Human Neutrophil Defensin-1, -3, and -4 Are Elevated in Nasal Aspirates from Children with Naturally Occurring Adenovirus Infection.
Viral respiratory infections in children have become a medical concern and pose financial burden around the world [1, 2]. More than 100 different viruses can infect children with adenovirus (AdV) accounting for 3-5%  of respiratory disease: 2-10% of bronchiolitis, 3-9% of croup, and 4-10% of pneumonia [1, 4]. While most adenoviral diseases are self-limiting, fatal illness occurs in immunocompromised patients  and, rarely, in healthy children and adults. In children, clinical symptoms are usually mild and include rhinorrhea, headache, fever (pharingoconjunctival fever), and cough [6-8]. AdV are nonenveloped viruses, 70-920 nm in diameter, and its replication initiates when the viral vertices bind to the host cell surface receptors (CAR or complement protein CD46) and cell internalization occurs by endocytosis. Adenovirus has reportedly been involved in both community-acquired outbreaks [9, 10] and outbreaks of severe acute respiratory disease in military recruits in China [11, 12].
Defensins are antimicrobial peptides, effective against wide spectrum of pathogens including Gram-positive and Gram-negative bacteria, enveloped and nonenveloped viruses, and some fungi species. Humans secrete two types of defensins, namely, alpha- (6 subtypes) and beta- (31 subtypes) defensins [6, 13]. Alpha-defensins are 30-50% of total protein in neutrophils . Human neutrophil peptides (HNP-1 to HNP-4) are produced by leukocytes , while the human defensins (HD-5 and HD-6) are secreted by intestinal paneth cells . The sequences of HNP-1, -2, and -3 are almost identical. They differ only in their N-terminal amino acid, which is alanine in HNP-1 but is substituted by aspartic acid in HNP-3. However, they have different biological properties. Indeed, it was reported that HNP-4 is 100 times more potent against E. coli and four times more potent against both Streptococcus faecalis and Candida albicans compared with HNP-1-3 . Several in vitro studies have shown that HNPs exert antiviral activity. For example, Bastian and Schafer demonstrated that HNP-1 significantly reduced adenovirus type 5 infections of 293 cells, as compared to the normal . This study investigates the presence of HNP-1-4 in nasal aspirates derived from children with naturally occurring adenovirus respiratory infections during symptomatic and asymptomatic episodes.
Between June 2012 and May 2015, 14 volunteers were recruited from 280 children registers kept in the National Institute for Respiratory Diseases (Mexico City, Mexico) from a longitudinal study on virus respiratory infection conducted in the school "Rey Tizoc," Xochimilco, Mexico City. Inclusion criteria were as follows: (1) clinical diagnosis of nasal virus infection made by pediatrician; (2) age between 6-12 years and gender indistinct; and (3) positive immunofluorescence to adenovirus. Exclusion criteria were as follows: (1) presence of clinical symptoms that suggested bacterial infection; (2) treatment using antibiotic medication, antihistamines, nonsteroidal anti-inflammatory drugs, nasal/systemic corticosteroids, or a nasal/oral decongestant within 2 weeks of the beginning of clinical symptoms; and (3) children who had coinfection with other viruses detected by immunofluorescence assay . Parents and children gave their written and verbal consent. The subjective respiratory symptoms of children were assessed using a 4-point scale: 0 = absent, 1 = mild, 2 = moderate, and 3 = severe. Upper respiratory tract symptoms were the runny nose, sneezing, blocked nose, sore throat, hoarse voice, headaches, aches or pains elsewhere, and chillness, fever, or shivers. Lower respiratory tract symptoms were cough, shortness of breath, and wheeze. Scores were added to give daily upper and lower respiratory tract scores, respectively. A nasal aspirate sample was collected from the child if the upper respiratory tract score was [greater than or equal to]1. The institutes' ethical committee approved the study, project code B04-14.
2.1. Sampling. Nasal aspirate samples were collected from children suffering from common cold confirmed diagnosis by the pediatrician based on their symptoms; the sampling method is noninvasive and user-friendly and allows sampling without causing major discomfort. Nasal aspirates were suspended (1 : 10) in virus transport medium and immediately transported to the laboratory on ice, for further processing. Samples were collected within 48 hours of developing respiratory symptoms in all children selected to participate in this study. Two weeks later, control samples were collected from the same children after recovery from infection. A total of 28 samples were collected for this study (symptomatic = 14 and asymptomatic = 14).
