1
|
Baird T, Bell S. Cystic Fibrosis-Related Nontuberculous Mycobacterial Pulmonary Disease. Clin Chest Med 2023; 44:847-860. [PMID: 37890921 DOI: 10.1016/j.ccm.2023.06.008] [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] [Indexed: 10/29/2023]
Abstract
Non-tuberculous mycobacteria (NTM) infection is a major cause of morbidity in people with cystic fibrosis (pwCF) with rates of infection increasing worldwide. Accurate diagnosis and decisions surrounding best management remain challenging. Treatment guidelines have been developed to assist physicians in managing NTM in pwCF, but involve prolonged and complex mycobacterial regimens, often associated with significant toxicity. Fortunately, current management and outcomes of NTM in CF are likely to evolve due to improved understanding of disease acquisition, better diagnostics, emerging antimycobacterial therapies, and the widespread uptake of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies.
Collapse
Affiliation(s)
- Timothy Baird
- Department of Respiratory Medicine, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia; Sunshine Coast Health Institute, Sunshine Coast, Queensland, Australia; University of the Sunshine Coast, Sunshine Coast, Queensland, Australia.
| | - Scott Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia; Children's Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia
| |
Collapse
|
2
|
Burke A, Thomson RM, Wainwright CE, Bell SC. Nontuberculous Mycobacteria in Cystic Fibrosis in the Era of Cystic Fibrosis Transmembrane Regulator Modulators. Semin Respir Crit Care Med 2023; 44:287-296. [PMID: 36649736 DOI: 10.1055/s-0042-1759883] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Nontuberculous mycobacteria (NTM) are a group of mycobacteria which represent opportunistic pathogens that are of increasing concern in people with cystic fibrosis (pwCF). The acquisition has been traditionally though to be from environmental sources, though recent work has suggested clustered clonal infections do occur and transmission potential demonstrated among pwCF attending CF specialist centers. Guidelines for the screening, diagnosis, and identification of NTM and management of pwCF have been published. The emergence of CF-specific therapies, in particular cystic fibrosis transmembrane regulator (CFTR) modulator drugs, have led to significant improvement in the health and well-being of pwCF and may lead to challenges in sampling the lower respiratory tract including to screen for NTM. This review highlights the epidemiology, modes of acquisition, screening and diagnosis, therapeutic approaches in the context of improved clinical status for pwCF, and the clinical application of CFTR modulator therapies.
Collapse
Affiliation(s)
- Andrew Burke
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Rachel M Thomson
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia.,Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - Claire E Wainwright
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland, South Brisbane, Australia
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland, South Brisbane, Australia.,Translational Research Institute, Woolloongabba, Australia
| |
Collapse
|
3
|
Allen L, Allen L, Carr SB, Davies G, Downey D, Egan M, Forton JT, Gray R, Haworth C, Horsley A, Smyth AR, Southern KW, Davies JC. Future therapies for cystic fibrosis. Nat Commun 2023; 14:693. [PMID: 36755044 PMCID: PMC9907205 DOI: 10.1038/s41467-023-36244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Abstract
We are currently witnessing transformative change for people with cystic fibrosis with the introduction of small molecule, mutation-specific drugs capable of restoring function of the defective protein, cystic fibrosis transmembrane conductance regulator (CFTR). However, despite being a single gene disorder, there are multiple cystic fibrosis-causing genetic variants; mutation-specific drugs are not suitable for all genetic variants and also do not correct all the multisystem clinical manifestations of the disease. For many, there will remain a need for improved treatments. Those patients with gene variants responsive to CFTR modulators may have found these therapies to be transformational; research is now focusing on safely reducing the burden of symptom-directed treatment. However, modulators are not available in all parts of the globe, an issue which is further widening existing health inequalities. For patients who are not suitable for- or do not have access to- modulator drugs, alternative approaches are progressing through the trials pipeline. There will be challenges encountered in design and implementation of these trials, for which the established global CF infrastructure is a major advantage. Here, the Cystic Fibrosis National Research Strategy Group of the UK NIHR Respiratory Translational Research Collaboration looks to the future of cystic fibrosis therapies and consider priorities for future research and development.
