
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Carolyn F McCabe
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Tamara R Jones
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Peter Xk Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Steven E Domino
- Department of Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dana C Dolinoy
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Vasantha Padmanabhan
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Charles F Burant
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jaclyn M Goodrich
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Wong MWK, Thalamuthu A, Braidy N, Mather KA, Liu Y, Ciobanu L, Baune BT, Armstrong NJ, Kwok J, Schofield P, Wright MJ, Ames D, Pickford R, Lee T, Poljak A, Sachdev PS. Genetic and environmental determinants of variation in the plasma lipidome of older Australian twins. eLife 2020; 9:e58954. [PMID: 32697195 PMCID: PMC7394543 DOI: 10.7554/elife.58954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/20/2020] [Indexed: 12/11/2022] Open
Abstract
The critical role of blood lipids in a broad range of health and disease states is well recognised but less explored is the interplay of genetics and environment within the broader blood lipidome. We examined heritability of the plasma lipidome among healthy older-aged twins (75 monozygotic/55 dizygotic pairs) enrolled in the Older Australian Twins Study (OATS) and explored corresponding gene expression and DNA methylation associations. 27/209 lipids (13.3%) detected by liquid chromatography-coupled mass spectrometry (LC-MS) were significantly heritable under the classical ACE twin model (h2 = 0.28-0.59), which included ceramides (Cer) and triglycerides (TG). Relative to non-significantly heritable TGs, heritable TGs had a greater number of associations with gene transcripts, not directly associated with lipid metabolism, but with immune function, signalling and transcriptional regulation. Genome-wide average DNA methylation (GWAM) levels accounted for variability in some non-heritable lipids. We reveal a complex interplay of genetic and environmental influences on the ageing plasma lipidome.
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Affiliation(s)
- Matthew WK Wong
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
| | - Anbupalam Thalamuthu
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
| | - Nady Braidy
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
| | - Karen A Mather
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
- Neuroscience Research AustraliaSydneyAustralia
| | - Yue Liu
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
| | - Liliana Ciobanu
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
- The University of Adelaide, Adelaide Medical School, Discipline of PsychiatryAdelaideAustralia
| | - Bernhardt T Baune
- The University of Adelaide, Adelaide Medical School, Discipline of PsychiatryAdelaideAustralia
- Department of Psychiatry, University of MünsterMünsterGermany
- Department of Psychiatry, Melbourne Medical School, The University of MelbourneMelbourneAustralia
- The Florey Institute of Neuroscience and Mental Health, The University of MelbourneMelbourneAustralia
| | | | - John Kwok
- Brain and Mind Centre, The University of SydneySydneyAustralia
| | - Peter Schofield
- Neuroscience Research AustraliaSydneyAustralia
- School of Medical Sciences, University of New South WalesSydneyAustralia
| | - Margaret J Wright
- Queensland Brain Institute, University of QueenslandBrisbaneAustralia
- Centre for Advanced Imaging, University of QueenslandBrisbaneAustralia
| | - David Ames
- University of Melbourne Academic Unit for Psychiatry of Old AgeKewAustralia
- National Ageing Research InstituteParkvilleAustralia
| | - Russell Pickford
- Bioanalytical Mass Spectrometry Facility, University of New South WalesSydneyAustralia
| | - Teresa Lee
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
- Neuropsychiatric Institute, Euroa Centre, Prince of Wales HospitalSydneyAustralia
| | - Anne Poljak
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
- School of Medical Sciences, University of New South WalesSydneyAustralia
- Bioanalytical Mass Spectrometry Facility, University of New South WalesSydneyAustralia
| | - Perminder S Sachdev
- Centre for Healthy Brain Ageing, School of Psychiatry, Faculty of Medicine, University of New South WalesSydneyAustralia
- Neuropsychiatric Institute, Euroa Centre, Prince of Wales HospitalSydneyAustralia
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Wei F, Lamichhane S, Orešič M, Hyötyläinen T. Lipidomes in health and disease: Analytical strategies and considerations. Trends Analyt Chem 2019. [DOI: 10.1016/j.trac.2019.115664] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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