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Christensen GM, Marcus M, Naudé PJW, Vanker A, Eick SM, Caudle WM, Malcolm-Smith S, Suglia SF, Chang HH, Zar HJ, Stein DJ, Hüls A. Joint effects of prenatal exposure to indoor air pollution and psychosocial factors on early life inflammation. ENVIRONMENTAL RESEARCH 2024; 252:118822. [PMID: 38565416 DOI: 10.1016/j.envres.2024.118822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024]
Abstract
It is hypothesized that air pollution and stress impact the central nervous system through neuroinflammatory pathways Despite this, the association between prenatal exposure to indoor air pollution and psychosocial factors on inflammatory markers in infancy has been underexplored in epidemiology studies. This study investigates the individual and joint effects of prenatal exposure to indoor air pollution and psychosocial factors on early life inflammation (interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)). We analyzed data from the South African Drakenstein Child Health Study (N = 225). Indoor air pollution and psychosocial factor measurements were taken in the 2nd trimester of pregnancy. Circulating inflammatory markers (IL-1β, Il-6, and TNF-α) were measured in serum in the infants at 6 weeks postnatal. Linear regression models were used to investigate associations between individual exposures and inflammatory markers. To investigate joint effects of environmental and psychosocial factors, Self-Organizing Maps (SOM) were used to create exposure profile clusters. These clusters were added to linear regression models to investigate the associations between exposure profiles and inflammatory markers. All models were adjusted for maternal age, maternal HIV status, and ancestry to control for confounding. Most indoor air pollutants were positively associated with inflammatory markers, particularly benzene and TNF-α in single pollutant models. No consistent patterns were found for psychosocial factors in single-exposure linear regression models. In joint effects analyses, the SOM profile with high indoor air pollution, low SES, and high maternal depressive symptoms were associated with higher inflammation. Indoor air pollutants were consistently associated with increased inflammation in both individual and joint effects models, particularly in combination with low SES and maternal depressive symptoms. The trend for individual psychosocial factors was not as clear, with mainly null associations. As we have observed pro- and anti-inflammatory effects, future research should investigate joint effects of these exposures on inflammation and their health effects.
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Affiliation(s)
- Grace M Christensen
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michele Marcus
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Petrus J W Naudé
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Aneesa Vanker
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Stephanie M Eick
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - W Michael Caudle
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Susan Malcolm-Smith
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Howard H Chang
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Neuroscience Institute, University of Cape Town, Cape Town, South Africa; South African Medical Research Council (SAMRC) Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Anke Hüls
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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2
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Hazlehurst MF, Sathyanarayana S. Invited Perspective: Prenatal PM2.5 Exposure Associated with Adverse Birth Outcomes Requiring Medical Interventions. ENVIRONMENTAL HEALTH PERSPECTIVES 2024; 132:11303. [PMID: 38271059 PMCID: PMC10810298 DOI: 10.1289/ehp14290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Marnie F. Hazlehurst
- Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Sheela Sathyanarayana
- Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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3
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Wang Y, Li Q, Luo Z, Zhao J, Lv Z, Deng Q, Liu J, Ezzati M, Baumgartner J, Liu H, He K. Ultra-high-resolution mapping of ambient fine particulate matter to estimate human exposure in Beijing. COMMUNICATIONS EARTH & ENVIRONMENT 2023; 4:451. [PMID: 38130441 PMCID: PMC7615407 DOI: 10.1038/s43247-023-01119-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
With the decreasing regional-transported levels, the health risk assessment derived from fine particulate matter (PM2.5) has become insufficient to reflect the contribution of local source heterogeneity to the exposure differences. Here, we combined the both ultra-high-resolution PM2.5 concentration with population distribution to provide the personal daily PM2.5 internal dose considering the indoor/outdoor exposure difference. A 30-m PM2.5 assimilating method was developed fusing multiple auxiliary predictors, achieving higher accuracy (R2 = 0.78-0.82) than the chemical transport model outputs without any post-simulation data-oriented enhancement (R2 = 0.31-0.64). Weekly difference was identified from hourly mobile signaling data in 30-m resolution population distribution. The population-weighted ambient PM2.5 concentrations range among districts but fail to reflect exposure differences. Derived from the indoor/outdoor ratio, the average indoor PM2.5 concentration was 26.5 μg/m3. The internal dose based on the assimilated indoor/outdoor PM2.5 concentration shows high exposure diversity among sub-groups, and the attributed mortality increased by 24.0% than the coarser unassimilated model.
