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Tian M, Zhan Y, Cao J, Gao J, Sun J, Zhang L. Targeting blood-brain barrier for sepsis-associated encephalopathy: Regulation of immune cells and ncRNAs. Brain Res Bull 2024; 209:110922. [PMID: 38458135 DOI: 10.1016/j.brainresbull.2024.110922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/14/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
Sepsis causes significant morbidity and mortality worldwide, most surviving patients show acute or chronic mental disorders, which are known as sepsis-associated encephalopathy (SAE). SAE involves many pathological processes, including the blood-brain barrier (BBB) damage. The BBB is located at the interface between the central nervous system and the surrounding environment, which protects the central nervous system (CNS) from the invasion of exogenous molecules, harmful substances or microorganisms in the blood. Recently, a growing number of studies have indicated that the BBB destruction was involved in SAE and played an important role in SAE-induced brain injury. In the present review, we firstly reveal the pathological processes of SAE such as the neurotransmitter disorders, oxidative stress, immune dysfunction and BBB destruction. Moreover, we introduce the structure of BBB, and describe the immune cells including microglia and astrocytes that participate in the BBB destruction after SAE. Furthermore, in view of the current research on non-coding RNAs (ncRNAs), we explain the regulatory mechanism of ncRNAs including long noncoding RNAs (lncRNAs), microRNAs (miRNAs) and circular RNAs (circRNAs) on BBB in the processes of SAE. Finally, we propose some challenges and perspectives of regulating BBB functions in SAE. Hence, on the basis of these effects, both immune cells and ncRNAs may be developed as therapeutic targets to protect BBB for SAE patients.
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Affiliation(s)
- Mi Tian
- Department of Anesthesiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu Province, China
| | - Yunliang Zhan
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jinyuan Cao
- Department of Anesthesiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu Province, China
| | - Jinqi Gao
- Department of Anesthesiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu Province, China
| | - Jie Sun
- Department of Anesthesiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu Province, China.
| | - Li Zhang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China.
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De Felice B, Coppola C, Bonavita S, Signoriello E, Montanino C, Farinella F. Exploring Circulating Long Non-Coding RNAs in Mild Cognitive Impairment Patients' Blood. Biomedicines 2023; 11:2963. [PMID: 38001964 PMCID: PMC10669861 DOI: 10.3390/biomedicines11112963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/27/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Mild cognitive impairment (MCI) is a transitional clinical stage prior to dementia. Patients with amnestic MCI have a high risk of progression toward Alzheimer's disease. Both amnestic mild cognitive impairment and sporadic Alzheimer's disease are multifactorial disorders consequential from a multifaceted cross-talk among molecular and biological processes. Non-coding RNAs play an important role in the regulation of gene expression, mainly long non-coding RNAs (lncRNAs), that regulate other RNA transcripts through binding microRNAs. Cross-talk between RNAs, including coding RNAs and non-coding RNAs, produces a significant regulatory network all through the transcriptome. The relationship of genes and non-coding RNAs could improve the knowledge of the genetic factors contributing to the predisposition and pathophysiology of MCI. The objective of this study was to identify the expression patterns and relevant lncRNA-associated miRNA regulatory axes in the blood of MCI patients, which includes lncRNA-SNHG16, lncRNA-H19, and lncRNA-NEAT1. Microarray investigations have demonstrated modifications in the expression of long non-coding RNAs (lncRNA) in the blood of patients with MCI compared with control samples. This is the first study to explore lncRNA profiles in mild cognitive impairment blood. Our study proposes RNAs targets involved in molecular pathways connected to the pathogenesis of MCI.
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Affiliation(s)
- Bruna De Felice
- Dipartimento di Scienze e Tecnologie Ambientali, Biologiche e Farmaceutiche, Università degli Studi della Campania “Luigi Vanvitelli”, Via G. Vivaldi 42, 81100 Caserta, Italy;
| | - Cinzia Coppola
- Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (C.C.); (S.B.); (E.S.)
