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Ledger EL, Smith DJ, Teh JJ, Wood ME, Whibley PE, Morrison M, Goldberg JB, Reid DW, Wells TJ. Impact of CFTR Modulation on Pseudomonas aeruginosa Infection in People With Cystic Fibrosis. J Infect Dis 2024; 230:e536-e547. [PMID: 38442240 PMCID: PMC11420785 DOI: 10.1093/infdis/jiae051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Pseudomonas aeruginosa is a multidrug-resistant pathogen causing recalcitrant pulmonary infections in people with cystic fibrosis (pwCF). Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have been developed that partially correct the defective chloride channel driving disease. Despite the many clinical benefits, studies in adults have demonstrated that while P. aeruginosa sputum load decreases, chronic infection persists. Here, we investigate how P. aeruginosa in pwCF may change in the altered lung environment after CFTR modulation. METHODS P. aeruginosa strains (n = 105) were isolated from the sputum of 11 chronically colonized pwCF at baseline and up to 21 months posttreatment with elexacaftor-tezacaftor-ivacaftor or tezacaftor-ivacaftor. Phenotypic characterization and comparative genomics were performed. RESULTS Clonal lineages of P. aeruginosa persisted after therapy, with no evidence of displacement by alternative strains. We identified commonly mutated genes among patient isolates that may be positively selected for in the CFTR-modulated lung. However, classic chronic P. aeruginosa phenotypes such as mucoid morphology were sustained, and isolates remained just as resistant to clinically relevant antibiotics. CONCLUSIONS Despite the clinical benefits of CFTR modulators, clonal lineages of P. aeruginosa persist that may prove just as difficult to manage in the future, especially in pwCF with advanced lung disease.
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Affiliation(s)
- Emma L Ledger
- Frazer Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Daniel J Smith
- Northside Clinical Unit, The University of Queensland, Brisbane, Australia
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Jing Jie Teh
- Frazer Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Michelle E Wood
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Page E Whibley
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Mark Morrison
- Frazer Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, Brisbane, Australia
| | - Joanna B Goldberg
- Department of Pediatrics, Division of Pulmonary, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David W Reid
- Northside Clinical Unit, The University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, Brisbane, Australia
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Timothy J Wells
- Frazer Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Australian Infectious Diseases Research Centre, Brisbane, Australia
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Hampton TH, Barnaby R, Roche C, Nymon A, Fukutani KF, MacKenzie TA, Stanton BA. Gene expression responses of CF airway epithelial cells exposed to elexacaftor/tezacaftor/ivacaftor (ETI) suggest benefits beyond improved CFTR channel function. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.08.28.610162. [PMID: 39257747 PMCID: PMC11383677 DOI: 10.1101/2024.08.28.610162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
The combination of elexacaftor/tezacaftor/ivacaftor (ETI, Trikafta) reverses the primary defect in Cystic Fibrosis (CF) by improving CFTR mediated Cl - and HCO 3 - secretion by airway epithelial cells (AEC), leading to improved lung function and less frequent exacerbations and hospitalizations. However, studies have shown that CFTR modulators like ivacaftor, a component of ETI, has numerous effects on CF cells beyond improved CFTR channel function. Because little is known about the effect of ETI on CF AEC gene expression we exposed primary human AEC to ETI for 48 hours and interrogated the transcriptome by RNA-seq and qPCR. ETI increased defensin gene expression ( DEFB1 ) an observation consistent with reports of decreased bacterial burden in the lungs of people with CF (pwCF). ETI also decreased MMP10 and MMP12 gene expression, suggesting that ETI may reduce proteolytic induced lung destruction in CF. ETI also reduced the expression of the stress response gene heme oxygenase ( HMOX1 ). qPCR analysis confirmed DEFB1, HMOX1, MMP10 and MMP12 gene expression results observed by RNA-seq. Gene pathway analysis revealed that ETI decreased inflammatory signaling, cellular proliferation and MHC Class II antigen presentation. Collectively, these findings suggest that the clinical observation that ETI reduces lung infections in pwCF is related in part to drug induced increases in DEFB1 , and that ETI may reduce lung damage by reducing MMP10 and MMP12 gene expression, which is predicted to reduce matrix metalloprotease activity. Moreover, pathway analysis also identified several genes responsible for the ETI induced reduction in inflammation observed in people with CF. New and Noteworthy Gene expression responses by CF AEC exposed to ETI suggest that in addition to improving CFTR channel function, ETI is likely to increase resistance to bacterial infection by increasing levels of beta defensin 1 (hBD-1). ETI may also reduce lung damage by suppressing MMP10, and reduce airway inflammation by repressing proinflammatory cytokine secretion by AEC cells.