2.2. Viral Detection. An immunofluorescence kit from Light diagnostics[R], Merck Millipore, IFA panel for detection and identification of respiratory viruses, namely, RSV, influenza A, influenza B, adenovirus, and parainfluenza 1, 2, and 3 was used to confirm the virus infection and to detect the causative pathogen. At least 2 cells proved positive for the pathogen. Detection of other viruses was made to prevent selecting samples with coinfection from other viruses.
2.3. Differential Cell Counts. Nasal cells obtained from NAs were counted by flow cytometry (FACS Calibur cytometer, Becton Dickinson). All measurements were performed according to the manufacturer's instructions. Cells were suspended at the concentration of 50,000 cells/ml in FACS solution, and they were analyzed by the size and granularity.
2.4. HNP-1-4 Measurements. a-Defensins were measured in nasal aspirates using specific ELISA kits purchased from Cloud-Clone Corp (alpha-defensins-1 and -3) and MyBioSource (MBS) (alpha-defensins-2 and -4). ELISAs were performed according to the manufacturer's protocols. A tracer antibody conjugated to biotin for capture and streptavidin-peroxidase conjugate to reveal the reaction using the substrate tetramethylbenzidine (TMB) was used. The absorbance was measured at 450 nm on an iMark microplate reader (Bio-Rad). The HNP's concentrations were calculated from each standard curve. The lower limit of detection for HNP-1, HNP-2, HNP-3, and HNP-4 were 0.31 ng/ml, 100 pg/ml, 0.46 ng/ml, and 31.2 pg/ml, respectively.
2.5. Statistical Methods. Descriptive statistics were expressed as media (interquartile range); nonparametric analysis was used as two samples. The Mann-Whitney test was used for comparison of defensins values between the groups. The Spearman test was used to evaluate correlations between defensins and cellularity; cell counts were log 10-transformed to facilitate data analysis. Analysis and graphs were calculated using STATA statistical software, version 13 (StataCorp LP, College Station, Texas). In all analysis, p < 0.05 was considered statistically significant.
Between June 2012 and May 2015, 14 children (4.7%) were diagnosed natural adenovirus infection from 280 children (12 females (mean (age): 7.89 (6-12 years))). None of them were taking any medication and clinical symptoms ranged from mild to moderate (none of the children required hospitalization), Table 1. NAs were obtained from all the children during the acute respiratory infection and when asymptomatic.
3.1. Measurements of HNP-1-4 in Nasal Secretions. Measurements of defensins showed increased levels of HNP-1, -3, and -4 in nasal aspirates from children with naturally occurring acute adenovirus respiratory infections as compared with samples from the same children when they had been asymptomatic. Results are expressed as median (range): HNP-1: 125.6 ng/ml (44.4-341) versus 12.9ng/ml (11.4-22.9) (p < 0.001); HNP-3: 8.5 ng/ml (5.8-12.3) versus 4.7 ng/ml (3.2-5.3) (p < 0.001); and HNP-4: 2801 pg/ml (2099-3452) versus 1813 pg/ml (1383-2333) (p < 0.001), Figures 1(a), 1(c), and 1(d). In contrast, no changes in the levels of HNP-2 had statistical significance of 90 ng/ml (17-153) versus 73 ng/ml (0-187) (p = 0.9), Figure 1(b).
3.2. Differential Cell Counts. The total cell count measurements were several folds higher in the symptomatic state when compared with the asymptomatic state; median (range) values were 500 (300-1040) cells/[mL.sup.-1] and 48 (32-66) cells/[mL.sup.-1], respectively. All inflammatory cells measured were found to be increased in the symptomatic group (neutrophils, 200-fold; macrophages, 100-fold; and lymphocytes, 150-fold; Table 2) compared with the asymptomatic group. However, eosinophils were present in only few samples, and there was no significant difference (Table 2).
There was a significant positive correlation between HNP-4 and neutrophil numbers in the adenoviral-infected nasal aspirate samples (p = 0.01; r = 0.62), Figure 2. In contrast, there was no correlation between [alpha]-neutrophil numbers and any of the other defensins (HNP-1: p = 0.08, r = -0.48; HNP-2: p = 0.26, r = -0.32; and HNP-3: p = 0.85, r = 0.05).
3.3. Correlation between HNPs and Symptom Score. To investigate the relationship between HNPs and symptom score, we sought Spearman's rank correlation between the levels of HNP-1, -2, -3, and -4 with symptom score. There was not a significant correlation between HNPs and symptom score (data not shown).
