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Serrao F, Tiberi E, Verdolotti T, Romeo DMM, Corsello M, Pede E, Cota F, Costa S, Gallini F, Colosimo C, Mercuri EM, Vento G. pCO2 values in asphyxiated infants under therapeutic hypothermia after tailored respiratory management: a retrospective cohort study. Front Pediatr 2024; 11:1293526. [PMID: 38322242 PMCID: PMC10844519 DOI: 10.3389/fped.2023.1293526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/29/2023] [Indexed: 02/08/2024] Open
Abstract
Background Hypoxic-ischemic encephalopathy (HIE) represents one of the major causes of neonatal death and long-term neurological disability. Both hypoxic-ischemic insults and therapeutic hypothermia (TH) can affect respiratory function. Currently, there is no evidence regarding optimal respiratory management in these infants. Methods This is a retrospective cohort study examining newborns with HIE treated with TH between January 2015 and September 2020. The study population was divided into two groups based on different respiratory assistance during TH: spontaneous breathing (Group A) or mechanical ventilation (Group B). The primary outcome of the study was the mean pCO2 ± SD evaluation during TH in ventilated and non-ventilated asphyxiated infants. The secondary outcome was the correlation between ventilation strategy and short-term neurologic outcome according to Rutherford et al.'s MRI scoring system. Results A total of 126 newborns were enrolled, 75 in Group A and 51 in Group B. Respiratory management was individualized, and volume guarantee (VG) ventilation was the first choice for ventilated infants. Group B infants showed more severe conditions at birth. During TH, ventilated infants showed optimal mean pCO2 comparable with those breathing spontaneously (40.6 mmHg vs. 42.3 mmHg, respectively, p 0.091), with no significant difference in pCO2 standard deviation between (7.7 mmHg vs. 8.1 mmHg, respectively, p 0.522). Mean pH, pH standard deviation, mean pO2, pO2 standard deviation, and mean respiratory rate also did not differ between groups. MRI patterns of brain injury predictive of abnormal neurodevelopmental outcomes were similar in both groups. Logistic regression analysis demonstrated that only umbilical cord arterial blood pH-affected MRI lesions were associated with poor neurodevelopmental outcomes (OR 1.505; CI 95% 1.069-2.117). Conclusions Infants cooled after HIE should receive individualized respiratory management, not necessarily involving intubation. In those infants requiring mechanical ventilation, a volume-targeted strategy appeared to be effective in maintaining stable blood gas levels. Short-term neurological outcomes appeared comparable in ventilated and non-ventilated infants.
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Affiliation(s)
- Francesca Serrao
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eloisa Tiberi
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Tommaso Verdolotti
- Radiology and Neuroradiology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Domenico Marco Maurizio Romeo
- Pediatric Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Mirta Corsello
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elisa Pede
- Pediatric Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Francesco Cota
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Simonetta Costa
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Gallini
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cesare Colosimo
- Radiology and Neuroradiology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Eugenio Maria Mercuri
- Pediatric Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Giovanni Vento
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Devi U, Pullattayil AK, Chandrasekaran M. Hypocarbia is associated with adverse outcomes in hypoxic ischaemic encephalopathy (HIE). Acta Paediatr 2023; 112:635-641. [PMID: 36662594 DOI: 10.1111/apa.16679] [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: 12/03/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
AIM Hypocarbia in the early postnatal period might exacerbate brain injury in babies with hypoxic ischaemic encephalopathy following birth asphyxia. This mini-review summarised studies on pCO2 values that were monitored periodically in term newborns with moderate/severe hypoxic-ischaemic encephalopathy and correlated with short or long-term outcomes. METHODS We searched the databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), web of science and the Cochrane Library and identified nine studies. RESULTS Among the nine included studies, therapeutic hypothermia was administered in seven studies. In most studies, blood pCO2 levels were measured from birth till 72 h of life or till the endpoint of therapeutic hypothermia. Eight studies showed that any hypocarbia (moderate or severe, or cumulative) was associated with an increased risk of adverse outcomes in the form of brain injury in MRI, death or neurodevelopmental disability. CONCLUSION Hypocarbia could lead to adverse short-term and long-term outcomes despite therapeutic hypothermia in neonates with HIE. Hence, it is vital to monitor pCO2 levels closely in these infants and consider strategies to maintain pCO2 levels in the normal range.
