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Friaza V, Rojas P, de la Horra C, García E, Morilla R, Pavón A, de Armas Y, Vallejo-Vaz AJ, Salsoso R, Medrano FJ, Calderón EJ. Fungal microbiota in newborn infants with and without respiratory distress syndrome. PLoS One 2024; 19:e0302027. [PMID: 38598489 PMCID: PMC11006121 DOI: 10.1371/journal.pone.0302027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Pneumocytis jirovecii infection in preterm newborns has recently been associated with neonatal respiratory distress syndrome and bronchopulmonary dysplasia. Changes in the bacterial microbiota of the airways have also been described in infants with bronchopulmonary dysplasia. However, until now there has been no information on the airway mycobiota in newborns. The purpose of this study was to describe the airway mycobiota in term and preterm newborns and its possible association with respiratory distress syndrome. METHODS Twenty-six matched preterm newborns with and without respiratory distress syndrome were studied, as well as 13 term babies. The identification of the fungal microbiota was carried out using molecular procedures in aspirated nasal samples at birth. RESULTS The ascomycota phylum was identified in 89.7% of newborns, while the basidiomycota phylum was found in 33.3%. Cladosporium was the predominant genus in both term and preterm infants 38.4% vs. 73% without statistical differences. Candida sake and Pneumocystis jirovecii were only found in preterm infants, suggesting a potential relationship with the risk of prematurity. CONCLUSIONS This is the first report to describe the fungal microbiota of the airways in term and preterm infants with and without respiratory distress syndrome. Although no differences have been observed, the number of cases analyzed could be small to obtain conclusive results, and more studies are needed to understand the role of the fungal microbiota of the airways in neonatal respiratory pathology.
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Affiliation(s)
- Vicente Friaza
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
| | - Pilar Rojas
- Neonatology Unit, Virgen del Rocío University Children’s Hospital, Seville, Spain
| | - Carmen de la Horra
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
| | - Elisa García
- Neonatology Unit, Virgen del Rocío University Children’s Hospital, Seville, Spain
| | - Rubén Morilla
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
- Departamento de Enfermería, Universidad de Sevilla, Seville, Spain
| | - Antonio Pavón
- Neonatology Unit, Virgen del Rocío University Children’s Hospital, Seville, Spain
| | - Yaxsier de Armas
- Department of Clinical Microbiology Diagnostic, Hospital Center of Institute of Tropical Medicine “Pedro Kourí”, Havana, Cuba
- Pathology Department, Hospital Center of Institute of Tropical Medicine ʺPedro Kouríʺ, Havana, Cuba
| | - Antonio J. Vallejo-Vaz
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
- Departamento de Medicina, Hospital Universitario Virgen del Rocío, Facultad de Medicina, Universidad de Sevilla, Seville, Spain
| | - Rocío Salsoso
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
| | - Francisco J. Medrano
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
- Departamento de Medicina, Hospital Universitario Virgen del Rocío, Facultad de Medicina, Universidad de Sevilla, Seville, Spain
| | - Enrique J. Calderón
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Seville, Spain
- Departamento de Medicina, Hospital Universitario Virgen del Rocío, Facultad de Medicina, Universidad de Sevilla, Seville, Spain
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Wang H, Wang Y. What Makes the Gut-Lung Axis Working? From the Perspective of Microbiota and Traditional Chinese Medicine. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:8640014. [PMID: 38274122 PMCID: PMC10810697 DOI: 10.1155/2024/8640014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/21/2023] [Accepted: 01/08/2024] [Indexed: 01/27/2024]
Abstract
Background An increasing number of studies have proved that gut microbiota is involved in the occurrence and development of various lung diseases and can interact with the diseased lung. The concept of the gut-lung axis (GLA) provides a new idea for the subsequent clinical treatment of lung diseases through human microbiota. This review aims to summarize the microbiota in the lung and gut and the interaction between them from the perspectives of traditional Chinese medicine and modern medicine. Method We conducted a literature search by using the search terms "GLA," "gut microbiota," "spleen," and "Chinese medicine" in the databases PubMed, Web of Science, and CNKI. We then explored the mechanism of action of the gut-lung axis from traditional Chinese medicine and modern medicine. Results The lung and gut microbiota enable the GLA to function through immune regulation, while metabolites of the gut microbiota also play an important role. The spleen can improve the gut microbiota to achieve the regulation of the GLA. Conclusion Improving the gut microbiota through qi supplementation and spleen fortification provides a new approach to the clinical treatment of lung diseases by regulating the GLA. Currently, our understanding of the GLA is limited, and more research is needed to explain its working principle.