The present study has shown that adenovirus-infected children release high concentrations of HNP-1, -3, and -4. In parallel, we observed increase in neutrophils which is a major source of HNPs. There was no difference in the concentrations of HNP-2. These findings suggest that HNP1, -3, and -4 are involved in the pathogenesis of adenovirus.
Adenoviruses are nonenveloped viruses whose structure consists of an icosahedral capsid with homotrimeric core and linear nonsegmented double-stranded DNA genome. Innate immunity of the host prevents the virus from entering the cell by directly binding to the virus or its components. However, adenovirus adapts to the microenvironment by degrading some of its structural components and counters innate defense by early proteins, E1A, E1B, E3, and E4, and two noncoding RNAs, VA-I and VA-II. Adenovirus replication then initiates when the viral vertices bind to the host cell surface receptors (CAR or complement protein CD46), and internalization occurs by endocytosis. Eventually, penton attaches to integrins causing vesicle membrane breakage and releasing the viral DNA into the host cell cytoplasm; it migrates to the host nucleus and hijacks the host replication mechanism, using it to produce viral DNA and proteins. Then, infected host cell lysis occurs to release progeny virions.
In the present study, we have shown that adenovirus infection induces the release of the HNP-1, -3, and -4, into the upper airways of 6-12-year-old children. Previous studies have investigated the effect of [alpha]-defensins on adenovirus. In 2001, Bastian and Schafer demonstrated that HNP-1, but not HBD-2, neutralizes adenovirus (AdV5) infection in vitro. Indeed, HNP-1 inhibited the adenoviral infection of 293 cells in a concentration range of 2 to 50 mg/ml . In contrast, human beta-defensin-(HBD-) 2 did not reduce infection of 293 cells by AdV5 at doses up to 50mg/ml . In 2010, Smith et al. showed that not only HNP-1 but also HD-5 inhibited adenoviral infection (A, B1, B2, and C) of A549 airway epithelial cells . Increased HNPs have been found in experimental rhinovirus in 15 asthma patients as compared with 10 normal controls . In this last study, however, the ELISA did not discriminate among the different HNP-1-3 and did not detect HNP-4. In the present study, the use of highly specific ELISAs allowed demonstrating that HNP-1 was released in higher concentrations followed by HNP-3 and HNP-4 in adenovirus-infected children. There was no significant difference in HNP-2 concentrations between the samples. To our knowledge, this study is the first to report the individual concentrations of the 4 HNPs in adenovirus infections. The mechanisms by which HNP-1-4 may inhibit virus infection are not fully understood. A mechanism for selective binding of defensins to nonenveloped viral capsids has been proposed. Fascinating experiments from Nguygen et al. revealed that HD-5 blocked the uncoating mechanism of the virus by stabilizing the capsid in BrdU-labeled HAdV-5 . Single alanine mutagenesis assay revealed HNP-1 and HD-5 require hydrophobic and charged residues for antiadenoviral activity. HNP-1 had more than 2-fold effects of IC50, and when W26 and F28 were substituted by alanine, the mutations were deleterious, which aligned with Y27 and L29 of HD-5 in linear sequence. When these mutations were reversed using nonnatural amino acids, the antiadenoviral activity was restored. These aromatic residues are located on the opposite of beta sheet and stabilize the hydrophobic core . Based on this finding, one could predict HNP-4 may also require hydrophobicity for antiadenovirus activity as F26 and Y28 align linearly with HNP-1-3 and HD-5 . Interestingly, HNP-4 has F26 (aromatic; nonpolar) as F28 in HNP-1-3 and Y28 (aromatic; polar) as HD-5 with Y27 which suggest it may have also antiadenoviral activity. Evidence for an in vivo role of [alpha]-defensin as antiviral agents in adenovirus infection derives from a study conducted by Gounder et al. showed that a mouse model deficient in activated [alpha]-defensins in the small intestine is more susceptible to disease upon oral viral infection . Alpha-defensins have also been found to inhibit several enveloped viruses by binding to glycoproteins especially glycoprotein 120 in HIV-1 infection reducing the number of viruses that enter the cell. HNP-4 and HD-6 inhibit HSV-1 and HSV-2 by binding to heparin sulphate, blocking the receptor binding [23, 24].