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Armbruster CR, Hilliam YK, Zemke AC, Atteih S, Marshall CW, Moore J, Koirala J, Krainz L, Gaston JR, Lee SE, Cooper VS, Bomberger JM. Persistence and evolution of Pseudomonas aeruginosa following initiation of highly effective modulator therapy in cystic fibrosis. mBio 2024; 15:e0051924. [PMID: 38564694 PMCID: PMC11077959 DOI: 10.1128/mbio.00519-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Today, more than 90% of people with cystic fibrosis (pwCF) are eligible for the highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy called elexacaftor/tezacaftor/ivacaftor (ETI) and its use is widespread. Given the drastic respiratory symptom improvement experienced by many post-ETI, clinical studies are already underway to reduce the number of respiratory therapies, including antibiotic regimens, that pwCF historically relied on to combat lung disease progression. Early studies suggest that bacterial burden in the lungs is reduced post-ETI, yet it is unknown how chronic Pseudomonas aeruginosa populations are impacted by ETI. We found that pwCF remain infected throughout their upper and lower respiratory tract with their same strain of P. aeruginosa post-ETI, and these strains continue to evolve in response to the newly CFTR-corrected airway. Our work underscores the continued importance of CF airway microbiology in the new era of highly effective CFTR modulator therapy. IMPORTANCE The highly effective cystic fibrosis transmembrane conductance regulator modulator therapy Elexakaftor/Tezacaftor/Ivacaftor (ETI) has changed cystic fibrosis (CF) disease for many people with cystic fibrosis. While respiratory symptoms are improved by ETI, we found that people with CF remain infected with Pseudomonas aeruginosa. How these persistent and evolving bacterial populations will impact the clinical manifestations of CF in the coming years remains to be seen, but the role and potentially changing face of infection in CF should not be discounted in the era of highly effective modulator therapy.
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Affiliation(s)
- Catherine R. Armbruster
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Microbiology and Immunology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Yasmin K. Hilliam
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Microbiology and Immunology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Anna C. Zemke
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samar Atteih
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - John Moore
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Junu Koirala
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Leah Krainz
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jordan R. Gaston
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stella E. Lee
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vaughn S. Cooper
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer M. Bomberger
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Microbiology and Immunology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
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Burgel PR, Ballmann M, Drevinek P, Heijerman H, Jung A, Mainz JG, Peckham D, Plant BJ, Schwarz C, Taccetti G, Smyth A. Considerations for the use of inhaled antibiotics for Pseudomonas aeruginosa in people with cystic fibrosis receiving CFTR modulator therapy. BMJ Open Respir Res 2024; 11:e002049. [PMID: 38702073 PMCID: PMC11086488 DOI: 10.1136/bmjresp-2023-002049] [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: 09/01/2023] [Accepted: 04/11/2024] [Indexed: 05/06/2024] Open
Abstract
The major cause of mortality in people with cystic fibrosis (pwCF) is progressive lung disease characterised by acute and chronic infections, the accumulation of mucus, airway inflammation, structural damage and pulmonary exacerbations. The prevalence of Pseudomonas aeruginosa rises rapidly in the teenage years, and this organism is the most common cause of chronic lung infection in adults with cystic fibrosis (CF). It is associated with an accelerated decline in lung function and premature death. New P. aeruginosa infections are treated with antibiotics to eradicate the organism, while chronic infections require long-term inhaled antibiotic therapy. The prevalence of P. aeruginosa infections has decreased in CF registries since the introduction of CF transmembrane conductance regulator modulators (CFTRm), but clinical observations suggest that chronic P. aeruginosa infections usually persist in patients receiving CFTRm. This indicates that pwCF may still need inhaled antibiotics in the CFTRm era to maintain long-term control of P. aeruginosa infections. Here, we provide an overview of the changing perceptions of P. aeruginosa infection management, including considerations on detection and treatment, the therapy burden associated with inhaled antibiotics and the potential effects of CFTRm on the lung microbiome. We conclude that updated guidance is required on the diagnosis and management of P. aeruginosa infection. In particular, we highlight a need for prospective studies to evaluate the consequences of stopping inhaled antibiotic therapy in pwCF who have chronic P. aeruginosa infection and are receiving CFTRm. This will help inform new guidelines on the use of antibiotics alongside CFTRm.
