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Kartal Y, Bozdemir Özel C, Çakmak A, Sonbahar Ulu H, İnal İnce D, Ademhan Tural D, Eryılmaz Polat S, Hızal M, Özçelik U, Karahan S, Budak MT, Girgin G, Arıkan H, Sabuncuoğlu S. The relationship between lung function, exercise capacity, oxidant and antioxidant response in primary ciliary dyskinesia and cystic fibrosis. Turk J Pediatr 2024; 66:309-322. [PMID: 39024596 DOI: 10.24953/turkjpediatr.2024.4581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/14/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND There is a need to identify the complex interplay between various physiological mechanisms in primary ciliary dyskinesia (PCD) and cystic fibrosis (CF). The study investigated the interaction between respiratory function, exercise capacity, muscle strength, and inflammatory and oxidant/antioxidant responses in patients with PCD and CF. METHODS The study included 30 PCD patients, 30 CF patients, and 29 age and sex-matched healthy subjects. Exercise capacity was assessed using the modified shuttle walk test (MSWT). Handgrip strength (HGS) was used to evaluate general muscle strength. Oxidative stress-inflammatory parameters were also assessed. Pulmonary function test was performed by spirometry. Regarding the forced expiratory volume in 1 second (FEV1) z-score, patients with PCD and CF were subdivided into normal, mild, and severe/moderate groups. RESULTS Forced vital capacity (FVC) z-scores were lower in PCD and CF patients than controls. FEV1, FEV1/FVC, peak expiratory flow (PEF), and forced mid expiratory flow (FEF25-75%) z-scores were lower in PCD than in the other groups. HGS was lower in both mild PCD and normal CF patients relative to the controls. MSWT distance was lower in severe/moderate PCD patients than controls. Catalase (CAT), glutathione S-transferase (GST), glutathione peroxidase (GPx), and malondialdehyde (MDA) levels did not differ significantly among the study groups, but superoxide dismutase (SOD) level in severe/moderate PCD, and glutathione (GSH) level in normal CF were higher than in controls. Interleukin-6 (IL-6) level was higher in patients with normal PCD and CF compared to the controls. IL-1β level was higher in PCD compared to controls. Additionally, correlations among these parameters were also determined in some patient groups. CONCLUSION Homeostasis related to respiratory function, aerobic performance, muscle strength, inflammatory response, and oxidant/antioxidant balance were affected in PCD and CF. Evaluating these mechanisms together may contribute to elucidating the pathophysiology of these rare diseases.
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Affiliation(s)
- Yasemin Kartal
- Department of Physiology, Faculty of Medicine, Kırklareli University, Kırklareli, Türkiye
- Department of Physiology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Cemile Bozdemir Özel
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Eskisehir Osmangazi University, Eskisehir, Türkiye
| | - Aslıhan Çakmak
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Türkiye
| | - Hazal Sonbahar Ulu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Türkiye
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Akdeniz University, Antalya, Türkiye
| | - Deniz İnal İnce
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Türkiye
| | - Dilber Ademhan Tural
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Sanem Eryılmaz Polat
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Mina Hızal
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Uğur Özçelik
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Sevilay Karahan
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Murat Timur Budak
- Department of Physiology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Gözde Girgin
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Hacettepe University, Ankara, Türkiye
| | - Hülya Arıkan
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Türkiye
- Department of Physiotheraphy and Rehabilitation, Faculty of Health Sciences, Atılım University, Ankara, Türkiye
| | - Suna Sabuncuoğlu
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Hacettepe University, Ankara, Türkiye
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Reula A, Castillo-Corullón S, Armengot M, Herrera G, Escribano A, Dasí F. Redox Imbalance in Nasal Epithelial Cells of Primary Ciliary Dyskinesia Patients. Antioxidants (Basel) 2024; 13:190. [PMID: 38397788 PMCID: PMC10885940 DOI: 10.3390/antiox13020190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Primary Ciliary Dyskinesia (PCD) represents a rare condition marked by an abnormal mobility pattern of cilia and flagella, resulting in impaired mucociliary clearance. This deficiency leads to recurrent infections and persistent inflammation of the airways. While previous studies have indicated heightened oxidative stress levels in the exhaled breath condensate of pediatric PCD patients, the assessment of oxidative stress within the affected respiratory tissue remains unexplored. Aims: To assess the oxidative status of human nasal epithelial cells (NECs) in PCD patients. Methods: Thirty-five PCD patients and thirty-five healthy control subjects were prospectively included in the study. Levels of reactive oxygen species (ROS), reactive nitrogen species (RNS), glutathione (GSH), intracellular Ca2+, plasma membrane potential, and oxidative damage in lipids and proteins were measured. In addition, apoptosis and mitochondrial function were analyzed by flow cytometry in NECs. Results: NECs from PCD patients showed reduced levels of apoptosis (p = 0.004), superoxide anion (O2-, p = 0.018), peroxynitrite (ONOO-, p = 0.007), nitric oxide (NO, p = 0.007), mitochondrial hydrogen peroxide (mtH2O2, p < 0.0001), and mitochondrial superoxide anion (mtO2-, p = 0.0004) and increased mitochondrial mass (p = 0.009) compared to those from healthy individuals. No significant differences were observed in oxidized proteins (p = 0.137) and the oxidized/reduced lipid ratio (p = 0.7973). The oxidative profile of NEC cells in PCD patients, according to their ciliary motility, recurrent otitis, recurrent pneumonia, atelectasis, bronchiectasis, and situs inversus, showed no statistically significant differences in the parameters studied. Conversely, patients with chronic rhinosinusitis exhibited lower levels of ONOO- than PCD patients without this condition, with no significant differences related to other symptoms. Conclusions: Our findings strongly suggest the presence of a redox imbalance, specifically leaning toward a reductive state, in PCD patients.
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Affiliation(s)
- Ana Reula
- Valencia University Clinical Hospital Research Foundation, Instituto de Investigación Sanitaria INCLIVA, Avda. Menéndez y Pelayo, 4, 46010 Valencia, Spain; (A.R.); (S.C.-C.); (A.E.)
- Rare Respiratory Diseases Research Group, Department of Physiology, School of Medicine, University of Valencia, Avda. Blasco Ibáñez, 17, 46010 Valencia, Spain
- Biomedical Sciences Department, CEU-Cardenal Herrera University, 12006 Castellón, Spain
- Molecular, Cellular, and Genomic Biomedicine Group, IIS La Fe, 46026 Valencia, Spain;
| | - Silvia Castillo-Corullón
- Valencia University Clinical Hospital Research Foundation, Instituto de Investigación Sanitaria INCLIVA, Avda. Menéndez y Pelayo, 4, 46010 Valencia, Spain; (A.R.); (S.C.-C.); (A.E.)