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Affiliation(s)
- Hui Wang
- Zhejiang Chinese Medical University, Hangzhou 310000, China
| | - Ying Wang
- Zhejiang Chinese Medical University, Hangzhou 310000, China
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3
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Vongbhavit K, Salinero LK, Kalanetra KM, Masarweh C, Yu A, Taft DH, Mills DA, Underwood MA. A comparison of bacterial colonization between nasogastric and orogastric enteral feeding tubes in infants in the neonatal intensive care unit. J Perinatol 2022; 42:1446-1452. [PMID: 35840710 PMCID: PMC9616717 DOI: 10.1038/s41372-022-01452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/03/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Feeding tubes harbor microbial contaminants; studies to date have not explored differences between orogastric (OG) and nasogastric (NG) tube biofilms. We sought to extend a previous analysis by comparing bacterial colonization by location (OG v NG) and by evaluating clinical factors that may affect tube bacterial populations. STUDY DESIGN The pharyngeal segments of 41 infant feeding tubes (14 OG and 27 NG) from 41 infants were analyzed by next generation 16 S rRNA sequencing on the MiSeq platform. RESULTS At the phylum level, Proteobacteria had the highest relative abundance of both OG and NG tubes. At the genus/species level, nine taxa differed significantly between OG and NG tubes. Alpha and beta diversity analyses showed significant differences between OG and NG tubes with relatively little contribution from clinical factors. CONCLUSION The route of feeding tube insertion (oral vs nasal) had a greater impact on bacterial colonization than the assessed clinical factors.
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Affiliation(s)
- Kannikar Vongbhavit
- Department of Pediatrics, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornayok, Thailand
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Lauren K Salinero
- Department of Food Science and Technology, University of California Davis, Davis, CA, USA
| | - Karen M Kalanetra
- Department of Food Science and Technology, University of California Davis, Davis, CA, USA
| | - Chad Masarweh
- Department of Food Science and Technology, University of California Davis, Davis, CA, USA
| | - Alice Yu
- Department of Food Science and Technology, University of California Davis, Davis, CA, USA
| | - Diana H Taft
- Department of Food Science and Technology, University of California Davis, Davis, CA, USA
| | - David A Mills
- Department of Food Science and Technology, University of California Davis, Davis, CA, USA
| | - Mark A Underwood
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
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4
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Zhang Z, Jiang J, Li Z, Wan W. The Change of Cytokines and Gut Microbiome in Preterm Infants for Bronchopulmonary Dysplasia. Front Microbiol 2022; 13:804887. [PMID: 35387067 PMCID: PMC8978829 DOI: 10.3389/fmicb.2022.804887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/27/2022] [Indexed: 01/02/2023] Open
Abstract
Background Bronchopulmonary dysplasia (BPD) is a devastating form of chronic lung disease that develops in preterm infants. BPD is speculated to arise from abnormal inflammatory responses, which is related to the composition of commensal microbiota, leading us to hypothesize that BPD susceptibility could be influenced by gut microbiota through inflammatory responses. This study is aimed to detect cytokines and the differences in fecal gut microbial composition in the BPD patients. Methods Between June 2018 and June 2020, preterm infants born at gestational age ≤30 weeks were recruited. The clinical data of infant characteristics were collected. On days 3–7 and 14–28 after birth, fresh stool samples and serum were collected. The gut microbiota composition between the BPD group and controls was detected by 16S rRNA sequencing. On days 3–7 and days 14–28, ten cytokines including IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IFN-γ, and TNF-α were detected in the serum. Results This study enrolled 38 preterm infants; the number of preterm infants in the BPD group and control group was, respectively, 18 and 20. The gestational age (27.4 ± 1.5 weeks vs. 29.5 ± 0.9 weeks, p = 0.000) and birth weight (971 ± 240 g vs. 1262 ± 335 g, p = 0.000) of the BPD group were lower than those of the control group. The present study found that the BPD group had high levels of IL-1β, IL-4, IL-6, IL-8, and TNF-α, whereas IL-10 was decreased. The Shannon diversity index of the BPD group was lower. The relative abundances of Proteobacteria in BPD group increased significantly from days 3–7 to days 14–28, while the Firmicutes was decreased. On days 14–28, the relative abundances of Proteobacteria in BPD group were significantly higher than those in the control group, while the Firmicutes was lower. Conclusion Bronchopulmonary dysplasia could be influenced by gut microbiota through inflammatory responses. More studies are needed to explore the imbalance of cytokines and microbiome in BPD infants and whether it could be reversed by probiotics. This study provided a novel perspective for treating BPD.
