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Pat Y, Ogulur I, Yazici D, Mitamura Y, Cevhertas L, Küçükkase OC, Mesisser SS, Akdis M, Nadeau K, Akdis CA. Effect of altered human exposome on the skin and mucosal epithelial barrier integrity. Tissue Barriers 2023; 11:2133877. [PMID: 36262078 PMCID: PMC10606824 DOI: 10.1080/21688370.2022.2133877] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/23/2022] [Accepted: 08/27/2022] [Indexed: 10/24/2022] Open
Abstract
Pollution in the world and exposure of humans and nature to toxic substances is continuously worsening at a rapid pace. In the last 60 years, human and domestic animal health has been challenged by continuous exposure to toxic substances and pollutants because of uncontrolled growth, modernization, and industrialization. More than 350,000 new chemicals have been introduced to our lives, mostly without any reasonable control of their health effects and toxicity. A plethora of studies show exposure to these harmful substances during this period with their implications on the skin and mucosal epithelial barrier and increasing prevalence of allergic and autoimmune diseases in the context of the "epithelial barrier hypothesis". Exposure to these substances causes an epithelial injury with peri-epithelial inflammation, microbial dysbiosis and bacterial translocation to sub-epithelial areas, and immune response to dysbiotic bacteria. Here, we provide scientific evidence on the altered human exposome and its impact on epithelial barriers.
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Affiliation(s)
- Yagiz Pat
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
- Department of Medical Microbiology, Faculty of Medicine, Aydin Menderes University, Turkey
| | - Ismail Ogulur
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Duygu Yazici
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Yasutaka Mitamura
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Lacin Cevhertas
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
- Department of Medical Immunology, Institute of Health Sciences, Bursa Uludag University, Turkey
| | - Ozan C Küçükkase
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Sanne S Mesisser
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Kari Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University and Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
- Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
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Salahuddin M, Khan DA, Ayub S, Shahzad T, Irfan M. Biomass Smoke–Associated Lung Diseases. CURRENT PULMONOLOGY REPORTS 2023; 12:151-161. [DOI: 10.1007/s13665-023-00318-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 09/01/2023]
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Kizhakke Puliyakote AS, Stapleton EM, Durairaj K, Karuppusamy K, Kathiresan GB, Shanmugam K, Abdul Rahim S, Navaneethakrishnan S, Bilas M, Huang R, Metwali N, Jeronimo M, Chan KS, Guo J, Nagpal P, Peters TM, Thorne PS, Comellas AP, Hoffman EA. Imaging-based assessment of lung function in a population cooking indoors with biomass fuel: a pilot study. J Appl Physiol (1985) 2023; 134:710-721. [PMID: 36759166 PMCID: PMC10027118 DOI: 10.1152/japplphysiol.00286.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023] Open
Abstract
Biomass fuels (wood) are commonly used indoors in underventilated environments for cooking in the developing world, but the impact on lung physiology is poorly understood. Quantitative computed tomography (qCT) can provide sensitive metrics to compare the lungs of women cooking with wood vs. liquified petroleum gas (LPG). We prospectively assessed (qCT and spirometry) 23 primary female cooks (18 biomass, 5 LPG) with no history of cardiopulmonary disease in Thanjavur, India. CT was obtained at coached total lung capacity (TLC) and residual volume (RV). qCT assessment included texture-derived ground glass opacity [GGO: Adaptive Multiple Feature Method (AMFM)], air-trapping (expiratory voxels ≤ -856HU) and image registration-based assessment [Disease Probability Measure (DPM)] of emphysema, functional small airways disease (%AirTrapDPM), and regional lung mechanics. In addition, within-kitchen exposure assessments included particulate matter <2.5 μm(PM2.5), black carbon, β-(1, 3)-d-glucan (surrogate for fungi), and endotoxin. Air-trapping went undetected at RV via the threshold-based measure (voxels ≤ -856HU), possibly due to density shifts in the presence of inflammation. However, DPM, utilizing image-matching, demonstrated significant air-trapping in biomass vs. LPG cooks (P = 0.049). A subset of biomass cooks (6/18), identified using k-means clustering, had markedly altered DPM-metrics: greater air-trapping (P < 0.001), lower TLC-RV volume change (P < 0.001), a lower mean anisotropic deformation index (ADI; P < 0.001), and elevated % GGO (P < 0.02). Across all subjects, a texture measure of bronchovascular bundles was correlated to the log-transformed β-(1, 3)-d-glucan concentration (P = 0.026, R = 0.46), and black carbon (P = 0.04, R = 0.44). This pilot study identified environmental links with qCT-based lung pathologies and a cluster of biomass cooks (33%) with significant small airways disease.NEW & NOTEWORTHY Quantitative computed tomography has identified a cluster of women (33%) cooking with biomass fuels (wood) with image-based markers of functional small airways disease and associated alterations in regional lung mechanics. Texture and image registration-based metrics of lung function may allow for early detection of potential inflammatory processes that may arise in response to inhaled biomass smoke, and help identify phenotypes of chronic lung disease prevalent in nonsmoking women in the developing world.