Neutrophils are known as the major cellular source of HNPs. In our study, neutrophil recruitment was a feature of adenovirus-infected children. Indeed, 200-fold increase in neutrophil numbers was observed during the symptomatic period suggesting these cells migrate into the virus inflammatory site and release HNPs locally. In support of this observation, we found a significant correlation between HNP-4 and neutrophil numbers in the present study.
Interestingly, previous studies have demonstrated that HNPs induce the production neutrophil attractant interleukin (IL)-8 from monocytes and both airway and intestinal epithelial cells in vitro [25, 26]. We and other groups demonstrated that children infected with respiratory viruses including adenovirus induce the release of IL-8 in the upper respiratory airways [27, 28]. Thus, IL-8 production during the adenovirus infection process may recruit neutrophils which in turn release HNPs. These defensins may then stimulate further IL-8 production amplifying neutrophil migration to protect the airways from infection. The lack of correlations between HNPs and score symptoms in the present study raises some doubts about their role in the airways. However, we have previously shown that such correlations are sometimes difficult to find in clinical studies  where many variables may affect the strength of a relationship between two biologic measurements as other antivirus mediators are released including interferons .
Our study has some potential limitations. First, we did not investigate any of the seven different adenovirus subtypes (A to G). However, subtypes B and C most frequently cause mild respiratory infections, and it is likely that these two adenoviruses subtypes could have infected children participating in this study. And secondly, adenovirus causes more severe symptoms in children below 3 years of age  Volunteers participating in this study were 6-12 years, and it is likely that the inflammatory changes in their airways may not mirror those observed in younger children.
In summary, we have shown that children suffering from adenovirus-induced naturally occurring common cold release high concentrations of the HNP-1, -3, and -4, but not HNP-2, in the upper airways. Interestingly, a parallel increased number of neutrophils were observed, suggesting these cells may be a potential source of the HNPs during the adenovirus infection process. The exact mechanism responsible for the increase in HNP levels remains to be elucidated.
HNP: Human neutrophil peptide ELISA: Enzyme-linked immunosorbent assay AdV: Adenovirus HPV: Human papillomavirus HBD: Human beta-defensins HD: Human defensin MMP: Matrix metalloproteinase W: Tryptophan F: Phenylalanine Y: Tyrosine CAR: Coxsackievirus and adenovirus receptor UTI: Upper respiratory tract infections TMB: Tetramethylbenzidine.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
The authors are grateful to the Consejo Nacional de Ciencia y Tecnologia, Mexico, for financial support.
 J. Abd-Jamil, B.-T. Teoh, E. H. Hassan, N. Roslan, and S. AbuBakar, "Molecular identification of adenovirus causing respiratory tract infection in pediatric patients at the University of Malaya Medical Center 2010," BMC Pediatrics, vol. 10, p. 46, 2010.
 S. Shaw, "Seasonality and selective trends in viral acute respiratory tract infections," Medical Hypotheses, vol. 86, pp. 104-119, 2016.
 J. G. Smith and G. R. Nemerow, "Mechanism of adenovirus neutralization by human [alpha]-defensins," Cell Host and Microbe, vol. 3, no. 1, pp. 11-19, 2008.
 M.-P. Lu, L.-Y. Ma, Q. Zheng, L.-L. Dong, and Z.-M. Chen, "Clinical characteristics of adenovirus associated lower respiratory tract infection in children," World Journal of Pediatrics, vol. 9, no. 4, pp. 346-349, 2013.
 H. Shike, C. Shimizu, J. Kanegaye, J. L. Foley, and J. C. Burns, "Quantitation of adenovirus genome during acute infection in normal children," Pediatric Infectious Disease Journal, vol. 24, no. 1, pp. 29-33, 2005.
 E. Guani, T. Santos, S. O. Lugo, and L. M. Teran, "Antimicrobial peptides: general overview and clinical implications in human health and disease," Clinical Immunology, vol. 135, no. 1, pp. 1-11, 2010.
 R. H. Parrott, W. P. Rowe, R. J. Huebner, H. W. Bernton, and N. B. McCullough, "Outbreak of febrile pharyngitis and conjunctivitis associated with type 3 adenoidal-pharyngeal-conjunctival virus infections," New England Journal of Medicine, vol. 251, no. 27, pp. 1087-1090, 1954.
 H. R. Harrison, P. Howe, L. Minnich, and C. George Ray, "Cluster of adenovirus 19 infection with multiple clinical manifestations," Journal of Pediatrics, vol. 94, no. 6, pp. 917-919, 1979.
