1
|
Moradi MT, Fadaei R, Sharafkhaneh A, Khazaie H, Gozal D. The role of lncRNAs in intermittent hypoxia and sleep Apnea: A review of experimental and clinical evidence. Sleep Med 2024; 113:188-197. [PMID: 38043330 DOI: 10.1016/j.sleep.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
In this narrative review, we present a comprehensive assessment on the putative roles of long non-coding RNAs (lncRNAs) in intermittent hypoxia (IH) and sleep apnea. Collectively, the evidence from cell culture, animal, and clinical research studies points to the functional involvement of lncRNAs in the pathogenesis, diagnosis, and potential treatment strategies for this highly prevalent disorder. Further research is clearly warranted to uncover the mechanistic pathways and to exploit the therapeutic potential of lncRNAs, thereby improving the management and outcomes of patients suffering from sleep apnea.
Collapse
Affiliation(s)
- Mohammad-Taher Moradi
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Fadaei
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Amir Sharafkhaneh
- Sleep Disorders and Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Habibolah Khazaie
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - David Gozal
- Joan C. Edwards School of Medicine, Marshall University, 1600 Medical Center Dr, Huntington, WV, 25701, USA.
| |
Collapse
|
2
|
Jurado A, Ulldemolins A, Lluís H, Gasull X, Gavara N, Sunyer R, Otero J, Gozal D, Almendros I, Farré R. Fast cycling of intermittent hypoxia in a physiomimetic 3D environment: A novel tool for the study of the parenchymal effects of sleep apnea. Front Pharmacol 2023; 13:1081345. [PMID: 36712654 PMCID: PMC9879064 DOI: 10.3389/fphar.2022.1081345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Patients with obstructive sleep apnea (OSA) experience recurrent hypoxemic events with a frequency sometimes exceeding 60 events/h. These episodic events induce downstream transient hypoxia in the parenchymal tissue of all organs, thereby eliciting the pathological consequences of OSA. Whereas experimental models currently apply intermittent hypoxia to cells conventionally cultured in 2D plates, there is no well-characterized setting that will subject cells to well-controlled intermittent hypoxia in a 3D environment and enable the study of the effects of OSA on the cells of interest while preserving the underlying tissue environment. Aim: To design and characterize an experimental approach that exposes cells to high-frequency intermittent hypoxia mimicking OSA in 3D (hydrogels or tissue slices). Methods: Hydrogels made from lung extracellular matrix (L-ECM) or brain tissue slices (300-800-μm thickness) were placed on a well whose bottom consisted of a permeable silicone membrane. The chamber beneath the membrane was subjected to a square wave of hypoxic/normoxic air. The oxygen concentration at different depths within the hydrogel/tissue slice was measured with an oxygen microsensor. Results: 3D-seeded cells could be subjected to well-controlled and realistic intermittent hypoxia patterns mimicking 60 apneas/h when cultured in L-ECM hydrogels ≈500 μm-thick or ex-vivo in brain slices 300-500 μm-thick. Conclusion: This novel approach will facilitate the investigation of the effects of intermittent hypoxia simulating OSA in 3D-residing cells within the parenchyma of different tissues/organs.
