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Eaton M, McMahon JA, Salzar R. Evaluating the Limits in the Biomechanics of Blunt Lung Injury. J Biomech Eng 2022; 144:1139367. [PMID: 35266988 DOI: 10.1115/1.4054057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Indexed: 11/08/2022]
Abstract
Thoracic blunt trauma is evident in up to one fifth of all hospital admissions, and is second only to head trauma in motor vehicle crashes. One of the most problematic injury mechanisms associated with blunt thoracic trauma is pulmonary contusion, occurring in up to 75% of blunt thoracic trauma cases. The source and effects of pulmonary contusion caused by blunt lung injury are not well defined, especially within the field of continuum biomechanics. This, paired with unreliable diagnostics for pulmonary contusion, leads to uncertainty in both the clinical entity and mechanics of how to predict presence of injury. There is a distinct need to combine the clinical aspects with mechanical insights through the identification and mitigation of blunt lung trauma and material testing and modeling. This is achieved through using the mechanical insights of lung tissue behavior in order to better understand the injurious mechanisms and courses of treatment of blunt-caused pulmonary contusion. This paper hopes to act as a step forward in connecting two perspectives of blunt lung injury, the clinical entity and mechanical testing and modeling, by reviewing the known literature and identifying the unknowns within the two related fields. Through a review of related literature, clinical evidence is correlated to mechanical data to gain a better understanding of what is being missed in identification and response to blunt lung injury as a whole.
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Affiliation(s)
- Madelyn Eaton
- Department of MAE, University of Virginia, 4040 Lewis and Clark Dr, Charlottesville, VA 22911
| | - Justin A McMahon
- Department of MAE, University of Virginia, 4040 Lewis and Clark Dr, Charlottesville, VA 22911
| | - Robert Salzar
- Department of MAE, University of Virginia, 4040 Lewis and Clark Dr, Charlottesville, VA 22911
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Xiao Q, Wang Y, Sun L, Lu S, Li J, Chen Y, Wu Y. Immediate Prone Positioning After Massive Gastric Aspiration Reduces Lung Injury Possibly by Attenuating Interleukin-6-Mediated Lung-Tissue Inflammation in Pigs. Biol Res Nurs 2019; 22:64-74. [PMID: 31529988 DOI: 10.1177/1099800419875521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gastric aspiration, which can cause acute, diffuse, inflammatory lung injury, is of particular concern in critically ill patients. This study aimed to determine the effects of immediate prone positioning on the degree of lung injury and inflammatory response induced by gastric aspiration. Following induction of gastric aspiration by injection of gastric fluid, 16 healthy pigs were randomized to one of two groups: supine position (SP) or prone position (PP). After ventilation and monitoring for 6 hr, all pigs were euthanized. The ratio of the partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2) and the partial pressure of arterial carbon dioxide (PaCO2) were recorded during the 6-hr study period. Serum levels of interleukin (IL)-6 were measured every 2 hr, and the mean optical density (MOD) of IL-6 in lung tissues and lung-injury scores were measured at the end of the experiment. The PP group showed a significantly higher PaO2/FIO2 ratio, lower serum IL-6 concentration (p = .015), lower lung-injury scores (p = .012), and lower IL-6 concentration and MOD of IL-6 in lung tissue, especially in dorsal (p = .001, p = .021, respectively) and nondependent regions (p = .005, p = .035, respectively) than the SP group. There were no statistically significant differences in PaCO2 between the groups. Lung-injury severity was positively correlated with the IL-6 concentration and MOD of IL-6 in lung tissues (p < .05). These results suggest that immediate prone positioning alleviated the degree of aspiration-induced lung injury, possibly through mitigating IL-6-mediated lung inflammation.
