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Yang Y, Hang W, Li J, Liu T, Hu Y, Fang F, Yan D, McQuillan PM, Wang M, Hu Z. Effect of General Anesthetic Agents on Microglia. Aging Dis 2024; 15:1308-1328. [PMID: 37962460 PMCID: PMC11081156 DOI: 10.14336/ad.2023.1108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
The effects of general anesthetic agents (GAAs) on microglia and their potential neurotoxicity have attracted the attention of neuroscientists. Microglia play important roles in the inflammatory process and in neuromodulation of the central nervous system. Microglia-mediated neuroinflammation is a key mechanism of neurocognitive dysfunction during the perioperative period. Microglial activation by GAAs induces anti-inflammatory and pro-inflammatory effects in microglia, suggesting that GAAs play a dual role in the mechanism of postoperative cognitive dysfunction. Understanding of the mechanisms by which GAAs regulate microglia may help to reduce the incidence of postoperative adverse effects. Here, we review the actions of GAAs on microglia and the consequent changes in microglial function. We summarize clinical and animal studies associating microglia with general anesthesia and describe how GAAs interact with neurons via microglia to further explore the mechanisms of action of GAAs in the nervous system.
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Affiliation(s)
- Yanchang Yang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Wenxin Hang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Jun Li
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Department of Anesthesiology, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China.
| | - Tiantian Liu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Department of Anesthesiology, Ningbo Women and Children's Hospital, Ningbo, China.
| | - Yuhan Hu
- Cell Biology Department, Yale University, New Haven, CT, USA.
| | - Fuquan Fang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Dandan Yan
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Patrick M. McQuillan
- Department of Anesthesiology, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA.
| | - Mi Wang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Zhiyong Hu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Liu Y, Zhang G, Wu J, Meng Y, Hu J, Fu H, Yang D. CARMA3 Drives NF-κB Activation and Promotes Intervertebral Disc Degeneration: Involvement of CARMA3-BCL10-MALT1 Signalosome. Inflammation 2024:10.1007/s10753-024-02016-3. [PMID: 38607566 DOI: 10.1007/s10753-024-02016-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/27/2024] [Accepted: 03/30/2024] [Indexed: 04/13/2024]
Abstract
Intervertebral disc degeneration (IDD) diseases are common and frequent diseases in orthopedics. The caspase recruitment domain (CARD) and membrane-associated guanylate kinase-like protein 3 (CARMA3) is crucial in the activation of the NF-κB pathway. However, the biological function of CARMA3 in IDD remains unknown. Here, CARMA3 expression was elevated in nucleus pulposus (NP) tissues of IDD rats and nutrient deprivation (ND)-induced NP cells. The main pathological manifestations observed in IDD rats were shrinkage of the NP, reduction of NP cells, fibrosis of NP tissues, and massive reduction of proteoglycans. These changes were accompanied by a decrease in the expression of collagen II and aggrecan, an increase in the expression of the extracellular matrix (ECM) catabolic proteases MMP-3, MMP-13, and metalloprotease with ADAMTS-5, and an increase in the activity of the pro-apoptotic protease caspase-3. The expression of p-IκBαSer32/36 and p-p65Ser536 was also upregulated. However, these effects were reversed with the knockdown of CARMA3. Mechanistically, CARMA3 bound to BCL10 and MALT1 to form a signalosome. Knockdown of CARMA3 reduced the CARMA3-BCL10-MALT1 signalosome-mediated NF-κB activation. CARMA3 activated the NF-κB signaling pathway in a manner that bound to BCL10 and MALT1 to form a signalosome, which affects NP cell damage and is involved in the development of IDD. This supports CARMA3-BCL10-MALT1-NF-κB as a promising targeting axis for the treatment of IDD.
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Affiliation(s)
- Yadong Liu
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China
| | - Guiqi Zhang
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China
| | - Jiani Wu
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China
| | - Yi Meng
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China
| | - Jianyu Hu
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China
| | - Hao Fu
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China
| | - Dongfang Yang
- Department of Orthopedics, Central Hospital of Dalian University of Technology, No. 826 Xinan Road, Dalian, People's Republic of China.