Collapse
Affiliation(s)
- Alicia Jurado
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Anna Ulldemolins
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Helena Lluís
- Neurophysiology Laboratory, Department of Biomedicine, School of Medicine, Institute of Neurosciences, University of Barcelona, Barcelona, Spain,Institut Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain
| | - Xavier Gasull
- Neurophysiology Laboratory, Department of Biomedicine, School of Medicine, Institute of Neurosciences, University of Barcelona, Barcelona, Spain,Institut Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain
| | - Núria Gavara
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain,The Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Raimon Sunyer
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain,The Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Jorge Otero
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain,The Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain,CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - David Gozal
- Department of Child Health, The University of Missouri School of Medicine, Columbia, KY, United States
| | - Isaac Almendros
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain,Institut Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain,CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain,Institut Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain,CIBER de Enfermedades Respiratorias, Madrid, Spain,*Correspondence: Ramon Farré,
| |
Collapse
|
3
|
Farré R, Almendros I, Martínez-García MÁ, Gozal D. Experimental Models to Study End-Organ Morbidity in Sleep Apnea: Lessons Learned and Future Directions. Int J Mol Sci 2022; 23:ijms232214430. [PMID: 36430904 PMCID: PMC9696027 DOI: 10.3390/ijms232214430] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Sleep apnea (SA) is a very prevalent sleep breathing disorder mainly characterized by intermittent hypoxemia and sleep fragmentation, with ensuing systemic inflammation, oxidative stress, and immune deregulation. These perturbations promote the risk of end-organ morbidity, such that SA patients are at increased risk of cardiovascular, neurocognitive, metabolic and malignant disorders. Investigating the potential mechanisms underlying SA-induced end-organ dysfunction requires the use of comprehensive experimental models at the cell, animal and human levels. This review is primarily focused on the experimental models employed to date in the study of the consequences of SA and tackles 3 different approaches. First, cell culture systems whereby controlled patterns of intermittent hypoxia cycling fast enough to mimic the rates of episodic hypoxemia experienced by patients with SA. Second, animal models consisting of implementing realistic upper airway obstruction patterns, intermittent hypoxia, or sleep fragmentation such as to reproduce the noxious events characterizing SA. Finally, human SA models, which consist either in subjecting healthy volunteers to intermittent hypoxia or sleep fragmentation, or alternatively applying oxygen supplementation or temporary nasal pressure therapy withdrawal to SA patients. The advantages, limitations, and potential improvements of these models along with some of their pertinent findings are reviewed.
Collapse
Affiliation(s)
- Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
- CIBER de Enfermedades Respiratorias, 1964603 Madrid, Spain
- Institut Investigacions Biomediques August Pi Sunyer, 08036 Barcelona, Spain
- Correspondence: (R.F.); (D.G.)
| | - Isaac Almendros
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
- CIBER de Enfermedades Respiratorias, 1964603 Madrid, Spain
- Institut Investigacions Biomediques August Pi Sunyer, 08036 Barcelona, Spain
| | - Miguel-Ángel Martínez-García
- CIBER de Enfermedades Respiratorias, 1964603 Madrid, Spain
- Pneumology Department, University and Polytechnic La Fe Hospital, 46026 Valencia, Spain
| | - David Gozal
- Department of Child Health and Child Health Research Institute, School of Medicine, The University of Missouri, Columbia, MO 65201, USA
- Correspondence: (R.F.); (D.G.)
| |
Collapse
|
4
|
Marhuenda E, Villarino A, Narciso M, Elowsson L, Almendros I, Westergren-Thorsson G, Farré R, Gavara N, Otero J. Development of a physiomimetic model of acute respiratory distress syndrome by using ECM hydrogels and organ-on-a-chip devices. Front Pharmacol 2022; 13:945134. [PMID: 36188621 PMCID: PMC9517737 DOI: 10.3389/fphar.2022.945134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Acute Respiratory Distress Syndrome is one of the more common fatal complications in COVID-19, characterized by a highly aberrant inflammatory response. Pre-clinical models to study the effect of cell therapy and anti-inflammatory treatments have not comprehensively reproduced the disease due to its high complexity. This work presents a novel physiomimetic in vitro model for Acute Respiratory Distress Syndrome using lung extracellular matrix-derived hydrogels and organ-on-a-chip devices. Monolayres of primary alveolar epithelial cells were cultured on top of decellullarized lung hydrogels containing primary lung mesenchymal stromal cells. Then, cyclic stretch was applied to mimic breathing, and an inflammatory response was induced by using a bacteriotoxin hit. Having simulated the inflamed breathing lung environment, we assessed the effect of an anti-inflammatory drug (i.e., dexamethasone) by studying the secretion of the most relevant inflammatory cytokines. To better identify key players in our model, the impact of the individual factors (cyclic stretch, decellularized lung hydrogel scaffold, and the presence of mesenchymal stromal cells) was studied separately. Results showed that developed model presented a more reduced inflammatory response than traditional models, which is in line with what is expected from the response commonly observed in patients. Further, from the individual analysis of the different stimuli, it was observed that the use of extracellular matrix hydrogels obtained from decellularized lungs had the most significant impact on the change of the inflammatory response. The developed model then opens the door for further in vitro studies with a better-adjusted response to the inflammatory hit and more robust results in the test of different drugs or cell therapy.
