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Cedzyński M, Świerzko AS. Collectins and ficolins in neonatal health and disease. Front Immunol 2023; 14:1328658. [PMID: 38193083 PMCID: PMC10773719 DOI: 10.3389/fimmu.2023.1328658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/04/2023] [Indexed: 01/10/2024] Open
Abstract
The immune system starts to develop early in embryogenesis. However, at birth it is still immature and associated with high susceptibility to infection. Adaptation to extrauterine conditions requires a balance between colonization with normal flora and protection from pathogens. Infections, oxidative stress and invasive therapeutic procedures may lead to transient organ dysfunction or permanent damage and perhaps even death. Newborns are primarily protected by innate immune mechanisms. Collectins (mannose-binding lectin, collectin-10, collectin-11, collectin-12, surfactant protein A, surfactant protein D) and ficolins (ficolin-1, ficolin-2, ficolin-3) are oligomeric, collagen-related defence lectins, involved in innate immune response. In this review, we discuss the structure, specificity, genetics and role of collectins and ficolins in neonatal health and disease. Their clinical associations (protective or pathogenic influence) depend on a variety of variables, including genetic polymorphisms, gestational age, method of delivery, and maternal/environmental microflora.
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Affiliation(s)
- Maciej Cedzyński
- Laboratory of Immunobiology of Infections, Institute of Medical Biology, Polish Academy of Sciences, Łódź, Poland
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Emery L, Kane E, Anderson-Fears K, Liu D, Floros J, Gandhi CK. Association of surfactant protein A2 with acute respiratory failure in children. Pediatr Int 2023; 65:e15672. [PMID: 37888536 PMCID: PMC10617656 DOI: 10.1111/ped.15672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Interactions among single nucleotide polymorphisms (SNPs) of surfactant protein (SP) are associated with acute respiratory failure (ARF) and its short-term outcome, pulmonary dysfunction at discharge (PDAD) in children. However, genetic association studies using individual SNPs have not been conducted before. We hypothesize that SP genetic variants are associated with pediatric ARF and its short-term complications by themselves. METHODS We used available genotype and clinical data in the Floros biobank consisting of 248 children aged ≤24 months with ARF; 86 developed PDAD. A logistic regression analysis was performed for each of the 14 selected SNPs, SP-A1 and SP-A2 genotypes. A p-value less than the Bonferroni correction threshold was considered significant. A likelihood ratio test was done to compare two models (one with demographic data and another with genetic variants). RESULTS Before Bonferroni correction, female sex is associated with a decreased risk of ARF. Black race and the rs721917 of the SFTPD are associated with increased risk of ARF. After Bonferroni correction, the 1A0 1A1 genotype of SFTPA2 was associated with decreased risk of ARF. The likelihood ratio test showed that the model of the genotype information with demographic data was a better fit to predict ARF risk. None of the SP SNPs and SP-A1, SP-A2 genotypes were associated with PDAD. CONCLUSION Our results indicate that SNPs and genotypes of SPs involved in innate immunity and host defense play an important role in ARF and, in the future, may be used as biomarkers.
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Affiliation(s)
- Lucy Emery
- Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Elizabeth Kane
- Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Keenan Anderson-Fears
- Department of Public Health Science, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Dajiang Liu
- Department of Public Health Science, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Joanna Floros
- Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Obstetrics & Gynecology, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Chintan K Gandhi
- Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, Pennsylvania, United States of America
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Takahashi T, Takahashi Y, Fee EL, Usuda H, Furfaro L, Newnham JP, Jobe AH, Kemp MW. Single nucleotide polymorphisms in surfactant protein A1 are not associated with a lack of responsiveness to antenatal steroid therapy in a pregnant sheep model. Physiol Rep 2022; 10:e15477. [PMID: 36200269 PMCID: PMC9535346 DOI: 10.14814/phy2.15477] [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] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 06/16/2023] Open
Abstract
Treatment with antenatal steroids (ANS) is standard practice for reducing the risk of respiratory distress in the preterm infant. Despite clear overall benefits when appropriately administered, many fetuses fail to derive benefit from ANS therapies. In standardized experiments using a pregnant sheep model, we have demonstrated that around 40% of ANS-exposed lambs did not have functional lung maturation significantly different from that of saline-treated controls. Surfactant protein A is known to play an important role in lung function. In this genotyping study, we investigated the potential correlation between polymorphisms in SFTPA1, messenger RNA and protein levels, and ventilation outcomes in animals treated with ANS. 45 preterm lambs were delivered 48 h after initial ANS therapy and 44 lambs were delivered 8 days after initial ANS therapy. The lambs were ventilated for 30 min after delivery. SFTPA1 mRNA expression in lung tissue was not correlated with arterial blood PaCO2 values at 30 min of ventilation in lambs delivered 48 h after treatment. SFTPA1 protein in lung tissue was significantly correlated with PaCO2 at 30 min of ventilation in lambs ventilated both 48 h and 8 days after ANS treatment. Six different single nucleotide polymorphisms (SNPs) in the Ovis aries SFTPA1 sequence were detected by Sanger Sequencing. No individual SNPs or SNP haplotypes correlated with alterations in PaCO2 at 30 min of ventilation or SFTPA1 protein levels in the lung. For the subset of animals analyzed in the present study, variable lung maturation responses to ANS therapy were not associated with mutations in SFTPA1.
