Mais les résultats doivent être attendus longtemps et il n'y a généralement pas de temps metronidazole prix L'autre cas, c'est que l'achat d'un ou d'un autre antibiotique dans une pharmacie classique nécessite des dépenses matérielles considérables et pas toutes les personnes ne peuvent acheter des produits pharmaceutiques aussi coûteux.
Onoda.qxd
10.1053.paor.1999.0181 available online at http://www.idealibrary.com on
Radiation Induced Endothelial Cell Retraction in vitro: Correlation with Acute Pulmonary Edema
James M ONODA, Seema S KANTAK, Clement A DIGLIO
The Gershenson Radiation Oncology Center and the Departments of Radiation Oncology and Pathology, Wayne
State University School of Medicine, Detroit, USA
We determined the effects of low dose radiation racic or whole body radiation (≥500 cGy). Little or (<200 cGy) on the cell-cell integrity of confluent no data is available concerning time intervals <1 monolayers of pulmonary microvascular endothe- day post irradiation, possibly because of the pre- lial cells (PMEC). We observed dose- and time- sumption that edema is mediated, at least in part, by dependent reversible radiation induced injuries to endothelial cell death or irreversible loss of barrier PMEC monolayers characterized by retraction (loss permeability functions which may only arise ≥1 day of cell-cell contact) mediated by cytoskeletal F-actin post irradiation. However, our in vitro data suggest reorganization. Radiation induced reorganization that loss of endothelial barrier function may occur of F-actin microfilament stress fibers was observed rapidly and at low dose levels (≤200 cGy). Therefo-
≥30 minutes post irradiation and correlated posi- re, we determined radiation effects on lung wet tively with loss of cell-cell integrity. Cells of irradi- weight and observed significant increases in wet ated monolayers recovered to form contact inhibit- weight (standardized per dry weight or per mouse ed monolayers ≥24 hours post irradiation; concomi- weight) in ≤5 hours post thoracic exposure to 50–200 tantly, the depolymerized microfilaments organized cGy x-radiation. We suggest that a single fraction of to their pre-irradiated state as microfilament stress radiation even at low dose levels used in radiother- fibers arrayed parallel to the boundaries of adjacent apy, may induce pulmonary edema by a reversible contact-inhibited cells. Previous studies by other loss of endothelial cell-cell integrity and permeabil- investigators have measured slight but significant ity barrier function. (Pathology Oncology Research increases in mouse lung wet weight >1 day post tho- Introduction
included in the radiation treatment field.1,2 These injuriesare thought to be largely a result of the lethal irradiation of
We are in general agreement with those investigators
the endothelium and are manifest by loss of endothelial
that have described a role for radiation-induced alterations
monolayer integrity and denudation of the microvascular
in the pulmonary endothelial structure and function as the
lumen.3,4 However, most studies directed towards analysis
critical mediator of the pathogenesis of lung injury. It is
of edema in animals exposed to single fractions of high
known that the severity of radiation induced injuries to the
dose (>500 cGy) radiation, as opposed to the lower dose
endothelium is largely dependent on the volume of lung
The radiation-induced loss of endothelial cell integrity
leads to the exposure of basal lamina which results in the
Received: Febr 16, 1999; accepted: Febr 23, 1999
leakage of plasma from vessels into the interstitium.7,8
Correspondence: Dr. James ONODA, research director, Biomide
This radiation-induced vascular permeability is an essen-
Corporation, 407 Life Science Building, Wayne State University,
tial element, if not an initiator, for the development of the
Detroit, MI 48202, USA; Tel: 313 577 2184; fax: 248 594 4884;E-mail: [email protected]
acute and late radiation injuries of edema and fibrosis.9-11
These studies were supported by PHS CA50465 and the Gershen-
The time course between lethal exposure and denudation
or loss of vascular integrity has usually been found to be
1999 W. B. Saunders & Company Ltd on behalf of the Arányi Lajos Foundation
approximately several days to several weeks post irradia-
radiation damage, including the loss of barrier function.22,23
tion.5,8 In contrast the immediate and reversible effects of
Thus, we sought to test, indirectly, whether radiation-
