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Reddout-Beam C, Hernandez LP, Salak-Johnson JL. Timing of Maternal Stress Differentially Affects Immune and Stress Phenotypes in Progeny. Animals (Basel) 2024; 14:3074. [PMID: 39518797 PMCID: PMC11545280 DOI: 10.3390/ani14213074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 10/11/2024] [Accepted: 10/22/2024] [Indexed: 11/16/2024] Open
Abstract
Maternal stress during gestation may affect the development and responsiveness of the hypothalamic-pituitary-adrenal axis (HPA) and immune system in the progeny. Stressor type, duration and gestational stage at which the stressor occurs may all influence the short and long-term effects on the future progeny. The present study advances the characterization of the timing of gestational stress on the stress responsiveness and immune and behavioral phenotypes of the progeny. First, parity sows were hand-fed hydrocortisone acetate (stressed) or placebo (controls) during mid or late gestation. Colostrum and cord blood were collected. Blood samples were obtained from a subset of piglets (n = 36) born to these sows during lactation, pre- and post-weaning, and during an ACTH challenge. Stress and immune measures were assessed. Piglets born to sows stressed during mid-gestation had reduced measures of humoral immunity, including immunoglobulins and interleukin-4. Conversely, piglets born to late-stressed sows exhibited a delayed or dampened stress response to weaning and an ACTH challenge. They also had a skewed pro-inflammatory phenotype, as evidenced by increased interleukin-17 and tumor necrosis factor-α. Overall, these data suggest that the stage of gestation at which gestational stress occurs has differential effects on the HPA axis and immune development of the progeny, resulting in differential stress responsiveness and immune and behavioral phenotypes.
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Affiliation(s)
| | | | - Janeen L. Salak-Johnson
- Department of Animal and Food Sciences, Oklahoma State University, Stillwater, OK 74078, USA; (C.R.-B.); (L.P.H.)
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Xiang L, Wang X, Li Y, Liu HW, Zhang X, Mu X, Liu C, Hu M. Development of the temporomandibular joint in miniature pig embryos. J Morphol 2021; 283:134-143. [PMID: 34800049 DOI: 10.1002/jmor.21432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/08/2022]
Abstract
The temporomandibular joint (TMJ) is a synovial joint involved in sliding and hinge movements of lower jaw in mammals. Studies on TMJ development in embryos have been mainly performed using rodents. However, the TMJ structure in rodents differs in several aspects from that in humans. There are few studies on the embryonic development of TMJ in large mammals. In the present study, we investigated the embryonic developmental characteristics of the TMJ in pigs histologically. Embryonic day 35 (E35), E45, E55, E75, E90, and postnatal day 1(P1) embryos/fetuses from the pigs were used for the study. The results showed condensation of mesenchymal cells on E35. The inferior articular cavity was formed on E45, together with a narrow crack in the superior articular cavity region. The superior and inferior articular cavities and articular disc of the TMJ were completely formed on E55. On E75, the condyle showed an obvious conical shape and the superior and inferior joint cavities were enlarged. Furthermore, the mandibular ramus and mandibular body under the neck of the condyle were ossified from E75 to P1 day. The chondrocyte layer of the condyle was significantly thinner from E75 to P1. It is speculated that the spatiotemporal development of the TMJ in miniature pig embryos is similar to that in humans. Embryonic development of the pig TMJ is an important bridge for translating the results of rodent research to medical applications.