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (C.C.); (S.B.); (E.S.)
| | - Elisabetta Signoriello
- Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (C.C.); (S.B.); (E.S.)
| | - Concetta Montanino
- Dipartimento di Scienze e Tecnologie Ambientali, Biologiche e Farmaceutiche, Università degli Studi della Campania “Luigi Vanvitelli”, Via G. Vivaldi 42, 81100 Caserta, Italy;
| | - Federica Farinella
- Division of Clinical Pathology, Laboratori Vita S.r.l., Via Sabaudia 19, 04100 Latina, Italy;
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Luo S, Lyu Z, Ge L, Li Y, Liu Y, Yuan Y, Zhao R, Huang L, Zhao J, Huang H, Luo Y. ATAXIA TELANGIECTASIA MUTATED PROTECTS AGAINST LIPOPOLYSACCARIDE-INDUCED BLOOD-BRAIN BARRIER DISRUPTION BY REGULATING ATK/DRP1-MEDIATED MITOCHONDRIAL HOMEOSTASIS. Shock 2023; 60:100-109. [PMID: 37141173 PMCID: PMC10417231 DOI: 10.1097/shk.0000000000002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/26/2023] [Indexed: 05/05/2023]
Abstract
ABSTRACT Background: Protein kinase ataxia telangiectasia mutated (ATM) regulates the function of endothelial cells and responds quickly to endotoxin. However, the function of ATM in lipopolysaccharide (LPS)-induced blood-brain barrier (BBB) disruption remains unknown. This study aimed to investigate the role and underlying mechanism of ATM in the regulation of the BBB function in sepsis. Methods: We used LPS to induce BBB disruption in vivo and to establish an in vitro model of cerebrovascular endothelial cells. Blood-brain barrier disruption was assessed by measuring Evans blue leakage and expression of vascular permeability regulators. To investigate the role of ATM, its inhibitor AZD1390 and clinically approved doxorubicin, an anthracycline that can activate ATM, were administered as scheduled. To explore the underlying mechanism, protein kinase B (AKT) inhibitor MK-2206 was administered to block the AKT/dynamin-related protein 1 (DRP1) pathway. Results: Lipopolysaccharide challenge induced significant BBB disruption, ATM activation, and mitochondrial translocation. Inhibiting ATM with AZD1390 aggravated BBB permeability as well as the following neuroinflammation and neuronal injury, while activation of ATM by doxorubicin abrogated these defects. Further results obtained in brain microvascular endothelial cells showed that ATM inhibition reduced the phosphorylation of DRP1 at serine (S) 637, promoted excessive mitochondrial fission, and resulted in mitochondrial malfunction. By activating ATM, doxorubicin increased the protein binding between ATM and AKT and promoted the phosphorylated activation of AKT at S473, which could directly phosphorylate DRP1 at S637 to repress excessive mitochondrial fission. Consistently, the protective role of ATM was abolished by the AKT inhibitor MK-2206. Conclusions: Ataxia telangiectasia mutated protects against LPS-induced BBB disruption by regulating mitochondrial homeostasis, at least in part, through the AKT/DRP1 pathway.
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Affiliation(s)
- Shiyuan Luo
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuochen Lyu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lingling Ge
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Yinjiao Li
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuqi Liu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Yuan
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Rui Zhao
- Institute for Developmental and Regenerative Cardiovascular Medicine, MOE-Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Huang
- Department of Molecular, Cell and Cancer Biology Program in Molecular Medicine University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jianyuan Zhao
- Institute for Developmental and Regenerative Cardiovascular Medicine, MOE-Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongjun Huang
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Dong Z, Jia L, Han W, Wang Y, Sheng M, Ren Y, Weng Y, Li H, Yu W. The protective effect of lncRNA NEAT1/miR-122-5p/Wnt1 axis on hippocampal damage in hepatic ischemic reperfusion young mice. Cell Signal 2023; 107:110668. [PMID: 37004832 DOI: 10.1016/j.cellsig.2023.110668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
Hepatic ischemic reperfusion (HIR) is a common pathophysiological process in many surgical procedures such as liver transplantation (LT) and hepatectomy. And it is also an important factor leading to perioperative distant organ damage. Children undergoing major liver surgery are more susceptible to various pathophysiological processes, including HIR, since their brains are still developing and the physiological functions are still incomplete, which can lead to brain damage and postoperative cognitive impairment, thus seriously affecting the long-term prognosis of the children. However, the present treatments of mitigating HIR-induced hippocampal damage are not proven to be effective. The important role of microRNAs (miRNAs) in the pathophysiological processes of many diseases and in the normal development of the body has been confirmed in several studies. The current study explored the role of miR-122-5p in HIR-induced hippocampal damage progression. HIR-induced hippocampal damage mouse model was induced by clamping the left and middle lobe vessels of the liver of young mice for 1 h, removing the vessel clamps and re-perfusing them for 6 h. The changes in the level of miR-122-5p in the hippocampal tissues were measured, and its influences on the activity as well as apoptotic rate of neuronal cells were investigated. Short interfering RNA modified with 2'-O-methoxy substitution targeting long-stranded non-coding RNA (lncRNA) nuclear enriched transcript 1 (NEAT1) as well as miR-122-5p antagomir were used to further clarify the role played by the corresponding molecules in hippocampal injury in young mice with HIR. The result obtained in our study was that the expression of miR-122-5p in the hippocampal tissue of young mice receiving HIR is reduced. Upregulated expression of miR-122-5p reduces the viability of neuronal cells and promotes the development of apoptosis, thereby aggravating the damage of hippocampal tissue in HIR young mice. Additionally, in the hippocampal tissue of young mice receiving HIR, lncRNA NEAT1 exerts some anti-apoptotic effects by binding to miR-122-5p, promoting the expression of Wnt1 pathway. An essential observation of this study was the binding of lncRNA NEAT1 to miR-122-5p, which upregulates Wnt1 and inhibits HIR-induced hippocampal damage in young mice.
