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Ivanciuc T, Patrikeev I, Qu Y, Motamedi M, Jones-Hall Y, Casola A, Garofalo RP. Micro-CT Features of Lung Consolidation, Collagen Deposition and Inflammation in Experimental RSV Infection Are Aggravated in the Absence of Nrf2. Viruses 2023; 15:1191. [PMID: 37243277 PMCID: PMC10223011 DOI: 10.3390/v15051191] [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: 04/24/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Severe respiratory syncytial virus (RSV) infections in early life have been linked to the development of chronic airway disease. RSV triggers the production of reactive oxygen species (ROS), which contributes to inflammation and enhanced clinical disease. NF-E2-related factor 2 (Nrf2) is an important redox-responsive protein that helps to protect cells and whole organisms from oxidative stress and injury. The role of Nrf2 in the context of viral-mediated chronic lung injury is not known. Herein, we show that RSV experimental infection of adult Nrf2-deficient BALB/c mice (Nrf2-/-; Nrf2 KO) is characterized by enhanced disease, increased inflammatory cell recruitment to the bronchoalveolar compartment and a more robust upregulation of innate and inflammatory genes and proteins, compared to wild-type Nrf2+/+ competent mice (WT). These events that occur at very early time points lead to increased peak RSV replication in Nrf2 KO compared to WT mice (day 5). To evaluate longitudinal changes in the lung architecture, mice were scanned weekly via high-resolution micro-computed tomography (micro-CT) imaging up to 28 days after initial viral inoculation. Based on micro-CT qualitative 2D imaging and quantitative reconstructed histogram-based analysis of lung volume and density, we found that RSV-infected Nrf2 KO mice developed significantly greater and prolonged fibrosis compared to WT mice. The results of this study underscore the critical role of Nrf2-mediated protection from oxidative injury, not only in the acute pathogenesis of RSV infection but also in the long-term consequences of chronic airway injury.
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Affiliation(s)
- Teodora Ivanciuc
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX 77555, USA; (T.I.); (Y.Q.); (A.C.)
| | - Igor Patrikeev
- Department of Ophthalmology & Visual Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA; (I.P.); (M.M.)
| | - Yue Qu
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX 77555, USA; (T.I.); (Y.Q.); (A.C.)
| | - Massoud Motamedi
- Department of Ophthalmology & Visual Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA; (I.P.); (M.M.)
- Biomedical Engineering Center, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Yava Jones-Hall
- Department of Veterinary Pathobiology, Texas A&M College of Veterinary Medicine and Biomedical Sciences, College Station, TX 77843, USA;
| | - Antonella Casola
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX 77555, USA; (T.I.); (Y.Q.); (A.C.)
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA
- Sealy Institute for Vaccine Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Roberto P. Garofalo
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX 77555, USA; (T.I.); (Y.Q.); (A.C.)
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA
- Sealy Institute for Vaccine Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
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2
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Rossi ML, Escobar-Diaz MC, Hadley SM, Randanne PC, Sanchez-de-Toledo J, Jordan I. Echocardiographic Markers of Mild Pulmonary Hypertension are not Correlated with Worse Respiratory Outcomes in Infants with Bronchiolitis. Pediatr Cardiol 2023; 44:237-244. [PMID: 36401628 DOI: 10.1007/s00246-022-03043-3] [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: 08/24/2022] [Accepted: 11/01/2022] [Indexed: 11/21/2022]
Abstract
Pulmonary hypertension has been reported as a crucial factor in the pathophysiology of severe bronchiolitis. The aim of this study was to evaluate pulmonary artery pressure (PAP) in patients with bronchiolitis and to analyze their correlation with clinical outcomes. This prospective cohort study examined children admitted for bronchiolitis. PAP was assessed by right ventricle (RV) acceleration/ejection time ratio (AT/ET), isovolumic relaxation time, eccentricity index, and the presence of a pulmonary systolic notch. Pulmonary hypertension (PH) was considered if at least two altered parameters were present. Severity of clinical course was established by higher N-terminal (NT)-prohormone BNP (NT-proBNP) values, the need for positive pressure respiratory support (PPRS), and the duration of hospital admission. One hundred sixty-nine children were included in analysis. Sixty-eight patients (40%) required PPRS, and those patients had increased NT-proBNP values and worse tricuspid annular systolic excursion (TAPSE) compared to mild cases (p < 0.001and p < 0.001, respectively). Twenty-two (13%) cases had at least two altered parameters of PAP and met criteria for presumed PH, with no differences in NT-proBNP values, TAPSE, need for PPRS or hospital length of stay compared to normal PAP group (p = 0.98, p = 0.07, p = 0.94 and p = 0.64, respectively). We found no correlation between altered RV AT/ET and worse cardiac function, NT-proBNP values or hospital length of stay. In our cohort, the presence of echocardiographic findings of PH were not associated with worse clinical outcomes. Patients with severe bronchiolitis had higher values of NT-proBNP but, interestingly, no clear association with PH.