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Affiliation(s)
- Lei Xiang
- Department of Stomatology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Xuewen Wang
- Institute for Laboratory Animal Resources, National Institutes for Food and Drug Control, Beijing, China
| | - Yongfeng Li
- Department of Stomatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hua Wei Liu
- Department of Stomatology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Xianhua Zhang
- Department of Stomatology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Xiaodan Mu
- Department of Stomatology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Changkui Liu
- Department of Stomatology, School of Stomatology, Xi'an Medical University, Xi'an, China
| | - Min Hu
- Department of Stomatology, the First Medical Center of PLA General Hospital, Beijing, China
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Jiang D, Koehler RC, Liu X, Kulikowicz E, Lee JK, Lu H, Liu P. Quantitative validation of MRI mapping of cerebral venous oxygenation with direct blood sampling: A graded-O 2 study in piglets. Magn Reson Med 2021; 86:1445-1453. [PMID: 33755253 PMCID: PMC8184598 DOI: 10.1002/mrm.28786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/12/2021] [Accepted: 03/08/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE To validate two neonatal cerebral venous oxygenation (Yv ) MRI techniques, T2 relaxation under phase contrast (TRUPC) and accelerated TRUPC (aTRUPC) MRI, with oxygenation measured with direct blood sampling. METHODS In vivo experiments were performed on seven healthy newborn piglets. For each piglet, a catheter was placed in the superior sagittal sinus to obtain venous blood samples for blood gas oximetry measurement as a gold standard. During the MRI experiment, three to five venous oxygenation levels were achieved in each piglet by varying inhaled O2 content and breathing rate. Under each condition, Yv values of the superior sagittal sinus measured by TRUPC, aTRUPC, and blood gas oximetry were obtained. The Yv quantification in TRUPC and aTRUPC used a standard bovine blood calibration model. The aTRUPC scan was repeated twice to assess its reproducibility. Agreements among TRUPC Yv , aTRUPC Yv , and blood gas oximetry were evaluated by intraclass correlation coefficient (ICC) and paired Student's t-test. RESULTS The mean hematocrit was 23.6 ± 6.5% among the piglets. Across all measurements, Yv values were 51.9 ± 21.3%, 54.1 ± 18.8%, and 53.7 ± 19.2% for blood gas oximetry, TRUPC and aTRUPC, respectively, showing no significant difference between any two methods (P > .3). There were good correlations between TRUPC and blood gas Yv (ICC = 0.801; P < .0001), between aTRUPC and blood gas Yv (ICC = 0.809; P < .0001), and between aTRUPC and TRUPC Yv (ICC = 0.887; P < .0001). The coefficient of variation of aTRUPC Yv was 8.1 ± 9.9%. CONCLUSION The values of Yv measured by TRUPC and aTRUPC were in good agreement with blood gas oximetry. These findings suggest that TRUPC and aTRUPC can provide accurate quantifications of Yv in major cerebral veins.
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Affiliation(s)
- Dengrong Jiang
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ewa Kulikowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hanzhang Lu
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Peiying Liu
- The Russell H. Morgan Department of Radiology & Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Fil JE, Joung S, Hayes CA, Dilger RN. Influence of Rearing Environment on Longitudinal Brain Development, Object Recognition Memory, and Exploratory Behaviors in the Domestic Pig ( Sus scrofa). Front Neurosci 2021; 15:649536. [PMID: 33841090 PMCID: PMC8024486 DOI: 10.3389/fnins.2021.649536] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Over the last 40 years, the domestic pig has emerged as a prominent preclinical model as this species shares similarities with humans with regard to immunity, gastrointestinal physiology, and neurodevelopment. Artificial rearing of pigs provides a number of advantages over conventional rearing (i.e., true maternal care), including careful control of nutrient intake and environment conditions. Yet there remains a gap in knowledge when comparing brain development between sow-reared and artificially reared domestic pigs. Thus, our research sought to model brain development and assess recognition memory in a longitudinal manner by directly comparing rearing environments. Methods Forty-four intact (i.e., not castrated) male pigs were artificially reared or sow-reared from postnatal day 2 until postnatal week 4. After postnatal week 4, all pigs were housed in a group setting within the same environment until postnatal week 24. Magnetic resonance imaging was conducted on pigs at 8 longitudinal time-points to model developmental trajectories of brain macrostructural and microstructural outcomes. Additionally, pigs behavior were tested using the novel object recognition task at postnatal weeks 4 and 8. Results Throughout the 24-week study, no differences between rearing groups were noted in weekly body weights, average growth and feed intake patterns, or feed efficiency. Whole brain, gray matter, white matter, and cerebrospinal fluid growth patterns also did not differ between pigs assigned to different early-life rearing environments. Moreover, minimal differences in regional absolute volumes and fractional anisotropy developmental trajectories were identified, though artificially reared pigs exhibited higher initial rates of myelination in multiple brain regions compared with sow-reared pigs. Furthermore, behavioral assessment at both PNW 4 and 8 suggested little influence of rearing environment on recognition memory, however, an age-dependent increase in object recognition memory was observed in the sow-reared group. Conclusion Our findings suggest that early-life rearing environment influences the rate of development in some brain regions but has little influence on overall brain growth and object recognition memory and exploratory behaviors in the domestic pig. Artificial rearing may promote maturation in certain brain areas but does not appear to elicit long-term effects in outcomes including brain structure or object recognition memory.