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Affiliation(s)
- Zhenjie Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjing Jiang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenghong Li
- Department of Pediatrics, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weilin Wan
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Tirone C, Paladini A, De Maio F, Tersigni C, D'Ippolito S, Di Simone N, Monzo FR, Santarelli G, Bianco DM, Tana M, Lio A, Menzella N, Posteraro B, Sanguinetti M, Lanzone A, Scambia G, Vento G. The Relationship Between Maternal and Neonatal Microbiota in Spontaneous Preterm Birth: A Pilot Study. Front Pediatr 2022; 10:909962. [PMID: 35935374 PMCID: PMC9353181 DOI: 10.3389/fped.2022.909962] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
The newborn's microbiota composition at birth seems to be influenced by maternal microbiota. Maternal vaginal microbiota can be a determining factor of spontaneous Preterm Birth (SPPTB), the leading cause of perinatal mortality. The aim of the study is to investigate the likelihood of a causal relationship between the maternal vaginal microbiota composition and neonatal lung and intestinal microbiota profile at birth, in cases of SPPTB. The association between the lung and/or meconium microbiota with the subsequent development of bronchopulmonary dysplasia (BPD) was also investigated. Maternal vaginal swabs, newborns' bronchoalveolar lavage fluid (BALF) (1st, 3rd, 7th day of life) and first meconium samples were collected from 20 women and 23 preterm newborns with gestational age ≤ 30 weeks (12 = SPPTB; 11 = Medically Indicated Preterm Birth-MIPTB). All the samples were analyzed for culture examination and for microbiota profiling using metagenomic analysis based on the Next Generation Sequencing (NGS) technique of the bacterial 16S rRNA gene amplicons. No significant differences in alpha e beta diversity were found between the neonatal BALF samples of SPPTB group and the MIPTB group. The vaginal microbiota of mothers with SPPTB showed a significant difference in alpha diversity with a decrease in Lactobacillus and an increase in Proteobacteria abundance. No association was found between BALF and meconium microbiota with the development of BPD. Vaginal colonization by Ureaplasma bacteria was associated with increased risk of both SPPTB and newborns' BPD occurrence. In conclusion, an increase in α-diversity values and a consequent fall in Lactobacillus in vaginal environment could be associated to a higher risk of SPPTB. We could identify neither a specific neonatal lung or meconium microbiota profiles in preterm infants born by SPPTB nor a microbiota at birth suggestive of subsequent BPD development. Although a strict match has not been revealed between microbiota of SPPTB mother-infant couples, a relationship cannot be excluded. To figure out the reciprocal influence of the maternal-neonatal microbiota and its potential role in the pathogenesis of SPPTB and BPD further research is needed.
