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Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19 – nejm.org

Summary

Background

Progressive respiratory failure is the first motive within the assist of loss of life within the coronavirus illness 2019 (Covid-19) pandemic. No topic in fashion passion within the pathophysiology of the illness, comparatively itsy-bitsy is significant about the connected morphologic and molecular changes within the peripheral lung of patients who die from Covid-19.

Strategies

We examined 7 lungs obtained all the way by post-mortem from patients who died from Covid-19 and in contrast them with 7 lungs obtained all the way by post-mortem from patients who died from acute respiratory wound syndrome (ARDS) secondary to influenza A(H1N1) an infection and 10 age-matched, uninfected take care of a watch on lungs. The lungs like been studied with the use of seven-colour immunohistochemical prognosis, micro–computed tomographic imaging, scanning electron microscopy, corrosion casting, and recount multiplexed size of gene expression.

Results

In patients who died from Covid-19–connected or influenza-connected respiratory failure, the histologic sample within the peripheral lung was diffuse alveolar harm with perivascular T-cell infiltration. The lungs from patients with Covid-19 also showed distinctive vascular ingredients, consisting of excessive endothelial harm connected to the presence of intracellular virus and disrupted cell membranes. Histologic prognosis of pulmonary vessels in patients with Covid-19 showed in fashion thrombosis with microangiopathy. Alveolar capillary microthrombi like been 9 instances as prevalent in patients with Covid-19 as in patients with influenza (P<0.001). In lungs from patients with Covid-19, the volume of recent vessel enhance — predominantly by a mechanism of intussusceptive angiogenesis — was 2.7 instances as high as that within the lungs from patients with influenza (P<0.001).

Conclusions

In our little sequence, vascular angiogenesis nicely-known the pulmonary pathobiology of Covid-19 from that of equally excessive influenza virus an infection. The universality and clinical implications of our observations require extra learn to outline. (Funded by the Nationwide Institutes of Neatly being and others.)

Introduction

Infection with excessive acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in other folks is connected to a sizable spectrum of clinical respiratory syndromes, starting from gentle higher airway symptoms to innovative existence-threatening viral pneumonia.1,2 Clinically, patients with excessive coronavirus illness 2019 (Covid-19) like labored respiratory and innovative hypoxemia and on the total receive mechanical ventilatory give a enhance to. Radiographically, peripheral lung floor-glass opacities on computed tomographic (CT) imaging of the chest fulfill the Berlin requirements for acute respiratory wound syndrome (ARDS).3,4 Histologically, the hallmark of the early a part of ARDS is diffuse alveolar harm with edema, hemorrhage, and intraalveolar fibrin deposition, as described by Katzenstein et al.5 Diffuse alveolar harm is a nonspecific discovering, because it may perchance probably well well additionally fair like noninfectious or infectious causes, alongside side Heart East respiratory syndrome coronavirus (MERS-CoV),6 SARS-CoV,7 SARS-CoV-2,8-10 and influenza viruses.11

Among the many distinctive ingredients of Covid-19 are the vascular changes connected to the illness. With appreciate to diffuse alveolar harm in SARS-CoV7 and SARS-CoV-2 an infection,8,12 the formation of fibrin thrombi has been noticed anecdotally but now not studied systematically. Clinically, many patients like elevated d-dimer stages, as nicely as cutaneous changes of their extremities suggesting thrombotic microangiopathy.13 Diffuse intravascular coagulation and sizable-vessel thrombosis like been linked to multisystem organ failure.14-16 Peripheral pulmonary vascular changes are much less nicely characterized; nevertheless, vasculopathy within the gasoline-trade networks, looking on its cease on the matching of ventilation and perfusion that outcomes, may perchance well well potentially contribute to hypoxemia and the effects of posture (e.g., prone positioning) on oxygenation.17

No topic old abilities with SARS-CoV18 and early abilities with SARS-CoV-2, the morphologic and molecular changes connected to those infections within the peripheral lung will now not be nicely documented. Here, we explore the morphologic and molecular ingredients of lungs obtained all the way by post-mortem from patients who died from Covid-19, in comparison with those of lungs from patients who died from influenza and age-matched, uninfected take care of a watch on lungs.