- Paediatrics Unit, Department of Pediatrics, Obstetrics and Gynecology, Hospital Clínico Universitario Valencia, University of Valencia, 46022 Valencia, Spain
| | - Miguel Armengot
- Molecular, Cellular, and Genomic Biomedicine Group, IIS La Fe, 46026 Valencia, Spain;
- ENT Unit, Department of Surgery, School of Medicine, Hospital La Fe, University of Valencia, Avda. Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - Guadalupe Herrera
- Flow Cytometry Unit, Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, University of Valencia, Avda. Menéndez y Pelayo, 4, 46010 Valencia, Spain;
| | - Amparo Escribano
- Valencia University Clinical Hospital Research Foundation, Instituto de Investigación Sanitaria INCLIVA, Avda. Menéndez y Pelayo, 4, 46010 Valencia, Spain; (A.R.); (S.C.-C.); (A.E.)
- Paediatrics Unit, Department of Pediatrics, Obstetrics and Gynecology, Hospital Clínico Universitario Valencia, University of Valencia, 46022 Valencia, Spain
| | - Francisco Dasí
- Valencia University Clinical Hospital Research Foundation, Instituto de Investigación Sanitaria INCLIVA, Avda. Menéndez y Pelayo, 4, 46010 Valencia, Spain; (A.R.); (S.C.-C.); (A.E.)
- Rare Respiratory Diseases Research Group, Department of Physiology, School of Medicine, University of Valencia, Avda. Blasco Ibáñez, 17, 46010 Valencia, Spain
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3
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Chang AB, Morgan LC, Duncan EL, Chatfield MD, Schultz A, Leo PJ, McCallum GB, McInerney-Leo AM, McPhail SM, Zhao Y, Kruljac C, Smith-Vaughan HC, Morris PS, Marchant JM, Yerkovich ST, Cook AL, Wurzel D, Versteegh L, O'Farrell H, McElrea MS, Fletcher S, D'Antoine H, Stroil-Salama E, Robinson PJ, Grimwood K. Reducing exacerbations in children and adults with primary ciliary dyskinesia using erdosteine and/or azithromycin therapy (REPEAT trial): study protocol for a multicentre, double-blind, double-dummy, 2×2 partial factorial, randomised controlled trial. BMJ Open Respir Res 2022; 9:9/1/e001236. [PMID: 35534039 PMCID: PMC9086630 DOI: 10.1136/bmjresp-2022-001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/20/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Primary ciliary dyskinesia (PCD) is a rare, progressive, inherited ciliopathic disorder, which is incurable and frequently complicated by the development of bronchiectasis. There are few randomised controlled trials (RCTs) involving children and adults with PCD and thus evidence of efficacy for interventions are usually extrapolated from people with cystic fibrosis. Our planned RCT seeks to address some of these unmet needs by employing a currently prescribed (but unapproved for long-term use in PCD) macrolide antibiotic (azithromycin) and a novel mucolytic agent (erdosteine). The primary aim of our RCT is to determine whether regular oral azithromycin and erdosteine over a 12-month period reduces acute respiratory exacerbations among children and adults with PCD. Our primary hypothesis is that: people with PCD who regularly use oral azithromycin and/or erdosteine will have fewer exacerbations than those receiving the corresponding placebo medications. Our secondary aims are to determine the effect of the trial medications on PCD-specific quality-of-life (QoL) and other clinical outcomes (lung function, time-to-next exacerbation, hospitalisations) and nasopharyngeal bacterial carriage and antimicrobial resistance. Methods and analysis We are currently undertaking a multicentre, double-blind, double-dummy RCT to evaluate whether 12 months of azithromycin and/or erdosteine is beneficial for children and adults with PCD. We plan to recruit 104 children and adults with PCD to a parallel, 2×2 partial factorial superiority RCT at five sites across Australia. Our primary endpoint is the rate of exacerbations over 12 months. Our main secondary outcomes are QoL, lung function and nasopharyngeal carriage by respiratory bacterial pathogens and their associated azithromycin resistance. Ethics and dissemination Our RCT is conducted in accordance with Good Clinical Practice and the Australian legislation and National Health and Medical Research Council guidelines for ethical conduct of Research, including that for First Nations Australians. Trial registration number ACTRN12619000564156.
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Affiliation(s)
- Anne B Chang
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia .,Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Lucy C Morgan
- Department of Health and Ageing, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Emma L Duncan
- School of Life Course & Population Sciences, King's College London, London, UK.,Department of Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Australian Translational Genomics Centre, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Mark D Chatfield
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - André Schultz
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Paul J Leo
- Australian Translational Genomics Centre, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gabrielle B McCallum
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Aideen M McInerney-Leo
- University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Yuejen Zhao
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Health Gains Planning, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | | | - Heidi C Smith-Vaughan
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Peter S Morris
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Julie M Marchant
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Stephanie T Yerkovich
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Anne L Cook
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Danielle Wurzel
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Lesley Versteegh
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Hannah O'Farrell
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Margaret S McElrea
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Sabine Fletcher
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Heather D'Antoine
- Child Health Division and NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Enna Stroil-Salama
- Lung Foundation of Australia, Metro South Health, Brisbane, Queensland, Australia.,Brisbane South Palliative Care Collaborative, Metro South, Queensland Health, Brisbane, Queensland, Australia
| | - Phil J Robinson
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Keith Grimwood
- Departments of Infectious Disease and Paediatrics, Gold Coast Health, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, and Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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4
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Gahleitner F, Thompson J, Jackson CL, Hueppe JF, Behan L, Dehlink E, Goutaki M, Halbeisen F, Queiroz APL, Thouvenin G, Kuehni CE, Latzin P, Lucas JS, Rubbo B. Lower airway clinical outcome measures for use in primary ciliary dyskinesia research: a scoping review. ERJ Open Res 2021; 7:00320-2021. [PMID: 34853782 PMCID: PMC8628193 DOI: 10.1183/23120541.00320-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/31/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives Disease-specific, well-defined and validated clinical outcome measures are essential in designing research studies. Poorly defined outcome measures hamper pooling of data and comparisons between studies. We aimed to identify and describe pulmonary outcome measures that could be used for follow-up of patients with primary ciliary dyskinesia (PCD). Methods We conducted a scoping review by systematically searching MEDLINE, Embase and the Cochrane Database of Systematic Reviews online databases for studies published from 1996 to 2020 that included ≥10 PCD adult and/or paediatric patients. Results We included 102 studies (7289 patients). 83 studies reported on spirometry, 11 on body plethysmography, 15 on multiple-breath washout, 36 on high-resolution computed tomography (HRCT), 57 on microbiology and 17 on health-related quality of life. Measurement and reporting of outcomes varied considerably between studies (e.g. different scoring systems for chest HRCT scans). Additionally, definitions of outcome measures varied (e.g. definition of chronic colonisation by respiratory pathogen), impeding direct comparisons of results. Conclusions This review highlights the need for standardisation of measurements and reporting of outcome measures to enable comparisons between studies. Defining a core set of clinical outcome measures is necessary to ensure reproducibility of results and for use in future trials and prospective cohorts.