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Ma T, Li H, Liu H, Peng Y, Lin T, Deng Z, Jia N, Chen Z, Wang P. Neat1 promotes acute kidney injury to chronic kidney disease by facilitating tubular epithelial cells apoptosis via sequestering miR-129-5p. Mol Ther 2022; 30:3313-3332. [PMID: 35619557 PMCID: PMC9552914 DOI: 10.1016/j.ymthe.2022.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/21/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022] Open
Abstract
Acute kidney injury (AKI) is increasingly identified as a crucial risk factor for progression to CKD. However, the factors governing AKI to CKD progression remain largely unknown. By high-throughput RNA sequencing, we found that Neat1_2, a transcript variant of Neat1, was upregulated in 40-min ischemia/reperfusion injury (IRI), which resulted in the development of renal fibrotic lesions. The upregulation of Neat1_2 in hypoxia-treated TECs was attributed to p53 transcriptional regulation. Gain- and loss-of-function studies, both in vitro and in vivo, demonstrated that Neat1_2 promoted apoptosis of injured TECs induced by IRI and caused tubulointerstitial inflammation and fibrosis. Mechanistically, Neat1_2 shares miRNA response elements with FADD, CASP-8, and CASP-3. Neat1_2 competitively binds to miR-129-5p and prevents miR-129-5p from decreasing the levels of FADD, CASP-8, and CASP-3, and ultimately facilitates TEC apoptosis. Increased expression of Neat1_2 associated with kidney injury and TEC apoptosis was recapitulated in human AKI, highlighting its clinical relevance. These findings suggest that preventing TEC apoptosis by hindering Neat1_2 expression may be a potential therapeutic strategy for AKI to CKD progression.
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Affiliation(s)
- Tongtong Ma
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hongwei Li
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou 510515, China
| | - Hui Liu
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Yili Peng
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou 510515, China
| | - Tong Lin
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou 510515, China
| | - Zhiya Deng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Nan Jia
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou 510515, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Peng Wang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou 510515, China.
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Ge C, Deng F, Chen W, Ye Z, Zhang L, Ai Y, Zou Y, Peng Q. Machine learning for early prediction of sepsis-associated acute brain injury. Front Med (Lausanne) 2022; 9:962027. [PMID: 36262275 PMCID: PMC9575145 DOI: 10.3389/fmed.2022.962027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/12/2022] [Indexed: 12/01/2022] Open
Abstract
Background Sepsis-associated encephalopathy (SAE) is defined as diffuse brain dysfunction associated with sepsis and leads to a high mortality rate. We aimed to develop and validate an optimal machine-learning model based on clinical features for early predicting sepsis-associated acute brain injury. Methods We analyzed adult patients with sepsis from the Medical Information Mart for Intensive Care (MIMIC III) clinical database. Candidate models were trained using random forest, support vector machine (SVM), decision tree classifier, gradients boosting machine (GBM), multiple layer perception (MLP), extreme gradient boosting (XGBoost), light gradients boosting machine (LGBM) and a conventional logistic regression model. These methods were applied to develop and validate the optimal model based on its accuracy and area under curve (AUC). Results In total, 12,460 patients with sepsis met inclusion criteria, and 6,284 (50.4%) patients suffered from sepsis-associated acute brain injury. Compared other models, the LGBM model achieved the best performance. The AUC for both train set and test set indicated excellent validity (Trainset AUC 0.91, Testset AUC 0.87). Feature importance analysis showed that glucose, age, mean arterial pressure, heart rate, hemoglobin, and length of ICU stay were the top 6 important clinical factors to predict occurrence of sepsis-associated acute brain injury. Conclusion Almost half of patients admitted to ICU with sepsis had sepsis-associated acute brain injury. The LGBM model better identify patients with sepsis-associated acute brain injury than did other machine-learning models. Glucose, age, and mean arterial pressure were the three most important clinical factors to predict occurrence of sepsis-associated acute brain injury.
