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Xu J, Li J, Wang X, An Y, Liu W, Luo R, Sun C. IRF4 Knockdown Inhibits the Chronic Rhinosinusitis Without Nasal Polyps Development by Regulating NLRP3/Caspase-1/GSDMD-Mediated Pyroptosis. Biochem Genet 2024:10.1007/s10528-024-10792-8. [PMID: 38635014 DOI: 10.1007/s10528-024-10792-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/21/2024] [Indexed: 04/19/2024]
Abstract
Chronic rhinosinusitis without nasal polyps (CRSsNP) is a CRS phenotype. However, the mechanisms of CRSsNP remains unclear. Differentially expressed genes (DEGs) were obtained from the GSE36830 and GSE198950 datasets through the GEO2R tool. The six hub genes were screened by the protein-protein interaction (PPI) network analysis and Cytoscape software. Then we constructed the mouse models of CRS and verified the expression levels of hub genes by reverse transcription quantitative PCR (RT-qPCR). Hematoxylin-eosin (HE) staining was employed to observe pathological alterations in mouse tissues. Casepase-3 expression was detected by immunohistochemistry (IHC). The levels of TNF-α, IL-12, IL-6, IL-1β, LDH, and IL-18 were evaluated using enzyme-linked immunosorbent assay (ELISA). Pyroptosis-related protein expressions were measured by western blotting. Cell counting kit-8 (CCK-8) and flow cytometry were performed to assess the proliferation and apoptosis of lipopolysaccharide (LPS)-induced NP69 cells. Six hub DEGs were identified. The expression levels of IRF4, IKZF1, and CD79A were obviously increased in CRSsNP, while those of ADH6, ADH1A, and LDHC were significantly decreased. IRF4 knockdown attenuated the pathologic features of CRSsNP. IRF4 knockdown reduced levels of the TNF-α, IL-12, IL-6 IL-1β, LDH, and IL-18 as well as the proteins expression of Casepase-1, GSDMD, and NLRP3 both in vivo and in vitro, implying that inflammation and pyroptosis were inhibited. IRF4 knockdown hinders the development of CRSsNP by inhibiting the inflammatory response and NLRP3/Caspase-1/GSDMD-mediated pyroptosis, which offers novel promising treatment strategies for clinical intervention.
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Affiliation(s)
- Jun Xu
- Department of Otorhinolaryngology, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, No. 9, Jinsui Road, Guangzhou, 510623, China.
| | - Jiahui Li
- Department of Otorhinolaryngology, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, No. 9, Jinsui Road, Guangzhou, 510623, China
| | - Xiaoya Wang
- Department of Otorhinolaryngology, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, No. 9, Jinsui Road, Guangzhou, 510623, China
| | - Yunsong An
- Department of Otolaryngology-Head and Neck Surgery, Guangdong Provincial People's Hospital, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Wenlong Liu
- Department of Otorhinolaryngology, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, No. 9, Jinsui Road, Guangzhou, 510623, China
| | - Renzhong Luo
- Department of Otorhinolaryngology, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, No. 9, Jinsui Road, Guangzhou, 510623, China
| | - Changzhi Sun
- Department of Otorhinolaryngology, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou, No. 9, Jinsui Road, Guangzhou, 510623, China.