 L. S. Mitchell, B. Taylor, W. Reimels, F. F. Barrett, and J. P. Devincenzo, "Adenovirus 7a: a community-acquired outbreak in a children's hospital," Pediatric Infectious Disease Journal, vol. 19, no. 10, pp. 996-1000, 2000.
 H. Ghanaiem, D. Averbuch, and B. Z. Koplewitz, "An outbreak of adenovirus type 7 in a residential facility for severely disabled children," Pediatric Infectious Disease Journal, vol. 30, no. 11, pp. 948-952, 2011.
 Y. Dongliu, Y. Guoliang, X. Haocheng, Q. Shuaijia, B. Li, and J. Yanglei, "Outbreak of acute febrile respiratory illness caused by human adenovirus B P14H11F14 in a military training camp in Shandong China," Archives of Virology, vol. 161, no. 9, pp. 2481-2489, 2016.
 J. Cheng, X. Qi, D. Chen et al., "Epidemiology and transmission characteristics of human adenovirus type 7 caused acute respiratory disease outbreak in military trainees in East China," American Journal of Translational Research, vol. 8, no. 5, pp. 2331-2342, 2016.
 S. S. Wilson, M. E. Wiens, and J. G. Smith, "Antiviral mechanisms of human defensins," Journal of Molecular Biology, vol. 425, no. 24, pp. 4965-4980, 2013.
 G. Rohde, S. D. Message, J. J. Haas et al., "CXC chemokines and antimicrobial peptides in rhinovirus-induced experimental asthma exacerbations," Clinical and Experimental Allergy, vol. 44, no. 7, pp. 930-939, 2014.
 K. Nakamura, N. Sakuragi, A. Takakuwa, and T. Ayabe, "Paneth cell a-defensins and enteric microbiota in health and disease," Bioscience of Microbiota, Food and Health, vol. 35, no. 2, pp. 57-67, 2016.
 C. G Wilde, J. E Griffith, M. N. Marra, J. L. Snable, and R. W. Scott, "Purification and characterization of human neutrophil peptide 4, a novel member of the defensins family," Journal of Biological Chemistry, vol. 264, no. 19, pp. 11200-11203, 1989.
 A. Bastian and H. Schafer, "Human a-defensin 1 (HNP-1) inhibits adenoviral infection in vitro," Regulatory Peptides, vol. 101, no. 1-3, pp. 157-161, 2001.
 J. Antiago, J. L. Hernandez, M. E. Manjarrez et al., "Role of monocyte chemotactic protein-3 and -4 in children with virus exacerbation of asthma," European Respiratory Journal, vol. 32, no. 5, pp. 1243-1242, 2008.
 J. G. Smith, M. Silvestry, S. Lindert, W. Lu, G. R. Nemerow, and P. L. Stewart, "Insight into the mechanisms of adenovirus capsid disassembly from studies of defensin neutralization," PLoS Pathogens, vol. 6, no. 6, article e1000959, 2010.
 E. K. Nguyen, G. R. Nemerow, and J. G. Smith, "Direct evidence from single-cell analysis that human alpha-defensins block adenovirus uncoating to neutralize infection," Journal of Virology, vol. 84, no. 8, pp. 4041-4049, 2010.
 V. R. Tenge, A. P. Gounder, M. E. Wiens, W. Lu, and J. G. Smith, "Delineation of interfaces on human alpha-defensins critical for human adenovirus and human papillomavirus inhibition," PLoS Pathogens, vol. 10, no. 9, article e1004360, 2014.
 A. P. Gounder, N. D. Myers, P. M. Treuting et al., "Defensins potentiate a neutralizing antibody response to enteric viral infection," PLoS Pathogens, vol. 12, no. 3, article e1005474, 2016.
 E. Hazrati, B. Galen, W. Lu et al., "Human alpha- and beta-defensins block multiple steps in herpes simplex virus infection," Journal of Immunology, vol. 177, no. 12, pp. 86588666, 2006.
 S. S. Wilson, M. E. Wiens, M. K. Holly et al., "Defensins at the mucosal surface: latest insights into defensin-virus interactions," Journal of Virology, vol. 90, no. 11, pp. 5216-5218, 2016.
 F. Syeda, H. Y. Liu, E. Tullis, M. Liu, A. S. Slutsky, and H. Zhang, "Differential signaling mechanisms of HNP-induced IL-8 production in human lung epithelial cells and monocytes," Journal of Cellular Physiology, vol. 214, no. 3, pp. 820-827, 2008.