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Affiliation(s)
- Pierre-Régis Burgel
- Université Paris Cité, Institut Cochin, Inserm U1016, Paris, France
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- ERN-lung CF Network, Frankfurt, Germany
| | - Manfred Ballmann
- Kinder- und Jugendklinik der Universitätsmedizin Rostock, Rostock, Germany
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Harry Heijerman
- Department of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andreas Jung
- Division of Respiratory Medicine, University Children's Hospital, Zurich, Switzerland
| | - Jochen G Mainz
- Medizinische Hochschule Brandenburg (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Daniel Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Barry J Plant
- Cork Adult Cystic Fibrosis Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Carsten Schwarz
- HMU-Health and Medical University Potsdam, Internal Medicine and Pneumology, Clinic Westbrandenburg, Division of Cystic Fibrosis, CF Center Westbrandenburg, Campus Potsdam, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Department of Paediatric Medicine, Florence, Italy
| | - Alan Smyth
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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Dittrich AM, Sieber S, Naehrlich L, Burkhart M, Hafkemeyer S, Tümmler B. Use of elexacaftor/tezacaftor/ivacaftor leads to changes in detection frequencies of Staphylococcus aureus and Pseudomonas aeruginosa dependent on age and lung function in people with cystic fibrosis. Int J Infect Dis 2024; 139:124-131. [PMID: 38036261 DOI: 10.1016/j.ijid.2023.11.013] [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: 07/20/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES The impressive improvements of cystic fibrosis (CF) transmembrane conductance regulator (CFTR) function by elexacaftor/tezacaftor/ivacaftor (ETI) result in changes in the detection frequencies of Staphylococcus aureus (SA) and Pseudomonas aeruginosa (PA). We assessed determinants of the response to ETI with regards to SA and PA detection frequencies as documented in the German CF registry for people with CF (pwCF) ≥12 years. METHODS We evaluated changes in the detection frequencies of SA and PA for 21 months before and after initiation of ETI and used different statistical tests to identify determinants of detection changes. RESULTS We included data from 1092 pwCF with results from culture-dependent diagnostics for SA and PA detection from 7944 microbiological samples before and 6.845 microbiological samples after initiation of ETI. Detections of SA decreased from 54.3% to 44.3% and 40.2% and those of PA from 39.9% to 31.9% and 22.6% 3 and 21 months after initiation of therapy, respectively (all P <0.001). Reduction of SA and PA were observed in throat swabs and sputa, associated significantly with age, previous lung function, and were dependent on pre-ETI colonization status. CONCLUSIONS The different patterns of reductions of SA and PA suggest that pathogen-specific biological processes govern the responsiveness of microbiological colonization towards ETI in pwCF.
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Affiliation(s)
- Anna-Maria Dittrich
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany.