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Brar T, McCabe C, Miglani A, Marino M, Lal D. Tissue Eosinophilia is Superior to an Analysis by Polyp Status for the Chronic Rhinosinusitis Transcriptome: An RNA Study. Laryngoscope 2023; 133:2480-2489. [PMID: 36594502 DOI: 10.1002/lary.30544] [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: 09/01/2022] [Revised: 11/29/2022] [Accepted: 12/11/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE RNA sequencing (transcriptomics) is used to study biological pathways. However, the yield of data depends on comparing well-characterized cohorts. We compared tissue eosinophilia versus nasal polyp (NP) status as the metric to characterize transcriptomic mechanisms at play in eosinophilic and non-eosinophilic chronic rhinosinusitis (CRS) versus controls. METHODS RNA sequencing was conducted on sinonasal tissue samples of CRS and controls. Analyses were conducted based on polyp status [with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP)] as well as tissue eosinophil levels per high power field (eos/hpf)[non-eosinophilic (<10 eos/hpf, neCRS) or eosinophilic (≥10 eos/hpf, eCRS)]. The yield of differentially expressed genes (DEGs) and biological pathways through Ingenuity Pathway Analysis (IPA) were compared. RESULTS CRS tissue differed from controls by 736 statistically significant DEGs. Both NP status and tissue eosinophilia were effective in differentiating CRS from controls and into two distinct subgroups. Statistically significant DEGs identified when comparing CRS by NP status were 60, whereas 110 DEGs were identified using eosinophil cutoff ≥10 and <10 eos/hpf. Additionally, heatmaps showed greater homogeneity within each CRS subgroup when analyzed by tissue eosinophilia versus NP status. On IPA, the IL-17 signaling pathway was significantly different only by tissue eosinophilia status, not NP status, being higher in CRS <10 eos/hpf. CONCLUSION Tissue eosinophilia is superior to an analysis by NP status for the study of CRS transcriptome by RNA sequencing in identifying DEGs. Classification of CRS samples by eosinophil counts agnostic of NP status may offer advantageous insights into CRS pathogenetic mechanisms. LEVEL OF EVIDENCE 3 Laryngoscope, 133:2480-2489, 2023.
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Affiliation(s)
- Tripti Brar
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Phoenix, Arizona, USA
| | - Chantal McCabe
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Amar Miglani
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Phoenix, Arizona, USA
| | - Michael Marino
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Phoenix, Arizona, USA
| | - Devyani Lal
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Phoenix, Arizona, USA
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Kato A, Schleimer RP, Bleier BS. Mechanisms and pathogenesis of chronic rhinosinusitis. J Allergy Clin Immunol 2022; 149:1491-1503. [PMID: 35245537 PMCID: PMC9081253 DOI: 10.1016/j.jaci.2022.02.016] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/07/2022] [Accepted: 02/18/2022] [Indexed: 11/19/2022]
Abstract
Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by local inflammation of the upper airways and is historically divided into 2 main phenotypes: CRS with nasal polyps and CRS without nasal polyps. Inflammation in CRS is mainly characterized by 3 endotypes based on elevation of canonical lymphocyte cytokines: type (T) 1 (T1) by TH1 cytokine IFN-γ, T2 by TH2 cutokines IL-4, IL-5, and IL-13, and T3 by TH17 cytokines including IL-17. Inflammation in both CRS without nasal polyps and CRS with nasal polyps is highly heterogeneous, and the frequency of various endotypes varies geographically around the world. This finding complicates establishment of a unified understanding of the mechanisms of pathogenesis in CRS. Sinonasal epithelium acts as a passive barrier, and epithelial barrier dysfunction is a common feature in CRS induced by endotype-specific cytokines directly and indirectly. The sinonasal epithelium also participates in both innate immunity via recognition by innate pattern-recognition receptors and promotes and regulates adaptive immunity via release of chemokines and innate cytokines including thymic stromal lymphopoietin. The purpose of this review was to discuss the contribution of the epithelium to CRS pathogenesis and to update the field regarding endotypic heterogeneity and various mechanisms for understanding pathogenesis in CRS.
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Affiliation(s)
- Atsushi Kato
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago.
| | - Robert P Schleimer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago
| | - Benjamin S Bleier
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston
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Kato A, Peters AT, Stevens WW, Schleimer RP, Tan BK, Kern RC. Endotypes of chronic rhinosinusitis: Relationships to disease phenotypes, pathogenesis, clinical findings, and treatment approaches. Allergy 2022; 77:812-826. [PMID: 34473358 PMCID: PMC9148187 DOI: 10.1111/all.15074] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/25/2021] [Indexed: 02/06/2023]
Abstract
Chronic rhinosinusitis (CRS) is a common clinical syndrome that produces significant morbidity and costs to our health system. The study of CRS has progressed from an era focused on phenotype to include endotype-based information. Phenotypic classification has identified clinical heterogeneity in CRS based on endoscopically observed features such as presence of nasal polyps, presence of comorbid or systemic diseases, and timing of disease onset. More recently, laboratory-based findings have established CRS endotype based upon specific mechanisms or molecular biomarkers. Understanding the basis of widespread heterogeneity in the manifestations of CRS is advanced by findings that the three main endotypes, Type 1, 2, and 3, orchestrate the expression of three distinct large sets of genes. The development and use of improved methods of endotyping disease in the clinic are ushering in an expansion of the use of biological therapies targeting Type 2 inflammation now and perhaps other inflammatory endotypes in the near future. The purpose of this review is to discuss the phenotypic and endotypic heterogeneity of CRS from the perspective of advancing the understanding of the pathogenesis and improvement of treatment approaches and outcomes.