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Affiliation(s)
- Chenglong Ge
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,Hunan Provincial Clinical Research Center for Critical Care Medicine, Changsha, China
| | - Fuxing Deng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Chen
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,Hunan Provincial Clinical Research Center for Critical Care Medicine, Changsha, China
| | - Zhiwen Ye
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,Hunan Provincial Clinical Research Center for Critical Care Medicine, Changsha, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,Hunan Provincial Clinical Research Center for Critical Care Medicine, Changsha, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,Hunan Provincial Clinical Research Center for Critical Care Medicine, Changsha, China
| | - Yu Zou
- Department of Anesthesia, Xiangya Hospital, Central South University, Changsha, China
| | - Qianyi Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Changsha, China,Hunan Provincial Clinical Research Center for Critical Care Medicine, Changsha, China,*Correspondence: Qianyi Peng,
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The role of long noncoding RNA (lncRNA) nuclear-enriched abundant transcript 1 (NEAT1) in immune diseases. Transpl Immunol 2022; 75:101716. [PMID: 36126903 DOI: 10.1016/j.trim.2022.101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
The long noncoding RNA (lncRNA) nuclear-enriched abundant transcript 1 (NEAT1) has been shown to be involved in the pathogenesis of several diseases. Herein, we discuss recent developments and insights into NEAT1 and its contribution to a variety of immune disorders. Our evaluations revealed that NEAT1's function in immune diseases seems to be focused on the modulation of paraspeckle expression and it is primarily associated with the nuclear retention of its mRNA. NEAT1 is also involved in the sequestration of paraspeckle proteins and in affecting the transcriptional expression of specific immune regulators. The expression of NEAT1 may be aberrantly upregulated in several immune pathologies, indicating that it could serve as a potential prognostic biomarker in these conditions. We summarized describing the expression changes and the role of NEAT1 in several immune diseases. We also described the mechanism of its regulation of the immune cell differentiation and function of NEAT1 in different disease.
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MOBT Alleviates Pulmonary Fibrosis through an lncITPF-hnRNP-l-Complex-Mediated Signaling Pathway. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27165336. [PMID: 36014574 PMCID: PMC9414852 DOI: 10.3390/molecules27165336] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022]
Abstract
Pulmonary fibrosis is characterized by the destruction of alveolar architecture and the irreversible scarring of lung parenchyma, with few therapeutic options and effective therapeutic drugs. Here, we demonstrate the anti-pulmonary fibrosis of 3-(4-methoxyphenyl)-4-oxo-4H-1-benzopyran-7-yl(αS)-α,3,4-trihydroxybenzenepropanoate (MOBT) in mice and a cell model induced by bleomycin and transforming growth factor-β1. The anti-pulmonary fibrosis of MOBT was evaluated using a MicroCT imaging system for small animals, lung function analysis and H&E and Masson staining. The results of RNA fluorescence in situ hybridization, chromatin immunoprecipitation (ChIP)-PCR, RNA immunoprecipitation, ChIP-seq, RNA-seq, and half-life experiments demonstrated the anti-pulmonary fibrotic mechanism. Mechanistic dissection showed that MOBT inhibited lncITPF transcription by preventing p-Smad2/3 translocation from the cytoplasm to the nucleus, resulting in a reduction in the amount of the lncITPF–hnRNP L complex. The decreased lncITPF–hnRNP L complex reduced MEF2c expression by blocking its alternative splicing, which in turn inhibited the expression of MEF2c target genes, such as TAGLN2 and FMN1. Briefly, MOBT alleviated pulmonary fibrosis through the lncITPF–hnRNP-l-complex-targeted MEF2c signaling pathway. We hope that this study will provide not only a new drug candidate but also a novel therapeutic drug target, which will bring new treatment strategies for pulmonary fibrosis.
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