non-lethal levels of radiation on endothelial morphological
induced lipoxygenase metabolites play a role in acute
integrity have gone relatively unstudied. Moreover, non-
edema by pretreatment with the non-specific lipoxygenase
lethal radiation may be a contributing cause or even the
initiator of acute post radiation lung injuries. Becauseedema should be detected at time intervals (<1 day) post
Materials and Methods
irradiation that are much earlier than the observed denuda-tion of vascular structures, we felt it important to examine
Pulmonary microvascular endothelial cells (PMEC)
the effects of non-lethal radiation at short time intervalspost radiation. In addition, the dose levels used in the stud-
Lungs were aseptically removed from C57Bl6J mice
ies reported here are significant in that they are within the
and immersed in Ca++ and Mg++ free Hank’s Balanced Salt
range that lung microvasculature in the target volume
Solution (HBSS). Following this initial wash, the pleural
would receive during a single exposure of fractionated
lining of the lung was fixed gently by applying 70%
radiotherapy, or that the lung microvasculature in the
ethanol over the lung surface. This procedure eliminated
treatment field might receive during the cumulative course
mesothelial cell contamination in the developing culture
preparation. After rinsing in HBSS, small tissue pinches
Reports by other investigators suggest that the rapid
(1–2 mm), using fine forceps, were obtained close to the
and reversible endothelial retraction could be a result of F-
lung periphery to avoid obvious large vessels. Tissue
actin reorganization.14,15 For example, increased perme-
explants were then treated with 0.1% collagenase (Type II,
ability of the pulmonary microvasculature has been shown
Worthington, Malvern, Pa) in Ca++, Mg++ free HBSS for 20
to follow the disruption of the microfilament apparatus
min at 37°C. The collagenase treated tissue was carefully
and the disruption (loss of cell-cell contact) between
removed and plated as explants into 100 mm tissue culture
apparently healthy endothelial cells. It was demonstrated
dishes containing Dulbecco’s modified Eagle’s medium
that retraction of the cell cytoplasm and the disruption of
(DMEM) supplemented with 20% fetal bovine serum
the microfilament bundles occurred upon the exposure of
(FBS). Isolated colonies of endothelial cells devoid of
pulmonary artery endothelial cell monolayers to cytoske-
spindle cells were selectively trypsinized using colony
letal disrupting agents (e.g., hormone, oxidants) and were
penicylinders. Three separate endothelial cell clones were
presumably responsible for the increased permeabili-
isolated, grown to confluency and recloned. One surviving
ty.14,16,17 Therefore, the initial focus of studies presented
clone was established and routinely subcultured at split
here are the effects of low dose radiation on the morphol-
ratios 1:2 every 7–10 days and was designated PMEC
ogy and microfilaments organization of confluent, con-
(pulmonary mouse endothelial cell). Endothelial cell char-
tact-inhibited pulmonary microvascular endothelial cell
acteristics were verified by growth behavior pattern, pres-
monolayers. We examined the rate and extent of endothe-
ence of factor VIII and prostanoid production according to
lial retraction by phase contrast microscopy as well as the
previously published procedures. For use in the studies
rate and extent of F-actin depolymerization by indirect im-
presented here, PMEC (between passages 14–20) were
cultured in sterile DMEM +10% FBS. They were main-
Acute radiation damage to the endothelium results in
tained at 37°C, 95% room air, 5% CO in a water saturat-
metabolic dysfunction of eicosanoid metabolism and
ed incubator. Medium was changed every three days and
increased permeability.18 Similar observations have been
cultures were passaged [2.5 mM EDTA (Sigma Chemical
made in vivo and in vitro in normal host tissue and in
Co, St Louis, MO) and 0.25% trypsin (Worthington Bio-
tumors.19 It is apparent that the amount of radiation (i.e.,
chemical Corporation, Freehold, NJ)] when a contact-inhi-
300–5000 cGy) as well as the time interval between radia-
bited monolayer was achieved (approximately once a
tion and determination of response (i.e., 1–14 days), are
week). Cultures used for experimental purposes were
critical variables affecting the perceived response(s) of
seeded in T-75 culture flasks and used when confluent.