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Affiliation(s)
- Chiara Tirone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Neonatologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angela Paladini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Neonatologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flavio De Maio
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Chiara Tersigni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Clinica Ostetrica e Ginecologica, Rome, Italy
| | - Silvia D'Ippolito
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Clinica Ostetrica e Ginecologica, Rome, Italy
| | - Nicoletta Di Simone
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
| | - Francesca Romana Monzo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Santarelli
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Delia Mercedes Bianco
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Milena Tana
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Neonatologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Lio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Neonatologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicoletta Menzella
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Neonatologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Brunella Posteraro
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Lanzone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Dipartimento di Scienze della Vita e Sanitá Pubblica, Universitȧ Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Dipartimento di Scienze della Vita e Sanitá Pubblica, Universitȧ Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Fondazione Policlinico Universitario A. Gemelli IRCCS, U.O.C. di Neonatologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy.,Istituto di Clinica Pediatrica, Università Cattolica del Sacro Cuore, Rome, Italy
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Chen SM, Lin CP, Jan MS. Early Gut Microbiota Changes in Preterm Infants with Bronchopulmonary Dysplasia: A Pilot Case-Control Study. Am J Perinatol 2021; 38:1142-1149. [PMID: 32446254 DOI: 10.1055/s-0040-1710554] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD) is a complex chronic lung disease that primarily affects premature or critically ill infants. This pilot study investigated early changes in gut microbiota composition in BPD patients and explored the potential risk factors associated with these changes. STUDY DESIGN Preterm infants admitted to our neonatal intensive care unit with a gestational age of 26 to 32 weeks were prospectively surveyed and eligible for stool collection on days 7 and 28 of postnatal age between February 2016 and June 2017. A 16S rRNA sequencing approach was applied to compare the gut microbiota composition between the BPD group and controls. Multiple linear regression analysis was used to identify the predictor variables. RESULTS Eight subjects in the BPD group and 10 subjects in the preterm group were analyzed during the observation period. Actinobacteria, Proteobacteria, Bacteroidetes, and Firmicutes were the four dominant bacteria phyla of intestinal microflora. A significantly lower diversity of gut microbiota was observed in the BPD group compared with the preterm group on day 28 (number of observed operational taxonomic units, p = 0.034; abundance-based coverage estimator, p = 0.022; Shannon index, p = 0.028). Multiple linear regression analysis revealed that high Neonatal Therapeutic Intervention Scoring System score (≧19) at 24 hours was statistically significant in predicting the proportion of aerobic with facultative anaerobic bacteria on day 28 (p = 0.002). CONCLUSION Infants with BPD are prone to develop gut dysbiosis in early life. A higher severity of illness and treatment intensity may indicate a higher risk of disrupting an anaerobic environment in the gut during the first month of life. KEY POINTS · BPD patients are prone to develop gut dysbiosis.. · Lower diversity of gut microbiota.. · Higher risk of disrupting anaerobic environment..
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Affiliation(s)
- Shan-Ming Chen
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan.,Department of Pediatrics, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ching-Pin Lin
- Division of Hepatology and Gastroenterology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Biochemistry, Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
| | - Ming-Shiou Jan
- Institute of Biochemistry, Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan.,Immunology Research Center, Chung Shan Medical University, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Chung Shan Medical University, Taichung, Taiwan
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7
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Liu Y, Wang J, Wu C. Microbiota and Tuberculosis: A Potential Role of Probiotics, and Postbiotics. Front Nutr 2021; 8:626254. [PMID: 34026804 PMCID: PMC8138307 DOI: 10.3389/fnut.2021.626254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis attacking the lungs and other organs, is one of the most common infectious disease worldwide. According to the WHO's 2020 report, a quarter of the world's population were infected with M. tuberculosis, and ~1.4 million people died of TB. Therefore, TB is a significant public health concern, which requires cost-effective strategies for prevention and treatment. The microbiota has been considered as a “forgotten organ” and a complex dynamic ecosystem, which plays a significant role in many physiological processes, and its dysbiosis is closely associated with infectious disease. Recently, a few studies have indicated associations between TB and microbiota. This review summarizes studies concerning the alterations of the gut and respiratory microbiota in TB, and their relationship with host susceptibility to M. tuberculosis infection, indicating that microbiota signatures in different stages in TB progression could be considered as biomarkers for TB diagnosis and control. In addition, the potential role of probiotics and postbiotics in TB treatment was discussed.