Collapse
Affiliation(s)
- Esther Marhuenda
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Alvaro Villarino
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
| | - Maria Narciso
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
- The Institute for Bioengineering of Catalonia, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Linda Elowsson
- Lung Biology, Biomedical Center, Department of Medical Science,Lund University, Lund, Sweden
| | - Isaac Almendros
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | - Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Núria Gavara
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- The Institute for Bioengineering of Catalonia, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Jorge Otero
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, University de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- The Institute for Bioengineering of Catalonia, The Barcelona Institute of Science and Technology, Barcelona, Spain
- *Correspondence: Jorge Otero,
| |
Collapse
|
5
|
Farré R, Gozal D, Almendros I. Human experimental models: seeking to enhance multiscale research in sleep apnoea. Eur Respir J 2021; 58:58/4/2101169. [PMID: 34620681 DOI: 10.1183/13993003.01169-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain .,CIBER de Enfermedades Respiratorias, Madrid, Spain.,Institut Investigacions Biomediques August Pi Sunyer, Barcelona, Spain
| | - David Gozal
- Dept of Child Health, The University of Missouri School of Medicine, Columbia, MO, USA
| | - Isaac Almendros
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain.,Institut Investigacions Biomediques August Pi Sunyer, Barcelona, Spain
| |
Collapse
|
6
|
Heterogeneity of Melanoma Cell Responses to Sleep Apnea-Derived Plasma Exosomes and to Intermittent Hypoxia. Cancers (Basel) 2021; 13:cancers13194781. [PMID: 34638272 PMCID: PMC8508428 DOI: 10.3390/cancers13194781] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is associated with increased cutaneous melanoma incidence and adverse outcomes. Exosomes are secreted by most cells, and play a role in OSA-associated tumor progression and metastasis. We aimed to study the effects of plasma exosomes from OSA patients before and after adherent treatment with continuous positive airway pressure (CPAP) on melanoma cells lines, and also to identify exosomal miRNAs from melanoma cells exposed to intermittent hypoxia (IH) or normoxia. Plasma-derived exosomes were isolated from moderate-to-severe OSA patients before (V1) and after (V2) adherent CPAP treatment for one year. Exosomes were co-incubated with three3 different melanoma cell lines (CRL 1424; CRL 1619; CRL 1675) that are characterized by genotypes involving different mutations in BRAF, STK11, CDKN2A, and PTEN genes to assess the effect of exosomes on cell proliferation and migration, as well as on pAMK activity in the presence or absence of a chemical activator. Subsequently, CRL-1424 and CRL-1675 cells were exposed to intermittent hypoxia (IH) and normoxia, and exosomal miRNAs were identified followed by GO and KEG pathways and gene networks. The exosomes from these IH-exposed melanoma cells were also administered to THP1 macrophages to examine changes in M1 and M2 polarity markers. Plasma exosomes from V1 increased CRL-1424 melanoma cell proliferation and migration compared to V2, but not the other two cell lines. Exposure to CRL-1424 exosomes reduced pAMPK/tAMPK in V1 compared to V2, and treatment with AMPK activator reversed the effects. Unique exosomal miRNAs profiles were identified for CRL-1424 and CRL-1675 in IH compared to normoxia, with six miRNAs being regulated and several KEGG pathways were identified. Two M1 markers (CXCL10 and IL6) were significantly increased in monocytes when treated with exosomes from IH-exposed CRL-1424 and CRL-1625 cells. Our findings suggest that exosomes from untreated OSA patients increase CRL-1424 melanoma malignant properties, an effect that is not observed in two other melanoma cell lines. Exosomal cargo from CRL-1424 cells showed a unique miRNA signature compared to CRL-1675 cells after IH exposures, suggesting that melanoma cells are differentially susceptible to IH, even if they retain similar effects on immune cell polarity. It is postulated that mutations in STK-11 gene encoding for the serine/threonine kinase family that acts as a tumor suppressor may underlie susceptibility to IH-induced metabolic dysfunction, as illustrated by CRL-1424 cells.
Collapse
|
7
|
Experimental Setting for Applying Mechanical Stimuli to Study the Endothelial Response of Ex Vivo Vessels under Realistic Pathophysiological Environments. Life (Basel) 2021; 11:life11070671. [PMID: 34357043 PMCID: PMC8306098 DOI: 10.3390/life11070671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022] Open
Abstract
This paper describes the design, construction and testing of an experimental setting, making it possible to study the endothelium under different pathophysiological conditions. This novel experimental approach allows the application of the following stimuli to an ex vivo vessel in a physiological bath: (a) a realistic intravascular pressure waveform defined by the user; (b) shear stress in the endothelial layer since, in addition to the pressure waveform, the flow through the vessel can be independently controlled by the user; (c) conditions of hypo/hyperoxia and hypo/hypercapnia in an intravascular circulating medium. These stimuli can be applied alone or in different combinations to study possible synergistic or antagonistic effects. The setting performance is illustrated by a proof of concept in an ex vivo rabbit aorta. The experimental setting is easy to build by using very low-cost materials widely available. Online Supplement files provide all the technical information (e.g., circuits, codes, 3D printer drivers) following an open-source hardware approach for free replication.