endothelial cells to radiation.18-20 Recent studies havedemonstrated that significant levels of lipoxygenase prod-
Endothelial cell retraction studies
ucts are released from irradiated bovine aortic endothelialcells.21 Moreover, we have observed (data not reported)
PMEC were grown to confluency in alternate rows of
that radiation stimulates endothelial cell (PMEC) biosyn-
16 mm 24-well plates (Falcon 3047, flat-bottom). Cells
thesis of several eicosanoid metabolites including the
were plated at the appropriate density (1.5x105 cells/well)
lipoxygenase products 11-, 12-, and 15-HETE and unre-
so that a confluent monolayer was formed in less than 48
solved leukotrienes. Products of both the COX and the
hours. Monolayers were irradiated using a Picker X-ray
LOX pathways have been implicated in several aspects of
unit (dose rate of 205 cGy/ min, 280 kV, 20 mA, 1.3 mm
Endothelial Cell Retraction and Pulmonary Edema
Cu HVL). Following X-irradiation, samples were incubat-
(between the mediastinum and head). In all experiments,
ed 37°C 5% CO ) for various time intervals (0, 2, 4, 8, 24,
mice were randomly chosen front stock cages for each treat-
48 hour). After the appropriate incubation period, culture
ment group. Mice were pretreated, simultaneously treated
medium was aspirated from the wells and 1 ml of fixative
and/or post-treated with specific lipoxygenase inhibitors
(1% paraformaldehyde, 2% glutaraldehyde in HBSS, pH
using specific schedules and vehicles. [Note: Animal care
7,4) was added. Cells were fixed for 10 minutes at room
was in accordance with institutional guidelines.]
temperature. They were than washed once and storedunder 0.75 ml of HBSS. After fixation samples were
immediately observed under phase-contrast and pho-tographed at a magnification of 400x using Kodak Pan-
Immediately after sacrifice, the lungs were dissected and
rinsed by saline spray under a dissecting microscope to becleaned of all other tissue. Care was taken that the saline
Immunofluorescent staining of cytoskeletal elements
did not enter the trachea by inverting the lungs and gentlyshaking off the fluid. After cleaning, the lungs were placed
Rhodamine-labeled phalloidin (Molecular Probes Inc.,
on absorbent tissue, gently blotted five times and trans-
Eugene, Oregon) was used for identification of F-actin fil-
ferred into pre-weighed polycarbonate weigh boats which
aments. Sterile 18 mm2 coverslips were transferred to 35
were covered and weighed. Dry weights were also deter-
mm 6-well flat bottom plates (Corning, NY). PMEC
mined. Lungs were dried for about 40 hours in an oven at
(2.5x105 cells/ml) were added to coverslips in DMEM +
60°C and reweighed. The weight of each lungs was deter-
10% FBS to form contact-inhibited monolayers in 48
mined and correlated with dry weight and mouse weight.
hours. Monolayers were irradiated (12.5-200 cGy) and
The average weight of <7 week old mice is approx. 12
then were terminated at appropriate time intervals post
grams. Mice were irradiated on same day (Wednesday) of
irradiation. Lysis squirting was used to access the cytoske-
each week at the same time of day (9:00 AM) to standard-
leton of PMEC. This technique uses osmotic swelling and
ize for possible chronological effects on weight etc.
cell lysis to remove the dorsal cell surface to expose the
[Control and irradiated C57Bl6J mice were sacrificed by
cytoskeletal elements. Cells were rinsed with HEPES
three methods, CO gassing, sodium pentobarbitol anesthe-
buffer (10 mM HEPES, 100 mM KCl, 5 mM MgCl 3 mM
sia and direct cervical dislocation. No significant differ-
EGTA, pH 7.0) and then incubated (10 min) in a 20% dilu-
ences in lung weights among groups were observed.]
tion of HEPES buffer to induce osmotic swelling and celllysis visualized by visual inspection using phase-contrast
Results
microscopy. After cell lysis samples were rinsed rigorous-ly (to remove membrane fragments), and fixed with 4%
Radiation therapy of the thorax for treatment of breast
paraformaldehyde in HEPES buffer (room temperature
and lung cancer and Hodgkin’s disease is often associated
(30 min). Samples were then washed 3X with HEPES
with pulmonary edema and fibrosis resulting in compro-
buffer. Labeling of F-actin (rhodamine phalloidin) was
mised lung function.1,2 At the clinical level the manifesta-
accomplished by a single step staininq using 75 µl of 1:50
tion of these pathological states can only be detected a
rhodamine phalloidin. After labeling, samples were rinsed
posteriori when the patient is symptomatic for these syn-
(5x, HEPES) and mounted in a medium containing 1:2
dromes. We believe that an understanding of the mecha-
glycerol:HBSS supplemented with 0.1 g Cytifluor (Amer-
nism(s) which mediate radiation induced edema and fibro-
sham, Arlington Heights, IL) and 0.2 g of Mowiol 4–88
sis may lead to the development of adjuvant therapies and
(Calbiochem Corporation, La Jolla, CA) to prevent rapid
the use of specific inhibitors of eicosanoid metabolism to
quenching under fluorescent excitement. Samples were
greatly reduce or inhibit the development of these injuries.