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Affiliation(s)
- Abhilash S Kizhakke Puliyakote
- Department of Radiology, University of California, San Diego, La Jolla, California, United States
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Emma M Stapleton
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States
| | - Kumar Durairaj
- Department of Physics, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | - Kesavan Karuppusamy
- Department of Physics, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | - Geetha B Kathiresan
- Department of Electronics and Communication Engineering, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | - Kumaran Shanmugam
- Department of Biotechnology, Periyar Maniammai Institute of Science and Technology, Thanjavur, India
| | | | | | - Monalisa Bilas
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
| | - Rui Huang
- School of Economics, Nanjing University, Nanjing, People's Republic of China
| | - Nervana Metwali
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, United States
| | - Matthew Jeronimo
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kung-Sik Chan
- Department of Statistics and Actuarial Science, University of Iowa, Iowa City, Iowa, United States
| | - Junfeng Guo
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
| | - Prashant Nagpal
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Thomas M Peters
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, United States
| | - Peter S Thorne
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, United States
| | - Alejandro P Comellas
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States
| | - Eric A Hoffman
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
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Ismail AU, Ibrahim SA, Gambo MD, Muhammad RF, Badamasi MM, Sulaiman I. Impact of differential occupational LPG exposure on cardiopulmonary indices, liver function, and oxidative stress in Northwestern city of Nigeria. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 862:160881. [PMID: 36521592 DOI: 10.1016/j.scitotenv.2022.160881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 06/17/2023]
Abstract
Exposure to hydrocarbon products has been associated with numerous health risks and toxicities. Outdoor or indoor occupational exposure to highly volatile and lipid-soluble hydrocarbons has been linked to impairment of respiratory, cardiovascular, and liver functions. This study is aimed at determining the potential impact of occupational exposure to liquefied petroleum gas (LPG) in varying work environments. Respiratory symptoms, oxidative stress, cardio-pulmonary, and liver function parameters were assessed among LPG workers in the Kano metropolis, Nigeria. Study subjects were recruited from LPG filling stations and street LPG retail shops. Results of the study showed that the forced vital capacity (FVC) of LPG station workers was significantly lower (2.81 L/min; H = 22.473, p < 0.001) relative to the values recorded among LPG retail shop workers and the controls (3.54 L/min and 4.24 L/min respectively). A similar reduction was seen in the forced expiratory volume in the first second (FEV1) and the forced expiratory flow in 25-75 % of forced vital capacity (FEF25-75) obtained from the filling station workers (H = 32.722, p < 0.001 & H = 15.655, p <0.001 respectively). Furthermore, exposure to non-combusted LPG increased systolic blood pressure, mean arterial pressure, and serum liver enzymes. Findings from this study revealed that despite the high amount of coarse particulate matter in LPG retail shops, the filling station workers are more susceptible to the impairment of lung function possibly due to the high quantity of total volatile organic compounds (TVOCs) in the filling station environment.
