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Hussein Z, Marcus HJ, Grieve J, Dorward N, Kosmin M, Fersht N, Bouloux PM, Jaunmuktane Z, Baldeweg SE. Pituitary function at presentation and following therapy in patients with non-functional pituitary macroadenomas: a single centre retrospective cohort study. Endocrine 2023; 82:143-151. [PMID: 37389717 PMCID: PMC10462492 DOI: 10.1007/s12020-023-03434-3] [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: 07/18/2022] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Non-functioning pituitary macroadenomas (NFPMs) may present with hypopituitarism. Pituitary surgery and radiotherapy pose an additional risk to pituitary function. OBJECTIVES To assess the incidence of hypopituitarism at presentation, the impact of treatment, and the likelihood of endocrine recovery during follow-up. METHODS All patients treated surgically with and without radiotherapy for NFPMs between 1987 and 2018 who had longer than six months follow-up were identified. Demographics, presentation, investigation, treatment, and outcomes were collected. RESULTS In total, 383 patients were identified. The median age was 57 years, with a median follow-up of 8 years. Preoperatively, 227 patients (227/375; 61%) had evidence of at least one pituitary deficiency. Anterior panhypopituitarism was more common in men (p = 0.001) and older patients (p = 0.005). Multiple hormone deficiencies were associated with large tumours (p = 0.03). Patients treated with surgery and radiotherapy had a higher incidence of all individual pituitary hormone deficiency, anterior panhypopituitarism, and significantly lower GH, ACTH, and TSH deficiencies free survival probability than those treated with surgery alone. Recovery of central hypogonadism, hypothyroidism, and anterior panhypopituitarism was also less likely to be reported in those treated with surgery and radiotherapy. Those with preoperative hypopituitarism had a higher risk of pituitary impairment at latest review than those presented with normal pituitary function (p = 0.001). CONCLUSION NFPMs are associated with a significant degree of hypopituitarism at time of diagnosis and post-therapy. The combination of surgery and radiotherapy is associated with a higher risk of pituitary dysfunction. Recovery of pituitary hormone deficit may occur after treatment. Patients should have regular ongoing endocrine evaluation post-treatment to assess changes in pituitary function and the need for long-term replacement therapy.
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Affiliation(s)
- Ziad Hussein
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield, UK.
- Division of Medicine, University College London, London, UK.
- Department of Endocrinology, University College London Hospitals, London, UK.
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Joan Grieve
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Neil Dorward
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael Kosmin
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - Naomi Fersht
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - Pierre Marc Bouloux
- Centre for Neuroendocrinology, Royal Free Campus, University College Medical School, University College London, London, UK
| | | | - Stephanie E Baldeweg
- Division of Medicine, University College London, London, UK
- Department of Endocrinology, University College London Hospitals, London, UK
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Sewaybricker LE, Huang A, Chandrasekaran S, Melhorn SJ, Schur EA. The Significance of Hypothalamic Inflammation and Gliosis for the Pathogenesis of Obesity in Humans. Endocr Rev 2023; 44:281-296. [PMID: 36251886 DOI: 10.1210/endrev/bnac023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/12/2022] [Indexed: 11/19/2022]
Abstract
Accumulated preclinical literature demonstrates that hypothalamic inflammation and gliosis are underlying causal components of diet-induced obesity in rodent models. This review summarizes and synthesizes available translational data to better understand the applicability of preclinical findings to human obesity and its comorbidities. The published literature in humans includes histopathologic analyses performed postmortem and in vivo neuroimaging studies measuring indirect markers of hypothalamic tissue microstructure. Both support the presence of hypothalamic inflammation and gliosis in children and adults with obesity. Findings predominantly point to tissue changes in the region of the arcuate nucleus of the hypothalamus, although findings of altered tissue characteristics in whole hypothalamus or other hypothalamic regions also emerged. Moreover, the severity of hypothalamic inflammation and gliosis has been related to comorbid conditions, including glucose intolerance, insulin resistance, type 2 diabetes, and low testosterone levels in men, independent of elevated body adiposity. Cross-sectional findings are augmented by a small number of prospective studies suggesting that a greater degree of hypothalamic inflammation and gliosis may predict adiposity gain and worsening insulin sensitivity in susceptible individuals. In conclusion, existing human studies corroborate a large preclinical literature demonstrating that hypothalamic neuroinflammatory responses play a role in obesity pathogenesis. Extensive or permanent hypothalamic tissue remodeling may negatively affect the function of neuroendocrine regulatory circuits and promote the development and maintenance of elevated body weight in obesity and/or comorbid endocrine disorders.