Collapse
|
8
|
Sanz-Rubio D, Khalyfa A, Qiao Z, Ullate J, Marin JM, Kheirandish-Gozal L, Gozal D. Cell-Selective Altered Cargo Properties of Extracellular Vesicles Following In Vitro Exposures to Intermittent Hypoxia. Int J Mol Sci 2021; 22:ijms22115604. [PMID: 34070558 PMCID: PMC8198838 DOI: 10.3390/ijms22115604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/09/2021] [Accepted: 05/19/2021] [Indexed: 01/09/2023] Open
Abstract
Intermittent hypoxia (IH), a hallmark of obstructive sleep apnea (OSA), is associated with cardiovascular and metabolic dysfunction. However, the mechanisms underlying these morbidities remain poorly delineated. Extracellular vesicles (EVs) mediate intercellular communications, play pivotal roles in a multitude of physiological and pathological processes, and could mediate IH-induced cellular effects. Here, the effects of IH on human primary cells and the release of EVs were examined. Microvascular endothelial cells (HMVEC-d), THP1 monocytes, THP1 macrophages M0, THP1 macrophages M1, THP1 macrophages M2, pre-adipocytes, and differentiated adipocytes (HAd) were exposed to either room air (RA) or IH for 24 h. Secreted EVs were isolated and characterized using transmission electron microscopy, nanoparticle tracking analysis, and Western blotting. The effects of each of the cell-derived EVs on endothelial cell (EC) monolayer barrier integrity, on naïve THP1 macrophage polarity, and on adipocyte insulin sensitivity were also evaluated. IH did not alter EVs cell quantal release, but IH-EVs derived from HMVEC-d (p < 0.01), THP1 M0 (p < 0.01) and HAd (p < 0.05) significantly disrupted HMVEC-d monolayer integrity, particularly after H2O2 pre-conditioning. IH-EVs from HMVEC-d and THP1 M0 elicited M2-polarity changes did not alter insulin sensitivity responses. IH induces cell-selective changes in EVs cargo, which primarily seem to target the emergence of endothelial dysfunction. Thus, changes in EVs cargo from selected cell sources in vivo may play causal roles in some of the adverse outcomes associated with OSA.
Collapse
Affiliation(s)
- David Sanz-Rubio
- Department of Child Health, Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA; (D.S.-R.); (Z.Q.); (J.U.); (L.K.-G.); (D.G.)
- Translational Research Unit, Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria de Aragón (IISAragón), 50009 Zaragoza, Spain;
| | - Abdelnaby Khalyfa
- Department of Child Health, Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA; (D.S.-R.); (Z.Q.); (J.U.); (L.K.-G.); (D.G.)
- Correspondence: ; Tel.: +1-573-884-7685
| | - Zhuanhong Qiao
- Department of Child Health, Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA; (D.S.-R.); (Z.Q.); (J.U.); (L.K.-G.); (D.G.)
| | - Jorge Ullate
- Department of Child Health, Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA; (D.S.-R.); (Z.Q.); (J.U.); (L.K.-G.); (D.G.)
| | - José M. Marin
- Translational Research Unit, Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria de Aragón (IISAragón), 50009 Zaragoza, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERes), 28029 Madrid, Spain
| | - Leila Kheirandish-Gozal
- Department of Child Health, Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA; (D.S.-R.); (Z.Q.); (J.U.); (L.K.-G.); (D.G.)
| | - David Gozal
- Department of Child Health, Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO 65201, USA; (D.S.-R.); (Z.Q.); (J.U.); (L.K.-G.); (D.G.)