Collapse
Affiliation(s)
| | | | - Siobhan B Carr
- Royal Brompton & Harefield Hospital, Guy's & St Thomas' Trust, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Gwyneth Davies
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children, London, UK
| | - Damian Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - Julian T Forton
- Noah's Ark Children's Hospital for Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Robert Gray
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Charles Haworth
- Royal Papworth Hospital and Department of Medicine, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Alexander Horsley
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
- Manchester Adult CF Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alan R Smyth
- School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Institute in the Park, Alder Hey Children's Hospital, Liverpool, UK
| | - Jane C Davies
- Royal Brompton & Harefield Hospital, Guy's & St Thomas' Trust, London, UK.
- National Heart & Lung Institute, Imperial College London, London, UK.
| |
Collapse
|
4
|
Dedrick RM, Smith BE, Cristinziano M, Freeman KG, Jacobs-Sera D, Belessis Y, Whitney Brown A, Cohen KA, Davidson RM, van Duin D, Gainey A, Garcia CB, Robert George CR, Haidar G, Ip W, Iredell J, Khatami A, Little JS, Malmivaara K, McMullan BJ, Michalik DE, Moscatelli A, Nick JA, Tupayachi Ortiz MG, Polenakovik HM, Robinson PD, Skurnik M, Solomon DA, Soothill J, Spencer H, Wark P, Worth A, Schooley RT, Benson CA, Hatfull GF. Phage Therapy of Mycobacterium Infections: Compassionate Use of Phages in 20 Patients With Drug-Resistant Mycobacterial Disease. Clin Infect Dis 2023; 76:103-112. [PMID: 35676823 PMCID: PMC9825826 DOI: 10.1093/cid/ciac453] [Citation(s) in RCA: 104] [Impact Index Per Article: 104.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/23/2022] [Accepted: 06/01/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Nontuberculous Mycobacterium infections, particularly Mycobacterium abscessus, are increasingly common among patients with cystic fibrosis and chronic bronchiectatic lung diseases. Treatment is challenging due to intrinsic antibiotic resistance. Bacteriophage therapy represents a potentially novel approach. Relatively few active lytic phages are available and there is great variation in phage susceptibilities among M. abscessus isolates, requiring personalized phage identification. METHODS Mycobacterium isolates from 200 culture-positive patients with symptomatic disease were screened for phage susceptibilities. One or more lytic phages were identified for 55 isolates. Phages were administered intravenously, by aerosolization, or both to 20 patients on a compassionate use basis and patients were monitored for adverse reactions, clinical and microbiologic responses, the emergence of phage resistance, and phage neutralization in serum, sputum, or bronchoalveolar lavage fluid. RESULTS No adverse reactions attributed to therapy were seen in any patient regardless of the pathogen, phages administered, or the route of delivery. Favorable clinical or microbiological responses were observed in 11 patients. Neutralizing antibodies were identified in serum after initiation of phage delivery intravenously in 8 patients, potentially contributing to lack of treatment response in 4 cases, but were not consistently associated with unfavorable responses in others. Eleven patients were treated with only a single phage, and no phage resistance was observed in any of these. CONCLUSIONS Phage treatment of Mycobacterium infections is challenging due to the limited repertoire of therapeutically useful phages, but favorable clinical outcomes in patients lacking any other treatment options support continued development of adjunctive phage therapy for some mycobacterial infections.
