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Schulz M, Alekseeva T, Anthes J, Macas J, Michels B, Möckl A, Niesel K, Salamero-Boix A, Stein S, Farin H, Plate KH, Reiss Y, Rödel F, Sevenich L. OTME-6. Deep sequencing reveals heterogeneity of brain metastasis-associated macrophages and microglia and uncovers their cell type-specific functions within the tumor microenvironment. Neurooncol Adv 2021. [PMCID: PMC8265016 DOI: 10.1093/noajnl/vdab070.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Macrophages represent a highly plastic cell type,indispensable for tissue and organ homeostasis, as well as innate immunity. Basic and translational research attributed tumor-promoting functions to macrophages, and their presence is often associated to poor patient prognosis and therapy resistance. While brain-resident macrophages, the so-called microglia (MG), represent the major immune cell type in the parenchyma under normal conditions, primary and metastatic brain tumors induce the recruitment of different immune cell types from the periphery, including monocyte-derived macrophages (MDM). Controversy remained about the redundancy of disease-associated molecular signatures and functions. The identification of markers that reliably distinguish brain-resident from blood-borne tumor-associated macrophages (TAMs) allowed the interrogation of molecular traits of different TAM populations in mouse and human brain tumors.
Using RNA-Seq, we demonstrated that TAMs rapidly acquire disease-associated transcriptional programs upon initial tumor infiltration, while gene expression remained stable during different stages of BrM progression. Across different BrM models, disease-associated transcriptional changes revealed lineage-specific, non-redundant functions of TAM populations, which was further reflected by cell type-specific occupation of different niches within the BrM microenvironment. Furthermore, we observed dose- and cell type-specific immune modulatory effects of whole brain radiotherapy on myeloid cells in BrM leading to a transient loss of disease-associated transcriptional programs predominately in blood-borne myeloid populations. This effect can at least in part be attributed to a replenishment of the recruited macrophage pool. This observation was further supported by scRNA-Seq analyses revealing higher heterogeneity of TAM-MDM compared to TAM-MG under treatment-naïve conditions and in response to radiotherapy.
Together, our results point towards the phenotypic plasticity of TAMs, especially MDMs, and the contribution of each compartment in instigating cancer-associated inflammation or the establishment of an immuno-suppressive TME. While TAM-MG exert functions related to pro-inflammatory responses, TAM-MDM are rather involved in tissue repair and regulation of adaptive immune cell functions.
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Affiliation(s)
- Michael Schulz
- Georg-Speyer-Haus, Frankfurt, Germany
- Biological Science Faculty, Goethe University, Frankfurt, Germany
| | | | | | - Jandranka Macas
- Institute of Neurology, University Hospital, Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
| | - Birgitta Michels
- Georg-Speyer-Haus, Frankfurt, Germany
- German Cancer Consortium /German Cancer Research Center, Heidelberg, Germany
| | | | | | - Anna Salamero-Boix
- Georg-Speyer-Haus, Frankfurt, Germany
- Biological Science Faculty, Goethe University, Frankfurt, Germany
| | | | - Henner Farin
- Georg-Speyer-Haus, Frankfurt, Germany
- German Cancer Consortium /German Cancer Research Center, Heidelberg, Germany
| | - Karl H Plate
- Institute of Neurology, University Hospital, Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
| | - Yvonne Reiss
- Institute of Neurology, University Hospital, Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
| | - Franz Rödel
- Department of Radiotherapy and Oncology, Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
| | - Lisa Sevenich
- Georg-Speyer-Haus, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
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Schulz M, Michels B, Niesel K, Stein S, Farin H, Rödel F, Sevenich L. Cellular and Molecular Changes of Brain Metastases-Associated Myeloid Cells during Disease Progression and Therapeutic Response. iScience 2020; 23:101178. [PMID: 32480132 PMCID: PMC7262568 DOI: 10.1016/j.isci.2020.101178] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/30/2020] [Accepted: 05/13/2020] [Indexed: 01/01/2023] Open
Abstract
Brain-resident microglia and bone marrow-derived macrophages represent the most abundant non-cancerous cells in the brain tumor microenvironment with critical functions in disease progression and therapeutic response. To date little is known about genetic programs that drive disease-associated phenotypes of microglia and macrophages in brain metastases. Here we used cytometric and transcriptomic analyses to define cellular and molecular changes of the myeloid compartment at distinct stages of brain metastasis and in response to radiotherapy. We demonstrate that genetic programming of tumor education in myeloid cells occurs early during metastatic onset and remains stable throughout tumor progression. Bulk and single cell RNA sequencing revealed distinct gene signatures in brain-resident microglia and blood-borne monocytes/macrophages during brain metastasis and in response to therapeutic intervention. Our data provide a framework for understanding the functional heterogeneity of brain metastasis-associated myeloid cells based on their origin.