| |
Collapse
|
9
|
Bhattacharya S, Calar K, Evans C, Petrasko M, de la Puente P. Bioengineering the Oxygen-Deprived Tumor Microenvironment Within a Three-Dimensional Platform for Studying Tumor-Immune Interactions. Front Bioeng Biotechnol 2020; 8:1040. [PMID: 33015012 PMCID: PMC7498579 DOI: 10.3389/fbioe.2020.01040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/11/2020] [Indexed: 12/18/2022] Open
Abstract
Oxygen deprivation within tumors is one of the most prevalent causes of resilient cancer cell survival and increased immune evasion in breast cancer (BCa). Current in vitro models do not adequately mimic physiological oxygen levels relevant to breast tissue and its tumor-immune interactions. In this study, we propose an approach to engineer a three-dimensional (3D) model (named 3D engineered oxygen, 3D-O) that supports the growth of BCa cells and generates physio- and pathophysiological oxygen levels to understand the role of oxygen availability in tumor-immune interactions. BCa cells (MDA-MB-231 and MCF-7) were embedded into plasma-derived 3D-O scaffolds that reflected physio- and pathophysiological oxygen levels relevant to the healthy and cancerous breast tissue. BCa cells grown within 3D-O scaffolds were analyzed by flow cytometry, confocal imaging, immunohistochemistry/immunofluorescence for cell proliferation, extracellular matrix protein expression, and alterations in immune evasive outcomes. Exosome secretion from 3D-O scaffolds were evaluated using the NanoSight particle analyzer. Peripheral blood mononuclear cells were incorporated on the top of 3D-O scaffolds and the difference in tumor-infiltrating capabilities as a result of different oxygen content were assessed by flow cytometry and confocal imaging. Lastly, hypoxia and Programmed death-ligand 1 (PD-L1) inhibition were validated as targets to sensitize BCa cells in order to overcome immune evasion. Low oxygen-induced adaptations within 3D-O scaffolds validated known tumor hypoxia characteristics such as reduced BCa cell proliferation, increased extracellular matrix protein expression, increased extracellular vesicle secretion and enhanced immune surface marker expression on BCa cells. We further demonstrated that low oxygen in 3D-O scaffolds significantly influence immune infiltration. CD8+ T cell infiltration was impaired under pathophysiological oxygen levels and we were also able to establish that hypoxia and PD-L1 inhibition re-sensitized BCa cells to cytotoxic CD8+ T cells. Bioengineering the oxygen-deprived BCa tumor microenvironment in our engineered 3D-O physiological and tumorous scaffolds supported known intra-tumoral hypoxia characteristics allowing the study of the role of oxygen availability in tumor-immune interactions. The 3D-O model could serve as a promising platform for the evaluation of immunological events and as a drug-screening platform tool to overcome hypoxia-driven immune evasion.
Collapse
Affiliation(s)
- Somshuvra Bhattacharya
- Cancer Biology and Immunotherapies Group, Sanford Research, Sioux Falls, SD, United States
| | - Kristin Calar
- Cancer Biology and Immunotherapies Group, Sanford Research, Sioux Falls, SD, United States
| | - Claire Evans
- Histology and Imaging Core, Sanford Research, Sioux Falls, SD, United States
| | - Mark Petrasko
- Cancer Biology and Immunotherapies Group, Sanford Research, Sioux Falls, SD, United States
- Sanford PROMISE, Sanford Research, Sioux Falls, SD, United States
| | - Pilar de la Puente
- Cancer Biology and Immunotherapies Group, Sanford Research, Sioux Falls, SD, United States
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States
- Flow Cytometry Core, Sanford Research, Sioux Falls, SD, United States
| |
Collapse
|
10
|
Tretter V, Zach ML, Böhme S, Ullrich R, Markstaller K, Klein KU. Investigating Disturbances of Oxygen Homeostasis: From Cellular Mechanisms to the Clinical Practice. Front Physiol 2020; 11:947. [PMID: 32848874 PMCID: PMC7417655 DOI: 10.3389/fphys.2020.00947] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/14/2020] [Indexed: 12/22/2022] Open
Abstract
Soon after its discovery in the 18th century, oxygen was applied as a therapeutic agent to treat severely ill patients. Lack of oxygen, commonly termed as hypoxia, is frequently encountered in different disease states and is detrimental to human life. However, at the end of the 19th century, Paul Bert and James Lorrain Smith identified what is known as oxygen toxicity. The molecular basis of this phenomenon is oxygen's readiness to accept electrons and to form different variants of aggressive radicals that interfere with normal cell functions. The human body has evolved to maintain oxygen homeostasis by different molecular systems that are either activated in the case of oxygen under-supply, or to scavenge and to transform oxygen radicals when excess amounts are encountered. Research has provided insights into cellular mechanisms of oxygen homeostasis and is still called upon in order to better understand related diseases. Oxygen therapy is one of the prime clinical interventions, as it is life saving, readily available, easy to apply and economically affordable. However, the current state of research also implicates a reconsidering of the liberal application of oxygen causing hyperoxia. Increasing evidence from preclinical and clinical studies suggest detrimental outcomes as a consequence of liberal oxygen therapy. In this review, we summarize concepts of cellular mechanisms regarding different forms of disturbed cellular oxygen homeostasis that may help to better define safe clinical application of oxygen therapy.
