Cigarette smoke exposure facilitates allergic sensitization in mice

Katrien B Moerloose, Lander J Robays, Tania Maes, Guy G Brusselle, Kurt G Tournoy, Guy F Joos, Katrien B Moerloose, Lander J Robays, Tania Maes, Guy G Brusselle, Kurt G Tournoy, Guy F Joos

Abstract

Background: Active and passive smoking are considered as risk factors for asthma development. The mechanisms involved are currently unexplained.

Objective: The aim of this study was to determine if cigarette smoke exposure could facilitate primary allergic sensitization.

Methods: BALB/c mice were exposed to aerosolized ovalbumin (OVA) combined with air or tobacco smoke (4 exposures/day) daily for three weeks. Serology, lung cytopathology, cytokine profiles in bronchoalveolar lavage fluid (BALF) and on mediastinal lymph node cultures as well as lung function tests were performed after the last exposure. The natural history and the immune memory of allergic sensitization were studied with in vivo recall experiments.

Results: Exposure to OVA induced a small increase in OVA-specific serum IgE as compared with exposure to PBS (P < 0.05), while no inflammatory reaction was observed in the airways. Exposure to cigarette smoke did not induce IgE, but was characterized by a small but significant neutrophilic inflammatory reaction. Combining OVA with cigarette smoke not only induced a significant increase in OVA-specific IgE but also a distinct eosinophil and goblet cell enriched airway inflammation albeit that airway hyperresponsiveness was not evidenced. FACS analysis showed in these mice increases in dendritic cells (DC) and CD4+ T-lymphocytes along with a marked increase in IL-5 measured in the supernatant of lymph node cell cultures. Immune memory experiments evidenced the transient nature of these phenomena.

Conclusion: In this study we show that mainstream cigarette smoke temporary disrupts the normal lung homeostatic tolerance to innocuous inhaled allergens, thereby inducing primary allergic sensitization. This is characterized not only by the development of persistent IgE, but also by the emergence of an eosinophil rich pulmonary inflammatory reaction.

Figures

Figure 1
Figure 1
Serum ovalbumin-specific IgE and IgG1 (U/ml) in mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 2

Number of eosinophils, lymphocytes and…

Figure 2

Number of eosinophils, lymphocytes and dendritic cells in bronchoalveolar lavage fluid of mice…

Figure 2
Number of eosinophils, lymphocytes and dendritic cells in bronchoalveolar lavage fluid of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 3

Number of dendritic cells, CD4+…

Figure 3

Number of dendritic cells, CD4+ T-lymphocytes and CD8+ T-lymphocytes in lung tissue of…

Figure 3
Number of dendritic cells, CD4+ T-lymphocytes and CD8+ T-lymphocytes in lung tissue of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 4

Eosinophils per mm 2 in…

Figure 4

Eosinophils per mm 2 in the airway wall of mice exposed to phosphate…

Figure 4
Eosinophils per mm2 in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P < 0.01; **P < 0.001).

Figure 5

Goblet cells in the airway…

Figure 5

Goblet cells in the airway wall of mice exposed to phosphate buffered saline…

Figure 5
Goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: Pbm = perimeter of basement membrane (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 6

Eosinophils and goblet cells in…

Figure 6

Eosinophils and goblet cells in the airway wall of mice exposed to phosphate…

Figure 6
Eosinophils and goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. A. Congo red staining for eosinophils in OVA- and air-exposed mice. B. Congo red staining for eosinophils in simultaneously OVA- and smoke-exposed mice. The arrows are indicating eosinophils. C. Periodic acid-Schiff staining for goblet cells in OVA- and air-exposed mice. D. Periodic acid-Schiff staining for goblet cells in simultaneously OVA- and smoke-exposed mice.