Strategies

Patient Different and Workflow

We analyzed pulmonary post-mortem specimens from seven patients who died from respiratory failure triggered by SARS-CoV-2 an infection and in contrast them with lungs from seven patients who died from pneumonia triggered by influenza A virulent illness subtype H1N1 (A[H1N1]) — a strain connected to the 1918 and 2009 influenza pandemics. The lungs from patients with influenza like been archived tissue from the 2009 pandemic and like been chosen for the most productive likely match with appreciate to age, intercourse, and illness severity from amongst the autopsies performed on the Hannover Clinical College. Ten lungs that had been donated but now not old for transplantation served as uninfected take care of a watch on specimens. The Covid-19 neighborhood consisted of lungs from two female and five male patients with suggest (±SD) ages of 68±9.2 years and 80±11.5 years, respectively (clinical details are supplied in Desk S1A within the Supplementary Appendix, within the market with the corpulent textual allege material of this text at NEJM.org). The influenza neighborhood consisted of lungs from two female and five male patients with suggest ages of 62.5±4.9 years and 55.4±10.9 years, respectively. Five of the uninfected lungs like been from female donors (suggest age, 68.2±6.9 years), and five like been from male donors (suggest age, 79.2±3.3 years) (clinical details are supplied in Desk S1B). The take into tale was accredited by and performed in accordance to necessities of the ethics committees on the Hannover Clinical College and the College of Leuven. There was no industrial give a enhance to for this take into tale.

All lungs like been comprehensively analyzed with the use of microCT, histopathological, and multiplexed immunohistochemical prognosis, transmission and scanning electron microscopy, corrosion casting, and recount multiplexed gene-expression prognosis, as described in detail within the Strategies a part of the Supplementary Appendix.

Statistical Diagnosis

All comparisons of numeric variables (alongside side those within the gene-expression prognosis) like been performed with Student’s t-test familywise error rates as a consequence of multiplicity location at 0.05 with the use of the Benjamini–Hochberg way of controlling unfounded discovery rates. Customary P values are reported beautiful for the assessments that met the requirements for unfounded discovery rates. All confidence intervals like been calculated on the basis of the t-distribution, as nicely. Additional particulars are supplied within the Strategies a part of the Supplementary Appendix.

Results

Unsafe Examination

The suggest (±SE) weight of the lungs from patients with confirmed influenza pneumonia was very a lot higher than that from patients with confirmed Covid-19 (2404±560 g vs. 1681±49 g; P=0.04). The suggest weight of the uninfected take care of a watch on lungs (1045±91 g) was very a lot decrease than those within the influenza neighborhood (P=0.003) and the Covid-19 neighborhood (P<0.001).

Angiocentric Inflammation

Figure 1. Figure 1. Lymphocytic Inflammation in a Lung from a Patient Who Died from Covid-19.

The spoiled appearance of a lung from a affected person who died from coronavirus illness 2019 (Covid-19) is confirmed in Panel A (the scale bar corresponds to 1 cm). The histopathological examination, confirmed in Panel B, revealed interstitial and perivascular predominantly lymphocytic pneumonia with multifocal endothelialitis (hematoxylin–eosin staining; the scale bar corresponds to 200 μm).

All lung specimens from the Covid-19 neighborhood had diffuse alveolar harm with necrosis of alveolar lining cells, pneumocyte kind 2 hyperplasia, and linear intraalveolar fibrin deposition (Figure 1). In four of seven instances, the changes like been focal, with handiest gentle interstitial edema. The last three instances had homogeneous fibrin deposits and marked interstitial edema with early intraalveolar group. The specimens within the influenza neighborhood had florid diffuse alveolar harm with extensive interstitial edema and in depth fibrin deposition in all instances. To boot to, three specimens within the influenza neighborhood had focal organizing and resorptive irritation (Fig. S2). These changes like been reflected within the great higher weight of the lungs from patients with influenza.

Immunohistochemical prognosis of angiotensin-changing enzyme 2 (ACE2) expression, measured as suggest (±SD) relative counts of ACE2-particular cells per area of behold, in uninfected take care of a watch on lungs showed scarce expression of ACE2 in alveolar epithelial cells (0.053±0.03) and capillary endothelial cells (0.066±0.03). In lungs from patients with Covid-19 and lungs from patients with influenza, the relative counts of ACE2-particular cells per area of behold like been 0.25±0.14 and 0.35±0.15, respectively, for alveolar epithelial cells and 0.49±0.28 and 0.55±0.11, respectively, for endothelial cells. Furthermore, ACE2-particular lymphocytes weren’t seen in perivascular tissue or within the alveoli of the take care of a watch on lungs but like been show within the lungs within the Covid-19 neighborhood and the influenza neighborhood (relative counts of 0.22±0.18 and 0.15±0.09, respectively). (Crucial points of counting are supplied in Desk S2.)