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Affiliation(s)
- Michael Schulz
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany; Biological Sciences, Faculty 15, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Birgitta Michels
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany; Biological Sciences, Faculty 15, Goethe University Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katja Niesel
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany
| | - Stefan Stein
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany
| | - Henner Farin
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany; Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Franz Rödel
- Department of Radiotherapy and Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany; Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Lisa Sevenich
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Germany and German Cancer Research Center (DKFZ), Heidelberg, Germany; Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany.
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Lamberti G, Plattner C, Blattner P, Scheidl S, Finotello F, Rieder D, Krogsdam A, Farin H, Greten F, Öfner-Velano D, de Miranda N, Aebersold R, Huber L, Trajanoski Z. Abstract B60: Perturbation biology of colorectal cancer organoids reveals patient-specific signaling rewiring and interference with immunity. Cancer Immunol Res 2020. [DOI: 10.1158/2326-6074.tumimm19-b60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Colorectal cancer (CRC), a cancer with 1.4 million new cases diagnosed annually worldwide, is refractory to immunotherapy (with the exception of a minority of tumors with microsatellite instability). This is somehow paradoxical as CRC is a cancer which we have shown is under immunologic control and that tumor-infiltrating lymphocytes represent a strong independent predictor of survival (1). Based on our previous work showing that the immunophenotypes are determined by the genotypes (2), we hypothesized that mutations are rewiring signaling pathways and thereby modulate the recognition of tumor cells by T cells. In order to investigate rewiring of signaling networks and their interference with immunity for individual patients, we developed an experimental-computational concept using perturbation experiments with patient-derived tumor organoids. A biobank of CRC organoids was generated from histologically verified tumor samples, normal tissue, and liver metastases obtained from CRC patients (n=22). Comprehensive characterization of the organoids (exome sequencing, RNA sequencing, and proteomics) and of the tumors (multiplexed immunofluorescence for 6 immune cell types) was carried out and the resulting data were used to prioritize perturbation experiments. Patient-derived organoids were then perturbed with kinase inhibitors (MEKi, PI3Ki, mTORi, TBK1i, IKKi, BRAFi, and TAKi) and large-scale phosphoproteomic profiling using data-independent acquisition (SWATH-MS) was carried out. Deep phosphoproteomic profiling of perturbed organoids enabled reconstruction of patient-specific signaling networks and revealed profound rewiring by targeted drugs and interference with immune-related pathways, suggesting possible pharmacologic modulation by approved targeted agents to induce immunogenic effects. We show for the first time that systematic and comprehensive analysis of the signaling rewiring can provide a mechanistic rationale for immunotherapy-based combination regimens in CRC. This work is an important step towards the development of a precision immuno-oncology platform that integrates tumor organoids with high-throughput and high-content data for making therapeutic recommendations for individual patients.
References
1. Galon J, Costes A, Sanchez-Cabo F, Kirilovsky A, Mlecnik B, Lagorce-Pages C, Tosolini M, Camus M, Berger A, Wind P, et al. Type, density, and location of immune cells within human colorectal tumors predict clinical outcome. Science 2006;313:1960-1964.
2. Angelova M, Charoentong P, Hackl H, Fischer ML, Snajder R, Krogsdam AM, Waldner MJ, Bindea G, Mlecnik B, Galon J, Trajanoski Z: Characterization of the immunophenotypes and antigenomes of colorectal cancers reveals distinct tumor escape mechanisms and novel targets for immunotherapy. Genome Biol 2015;16:64.