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Affiliation(s)
- Atsushi Kato
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert P Schleimer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce K Tan
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert C Kern
- Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Wang H, Song J, Pan L, Deng Y, Yao Y, Wang Z, Liao B, Ma J, Zeng M, Liu Z. Regional differences in ACE2 expression in the sinonasal mucosa of adult Chinese patients with chronic rhinosinusitis. Allergy 2021; 76:1565-1568. [PMID: 33037637 PMCID: PMC7675498 DOI: 10.1111/all.14623] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Hai Wang
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Jia Song
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Li Pan
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Yi‐Ke Deng
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Yin Yao
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Zhi‐Chao Wang
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Bo Liao
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Jin Ma
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Ming Zeng
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Zheng Liu
- Department of Otolaryngology‐Head and Neck Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
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Carle TR, Wu TJ, Wung V, Suh JD, Wang MB, Wells CR, Rossetti M, Lee JT. Assessment of Biomarker Heterogeneity in Sinus Versus Inferior Turbinate Tissue in Patients Without Chronic Rhinosinusitis. Am J Rhinol Allergy 2021; 36:33-40. [PMID: 33910378 DOI: 10.1177/19458924211012808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Currently, no consensus exists on the appropriate control specimen site to utilize in studies evaluating for biomarkers in chronic rhinosinusitis (CRS). Studies thus far have utilized tissue from various anatomic sites despite regional heterogeneity. OBJECTIVE We set out to quantify the differences in biomarker levels present in inferior turbinate versus sphenoid sinus mucosa in paired healthy control patients. We hypothesize that statistically significant differences in cytokine/chemokine expression exist between these two distinct sites. METHODS A 38-plex commercially available cytokine/chemokine Luminex Assay was performed on 54 specimens encompassing paired inferior turbinate and sphenoid sinus mucosa samples from 27 patients undergoing endoscopic anterior skull base surgery. Patients with a history of CRS were excluded. Paired sample t-tests and Fisher's exact tests were performed. RESULTS Twenty-seven patients were included in the study, including 10 male and 17 female patients with an average age of 48 years. The following 8 biomarkers had statistically significant concentration differences between inferior turbinate mucosa and sphenoid mucosa sites: Flt-3L, Fractalkine, IL-12p40, IL-1Ra, IP-10, MCP-1, MIP-1β, and VEGF, with all P-values <0.01. CONCLUSION No consensus exists regarding the optimal choice of control specimen for CRS research. We present statistically significant quantitative differences in biomarker levels between paired inferior turbinate and sphenoid mucosa samples. This confirms the presence of heterogeneity between different subsites of sinonasal mucosa and highlights the need for standardization in future CRS research.