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Affiliation(s)
- Qian Xiao
- School of Nursing, Capital Medical University, Beijing, China
| | - Yanling Wang
- School of Nursing, Capital Medical University, Beijing, China
| | - Liu Sun
- School of Nursing, Capital Medical University, Beijing, China
| | - Sai Lu
- College of Health and Biomedicine, Victoria University, Melbourne, Australia
| | - Jia Li
- School of Nursing, Capital Medical University, Beijing, China
| | - Yun Chen
- School of Nursing, Capital Medical University, Beijing, China
| | - Ying Wu
- School of Nursing, Capital Medical University, Beijing, China
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Sharpe JP, Khan NR, Chatterjee AR, Huang J, Magnotti LJ, Croce MA, Fabian TC. Investigating Cyclooxygenase Inhibition in a Rat Pulmonary Contusion Model: A Laboratory Study Finding No Improvement with Ibuprofen. Am Surg 2017. [DOI: 10.1177/000313481708300635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimal advances have been made in the management of pulmonary contusions (PCs). The purpose of this study was to evaluate the impact of cyclooxygenase inhibition on outcomes following PC in a rat model. PC was induced in anesthetized adult rats. Ibuprofen was given to the treatment group (TG) and water was given to the control group (CG). Lung injury was assessed with pulse oximetry, arterial blood gases, CT, and histopathologic examination. Inflammation was measured with both serum and bronchoalveolar lavage (BAL) levels of tumor necrosis factor a and interleukin-6. Rats in the TG did not differ from rats in the CG with respect to oxygenation. Pathologic examination demonstrated a trend toward more inflammatory infiltrate in the CG, yet the sizes of the contusions were larger in the TG. The CG trended toward decreased levels of interleukin-6 in the serum and BAL at both three and seven days. While BAL levels of tumor necrosis factor a were increased in the TG at three days compared to the CG, they trended toward a reduced amount at seven days. Our data do not support cyclooxygenase inhibition for treatment to decrease the respiratory compromise associated with PC in this model of rat PCs.
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Affiliation(s)
- John P. Sharpe
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and Department of Radiology
| | - Nick R. Khan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and Department of Radiology
| | | | - Jinsong Huang
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and Department of Radiology
| | - Louis J. Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and Department of Radiology
| | - Martin A. Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and Department of Radiology
| | - Timothy C. Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee and Department of Radiology
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Kurt A, Turut H, Acipayam A, Kirbas A, Yuce S, Cumhur Cure M, Cure E. Investigation of surfactant protein-D and interleukin-6 levels in patients with blunt chest trauma with multiple rib fractures and pulmonary contusions: a cross-sectional study in Black Sea Region of Turkey. BMJ Open 2016; 6:e011797. [PMID: 27733410 PMCID: PMC5073616 DOI: 10.1136/bmjopen-2016-011797] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Multiple rib fractures (RFs) and pulmonary contusions (PCs), with resulting systemic lung inflammation, are the most common injuries caused by blunt chest trauma (BCT) in motor vehicle accidents. This study examined levels of the inflammation marker interleukin (IL)-6 and those of the acute-phase reactant surfactant protein (SP)-D in patients with BCT. DESIGN Prospective, cross-sectional, observational study. SETTING Single-centre, tertiary care hospital in the Black Sea Region of Turkey. PARTICIPANTS The study included 60 patients with BCT who were hospitalised in our thoracic surgery department. PARAMETERS MEASURES The SP-D and IL-6 serum levels of patients with RFs (two or more RFs) (n=30) and patients with PCs (n=30) were measured after 6 hours, 24 hours and 7 days, and compared with those of age-matched and gender-matched healthy participants. RESULTS The 6-hour serum SP-D levels of the RFs (p=0.017) and PCs (p<0.001) groups were significantly higher than those of the healthy controls. The 24-hour and 7-day SP-D levels of both groups were also higher than the control group. The serum IL-6 levels of both groups were significantly higher than those of the control group. We have found Injury Severity Score to be independently related to 6-hour IL-6 (β=1.414, p<0.001) and 24-hour IL-6 levels (β=1.067, p<0.001). The development of complications was independently related to 6-hour SP-D level (β=0.211, p=0.047). CONCLUSIONS RFs and PCs after BCT lead to local and systemic inflammation due to lung injury. The levels of the systemic inflammation marker IL-6 and those of the acute-phase reactant SP-D were elevated in the present study. The SP-D level may be used as a marker in the follow-up of BCT-related complications.