Within the lungs from patients with Covid-19 and patients with influenza, identical suggest (±SD) numbers of CD3-particular T cells like been learned within a 200-μm radius of precapillary and postcapillary vessel partitions in 20 fields of examination per affected person (26.2±13.1 for Covid-19 and 14.8±10.8 for influenza). With the same area dimension old for examination, CD4-particular T cells like been more hundreds of in lungs from patients with Covid-19 than in lungs from patients with influenza (13.6±6.0 vs. 5.8±2.5, P=0.04), whereas CD8-particular T cells like been much less hundreds of (5.3±4.3 vs. 11.6±4.9, P=0.008). Neutrophils (CD15 particular) like been very a lot much less hundreds of adjoining to the alveolar epithelial lining within the Covid-19 neighborhood than within the influenza neighborhood (0.4±0.5 vs. 4.8±5.2, P=0.002).

A multiplexed prognosis of irritation-connected gene expression examining 249 genes from the nCounter Inflammation Panel (NanoString Applied sciences) revealed similarities and differences between the specimens within the Covid-19 neighborhood and other folks within the influenza neighborhood. A total of 79 irritation-connected genes like been differentially regulated handiest in specimens from patients with Covid-19, whereas 2 genes like been differentially regulated handiest in specimens from patients with influenza; a shared expression sample was learned for 7 genes (Fig. S1).

Thrombosis and Microangiopathy

Figure 2. Figure 2. Microthrombi within the Interalveolar Septa of a Lung from a Patient Who Died from Covid-19.

The interalveolar septum of this affected person (Patient 4 in Desk S1A within the Supplementary Appendix) reveals a itsy-bitsy expanded alveolar partitions with more than one fibrinous microthrombi (arrowheads) within the alveolar capillaries. Extravasated erythrocytes and a loose community of fibrin may perchance even be seen within the intraalveolar home (hematoxylin–eosin staining; the scale bar corresponds to 50 μm).

The pulmonary vasculature of the lungs within the Covid-19 neighborhood and the influenza neighborhood was analyzed with hematoxylin–eosin, trichrome, and immunohistochemical staining (as described within the Strategies a part of the Supplementary Appendix). Diagnosis of precapillary vessels showed that in four of the seven lungs from patients with Covid-19 and four of the seven lungs from the patients with influenza, thrombi like been repeatedly show in pulmonary arteries with a diameter of 1 mm to 2 mm, with out total luminal obstruction (Figs. S3 and S5). Fibrin thrombi of the alveolar capillaries may perchance well well maybe be seen within the total lungs from each teams of patients (Figure 2). Alveolar capillary microthrombi like been 9 instances as prevalent in patients with Covid-19 as in patients with influenza (suggest [±SD] series of distinct thrombi per square centimeter of vascular lumen home, 159±73 and 16±16, respectively; P=0.002). Intravascular thrombi in postcapillary venules of decrease than 1 mm diameter like been seen in decrease numbers within the lungs from patients with Covid-19 than in those from patients with influenza (12±14 vs. 35±16, P=0.02). Two lungs within the Covid-19 neighborhood had involvement of all segments of the vasculature, in comparison with four of the lungs within the influenza neighborhood; in three of the lungs within the Covid-19 neighborhood and three of the lungs within the influenza neighborhood, blended capillary and venous thrombi like been learned with out arterial thrombi.

The histologic findings like been supported by 3-dimensional microCT of the pulmonary specimens: the lungs from patients with Covid-19 and from patients with influenza showed almost total occlusions of precapillary and postcapillary vessels.

Angiogenesis

Figure 3. Figure 3. Microvascular Alterations in Lungs from Patients Who Died from Covid-19.

Panels A and B show scanning electron micrographs of microvascular corrosion casts from the skinny-walled alveolar plexus of a healthy lung (Panel A) and the sizable architectural distortion seen in lungs injured by Covid-19 (Panel B). The loss of a clearly seen vessel hierarchy within the alveolar plexus is the consequences of recent blood-vessel formation by intussusceptive angiogenesis. Panel C reveals the intussusceptive pillar localizations (arrowheads) at higher magnification. Panel D is a transmission electron micrograph showing ultrastructural ingredients of endothelial cell destruction and SARS-CoV-2 seen for the period of the cell membrane (arrowheads) (the scale bar corresponds to 5 μm). RC denotes red cell.