Figure 7

Cytokines in BAL fluid supernatant…

Figure 7

Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline…

Figure 7
Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: TARC = thymus and activation regulated chemokine (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 8

Cytokines IL-4, IL-5, IL-10 and…

Figure 8

Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml)…

Figure 8
Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml) after stimulation with OVA (0, 10 and 100 μg/ml). Mice were exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (* P
All figures (8)
Similar articles
Cited by
References
    1. Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma. 1999;36:257–264. - PubMed
    1. Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194–1200. doi: 10.1056/NEJM199810223391703. - DOI - PubMed
    1. Siroux V, Pin I, Oryszczyn MP, Le Moual N, Kauffmann F. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the Genetics and Environment of Asthma. Eur Respir J. 2000;15:470–477. doi: 10.1034/j.1399-3003.2000.15.08.x. - DOI - PubMed
    1. Seymour BW, Pinkerton KE, Friebertshauser KE, Coffman RL, Gershwin LJ. Second-hand smoke is an adjuvant for T helper-2 responses in a murine model of allergy. J Immunol. 1997;159:6169–6175. - PubMed
    1. Moerloose KB, Pauwels RA, Joos GF. Short-term cigarette smoke exposure enhances allergic airway inflammation in mice. Am J Respir Crit Care Med. 2005;172:168–172. doi: 10.1164/rccm.200409-1174OC. - DOI - PubMed
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Figure 2
Figure 2
Number of eosinophils, lymphocytes and dendritic cells in bronchoalveolar lavage fluid of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 3

Number of dendritic cells, CD4+…

Figure 3

Number of dendritic cells, CD4+ T-lymphocytes and CD8+ T-lymphocytes in lung tissue of…

Figure 3
Number of dendritic cells, CD4+ T-lymphocytes and CD8+ T-lymphocytes in lung tissue of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 4

Eosinophils per mm 2 in…

Figure 4

Eosinophils per mm 2 in the airway wall of mice exposed to phosphate…

Figure 4
Eosinophils per mm2 in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P < 0.01; **P < 0.001).

Figure 5

Goblet cells in the airway…

Figure 5

Goblet cells in the airway wall of mice exposed to phosphate buffered saline…

Figure 5
Goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: Pbm = perimeter of basement membrane (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 6

Eosinophils and goblet cells in…

Figure 6

Eosinophils and goblet cells in the airway wall of mice exposed to phosphate…

Figure 6
Eosinophils and goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. A. Congo red staining for eosinophils in OVA- and air-exposed mice. B. Congo red staining for eosinophils in simultaneously OVA- and smoke-exposed mice. The arrows are indicating eosinophils. C. Periodic acid-Schiff staining for goblet cells in OVA- and air-exposed mice. D. Periodic acid-Schiff staining for goblet cells in simultaneously OVA- and smoke-exposed mice.

Figure 7

Cytokines in BAL fluid supernatant…

Figure 7

Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline…

Figure 7
Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: TARC = thymus and activation regulated chemokine (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 8

Cytokines IL-4, IL-5, IL-10 and…

Figure 8

Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml)…

Figure 8
Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml) after stimulation with OVA (0, 10 and 100 μg/ml). Mice were exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (* P
All figures (8)
Similar articles
Cited by
References
    1. Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma. 1999;36:257–264. - PubMed
    1. Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194–1200. doi: 10.1056/NEJM199810223391703. - DOI - PubMed
    1. Siroux V, Pin I, Oryszczyn MP, Le Moual N, Kauffmann F. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the Genetics and Environment of Asthma. Eur Respir J. 2000;15:470–477. doi: 10.1034/j.1399-3003.2000.15.08.x. - DOI - PubMed
    1. Seymour BW, Pinkerton KE, Friebertshauser KE, Coffman RL, Gershwin LJ. Second-hand smoke is an adjuvant for T helper-2 responses in a murine model of allergy. J Immunol. 1997;159:6169–6175. - PubMed
    1. Moerloose KB, Pauwels RA, Joos GF. Short-term cigarette smoke exposure enhances allergic airway inflammation in mice. Am J Respir Crit Care Med. 2005;172:168–172. doi: 10.1164/rccm.200409-1174OC. - DOI - PubMed
Show all 29 references
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Figure 3
Figure 3
Number of dendritic cells, CD4+ T-lymphocytes and CD8+ T-lymphocytes in lung tissue of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 4

Eosinophils per mm 2 in…

Figure 4

Eosinophils per mm 2 in the airway wall of mice exposed to phosphate…

Figure 4
Eosinophils per mm2 in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P < 0.01; **P < 0.001).