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Affiliation(s)
- Aysel Kurt
- Department of Thoracic Surgery, School of Medicine, Recep Tayyip Erdogan University,Rize, Turkey
| | - Hasan Turut
- Department of Thoracic Surgery, School of Medicine, Recep Tayyip Erdogan University,Rize, Turkey
| | - Ahmet Acipayam
- Department of Thoracic Surgery, Burdur State Hospital, School of Medicine, Burdur, Turkey
| | - Aynur Kirbas
- Department of Biochemistry, School of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Suleyman Yuce
- Department of Internal Medicine, Kumru State Hospital, Ordu, Turkey
| | - Medine Cumhur Cure
- Department of Biochemistry, School of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Erkan Cure
- Department of Internal Medicine, School of Medicine, Recep Tayyip Erdogan University,Rize, Turkey
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Ali R, Shahid A, Ali N, Hasan SK, Majed F, Sultana S. Amelioration of Benzo[a]pyrene-induced oxidative stress and pulmonary toxicity by Naringenin in Wistar rats: A plausible role of COX-2 and NF-κB. Hum Exp Toxicol 2016; 36:349-364. [PMID: 27206700 DOI: 10.1177/0960327116650009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Naringenin is a naturally occurring flavanones and has been found to exhibit free radical scavenging, enzyme inhibition, antioxidants, anti-inflammatory, and anticancer activities. Present study was designed to evaluate the protective role of naringenin against benzo[a]pyrene (B[a]P)-induced oxidative stress and pulmonary toxicity. Rats were treated with naringenin at a dose of 100 mg/kg body weight (b. wt.), by oral gavage. B[a]P in a single dose of 50 mg/kg b. wt. was given intraperitoneally. Total protein, total cell counts, lactate dehydrogenase, lipid peroxidation, reduced glutathione, antioxidant enzymes activities, lung histology and expression of nuclear factor kappa B (NF-κB), and cyclo-oxygenase-2 (COX-2) was assessed to evaluate protective effects of naringenin. Histopathological and immunohistochemical studies were also carried out to observe lung toxicity and inflammation. B[a]P administration enhanced the levels of lung injury markers and reduced antioxidant enzymes activities. Naringenin treatment attenuated the levels of oxidative stress by restoring antioxidant enzymes, further improved lung histological damage and significant decrease in inflammatory responses. Naringenin also effectively decreased the expression of NF-κB, and COX-2 induced by B[a]P. These findings suggest that naringenin supplementation is beneficial in maintaining the integrity of alveoli and the epithelium that may be used as a protective agent in B[a]P-induced oxidative stress and lung damage. However, further studies are warranted to elucidate the potential mechanism of action of naringenin.
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Affiliation(s)
- R Ali
- Department of Medical Elementology and Toxicology, Section of Molecular Carcinogenesis and Chemoprevention Toxicology, Jamia Hamdard (Hamdard University), Hamdard Nagar, New Delhi, India
| | - A Shahid
- Department of Medical Elementology and Toxicology, Section of Molecular Carcinogenesis and Chemoprevention Toxicology, Jamia Hamdard (Hamdard University), Hamdard Nagar, New Delhi, India
| | - N Ali
- Department of Medical Elementology and Toxicology, Section of Molecular Carcinogenesis and Chemoprevention Toxicology, Jamia Hamdard (Hamdard University), Hamdard Nagar, New Delhi, India
| | - S K Hasan
- Department of Medical Elementology and Toxicology, Section of Molecular Carcinogenesis and Chemoprevention Toxicology, Jamia Hamdard (Hamdard University), Hamdard Nagar, New Delhi, India
| | - F Majed
- Department of Medical Elementology and Toxicology, Section of Molecular Carcinogenesis and Chemoprevention Toxicology, Jamia Hamdard (Hamdard University), Hamdard Nagar, New Delhi, India
| | - S Sultana
- Department of Medical Elementology and Toxicology, Section of Molecular Carcinogenesis and Chemoprevention Toxicology, Jamia Hamdard (Hamdard University), Hamdard Nagar, New Delhi, India