Collapse
Affiliation(s)
- Rebekah M Dedrick
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bailey E Smith
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Madison Cristinziano
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Krista G Freeman
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deborah Jacobs-Sera
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yvonne Belessis
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | | | - Keira A Cohen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rebecca M Davidson
- Center for Genes, Environment, and Health, National Jewish Health, Denver, Colorado, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Andrew Gainey
- Department of Pharmacy, Division of Pediatric Infectious Diseases, Prisma Health Children's Hospital–Midlands, Columbia, South Carolina, USA
| | | | - C R Robert George
- New South Wales Health Pathology Microbiology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Ghady Haidar
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Winnie Ip
- Department of Pediatric Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Jonathan Iredell
- Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, New South Wales, Australia
| | - Ameneh Khatami
- Department of Infectious Diseases and Microbiology, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Discipline of Child and Adolescent Health, University of Syndey, Sydney, New South Wales, Australia
| | - Jessica S Little
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Brendan J McMullan
- Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, New South Wales, Australia
| | - David E Michalik
- Miller Children’s and Women’s Hospital, Division of Pediatric Infectious Diseases, Long Beach, California, USA
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Instituto Giannina Gaslini, Genoa, Italy
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Maria G Tupayachi Ortiz
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Hari M Polenakovik
- Internal Medicine Department, Dayton Children’s Hospital, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Mikael Skurnik
- Department of Bacteriology and Immunology, Human Microbiome Research Program, University of Helsinki, Helsinki, Finland
- Division of Clinical Microbiology, Helsinki University Hospital, Helsinki, Finland
| | - Daniel A Solomon
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Helen Spencer
- Respiratory Medicine and Cardiothoracic Transplantation, Great Ormond Street Hospital, London, United Kingdom
| | - Peter Wark
- Immune Health Program, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - Austen Worth
- Department of Pediatric Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Robert T Schooley
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, California, USA
| | - Constance A Benson
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, California, USA
| | - Graham F Hatfull
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
5
|
Antos NJ, Savant AP. Cystic fibrosis year in review 2020: Section 2 pulmonary disease, infections, and inflammation. Pediatr Pulmonol 2022; 57:347-360. [PMID: 34033706 DOI: 10.1002/ppul.25459] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/20/2022]
Abstract
The outlook for those with cystic fibrosis (CF) has never been brighter with ever increasing life expectancy and the approval of the highly effective CFTR modulators, such as elexacaftor/tezacaftor/ivacaftor. With that being said, the progressive pulmonary decline and importance of lung health, infection, and inflammation in CF remains. This review is the second part in a three-part CF Year in Review 2020. Part one focused on the literature related to CFTR modulators while part three will feature the multisystem effects related to CF. This review focuses on articles from Pediatric Pulmonology, including articles from other journals that are of particular interest to clinicians. Herein, we highlight studies published during 2020 related to CF pulmonary disease, infection, treatment, and diagnostics.
Collapse
Affiliation(s)
- Nicholas J Antos
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pediatric Pulmonology, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Adrienne P Savant
- Department of Pediatrics, Children's Hospital of New Orleans, New Orleans, Louisiana, USA.,Department of Pediatrics, Tulane University, New Orleans, Louisiana, USA
| |
Collapse
|
6
|
Llibre A, Dedicoat M, Burel JG, Demangel C, O’Shea MK, Mauro C. Host Immune-Metabolic Adaptations Upon Mycobacterial Infections and Associated Co-Morbidities. Front Immunol 2021; 12:747387. [PMID: 34630426 PMCID: PMC8495197 DOI: 10.3389/fimmu.2021.747387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/08/2021] [Indexed: 12/14/2022] Open
Abstract
Mycobacterial diseases are a major public health challenge. Their causative agents include, in order of impact, members of the Mycobacterium tuberculosis complex (causing tuberculosis), Mycobacterium leprae (causing leprosy), and non-tuberculous mycobacterial pathogens including Mycobacterium ulcerans. Macrophages are mycobacterial targets and they play an essential role in the host immune response to mycobacteria. This review aims to provide a comprehensive understanding of the immune-metabolic adaptations of the macrophage to mycobacterial infections. This metabolic rewiring involves changes in glycolysis and oxidative metabolism, as well as in the use of fatty acids and that of metals such as iron, zinc and copper. The macrophage metabolic adaptations result in changes in intracellular metabolites, which can post-translationally modify proteins including histones, with potential for shaping the epigenetic landscape. This review will also cover how critical tuberculosis co-morbidities such as smoking, diabetes and HIV infection shape host metabolic responses and impact disease outcome. Finally, we will explore how the immune-metabolic knowledge gained in the last decades can be harnessed towards the design of novel diagnostic and therapeutic tools, as well as vaccines.