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Affiliation(s)
- Joanne E Fil
- Neuroscience Program, University of Illinois, Urbana, IL, United States
| | - Sangyun Joung
- Neuroscience Program, University of Illinois, Urbana, IL, United States
| | - Courtney A Hayes
- College of Veterinary Medicine, University of Illinois, Urbana, IL, United States
| | - Ryan N Dilger
- Neuroscience Program, University of Illinois, Urbana, IL, United States.,Department of Animal Sciences, University of Illinois, Urbana, IL, United States.,Division of Nutritional Sciences, University of Illinois, Urbana, IL, United States
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Ringer SK, Clausen NG, Spielmann N, Weiss M. Effects of hypothermia and hypothermia combined with hypocapnia on cerebral tissue oxygenation in piglets. Paediatr Anaesth 2020; 30:970-976. [PMID: 32506675 DOI: 10.1111/pan.13943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypothermia and its combination with hypocapnia are frequently associated with anesthesia. AIMS The goal was to investigate the effects of hypothermia and hypothermia combined with hypocapnia (hypothermia-hypocapnia) on cerebral tissue oxygenation in anesthetized piglets. METHODS Twenty anesthetized piglets were randomly allocated to hypothermia (n = 10) or hypothermia-hypocapnia (n = 10). Cerebral monitoring comprised a tissue oxygen partial pressure (PtO2 ), a laser Doppler probe, and a near-infrared spectroscopy sensor, measuring regional oxygen saturation (rSO2 ). After baseline recordings, hypothermia (35.5-36.0°C) with or without hypocapnia (target PaCO2 : 28-30 mm Hg) was induced. Once treatment goals were achieved (Tr0), they were maintained for 30 minutes (Tr30). RESULTS No changes in PtO2 but a significant increase in rSO2 (Tr0 (mean difference 8.9[95% CI for difference3.99 to 13.81], P < .001); Tr30 (10.8[6.20 to 15.40], P < .001)) were detected during hypothermia. With hypothermia-hypocapnia, a decrease in PtO2 (Tr0 (-3.2[-6.01 to -0.39], P = .021; Tr30 (-3.3[-5.8 to -0.80], P = .006)) and no significant changes in rSO2 occurred. Cerebral blood flow decreased significantly from baseline to Tr0 independently of treatment (-0.89[-0.18 to -0.002], P = .042), but this was more consistently observed with hypothermia-hypocapnia. CONCLUSIONS The hypothermia-induced reduction in oxygen delivery was compensated by lowered metabolic demand. However, hypothermia was not able to compensate for an additional reduction in oxygen delivery caused by simultaneous hypocapnia. This resulted in a PtO2 drop, which was not reflected by a downshift in rSO2 .