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Affiliation(s)
- Maria Lucia Rossi
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain. .,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.
| | - Maria Clara Escobar-Diaz
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain
| | | | - Paula Cecilia Randanne
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
| | - Joan Sanchez-de-Toledo
- Department of Pediatric Cardiology, Sant Joan de Deu Hospital, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain.,Cardiovascular Research Group, Sant Joan de Déu Research Institute, Barcelona, Spain.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Iolanda Jordan
- Pediatric Intensive Care Unit. Hospital Sant Joan de Déu, Barcelona, Spain.,Institut de Recerca Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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3
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Abstract
Major advances in biomedical imaging have occurred over the last 2 decades and now allow many physiological, cellular, and molecular processes to be imaged noninvasively in small animal models of cardiovascular disease. Many of these techniques can be also used in humans, providing pathophysiological context and helping to define the clinical relevance of the model. Ultrasound remains the most widely used approach, and dedicated high-frequency systems can obtain extremely detailed images in mice. Likewise, dedicated small animal tomographic systems have been developed for magnetic resonance, positron emission tomography, fluorescence imaging, and computed tomography in mice. In this article, we review the use of ultrasound and positron emission tomography in small animal models, as well as emerging contrast mechanisms in magnetic resonance such as diffusion tensor imaging, hyperpolarized magnetic resonance, chemical exchange saturation transfer imaging, magnetic resonance elastography and strain, arterial spin labeling, and molecular imaging.
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Affiliation(s)
- David E Sosnovik
- Cardiology Division, Cardiovascular Research Center (D.E.S.), Massachusetts General Hospital and Harvard Medical School, Boston.,A.A. Martinos Center for Biomedical Imaging (D.E.S.), Massachusetts General Hospital and Harvard Medical School, Boston.,Harvard-MIT Program in Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Cambridge (D.E.S.)
| | - Marielle Scherrer-Crosbie
- Cardiology Division, Hospital of the University of Pennsylvania and Perelman School of Medicine, Philadelphia (M.S.-C)
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4
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Savedchuk S, Raslan R, Nystrom S, Sparks MA. Emerging Viral Infections and the Potential Impact on Hypertension, Cardiovascular Disease, and Kidney Disease. Circ Res 2022; 130:1618-1641. [PMID: 35549373 DOI: 10.1161/circresaha.122.320873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Viruses are ubiquitous in the environment and continue to have a profound impact on human health and disease. The COVID-19 pandemic has highlighted this with impressive morbidity and mortality affecting the world's population. Importantly, the link between viruses and hypertension, cardiovascular disease, and kidney disease has resulted in a renewed focus and attention on this potential relationship. The virus responsible for COVID-19, SARS-CoV-2, has a direct link to one of the major enzymatic regulatory systems connected to blood pressure control and hypertension pathogenesis, the renin-angiotensin system. This is because the entry point for SARS-CoV-2 is the ACE2 (angiotensin-converting enzyme 2) protein. ACE2 is one of the main enzymes responsible for dampening the primary effector peptide Ang II (angiotensin II), metabolizing it to Ang-(1-7). A myriad of clinical questions has since emerged and are covered in this review. Several other viruses have been linked to hypertension, cardiovascular disease, and kidney health. Importantly, patients with high-risk apolipoprotein L1 (APOL1) alleles are at risk for developing the kidney lesion of collapsing glomerulopathy after viral infection. This review will highlight several emerging viruses and their potential unique tropisms for the kidney and cardiovascular system. We focus on SARS-CoV-2 as this body of literature in regards to cardiovascular disease has advanced significantly since the COVID-19 pandemic.
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Affiliation(s)
- Solomiia Savedchuk
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S., S.N., M.A.S.)
| | - Rasha Raslan
- Internal Medicine, Virginia Commonwealth University, Richmond (R.R.)
| | - Sarah Nystrom
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S., S.N., M.A.S.)
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S., S.N., M.A.S.)
- Renal Section, Durham VA Health Care System, NC (M.A.S.)