Citation Format: Giorgia Lamberti, Christina Plattner, Peter Blattner, Stefan Scheidl, Francesca Finotello, Dietmar Rieder, Anne Krogsdam, Henner Farin, Florian Greten, Dietmar Öfner-Velano, Noel de Miranda, Ruedi Aebersold, Lukas Huber, Zlatko Trajanoski. Perturbation biology of colorectal cancer organoids reveals patient-specific signaling rewiring and interference with immunity [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr B60.
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Affiliation(s)
| | | | | | | | | | | | - Anne Krogsdam
- 1Medical University of Innsbruck, Innsbruck, Austria,
| | | | | | | | | | | | - Lukas Huber
- 1Medical University of Innsbruck, Innsbruck, Austria,
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Schulz M, Niesel K, Boix AS, Chae WH, Michels B, Schaeffer A, Strecker M, Alekseeva T, Stein S, Farin H, Roedel F, Harter P, Plate K, Sevenich L. Abstract A111: Effects of ionizing radiation on brain metastasis-associated inflammation and its implication for immunotherapy. Cancer Immunol Res 2019. [DOI: 10.1158/2326-6074.cricimteatiaacr18-a111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Brain metastases represent the most common intracranial tumor in adults associated with poor prognosis and median survival of only a few months. Despite current success in the development of targeted or immuno-therapies against different cancer entities, those strategies are ineffective against brain metastases. Hence, treatment options for brain metastasis patients largely remain limited to surgical resection and radio- and/or chemotherapy. This paucity can in part be attributed to the immune-privileged status of the brain where the blood brain-barrier restricts the entry of blood-borne immune cells. However, recent insights into the immune landscape of primary brain cancers indicate that tumor progression leads to an infiltration of blood-borne immune cells into the brain. We employ a comprehensive set of experimental brain metastasis models to characterize the immune landscape of brain metastases from different primary cancer entities at distinct disease stages and in response to radiotherapy. Our data indicate that brain metastases induce massive infiltration of myeloid and lymphoid cell populations into the central nervous system. This leads to the establishment of a dynamic and highly complex tumor microenvironment that affects tumor progression and therapy response. Fractionated whole-brain radiotherapy leads to enhanced infiltration of blood-borne myeloid and lymphoid cells. Transcriptome analysis of brain-resident and recruited myeloid cells indicate a switch from a proinflammatory towards an immune-suppressive environment at advanced disease stages. Importantly, radiotherapy was found to induce gene signatures that are associated with proinflammatory innate immune responses that could revert the establishment of an immune-suppressive environment. Consequently, radiotherapy might sensitize brain metastases towards immuno-therapies. Our goal is to identify pathways or molecular targets that are induced by radiotherapy in the tumor microenvironment to overcome resistance against immuno-therapy. In this project, we seek to test strategies to maintain or induce proinflammatory immune responses for improved targeted or immuno-therapies against brain metastasis.
Citation Format: Michael Schulz, Katja Niesel, Anna Salamero Boix, Woon Hyung Chae, Birgitta Michels, Alexander Schaeffer, Maja Strecker, Tijna Alekseeva, Stefan Stein, Henner Farin, Franz Roedel, Patrick Harter, Karlheinz Plate, and Lisa Sevenich. Effects of ionizing radiation on brain metastasis-associated inflammation and its implication for immunotherapy [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr A111.