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Affiliation(s)
- Florian Gahleitner
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Paediatric Respiratory Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
| | - James Thompson
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Claire L Jackson
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Jana F Hueppe
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Laura Behan
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Eleonora Dehlink
- Division of Pediatric Pulmonology, Allergy and Endocrinology, Dept of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Florian Halbeisen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, Dept of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ana Paula L Queiroz
- School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Guillaume Thouvenin
- AP-HP, Pneumologic Unit, Trousseau Hospital, Sorbonne Universités, INSERM, Centre de Recherche Saint-Antoine, Paris, France
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Philipp Latzin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Jane S Lucas
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Bruna Rubbo
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,School of Clinical and Experimental Science, University of Southampton, Faculty of Medicine, Southampton, UK.,School of Health Sciences, University of Southampton, Faculty of Environmental and Life Sciences, Southampton, UK
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5
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Oxidative Stress and Endoplasmic Reticulum Stress in Rare Respiratory Diseases. J Clin Med 2021; 10:jcm10061268. [PMID: 33803835 PMCID: PMC8003245 DOI: 10.3390/jcm10061268] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 02/07/2023] Open
Abstract
Several studies have shown that some rare respiratory diseases, such as alpha-1 antitrypsin deficiency (AATD), idiopathic pulmonary fibrosis (IPF), cystic fibrosis (CF), and primary ciliary dyskinesia (PCD) present oxidative stress (OS) and endoplasmic reticulum (ER) stress. Their involvement in these pathologies and the use of antioxidants as therapeutic agents to minimize the effects of OS are discussed in this review.
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New Laboratory Protocol to Determine the Oxidative Stress Profile of Human Nasal Epithelial Cells Using Flow Cytometry. J Clin Med 2021; 10:jcm10061172. [PMID: 33799667 PMCID: PMC7998408 DOI: 10.3390/jcm10061172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/26/2021] [Accepted: 03/05/2021] [Indexed: 12/29/2022] Open
Abstract
Several studies have shown the importance of oxidative stress (OS) in respiratory disease pathogenesis. It has been reported that the nasal epithelium may act as a surrogate for the bronchial epithelium in several respiratory diseases involving OS. However, the sample yields obtained from nasal biopsies are modest, limiting the number of parameters that can be determined. Flow cytometry has been widely used to evaluate cellular OS profiles. It has the advantage that analyses can be performed using a small amount of sample. Therefore, we aimed to set up a new method based on flow cytometry to assess the oxidative profile of human nasal epithelial cells which could be used in research on respiratory diseases. Levels of total nitric oxide, superoxide anion, peroxynitrite, and intracellular peroxides were measured. Reduced thiol levels, such as antioxidant-reduced glutathione and oxidative damaged lipids and proteins, were also analysed. The intracellular calcium levels, plasma membrane potential, apoptosis, and percentage of live cells were also studied. Finally, a strategy to evaluate the mitochondrial function, including mitochondrial hydrogen peroxide, superoxide anion, mitochondrial mass, and membrane potential, was set up. Using small amounts of sample and a non-invasive sampling technique, the described method enables the measurement of a comprehensive set of OS parameters in nasal epithelial cells, which could be useful in research on respiratory diseases.
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7
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Bodini A, Pecoraro L, Tenero L, Pezzella V, Pradal U, Piacentini G. Isoprostane-8 in the exhaled breath condensate: Could it represent a noninvasive strategic tool for primary ciliary dyskinesia diagnosis and management? Lung India 2021; 38:241-244. [PMID: 33942748 PMCID: PMC8194433 DOI: 10.4103/lungindia.lungindia_617_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives: Exhaled breath condensate (EBC) represents a potential diagnostic tool for Primary Ciliary Diskinesia (PCD). An increased oxidative stress is present in the airways of children affected and many neutrophil chemoattractants and markers of oxidative stress can be involved. The aim of the study is to evaluate leukotriene B4 (LTB-4), interleukin 8 (IL-8), 8-isoprostane (8-IP) concentration in PCD subjects, investigating their potential role as non-invasive markers of inflammation for the diagnosis and management of PCD. Methods: Cross-sectional study. 43 patients were enrolled in the study and divided in two groups: PCD (27) and healthy subjects (16). Physical examination, lung function test, nFeNO measurement and EBC collection were performed in all subjects. Results: PCD subjects showed an EBC 8-IP concentration significantly higher than the control group (median value: 11.9 pg/ml; IQR, 5.5–24.0 vs. median, 6.7 pg/ml; IQR, 2.5–11.3, p-value of Wilcoxon rank-sum test 0.0436). LTB4 EBC concentration did not differ between the two group (median, 4.3 pg/ml; IQR, 3.0–8.8 vs. 7.5 pg/ml; IQR, 3.0–9.5; P=0.4901). No significant correlation was found between FEV1 and EBC 8-IP (r=-0.10, P=0.6314) or LTB4 concentration (r=0.03, P=0.8888) in PCD subjects. No significant correlation was found between nFeNO and EBC 8-IP (r=-0.31, P=0.1385) or LTB4 (r=0.04, P=0.8565) in PCD subjects. Conclusions: EBC 8-IP levels are significantly increased in PCD subjects, highlighting the role of oxidative stress in airway inflammation. It could have a potential role as a non-invasive marker of inflammation for the diagnosis and management of PCD, although a therapeutic application of this evidence seems far.
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Affiliation(s)
- Alessandro Bodini
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Unit, University of Verona, Verona, Italy
| | - Luca Pecoraro
- Pediatric Clinic, ASST Mantova, Mantova; Department of Medicine, University of Verona, Verona, Italy
| | - Laura Tenero
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Unit, University of Verona, Verona, Italy
| | - Vincenza Pezzella
- Department of Women, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ugo Pradal
- Pediatric Clinic, Santa Maria del Carmine Hospital, Rovereto (TN), Italy
| | - Giorgio Piacentini
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Unit, University of Verona, Verona, Italy
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Abstract
Motile cilia are highly complex hair-like organelles of epithelial cells lining the surface of various organ systems. Genetic mutations (usually with autosomal recessive inheritance) that impair ciliary beating cause a variety of motile ciliopathies, a heterogeneous group of rare disorders. The pathogenetic mechanisms, clinical symptoms and severity of the disease depend on the specific affected genes and the tissues in which they are expressed. Defects in the ependymal cilia can result in hydrocephalus, defects in the cilia in the fallopian tubes or in sperm flagella can cause female and male subfertility, respectively, and malfunctional motile monocilia of the left-right organizer during early embryonic development can lead to laterality defects such as situs inversus and heterotaxy. If mucociliary clearance in the respiratory epithelium is severely impaired, the disorder is referred to as primary ciliary dyskinesia, the most common motile ciliopathy. No single test can confirm a diagnosis of motile ciliopathy, which is based on a combination of tests including nasal nitric oxide measurement, transmission electron microscopy, immunofluorescence and genetic analyses, and high-speed video microscopy. With the exception of azithromycin, there is no evidence-based treatment for primary ciliary dyskinesia; therapies aim at relieving symptoms and reducing the effects of reduced ciliary motility.