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Affiliation(s)
- Yue Liu
- Key Laboratory of Medical Molecular Cell Biology of Shanxi Province, Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China.,The Provincial Key Laboratories for Prevention and Treatment of Major Infectious Diseases Shanxi, Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China
| | - Jiaqi Wang
- Key Laboratory of Medical Molecular Cell Biology of Shanxi Province, Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China.,The Provincial Key Laboratories for Prevention and Treatment of Major Infectious Diseases Shanxi, Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China
| | - Changxin Wu
- Key Laboratory of Medical Molecular Cell Biology of Shanxi Province, Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China.,The Provincial Key Laboratories for Prevention and Treatment of Major Infectious Diseases Shanxi, Institutes of Biomedical Sciences, Shanxi University, Taiyuan, China
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8
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Is the Newborn Microbiome Disrupted by Routine Newborn Suctioning? An Exploratory Approach for Policy Development. J Perinat Neonatal Nurs 2020; 34:231-238. [PMID: 32697543 DOI: 10.1097/jpn.0000000000000499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
An invasive procedure commonly used in the perinatal setting is newborn suctioning at birth. Routine newborn suctioning, without indication, is not recommended by the American Academy of Pediatrics, the American Heart Association, and the European Resuscitation Council for the newborn with spontaneous respirations, adequate crying, and good muscle tone. Whether to suction a newborn is a difficult practice decision made daily by the perinatal nurse. A primary element of this practice decision is the consideration that newborn suctioning has the potential to affect health outcomes. Furthermore, routine newborn suctioning may be disrupting the newborn microbiome by removing commensal bacteria and potentially, negatively affecting newborn health. This article will explore the connection between the practice of routine newborn suctioning in the perinatal setting and the potential to disrupt the newborn microbiome. The methods employed and reported in this article consisted of review of literature and review of clinical guidelines and a descriptive study to determine the scope of practice of newborn suctioning. The premise of whether the practice of routine newborn suctioning at birth may be disrupting the newborn microbiome will also be considered. Finally, developing a microbiome-centric perspective will be explored.
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Brewer MR, Maffei D, Cerise J, Ahn S, DeVoti J, Codipilly C, Lee A, Weinberger B. Determinants of the lung microbiome in intubated premature infants at risk for bronchopulmonary dysplasia. J Matern Fetal Neonatal Med 2019; 34:3220-3226. [PMID: 31736368 DOI: 10.1080/14767058.2019.1681961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Airway dysbiosis in premature infants may be associated with bronchopulmonary dysplasia (BPD). Early oropharyngeal colostrum (OPC) administration alters the oral microbiome, which may impact the lung microbiome. We aim to compare the oral and tracheal microbiota during the first week of life, and to determine whether early OPC administration affects microbial diversity or leukocyte inflammatory activity in the lung. METHODS Intubated premature infants (n = 42) were evaluated. The oral microbiome was characterized on day of life (DOL) 3, and the tracheal microbiome on DOL 3 and DOL 7, using 16S ribosomal DNA sequencing. Gene expression for inflammatory markers was quantified in airway leukocytes by real-time q-PCR. RESULTS The oral and tracheal microbiota were significantly different on DOL 3, but the tracheal microbiome on DOL 7 was more similar to the oral from DOL 3. Tracheal bacterial diversity decreased from DOL 3 to DOL 7. Longer time to first OPC administration tended to be associated with lower bacterial diversity in the airways. CONCLUSIONS The tracheal microbiome in intubated premature infants in the first week is likely determined, in part, by the composition of the oral microbiome. Bacterial diversity in intubated babies decreases during the first week of life, a pattern that could be consistent with risk for BPD. Decreased bacterial diversity and increased inflammatory activity in the lung may also be associated with delayed administration of OPC.