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Affiliation(s)
- Michael Schulz
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Katja Niesel
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Anna Salamero Boix
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Woon Hyung Chae
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Birgitta Michels
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Alexander Schaeffer
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Maja Strecker
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Tijna Alekseeva
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Stefan Stein
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Henner Farin
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Franz Roedel
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Patrick Harter
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Karlheinz Plate
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
| | - Lisa Sevenich
- Institute for Tumor Biology and Experimental Therapy, Georg-Speyer-Haus, Frankfurt, Germany; Edininger Institute (Institute of Neurology), KGU, Frankfurt, Germany
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Ciardiello F, Bang YJ, Bendell J, Cervantes A, Brachmann R, Zhang K, Raponi M, Farin H, Shen L. A phase III, double-blind, randomized study of pamiparib versus placebo as maintenance therapy in patients with inoperable, locally advanced, or metastatic gastric cancer that responded to platinum-based first-line chemotherapy. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy282.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ciardiello F, Bang Y, Bendell J, Cervantes A, Brachmann R, Zhang Y, Raponi M, Farin H, Shen L. A phase 3, double-blind, randomized study of pamiparib versus placebo as maintenance therapy in patients with inoperable, locally advanced, or metastatic gastric cancer that responded to platinum-based first-line chemotherapy - Trial in progress. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy151.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kruse‐Jarres R, St‐Louis J, Greist A, Shapiro A, Smith H, Chowdary P, Drebes A, Gomperts E, Bourgeois C, Mo M, Novack A, Farin H, Ewenstein B. Efficacy and safety ofOBI‐1, an antihaemophilic factorVIII(recombinant), porcine sequence, in subjects with acquired haemophilia A. Haemophilia 2015; 21:162-170. [DOI: 10.1111/hae.12627] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- R. Kruse‐Jarres
- Section of Hematology/Oncology Tulane University New Orleans LA USA
| | - J. St‐Louis
- Division of Hematology Hôpital Maisonneuve‐Rosemont University of Montreal Montreal QC Canada
| | - A. Greist
- Indiana Hemophilia and Thrombosis Center Indianapolis IN USA
| | - A. Shapiro
- Indiana Hemophilia and Thrombosis Center Indianapolis IN USA
| | - H. Smith
- Division of Hematology/Oncology Tufts New England Medical Center Boston MA USA
| | - P. Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit Royal Free Hospital London UK
| | - A. Drebes
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit Royal Free Hospital London UK
| | - E. Gomperts
- Division of Hematology/Oncology Children's Hospital of Los Angeles Los Angeles CA USA
| | | | - M. Mo
- Baxter Healthcare Westlake Village CA USA
| | - A. Novack
- Baxter Healthcare Westlake Village CA USA
| | - H. Farin
- Baxter Healthcare Westlake Village CA USA
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Lemoine R, Bigorgne A, Farin H, Saint Basile GD. [TTC7A, a critical effector for the intestinal and immune system homeostasis]. Med Sci (Paris) 2014; 30:616-8. [PMID: 25014447 DOI: 10.1051/medsci/20143006006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Roxane Lemoine
- Inserm, unité U1163, laboratoire homéostasie normale et pathologique du système immunitaire, hôpital Necker Enfants-malades, Paris, France - Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine , 24, boulevard du Montparnasse, 75015 Paris, France
| | - Amélie Bigorgne
- Inserm, unité U1163, laboratoire homéostasie normale et pathologique du système immunitaire, hôpital Necker Enfants-malades, Paris, France - Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine , 24, boulevard du Montparnasse, 75015 Paris, France
| | - Henner Farin
- Hubrecht Institute for Developmental Biology and Stem Cell Research and University Medical Centre Utrecht, Uppsalalaan 8, 3584CT Utrecht, Pays-Bas
| | - Geneviève de Saint Basile
- Inserm, unité U1163, laboratoire homéostasie normale et pathologique du système immunitaire, hôpital Necker Enfants-malades, Paris, France - Université Paris Descartes-Sorbonne Paris Cité, Institut Imagine , 24, boulevard du Montparnasse, 75015 Paris, France
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Lüdtke T, Farin H, Rudat C, Schuster-Gossler K, Petry M, Barnett P, Christoffels V, Kispert A. Tbx2 Controls Lung Growth by Direct Repression of the Cell Cycle Inhibitor Genes Cdkn1a and Cdkn1b. Pneumologie 2014. [DOI: 10.1055/s-0034-1376844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kisker C, Aledort L, Farin H. Efficacy evaluation of products for treatment of bleeding episodes. Haemophilia 2012; 18:e367-e369. [PMID: 22816674 DOI: 10.1111/j.1365-2516.2012.02911.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2012] [Indexed: 06/01/2023]
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Bahr R, Christenson R, Farin H, Hand M, Long JM. Prodromal symptoms of acute myocardial infarction: overview of evidence. Md Med 2001; Suppl:49-59. [PMID: 11434061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Affiliation(s)
- R Bahr
- St. Agnes HealthCare, Baltimore, Maryland, USA
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