Figure 5

Goblet cells in the airway…

Figure 5

Goblet cells in the airway wall of mice exposed to phosphate buffered saline…

Figure 5
Goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: Pbm = perimeter of basement membrane (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 6

Eosinophils and goblet cells in…

Figure 6

Eosinophils and goblet cells in the airway wall of mice exposed to phosphate…

Figure 6
Eosinophils and goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. A. Congo red staining for eosinophils in OVA- and air-exposed mice. B. Congo red staining for eosinophils in simultaneously OVA- and smoke-exposed mice. The arrows are indicating eosinophils. C. Periodic acid-Schiff staining for goblet cells in OVA- and air-exposed mice. D. Periodic acid-Schiff staining for goblet cells in simultaneously OVA- and smoke-exposed mice.

Figure 7

Cytokines in BAL fluid supernatant…

Figure 7

Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline…

Figure 7
Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: TARC = thymus and activation regulated chemokine (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 8

Cytokines IL-4, IL-5, IL-10 and…

Figure 8

Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml)…

Figure 8
Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml) after stimulation with OVA (0, 10 and 100 μg/ml). Mice were exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (* P
All figures (8)
Similar articles
Cited by
References
    1. Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma. 1999;36:257–264. - PubMed
    1. Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194–1200. doi: 10.1056/NEJM199810223391703. - DOI - PubMed
    1. Siroux V, Pin I, Oryszczyn MP, Le Moual N, Kauffmann F. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the Genetics and Environment of Asthma. Eur Respir J. 2000;15:470–477. doi: 10.1034/j.1399-3003.2000.15.08.x. - DOI - PubMed
    1. Seymour BW, Pinkerton KE, Friebertshauser KE, Coffman RL, Gershwin LJ. Second-hand smoke is an adjuvant for T helper-2 responses in a murine model of allergy. J Immunol. 1997;159:6169–6175. - PubMed
    1. Moerloose KB, Pauwels RA, Joos GF. Short-term cigarette smoke exposure enhances allergic airway inflammation in mice. Am J Respir Crit Care Med. 2005;172:168–172. doi: 10.1164/rccm.200409-1174OC. - DOI - PubMed
Show all 29 references
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Figure 4
Figure 4
Eosinophils per mm2 in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (*P < 0.01; **P < 0.001).
Figure 5
Figure 5
Goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: Pbm = perimeter of basement membrane (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 6

Eosinophils and goblet cells in…

Figure 6

Eosinophils and goblet cells in the airway wall of mice exposed to phosphate…

Figure 6
Eosinophils and goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. A. Congo red staining for eosinophils in OVA- and air-exposed mice. B. Congo red staining for eosinophils in simultaneously OVA- and smoke-exposed mice. The arrows are indicating eosinophils. C. Periodic acid-Schiff staining for goblet cells in OVA- and air-exposed mice. D. Periodic acid-Schiff staining for goblet cells in simultaneously OVA- and smoke-exposed mice.

Figure 7

Cytokines in BAL fluid supernatant…

Figure 7

Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline…

Figure 7
Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: TARC = thymus and activation regulated chemokine (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 8