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Schreiter D, Carvalho NC, Katscher S, Mende L, Reske AP, Spieth PM, Carvalho AR, Beda A, Lachmann B, Amato MBP, Wrigge H, Reske AW. Experimental blunt chest trauma--cardiorespiratory effects of different mechanical ventilation strategies with high positive end-expiratory pressure: a randomized controlled study. BMC Anesthesiol 2016; 16:3. [PMID: 26757894 PMCID: PMC4709895 DOI: 10.1186/s12871-015-0166-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/09/2015] [Indexed: 02/01/2023] Open
Abstract
Background Uncertainty persists regarding the optimal ventilatory strategy in trauma patients developing acute respiratory distress syndrome (ARDS). This work aims to assess the effects of two mechanical ventilation strategies with high positive end-expiratory pressure (PEEP) in experimental ARDS following blunt chest trauma. Methods Twenty-six juvenile pigs were anesthetized, tracheotomized and mechanically ventilated. A contusion was applied to the right chest using a bolt-shot device. Ninety minutes after contusion, animals were randomized to two different ventilation modes, applied for 24 h: Twelve pigs received conventional pressure-controlled ventilation with moderately low tidal volumes (VT, 8 ml/kg) and empirically chosen high external PEEP (16cmH2O) and are referred to as the HP-CMV-group. The other group (n = 14) underwent high-frequency inverse-ratio pressure-controlled ventilation (HFPPV) involving respiratory rate of 65breaths · min−1, inspiratory-to-expiratory-ratio 2:1, development of intrinsic PEEP and recruitment maneuvers, compatible with the rationale of the Open Lung Concept. Hemodynamics, gas exchange and respiratory mechanics were monitored during 24 h. Computed tomography and histology were analyzed in subgroups. Results Comparing changes which occurred from randomization (90 min after chest trauma) over the 24-h treatment period, groups differed statistically significantly (all P values for group effect <0.001, General Linear Model analysis) for the following parameters (values are mean ± SD for randomization vs. 24-h): PaO2 (100 % O2) (HFPPV 186 ± 82 vs. 450 ± 59 mmHg; HP-CMV 249 ± 73 vs. 243 ± 81 mmHg), venous admixture (HFPPV 34 ± 9.8 vs. 11.2 ± 3.7 %; HP-CMV 33.9 ± 10.5 vs. 21.8 ± 7.2 %), PaCO2 (HFPPV 46.9 ± 6.8 vs. 33.1 ± 2.4 mmHg; HP-CMV 46.3 ± 11.9 vs. 59.7 ± 18.3 mmHg) and normally aerated lung mass (HFPPV 42.8 ± 11.8 vs. 74.6 ± 10.0 %; HP-CMV 40.7 ± 8.6 vs. 53.4 ± 11.6 %). Improvements occurring after recruitment in the HFPPV-group persisted throughout the study. Peak airway pressure and VT did not differ significantly. HFPPV animals had lower atelectasis and inflammation scores in gravity-dependent lung areas. Conclusions In this model of ARDS following unilateral blunt chest trauma, HFPPV ventilation improved respiratory function and fulfilled relevant ventilation endpoints for trauma patients, i.e. restoration of oxygenation and lung aeration while avoiding hypercapnia and respiratory acidosis.
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Affiliation(s)
- Dierk Schreiter
- Helios Park Clinic, Department of Intensive Care Medicine, Leipzig, Germany.
| | - Nadja C Carvalho
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany. .,Department of Electronic Engineering, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Sebastian Katscher
- Sana Kliniken Leipziger Land, Department of Orthopedic, Trauma and Hand Surgery, Borna, Germany.
| | - Ludger Mende
- Intensive Care Unit, Sana Kliniken Leipziger Land, Borna, Germany.
| | - Alexander P Reske
- Anesthesiology and Intensive Care Medicine, Fachkrankenhaus Coswig, Coswig, Sachsen, Germany.
| | - Peter M Spieth
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Alysson R Carvalho
- Carlos Chagas Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Alessandro Beda
- Department of Electronic Engineering, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Burkhard Lachmann
- Department of Anesthesiology and Intensive Care Medicine, Charité, Berlin Medical University, Berlin, Germany.
| | - Marcelo B P Amato
- Cardio-Pulmonary Department, Pulmonary Division, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany.
| | - Andreas W Reske
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany.