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Jin N, Xue Z. Benefits of remimazolam as an anesthetic sedative for older patients: A review. Heliyon 2024; 10:e25399. [PMID: 38370247 PMCID: PMC10867616 DOI: 10.1016/j.heliyon.2024.e25399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024] Open
Abstract
Owing to the decreased levels of receptors in the peripheral and central nervous systems, the functions of various organ systems decline in older patients. When administering anesthesia to older patients, it is necessary to consider the effects of medication on the homeostatic balance. Remimazolam, a new benzodiazepine, was recently developed as an anesthetic drug that has shown promise in clinical anesthesia application owing to its molecular structure, targets, pharmacodynamics, and pharmacokinetic characteristics. Remimazolam exhibits a rapid onset and metabolism, with minor effects on liver and kidney functions. Moreover, the drug has a specific antagonist, flumazenil. It is safer to use in older patients than other anesthetic sedatives and has been widely used since its introduction. Comparisons of the pharmacokinetics, metabolic pathways, effects on target organs, and hemodynamics of different drugs with those of commonly used anesthetic sedative drugs are useful to inform clinical practice. This article elaborates on the benefits of remimazolam compared with those of other anesthetic sedatives for sedation in older patients to demonstrate how it offers a new option for anesthetics in older patients. In cases involving older patients with increased clinical complexities or very old patients requiring anesthesia, remimazolam can be selected as the preferred anesthetic sedative, as outlined in this review.
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Affiliation(s)
- Ning Jin
- Department of Anesthesiology, Benxi Central Hospital, Benxi, 117000, Liaoning Province, China
| | - Zhiqiang Xue
- Department of Anesthesiology, Benxi Central Hospital, Benxi, 117000, Liaoning Province, China
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Sun C, Liu D, Gao S, Xiu M, Zhang Z. Propofol Ameliorates Spinal Cord Injury Process by Mediating miR-672-3p/TNIP2 Axis. Biochem Genet 2024:10.1007/s10528-024-10718-4. [PMID: 38379038 DOI: 10.1007/s10528-024-10718-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
Propofol has been found to have a protective effect against spinal cord injury (SCI). However, the underlying molecular mechanism of propofol regulating SCI process remains unclear. In this study, lipopolysaccharide (LPS)-induced PC12 cells were used to build SCI cell models. Cell viability and apoptosis were determined by cell counting kit 8 assay, flow cytometry, and caspase-3 activity detection. The protein levels of apoptosis-related markers and TNFAIP3 interacting protein 2 (TNIP2) were assessed using western blot analysis, and the levels of inflammatory factors were detected using ELISA. Cell oxidative stress was evaluated by measuring malondialdehyde (MDA) and reactive oxygen species (ROS) levels. The expression of microRNA (miR)-672-3p was examined by quantitative real-time PCR. SCI rat models were constructed to assess the effect of propofol in vivo. We found that propofol treatment promoted viability, while inhibited apoptosis, inflammation and oxidative stress of LPS-induced PC12 cells. Propofol decreased miR-672-3p expression, and miR-672-3p overexpression eliminated the inhibiting effect of propofol on LPS-induced PC12 cell injury. Besides, miR-672-3p targeted TNIP2, and TNIP2 knockdown reversed the protective effect of miR-672-3p inhibitor or propofol against LPS-induced PC12 cell injury. In vivo experiments, propofol treatment enhanced the motor function recovery and inhibited apoptosis of SCI rat models. In conclusion, propofol increased TNIP2 level by reducing miR-672-3p expression, thereby alleviating LPS-induced PC12 cell injury and improving the motor function of SCI rat models.
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Affiliation(s)
- Chengliang Sun
- Department of Anesthesiology, the First People's Hospital of Lianyungang, No.182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, 222000, China
| | - Dongzhi Liu
- Department of Anesthesiology, the First People's Hospital of Lianyungang, No.182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, 222000, China
| | - Shunheng Gao
- Department of Anesthesiology, the First People's Hospital of Lianyungang, No.182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, 222000, China
| | - Mingyu Xiu
- Department of Anesthesiology, the First People's Hospital of Lianyungang, No.182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, 222000, China
| | - Zhaojian Zhang
- Department of Anesthesiology, the First People's Hospital of Lianyungang, No.182, Tongguan North Road, Haizhou District, Lianyungang, Jiangsu, 222000, China.