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Affiliation(s)
- Mariana R Brewer
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Lilling Family Neonatal Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, New Hyde Park, NY, USA
| | - Diana Maffei
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Lilling Family Neonatal Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, New Hyde Park, NY, USA
| | - Jane Cerise
- Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Great Neck, NY, USA
| | - Seungjun Ahn
- Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Great Neck, NY, USA
| | - James DeVoti
- Immunology and Inflammation, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Champa Codipilly
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Lilling Family Neonatal Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, New Hyde Park, NY, USA
| | - Annette Lee
- Translational Genetics, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Barry Weinberger
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, Lilling Family Neonatal Research Laboratory, Feinstein Institutes for Medical Research, Northwell Health, New Hyde Park, NY, USA
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10
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Grier A, McDavid A, Wang B, Qiu X, Java J, Bandyopadhyay S, Yang H, Holden-Wiltse J, Kessler HA, Gill AL, Huyck H, Falsey AR, Topham DJ, Scheible KM, Caserta MT, Pryhuber GS, Gill SR. Neonatal gut and respiratory microbiota: coordinated development through time and space. MICROBIOME 2018; 6:193. [PMID: 30367675 PMCID: PMC6204011 DOI: 10.1186/s40168-018-0566-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 09/28/2018] [Indexed: 05/09/2023]
Abstract
BACKGROUND Postnatal development of early life microbiota influences immunity, metabolism, neurodevelopment, and infant health. Microbiome development occurs at multiple body sites, with distinct community compositions and functions. Associations between microbiota at multiple sites represent an unexplored influence on the infant microbiome. Here, we examined co-occurrence patterns of gut and respiratory microbiota in pre- and full-term infants over the first year of life, a period critical to neonatal development. RESULTS Gut and respiratory microbiota collected as longitudinal rectal, throat, and nasal samples from 38 pre-term and 44 full-term infants were first clustered into community state types (CSTs) on the basis of their compositional profiles. Multiple methods were used to relate the occurrence of CSTs to temporal microbiota development and measures of infant maturity, including gestational age (GA) at birth, week of life (WOL), and post-menstrual age (PMA). Manifestation of CSTs followed one of three patterns with respect to infant maturity: (1) chronological, with CST occurrence frequency solely a function of post-natal age (WOL), (2) idiosyncratic to maturity at birth, with the interval of CST occurrence dependent on infant post-natal age but the frequency of occurrence dependent on GA at birth, and (3) convergent, in which CSTs appear first in infants of greater maturity at birth, with occurrence frequency in pre-terms converging after a post-natal interval proportional to pre-maturity. The composition of CSTs was highly dissimilar between different body sites, but the CST of any one body site was highly predictive of the CSTs at other body sites. There were significant associations between the abundance of individual taxa at each body site and the CSTs of the other body sites, which persisted after stringent control for the non-linear effects of infant maturity. Canonical correlations exist between the microbiota composition at each pair of body sites, with the strongest correlations between proximal locations. CONCLUSION These findings suggest that early microbiota is shaped by neonatal innate and adaptive developmental responses. Temporal progression of CST occurrence is influenced by infant maturity at birth and post-natal age. Significant associations of microbiota across body sites reveal distal connections and coordinated development of the infant microbial ecosystem.
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Affiliation(s)
- Alex Grier
- Genomics Research Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Andrew McDavid
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Bokai Wang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - James Java
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sanjukta Bandyopadhyay
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeanne Holden-Wiltse
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Haeja A Kessler
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Ann L Gill
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Heidie Huyck
- Medicine-Infectious Disease, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Ann R Falsey
- Medicine-Infectious Disease, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - David J Topham
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY, 14642, USA
- Center for Vaccine Biology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kristin M Scheible
- Division of Neonatology, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Mary T Caserta
- Division of Infectious Disease, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Gloria S Pryhuber
- Division of Neonatology, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Steven R Gill
- Genomics Research Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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11
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Sterile Inflammation Enhances ECM Degradation in Integrin β1 KO Embryonic Skin. Cell Rep 2018; 16:3334-3347. [PMID: 27653694 DOI: 10.1016/j.celrep.2016.08.062] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/14/2016] [Accepted: 08/18/2016] [Indexed: 01/02/2023] Open
Abstract
Epidermal knockout of integrin β1 results in complete disorganization of the basement membrane (BM), resulting in neonatal lethality. Here, we report that this disorganization is exacerbated by an early embryonic inflammatory response involving the recruitment of tissue-resident and monocyte-derived macrophages to the dermal-epidermal junction, associated with increased matrix metalloproteinase activity. Remarkably, the skin barrier in the integrin β1 knockout animals is intact, suggesting that this inflammatory response is initiated in a sterile environment. We demonstrate that the molecular mechanism involves de novo expression of integrin αvβ6 in the basal epidermal cells, which activates a TGF-β1 driven inflammatory cascade resulting in upregulation of dermal NF-κB in a Tenascin C-dependent manner. Importantly, treatment of β1 KO embryos in utero with small molecule inhibitors of TGF-βR1 and NF-κB results in marked rescue of the BM defects and amelioration of immune response, revealing an unconventional immuno-protective role for integrin β1 during BM remodeling.