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5
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Rodriguez-Gonzalez M, Rodriguez-Campoy P, Estalella-Mendoza A, Castellano-Martinez A, Flores-Gonzalez JC. Characterization of Cardiopulmonary Interactions and Exploring Their Prognostic Value in Acute Bronchiolitis: A Prospective Cardiopulmonary Ultrasound Study. Tomography 2022; 8:142-157. [PMID: 35076624 PMCID: PMC8788562 DOI: 10.3390/tomography8010012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 12/14/2022] Open
Abstract
We aimed to delineate cardiopulmonary interactions in acute bronchiolitis and to evaluate the capacity of a combined cardiopulmonary ultrasonography to predict the need for respiratory support. This was a prospective observational single-center study that includes infants <12 month of age admitted to a hospital due to acute bronchiolitis. All the included patients underwent clinical, laboratory and cardiopulmonary ultrasonographic evaluation at the same time point within 24 h of hospital admission. The existence of significant correlation between cardiac and respiratory parameters was the primary outcome. The association of different cardiopulmonary variables with the need of respiratory support higher than O2, the length of stay hospitalization, the PICU stay and the duration of respiratory support were a secondary outcome. We enrolled 112 infants (median age 1 (0.5–3) months; 62% males) hospitalized with acute bronchiolitis. Increased values of the pulmonary variables (BROSJOD score, pCO2 and LUS) showed moderate correlations with NT-proBNP and all echocardiographic parameters indicative of pulmonary hypertension and myocardial dysfunction (Tei index). Up to 36 (32%) infants required respiratory support during the hospitalization. This group presented with higher lung ultrasound score (p < 0.001) and increased values of NT-proBNP (p < 0.001), the Tei index (p < 0.001) and pulmonary artery pressures (p < 0.001). All the analyzed respiratory and cardiac variables showed moderate-to-strong correlations with the LOS of hospitalization and the time of respiratory support. Lung ultrasound and echocardiography showed a moderate-to-strong predictive accuracy for the need of respiratory support in the ROC analysis, with the AUC varying from 0.74 to 0.87. Those cases of bronchiolitis with a worse pulmonary status presented with a more impaired cardiac status. Cardiopulmonary ultrasonography could be a useful tool to easily identify high-risk populations for complicated acute bronchiolitis hospitalization.
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Affiliation(s)
| | - Patricia Rodriguez-Campoy
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, 11010 Cadiz, Spain; (P.R.-C.); (A.E.-M.); (J.C.F.-G.)
| | - Ana Estalella-Mendoza
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, 11010 Cadiz, Spain; (P.R.-C.); (A.E.-M.); (J.C.F.-G.)
| | - Ana Castellano-Martinez
- Pediatric Nephrology Division, Puerta del Mar University Hospital, 11010 Cadiz, Spain
- Correspondence:
| | - Jose Carlos Flores-Gonzalez
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, 11010 Cadiz, Spain; (P.R.-C.); (A.E.-M.); (J.C.F.-G.)
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6
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Scanlon KM, Chen L, Carbonetti NH. Pertussis Toxin Promotes Pulmonary Hypertension in an Infant Mouse Model of Bordetella pertussis Infection. J Infect Dis 2022; 225:172-176. [PMID: 34145457 PMCID: PMC8730479 DOI: 10.1093/infdis/jiab325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/16/2021] [Indexed: 11/13/2022] Open
Abstract
Pertussis, caused by Bordetella pertussis, is a reemerging disease that can produce severe disease manifestations in infants, including pulmonary hypertension (PH). B. pertussis-induced PH is a major risk factor for infection-induced death, but the molecular mechanisms promoting PH are unknown and there is no effective treatment. We examined B. pertussis-induced PH in infant and adult mouse models of pertussis by Fulton index, right heart catheterization, or Doppler echocardiogram. Our results demonstrate that B. pertussis-induced PH is age related and dependent on the expression of pertussis toxin by the bacterium. Hence, pertussis toxin-targeting treatments may ameliorate PH and fatal infant infection.