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Sanie-Jahromi F, Sanie Jahromi MS. In Vitro Effect of Propofol on the Expression of Genes Involved in Inflammation and Apoptosis in Corneal Activated Keratocytes. Cornea 2024; 43:105-110. [PMID: 37702602 DOI: 10.1097/ico.0000000000003378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/03/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE We investigated the effect of propofol (0.5, 5, and 50 μM) on the gene expression of inflammatory cytokines [ IL-1β , IL-6 , transforming growth factor β ( TGF-β ), and LIF ] and apoptosis process ( BCL-2 and Bax ) in corneal activated keratocytes (CAKs). METHODS CAKs (10 6 cells/10 cm 2 ) were exposed to propofol at a concentration of 0.5, 5, and 50 μM for 24 hours at 37°C. The control group did not receive propofol at the same time or under the same condition. Ribonucleic acid (RNA) extraction, complementary DNA (cDNA) synthesis, and real-time polymerase chain reaction (PCR) were performed to quantify the relative expression of IL-1β , IL-6 , TGF-β , LIF , BCL-2 , and Bax expression in the treated versus control cells. RESULT The results of this study showed that propofol treatment (0.5 and 5 μM) led to the downregulation of IL-1β and IL-6 gene expression in CAKs. TGF-β (with a role in fibrogenesis) was not changed in 0.5 and 5 μM propofol-treated CAKs, whereas CAKs treated with 50 μM propofol showed upregulation of the TGF-β gene. LIF (with a role in regeneration) was upregulated in 0.5 and 5 μM propofol-treated CAKs. The BCL-2/Bax ratio (as the antiapoptosis index) was increased in CAKs treated with 0.5 μM propofol and indicated the induction of an antiapoptotic effect. CONCLUSIONS We showed that CAKs treatment with propofol, at concentrations of 0.5 and 5 μM, could decrease the expression of genes related to inflammation and enhance the genes associated with cell regeneration. While 50 μM propofol treatment might induce CAK fibrogenesis. This proof-of-concept study could preserve a groundwork for future drug design for the treatment of corneal stromal diseases and ocular regenerative medicine.
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Affiliation(s)
- Fatemeh Sanie-Jahromi
- Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Universal Scientific Education and Research Network (USERN), Shiraz, Iran; and
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VanderZwaag J, Halvorson T, Dolhan K, Šimončičová E, Ben-Azu B, Tremblay MÈ. The Missing Piece? A Case for Microglia's Prominent Role in the Therapeutic Action of Anesthetics, Ketamine, and Psychedelics. Neurochem Res 2023; 48:1129-1166. [PMID: 36327017 DOI: 10.1007/s11064-022-03772-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 08/25/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
There is much excitement surrounding recent research of promising, mechanistically novel psychotherapeutics - psychedelic, anesthetic, and dissociative agents - as they have demonstrated surprising efficacy in treating central nervous system (CNS) disorders, such as mood disorders and addiction. However, the mechanisms by which these drugs provide such profound psychological benefits are still to be fully elucidated. Microglia, the CNS's resident innate immune cells, are emerging as a cellular target for psychiatric disorders because of their critical role in regulating neuroplasticity and the inflammatory environment of the brain. The following paper is a review of recent literature surrounding these neuropharmacological therapies and their demonstrated or hypothesized interactions with microglia. Through investigating the mechanism of action of psychedelics, such as psilocybin and lysergic acid diethylamide, ketamine, and propofol, we demonstrate a largely under-investigated role for microglia in much of the emerging research surrounding these pharmacological agents. Among others, we detail sigma-1 receptors, serotonergic and γ-aminobutyric acid signalling, and tryptophan metabolism as pathways through which these agents modulate microglial phagocytic activity and inflammatory mediator release, inducing their therapeutic effects. The current review includes a discussion on future directions in the field of microglial pharmacology and covers bidirectional implications of microglia and these novel pharmacological agents in aging and age-related disease, glial cell heterogeneity, and state-of-the-art methodologies in microglial research.
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Affiliation(s)
- Jared VanderZwaag
- Neuroscience Graduate Program, University of Victoria, Victoria, BC, Canada
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Torin Halvorson
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Kira Dolhan
- Department of Psychology, University of Victoria, Vancouver, BC, Canada
- Department of Biology, University of Victoria, Vancouver, BC, Canada
| | - Eva Šimončičová
- Neuroscience Graduate Program, University of Victoria, Victoria, BC, Canada
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Benneth Ben-Azu
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
- Department of Pharmacology, Faculty of Basic Medical Sciences, College of Health Sciences, Delta State University, Abraka, Delta State, Nigeria
| | - Marie-Ève Tremblay
- Neuroscience Graduate Program, University of Victoria, Victoria, BC, Canada.
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada.
- Département de médecine moléculaire, Université Laval, Québec City, QC, Canada.
- Axe Neurosciences, Centre de Recherche du CHU de Québec, Université Laval, Québec City, QC, Canada.
- Neurology and Neurosurgery Department, McGill University, Montreal, QC, Canada.
- Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, BC, Canada.