 K. Ibusuki, T. Sakiyama, S. Kanmura et al., "Human neutrophil peptides induce interleukin-8 in intestinal epithelial cells through the P2 receptor and ERK1/2 signaling pathways," International Journal of Molecular Medicine, vol. 35, no. 6, pp. 1603-1609, 2015.
 L. M. Teran, S. L. Johnston, J. M. Schroder, M. K. Church, and S. T. Holgate, "Role of nasal interleukin-8 in neutrophil recruitment and activation in children with virus-induced asthma," American Journal of Respiratory and Critical Care Medicine, vol. 155, no. 4, pp. 1362-1366, 1997.
 M. R. Moro, C. A. Bonville, M. Suryadevara et al., "Clinical features, adenovirus types, and local production of inflammatory mediators in adenovirus infections," Pediatric Infectious Disease Journal, vol. 28, no. 5, pp. 376-380, 2009.
 L. M. Teran, M. C. Seminario, J. K. Shute et al., "RANTES, macrophage-inhibitory protein 1alpha, and the eosinophil product major basic protein are released into upper respiratory secretions during virus-induced asthma exacerbations in children," Journal of Infectious Diseases, vol. 179, no. 3, pp. 677-681, 1999.
V. S. Priyadharshini, (1) F. Ramirez-Jimenez, (2) M. Molina-Macip, (2) C. Renteria-Rosales, (2) J. Santiago-Cruz, (2) Paola Zarate-Segura, (1) E. Lara- Padilla, (3) and Luis M. Teran [ID] (2)
(1) Escuela Superior de Medicina del Instituto Politecnico Nacional, Plan de San Luis y Diaz Miron, Casco de Santo Tomas, 11340 Mexico City, Mexico
(2) Instituto Nacional de Enfermedades Respiratorias "Ismael Cosio Villegas", Calzada Tlalpan No. 4502, Secciin XVI, 14080 Mexico City, Mexico
(3) Comision de Operacion y Fomento de Actividades Academicas del IPN, Mexico City, Mexico
Correspondence should be addressed to Luis M. Teran; firstname.lastname@example.org
Received 6 December 2017; Revised 17 April 2018; Accepted 4 July 2018; Published 31 July 2018
Academic Editor: Dario Olivieri
Caption: Figure 1: Levels of HNP-1-4 in nasal aspirates from children with naturally occurring adenovirus infection (symptomatic) and when well (asymptomatic). HNP-1-4 were measured by ELISA in nasal aspirates. Statistical analysis and Mann-Whitney U test were perfomed.
Caption: Figure 2: Correlation between HNP-4 and neutrophils in nasal aspirate samples from children with naturally occurring adenovirus infection. Statistical analysis was performed using Spearman's test.
Table 1: Clinical symptoms presented by AdV-positive children. Characteristic HAdV symptomatic (N = 14) Clinical symptoms N (%) Blocked nose 13 (92.85) Throat redness 14 (100) Fatigue 10 (71.42) Rhinorrhea 13 (92.8) Fever 6 (42.85) Chillness 5 (35.71) Cough 14 (100) Headache 7 (50) Chest pain 5 (35.71) Table 2: Differential and total cell counts in nasal aspirate fluids from symptomatic and asymptomatic. Cells Asymptomatic Symptomatic Neutrophils 0 (0-16) 52.0 (20.3-79.3) Macrophages 0 (0-3.0) 24.2 (12.70-44.4) Lymphocytes 0 (0-0) 7.2 (1.2-23.9) Eosinophils 0 (0-2.0) 1.9 (0-4.6) Epithelial 28 (50-34) 4.3 (2.3-15.6) Total 20 (1-50) 330 (100-4000) Data represented as median (range) x [10.sup.3] (symptomatic (n = 14); asymptomatic (n = 14)).
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Research Article|
|Author:||Priyadharshini, V.S.; Ramirez-Jimenez, F.; Molina-Macip, M.; Renteria-Rosales, C.; Santiago-Cruz, J.|
|Publication:||Canadian Respiratory Journal|
|Date:||Jan 1, 2018|
|Previous Article:||Cost Effectiveness of Bosentan for Pulmonary Arterial Hypertension: A Systematic Review.|
|Next Article:||Comparison of Mask Oxygen Therapy and High-Flow Oxygen Therapy after Cardiopulmonary Bypass in Obese Patients.|