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Affiliation(s)
- Taylor R Carle
- Department of Head and Neck Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Tara J Wu
- Department of Head and Neck Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Vivian Wung
- David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Marilene B Wang
- Department of Head and Neck Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Christine R Wells
- Department of Biostatistics, UCLA Statistical Consulting Group, Los Angeles, California
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, UCLA Immunogenetics Center, Los Angeles, California
| | - Jivianne T Lee
- Department of Head and Neck Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
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Klingler AI, Stevens WW, Tan BK, Peters AT, Poposki JA, Grammer LC, Welch KC, Smith SS, Conley DB, Kern RC, Schleimer RP, Kato A. Mechanisms and biomarkers of inflammatory endotypes in chronic rhinosinusitis without nasal polyps. J Allergy Clin Immunol 2020; 147:1306-1317. [PMID: 33326802 DOI: 10.1016/j.jaci.2020.11.037] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) without nasal polyps (CRSsNP) is a common disease that is characterized by multiple inflammatory endotypes. However, the molecular mechanisms in CRSsNP are poorly understood compared with those of polypoid CRS. OBJECTIVE Our aim was to identify mechanisms and biomarkers associated with inflammatory endotypes underpinning CRSsNP. METHODS Ethmoid tissues and nasal lavage fluids (NLFs) were obtained from control patients and patients with CRS. The gene expression profiles were determined by microarray analysis and quantitative RT-PCR, and expression of proteins was measured by ELISA and Luminex analysis. RESULTS Microarray found that compared with their levels of expression in control tissue, the levels of expression of 126, 241, and 545 genes were more than 3-fold and significantly elevated in CRSsNP with type 1 (T1) endotype, type 2 (T2) endotype, and type 3 (T3) endotype, respectively. Selected identified genes were confirmed by RT-PCR. Gene set enrichment analysis suggested that T1 CRSsNP was associated with IFN-γ signaling and antiviral immunity controlled by T cells (TH1 and CD8+), natural killer cells, and antigen-presenting cells; T2 CRSsNP was associated with STAT6 signaling and IgE-mediated activation controlled by eosinophils, mast cells, TH2 cells, group 2 innate lymphoid cells, and antigen-presenting cells; and T3 CRSsNP was associated with IL-17 signaling, acute inflammatory response, complement-mediated inflammation, and infection controlled by neutrophils, TH17 cells, B cells, and antigen-presenting cells. The results suggest that T1 (CXCL9 and CXCL10), T2 (eosinophilic proteins and CCL26), and T3 (CSF3) endotypic biomarkers in NLF may be able to distinguish tissue endotypes in CRSsNP. CONCLUSIONS Inflammatory endotypes in CRSsNP were controlled by different molecular mechanisms. NLF biomarker assays may allow for more precise and personalized medical treatments in CRS.
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Affiliation(s)
- Aiko I Klingler
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Bruce K Tan
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Julie A Poposki
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Leslie C Grammer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Kevin C Welch
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Stephanie S Smith
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - David B Conley
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert C Kern
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert P Schleimer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Atsushi Kato
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Stevens WW, Staudacher AG, Hulse KE, Carter RG, Winter DR, Abdala-Valencia H, Kato A, Suh L, Norton JE, Huang JH, Peters AT, Grammer LC, Price CPE, Conley DB, Shintani-Smith S, Tan BK, Welch KC, Kern RC, Schleimer RP. Activation of the 15-lipoxygenase pathway in aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2020; 147:600-612. [PMID: 32371071 DOI: 10.1016/j.jaci.2020.04.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) is characterized by asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), and an intolerance of medications that inhibit cyclooxygenase-1. Patients with AERD have more severe upper and lower respiratory tract disease than do aspirin-tolerant patients with CRSwNP. A dysregulation in arachidonic acid metabolism is thought to contribute to the enhanced sinonasal inflammation in AERD. OBJECTIVE Our aim was to utilize an unbiased approach investigating arachidonic acid metabolic pathways in AERD. METHODS Single-cell RNA sequencing (10× Genomics, Pleasanton, Calif) was utilized to compare the transcriptional profile of nasal polyp (NP) cells from patients with AERD and patients with CRSwNP and map differences in the expression of select genes among identified cell types. Findings were confirmed by traditional real-time PCR. Lipid mediators in sinonasal tissue were measured by mass spectrometry. Localization of various proteins within NPs was assessed by immunofluorescence. RESULTS The gene encoding for 15-lipooxygenase (15-LO), ALOX15, was significantly elevated in NPs of patients with AERD compared to NPs of patients with CRSwNP (P < .05) or