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12
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Pearl JE, Das M, Cooper AM. Immunological roulette: Luck or something more? Considering the connections between host and environment in TB. Cell Mol Immunol 2018; 15:226-232. [PMID: 29375129 DOI: 10.1038/cmi.2017.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/24/2017] [Accepted: 10/29/2017] [Indexed: 02/07/2023] Open
Abstract
Accurate prediction of which patient will progress from a sub-clinical Mycobacterium tuberculosis infection to active tuberculosis represents an elusive, yet critical, clinical research objective. From the individual perspective, progression can be considered to be the product of a series of unfortunate events or even a run of bad luck. Here, we identify the subtle physiological relationships that can influence the odds of progression to active TB and how this progression may reflect directed dysbiosis in a number of interrelated systems. Most infected individuals who progress to disease have apparently good immune responses, but these responses are, at times, compromised by either local or systemic environmental factors. Obvious disease promoting processes, such as tissue-damaging granulomata, usually manifest in the lung, but illness is systemic. This apparent dichotomy between local and systemic reflects a clear need to define the factors that promote progression to active disease within the context of the body as a physiological whole. We discuss aspects of the host environment that can impact expression of immunity, including the microbiome, glucocorticoid-mediated regulation, catecholamines and interaction between the gut, liver and lung. We suggest the importance of integrating precision medicine into our analyses of experimental outcomes such that apparently conflicting results are not contentious, but rather reflect the impact of these subtle relationships with our environment and microbiota.
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Affiliation(s)
- John E Pearl
- Leicester Tuberculosis Research Group (LTBRG), Department of Infection Immunity and Inflammation, University of Leicester, University Road, Leicester LE1 7RH, UK
| | - Mrinal Das
- Leicester Tuberculosis Research Group (LTBRG), Department of Infection Immunity and Inflammation, University of Leicester, University Road, Leicester LE1 7RH, UK
| | - Andrea M Cooper
- Leicester Tuberculosis Research Group (LTBRG), Department of Infection Immunity and Inflammation, University of Leicester, University Road, Leicester LE1 7RH, UK
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13
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Vientós-Plotts AI, Ericsson AC, Rindt H, Grobman ME, Graham A, Bishop K, Cohn LA, Reinero CR. Dynamic changes of the respiratory microbiota and its relationship to fecal and blood microbiota in healthy young cats. PLoS One 2017; 12:e0173818. [PMID: 28278278 PMCID: PMC5344508 DOI: 10.1371/journal.pone.0173818] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/27/2017] [Indexed: 12/15/2022] Open
Abstract
Advances in the field of metagenomics using culture-independent methods of microbial identification have allowed characterization of rich and diverse communities of bacteria in the lungs of healthy humans, mice, dogs, sheep and pigs. These data challenge the long held belief that the lungs are sterile and microbial colonization is synonymous with pathology. Studies in humans and animals demonstrate differences in the composition of airway microbiota in health versus disease suggesting respiratory dysbiosis occurs. Using 16S rRNA amplicon sequencing of DNA extracted from rectal and oropharyngeal (OP) swabs, bronchoalveolar lavage fluid (BALF), and blood, our objective was to characterize the fecal, OP, blood, and lower airway microbiota over time in healthy cats. This work in healthy cats, a species in which a respiratory microbiota has not yet been characterized, sets the stage for future studies in feline asthma in which cats serve as a comparative and translational model for humans. Fecal, OP and BALF samples were collected from six healthy research cats at day 0, week 2, and week 10; blood was collected at week 10. DNA was extracted, amplified via PCR, and sequenced using the Illumina MiSeq platform. Representative operational taxonomic units (OTUs) were identified and microbial richness and diversity were assessed. Principal component analysis (PCA) was used to visualize relatedness of samples and PERMANOVA was used to test for significant differences in microbial community composition. Fecal and OP swabs provided abundant DNA yielding a mean±SEM of 65,653±6,145 and 20,6323±4,360 sequences per sample, respectively while BALF and blood samples had lower coverage (1,489±430 and 269±18 sequences per sample, respectively). Oropharyngeal and fecal swabs were significantly richer than BALF (mean number OTUs 93, 88 and 36, respectively; p < 0.001) with no significant difference (p = 0.180) in richness between time points. PCA revealed site-specific microbial communities in the feces, and upper and lower airways. In comparison, blood had an apparent compositional similarity with BALF with regard to a few dominant taxa, but shared more OTUs with feces. Samples clustered more by time than by individual, with OP swabs having subjectively greater variation than other samples. In summary, healthy cats have a rich and distinct lower airway microbiome with dynamic bacterial populations. The microbiome is likely to be altered by factors such as age, environmental influences, and disease states. Further data are necessary to determine how the distinct feline microbiomes from the upper and lower airways, feces and blood are established and evolve. These data are relevant for comparisons between healthy cats and cats with respiratory disease.