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Affiliation(s)
- Tsukasa Takahashi
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Centre for Perinatal and Neonatal MedicineTohoku University HospitalSendaiJapan
| | - Yuki Takahashi
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Centre for Perinatal and Neonatal MedicineTohoku University HospitalSendaiJapan
| | - Erin L. Fee
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Haruo Usuda
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Centre for Perinatal and Neonatal MedicineTohoku University HospitalSendaiJapan
| | - Lucy Furfaro
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - John P. Newnham
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Alan H. Jobe
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Perinatal Research, Department of PediatricsCincinnati Children's Hospital Medical Centre, University of CincinnatiCincinnatiOhioUSA
| | - Matthew W. Kemp
- Division of Obstetrics and GynaecologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Centre for Perinatal and Neonatal MedicineTohoku University HospitalSendaiJapan
- School of Veterinary and Life SciencesMurdoch UniversityPerthWestern AustraliaAustralia
- Department of Obstetrics and GynaecologyYong Loo Lin School of Medicine, National University of SingaporeSingapore
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Depicolzuane LC, Roberts CM, Thomas NJ, Anderson-Fears K, Liu D, Barbosa JPP, Souza FR, Pimentel AS, Floros J, Gandhi CK. Hydrophilic But Not Hydrophobic Surfactant Protein Genetic Variants Are Associated With Severe Acute Respiratory Syncytial Virus Infection in Children. Front Immunol 2022; 13:922956. [PMID: 35903101 PMCID: PMC9317530 DOI: 10.3389/fimmu.2022.922956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infection-related hospitalization in the first year of life. Surfactant dysfunction is central to pathophysiologic mechanisms of various pulmonary diseases including RSV. We hypothesized that RSV severity is associated with single nucleotide polymorphisms (SNPs) of surfactant proteins (SPs). We prospectively enrolled 405 RSV-positive children and divided them into moderate and severe RSV disease. DNA was extracted and genotyped for sixteen specific SP gene SNPs. SP-A1 and A2 haplotypes were assigned. The association of RSV severity with SP gene SNPs was investigated by multivariate logistic regression. A likelihood ratio test was used to test the goodness of fit between two models (one with clinical and demographic data alone and another that included genetic variants). p ≤ 0.05 denotes statistical significance. A molecular dynamics simulation was done to determine the impact of the SFTPA2 rs1965708 on the SP-A behavior under various conditions. Infants with severe disease were more likely to be younger, of lower weight, and exposed to household pets and smoking, as well as having co-infection on admission. A decreased risk of severe RSV was associated with the rs17886395_C of the SFTPA2 and rs2243639_A of the SFTPD, whereas an increased risk was associated with the rs1059047_C of the SFTPA1. RSV severity was not associated with SNPs of SFTPB and SFTPC. An increased risk of severe RSV was associated with the 1A0 genotype of SFTPA2 in its homozygous or heterozygous form with 1A3. A molecular dynamic simulation study of SP-A variants that differ in amino acid 223, an important amino acid change (Q223K) between 1A0 and 1A3, showed no major impact on the behavior of these two variants except for higher thermodynamic stability of the K223 variant. The likelihood ratio test showed that the model with multi-allelic variants along with clinical and demographic data was a better fit to predict RSV severity. In summary, RSV severity was associated with hydrophilic (but not with hydrophobic) SPs gene variants. Collectively, our findings show that SP gene variants may play a key role in RSV infection and have a potential role in prognostication.