controls (P < .001). ALOX15 was predominantly expressed by epithelial cells. Expression levels significantly correlated with radiographic sinus disease severity (r = 0.56; P < .001) and were associated with asthma. The level of 15-oxo-eicosatetraenoic acid (15-Oxo-ETE), a downstream product of 15-LO, was significantly elevated in NPs from patients with CRSwNP (27.93 pg/mg of tissue) and NPs from patients with AERD (61.03 pg/mg of tissue) compared to inferior turbinate tissue from controls (7.17 pg/mg of tissue [P < .001]). Hydroxyprostaglandin dehydrogenase, an enzyme required for 15-Oxo-ETE synthesis, was predominantly expressed in mast cells and localized near 15-LO+ epithelium in NPs from patients with AERD. CONCLUSIONS Epithelial and mast cell interactions, leading to the synthesis of 15-Oxo-ETE, may contribute to the dysregulation of arachidonic acid metabolism via the 15-LO pathway and to the enhanced sinonasal disease severity observed in AERD.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Anna G Staudacher
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Kathryn E Hulse
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Roderick G Carter
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Deborah R Winter
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Hiam Abdala-Valencia
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Atsushi Kato
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Lydia Suh
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - James E Norton
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Julia H Huang
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Leslie C Grammer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Caroline P E Price
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - David B Conley
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | - Bruce K Tan
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Kevin C Welch
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert C Kern
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert P Schleimer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Staudacher AG, Peters AT, Kato A, Stevens WW. Use of endotypes, phenotypes, and inflammatory markers to guide treatment decisions in chronic rhinosinusitis. Ann Allergy Asthma Immunol 2020; 124:318-325. [PMID: 32007571 DOI: 10.1016/j.anai.2020.01.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/10/2020] [Accepted: 01/22/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE With the advent of new treatment options for Chronic Rhinosinusitis (CRS) comes the ability for physicians to provide more individualized patient care. Physicians are now tasked with identifying who may be the best candidate for a particular therapy. In this review, existing biomarkers and potentially new methods that could guide treatment choices in CRS patients will be discussed. DATA SOURCES Published literature obtained through PubMed searches. STUDY SELECTION Studies relevant to inflammatory endotypes, phenotypes, and biomarkers in CRS were included. RESULTS Currently, there are no clinically validated tools that determine the best therapeutic modality for CRS patients with or without nasal polyps (CRSwNP or CRSsNP). Patients with CRS can be classified into three endotypes based on the presence of type 1, type 2, or type 3 inflammation. CRS endotypes can be influenced by age and geographic location. Clinical application however may be limited since endotyping current requires basic research laboratory support. Clinical symptoms may also predict inflammatory endotypes with smell loss being indicative of type 2 inflammation. Numbers of tissue and/or peripheral eosinophils as well as levels of IgE may predict disease severity in CRSwNP but not necessarily treatment responses. Unique clinical phenotypes or biomarkers are especially lacking that predict type 1 or type 3 inflammation in CRSwNP or type 1, type 2, or type 3 inflammation in CRSsNP. CONCLUSION While significant progress has been made in characterizing endotypes, phenotypes, and biomarkers in CRS, additional studies are needed to determine if and how these factors could assist physicians in providing more individualized clinical care.
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Affiliation(s)
- Anna G Staudacher
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Atsushi Kato
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Cho DY, Hunter RC, Ramakrishnan VR. The Microbiome and Chronic Rhinosinusitis. Immunol Allergy Clin North Am 2020; 40:251-263. [PMID: 32278449 DOI: 10.1016/j.iac.2019.12.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Chronic rhinosinusitis (CRS) is persistent inflammation and/or infection of the nasal cavity and paranasal sinuses. Recent advancements in culture-independent molecular techniques have enhanced understanding of interactions between sinus microbiota and upper airway microenvironment. The dysbiosis hypothesis-alteration of microbiota associated with perturbation of the local ecological landscape-is suggested as a mechanism involved in CRS pathogenesis. This review discusses the complex role of the microbiota in health and in CRS and considerations in sinus microbiome investigation, dysbiosis of sinus microbiota in CRS, microbial interactions in CRS, and development of preclinical models. The authors conclude with future directions for CRS-associated microbiome research.