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Affiliation(s)
- Simone K Ringer
- Department of Clinical Diagnostics and Services, Section Anaesthesiology, Vetsuisse Faculty University of Zurich, Zurich, Switzerland
| | - Nicola G Clausen
- Department of Anaesthesiology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Nelly Spielmann
- Department of Anaesthesiology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anaesthesiology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
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Wei J, Wang ZA, Wang B, Jahan M, Wang Z, Wynn PC, Du Y. Characterization of porcine milk oligosaccharides over lactation between primiparous and multiparous female pigs. Sci Rep 2018; 8:4688. [PMID: 29549280 PMCID: PMC5856818 DOI: 10.1038/s41598-018-23025-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/05/2018] [Indexed: 01/27/2023] Open
Abstract
Milk oligosaccharides (MOs) are complex carbohydrates with multifunctional health benefits for the neonate. Poor reproductive performance in primiparous gilts limits their productivity. Changes in the structure and abundance of porcine MO (PMOs) through lactation with parity remains unknown and may explain superior new-born growth in litters from multiparous sows relative to gilts. We report 55 PMOs structures, of which 25 are new (17 sialylated and 8 neutral). Their incidence in gilt and sow colostrum was almost identical (53 vs. 54), but not in transitional milk (48 vs. 53) nor mature milk (41 vs. 47). These PMOs including neutral-, sialyl- and fucosyl- MOs in colostrum were more abundant in the gilt than the sow, but always decreased during lactation. Structural diversity decreased, although fucosylated MO were conserved. In conclusion, high diversity and levels of MO in porcine milk is parity dependent. Given the similarity between porcine and human MO profiles, our findings may help define key roles for MOs as potential dietary additives to improve growth of neonates from first pregnancies in both human and sows.
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Affiliation(s)
- Jinhua Wei
- State Key Laboratory of Biochemical Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing, 100190, P.R. China.,Key Laboratory of Biopharmaceutical Production & Formulation Engineering, PLA, Beijing, 100190, P.R. China
| | - Zhuo A Wang
- State Key Laboratory of Biochemical Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing, 100190, P.R. China.,Key Laboratory of Biopharmaceutical Production & Formulation Engineering, PLA, Beijing, 100190, P.R. China
| | - Bing Wang
- State Key Laboratory of Biochemical Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing, 100190, P.R. China. .,Graham Centre for Agricultural Innovation, Charles Sturt University, Wagga Wagga, NSW, 2650, Australia.
| | - Marefa Jahan
- Graham Centre for Agricultural Innovation, Charles Sturt University, Wagga Wagga, NSW, 2650, Australia
| | - Zhongfu Wang
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, College of Life Sciences, Northwest University, Xi'an, 710069, P.R. China
| | - Peter C Wynn
- Graham Centre for Agricultural Innovation, Charles Sturt University, Wagga Wagga, NSW, 2650, Australia
| | - Yuguang Du
- State Key Laboratory of Biochemical Engineering, Institute of Process Engineering, Chinese Academy of Sciences, Beijing, 100190, P.R. China. .,Key Laboratory of Biopharmaceutical Production & Formulation Engineering, PLA, Beijing, 100190, P.R. China.