Collapse
Affiliation(s)
- Alba Llibre
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Martin Dedicoat
- Department of Infectious Diseases, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Julie G. Burel
- Division of Vaccine Discovery, La Jolla Institute for Immunology, La Jolla, CA, United States
| | - Caroline Demangel
- Immunobiology of Infection Unit, Institut Pasteur, INSERM U1224, Paris, France
| | - Matthew K. O’Shea
- Department of Infectious Diseases, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Claudio Mauro
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| |
Collapse
|
7
|
Shteinberg M, Haq IJ, Polineni D, Davies JC. Cystic fibrosis. Lancet 2021; 397:2195-2211. [PMID: 34090606 DOI: 10.1016/s0140-6736(20)32542-3] [Citation(s) in RCA: 287] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/03/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022]
Abstract
Cystic fibrosis is a monogenic disease considered to affect at least 100 000 people worldwide. Mutations in CFTR, the gene encoding the epithelial ion channel that normally transports chloride and bicarbonate, lead to impaired mucus hydration and clearance. Classical cystic fibrosis is thus characterised by chronic pulmonary infection and inflammation, pancreatic exocrine insufficiency, male infertility, and might include several comorbidities such as cystic fibrosis-related diabetes or cystic fibrosis liver disease. This autosomal recessive disease is diagnosed in many regions following newborn screening, whereas in other regions, diagnosis is based on a group of recognised multiorgan clinical manifestations, raised sweat chloride concentrations, or CFTR mutations. Disease that is less easily diagnosed, and in some cases affecting only one organ, can be seen in the context of gene variants leading to residual protein function. Management strategies, including augmenting mucociliary clearance and aggressively treating infections, have gradually improved life expectancy for people with cystic fibrosis. However, restoration of CFTR function via new small molecule modulator drugs is transforming the disease for many patients. Clinical trial pipelines are actively exploring many other approaches, which will be increasingly needed as survival improves and as the population of adults with cystic fibrosis increases. Here, we present the current understanding of CFTR mutations, protein function, and disease pathophysiology, consider strengths and limitations of current management strategies, and look to the future of multidisciplinary care for those with cystic fibrosis.
Collapse
Affiliation(s)
- Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Iram J Haq
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, UK; Royal Brompton and Harefield, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| |
Collapse
|
8
|
Caverly LJ, Zimbric M, Azar M, Opron K, LiPuma JJ. Cystic fibrosis airway microbiota associated with outcomes of nontuberculous mycobacterial infection. ERJ Open Res 2021; 7:00578-2020. [PMID: 33898611 PMCID: PMC8053818 DOI: 10.1183/23120541.00578-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/29/2021] [Indexed: 01/03/2023] Open
Abstract
Rationale Pulmonary infections with nontuberculous mycobacteria (NTM) are increasingly prevalent in people with cystic fibrosis (CF). Clinical outcomes following NTM acquisition are highly variable, ranging from transient self-resolving infection to NTM pulmonary disease associated with significant morbidity. Relationships between airway microbiota and variability of NTM outcomes in CF are unclear. Objective To identify features of CF airway microbiota associated with outcomes of NTM infection. Methods 188 sputum samples, obtained from 24 subjects with CF, each with three or more samples collected from 3.5 years prior to, and up to 6 months following incident NTM infection, were selected from a sample repository. Sputum DNA underwent bacterial 16S rRNA gene sequencing. Airway microbiota were compared based on the primary outcome, a diagnosis of NTM pulmonary disease, using Wilcoxon rank-sum testing, autoregressive integrated moving average modelling and network analyses. Measurements and main results Subjects with and without NTM pulmonary disease were similar in clinical characteristics, including age and lung function at the time of incident NTM infection. Time-series analyses of sputum samples prior to incident NTM infection identified positive correlations between Pseudomonas, Streptococcus, Veillonella, Prevotella and Rothia with diagnosis of NTM pulmonary disease and with persistent NTM infection. Network analyses identified differences in clustering of taxa between subjects with and without NTM pulmonary disease, and between subjects with persistent versus transient NTM infection. Conclusions CF airway microbiota prior to incident NTM infection are associated with subsequent outcomes, including diagnosis of NTM pulmonary disease, and persistence of NTM infection. Associations between airway microbiota and NTM outcomes represent targets for validation as predictive markers and for future therapies.
Collapse
Affiliation(s)
- Lindsay J Caverly
- Dept of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Madsen Zimbric
- Dept of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michelle Azar
- Dept of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristopher Opron
- Dept of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John J LiPuma
- Dept of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|