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9
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Poeta M, Maglione M, Borrelli M, Santamaria F. Non-cystic fibrosis bronchiectasis in children and adolescents: Neglected and emerging issues. Pediatr Neonatol 2020; 61:255-262. [PMID: 31672477 DOI: 10.1016/j.pedneo.2019.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/16/2019] [Accepted: 09/24/2019] [Indexed: 12/14/2022] Open
Abstract
Pediatric non-cystic fibrosis (CF) bronchiectasis is characterized by endobronchial suppuration, airway neutrophilic inflammation and poor mucus clearance and is associated with persistent productive cough due to recurrent airway infections. Most recommendations are based on expert opinion or extrapolated from CF practice. The present narrative review aims to address some issues on the management of children or adolescents with non CF-bronchiectasis that still require attention, and analyze what available literature offers to reply to open questions. We focused on the potential offered by technological advances on lung disease assessment through novel chest imaging techniques and new or old pulmonary function tests. We also summarized the main novelties in the disease prevention and treatment. Finally, a novel diagnostic algorithm is proposed, that might help physicians in the daily clinical decision-making process. Future directions for research on pediatric non-CF bronchiectasis should include larger study populations and longer prospective clinical trials, as well as new clinical and laboratory endpoints to determine the underlying mechanisms of lung disease progression and support the role of new and existing treatments.
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Affiliation(s)
- Marco Poeta
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy
| | - Marco Maglione
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy
| | - Melissa Borrelli
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy.
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10
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Cheong A, Degani R, Tremblay KD, Mager J. A null allele of Dnaaf2 displays embryonic lethality and mimics human ciliary dyskinesia. Hum Mol Genet 2020; 28:2775-2784. [PMID: 31107948 DOI: 10.1093/hmg/ddz106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/12/2019] [Accepted: 05/13/2019] [Indexed: 01/30/2023] Open
Abstract
The dynein axonemal assembly factor (Dnaaf) protein family is involved in preassembly and stability of dynein arms before they are transported into the cilia. In humans, mutations in DNAAF genes lead to several diseases related to cilia defects such as primary ciliary dyskinesia (PCD; OMIM: 612518). Patients with PCD experience malfunctions in cilia motility, which can result in inflammation and infection of the respiratory tract among other defects. Previous studies have identified that a mutation in DNAAF2 results in PCD and that 40% of these patients also experience laterality defects. In an outbred genetic background, Dnaaf2 homozygotes die after birth and have left/right defects among other phenotypes. Here we characterize a novel null allele of Dnaaf2 obtained from the International Mouse Phenotyping Consortium. Our data indicate that on a defined C57bl/6NJ genetic background, homozygous Dnaaf2 mouse embryos fail to progress beyond organogenesis stages with many abnormalities including left-right patterning defects. These findings support studies indicating that hypomorphic mutations of human DNAAF2 can result in ciliary dyskinesia and identify Dnaaf2 as an essential component of cilia function in vivo.
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Affiliation(s)
- Agnes Cheong
- Department of Veterinary and Animal Sciences, University of Massachusetts, Amherst, MA 01003, USA
| | - Rinat Degani
- Department of Veterinary and Animal Sciences, University of Massachusetts, Amherst, MA 01003, USA
| | - Kimberly D Tremblay
- Department of Veterinary and Animal Sciences, University of Massachusetts, Amherst, MA 01003, USA
| | - Jesse Mager
- Department of Veterinary and Animal Sciences, University of Massachusetts, Amherst, MA 01003, USA
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11
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Zhang X, Wang X, Li H, Wang W, Zhao S. The value of nasal nitric oxide measurement in the diagnosis of primary ciliary dyskinesia. Pediatr Investig 2019; 3:209-213. [PMID: 32851324 PMCID: PMC7331418 DOI: 10.1002/ped4.12160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/08/2019] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Nasal nitric oxide (nNO) testing is a method used in the diagnosis of primary ciliary dyskinesia (PCD). It has not been evaluated in Chinese population. OBJECTIVE To establish a reference nNO value to assist in the diagnosis of PCD in Chinese children. METHODS nNO values were measured in children with PCD (n = 36), cystic fibrosis (CF) (n = 20), asthma (n = 45), post-infectious bronchiolitis obliterans (BO) (n = 41) and non-PCD/non-CF bronchiectasis (n = 32). The receiver operating characteristic nNO value for the diagnosis of PCD was plotted and the area under the curve was calculated. RESULTS nNO values were significantly lower in children with PCD (median 25.66 nL/min) than in children with asthma (186.26 ± 58.95 nL/ min), BO (143.47 ± 49.71 nL/min) and non-PCD/non-CF bronchiectasis (173.13 ± 63.80 nL/min), but not in children with CF (90.90 ± 43.20 nL/min). Notably however, no CF patient had an nNO value < 45 nL/min. A cut-off of 76 nL/min yielded the best sensitivity of 86.1%, and specificity of 91.4%, with an area under the curve of 0.920 (95% confidence interval 0.859-0.981) for the diagnosis of PCD. If CF was ruled out the specificity increased to nearly 100%. INTERPRETATION nNO testing is able to discriminate between patients with PCD and those with CF, asthma, post-infectious BO and non-PCD/non-CF bronchiectasis. A cut-off of 76 nL/min could be further examined in patients suspected of PCD, to establish an nNO reference value for PCD screening in Chinese children.