- Centre for Advanced Materials and Related Technology (CAMTEC), University of Victoria, Victoria, BC, Canada.
- Institute for Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada.
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Zhang M, Yin Y. Dual roles of anesthetics in postoperative cognitive dysfunction: Regulation of microglial activation through inflammatory signaling pathways. Front Immunol 2023; 14:1102312. [PMID: 36776829 PMCID: PMC9911670 DOI: 10.3389/fimmu.2023.1102312] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/17/2023] [Indexed: 01/28/2023] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a prevalent clinical entity following surgery and is characterized by declined neurocognitive function. Neuroinflammation mediated by microglia is the essential mechanism of POCD. Anesthetics are thought to be a major contributor to the development of POCD, as they promote microglial activation and induce neuroinflammation. However, this claim remains controversial. Anesthetics can exert both anti- and pro-inflammatory effects by modulating microglial activation, suggesting that anesthetics may play dual roles in the pathogenesis of POCD. Here, we review the mechanisms by which the commonly used anesthetics regulate microglial activation via inflammatory signaling pathways, showing both anti- and pro-inflammatory properties of anesthetics, and indicating how perioperative administration of anesthetics might either relieve or worsen POCD development. The potential for anesthetics to enhance cognitive performance based on their anti-inflammatory properties is further discussed, emphasizing that the beneficial effects of anesthetics vary depending on dose, exposure time, and patients' characteristics. To minimize the incidence of POCD, we recommend considering these factors to select appropriate anesthetics.
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Affiliation(s)
- Mengxue Zhang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.,Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Yiqing Yin
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.,Tianjin's Clinical Research Center for Cancer, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
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Yang L, Wei S, Zhang J, Hu Q, Hu W, Cao M, Zhang L, Wang Y, Wang P, Wang K. Construction of a predictive model for immunotherapy efficacy in lung squamous cell carcinoma based on the degree of tumor-infiltrating immune cells and molecular typing. Lab Invest 2022; 20:364. [PMID: 35962453 PMCID: PMC9373274 DOI: 10.1186/s12967-022-03565-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/02/2022] [Indexed: 12/20/2022]
Abstract
Background To construct a predictive model of immunotherapy efficacy for patients with lung squamous cell carcinoma (LUSC) based on the degree of tumor-infiltrating immune cells (TIIC) in the tumor microenvironment (TME). Methods The data of 501 patients with LUSC in the TCGA database were used as a training set, and grouped using non-negative matrix factorization (NMF) based on the degree of TIIC assessed by single-sample gene set enrichment analysis (GSEA). Two data sets (GSE126044 and GSE135222) were used as validation sets. Genes screened for modeling by least absolute shrinkage and selection operator (LASSO) regression and used to construct a model based on immunophenotyping score (IPTS). RNA extraction and qPCR were performed to validate the prognostic value of IPTS in our independent LUSC cohort. The receiver operating characteristic (ROC) curve was constructed to determine the predictive value of the immune efficacy. Kaplan–Meier survival curve analysis was performed to evaluate the prognostic predictive ability. Correlation analysis and enrichment analysis were used to explore the potential mechanism of IPTS molecular typing involved in predicting the immunotherapy efficacy for patients with LUSC. Results The training set was divided into a low immune cell infiltration type (C1) and a high immune cell infiltration type (C2) by NMF typing, and the IPTS molecular typing based on the 17-gene model could replace the results of the NMF typing. The area under the ROC curve (AUC) was 0.82. In both validation sets, the IPTS of patients who responded to immunotherapy were significantly higher than those who did not respond to immunotherapy (P = 0.0032 and P = 0.0451), whereas the AUC was 0.95 (95% CI = 1.00–0.84) and 0.77 (95% CI = 0.58–0.96), respectively. In our independent cohort, we validated its ability to predict the response to cancer immunotherapy, for the AUC was 0.88 (95% CI = 1.00–0.66). GSEA suggested that the high IPTS group was mainly involved in immune-related signaling pathways. Conclusions IPTS molecular typing based on the degree of TIIC in the TME could well predict the efficacy of immunotherapy in patients with LUSC with a certain prognostic value. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03565-7.
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Affiliation(s)
- Lingge Yang
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China
| | - Shuli Wei
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jingnan Zhang
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China
| | - Qiongjie Hu
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China
| | - Wansong Hu
- Department of Heart Center, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China
| | - Mengqing Cao
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China
| | - Long Zhang
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China
| | - Yongfang Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Pingli Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
| | - Kai Wang
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu, China.
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