We examined the microvascular architecture of the lungs from patients with Covid-19, lungs from patients with influenza, and uninfected take care of a watch on lungs with the use of scanning electron microscopy and microvascular corrosion casting. The lungs within the Covid-19 neighborhood had a distorted vascularity with structurally deformed capillaries (Figure 3). Elongated capillaries within the lungs from patients with Covid-19 showed sudden changes in caliber and the presence of intussusceptive pillars for the period of the capillaries (Figure 3C). Transmission electron microscopy of the Covid-19 endothelium showed ultrastructural harm to the endothelium, as nicely as the presence of intracellular SARS-CoV-2 (Figure 3D). The virus is also identified within the extracellular home.

Figure 4. Figure 4. Numeric Density of Aspects of Intussusceptive and Sprouting Angiogenesis in Lungs from Patients Who Died from Covid-19 or Influenza A(H1N1).

Angiogenic ingredients of sprouting and intussusceptive angiogenesis (intussusceptive pillars and sprouts, respectively) like been counted per area of behold in microvascular corrosion casts of lungs from patients with Covid-19 (red), lungs from patients with influenza A(H1N1) (blue), and take care of a watch on lungs (white). In Panels A and B, the numeric densities of angiogenic ingredients are summarized as box plots for intussusceptive and sprouting angiogenesis. The boxes deem the interquartile fluctuate, and the whiskers show the fluctuate (up to 1.5 instances the interquartile fluctuate). Outliers are denoted by singular points. A statistical comparison between lungs from patients Covid-19 and other folks from patients with influenza and uninfected take care of a watch on lungs showed an extraordinarily a lot higher frequency of angiogenesis within the patients with Covid-19 lungs, particularly intussusceptive angiogenesis (P values like been calculated with Student’s t-test, managed for the familywise error fee with a Benjamini–Hochberg unfounded discovery fee threshold of 0.05). Panels C and D show a chronological comparison of intussusceptive and sprouting angiogenesis in lungs from patients with Covid-19 and lungs from patients with influenza A(H1N1) plotted as a aim of the period of hospitalization. The numbers confirmed are Pearson correlation coefficients and P values (all displayed P values of 0.05 or decrease also hump the unfounded discovery fee threshold of 0.05). The median angiogenic aim depend for every affected person is displayed as one dot. The dusky areas encompassing the dotted linear regression lines are smoothed 95% confidence intervals. As a reference for elevated blood-vessel formation in lung ailments, intussusceptive and sprouting angiogenesis as learned in cease-stage nonspecific interstitial pneumonia (NSIP), a chronic interstitial lung illness, on the time of lung transplantation (an moderate of 1650 days from first consultation to lung transplantation) are confirmed (red box plots). Findings in healthy take care of a watch on lungs are also indicated (white box plots). The white and red box plots are displayed when it comes to the y axis but now not the x axis (as indicated by vertical dashed lines).

Within the lungs from patients with Covid-19, the density of intussusceptive angiogenic ingredients (suggest [±SE], 60.7±11.8 ingredients per area) was very a lot higher than that in lungs from patients with influenza (22.5±6.9) or in uninfected take care of a watch on lungs (2.1±0.6) (P<0.001 for every comparisons) (Figure 4A). The density of ingredients of outmoded sprouting angiogenesis was also higher within the Covid-19 neighborhood than within the influenza neighborhood (Figure 4B). When the pulmonary angiogenic aim depend was plotted as a aim of the length of health center take care of, the diploma of intussusceptive angiogenesis was learned to enlarge very a lot with rising period of hospitalization (P<0.001) (Figure 4C). In distinction, the lungs from patients with influenza had much less intussusceptive angiogenesis and no enlarge over time (Figure 4C). A identical sample was seen for sprouting angiogenesis (Figure 4D).

Figure 5. Figure 5. Relative Expression Diagnosis of Angiogenesis-Associated Genes in Lungs from Patients Who Died from Covid-19 or Influenza A(H1N1).