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Gong SD, Cui LH. Advances in understanding pathogenesis of gastroesophageal reflux-related cough. Shijie Huaren Xiaohua Zazhi 2014; 22:2665-2670. [DOI: 10.11569/wcjd.v22.i19.2665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux-related cough (GERC) refers to chronic cough caused by gastroesophageal reflux disease (GERD) and is one of the common causes of chronic cough in adults. Compared with typical GERD, GERC has its own characteristics in the pathogenesis of cough. The main mechanisms involve direct refluxate stimulation and indirect esophageal-bronchial reflection. In addition, the high sensitivity of cough receptors, acid-producing bacteria, nongastric H+/K+-ATPases and psychological factors are also important in the pathogenesis of GERC. GERC may be the result of the combined effects of multiple factors.
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Ayvaz S, Aksu B, Karaca T, Cemek M, Tarladacalisir YT, Ayaz A, Metin MS, Basaran U, Ayvaz AT, Aksu F, Pul M. Effects of methylene blue in acute lung injury induced by blunt chest trauma. Hippokratia 2014; 18:50-56. [PMID: 25125953 PMCID: PMC4103043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND We studied whether methylene blue (MB) treatment blunts chest trauma-induced lung injury in rats. MATERIAL AND METHODS Forty male Sprague-Dawley rats, 200-300g, were used. The rats were divided into five groups (n=8): control, early contusion (EC), early contusion + methylene blue (2 mg/kg, EC+MB), late contusion (LC), and late contusion + methylene blue (2 mg/kg, LC+MB). RESULTS Histopathological analysis showed increased hemorrhage, alveolar wall thickness, edema, and inflammatory cell infiltrates in the EC and LC rats, which decreased upon MB treatment. Immunohistochemical studies revealed that MB reduced activation of inducible nitric oxide synthase (iNOS) and the number of active terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL)-positive cells. A significant increase was observed in the malondialdehyde (MDA) and nitric oxide (NO) levels in the EC group compared to the control group (p<0.05). In addition, a significant decrease was reported in the glutathione (GSH), superoxide dismutase (SOD), and glutathione peroxidase (GPx) levels (p<0.01), but no significant difference was observed in the catalase (CAT) levels among the groups. The MDA level was significantly higher in the LC group compared to the control group, whereas the GSH level was significantly lower compared to the control group. The NO level in the EC+MB group was significantly lower when compared to the NO level in the EC group (p<0.05). CONCLUSION The present study provides evidence that MB might serve as a therapeutic treatment for blunt chest trauma.
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Affiliation(s)
- S Ayvaz
- Department of Pediatric Surgery, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - B Aksu
- Department of Pediatric Surgery, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - T Karaca
- Department of Histology and Embryology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - M Cemek
- Department of Bioengineering , Division of Biochemistry, Faculty of Chem. and Met. Eng., Yıldız Technical University, Istanbul, Turkey
| | - Y-T Tarladacalisir
- Department of Histology and Embryology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - A Ayaz
- Department of Bioengineering , Division of Biochemistry, Faculty of Chem. and Met. Eng., Yıldız Technical University, Istanbul, Turkey
| | - M-S Metin
- Department of Histology and Embryology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Un Basaran
- Department of Pediatric Surgery, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - A-T Ayvaz
- Department of Ophtalmology, Edirne State Hospital, Edirne, Turkey
| | - F Aksu
- Department of Cardiology, Edirne State Hospital, Edirne, Turkey
| | - M Pul
- Department of Pediatric Surgery, Faculty of Medicine, Trakya University, Edirne, Turkey
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Couret D, de Bourmont S, Prat N, Cordier PY, Soureau JB, Lambert D, Prunet B, Michelet P. A pig model for blunt chest trauma: no pulmonary edema in the early phase. Am J Emerg Med 2013; 31:1220-5. [DOI: 10.1016/j.ajem.2013.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/03/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022] Open
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Saba, Khan S, Parvez S, Chaudhari B, Ahmad F, Anjum S, Raisuddin S. Ellagic acid attenuates bleomycin and cyclophosphamide-induced pulmonary toxicity in Wistar rats. Food Chem Toxicol 2013; 58:210-9. [DOI: 10.1016/j.fct.2013.03.046] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 03/13/2013] [Accepted: 03/27/2013] [Indexed: 10/26/2022]
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