Collapse
Affiliation(s)
- Verena Tretter
- Department of Anaesthesia, General Intensive Care and Pain Therapy, Medical University Vienna, Vienna, Austria
| | | | | | | | | | | |
Collapse
|
11
|
Marhuenda E, Campillo N, Gabasa M, Martínez-García MA, Campos-Rodríguez F, Gozal D, Navajas D, Alcaraz J, Farré R, Almendros I. Effects of Sustained and Intermittent Hypoxia on Human Lung Cancer Cells. Am J Respir Cell Mol Biol 2020; 61:540-544. [PMID: 31573339 DOI: 10.1165/rcmb.2018-0412le] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
| | | | | | | | - Francisco Campos-Rodríguez
- Hospital Universitario de Valme, IBISSeville, Spain.,Centro de Investigación Biomédica en Red de Enfermedades RespiratoriasMadrid, Spain
| | - David Gozal
- University of Missouri School of MedicineColumbia, Missouri
| | - Daniel Navajas
- Universitat de BarcelonaBarcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades RespiratoriasMadrid, Spain.,Barcelona Institute of Science and TechnologyBarcelona, Spainand
| | - Jordi Alcaraz
- Universitat de BarcelonaBarcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades RespiratoriasMadrid, Spain.,Barcelona Institute of Science and TechnologyBarcelona, Spainand
| | - Ramon Farré
- Universitat de BarcelonaBarcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades RespiratoriasMadrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i SunyerBarcelona, Spain
| | - Isaac Almendros
- Universitat de BarcelonaBarcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades RespiratoriasMadrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i SunyerBarcelona, Spain
| |
Collapse
|
12
|
Olson KR, Gao Y, DeLeon ER, Markel TA, Drucker N, Boone D, Whiteman M, Steiger AK, Pluth MD, Tessier CR, Stahelin RV. Extended hypoxia-mediated H 2 S production provides for long-term oxygen sensing. Acta Physiol (Oxf) 2020; 228:e13368. [PMID: 31442361 DOI: 10.1111/apha.13368] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/16/2019] [Accepted: 08/18/2019] [Indexed: 12/23/2022]
Abstract
AIM Numerous studies have shown that H2 S serves as an acute oxygen sensor in a variety of cells. We hypothesize that H2 S also serves in extended oxygen sensing. METHODS Here, we compare the effects of extended exposure (24-48 hours) to varying O2 tensions on H2 S and polysulphide metabolism in human embryonic kidney (HEK 293), human adenocarcinomic alveolar basal epithelial (A549), human colon cancer (HTC116), bovine pulmonary artery smooth muscle, human umbilical-derived mesenchymal stromal (stem) cells and porcine tracheal epithelium (PTE) using sulphur-specific fluorophores and fluorometry or confocal microscopy. RESULTS All cells continuously produced H2 S in 21% O2 and H2 S production was increased at lower O2 tensions. Decreasing O2 from 21% to 10%, 5% and 1% O2 progressively increased H2 S production in HEK293 cells and this was partially inhibited by a combination of inhibitors of H2 S biosynthesis, aminooxyacetate, propargyl glycine and compound 3. Mitochondria appeared to be the source of much of this increase in HEK 293 cells. H2 S production in all other cells and PTE increased when O2 was lowered from 21% to 5% except for HTC116 cells where 1% O2 was necessary to increase H2 S, presumably reflecting the hypoxic environment in vivo. Polysulphides (H2 Sn , where n = 2-7), the key signalling metabolite of H2 S also appeared to increase in many cells although this was often masked by high endogenous polysulphide concentrations. CONCLUSION These results show that cellular H2 S is increased during extended hypoxia and they suggest this is a continuously active O2 -sensing mechanism in a variety of cells.