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Affiliation(s)
- Yongyue Wang
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
| | - Qiwei Li
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
| | - Zhenyu Luo
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
| | - Junchao Zhao
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
| | - Zhaofeng Lv
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
| | - Qiuju Deng
- Centre for Clinical and Epidemiologic Research, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jing Liu
- Centre for Clinical and Epidemiologic Research, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Majid Ezzati
- School of Public Health, Imperial College London, London SW72AZ, UK
| | - Jill Baumgartner
- School of Population and Global Health, McGill University, Montréal, QC H3A0G4, Canada
| | - Huan Liu
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
| | - Kebin He
- State Environmental Protection Key Laboratory of Sources and Control of Air Pollution Complex, State Key Joint Laboratory of Environmental Simulation and Pollution Control, School of Environment, Tsinghua University, Beijing 100084, China
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4
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Ziou M, Gao CX, Wheeler AJ, Zosky GR, Stephens N, Knibbs LD, Williamson GJ, Melody SM, Venn AJ, Dalton MF, Dharmage SC, Johnston FH. Primary and pharmaceutical care usage concurrent associations with a severe smoke episode and low ambient air pollution in early life. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 883:163580. [PMID: 37100138 DOI: 10.1016/j.scitotenv.2023.163580] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/10/2023] [Accepted: 04/15/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Due to climate change, landscape fires account for an increasing proportion of air pollution emissions, and their impacts on primary and pharmaceutical care are little understood. OBJECTIVES To evaluate associations between exposure in two early life periods to severe levels of PM2.5 from a mine fire, background PM2.5, and primary and pharmaceutical care. METHODS We linked records of births, general practitioner (GP) presentations and prescription dispensing for children born in the Latrobe Valley, Australia, 2012-2014, where a severe mine fire occurred in February-March 2014 in an area with otherwise low levels of ambient PM2.5. We assigned modelled exposure estimates for fire-related (cumulative over the fire and peak 24-hour average) and annual ambient PM2.5 to residential address. Associations with GP presentations and dispensing of prescribed medications in the first two years of life (exposure in utero) and in the two years post-fire (exposure in infancy) were estimated using two-pollutant quasi-Poisson regression models. RESULTS Exposure in utero to fire-related PM2.5 was associated with an increase in systemic steroid dispensing (Cumulative: IRR = 1.11, 95%CI = 1.00-1.24 per 240 μg/m3; Peak: IRR = 1.15, 95%CI = 1.00-1.32 per 45 μg/m3), while exposure in infancy was associated with antibiotic dispensing (Cumulative: IRR = 1.05, 95%CI = 1.00-1.09; Peak: IRR = 1.06, 95%CI = 1.00-1.12). Exposure in infancy to ambient PM2.5, despite relatively low levels from a global perspective (Median = 6.1 μg/m3), was associated with an increase in antibiotics (IRR = 1.10, 95%CI = 1.01-1.19 per 1.4 μg/m3) and in GP presentations (IRR = 1.05, 95%CI = 1.00-1.11), independently from exposure to the fire. We also observed differences in associations between sexes with GP presentations (stronger in girls) and steroid skin cream dispensing (stronger in boys). DISCUSSION Severe medium-term concentrations of PM2.5 were linked with increased pharmaceutical treatment for infections, while chronic low levels were associated with increased prescriptions dispensed for infections and primary care usage. Our findings also indicated differences between sexes.
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Affiliation(s)
- Myriam Ziou
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia
| | - Caroline X Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria 3052, Australia
| | - Amanda J Wheeler
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia; Commonwealth Scientific and Industrial Research Organisation (CSIRO) Oceans and Atmosphere, Aspendale, Victoria 3195, Australia
| | - Graeme R Zosky
- Tasmanian School of Medicine, University of Tasmania, Hobart, Tasmania 7000, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia
| | - Nicola Stephens
- Tasmanian School of Medicine, University of Tasmania, Hobart, Tasmania 7000, Australia
| | - Luke D Knibbs
- School of Public Health, The University of Sydney, NSW 2006, Australia; Public Health Research Analytics and Methods for Evidence, Public Health Unit, Sydney Local Health District, Camperdown, NSW 2050, Australia
| | - Grant J Williamson
- School of Natural Sciences, University of Tasmania, Sandy Bay, Tasmania 7005, Australia
| | - Shannon M Melody
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia
| | - Alison J Venn
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia
| | - Marita F Dalton
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia
| | - Shyamali C Dharmage
- Allergy and Lung Health Unit, School of Population and Global Health, The University of Melbourne, Carlton, Victoria 3052, Australia
| | - Fay H Johnston
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania 7000, Australia.