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Affiliation(s)
- Abubakar Usman Ismail
- Department of Human Physiology, Faculty of Basic Health Sciences, Al - Istiqama University, Nigeria; Department of Human Physiology, Faculty of Basic Medical Sciences, Bayero University, Nigeria
| | - Salisu Ahmed Ibrahim
- Department of Human Physiology, Faculty of Basic Medical Sciences, Bayero University, Nigeria
| | - Mahdi Dissi Gambo
- Department of Human Physiology, Faculty of Basic Medical Sciences, Bayero University, Nigeria
| | - Ramlah Farouq Muhammad
- Department of Human Physiology, Faculty of Basic Medical Sciences, Yusuf Maitama Sule University Kano, Nigeria
| | | | - Ibrahim Sulaiman
- Department of Human Physiology, Faculty of Basic Medical Sciences, Bayero University, Nigeria; Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados.
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Zhao C, Du M, Yang J, Guo G, Wang L, Yan Y, Li X, Lei M, Chen T. Changes in arsenic accumulation and metabolic capacity after environmental management measures in mining area. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 855:158652. [PMID: 36108864 DOI: 10.1016/j.scitotenv.2022.158652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 06/15/2023]
Abstract
Due to the public health concern of arsenic, environmental management measures in mining areas had been implemented. To assess the effect of environmental management measures in the mining area comprehensively, arsenic accumulation in the urine, hair, nails, and urinary metabolites of residents in a realgar mining area in Hunan province, China were investigated in 2019, and the changes in arsenic levels in the biomarkers during 2012-2019 were tracked. The importance of confounding factors (age, sex, occupation, residence, clinical history, vegetable source, cooking fuel, smoking, alcohol consumption, BMI) was analyzed using the Boruta algorithm. After the implementation of environmental management measures (including ceasing mining and smelting activities, building landfills, adjusting the planting structure, and soil restoration), urine, hair, and nail arsenic concentration decreased drastically but were still excessive. Arsenic accumulation was highest in older male miners who were long settled in the mining area and consumed homegrown vegetables. The only factor for changes in urinary arsenic levels was the cooking fuel type; residents using wood as cooking fuel experienced sustained arsenic exposure. Occupation and sex were important for determining arsenic changes in the hair and nails. Short-term arsenic accumulation in urine was affected by arsenic exposure, while long-term accumulation in hair and nails by arsenic metabolic capacity. The percentage of urinary arsenic metabolism and arsenic methylation indices of the participants in the mining area were within the normal range (%iAs: 10-30 %, %MMA: 10-20 %, % DMA: 60-80 %); samples indicated worse metabolic capacity than the reference population. The arsenic metabolic capacity of male miners was relatively weak, probably aggravated by alcohol drinking and smoking. Without soil remediation, arsenic exposure will continue. Homegrown vegetables and biomass fuels should be abandoned; reduced cigarette and alcohol consumption is recommended. Urinary arsenic would be more proper for assessing environmental remediation in mining areas.
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Affiliation(s)
- Chen Zhao
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China
| | - Meng Du
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jun Yang
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Guanghui Guo
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China
| | - Lingqing Wang
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China
| | - Yunxian Yan
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Xuewen Li
- Shandong University, School of Public Health, Jinan, Shandong, China
| | - Mei Lei
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Tongbin Chen
- Center for Environmental Remediation, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
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Ranzani OT, Bhogadi S, Milà C, Kulkarni B, Balakrishnan K, Sambandam S, Garcia-Aymerich J, Marshall JD, Kinra S, Tonne C. Association of ambient and household air pollution with lung function in young adults in an peri-urban area of South-India: A cross-sectional study. ENVIRONMENT INTERNATIONAL 2022; 165:107290. [PMID: 35594814 DOI: 10.1016/j.envint.2022.107290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/04/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Although there is evidence for the association between air pollution and decreased lung function in children, evidence for adolescents and young adults is scarce. For a peri-urban area in India, we evaluated the association of ambient PM2.5 and household air pollution with lung function for young adults who had recently attained their expected maximum lung function. METHODS We measured, using a standardized protocol, forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) in participants aged 20-26 years from the third follow-up of the population-based APCAPCS cohort (2010-2012) in 28 Indian villages. We estimated annual average PM2.5outdoors at residence using land-use regression. Biomass cooking fuel (a proxy for levels of household air pollution) was self-reported. We fitted a within-between linear-mixed model with random intercepts by village, adjusting for potential confounders. RESULTS We evaluated 1,044 participants with mean age of 22.8 (SD = 1) years (range 20-26 years); 327 participants (31%) were female. Only males reported use of tobacco smoking (9% of all participants, 13% of males). The mean ambient PM2.5 exposure was 32.9 (SD = 2.8) µg/m3; 76% reported use of biomass as cooking fuel. The adjusted association between 1 µg/m3 increase in PM2.5 was -27 ml (95% CI, -89 to 34) for FEV1 and -5 ml (95% CI, -93 to 76) for FVC. The adjusted association between use of biomass was -112 ml (95% CI, -211 to -13) for FEV1 and -142 ml (95% CI, -285 to 0) for FVC. The adjusted association was of greater magnitude for those with unvented stove (-158 ml, 95% CI, -279 to -36 for FEV1 and -211 ml, 95% CI, -386 to -36 for FVC). CONCLUSIONS We observed negative associations between ambient PM2.5 and household air pollution and lung function in young adults who had recently attained their maximum lung function.