Cytokines IL-4, IL-5, IL-10 and…

Figure 8

Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml)…

Figure 8
Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml) after stimulation with OVA (0, 10 and 100 μg/ml). Mice were exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (* P
All figures (8)
Similar articles
Cited by
References
    1. Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma. 1999;36:257–264. - PubMed
    1. Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194–1200. doi: 10.1056/NEJM199810223391703. - DOI - PubMed
    1. Siroux V, Pin I, Oryszczyn MP, Le Moual N, Kauffmann F. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the Genetics and Environment of Asthma. Eur Respir J. 2000;15:470–477. doi: 10.1034/j.1399-3003.2000.15.08.x. - DOI - PubMed
    1. Seymour BW, Pinkerton KE, Friebertshauser KE, Coffman RL, Gershwin LJ. Second-hand smoke is an adjuvant for T helper-2 responses in a murine model of allergy. J Immunol. 1997;159:6169–6175. - PubMed
    1. Moerloose KB, Pauwels RA, Joos GF. Short-term cigarette smoke exposure enhances allergic airway inflammation in mice. Am J Respir Crit Care Med. 2005;172:168–172. doi: 10.1164/rccm.200409-1174OC. - DOI - PubMed
Show all 29 references
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MeSH terms
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Figure 6
Figure 6
Eosinophils and goblet cells in the airway wall of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. A. Congo red staining for eosinophils in OVA- and air-exposed mice. B. Congo red staining for eosinophils in simultaneously OVA- and smoke-exposed mice. The arrows are indicating eosinophils. C. Periodic acid-Schiff staining for goblet cells in OVA- and air-exposed mice. D. Periodic acid-Schiff staining for goblet cells in simultaneously OVA- and smoke-exposed mice.
Figure 7
Figure 7
Cytokines in BAL fluid supernatant (pg/ml) of mice exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. Definition of abbreviations: TARC = thymus and activation regulated chemokine (n = 8 per group. Values are reported as mean ± SEM) (*P

Figure 8

Cytokines IL-4, IL-5, IL-10 and…

Figure 8

Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml)…

Figure 8
Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml) after stimulation with OVA (0, 10 and 100 μg/ml). Mice were exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (* P
All figures (8)
Similar articles
Cited by
References
    1. Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma. 1999;36:257–264. - PubMed
    1. Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194–1200. doi: 10.1056/NEJM199810223391703. - DOI - PubMed
    1. Siroux V, Pin I, Oryszczyn MP, Le Moual N, Kauffmann F. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the Genetics and Environment of Asthma. Eur Respir J. 2000;15:470–477. doi: 10.1034/j.1399-3003.2000.15.08.x. - DOI - PubMed
    1. Seymour BW, Pinkerton KE, Friebertshauser KE, Coffman RL, Gershwin LJ. Second-hand smoke is an adjuvant for T helper-2 responses in a murine model of allergy. J Immunol. 1997;159:6169–6175. - PubMed
    1. Moerloose KB, Pauwels RA, Joos GF. Short-term cigarette smoke exposure enhances allergic airway inflammation in mice. Am J Respir Crit Care Med. 2005;172:168–172. doi: 10.1164/rccm.200409-1174OC. - DOI - PubMed
Show all 29 references
Publication types
MeSH terms
[x]
Cite
Copy Download .nbib
Format: AMA APA MLA NLM
Figure 8
Figure 8
Cytokines IL-4, IL-5, IL-10 and IL-13 in lymph node cell culture supernatant (pg/ml) after stimulation with OVA (0, 10 and 100 μg/ml). Mice were exposed to phosphate buffered saline (PBS) or ovalbumin (OVA) combined with air or cigarette smoke (SM) for three weeks. (n = 8 per group. Values are reported as mean ± SEM) (* P
All figures (8)

References

    1. Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma. 1999;36:257–264.
    1. Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med. 1998;339:1194–1200. doi: 10.1056/NEJM199810223391703.
    1. Siroux V, Pin I, Oryszczyn MP, Le Moual N, Kauffmann F. Relationships of active smoking to asthma and asthma severity in the EGEA study. Epidemiological study on the Genetics and Environment of Asthma. Eur Respir J. 2000;15:470–477. doi: 10.1034/j.1399-3003.2000.15.08.x.
    1. Seymour BW, Pinkerton KE, Friebertshauser KE, Coffman RL, Gershwin LJ. Second-hand smoke is an adjuvant for T helper-2 responses in a murine model of allergy. J Immunol. 1997;159:6169–6175.
    1. Moerloose KB, Pauwels RA, Joos GF. Short-term cigarette smoke exposure enhances allergic airway inflammation in mice. Am J Respir Crit Care Med. 2005;172:168–172. doi: 10.1164/rccm.200409-1174OC.
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Source: PubMed

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