RNA was isolated from sections sampled without prolong adjoining to those old for complementary histologic and immunohistochemical analyses. RNA was isolated with the Maxwell RNA extraction machine (Promega) and, after quality take care of a watch on by Qubit prognosis (ThermoFisher), was old for extra prognosis. For the period of the NanoString route of, individual copies of all RNA molecules like been labeled with gene-issue bar codes and counted individually with the nCounter Diagnosis Machine (NanoString Applied sciences). The expression of angiogenesis-connected genes was measured with the NanoString nCounter PanCancer Progression panel (323 target genes annotated as connected for angiogenesis). The ensuing gene-expression details like been normalized to damaging take care of a watch on lanes (arithmetic suggest background subtraction), particular take care of a watch on lanes (geometric suggest normalization part), and all reference genes show on the panel (geometric suggest normalization part) with the use of nSolver Diagnosis Instrument, model 4.0. Confirmed within the Venn diagram are handiest genes which may perchance well well be statistically differentially expressed in comparison with expression in controls in each illness teams (Student’s t-test, managed for the familywise error fee with a Benjamini–Hochberg unfounded discovery fee threshold of 0.05). Up-law and down-law of genes is indicated by colored arrowheads suffixed to the gene symbols (red denotes up-law, red denotes down-law).

A multiplexed prognosis of angiogenesis-connected gene expression examining 323 genes from the nCounter PanCancer Progression Panel (NanoString Applied sciences) revealed differences between the specimens from patients with Covid-19 and other folks from patients with influenza. A total of 69 angiogenesis-connected genes like been differentially regulated handiest within the Covid-19 neighborhood, in comparison with 26 genes differentially regulated handiest within the influenza neighborhood; 45 genes had shared changes in expression (Figure 5).

Discussion

On this take into tale, we examined the morphologic and molecular ingredients of seven lungs obtained all the way by post-mortem from patients who died from SARS-CoV-2 an infection. The lungs from these patients like been in contrast with those obtained all the way by post-mortem from patients who had died from ARDS secondary to influenza A(H1N1) an infection and from uninfected controls. The lungs from the patients with Covid-19 and the patients with influenza shared a total morphologic sample of diffuse alveolar harm and infiltrating perivascular lymphocytes. There like been three distinctive angiocentric ingredients of Covid-19. The first aim was excessive endothelial harm connected to intracellular SARS-CoV-2 virus and disrupted endothelial cell membranes. 2d, the lungs from patients with Covid-19 had in fashion vascular thrombosis with microangiopathy and occlusion of alveolar capillaries.12,19 Third, the lungs from patients with Covid-19 had vital recent vessel enhance by a mechanism of intussusceptive angiogenesis. Despite the fact that our sample was little, the vascular ingredients we identified are in accordance to the presence of distinctive pulmonary vascular pathobiologic ingredients in some instances of Covid-19.

Our discovering of enhanced intussusceptive angiogenesis within the lungs from patients with Covid-19 in comparison with the lungs from patients with influenza was sudden. Contemporary vessel enhance can happen by outmoded sprouting or intussusceptive (nonsprouting) angiogenesis. The characteristic aim of intussusceptive angiogenesis is the presence of a pillar or post spanning the lumen of the vessel.20 Typically known as an intussusceptive pillar, this endothelial-lined intravascular structure is now not seen by gentle microscopy but is readily identifiable by corrosion casting and scanning electron microscopy.21 Despite the fact that tissue hypoxia was seemingly a total aim within the lungs from each these teams of patients, we speculate that the higher diploma of endothelialitis and thrombosis within the lungs from patients with Covid-19 may perchance well well additionally fair contribute to the relative frequency of sprouting and intussusceptive angiogenesis noticed in these patients. The relationship of those findings to the clinical route of Covid-19 requires extra learn to clarify.

A essential limitation of our take into tale is that the sample was little; we studied handiest 7 patients amongst the more than 320,000 other folks who like died from Covid-19, and the post-mortem details also signify static details. On the basis of the within the market details, we’re going to now not reconstruct the timing of loss of life within the context of an evolving illness route of. Moreover, there may perchance well well maybe be various factors that tale for the differences we noticed between patients with Covid-19 and other folks with influenza. As an illustration, now not one in every of the patients in our take into tale who died from Covid-19 had been handled with commonplace mechanical ventilation, whereas five of the seven patients who died from influenza had bought strain-managed ventilation. Within the same way, it is some distance likely that differences in detectable intussusceptive angiogenesis may perchance well well maybe be as a consequence of the assorted time programs of Covid-19 and influenza. These and various unknown factors must be regarded as when evaluating our details.22 On the different hand, our prognosis means that this probability is unlikely, particularly for the reason that diploma of intussusceptive angiogenesis within the patients with Covid-19 elevated very a lot with rising length of hospitalization, whereas within the patients with influenza it remained stable at an extraordinarily a lot decrease stage. Moreover, now we like confirmed intussusceptive angiogenesis to be the predominant angiogenic mechanism even in gradual phases of chronic lung harm.21