Collapse
Affiliation(s)
- Kenneth R. Olson
- Indiana University School of Medicine‐South Bend South Bend Indiana
| | - Yan Gao
- Indiana University School of Medicine‐South Bend South Bend Indiana
| | - Eric R. DeLeon
- Indiana University School of Medicine‐South Bend South Bend Indiana
- Department of Biological Sciences University of Notre Dame Notre Dame Indiana
| | - Troy A. Markel
- Indiana University School of Medicine Riley Hospital for Children at IU Health Indianapolis Indiana
| | - Natalie Drucker
- Indiana University School of Medicine Riley Hospital for Children at IU Health Indianapolis Indiana
| | - David Boone
- Indiana University School of Medicine‐South Bend South Bend Indiana
| | | | - Andrea K. Steiger
- Department of Chemistry and Biochemistry University of Oregon Eugene Oregon
| | - Michael D. Pluth
- Department of Chemistry and Biochemistry University of Oregon Eugene Oregon
| | | | - Robert V. Stahelin
- Department of Medicinal Chemistry and Molecular Pharmacology Purdue University West Lafayette Indiana
| |
Collapse
|
13
|
Bird MJ, Adant I, Windmolders P, Vander Elst I, Felgueira C, Altassan R, Gruenert SC, Ghesquière B, Witters P, Cassiman D, Vermeersch P. Oxygraphy Versus Enzymology for the Biochemical Diagnosis of Primary Mitochondrial Disease. Metabolites 2019; 9:metabo9100220. [PMID: 31658717 PMCID: PMC6835216 DOI: 10.3390/metabo9100220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/27/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022] Open
Abstract
Primary mitochondrial disease (PMD) is a large group of genetic disorders directly affecting mitochondrial function. Although next generation sequencing technologies have revolutionized the diagnosis of these disorders, biochemical tests remain essential and functional confirmation of the critical genetic diagnosis. While enzymological testing of the mitochondrial oxidative phosphorylation (OXPHOS) complexes remains the gold standard, oxygraphy could offer several advantages. To this end, we compared the diagnostic performance of both techniques in a cohort of 34 genetically defined PMD patient fibroblast cell lines. We observed that oxygraphy slightly outperformed enzymology for sensitivity (79 ± 17% versus 68 ± 15%, mean and 95% CI), and had a better discriminatory power, identifying 58 ± 17% versus 35 ± 17% as “very likely” for oxygraphy and enzymology, respectively. The techniques did, however, offer synergistic diagnostic prediction, as the sensitivity rose to 88 ± 11% when considered together. Similarly, the techniques offered varying defect specific information, such as the ability of enzymology to identify isolated OXPHOS deficiencies, while oxygraphy pinpointed PDHC mutations and captured POLG mutations that were otherwise missed by enzymology. In summary, oxygraphy provides useful information for the diagnosis of PMD, and should be considered in conjunction with enzymology for the diagnosis of PMD.
Collapse
Affiliation(s)
- Matthew J Bird
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
- Metabolomics Expertise Center, Center for Cancer Biology, CCB-VIB, 3000 Leuven, Belgium.
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, 3000 Leuven, Belgium.
| | - Isabelle Adant
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
- Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium.
| | - Petra Windmolders
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
| | - Ingrid Vander Elst
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
| | - Catarina Felgueira
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
| | - Ruqaiah Altassan
- Medical Genetics Department, King Faisal Specialist Hospital and Research Center, KSA MCD, Riyadh 43228, Saudi Arabia.
| | - Sarah C Gruenert
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center-University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany.
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, CCB-VIB, 3000 Leuven, Belgium.
- Metabolomics Expertise Center, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
| | - Peter Witters
- Metabolic Center, University Hospitals Leuven, 3000, Leuven, Belgium.
| | - David Cassiman
- Laboratory of Hepatology, Department of Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
- Metabolic Center, University Hospitals Leuven, 3000, Leuven, Belgium.
| | - Pieter Vermeersch
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, 3000 Leuven, Belgium.