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Affiliation(s)
- Karen M Scanlon
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ling Chen
- Department of Physiology and Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicholas H Carbonetti
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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7
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Li JW, Guo LW, Tao SY, Deng YH, Yang C, Qiao F. Analysis of healthcare-associated infection in patients with pulmonary arterial hypertension associated with congenital heart disease in PICU: Evidence from a tertiary hospital in western China. Front Pediatr 2022; 10:1076618. [PMID: 36619502 PMCID: PMC9811260 DOI: 10.3389/fped.2022.1076618] [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: 10/21/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The present study intends to analyze the targeted surveillance and risk factors for healthcare-associated infection (HAI) in patients with pulmonary arterial hypertension associated with congenital heart disease (CHD-PAH) in a Pediatric intensive care unit (PICU), and provide basis for formulating relevant prevention and control measures of HAI. METHODS Children (≤14 years old) who were admitted to the PICU for ≥2 calendar days from January 2018 to December 2021 were included. Targeted surveillance of HAI was described. RESULTS A total of 7,828 patients in PICU were monitored, and the total hospitalization days of the patients were 36,174. 108 cases of HAI occurred, with a per-case infection rate of 1.38% and a per-thousand day infection rate of 2.99. 1,129 patients with CHD-PAH were included, among which the total hospitalization days were 1,483. In this subpopulation, 38 cases of HAI were diagnosed, with a per-case infection rate of 3.37% and a per-thousand day infection rate of 25.62. The main site of HAI was lower respiratory tract (43.51%), followed by blood infection (34.26%) and surgical site infection (9.26%). 36 strains of pathogenic bacteria were detected from patients with HAI. The top three pathogens with the highest detection rate were Klebsiella pneumoniae (6 episodes, 16.67%), Enterococcus faecium (6 episodes, 16.67%) and Acinetobacter baumannii (4 episodes, 11.11%). The incidence of VAP, CAUTI and CLABSI was 2.78, 0.08 and 1.66 per 1,000 catheter days respectively. Analysis revealed that patients with CHD-PAH were younger and prone to receive surgical corrections. CHD-PAH could significantly increase the length of ICU stay, ventilator days, times of central venous catheterization and central venous catheterization days. The choice of different central venous catheter types differed significantly between the two groups. CONCLUSION Patients with CHD-PAH are characterized with excessive central venous catheterization operations, prolonged indwelling time, and more types of catheterization, which are considered to be risk factors for HAI, thus increasing the length of hospital stay. The clinical etiology is mainly G-bacteria, which requires reasonable selection of antibiotics and strict aseptic operation. Limiting unnecessary invasive procedures is helpful for reducing the incidence of postoperative HAI in PICU.
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Affiliation(s)
- Jing-Wen Li
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China
| | - Ling-Wen Guo
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China
| | - Si-Yuan Tao
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China
| | - Yu-Hua Deng
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China
| | - Cui Yang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fu Qiao
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China
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8
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Vu LD, Saravia J, Jaligama S, Baboeram Panday RV, Sullivan RD, Mancarella S, Cormier SA, Kimura D. Deficiency in ST2 signaling ameliorates RSV-associated pulmonary hypertension. Am J Physiol Heart Circ Physiol 2021; 321:H309-H317. [PMID: 34170196 DOI: 10.1152/ajpheart.00018.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pulmonary hypertension (PH) observed during respiratory syncytial virus (RSV) bronchiolitis is associated with morbidity and mortality, especially in children with congenital heart disease. Yet, the pathophysiological mechanisms of RSV-associated PH remain unclear. Therefore, this study aimed to investigate the pathophysiological mechanism of RSV-associated PH. We used a translational mouse model of RSV-associated PH, in which wild-type (WT) and suppression of tumorigenicity 2 (ST2) knockout neonatal mice were infected with RSV at 5 days old and reinfected 4 wk later. The development of PH in WT mice following RSV reinfection was evidenced by elevated right ventricle systolic pressure, shortened pulmonary artery acceleration time (PAT), and decreased PAT/ejection time (ET) ratio. It coincided with the augmentation of periostin and IL-13 expression and increased arginase bioactivity by both arginase 1 and 2 as well as induction of nitric oxide synthase (NOS) uncoupling. Absence of ST2 signaling prevented RSV-reinfected mice from developing PH by suppressing NOS uncoupling. In summary, ST2 signaling was involved in the development of RSV-associated PH. ST2 signaling inhibition may be a novel therapeutic target for RSV-associated PH.NEW & NOTEWORTHY We report that the pathogenic role of ST2-mediated type 2 immunity and mechanisms contribute to RSV-associated pulmonary hypertension. Inhibiting ST2 signaling may be a novel therapeutic target for this condition.
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Affiliation(s)
- Luan D Vu
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana.,Department of Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana
| | - Jordy Saravia
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Department of Immunology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sridhar Jaligama
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,IIT Research Institute, Chicago, Illinois
| | | | - Ryan D Sullivan
- Department of Comparative Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Salvatore Mancarella
- Department of Physiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Stephania A Cormier
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana.,Department of Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana.,Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Dai Kimura
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee
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9
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Rodriguez-Gonzalez M, Castellano-Martinez A, Perez-Reviriego AA. The increasing relevance of early detection of myocardial strain in acute bronchiolitis. Pediatr Pulmonol 2020; 55:2181-2183. [PMID: 32453914 DOI: 10.1002/ppul.24860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Moises Rodriguez-Gonzalez
- Division of Pediatric Cardiology, Puerta del Mar University Hospital, Cadiz, Spain.,Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cadiz, Spain
| | - Ana Castellano-Martinez
- Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cadiz, Spain.,Division of Pediatric Nephrology, Puerta del Mar University Hospital, Cadiz, Spain
| | - Alvaro Antonio Perez-Reviriego
- Division of Pediatric Cardiology, Puerta del Mar University Hospital, Cadiz, Spain.,Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, University of Cadiz, Cadiz, Spain
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