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Affiliation(s)
- Xiang Zhang
- The Second Department of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Xinglan Wang
- The Second Department of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Huimin Li
- The Second Department of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Wei Wang
- The Second Department of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
| | - Shunying Zhao
- The Second Department of Respiratory Medicine Beijing Children's Hospital Capital Medical University National Center for Children's Health Beijing China
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12
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Halbeisen FS, Jose A, de Jong C, Nyilas S, Latzin P, Kuehni CE, Goutaki M. Spirometric indices in primary ciliary dyskinesia: systematic review and meta-analysis. ERJ Open Res 2019; 5:00231-2018. [PMID: 31111042 PMCID: PMC6513038 DOI: 10.1183/23120541.00231-2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/28/2019] [Indexed: 12/19/2022] Open
Abstract
Primary ciliary dyskinesia (PCD) is a genetic, heterogeneous disease caused by dysfunction of cilia. Evidence is sparse and reports of lung function in PCD patients range from normal to severe impairment. This systematic review and meta-analysis of studies of lung function in PCD patients examines the spirometric indices of PCD patients and differences by age group and sex. We searched PubMed, Embase and Scopus for studies that described lung function in 10 or more patients with PCD. We performed meta-analyses and meta-regression to explain heterogeneity. We included 24 studies, ranging from 13 to 158 patients per study. The most commonly reported spirometric indices were forced expiratory volume in 1 s (FEV1) and forced vital capacity presented as mean and standard deviation of percent predicted values. We found considerable heterogeneity for both parameters (I2=94–96%). The heterogeneity remained when we stratified the analysis by age; however, FEV1 in adult patients was lower. Even after taking into account explanatory factors, the largest part of the between-studies variance remained unexplained. Heterogeneity could be explained by genetic differences between study populations, methodological factors related to the variability of study inclusion criteria or details on the performance and evaluation of lung function measurements that we could not account for. Prospective studies therefore need to use standardised protocols and international reference values. These results underline the possibility of distinct PCD phenotypes as in other chronic respiratory diseases. Detailed characterisation of these phenotypes and related genotypes is needed in order to better understand the natural history of PCD. Spirometric indices of PCD patients vary between published studies, which suggests not only the possibility of methodological differences between centres but also real differences in disease expression based on genotype–phenotype associationshttp://ow.ly/wopw30nYaJo
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Affiliation(s)
- Florian S Halbeisen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Anu Jose
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Carmen de Jong
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sylvia Nyilas
- Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland.,Dept of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Philipp Latzin
- Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
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13
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Reduced anaerobic and aerobic performance in children with primary ciliary dyskinesia. Eur J Pediatr 2018; 177:765-773. [PMID: 29487997 DOI: 10.1007/s00431-018-3121-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 10/17/2022]
Abstract
UNLABELLED Primary ciliary dyskinesia (PCD) restricts lifestyle and increases morbidity. The aim of the study was to investigate anaerobic and aerobic performance in children with PCD and their healthy counterparts. Thirty-one children with PCD and 29 age- and sex-matched healthy subjects were studied. Pulmonary function, hand grip strength (HGS), quadriceps strength (QMS), physical activity, anaerobic capacity (muscle power sprint test), and aerobic performance (modified shuttle walk test (MSWT)) were determined. Pulmonary function, HGS, QMS, mean anaerobic power (MAP), and MSWT distance in PCD were significantly lower than those of healthy subjects (p < 0.05). In PCD, the MAP was significantly correlated with age, FEV1, and the mean kcal for 3 days (p < 0.05), and age was its independent predictor (p < 0.05). The MSWT distance was significantly related to gender and weight (p < 0.05), and gender was selected as its independent predictor (p < 0.05). In healthy controls, the MAP was significantly associated with age, gender, FVC, FEV1, HGS, QMS, and the mean kcal for three days (p < 0.05). The MSWT distance was significantly related to weight and body mass index in healthy group (p < 0.05). CONCLUSION Anaerobic and aerobic performance is impaired in PCD from the early stages. Age determines anaerobic performance. Gender is the determinant of aerobic performance. Whether skeletal muscle characteristics and sex-related changes in body composition affect anaerobic and aerobic capacity in PCD children warrants further study. What is Known: • Exercise performance is determined by anaerobic and aerobic power. • Few studies have shown that PCD patients have lower aerobic performance which is associated with impaired lung function. What is New: • The present research indicated that both anaerobic and aerobic exercise capacity determined using field testing is impaired in PCD from the early stages. • Anaerobic capacity was found to be independently associated with age in PCD. Higher aerobic performance is independently associated with male gender.
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14
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Halbeisen F, Hogg C, Alanin MC, Bukowy-Bieryllo Z, Dasi F, Duncan J, Friend A, Goutaki M, Jackson C, Keenan V, Harris A, Hirst RA, Latzin P, Marsh G, Nielsen K, Norris D, Pellicer D, Reula A, Rubbo B, Rumman N, Shoemark A, Walker WT, Kuehni CE, Lucas JS. Proceedings of the 2nd BEAT-PCD conference and 3rd PCD training school: part 1. BMC Proc 2018; 12:1. [PMID: 29630684 PMCID: PMC5841193 DOI: 10.1186/s12919-018-0098-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Primary ciliary dyskinesia (PCD) is a rare heterogenous condition that causes progressive suppurative lung disease, chronic rhinosinusitis, chronic otitis media, infertility and abnormal situs. 'Better Experimental Approaches to Treat Primary Ciliary Dyskinesia' (BEAT-PCD) is a network of scientists and clinicians coordinating research from basic science through to clinical care with the intention of developing treatments and diagnostics that lead to improved long-term outcomes for patients. BEAT-PCD activities are supported by EU funded COST Action (BM1407). The second BEAT-PCD conference, and third PCD training school were held jointly in April 2017 in Valencia, Spain. Presentations and workshops focussed on advancing the knowledge and skills relating to PCD in: basic science, epidemiology, diagnostic testing, clinical management and clinical trials. The multidisciplinary conference provided an interactive platform for exchanging ideas through a program of lectures, poster presentations, breakout sessions and workshops. Three working groups met to plan consensus statements. Progress with BEAT-PCD projects was shared and new collaborations were fostered. In this report, we summarize the meeting, highlighting developments made during the meeting.