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Affiliation(s)
| | - Alyssa Huang
- Department of Pediatrics, University of Washington, Division of Endocrinology and Diabetes, Seattle Children's Hospital, Seattle, WA 98015, USA
| | | | - Susan J Melhorn
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Ellen A Schur
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
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Jang SH, Choi KH. Paroxysmal sympathetic hyperactivity concurrent with hypothalamic injury in a patient with intracerebral hemorrhage: A case report. Medicine (Baltimore) 2022; 101:e30058. [PMID: 35960042 PMCID: PMC9371555 DOI: 10.1097/md.0000000000030058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity (PSH) is characterized by exacerbated sympathetic discharge following severe brain injury. Here, we reports a patient diagnosed with PSH after ICH concurrent with hypothalamic injury, as demonstrated by diffusion tensor imaging (DTI). METHODS A 27-year-old man patient was diagnosed with spontaneous intraventricular hemorrhage and intracerebral hemorrhage in both frontal lobes. Two months after onset, brain magnetic resonance imaging of the brain revealed a leukomalactic lesion in the hypothalamus. Three months after the onset, he presented with intermittent high fever, tachycardia, tachypnea, systolic hypertension, diaphoresis, and aggravated rigidity. Infection was ruled out by a physical examination, laboratory tests, and radiological studies. After administrating morphine and bromocriptine, the clinical manifestations improved dramatically. RESULTS PSH after intracranial hemorrhage concurrent with the hypothalamic injury. Fractional anisotropy and mean diffusivity values of DTI were obtained in the hypothalamus. No significant difference in fractional anisotropy value was observed between the patient and control group (10 age-matched healthy male subjects) (P > .05). On the other hand, the mean diffusivity value was higher in the patient group than in the control group (P < .05), indicating hypothalamic injury. CONCLUSION PSH concurrent with hypothalamic injury was observed in a patient with stroke. This study suggests that DTI can be a useful imaging method for evaluating the hypothalamic state of patients presenting with PSH after brain injury.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Kyu Hwan Choi
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
- *Correspondence: Kyu Hwan Choi, MD, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, 317-1, Daemyung Dong, Namgu, Daegu 705-717, Republic of Korea. (e-mail: )
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Xu Y, Sun Y, Zhou K, Xie C, Li T, Wang Y, Zhang Y, Rodriguez J, Zhang X, Shao R, Wang X, Zhu C. Cranial irradiation alters neuroinflammation and neural proliferation in the pituitary gland and induces late-onset hormone deficiency. J Cell Mol Med 2020; 24:14571-14582. [PMID: 33174363 PMCID: PMC7754041 DOI: 10.1111/jcmm.16086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 12/20/2022] Open
Abstract
Cranial radiotherapy induces endocrine disorders and reproductive abnormalities, particularly in long-term female cancer survivors, and this might in part be caused by injury to the pituitary gland, but the underlying mechanisms are unknown. The aim of this study was to investigate the influence of cranial irradiation on the pituitary gland and related endocrine function. Female Wistar rat pups on postnatal day 11 were subjected to a single dose of 6 Gy whole-head irradiation, and hormone levels and organ structure in the reproductive system were examined at 20 weeks after irradiation. We found that brain irradiation reduced cell proliferation and induced persistent inflammation in the pituitary gland. The whole transcriptome analysis of the pituitary gland revealed that apoptosis and inflammation-related pathways were up-regulated after irradiation. In addition, irradiation led to significantly decreased levels of the pituitary hormones, growth hormone, adrenocorticotropic hormone, thyroid-stimulating hormone and the reproductive hormones testosterone and progesterone. To conclude, brain radiation induces reduction of pituitary and reproduction-related hormone secretion, this may due to reduced cell proliferation and increased pituitary inflammation after irradiation. Our results thus provide additional insight into the molecular mechanisms underlying complications after head irradiation and contribute to the discovery of preventive and therapeutic strategies related to brain injury following irradiation.