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Affiliation(s)
- Otavio T Ranzani
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain; CIBER Epidemiología y Salud Pública, Madrid, Spain
| | | | - Carles Milà
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain; CIBER Epidemiología y Salud Pública, Madrid, Spain
| | - Bharati Kulkarni
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra University (SRU), Chennai, India
| | - Sankar Sambandam
- Department of Environmental Health Engineering, Sri Ramachandra University (SRU), Chennai, India
| | - Judith Garcia-Aymerich
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain; CIBER Epidemiología y Salud Pública, Madrid, Spain
| | - Julian D Marshall
- Department of Civil and Environmental Engineering, University of Washington, Seattle, WA, USA
| | - Sanjay Kinra
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Cathryn Tonne
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra, Barcelona, Spain; CIBER Epidemiología y Salud Pública, Madrid, Spain.
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Stapleton EM, Welch JL, Ubeda EA, Xiang J, Zabner J, Thornell IM, Nonnenmann MW, Stapleton JT, Comellas AP. Urban particulate matter impairs airway-surface-liquid-mediated coronavirus inactivation. J Infect Dis 2021; 225:214-218. [PMID: 34734257 PMCID: PMC8689861 DOI: 10.1093/infdis/jiab545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/21/2021] [Indexed: 11/14/2022] Open
Abstract
Air pollution particulate matter (PM) is associated with SARS-CoV-2 infection and severity, although mechanistic studies are lacking. We tested whether airway surface liquid (ASL) from primary human airway epithelial cells is antiviral against SARS-CoV-2 and human alphacoronavirus 229E (CoV-229E) (responsible for common colds), and whether PM (urban, indoor air pollution [IAP], volcanic ash) affected ASL antiviral activity. ASL inactivated SARS-CoV-2 and CoV-229E. Independently, urban PM also decreased SARS-CoV-2 and CoV-229E infection, and IAP PM decreased CoV-229E infection. However, in combination, urban PM impaired ASL’s antiviral activity against both viruses, and the same effect occurred for IAP PM and ash against SARS-CoV-2, suggesting that PM may enhance SARS-CoV-2 infection.
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Affiliation(s)
- Emma M Stapleton
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Division of Pulmonary, Critical Care and Occupational Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Correspondence: Emma M. Stapleton, 6310F Pappajohn Biomedical Discovery Bldg, 169 Newton Rd, Iowa City, IA 52242 ()
| | - Jennifer L Welch
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Iowa City VA Health Care System, Iowa City, Iowa, USA
- Present affiliation: Animal and Plant Health Inspection Service, US Department of Agriculture, Ames, Iowa
| | - Erika A Ubeda
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jinhua Xiang
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Joseph Zabner
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Division of Pulmonary, Critical Care and Occupational Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Ian M Thornell
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Division of Pulmonary, Critical Care and Occupational Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Matthew W Nonnenmann
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jack T Stapleton
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Alejandro P Comellas
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Division of Pulmonary, Critical Care and Occupational Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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