analyzed at 600X magnification under oil using a Nikon
We used phase contrast photomicroscopy to record that
Optiphot Microscope. Micrographs were recorded on
radiation (50–200 cGy) initiates retraction of contact
inhibited PMEC monolayers. We found retraction wastime-dependent and dose-dependent24 in that the degree of
retraction increased as the time interval between radiationand observation increased. Figure 1a–d, is representative
Unanesthetized C57Bl6J male mice, Jackson Laborato-
of our studies. Figure 1a is control PMEC monolayer
ries, Bar Harbor ME (6–7 wk old) were exposed to 0.5–2.0
demonstrating the characteristic morphology contact-
Gy of radiation [X-ray source (Picker unit, 280 Kev) that
inhibited capillary endothelial cells. Figure 1b demon-
delivered 275 cGy/min.]. Mice were held in a plastic cylin-
strates the F-actin cytoskeleton prior to irradiation, Note
der which is blocked with lead and calibrated to ensure that
the prominent stress fiber spanning large areas of the cell
the target volume was restricted to the thoracic region
body. Retraction of cells of the PMEC monolayer was
Figure 1. Effect of x-irradiation (50 cGy) on the morphology of pulmonary microvascular endothelial cell monolayers (PMEC). PMEC were seeded on fibronectin 24 hours to form confluent monolayers. After irradiation, PMEC were incubated for various time intervals before fixation. This figure is representative of the studies. 1a represents PMEC monolayers prior to radiation exposure. The characteristic morphology of contact-inhibited capillary endothelial cells is clearly evident. 1b presents the F-actin cytoskele- ton prior to irradiation, Prominent stress fiber spanning large areas of the cell body are readily visible. 1c represents the retracted cells induced by a single fraction of 0.5 Gy. Concomitant analysis of F-actin demonstrated the loss of cytoskeletal organization, although some fibers are still visible at the retracted cell periphery (1d).
induced by a single fraction of 0.5 Gy. Significant retrac-
lag time for the induction of retraction or cytoskeletal reor-
tion was recorded 4–8 hours post exposure (Figure 1c).
Analysis of F-actin demonstrated the loss of cytoskeletal
Our working hypothesis predicts that radiation promotes
organization. The F-actin stress fibers have resolved,
endothelial retraction via stimulation of lipoxygenase
although some fibers are still visible at the retracted cell
metabolism. Accordingly, a general lipoxygenase inhibitor
periphery (Figure 1d). Retraction was reversible, and the
should inhibit radiation induced retraction. We treated con-
PMEC cells resumed their appearance as contact inhibited
fluent PMEC monolayers with the lipoxygenase inhibitor
monolayers within 24 to 30 hrs post irradiation, which cor-
NDGA (10 µM) 15 minutes prior to and during 50 cGy
responded to the repolymerization of F-actin fibers (not
radiation. Retraction was complete inhibited, whereas pre-
shown). The ability of the cells to regain their monolayer
treatment with the cyclooxygenase inhibitor indomethacin
appearance and develop cell-cell contacts indicates that
failed to inhibit retraction (data not shown).