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Affiliation(s)
- Usha Devi
- Neonatology, All India Institute of Medical Sciences, Bhubaneswar, India
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Carbon dioxide levels in neonates: what are safe parameters? Pediatr Res 2022; 91:1049-1056. [PMID: 34230621 PMCID: PMC9122818 DOI: 10.1038/s41390-021-01473-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 02/01/2023]
Abstract
There is no consensus on the optimal pCO2 levels in the newborn. We reviewed the effects of hypercapnia and hypocapnia and existing carbon dioxide thresholds in neonates. A systematic review was conducted in accordance with the PRISMA statement and MOOSE guidelines. Two hundred and ninety-nine studies were screened and 37 studies included. Covidence online software was employed to streamline relevant articles. Hypocapnia was associated with predominantly neurological side effects while hypercapnia was linked with neurological, respiratory and gastrointestinal outcomes and Retinpathy of prematurity (ROP). Permissive hypercapnia did not decrease periventricular leukomalacia (PVL), ROP, hydrocephalus or air leaks. As safe pCO2 ranges were not explicitly concluded in the studies chosen, it was indirectly extrapolated with reference to pCO2 levels that were found to increase the risk of neonatal disease. Although PaCO2 ranges were reported from 2.6 to 8.7 kPa (19.5-64.3 mmHg) in both term and preterm infants, there are little data on the safety of these ranges. For permissive hypercapnia, parameters described for bronchopulmonary dysplasia (BPD; PaCO2 6.0-7.3 kPa: 45.0-54.8 mmHg) and congenital diaphragmatic hernia (CDH; PaCO2 ≤ 8.7 kPa: ≤65.3 mmHg) were identified. Contradictory findings on the effectiveness of permissive hypercapnia highlight the need for further data on appropriate CO2 parameters and correlation with outcomes. IMPACT: There is no consensus on the optimal pCO2 levels in the newborn. There is no consensus on the effectiveness of permissive hypercapnia in neonates. A safe range of pCO2 of 5-7 kPa was inferred following systematic review.
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Williams E, Dassios T, O'Reilly N, Walsh A, Greenough A. End-tidal capnography monitoring in infants ventilated on the neonatal intensive care unit. J Perinatol 2021; 41:1718-1724. [PMID: 33649438 PMCID: PMC7917950 DOI: 10.1038/s41372-021-00978-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess whether end-tidal capnography (EtCO2) monitoring reduced the magnitude of difference in carbon dioxide (CO2) levels and the number of blood gases in ventilated infants. STUDY DESIGN A case-control study of a prospective cohort (n = 36) with capnography monitoring and matched historical controls (n = 36). RESULT The infants had a median gestational age of 31.6 weeks. A reduction in the highest CO2 level on day 1 after birth was observed after the introduction of EtCO2 monitoring (p = 0.043). There was also a reduction in the magnitude of difference in CO2 levels on days 1 (p = 0.002) and 4 (p = 0.049) after birth. There was no significant difference in the number of blood gases. CONCLUSION Continuous end-tidal capnography monitoring in ventilated infants was associated with a reduction in the degree of the magnitude of difference in CO2 levels and highest level of CO2 on the first day after birth.
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Affiliation(s)
- Emma Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Niamh O'Reilly
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison Walsh
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.
- NIHR Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
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End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage. Eur J Pediatr 2020; 179:555-559. [PMID: 31848749 PMCID: PMC7080666 DOI: 10.1007/s00431-019-03543-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/18/2022]
Abstract
Abnormal levels of end-tidal carbon dioxide (EtCO2) during resuscitation in the delivery suite are associated with intraventricular haemorrhage (IVH) development. Our aim was to determine whether carbon dioxide (CO2) levels in the first 3 days after birth reflected abnormal EtCO2 levels in the delivery suite, and hence, a prolonged rather than an early insult resulted in IVH. In addition, we determined if greater EtCO2level fluctuations during resuscitation occurred in infants who developed IVH. EtCO2 levels during delivery suite resuscitation and CO2 levels on the neonatal unit were evaluated in 58 infants (median gestational age 27.3 weeks). Delta EtCO2 was the difference between the highest and lowest level of EtCO2. Thirteen infants developed a grade 3-4 IVH (severe group). There were no significant differences in CO2 levels between those who did and did not develop an IVH (or severe IVH) on the NICU. The delta EtCO2 during resuscitation differed between infants with any IVH (6.2 (5.4-7.5) kPa) or no IVH (3.8 (2.7-4.3) kPA) (p < 0.001) after adjusting for differences in gestational age. Delta EtCO2 levels gave an area under the ROC curve of 0.940 for prediction of IVH.Conclusion: The results emphasize the importance of monitoring EtCO2 levels in the delivery suite.What is Known:• Abnormal levels of carbon dioxide (CO2) in the first few days after birth and abnormal end-tidal CO2levels (EtCO2) levels during resuscitation are associated in preterm infants with the risk of developing intraventricular haemorrhage (IVH).What is New:• There were no significant differences in NICU CO2levels between those who developed an IVH or no IVH.• There was a poor correlation between delivery suite ETCO2levels and NICU CO2levels.• Large fluctuations in EtCO2during resuscitation in the delivery suite were highly predictive of IVH development in preterm infants.