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Affiliation(s)
- Aida I. Vientós-Plotts
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Comparative Internal Medicine Laboratory, University of Missouri, Columbia, Missouri, United States of America
| | - Aaron C. Ericsson
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- University of Missouri Metagenomics Center, University of Missouri, Columbia, Missouri, United States of America
- Department of Veterinary Pathobiology, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- * E-mail: (ACE); (CRR)
| | - Hansjorg Rindt
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Comparative Internal Medicine Laboratory, University of Missouri, Columbia, Missouri, United States of America
| | - Megan E. Grobman
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Comparative Internal Medicine Laboratory, University of Missouri, Columbia, Missouri, United States of America
| | - Amber Graham
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
| | - Kaitlin Bishop
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
| | - Leah A. Cohn
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Comparative Internal Medicine Laboratory, University of Missouri, Columbia, Missouri, United States of America
| | - Carol R. Reinero
- College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri, United States of America
- Comparative Internal Medicine Laboratory, University of Missouri, Columbia, Missouri, United States of America
- * E-mail: (ACE); (CRR)
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14
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Abstract
The respiratory tract, once believed to be sterile, harbors diverse bacterial communities. The role of microorganisms within health and disease is slowly being unraveled. Evidence points to the neonatal period as a critical time for establishing stable bacterial communities and influencing immune responses important for long-term respiratory health. This review summarizes the evidence of early airway and lung bacterial colonization and the role the microbiome has on respiratory health in the short and long term. The challenges of neonatal respiratory microbiome studies and future research directions are also discussed.
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Affiliation(s)
- David J Gallacher
- Department of Child Health, School of Medicine, Cardiff University , Cardiff , UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University , Cardiff , UK
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15
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Miller WB. The Eukaryotic Microbiome: Origins and Implications for Fetal and Neonatal Life. Front Pediatr 2016; 4:96. [PMID: 27668211 PMCID: PMC5016513 DOI: 10.3389/fped.2016.00096] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/30/2016] [Indexed: 12/12/2022] Open
Abstract
All eukaryotic organisms are holobionts representing complex collaborations between the entire microbiome of each eukaryote and its innate cells. These linked constituencies form complex localized and interlocking ecologies in which the specific microbial constituents and their relative abundance differ substantially according to age and environmental exposures. Rapid advances in microbiology and genetic research techniques have uncovered a significant previous underestimate of the extent of that microbial contribution and its metabolic and developmental impact on holobionts. Therefore, a re-calibration of the neonatal period is suggested as a transitional phase in development that includes the acquisition of consequential collaborative microbial life from extensive environmental influences. These co-dependent, symbiotic relationships formed in the fetal and neonatal stages extend into adulthood and even across generations.
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Affiliation(s)
- William B Miller
- Independent Researcher, Previously affiliated with Pinnacle Health , Harrisburg, PA , USA
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16
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Abstract
Premature infants suffer significant respiratory morbidity during infancy with long-term negative consequences on health, quality of life, and health care costs. Enhanced susceptibility to a variety of infections and inflammation play a large role in early and prolonged lung disease following premature birth, although the mechanisms of susceptibility and immune dysregulation are active areas of research. This article reviews aspects of host-pathogen interactions and immune responses that are altered by preterm birth and that impact chronic respiratory morbidity in these children.
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Affiliation(s)
- Gloria S. Pryhuber
- Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 651, Rochester, NY 14642, USA,Department of Environmental Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA,Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 651, Rochester, NY 14642.
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17
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Curstedt T, Halliday HL, Hallman M, Saugstad OD, Speer CP. 30 years of surfactant research - from basic science to new clinical treatments for the preterm infant. Neonatology 2015; 107:314-6. [PMID: 26044097 DOI: 10.1159/000381160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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