energy-dependent cytoskeletal reorganization was not
Previous studies by other investigators have measured
impaired by 0.5 Gy radiation and suggests that levels of
slight but significant increases in mouse lung wet weight >1
radiation below that dose do not significantly impair nor-
day post thoracic or whole body radiation (>500 cGy).22,32
mal PMEC metabolic activity. There appears to be a
Little or no data is available concerning time intervals <1
threshold for radiation initiated PMEC retraction, and
day post irradiation, possibly because of the presumption
once crossed, further increases in radiation dose level fail
that edema is mediated, at least in part, by endothelial cell
to increase the rate or extent of retraction or decrease the
death or irreversible loss of barrier permeability functions
Endothelial Cell Retraction and Pulmonary Edema
in increased edema. There was a significant increase in lungwet weight at all dose levels five hours post irradiation
(Figure 3). At three hours post irradiation, 100 and 200
cGy, but not 50 cGy exposure resulted in significantlyincreased lung weights (data not shown). Finally, we
observed protective effect by pretreatment of animals withthe lipoxygenase inhibitor NDGA, which quite effectively
blocked acute edema (Figure 4). NDGA was administered
i.p. 15 minutes prior to radiation exposure. Discussion
In the treatment of pulmonary neoplasms, breast carci-
noma, esophageal carcinoma or Hodgkin’s disease, the riskof complications to the normal pulmonary tissues is a major
limitation in the prescription of the therapeutic dose.1-3 The
treatment of neoplasia by radiation requires part or thewhole of the thorax to be in the radiation field. Radiation
induced edema, pneumonitis and fibrosis are well-docu-mented complications in patients receiving such treat-
ments.25,26 Early reactions develop within days or weeks,
Figure 2. C57Bl6J mice were randomly selected for sham or
whereas late reactions require months or years.25-27 The clin-
exposure to 200 cGy radiation. Data are for individual total
ical presentation of radiation-induced lung damage princi-
lung weight from each mouse used in the study. The weight of
pally depends on the lung volume irradiated, the radiation
lungs from mice sacrificed 5 hours post radiation exposure were
dose and the pre-existing lung disease.28,29 Mah et al have
significantly different (p<0.01 by students t test) when com-
established a distinct dose-response relationship between
pared to the weight of lungs from mice in the sham irradiatedgroup or from mice sacrificed 48 hours post radiation exposure.
which may only arise >1 day post irradiation. However, ourworking hypothesis predicts that low dose radiation at lev-
els traditionally employed for radiotherapy should induceacute edema in the pulmonary microvasculature. Thisedema would be mediated by loss of endothelial cell-cell
integrity induced by the direct effects of radiation onmicrovascular endothelial morphology as well the impetussupplied by adherent and migrating neutrophils and mono-
cytes as they passage from the lumen to the subendothelial
matrix and to the interstitium. Our in vitro data clearlydemonstrated that loss of endothelial barrier function occurs
rapidly (≤4 hours) and at low dose levels (≤200 cGy). Therefore, we performed a series of studies to verify a cor-relation between the time and dose effects for radiation-
induced loss of endothelial cell-cell integrity in vitro andradiation induced acute edema (as determined by effects onlung wet weight) in vivo. We first demonstrated a time
course for radiation-induced edema. Mice were exposed to
thoracic radiation of 200 cGy. We observed significant
increases in lung wet weight (standardized per dry weight or
Figure 3. C57Bl6J mice were randomly selected for sham or
per mouse weight) for time points 3 and 5 hours post irradi-
exposure to 50, 100, or 200 cGy radiation. Data are for individ-
ation (Figure 2). By 48 hours post-irradiation, there was no
ual total lung weight from each mouse used in the study. The
statistically significant increase in lung weights, suggesting
weight of lungs from mice exposed to 100 or 200 cGy were sig-
a recovery from acute edema. We also observed a dose-
nificantly different (p<0.01 by student’s t test) when compared
response effect, with increased radiation exposure resulting
to the weight of lungs from mice in the sham irradiated group.
endothelial cells characterized by retraction and the result-ing loss of close contact between individual cells withinthe monolayer. By phase-contrast microscopy, one obser-ves an apparent retraction and loss of contact between
cells resulting in the formation of gaps (between the cells)The radiation-induced cellular retraction was time anddose-dependent. Retraction was first observed at >1 hour
post radiation and the extent of retraction increased with
time. At the earliest stage of retraction, the cells usually
demonstrated a loss of association with the adjacent cellsbut only in limited areas of the cell periphery, not around
the entire cell margin. The extent of loss of contact
between cells increased with time, and at maximum retrac-tion (>4 hours), there was a complete loss of contact bet-
ween adjacent retracted cells and large regions of themonolayer had resolved into isolated cells that were com-pletely separated from adjacent cells. We also observedthat the extent of retraction was dose dependent and that
the time interval to reach maximum retraction decreasedwith increased dose level. Figure 4. C57Bl6J mice were randomly selected for sham or
Because a role for microfilaments, but not for micro-
exposure to 200 cGy radiation. Sham mice were randomly treat-
tubules, has been previously demonstrated in transient
ed with NDGA (25 mM, ip injection, 15 minutes prior to pro-
hormone-induced cellular retraction and respreading, we
cedure) or vehicle. Mice exposed to 200 cGy radiation were sim-ilarly randomized to vehicle and NDGA treated groups. Data
examined the effects of radiation on microfilament organi-
are for individual total lung weight from each mouse used in the
zation. We observed that the centrally located stress fiber
study. The weight of lungs from sham exposed mice treated with
bundles “disappear” in response to radiation, and it is this
vehicle or NDGA were not significantly different and were
radiation induced depolymerization of the microfilaments
pooled. The weight of lungs from mice treated with vehicle and
that comprise the centrally located stress fiber bundles that
exposed to 200 cGy were significantly different (p<0.05) from
appears to be causal for the morphological change of
control mice. In contrast, the weight of lungs from mice treated
retraction. We observed an absolute and positive correla-
with NDGA prior to radiation exposure were similar to the con-
tion between radiation-induced F-actin depolymerization
and the dose- and time-dependent radiation-induced ret-raction. The time course for changes in microfilament or-
the incidence of acute radiation-induced pulmonary damage
ganization (i.e., F-actin depolymerization) were perfectly
for human pulmonary tissues to fractionated radiotherapy
coincident with the time course for morphological changes.