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Affiliation(s)
- Florian Halbeisen
- 1Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claire Hogg
- 2Primary Ciliary Dyskinesia Centre, Departments of Paediatrics and Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - Mikkel C Alanin
- 3Department of Otolaryngology - Head and Neck Surgery and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Zuzanna Bukowy-Bieryllo
- 4Department of Molecular and Clinical Genetics, Institute of Human Genetics Polish Academy of Sciences, Poznań, Poland
| | - Francisco Dasi
- 5Department of Physiology, Faculty of Medicine, Universitat de Valencia, Valencia, Spain.,UCIM Department, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Julie Duncan
- 7Primary Ciliary Dyskinesia Centre, Departments of Paediatrics and Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - Amanda Friend
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Myrofora Goutaki
- 1Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claire Jackson
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Victoria Keenan
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Amanda Harris
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert A Hirst
- Centre for PCD Diagnosis and Research, Department of Infection, Immunity and Inflammation, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK
| | - Philipp Latzin
- 10Paediatric Respiratory Medicine, University Children's Hospital of Bern, University of Bern, Bern, Switzerland
| | - Gemma Marsh
- 2Primary Ciliary Dyskinesia Centre, Departments of Paediatrics and Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK
| | - Kim Nielsen
- 11Danish PCD & chILD Centre, CF Centre Copenhagen Paediatric Pulmonary Service, ERN Accredited for PCD and CF Health Care, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dominic Norris
- Mammalian Genetics Unit, MRC Harwell Institute, Harwell Campus, Oxfordshire, UK
| | - Daniel Pellicer
- 5Department of Physiology, Faculty of Medicine, Universitat de Valencia, Valencia, Spain.,UCIM Department, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Ana Reula
- 5Department of Physiology, Faculty of Medicine, Universitat de Valencia, Valencia, Spain.,UCIM Department, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Bruna Rubbo
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nisreen Rumman
- Pediatric Department, Makassed Hospital, East Jerusalem, Palestine
| | - Amelia Shoemark
- 2Primary Ciliary Dyskinesia Centre, Departments of Paediatrics and Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, UK.,14School of Medicine, University of Dundee, Dundee, UK
| | - Woolf T Walker
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Claudia E Kuehni
- 1Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,10Paediatric Respiratory Medicine, University Children's Hospital of Bern, University of Bern, Bern, Switzerland
| | - Jane S Lucas
- 8Primary Ciliary Dyskinesia Centre, NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
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15
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Cockx M, Gouwy M, Van Damme J, Struyf S. Chemoattractants and cytokines in primary ciliary dyskinesia and cystic fibrosis: key players in chronic respiratory diseases. Cell Mol Immunol 2017; 15:312-323. [PMID: 29176750 DOI: 10.1038/cmi.2017.118] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/29/2017] [Accepted: 10/04/2017] [Indexed: 12/12/2022] Open
Abstract
Patients with primary ciliary dyskinesia (PCD) and cystic fibrosis (CF), two inherited disorders, suffer from recurrent airway infections characterized by persistent bacterial colonization and uncontrollable inflammation. Although present in high counts, neutrophils fail to clear infection in the airways. High levels of C-X-C motif chemokine ligand 8/interleukin-8 (CXCL8/IL-8), the most potent chemokine to attract neutrophils to sites of infection, are detected in the sputum of both patient groups and might cause the high neutrophil influx in the airways. Furthermore, in CF, airway neutrophils are highly activated because of the genetic defect and the high levels of proinflammatory chemoattractants and cytokines (e.g., CXCL8/IL-8, tumor necrosis factor-α and IL-17). The overactive state of neutrophils leads to lung damage and fuels the vicious circle of infection, excessive inflammation and tissue damage. The inflammatory process in CF airways is well characterized, whereas the lung pathology in PCD is far less studied. The knowledge of CF lung pathology could be useful to guide molecular investigations of the inflammatory processes in PCD lungs. Current available therapies can not completely remedy the chronic airway infections in these diseases. This review gives an overview of the role that chemoattractants and cytokines play in these neutrophil-dominated lung pathologies. Finally, the most frequently applied treatments in CF and PCD and new experimental therapies to reduce neutrophil-dominated airway inflammation are described.
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Affiliation(s)
- Maaike Cockx
- Laboratory of Molecular Immunology, Department of Microbiology and Immunology, Rega Institute for Medical Research, University of Leuven, 3000, Leuven, Belgium
| | - Mieke Gouwy
- Laboratory of Molecular Immunology, Department of Microbiology and Immunology, Rega Institute for Medical Research, University of Leuven, 3000, Leuven, Belgium
| | - Jo Van Damme
- Laboratory of Molecular Immunology, Department of Microbiology and Immunology, Rega Institute for Medical Research, University of Leuven, 3000, Leuven, Belgium.
| | - Sofie Struyf
- Laboratory of Molecular Immunology, Department of Microbiology and Immunology, Rega Institute for Medical Research, University of Leuven, 3000, Leuven, Belgium
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16
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Hou J, Zhang Y, Gong R, Zheng X, Yang X. Primary ciliary dyskinesia presenting with spontaneous pneumothorax: Case report and review of the literature. Respir Med Case Rep 2017; 21:167-170. [PMID: 28616378 PMCID: PMC5458054 DOI: 10.1016/j.rmcr.2017.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 05/16/2017] [Accepted: 05/25/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Primary ciliary dyskinesia (PCD) is an autosomal recessive heterogeneous group of conditions with variable clinical findings. CASE PRESENTATION A 36-year-old nonsmoking Chinese man present to the emergency department of our hospital with acute-onset breathlessness and sudden-onset left-sided chest pain. The patient had 6 years primary infertility and suffered from recurrent episodes of respiratory tract infections since childhood. Chest X-ray was performed, which showed a left-sided pneumothorax with lung collapse. His conditions improved in clinical symptoms after 3 days of closed thoracic drainage. Radiographic findings after lung recruitment revealed bronchiectasis and bronchiolitis but no situs inversus. Paranasal sinus computed tomography (CT) showed maxillary sinusitis and ethmoid sinusitis. Pulmonary function tests demonstrated severe obstructive ventilation functional impairment. Bronchial mucosal cilia showed the absence of both outer and inner dynein arms of the microtubules (ODA and IDA). A culture of bronchoalveolar lavage fluid was positive for Pseudomonas aeruginosa. His clinical symptoms and CT images showed improvement after 1 month of treatment. A literature review revealed that few patients are diagnosed with PCD complicated with spontaneous pneumothorax. Within one year of follow-up, the patient showed good responses to local ICS+ LA beta2 agonist combined with oral carbocistein. CONCLUSIONS Pneumothorax might be one of the complications of the PCD. Combination therapy including ICS+ LA beta2 agonist and carbocistein could be a potential therapy to reduce the frequency of acute exacerbations and delay progression of PCD.
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Affiliation(s)
- Jia Hou
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, Ningxia, China
| | - Yanan Zhang
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, Ningxia, China
| | - Ri Gong
- Radiology Department, General Hospital of Ningxia Medical University, Ningxia, China
| | - Xiwei Zheng
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, Ningxia, China
| | - Xia Yang
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, Ningxia, China
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17
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van Mastrigt E, de Jongste JC, Pijnenburg MW. The analysis of volatile organic compounds in exhaled breath and biomarkers in exhaled breath condensate in children - clinical tools or scientific toys? Clin Exp Allergy 2016; 45:1170-88. [PMID: 25394891 DOI: 10.1111/cea.12454] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Current monitoring strategies for respiratory diseases are mainly based on clinical features, lung function and imaging. As airway inflammation is the hallmark of many respiratory diseases in childhood, noninvasive methods to assess the presence and severity of airway inflammation might be helpful in both diagnosing and monitoring paediatric respiratory diseases. At present, the measurement of fractional exhaled nitric oxide is the only noninvasive method available to assess eosinophilic airway inflammation in clinical practice. We aimed to evaluate whether the analysis of volatile organic compounds (VOCs) in exhaled breath (EB) and biomarkers in exhaled breath condensate (EBC) is helpful in diagnosing and monitoring respiratory diseases in children. An extensive literature search was conducted in Medline, Embase and PubMed on the analysis and applications of VOCs in EB and EBC in children. We retrieved 1165 papers, of which nine contained original data on VOCs in EB and 84 on biomarkers in EBC. These were included in this review. We give an overview of the clinical applications in childhood and summarize the methodological issues. Several VOCs in EB and biomarkers in EBC have the potential to distinguish patients from healthy controls and to monitor treatment responses. Lack of standardization of collection methods and analysis techniques hampers the introduction in clinical practice. The measurement of metabolomic profiles may have important advantages over detecting single markers. There is a lack of longitudinal studies and external validation to reveal whether EB and EBC analysis have added value in the diagnostic process and follow-up of children with respiratory diseases. In conclusion, the use of VOCs in EB and biomarkers in EBC as markers of inflammatory airway diseases in children is still a research tool and not validated for clinical use.