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Affiliation(s)
- Do-Yeon Cho
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, 1155 Faculty Office Tower, 510 20th Street South, Birmingham, AL 35233, USA; Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ryan C Hunter
- Department of Microbiology & Immunology, University of Minnesota, 3-115 Microbiology Research Facility, 689 23rd Avenue SE, Minneapolis, MN 55455, USA
| | - Vijay R Ramakrishnan
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado, 12631 East 17th Avenue, B205, Aurora, CO 80045, USA.
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11
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Wang H, Li ZY, Jiang WX, Liao B, Zhai GT, Wang N, Zhen Z, Ruan JW, Long XB, Wang H, Liu WH, Liang GT, Xu WM, Kato A, Liu Z. The activation and function of IL-36γ in neutrophilic inflammation in chronic rhinosinusitis. J Allergy Clin Immunol 2018; 141:1646-1658. [DOI: 10.1016/j.jaci.2017.12.972] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 11/25/2017] [Accepted: 12/06/2017] [Indexed: 11/28/2022]
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12
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Kim DK, Kang SI, Kong IG, Cho YH, Song SK, Hyun SJ, Cho SD, Han SY, Cho SH, Kim DW. Two-Track Medical Treatment Strategy According to the Clinical Scoring System for Chronic Rhinosinusitis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:490-502. [PMID: 30088369 PMCID: PMC6082823 DOI: 10.4168/aair.2018.10.5.490] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE The previously reported Japanese clinical scoring study (JESREC) suggests that chronic rhinosinusitis (CRS) can be divided into 4 subtypes according to the degree of eosinophilic CRS (ECRS) and offers the information regarding the prognosis of CRS to clinicians. However, this scoring system has not yet been validated by an immunological study and needs to provide treatment guidelines based on underlying immunologic profiles. We investigated the immunologic profile of each CRS subgroup according to the JESREC classification and suggest its clinical application. METHODS A total of 140 CRS patients and 20 control subjects were enrolled. All patients were classified into 4 groups according to the JESREC (non-, mild, moderate and severe ECRS). Nasal tissues were analyzed for mRNA expression of major cytokines (IL-5, IL-10, IL-13, IL-17A, IL-22, IL-23p19, IFN-γ, periostin, thymic stromal lymphopoietin [TSLP] and ST2), major chemokines (CCL11, CCL24, CXCL1 and CXCL2), transcription factors (T-bet, GATA3, RORC and FOXP3) and COL1A1 for type I collagen. Protein levels of 3 major cytokines (IL-5, IL-17A and IFN-γ) were also measured by multiplex immunoassay. Principal component analysis (PCA) was conducted to investigate the overall profile of multiple mediators. RESULTS The moderate/severe ECRS showed up-regulation of type 2-related mediators (IL-5, IL-13, periostin, TSLP and ST-2), whereas INF-γ (type 1 cytokine) and CXCL1 (neutrophil chemokine) expressions were increased in non-/mild ECRS compared with moderate/severe ECRS. The JESREC classification reflected an immunological endotype. In PCA data, PCA1 indicates a relative type 2 profile, whereas PCA2 represents a type 1/type 17-related profile. In this analysis, mild ECRS was indistinguishable from non-ECRS, whereas moderate to severe ECRS showed a distinct distribution compared with non-ECRS. The JESREC classification could be divided into 2 categories, non-/mild vs. moderate/severe ECRS based on underlying immunological analyses. CONCLUSIONS The CRS clinical scoring system from the JESREC study reflects an inflammatory endotype. However, the immunologic profile of mild ECRS was similar to that of non-ECRS. Therefore, we propose type 2-targeted medical treatment for moderate to severe ECRS and type 1/type 17-targeted for non-ECRS and mild ECRS as the first treatment option.
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Affiliation(s)
- Dong Kyu Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Seong Il Kang
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Il Gyu Kong
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Young Hoon Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Seul Ki Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Se Jin Hyun
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Dong Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Yoon Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Ho Cho
- Division of Allergy-Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Dae Woo Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.