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, 3000 Leuven, Belgium.
| |
Collapse
|
14
|
Campillo N, Falcones B, Otero J, Colina R, Gozal D, Navajas D, Farré R, Almendros I. Differential Oxygenation in Tumor Microenvironment Modulates Macrophage and Cancer Cell Crosstalk: Novel Experimental Setting and Proof of Concept. Front Oncol 2019; 9:43. [PMID: 30788287 PMCID: PMC6373430 DOI: 10.3389/fonc.2019.00043] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022] Open
Abstract
Hypoxia is a common characteristic of many solid tumors that has been associated with tumor aggressiveness. Limited diffusion of oxygen generates a gradient of oxygen availability from the blood vessel to the interstitial space and may underlie the recruitment of macrophages fostering cancer progression. However, the available data based on the recruitment of circulating cells to the tumor microenvironment has been so far carried out by conventional co-culture systems which ignore the hypoxic gradient between the vessel to the tumor interstitium. Here, we have designed a novel easy-to-build cell culture device that enables evaluation of cellular cross-talk and cell migration while they are being simultaneously exposed to different oxygenation environments. As a proof-of-concept of the potential role of differential oxygenation among interacting cells we have evaluated the activation and recruitment of macrophages in response to hypoxic melanoma, breast, and kidney cancer cells. We found that hypoxic melanoma and breast cancer cells co-cultured with normoxic macrophages enhanced their directional migration. By contrast, hypoxic kidney cells were not able to increase their recruitment. We also identified well-described hypoxia-induced pathways which could contribute in the immune cell recruitment (VEGFA and PTGS2 genes). Moreover, melanoma and breast cancer increased their proliferation. However, oxygenation levels affected neither kidney cancer cell proliferation nor gene expression, which in turn resulted in no significant changes in macrophage migration and polarization. Therefore, the cell culture device presented here provides an excellent opportunity for researchers to reproduce the in vivo hypoxic gradients in solid tumors and to study their role in recruiting circulating cells to the tumor in specific types of cancer.
Collapse
Affiliation(s)
- Noelia Campillo
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Bryan Falcones
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Jordi Otero
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Roser Colina
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - David Gozal
- Department of Child Health, University of Missouri-School of Medicine, Columbia, MO, United States
| | - Daniel Navajas
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain.,Institute for Bioengineering of Catalonia, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Ramon Farré
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Isaac Almendros
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| |
Collapse
|
15
|
Lin YN, Lan XF, Liu ZR, Yan YR, Zhou JP, Li N, Sun XW, Li QY. Activation of ATM-c-IAP1 Pathway Mediates the Protective Effects of Estradiol in Human Vascular Endothelial Cells Exposed to Intermittent Hypoxia. Nat Sci Sleep 2019; 11:357-366. [PMID: 31819689 PMCID: PMC6886551 DOI: 10.2147/nss.s231456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/05/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Chronic intermittent hypoxia (CIH) contributes to the increased risk of cardiovascular diseases in obstructive sleep apnea (OSA). We previously reported the anti-apoptotic effects of estradiol (E2) on IH-exposed human umbilical vein endothelial cells (HUVECs). Herein, we employed a proteomic analysis to elucidate the mechanisms of the protective effects of E2 under IH exposure. METHODS HUVECs were divided into three groups: control, IH, and IH+E2 group. Isobaric tags for relative and absolute quantification (iTRAQ) were performed to compare protein profiles among the groups. Some of the identified proteins were validated by Western blotting. RESULTS A total of 185 proteins were differentially expressed in the IH+E2 group compared to the IH group. Bioinformatics analysis indicated that the effects of E2 may be linked to the regulation of cellular stress response. Among the differentially expressed proteins, we identified that serine-protein kinase ataxia telangiectasia mutated (ATM) and its downstream target, cellular inhibitor of apoptosis protein 1 (c-IAP1), were up-regulated by E2. We also observed that E2 decreased the level of cleaved caspase-3 and inhibited cell apoptosis in IH-exposed HUVECs. The inhibition of ATM abolished the anti-apoptotic effect of E2. CONCLUSION The ATM-c-IAP1 pathway is involved in the cardioprotective effects of E2 in HUVECs exposed to IH.
Collapse
Affiliation(s)
- Ying Ni Lin
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Institute of Respiratory Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| | - Xiao Fei Lan
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Department of Respiratory Medicine, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200335, People's Republic of China
| | - Zhuo Ran Liu
- Department of Thyroid and Vascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| | - Ya Ru Yan
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Institute of Respiratory Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| | - Jian Ping Zhou
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Institute of Respiratory Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| | - Ning Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Institute of Respiratory Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| | - Xian Wen Sun
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Institute of Respiratory Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| | - Qing Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China.,Institute of Respiratory Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, People's Republic of China
| |
Collapse
|