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GABA A receptor expression and white matter disruption in intrauterine growth restricted piglets. Int J Dev Neurosci 2017; 59:1-9. [PMID: 28219764 DOI: 10.1016/j.ijdevneu.2017.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 12/25/2022] Open
Abstract
Intrauterine growth restriction (IUGR) is one of the most common causes of perinatal mortality and morbidity. White matter and neuronal injury are major pathophysiological features of the IUGR neonatal brain. GABAA (γ-aminobutyric acid type A) receptors have been shown to play a role in oligodendrocyte differentiation and proliferation in the neonatal brain and may be a key factor in white matter injury and myelination in IUGR neonates. Whether there are impairments to the GABAergic system and neuronal cytoskeleton in IUGR brain has yet to be elucidated. This study aims to examine GABAA receptor α1 and α3 subunit protein expression and distribution in parietal cortex and hippocampus of the IUGR piglet at four different ages (term=115d - days gestational age), 100d, 104d, birth (postnatal day 0-P0) and P7 and to examine neuronal and myelination patterns. Significant alterations to GABAA receptor α1 and α3 protein expression levels were observed in the IUGR piglet brain of P7 IUGR piglets with significantly greater α3 expression compared to α1 expression in the hippocampus while there was virtually no difference between the two subunits in the parietal cortex. However a significantly lower α1/α3 ratio was evident in P7 IUGR cortex when compared with P7 NG cortex. Neuronal somatodendrites studied using MAP2 immunohistochemistry showed reduced and disrupted somatodendrites while MBP immunolabelling showed loss of axonal fibres from gestational day 104d through to P7. These findings provide insights into the effects of IUGR on the development of the GABA system, altered developmental maturation of GABAA receptor subunit expression in the IUGR brain may influence myelination and may partly explain the cognitive disabilities observed in IUGR. Understanding the mechanisms behind grey and white matter injury in the IUGR infant is essential to identifying targets for treatments to improve long-term outcomes for IUGR infants.
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Josephson J, Turner JM, Field CJ, Wizzard PR, Nation PN, Sergi C, Ball RO, Pencharz PB, Wales PW. Parenteral Soy Oil and Fish Oil Emulsions: Impact of Dose Restriction on Bile Flow and Brain Size of Parenteral Nutrition-Fed Neonatal Piglets. JPEN J Parenter Enteral Nutr 2015; 39:677-687. [PMID: 25326097 DOI: 10.1177/0148607114556494] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/01/2014] [Indexed: 11/22/2024]
Abstract
BACKGROUND Parenteral nutrition (PN)-associated liver disease (PNALD) remains a significant cause of morbidity and mortality for neonates dependent on PN. Total fat emulsion dose and composition, particularly the large amount of ω-6 long-chain polyunsaturated fatty acids in plant oils, have been proposed as risk factors for PNALD. We hypothesized restriction of the dose of emulsion would prevent PNALD, regardless of the composition, but growth could be compromised. METHODS Using a neonatal piglet model, we compared conventional soy oil emulsion (Intralipid), dosed high (SO10, n = 8: 10 g/kg/d) and low (SO5, n = 6: 5 g/kg/d), with fish oil (Omegaven), dosed low (FO5, n = 8: 5 g/kg/d). Piglets were given isonitrogenous PN for 14 days. The normal range for all parameters was determined by measurement in equivalent aged sow-reared piglets. RESULTS Bile flow was lower with high-dose Intralipid, outside the normal range, while higher for the other groups (SO10, 5.4 µg/g; SO5, 8.6 µg/g; FO5, 13.4 µg/g; P = .010; normal range, 6.5-12.2 µg/g). Total body weight was low in all treatment groups (SO10, 4.4 kg; SO5, 4.5 kg; FO5, 5.0 kg; P = .038; normal range, 5.2-7.3 kg). Brain weight was not different between groups (SO10, 40.3 g; SO5, 36.0 g; FO5, 36.6 g; P = .122; normal range, 41.8-51.4 g). Corrected for body weight, brain weight was lowest in the fish oil group (SO10, 9.3 g/kg; SO5, 8.0 g/kg; FO5, 7.3 g/kg; P < .001; normal range, 5.9-9.0 g/kg). CONCLUSION Low-dose fat emulsions reduce the risk of developing PNALD. Further investigation of the risk to brain development in neonates exposed to dose restriction, particularly with fish oil, is required.
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Affiliation(s)
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Canada Department of Agricultural Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Catherine J Field
- Department of Agricultural Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Consolato Sergi
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Ronald O Ball
- Department of Agricultural Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Paul B Pencharz
- Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada Departments of Pediatrics and Nutritional Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Canada Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada Departments of Pediatrics and Nutritional Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada Division of General Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada Group for Improvement of Intestinal Function and Treatment, Hospital for Sick Children, Toronto, Ontario, Canada
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