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Affiliation(s)
- Yiran Xu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Yanyan Sun
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Henan, China
| | - Kai Zhou
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuicui Xie
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Tao Li
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yafeng Wang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yaodong Zhang
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Neonatology, Children's Hospital of Zhengzhou University, Zhengzhou, China
| | - Juan Rodriguez
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Xiaoan Zhang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruijin Shao
- Department of Physiology/Endocrinology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Perinatal Center, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
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5
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Effects of craniopharyngioma cyst fluid on neurons and glial cells cultured from rat brain hypothalamus. J Chem Neuroanat 2018; 94:93-101. [PMID: 30339791 DOI: 10.1016/j.jchemneu.2018.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 11/20/2022]
Abstract
Craniopharyngiomas (CPs) are rare, epithelial tumors of the central nervous system (CNS) that could lead to manifestation of multiple post-operative symptoms, ranging from hormonal imbalance to obesity, diabetes, visual, neurological and neurocognitive impairments. CP is more frequent in children, and has been reported in middle aged adults as well. In fact, arterial laceration and/or brain stroke which may occur following the removal of some CPs is mainly due to calcification of that CPs along with strong attachments to the blood vessels. The dense oily fluid content of CPs is reported to cause brain tissue damage, demyelination and axonal loss in the hypothalamus; however, its exact effect on different cell types of CNS is still unexplored. In this study, we have collected CP cyst fluid (CCF) from mostly young patients during surgical removal and exposed it 9-10 days in vitro to the primary cultures derived from rat brain hypothalamus for 48 h. A gradual decline in cell viability was noted with increasing concentration of CCF. Moreover, a distinct degenerative morphological transformation was observed in neurons and glial cells, including appearance of blebbing and overall reduction of the cell volume. Further, enhanced expression of Caspase-3 in neurons and glial cells exposed to CCF by immunofluorescence imaging, supported by Western blot experiment suggest CCF induced apoptosis of hypothalamic cells in culture. In this study, we have demonstrated the deleterious effects of the cyst fluid on various cell types within the tumors originating region of the brain and its surroundings for the first time. Taken together, this finding could be beneficial towards identifying the region specific toxic effects of the cyst fluid and its underlying mechanism.
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Fjalldal S, Follin C, Svärd D, Rylander L, Gabery S, Petersén Å, van Westen D, Sundgren PC, Björkman-Burtscher IM, Lätt J, Ekman B, Johanson A, Erfurth EM. Microstructural white matter alterations and hippocampal volumes are associated with cognitive deficits in craniopharyngioma. Eur J Endocrinol 2018; 178:577-587. [PMID: 29599407 PMCID: PMC5937918 DOI: 10.1530/eje-18-0081] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/28/2018] [Indexed: 12/13/2022]
Abstract
CONTEXT Patients with craniopharyngioma (CP) and hypothalamic lesions (HL) have cognitive deficits. Which neural pathways are affected is unknown. OBJECTIVE To determine whether there is a relationship between microstructural white matter (WM) alterations detected with diffusion tensor imaging (DTI) and cognition in adults with childhood-onset CP. DESIGN A cross-sectional study with a median follow-up time of 22 (6-49) years after operation. SETTING The South Medical Region of Sweden (2.5 million inhabitants). PARTICIPANTS Included were 41 patients (24 women, ≥17 years) surgically treated for childhood-onset CP between 1958-2010 and 32 controls with similar age and gender distributions. HL was found in 23 patients. MAIN OUTCOME MEASURES Subjects performed cognitive tests and magnetic resonance imaging, and images were analyzed using DTI of uncinate fasciculus, fornix, cingulum, hippocampus and hypothalamus as well as hippocampal volumetry. RESULTS Right uncinate fasciculus was significantly altered (P ≤ 0.01). Microstructural WM alterations in left ventral cingulum were significantly associated with worse performance in visual episodic memory, explaining approximately 50% of the variation. Alterations in dorsal cingulum were associated with worse performance in immediate, delayed recall and recognition, explaining 26-38% of the variation, and with visuospatial ability and executive function, explaining 19-29%. Patients who had smaller hippocampal volume had worse general knowledge (P = 0.028), and microstructural WM alterations in hippocampus were associated with a decline in general knowledge and episodic visual memory. CONCLUSIONS A structure to function relationship is suggested between microstructural WM alterations in cingulum and in hippocampus with cognitive deficits in CP.