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Affiliation(s)
- Lynnlee C. Depicolzuane
- Center for Host defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, PA, United States
| | - Catherine M. Roberts
- Center for Host defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, PA, United States
| | - Neal J. Thomas
- Center for Host defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, PA, United States
| | - Keenan Anderson-Fears
- Department of Public Health Science, The Pennsylvania State College of Medicine, Hershey, PA, United States
| | - Dajiang Liu
- Department of Public Health Science, The Pennsylvania State College of Medicine, Hershey, PA, United States
| | | | - Felipe Rodrigues Souza
- Departamento de Química, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - André Silva Pimentel
- Departamento de Química, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joanna Floros
- Center for Host defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, PA, United States
- Department of Obstetrics & Gynecology, The Pennsylvania State College of Medicine, Hershey, PA, United States
- *Correspondence: Joanna Floros, ; Chintan K. Gandhi,
| | - Chintan K. Gandhi
- Center for Host defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, The Pennsylvania State College of Medicine, Hershey, PA, United States
- *Correspondence: Joanna Floros, ; Chintan K. Gandhi,
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Abbasi A, Chen C, Gandhi CK, Wu R, Pardo A, Selman M, Floros J. Single Nucleotide Polymorphisms (SNP) and SNP-SNP Interactions of the Surfactant Protein Genes Are Associated With Idiopathic Pulmonary Fibrosis in a Mexican Study Group; Comparison With Hypersensitivity Pneumonitis. Front Immunol 2022; 13:842745. [PMID: 35720392 PMCID: PMC9201215 DOI: 10.3389/fimmu.2022.842745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/09/2022] [Indexed: 01/12/2023] Open
Abstract
Surfactant proteins (SPs) are important for normal lung function and innate immunity of the lungs and their genes have been identified with significant genetic variability. Changes in quantity or quality of SPs due to genetic mutations or natural genetic variability may alter their functions and contribute to the host susceptibility for particular diseases. Alternatively, SP single nucleotide polymorphisms (SNPs) can serve as markers to identify disease risk or response to therapies, as shown for other genes in a number of other studies. In the current study, we evaluated associations of SFTP SNPs with idiopathic pulmonary fibrosis (IPF) by studying novel computational models where the epistatic effects (dominant, additive, recessive) of SNP-SNP interactions could be evaluated, and then compared the results with a previously published hypersensitivity pneumonitis (HP) study where the same novel models were used. Mexican Hispanic patients (IPF=84 & HP=75) and 194 healthy control individuals were evaluated. The goal was to identify SP SNPs and SNP-SNP interactions that associate with IPF as well as SNPs and interactions that may be unique to each of these interstitial diseases or common between them. We observed: 1) in terms of IPF, i) three single SFTPA1 SNPs to associate with decreased IPF risk, ii) three SFTPA1 haplotypes to associate with increased IPF risk, and iii) a number of three-SNP interactions to associate with IPF susceptibility. 2) Comparison of IPF and HP, i) three SFTPA1 and one SFTPB SNP associated with decreased risk in IPF but increased risk in HP, and one SFTPA1 SNP associated with decreased risk in both IPF and HP, ii) a number of three-SNP interactions with the same or different effect pattern associated with IPF and/or HP susceptibility, iii) one of the three-SNP interactions that involved SNPs of SFTPA1, SFTPA2, and SFTPD, with the same effect pattern, was associated with a disease-specific outcome, a decreased and increased risk in HP and IPF, respectively. This is the first study that compares the SP gene variants in these two phenotypically similar diseases. Our findings indicate that SNPs of all SFTPs may play an important role in the genetic susceptibility to IPF and HP. Importantly, IPF and HP share some SP genetic variants, suggesting common pathophysiological mechanisms and pathways regarding surfactant biogenesis, but also some differences, highlighting the diverse underlying pathogenic mechanisms between an inflammatory-driven fibrosis (HP) and an epithelial-driven fibrosis (IPF). Alternatively, the significant SNPs identified here, along with SNPs of other genes, could serve as markers to distinguish these two devastating diseases.
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Affiliation(s)
- Ata Abbasi
- Cellular and Molecular Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran.,Department of Pathology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Chixiang Chen
- Department of Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Chintan K Gandhi
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Rongling Wu
- Department of Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Annie Pardo
- Facultad de Ciencias, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Moises Selman
- Unidad de Investigación, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosio Villegas", Mexico City, Mexico
| | - Joanna Floros
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States.,Department of Obstetrics & Gynecology, Pennsylvania State University College of Medicine, Hershey, PA, United States
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Mikolajcikova S, Lasabova Z, Holubekova V, Skerenova M, Zibolenova J, Matasova K, Zibolen M, Calkovska A. The Common Haplotype GATGACA in Surfactant-Protein B Gene Is Protective for Respiratory Distress Syndrome in Preterm Neonates. Front Pediatr 2022; 10:851042. [PMID: 35692980 PMCID: PMC9174893 DOI: 10.3389/fped.2022.851042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Respiratory distress syndrome (RDS), a disorder of primary surfactant deficiency resulting in pulmonary insufficiency, remains a significant problem for preterm neonates. Associations between genetic variants of surfactant proteins and RDS have been reported, but haplotypes of the surfactant protein B gene (SFTPB) have not been studied. The aim of the study was to prove the hypothesis that certain haplotypes of SFTPB may be protective or risk factors for RDS. Methods The study was performed with 149 preterm infants, born <34 weeks of gestation, with 86 infants with mild RDS or without RDS (control group) and 63 infants with severe RDS (patient group). RDS was considered severe if multiple doses of exogenous surfactant and/or mechanical ventilation within the first 72 h of life were needed. The venous blood sample was used for the analysis of gene polymorphisms associated with RDS, genotyping, and haplotype estimation. Multivariate logistic regression analysis and the odds ratio were calculated to detect the contribution of the studied variables to the development of RDS. Results A new association of the common single nucleotide polymorphism (SNP) rs2304566 with RDS in premature infants was detected. Analysis of rs2304566 polymorphisms using a logistic regression model showed that there are two significant predictors inversely related to the occurrence of RDS (Apgar score of 5 min, CT and TT genotype in rs2304566 polymorphism). Gestational age, birth weight, and sex have border significance. Moreover, in the patient group, the frequency of the GATGACA haplotype in the SFTPB gene was lower (p = 0.037), and the GATGGCA haplotype was higher (p = 0.059) in comparison with the control group. Conclusion The common haplotype GATGACA of the SFTPB gene can be protective against RDS in preterm infants. The trend of a higher frequency of GATGGCA in the SFTPB gene in infants with severe RDS suggests that this haplotype may be a risk factor for RDS susceptibility.