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Lemyre B, Chau V. L’hypothermie pour les nouveau-nés atteints d’encéphalopathie hypoxo-ischémique. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxy051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brigitte Lemyre
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Vann Chau
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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Lemyre B, Chau V. Hypothermia for newborns with hypoxic-ischemic encephalopathy. Paediatr Child Health 2018; 23:285-291. [PMID: 30657134 DOI: 10.1093/pch/pxy028] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Therapeutic hypothermia is a standard of care for infants ≥36 weeks gestational age (GA) with moderate-to-severe hypoxic-ischemic encephalopathy. Because some studies included infants born at 35 weeks GA, hypothermia should be considered if they meet other criteria. Cooling for infants <35 weeks GA is not recommended. Passive cooling should be started promptly in community centres, in consultation with a tertiary care centre neonatologist, while closely monitoring the infant's temperature. Best evidence suggests that maintaining core body temperature between 33°C and 34°C for 72 hours, followed by a period of rewarming of 6 to 12 hours, is optimal. Antiepileptic medications should be used when clinical or electrographic seizures are present. Maintaining serum electrolytes and glucose within normal ranges, and avoiding hypo- or hypercarbia and hyperoxia, are important adjunct treatments. A brain magnetic resonance image (MRI) is advised shortly after rewarming and, in cases where earlier findings do not match the clinical picture, a repeat MRI after 10 days of life is suggested. Multidisciplinary neurodevelopmental follow-up is recommended.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Vann Chau
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Dix LML, Weeke LC, de Vries LS, Groenendaal F, Baerts W, van Bel F, Lemmers PMA. Carbon Dioxide Fluctuations Are Associated with Changes in Cerebral Oxygenation and Electrical Activity in Infants Born Preterm. J Pediatr 2017; 187:66-72.e1. [PMID: 28578157 DOI: 10.1016/j.jpeds.2017.04.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/05/2017] [Accepted: 04/20/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the effects of acute arterial carbon dioxide partial pressure changes on cerebral oxygenation and electrical activity in infants born preterm. STUDY DESIGN This retrospective observational study included ventilated infants born preterm with acute fluctuations of continuous end-tidal CO2 (etCO2) as a surrogate marker for arterial carbon dioxide partial pressure, during the first 72 hours of life. Regional cerebral oxygen saturation and fractional tissue oxygen extraction were monitored with near-infrared spectroscopy. Brain activity was monitored with 2-channel electroencephalography. Spontaneous activity transients (SATs) rate (SATs/minute) and interval between SATs (in seconds) were calculated. Ten-minute periods were selected for analysis: before, during, and after etCO2 fluctuations of ≥5 mm Hg. RESULTS Thirty-eight patients (mean ± SD gestational age of 29 ± 1.8 weeks) were included, with 60 episodes of etCO2 increase and 70 episodes of etCO2 decrease. During etCO2 increases, brain oxygenation increased (regional cerebral oxygen saturation increased, fractional tissue oxygen extraction decreased; P < .01) and electrical activity decreased (SATs/minute decreased, interval between SATs increased; P < .01). All measures recovered when etCO2 returned to baseline. During etCO2 decreases, brain oxygenation decreased (regional cerebral oxygen saturation decreased, fractional tissue oxygen extraction decreased; P < .01) and brain activity increased (SATs/minute increased, P < .05), also with recovery after return of etCO2 to baseline. CONCLUSION An acute increase in etCO2 is associated with increased cerebral oxygenation and decreased brain activity, whereas an acute decrease is associated with decreased cerebral oxygenation and slightly increased brain activity. Combining continuous CO2 monitoring with near-infrared spectroscopy may enable the detection of otherwise undetected fluctuations in arterial carbon dioxide partial pressure that may be harmful to the neonatal brain.