| | - Sarah Sieber
- STAT-UP Statistical Consulting & Data Science GmbH, Munich, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany; Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | | | | | - Burkhard Tümmler
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
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6
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Xu W, Wu T, Zhou Z, Zuo Z. Efficacy and safety profile of elexacaftor-tezacaftor-ivacaftor triple therapy on cystic fibrosis: a systematic review and single arm meta-analysis. Front Pharmacol 2023; 14:1275470. [PMID: 38186649 PMCID: PMC10768559 DOI: 10.3389/fphar.2023.1275470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background: Elexacaftor-Tezacaftor-Ivacaftor (ELE/TEZ/IVA) is believed to be an effective and well-tolerated treatment for cystic fibrosis (CF), but the exact efficacy and safety profile are still unknown. Objective: This study aimed to clarify the extent of functional restoration when patients are given with triple combination treatment and demonstrate the prevalence of adverse events, to evaluate the overall profile of ELE/TEZ/IVA on CF. Methods: A literature search was conducted in PubMed, Web of Science and Cochrane Library. Random effects single-arm meta-analysis was performed to decipher the basal characteristics of CF, the improvement and safety profile after ELE/TEZ/IVA treatment. Results: A total 53 studies were included in this analysis. For all the patients in included studies. 4 weeks after ELE/TEZ/IVA treatment, the increasement of percentage of predicted Forced Expiratory Volume in the first second (ppFEV1) was 9.23% (95%CI, 7.77%-10.70%), the change of percentage of predicted Forced Vital Capacity (ppFVC) was 7.67% (95%CI, 2.15%-13.20%), and the absolute change of Cystic Fibrosis Questionnaire-Revised (CFQ-R) score was 21.46 points (95%CI, 18.26-24.67 points). The Sweat chloride (SwCl) was significantly decreased with the absolute change of -41.82 mmol/L (95%CI, -44.38 to -39.25 mmol/L). 24 weeks after treatment, the increasement of ppFEV1 was 12.57% (95%CI, 11.24%-13.90%), the increasement of ppFVC was 10.44% (95%CI, 7.26%-13.63%), and the absolute change of CFQ-R score was 19.29 points (95%CI, 17.19-21.39 points). The SwCl was significantly decreased with the absolute change of -51.53 mmol/L (95%CI, -56.12 to -46.94 mmol/L). The lung clearance index2.5 (LCI2.5) was also decreased by 1.74 units (95%CI, -2.42 to -1.07 units). The body mass index increased by 1.23 kg/m2 (95%CI, 0.89-1.57 kg/m2). As for adverse events, 0.824 (95%CI, 0.769-0.879) occurred during ELE/TEZ/IVA period, while the incidence of severe adverse events was 0.066 (95%CI, 0.028-0.104). Conclusion: ELE/TEZ/IVA is a highly effective strategy and relatively safe for CF patients and needs to be sustained to achieve better efficacy. Systematic Review Registration: Identifier: CRD42023441840.
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Affiliation(s)
- Wenye Xu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Molecular Precision Medicine, Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ting Wu
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zijing Zhou
- Department of Cardiovascular Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhihong Zuo
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Molecular Precision Medicine, Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Hebestreit H, Thornton CS. Cystic fibrosis and the cardiovascular system: the unexpected heartache. Eur Respir J 2023; 62:2301253. [PMID: 37884293 DOI: 10.1183/13993003.01253-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 10/28/2023]
Affiliation(s)
| | - Christina S Thornton
- Division of Respirology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Tunney MM, Wark P. Long-term therapy with elexacaftor/tezacaftor/ivacaftor (ETI) in cystic fibrosis: improved clinical outcomes but infection and inflammation persist. Eur Respir J 2023; 62:2301008. [PMID: 37536727 DOI: 10.1183/13993003.01008-2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Michael M Tunney
- Halo Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Peter Wark
- College of Health Medicine and Wellbeing, University of Newcastle, New Lambton, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, Australia
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Rademacher J, Martin L, Theloe A, Stahl M, Mall MA, Joean O, Fuge J, Hansen G, Welte T, Schütz K, Ringshausen FC, Dittrich AM. Optimal treatment of the underlying aetiology is the most effective antimicrobial stewardship for chronic respiratory disease: a lesson learned from cystic fibrosis. ERJ Open Res 2023; 9:00356-2023. [PMID: 37650087 PMCID: PMC10463032 DOI: 10.1183/23120541.00356-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/25/2023] [Indexed: 09/01/2023] Open
Abstract
AMS in chronic lung disease can be challenging. Causal treatment of treatable traits may be the most successful AMS strategy for patients with any chronic pulmonary disease and should be brought into focus. https://bit.ly/3ptrmV8.
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Affiliation(s)
- Jessica Rademacher
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Luise Martin
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZL, associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité – Universitätsmedizin Berlin, corporate member of Freie Universitaet Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Mirjam Stahl
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZL, associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus A. Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZL, associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Oana Joean
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Gesine Hansen
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Katharina Schütz
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Felix C. Ringshausen
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
- European Reference Network on Rare and Complex Respiratory Diseases (ERN-LUNG), Frankfurt, Germany
- These authors contributed equally
| | - Anna M. Dittrich
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- These authors contributed equally
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