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Affiliation(s)
- E van Mastrigt
- Department of Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J C de Jongste
- Department of Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M W Pijnenburg
- Department of Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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18
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Fouka E, Lamprianidou E, Arvanitidis K, Filidou E, Kolios G, Miltiades P, Paraskakis E, Antoniadis A, Kotsianidis I, Bouros D. Low-Dose Clarithromycin Therapy Modulates Th17 Response In Non-Cystic Fibrosis Bronchiectasis Patients. Lung 2014; 192:849-55. [DOI: 10.1007/s00408-014-9619-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/22/2014] [Indexed: 12/27/2022]
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19
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Vogt B, Falkenberg C, Weiler N, Frerichs I. Pulmonary function testing in children and infants. Physiol Meas 2014; 35:R59-90. [PMID: 24557323 DOI: 10.1088/0967-3334/35/3/r59] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pulmonary function testing is performed in children and infants with the aim of documenting lung development with age and making diagnoses of lung diseases. In children and infants with an established lung disease, pulmonary function is tested to assess the disease progression and the efficacy of therapy. It is difficult to carry out the measurements in this age group without disturbances, so obtaining results of good quality and reproducibility is challenging. Young children are often uncooperative during the examinations. This is partly related to their young age but also due to the long testing duration and the unpopular equipment. We address a variety of examination techniques for lung function assessment in children and infants in this review. We describe the measuring principles, examination procedures, clinical findings and their interpretation, as well as advantages and limitations of these methods. The comparability between devices and centres as well as the availability of reference values are still considered a challenge in many of these techniques. In recent years, new technologies have emerged allowing the assessment of lung function not only on the global level but also on the regional level. This opens new possibilities for detecting regional lung function heterogeneity that might lead to a better understanding of respiratory pathophysiology in children.
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Affiliation(s)
- B Vogt
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
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20
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Irving SJ, Ives A, Davies G, Donovan J, Edey AJ, Gill SS, Nair A, Saunders C, Wijesekera NT, Alton EWFW, Hansell D, Hogg C, Davies JC, Bush A. Lung clearance index and high-resolution computed tomography scores in primary ciliary dyskinesia. Am J Respir Crit Care Med 2013; 188:545-9. [PMID: 23815669 DOI: 10.1164/rccm.201304-0800oc] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Lung clearance index (LCI) is a more sensitive measure of lung function than spirometry in cystic fibrosis (CF) and correlates well with abnormalities in high-resolution computed tomography (HRCT) scanning. We hypothesized LCI would be equally sensitive to lung disease in primary ciliary dyskinesia (PCD). OBJECTIVES To test the relationships between LCI, spirometry, and HRCT in PCD and to compare them to the established relationships in CF. METHODS Cross-sectional study of 127 patients with CF and 33 patients with PCD, all of whom had spirometry and LCI, of which a subset of 21 of each had HRCT performed. HRCT was scored for individual features and these features compared with physiological parameters. MEASUREMENTS AND MAIN RESULTS Unlike in CF, and contrary to our hypothesis, there was no correlation between spirometry and LCI in PCD and no correlation between HRCT features and LCI or spirometry in PCD. CONCLUSIONS We show for the first time that HRCT, spirometry, and LCI have different relationships in different airway diseases and that LCI does not appear to be a sensitive test of airway disease in advanced PCD. We hypothesize that this results from dissimilarities between the components of large and small airway disease in CF and PCD. These differences may in part lead to the different prognosis in these two neutrophilic airway diseases.
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Affiliation(s)
- Samantha J Irving
- Department of Paediatrics, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.
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Wells GD, Wilkes DL, Schneiderman JE, Rayner T, Elmi M, Selvadurai H, Dell SD, Noseworthy MD, Ratjen F, Tein I, Coates AL. Skeletal muscle metabolism in cystic fibrosis and primary ciliary dyskinesia. Pediatr Res 2011; 69:40-5. [PMID: 20938370 DOI: 10.1203/pdr.0b013e3181fff35f] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Previous studies have reported differences in muscle function and metabolism between patients with cystic fibrosis (CF) and healthy controls (HC), but it is currently unknown whether these abnormalities are specific to CF or also seen in other airway diseases. In this study, we used magnetic resonance spectroscopy (MRS) during exercise to assess muscle metabolism in CF patients. Twenty patients with CF and 20 age, gender, and habitual activity-matched HCs and a respiratory disease comparison group with primary ciliary dyskinesia (PCD; n = 10) were studied. Phosphorus MRS (P-MRS) was used to characterize muscle bioenergetic metabolism at rest and after high-, moderate-, and low-intensity exercise. CF patients exhibited lower resting ATP/phosphocreatine (PCr) ratio and significantly higher end-exercise pH values compared with both HC and PCD patients. Both CF and PCD patients demonstrated significantly slower PCr recovery time constants after high-intensity exercise. Our results suggest that not only there are specific abnormalities of muscle metabolism in CF patients but also there is a nonspecific impact of respiratory disease on muscle function.
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Affiliation(s)
- Greg D Wells
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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22
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Porro C, Lepore S, Trotta T, Castellani S, Ratclif L, Battaglino A, Di Gioia S, Martínez MC, Conese M, Maffione AB. Isolation and characterization of microparticles in sputum from cystic fibrosis patients. Respir Res 2010; 11:94. [PMID: 20618958 PMCID: PMC2910006 DOI: 10.1186/1465-9921-11-94] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 07/09/2010] [Indexed: 12/29/2022] Open
Abstract
Background Microparticles (MPs) are membrane vesicles released during cell activation and apoptosis. MPs have different biological effects depending on the cell from they originate. Cystic fibrosis (CF) lung disease is characterized by massive neutrophil granulocyte influx in the airways, their activation and eventually apoptosis. We investigated on the presence and phenotype of MPs in the sputum, a rich non-invasive source of inflammation biomarkers, of acute and stable CF adult patients. Methods Spontaneous sputum, obtained from 21 CF patients (10 acute and 11 stable) and 7 patients with primary ciliary dyskinesia (PCD), was liquefied with Sputasol. MPs were counted, visualized by electron microscopy, and identified in the supernatants of treated sputum by cytofluorimetry and immunolabelling for leukocyte (CD11a), granulocyte (CD66b), and monocyte-macrophage (CD11b) antigens. Results Electron microscopy revealed that sputum MPs were in the 100-500 nm range and did not contain bacteria, confirming microbiological tests. CF sputa contained higher number of MPs in comparison with PCD sputa. Levels of CD11a+-and CD66b+-, but not CD11b+-MPs were significantly higher in CF than in PCD, without differences between acute and stable patients. Conclusions In summary, MPs are detectable in sputa obtained from CF patients and are predominantly of granulocyte origin. This novel isolation method for MPs from sputum opens a new opportunity for the study of lung pathology in CF.