ACE2 is an integral membrane protein that appears to be the host-cell receptor for SARS-CoV-2.23,24 Our details showed very a lot higher numbers of ACE2-particular cells within the lungs from patients with Covid-19 and from patients with influenza than in those from uninfected controls. We learned higher numbers of ACE2-particular endothelial cells and vital changes in endothelial morphology, a discovering in accordance to a central aim of endothelial cells within the vascular a part of Covid-19. Endothelial cells within the specimens from patients with Covid-19 showed disruption of intercellular junctions, cell swelling, and a loss of contact with the basal membrane. The presence of SARS-CoV-2 virus for the period of the endothelial cells, a discovering in accordance to various learn,25 means that recount viral effects as nicely as perivascular irritation may perchance well well additionally fair contribute to the endothelial harm.

We file the presence of pulmonary intussusceptive angiogenesis and various pulmonary vascular ingredients within the lungs of seven patients who died from Covid-19. Additional work is wished to expose our findings to the clinical route in these patients. To assist others of their learn, our corpulent details location is supplied on the Vivli platform (https://vivli.org/) and can fair also be requested with the use of the following digital object identifier: https://doi.org/10.25934/00005576.

Funding and Disclosures

Supported by grants (HL94567 and HL134229, to Drs. Ackermann and Mentzer) from the Nationwide Institutes of Neatly being, a grant from the Botnar Research Centre for Runt one Neatly being (to Dr. Tzankov), a European Research Council Consolidator Grant (XHale) (771883, to Dr. Jonigk), and a grant (KFO311, to Dr. Jonigk) from Deutsche Forschungsgemeinschaft (Project Z2).

Disclosure forms supplied by the authors are within the market in with the corpulent textual allege material of this text at NEJM.org.

This article was printed on Might well 21, 2020, at NEJM.org.

We thank Kerstin Bahr, Jan Hinrich Braesen, Peter Braubach, Emily Brouwer, Annette Mueller Brechlin, Regina Engelhardt, Jasmin Haslbauer, Anne Hoefer, Nicole Kroenke, Thomas Menter, Mahtab Taleb Naghsh, Christina Petzold, Vincent Schmidt, and Pauline Tittmann for technical give a enhance to; Peter Boor of the German Covid-19 registry; and Lynnette Sholl, Hans Kreipe, Hans Michael Kvasnicka, and Jean Connors for worthwhile feedback. Dr. Jonigk thanks Anita Swiatlak for her persisted give a enhance to.

Author Affiliations

From the Institute of Pathology and Department of Molecular Pathology, Helios College Medical institution Wuppertal, College of Witten–Herdecke, Wuppertal (M.A.), the Institute of Purposeful and Clinical Anatomy, College Clinical Heart of the Johannes Gutenberg College Mainz, Mainz (M.A.), the Institute of Pathology (M.K., F.L., C.W., H.S., D.J.), the Department of Cardiothoracic, Transplantation, and Vascular Surgical plot (A.H.), and the Medical institution of Pneumology (T.W.), Hannover Clinical College, and the German Heart for Lung Research, Biomedical Research in Endstage and Obstructive Lung Illness Hannover (BREATH) (M.K., A.H., T.W., F.L., C.W., H.S., D.J.), Hannover — all in Germany; the Laboratory of Respiratory Diseases, BREATH, Department of Power Diseases, Metabolism, and Increasing old, KU Leuven, Leuven, Belgium (S.E.V., A.V.); the Institute of Pathology and Clinical Genetics, College Neatly being facility Basel, Basel, Switzerland (A.T.); and the Angiogenesis Foundation, Cambridge (W.W.L., V.W.L.), and the Laboratory of Adaptive and Regenerative Biology and the Division of Thoracic Surgical plot, Brigham and Ladies’s Neatly being facility, Harvard Clinical College, Boston (S.J.M.) — all in Massachusetts.

Tackle reprint requests to Dr. Mentzer on the Division of Thoracic Surgical plot, Brigham and Ladies’s Neatly being facility, Harvard Clinical College, 75 Francis St., Boston, MA 02115, or at [email protected].

Supplementary Self-discipline topic

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