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Homma T, Kato A, Sakashita M, Takabayashi T, Norton JE, Suh LA, Carter RG, Harris KE, Peters AT, Grammer LC, Min JY, Shintani-Smith S, Tan BK, Welch K, Conley DB, Kern RC, Schleimer RP. Potential Involvement of the Epidermal Growth Factor Receptor Ligand Epiregulin and Matrix Metalloproteinase-1 in Pathogenesis of Chronic Rhinosinusitis. Am J Respir Cell Mol Biol 2017; 57:334-345. [PMID: 28398769 DOI: 10.1165/rcmb.2016-0325oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a heterogeneous chronic inflammatory disease of the nose and paranasal sinuses that presents without or with nasal polyps (CRSwNP). Notable features of CRSwNP are the frequent presence of type 2 allergic inflammation and high prevalence of Staphylococcus aureus (SA) colonization. As inflammation persists, sinus tissue undergoes epithelial damage and repair along with polyp growth, despite active medical management. Because one feature of damaged tissue is enhancement of growth factor signaling, we evaluated the presence of epidermal growth factor receptor (EGFR) ligands and matrix metalloproteinases (MMPs) in CRS. The objectives of this study were to analyze the expression of EGFR ligands and MMPs in patients with CRS and to investigate the possible role of SA on epithelial activation. Sinonasal tissues were collected during surgery from control subjects and patients with CRS. Tissues were processed as described previously for analysis of mRNA (RT-PCR) and proteins (ELISA) for the majority of EGFR ligands within the tissue extracts. CRS tissue was used for evaluation of the distribution of epiregulin (EREG), an EGFR ligand, and MMP-1 by immunohistochemistry. In parallel studies, expression of these genes and proteins was analyzed in cultured primary airway epithelial cells. Elevated expression of EREG and MMP-1 mRNA and protein was observed in uncinate and polyp tissue from patients with CRSwNP. Immunohistochemistry study of clinical samples revealed that airway epithelial cells expressed both of these proteins. Cultured primary human airway epithelial cells expressed MMP-1, and MMP-1 was further induced by stimulation with EREG or heat-killed SA (HKSA). The induction of MMP-1 by HKSA was blocked by an antibody against EREG, suggesting that endogenous EREG induces MMP-1 after stimulation with HKSA. EREG and MMP-1 were found to be elevated in nasal polyp and uncinate tissues in patients with CRSwNP. Elevated expression of EREG and MMP-1 may be related to polyp formation in CRS, and colonization of SA might further enhance this process.
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Affiliation(s)
- Tetsuya Homma
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,2 Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Atsushi Kato
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Masafumi Sakashita
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,3 Division of Otorhinolaryngology Head and Neck Surgery, Department of Sensory and Locomotor Medicine, University of Fukui, Fukui, Japan; and
| | - Tetsuji Takabayashi
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,3 Division of Otorhinolaryngology Head and Neck Surgery, Department of Sensory and Locomotor Medicine, University of Fukui, Fukui, Japan; and
| | - James E Norton
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lydia A Suh
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Roderick G Carter
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kathleen E Harris
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anju T Peters
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leslie C Grammer
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jin-Young Min
- 4 Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Shintani-Smith
- 4 Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bruce K Tan
- 4 Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin Welch
- 4 Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David B Conley
- 4 Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert C Kern
- 4 Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert P Schleimer
- 1 Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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14
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Kim HK, Kook JH, Kang KR, Oh DJ, Kim TH, Lee SH. Increased expression of the aryl hydrocarbon receptor in allergic nasal mucosa, contributing to chemokine secretion in nasal epithelium. Am J Rhinol Allergy 2017; 30:107-12. [PMID: 27456584 DOI: 10.2500/ajra.2016.30.4311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pollutants produced by industrial and traffic-related activities have been linked to allergic responses. These noxious agents induce their effects through the aryl hydrocarbon receptor (AhR). OBJECTIVE We analyzed the expression and distribution pattern of AhR in normal and allergic nasal mucosa, and cytokine-driven regulation of its expression. The production levels of chemokine in cultured nasal epithelial cells were evaluated after stimulation with AhR ligand. METHODS The expression levels and distribution pattern of AhR in