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Affiliation(s)
- Chiara Porro
- Department of Biomedical Sciences, University of Foggia, Foggia, Italy.
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23
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Molina MA, Zhao W, Sankaran S, Schivo M, Kenyon NJ, Davis CE. Design-of-experiment optimization of exhaled breath condensate analysis using a miniature differential mobility spectrometer (DMS). Anal Chim Acta 2008; 628:155-61. [PMID: 18929003 DOI: 10.1016/j.aca.2008.09.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 08/24/2008] [Accepted: 09/05/2008] [Indexed: 10/21/2022]
Abstract
Analytical instruments that can measure small amounts of chemicals in complicated biological samples are often useful as diagnostic tools. However, it can be challenging to optimize these sensors using actual clinical samples, given the heterogeneous background and composition of the test materials. Here we use gas chromatography-differential mobility spectrometry (GC/DMS) to analyze the chemical content of human exhaled breath condensate (EBC). Ultimately, this system can be used for non-invasive disease diagnostics. Many parameters can be adjusted within this instrument system, and we implemented a factorial design-of-experiments to systematically test several combinations of parameter settings while concurrently analyzing effects and interactions. We examined four parameters that affect sensitivity and detection for our instrument, requiring a 2(4) factorial design. We optimized sensor function using EBC samples spiked with acetone, a known clinical biomarker in breath. Two outputs were recorded for each experiment combination: number of chemicals detected, and the amplitude of acetone signal. Our goal is to find the best parameter combination that yields the highest acetone peak while also preserving the largest number of other chemical peaks in the spectra. By optimizing the system, we can conduct further clinical experiments with our sensor more efficiently and accurately.
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Affiliation(s)
- Mary A Molina
- Department of Mechanical and Aeronautical Engineering, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
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24
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Carraro S, Baraldi E. Exhaled breath condensate in children: present knowledge and future prospects. J Breath Res 2008; 2:037003. [PMID: 21386164 DOI: 10.1088/1752-7155/2/3/037003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Exhaled breath condensate (EBC) is a safe and easy technique that enables several biomarkers of lung disease to be detected. Condensate collection requires only minimal cooperation and can easily be done by children as young as 4 years old. Some condensers have been adapted for use by younger children but EBC collection with these devices still poses significant drawbacks. EBC has been applied in the study of various respiratory diseases in children (mostly asthma and cystic fibrosis, but also other diseases such as primary ciliary dyskinesia). Several biomarkers of airway inflammation and oxidative stress have been detected in the EBC of these patients, demonstrating the role of different inflammatory pathways in the pathophysiology of respiratory diseases. Lately EBC has also been analyzed using new techniques, such as metabolomic analysis, an approach that enables the simultaneous assessment of several biocompounds with the potential identification of metabolite profiles characteristic of a given disease. Studies published so far support the promising role of EBC in investigating the pathophysiology of lung diseases. The noninvasiveness of this technique makes it particularly suitable for application in children.
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Affiliation(s)
- Silvia Carraro
- Department of Pediatrics, University of Padova, Allergy and Respiratory Medicine Unit, Via Giustiniani 3, 35128 Padova, Italy
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25
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Kulkarni N, Cooke MS, Grigg J. Neutrophils in induced sputum from healthy children: role of interleukin-8 and oxidative stress. Respir Med 2007; 101:2108-12. [PMID: 17618102 DOI: 10.1016/j.rmed.2007.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 05/01/2007] [Accepted: 05/25/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND It is unclear why the neutrophil differential count in induced sputum (IS) from normal children is highly variable. Since levels of neutrophil chemoattractant cytokines and oxidative stress are determinants of airway neutrophilia in animal models, we sought to determine the association between IS neutrophils from healthy children and (i) interleukin-8 (IL-8) and (ii) the oxidative stress marker 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG). METHODS IS was done using hypertonic saline. The proportion (differential %) and the absolute number of IS neutrophils were determined by light microscopy. IS IL-8 and 8-oxodG were determined using ELISA. Spearman's rank correlation (Rs) was used to assess relationship between variables. RESULTS Adequate IS samples for analysis were obtained from 64/114 healthy children. The median (interquartile range) neutrophil differential count (n=64) was 20.6% (5.67-56), and absolute neutrophil count (n=53) was 0.11x10(6) (0.01-0.77). Both the % neutrophils, and the absolute neutrophil count were associated with IL-8 (Rs=0.67, p<0.0001 and 0.60, p<0.0001, respectively), but there was no association between IS neutrophil variables and 8-oxodG (n=40). The repeatability (intraclass correlation coefficient-Ri) of the neutrophil differential count was 0.58 (n=15). CONCLUSIONS The variation in the proportion and number of neutrophils in the lower airway of healthy children is associated with IL-8, but not with oxidative stress. The IS neutrophil differential count in healthy children is relatively stable over several months.
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Affiliation(s)
- Neeta Kulkarni
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester LE2 7LX, UK
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26
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Ryberg H, Caidahl K. Chromatographic and mass spectrometric methods for quantitative determination of 3-nitrotyrosine in biological samples and their application to human samples. J Chromatogr B Analyt Technol Biomed Life Sci 2007; 851:160-71. [PMID: 17344105 DOI: 10.1016/j.jchromb.2007.02.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Revised: 01/29/2007] [Accepted: 02/01/2007] [Indexed: 11/24/2022]
Abstract
The permanent modification of soluble and protein-associated tyrosine by nitration results in the formation of 3-nitrotyrosine, which can be used as a marker of "nitro-oxidative" damage to proteins. Based on the analysis of patient materials, over 40 different diseases and/or conditions have been linked to increased nitration of tyrosine. They include many cardiovascular diseases, conditions associated with immunological reactions and neurological diseases. In this article we review the existing chromatographic and mass spectrometric methods for quantitative measurements of 3-nitrotyrosine in different human biological samples including plasma, either from the free amino acid pool or from hydrolyzed proteins from different matrices.
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Affiliation(s)
- Henrik Ryberg
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Göteborg, Göteborg, Sweden
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