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5
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Gorlanova O, Oller H, Marten A, Müller L, Laine-Carmelli J, Decrue F, Salem Y, Vienneau D, Hoogh KD, Gisler A, Usemann J, Korten I, Yammine S, Nahum U, Künstle N, Sinues P, Schulzke S, Latzin P, Fuchs O, Röösli M, Schaub B, Frey U. Ambient prenatal air pollution exposure is associated with low cord blood IL-17a in infants. Pediatr Allergy Immunol 2023; 34:e13902. [PMID: 36705042 DOI: 10.1111/pai.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/24/2022] [Accepted: 12/05/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Olga Gorlanova
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland.,Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heide Oller
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Andrea Marten
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Loretta Müller
- Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Fabienne Decrue
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Yasmin Salem
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland.,Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Danielle Vienneau
- Swiss Tropical and Public Health Institute Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Kees de Hoogh
- Swiss Tropical and Public Health Institute Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Amanda Gisler
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Jakob Usemann
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland.,Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Insa Korten
- Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sophie Yammine
- Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uri Nahum
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Noemi Künstle
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Pablo Sinues
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Sven Schulzke
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
| | - Philipp Latzin
- Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oliver Fuchs
- Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Röösli
- Swiss Tropical and Public Health Institute Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Bianca Schaub
- Department of Pulmonary and Allergy, Dr. von Hauner Children's Hospital, LMU, University of Munich, Munich, Germany
| | - Urs Frey
- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland
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- University Children's Hospital Basel UKBB, University of Basel, Basel, Switzerland.,Paediatric Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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6
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He S, Klevebro S, Baldanzi G, Pershagen G, Lundberg B, Eneroth K, Hedman AM, Andolf E, Almqvist C, Bottai M, Melén E, Gruzieva O. Ambient air pollution and inflammation-related proteins during early childhood. ENVIRONMENTAL RESEARCH 2022; 215:114364. [PMID: 36126692 DOI: 10.1016/j.envres.2022.114364] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND AIM Experimental studies show that short-term exposure to air pollution may alter cytokine concentrations. There is, however, a lack of epidemiological studies evaluating the association between long-term air pollution exposure and inflammation-related proteins in young children. Our objective was to examine whether air pollution exposure is associated with inflammation-related proteins during the first 2 years of life. METHODS In a pooled analysis of two birth cohorts from Stockholm County (n = 158), plasma levels of 92 systemic inflammation-related proteins were measured by Olink Proseek Multiplex Inflammation panel at 6 months, 1 year and 2 years of age. Time-weighted average exposure to particles with an aerodynamic diameter of <10 μm (PM10), <2.5 μm (PM2.5), and nitrogen dioxide (NO2) at residential addresses from birth and onwards was estimated via validated dispersion models. Stratified by sex, longitudinal cross-referenced mixed effect models were applied to estimate the overall effect of preceding air pollution exposure on combined protein levels, "inflammatory proteome", over the first 2 years of life, followed by cross-sectional protein-specific bootstrapped quantile regression analysis. RESULTS We identified significant longitudinal associations of inflammatory proteome during the first 2 years of life with preceding PM2.5 exposure, while consistent associations with PM10 and NO2 across ages were only observed among girls. Subsequent protein-specific analyses revealed significant associations of PM10 exposure with an increase in IFN-gamma and IL-12B in boys, and a decrease in IL-8 in girls at different percentiles of proteins levels, at age 6 months. Several inflammation-related proteins were also significantly associated with preceding PM10, PM2.5 and NO2 exposures, at ages 1 and 2 years, in a sex-specific manner. CONCLUSIONS Ambient air pollution exposure influences inflammation-related protein levels already during early childhood. Our results also suggest age- and sex-specific differences in the impact of air pollution on children's inflammatory profiles.
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Affiliation(s)
- Shizhen He
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Susanna Klevebro
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Gabriel Baldanzi
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Medical Sciences, Molecular Epidemiology, Uppsala University, Uppsala, Sweden
| | - Göran Pershagen
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Björn Lundberg
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Kristina Eneroth
- Environment and Health Administration, SLB-analys, Stockholm, Sweden
| | - Anna M Hedman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ellika Andolf
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Erik Melén
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Olena Gruzieva
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
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7
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Yavuz ST, Kalayci Ö, Eigenmann PA. Editorial to the special issue "Environmental influences on childhood asthma". Pediatr Allergy Immunol 2022; 33:e13828. [PMID: 35871455 DOI: 10.1111/pai.13828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Süleyman Tolga Yavuz
- Department of Pediatric Allergy, Children's Hospital, University of Bonn, Bonn, Germany
| | - Ömer Kalayci
- Hacettepe University School of Medicine, Ankara, Turkey
| | - Philippe A Eigenmann
- Department of Pediatrics, Gynecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
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