using average lung dose in the high dose region.30
For example, profound F-actin depolymerization was seen
Control of radiation lung damage has been attempted
at 2 hours post radiation at 50 and 100 cGy, which coin-
using many procedures which have centered on fractionat-
cides with the retraction seen at these two doses at 2 hours.
ed doses and low dose rates.31 Lung correction and shield-
Conversely, lower dose levels (12.5, 25 cGy) failed to ini-
ing are routinely employed in radiotherapeutic practice to
tiate F-actin depolymerization at 2 hours and no retraction
reduce adverse lung injury. Unfortunately in the treatment
of pulmonary and thoracic neoplasms it is inevitable that a
We also demonstrated (indirectly) a role for lipoxyge-
certain part of normal lung tissue will fall within the treat-
nase products in radiation-induced endothelial cell retrac-
ment volume. Adjuvant therapy using corticosteroids which
tion. Pretreatment with a variety of lipoxygenase inhibi-
are potent inhibitors of inflammatory edema32 are used to
tors (e.g., NDGA) blocked radiation-induced retraction.
prevent radiation injuries but the precise cellular/intracellu-
Inhibition was both dose- and time-dependent, and appli-
lar target sites of action are unknown.9,10 An understanding
cation of NDGA after irradiation failed to block retraction.
of the basic biochemical mechanisms underlying the events
In contrast, pretreatment with the cyclooxygenase inhibi-
leading to edema, pneumonitis and fibrosis would facilitate
tor, indomethacin, failed to block retraction.
the identification or specific inhibitors capable of blocking
We used the radiation dose levels and time course for
both the acute/early and late injuries.
PMEC retraction in vitro to design studies to determine
We report here that low dose radiation (50–200 cGy)
radiation-induced acute edema in vivo. We demonstrated
produces significant changes in the morphology and
that low dose thoracic radiation induces pulmonary edema
microfilament organization of pulmonary microvascular
as characterized by increased lung wet weight. The inci-
Endothelial Cell Retraction and Pulmonary Edema
dence of increased weight was radiation dose-dependent to
13.² Van Houtte P: Radiation and chemotherapy induced lung toxi-
2.0 Gy and was coincident with the time course for radia-
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15 minutes prior to radiation exposure inhibited radiation-
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induced edema. These observations were also in perfect
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pneumonitis after pulmonary irradiation for metastatic Wilm’s
suppress vascular response to radiation. Int J Rad Onc Biol Phy
VIII MULTIDISCIPLINARY SYMPOSIUM ON DESIGN AND EVALUATION OF DIGITAL CONTENT FOR EDUCATION VIII SIMPOSIO PLURIDISCIPLINAR SOBRE DISEÑO Y EVALUACIÓN DE CONTENIDOS DIGITALES PARA LA EDUCACIÓN PROGRAMA Versión del 3 de Junio de 2011 . Las presentaciones podrán hacerse en Español o en Inglés. Para cada Comunicación, se dispondrá de 15 minutos de presentación y discusión. Ciudad Real
Asthma Medications There are basic groups of medications used in the treatment ARNIE BAKER CYCLING Generic names are listed before trade names. Adrenergic Drugs Corticosteroids Theophyllines Drug Delivery This allows the breathing passages to open Many of the adrenergic and steroids medicines more, and then the steroid inhaler medicine will are available in table