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Affiliation(s)
- S Fjalldal
- Department of EndocrinologySkåne University Hospital, Lund, Sweden
| | - C Follin
- Department of EndocrinologySkåne University Hospital, Lund, Sweden
| | - D Svärd
- Department of Diagnostic RadiologyClinical Sciences
| | - L Rylander
- Division of Occupational and Environmental MedicineDepartment of Experimental Medical Science, Lund University, Lund, Sweden
| | - S Gabery
- Translational Neuroendocrine Research UnitDepartment of Experimental Medical Science, Lund University, Lund, Sweden
| | - Å Petersén
- Translational Neuroendocrine Research UnitDepartment of Experimental Medical Science, Lund University, Lund, Sweden
| | - D van Westen
- Department of Diagnostic RadiologyClinical Sciences
| | - P C Sundgren
- Department of Diagnostic RadiologyClinical Sciences
- Department of Medical Imaging and PhysiologySkåne University Hospital, Lund, Sweden
| | - I M Björkman-Burtscher
- Department of Diagnostic RadiologyClinical Sciences
- Department of Medical Imaging and PhysiologySkåne University Hospital, Lund, Sweden
| | - J Lätt
- Department of Medical Imaging and PhysiologySkåne University Hospital, Lund, Sweden
| | - B Ekman
- Department of Endocrinology and Medical and Health SciencesLinköping University, Linköping, Sweden
| | - A Johanson
- Department of Psychology and PsychiatrySkåne University Hospital, Lund, Sweden
| | - E M Erfurth
- Department of EndocrinologySkåne University Hospital, Lund, Sweden
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7
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Xu Y, Sun Y, Zhou K, Li T, Xie C, Zhang Y, Rodriguez J, Wu Y, Hu M, Shao LR, Wang X, Zhu C. Cranial Irradiation Induces Hypothalamic Injury and Late-Onset Metabolic Disturbances in Juvenile Female Rats. Dev Neurosci 2018; 40:120-133. [PMID: 29635235 DOI: 10.1159/000487923] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/22/2018] [Indexed: 12/17/2022] Open
Abstract
Cranial radiotherapy is one of the most effective tools for treating children with brain tumors. However, radiotherapy-induced late-onset side effects have a significant impact on patients' quality of life. The purpose of this study was to investigate the effects of irradiation on metabolism and the possible molecular and cellular mechanisms behind such effects. Female Wistar rats were subjected to a single dose of 6-Gy whole-brain irradiation on postnatal day 11. The animals were sacrificed 6 h or 20 weeks after irradiation. Cell death and proliferation, microglial activation, and inflammation were analyzed and RNA sequencing was performed. We found that irradiation led to a significantly increased body weight from 15 weeks (p < 0.05) along with white adipose tissue accumulation and adipocyte hypertrophy at 20 weeks, and these changes were accompanied by glucose and lipid metabolic disturbances as indicated by reduced glucose tolerance, increased insulin resistance, increased serum triglycerides, and an increased leptin/adiponectin ratio. Furthermore, irradiation induced cell death, microglial activation, inflammation, and persistent astrocyte reactivity in the hypothalamus. Hypothalamic transcriptome analysis showed that 865 genes were downregulated and 290 genes were upregulated in the irradiated group 20 weeks after irradiation, and further pathway analysis showed that the insulin resistance-related PI3K-Akt signaling pathway and the energy expenditure-related adipocytokine signaling pathway were downregulated. Gene Ontology enrichment analysis showed that the expression of fatty acid metabolism-related proteins and effector proteins was significantly different in the irradiation group. This study demonstrates that ionizing radiation to the juvenile female brain induces hypothalamic damage that is likely to be associated with delayed metabolic abnormalities, and this critical vulnerability of the hypothalamus to irradiation should be taken into consideration in the development of future protective strategies for radiotherapy.
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Affiliation(s)
- Yiran Xu
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Yanyan Sun
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Kai Zhou
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Tao Li
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatrics, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Cuicui Xie
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Yaodong Zhang
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatrics, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Juan Rodriguez
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Yanling Wu
- Department of Physiology/Endocrinology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Min Hu
- Department of Physiology/Endocrinology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Linus R Shao
- Department of Physiology/Endocrinology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Perinatal Center, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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