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Affiliation(s)
- Laura Marie Louise Dix
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Lauren Carleen Weeke
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Linda Simone de Vries
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Willem Baerts
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Petra Maria Anna Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands.
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Chandrasekharan PK, Rawat M, Nair J, Gugino SF, Koenigsknecht C, Swartz DD, Vali P, Mathew B, Lakshminrusimha S. Continuous End-Tidal Carbon Dioxide Monitoring during Resuscitation of Asphyxiated Term Lambs. Neonatology 2016; 109:265-73. [PMID: 26866711 PMCID: PMC4893001 DOI: 10.1159/000443303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/12/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program (NRP) recommends close monitoring of oxygenation during the resuscitation of newborns using a pulse oximeter. However, there are no guidelines for monitoring carbon dioxide (CO2) to assess ventilation. Considering that cerebral blood flow (CBF) correlates directly with PaCO2, continuous capnography monitoring of end-tidal CO2 (ETCO2) may limit fluctuations in PaCO2 and, therefore, CBF during resuscitation of asphyxiated infants. OBJECTIVE To evaluate whether continuous monitoring of ETCO2 with capnography during resuscitation of asphyxiated term lambs with meconium aspiration will prevent fluctuations in PaCO2 and carotid arterial blood flow (CABF). METHODS Fifty-four asphyxiated term lambs with meconium aspiration syndrome were mechanically ventilated from birth to 60 min of age. Ventilatory parameters were adjusted based on clinical observation (chest excursion) and frequent arterial blood gas analysis in 24 lambs (control group) and 30 lambs (capnography group) received additional continuous ETCO2 monitoring. Left CABF was monitored. We aimed to maintain PaCO2 between 35 and 50 mm Hg and ETCO2 between 30 and 45 mm Hg. RESULTS There was a significant correlation between ETCO2 and PaCO2 (R = 0.7, p < 0.001), between PaCO2 and carotid flow (R = 0.52, p < 0.001) and between ETCO2 and carotid flow (R = 0.5, p < 0.001). PaCO2 and CABF during the first 60 min of age showed significantly higher fluctuation in the control group compared to the capnography group. CONCLUSION Continuous monitoring of ETCO2 using capnography with mechanical ventilation during and after resuscitation in asphyxiated term lambs with meconium aspiration limits fluctuations in PaCO2 and CABF and may potentially limit brain injury.
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Shen Y, Wang Z, Wang J, Zhou Y, Chen H, Wu C, Haapasalo M. Bifunctional bioceramics stimulating osteogenic differentiation of a gingival fibroblast and inhibiting plaque biofilm formation. Biomater Sci 2016; 4:639-51. [DOI: 10.1039/c5bm00534e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A bifunctional Ca–Mg–Si bioceramic induces osteogenic differentiation of gingival fibroblasts and inhibits plaque biofilm formation.
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Affiliation(s)
- Ya Shen
- Division of Endodontics
- Oral Biological & Medical Sciences
- School of Dentistry
- University of British Columbia
- Vancouver BC
| | - Zhejun Wang
- Division of Endodontics
- Oral Biological & Medical Sciences
- School of Dentistry
- University of British Columbia
- Vancouver BC
| | - Jiao Wang
- Laboratory of Molecular Neural Biology
- School of Life Sciences
- Shanghai University
- Shanghai 200444
- China
| | - Yinghong Zhou
- Institute of Health & Biomedical Innovation
- Queensland University of Technology
- Brisbane
- Australia
| | - Hui Chen
- Department of Conservative Dentistry and Periodontics
- Affiliated Hospital of Stomatology
- Medical College
- Zhejiang University
- Hangzhou
| | - Chengtie Wu
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure
- Shanghai Institute of Ceramics
- Chinese Academy of Sciences
- Shanghai 200050
- People's Republic of China
| | - Markus Haapasalo
- Division of Endodontics
- Oral Biological & Medical Sciences
- School of Dentistry
- University of British Columbia
- Vancouver BC
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