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Affiliation(s)
- Silvia Mikolajcikova
- Clinic of Neonatology, Jessenius Faculty of Medicine, Comenius University and University Hospital, Martin, Slovakia
| | - Zora Lasabova
- Department of Molecular Biology and Genomics, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Veronika Holubekova
- Biomedical Centre Martin, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Maria Skerenova
- Biomedical Centre Martin, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Jana Zibolenova
- Department of Public Health, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Katarina Matasova
- Clinic of Neonatology, Jessenius Faculty of Medicine, Comenius University and University Hospital, Martin, Slovakia
| | - Mirko Zibolen
- Clinic of Neonatology, Jessenius Faculty of Medicine, Comenius University and University Hospital, Martin, Slovakia
| | - Andrea Calkovska
- Department of Physiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
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Gandhi CK, Thomas NJ, Meixia Y, Spear D, Fu C, Zhou S, Wu R, Keim G, Yehya N, Floros J. SNP–SNP Interactions of Surfactant Protein Genes in Persistent Respiratory Morbidity Susceptibility in Previously Healthy Children. Front Genet 2022; 13:815727. [PMID: 35401703 PMCID: PMC8989419 DOI: 10.3389/fgene.2022.815727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/21/2022] [Indexed: 01/10/2023] Open
Abstract
We studied associations of persistent respiratory morbidity (PRM) at 6 and 12 months after acute respiratory failure (ARF) in previously healthy children with single-nucleotide polymorphisms (SNPs) of surfactant protein (SP) genes. Of the 250 enrolled subjects, 155 and 127 were followed at 6 and 12 months after an ARF episode, respectively. Logistic regression analysis and SNP–SNP interaction models were used. We found that 1) in the multivariate analysis, an increased risk at 6 and 12 months was associated with rs1124_A and rs4715_A of SFTPC, respectively; 2) in a single SNP model, increased and decreased risks of PRM at both timepoints were associated with rs1124 of SFTPC and rs721917 of SFTPD, respectively; an increased risk at 6 months was associated with rs1130866 of SFTPB and rs4715 of SFTPC, and increased and decreased risks at 12 months were associated with rs17886395 of SFTPA2 and rs2243639 of SFTPD, respectively; 3) in a two-SNP model, PRM susceptibility at both timepoints was associated with a number of intergenic interactions between SNPs of the studied SP genes. An increased risk at 12 months was associated with one intragenic (rs1965708 and rs113645 of SFTPA2) interaction; 4) in a three-SNP model, decreased and increased risks at 6 and 12 months, respectively, were associated with an interaction among rs1130866 of SFTPB, rs721917 of SFTPD, and rs1059046 of SFTPA2. A decreased risk at 6 months was associated with an interaction among the same SNPs of SFTPB and SFTPD and the rs1136450 of SFTPA1. The findings revealed that SNPs of all SFTPs appear to play a role in long-term outcomes of ARF survivors and may serve as markers for disease susceptibility.
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Affiliation(s)
- Chintan K. Gandhi
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Neal J. Thomas
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Ye Meixia
- Center for Computational Biology, College of Biological Sciences and Technology, Beijing Forestry University, Beijing, China
| | - Debbie Spear
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Chenqi Fu
- Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Shouhao Zhou
- Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Rongling Wu
- Public Health Science, Pennsylvania State University College of Medicine, Hershey, PA, United States
| | - Garrett Keim
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Nadir Yehya
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Joanna Floros
- Center for Host Defense, Inflammation, and Lung Disease (CHILD) Research, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, United States
- Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, PA, United States
- *Correspondence: Joanna Floros,
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