normal, mild, and moderate-severe persistent allergic nasal mucosa were assessed by using real-time polymerase chain reaction, Western blot, and immunohistochemistry. The expression levels of AhR were determined in cultured nasal epithelial cells treated with T-helper 2 cytokines. In cultured epithelial cells stimulated with 2-(10H-indole-30-carbonyl)-thiazole-4-carboxylic acid methyl ester, the expression levels of granulocyte macrophage colony-stimulating factor, thymus and activation regulated chemokine, macrophage inflammatory protein 1 α, monocyte chemotactic protein 1, regulated on activation normal T-cell expressed and secreted, eotaxin, and interleukin 8 were measured with real-time polymerase chain reaction and enzyme-linked immunosorbent assay. RESULTS Expression of AhR was observed in normal and allergic nasal mucosa where it is distributed in the epithelial layer, submucosal glands, endothelial cells, and inflammatory cells. Its expression levels are increased in allergic nasal mucosa and upregulated after stimulation with T-helper 2 cytokines. The stimulation with 2-(10H-indole-30-carbonyl)-thiazole-4-carboxylic acid methyl ester resulted in increased production of chemokines in cultured epithelial cells. CONCLUSION Analysis of the study results indicated that increased expression levels of AhR may play a role in the pathogenesis of allergic rhinitis, which contributes to chemokine production in nasal mucosa.
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Affiliation(s)
- Ha Kyun Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul, South Korea
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15
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Corren J. Inflammatory Disorders Associated with Allergy: Overview of Immunopathogenesis and Implications for Treatment. Immunol Allergy Clin North Am 2017; 37:233-246. [PMID: 28366474 DOI: 10.1016/j.iac.2017.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A number of chronic inflammatory diseases are associated with IgE-mediated immunologic hypersensitivity, including atopic dermatitis, chronic rhinosinusitis, and asthma. Pathogenetic studies of well-characterized patient groups has allowed investigators to more precisely define the molecular pathways involved in these diseases. Specific cytokines and chemokines, as well as other unique proteins, have now been identified in each of these common disorders and a number of medications are currently in development for inhibiting their actions. Continual refinement of our understanding of the pathogenesis of these diseases will undoubtedly yield increasingly precise, and potentially more effective, treatments.
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Affiliation(s)
- Jonathan Corren
- Department of Medicine, Section of Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, 10780 Santa Monica Boulevard, Suite 280, Los Angeles, CA 90025, USA.
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16
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Mahdavinia M, Keshavarzian A, Tobin MC, Landay AL, Schleimer RP. A comprehensive review of the nasal microbiome in chronic rhinosinusitis (CRS). Clin Exp Allergy 2016; 46:21-41. [PMID: 26510171 DOI: 10.1111/cea.12666] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chronic rhinosinusitis (CRS) has been known as a disease with strong infectious and inflammatory components for decades. The recent advancement in methods identifying microbes has helped implicate the airway microbiome in inflammatory respiratory diseases such as asthma and COPD. Such studies support a role of resident microbes in both health and disease of host tissue, especially in the case of inflammatory mucosal diseases. Identifying interactive events between microbes and elements of the immune system can help us to uncover the pathogenic mechanisms underlying CRS. Here we provide a review of the findings on the complex upper respiratory microbiome in CRS in comparison with healthy controls. Furthermore, we have reviewed the defects and alterations of the host immune system that interact with microbes and could be associated with dysbiosis in CRS.
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Affiliation(s)
- M Mahdavinia
- Allergy and Immunology Section, Department of Immunology and Microbiology, Rush University Medical Center, Chicago, IL, USA
| | - A Keshavarzian
- Division of Digestive Diseases and Nutrition, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - M C Tobin
- Allergy and Immunology Section, Department of Immunology and Microbiology, Rush University Medical Center, Chicago, IL, USA
| | - A L Landay
- Allergy and Immunology Section, Department of Immunology and Microbiology, Rush University Medical Center, Chicago, IL, USA
| | - R P Schleimer
- Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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17
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Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.
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Affiliation(s)
- Nsangou Ghogomu
- a Feinberg School of Medicine, Department of Otolaryngology, Head and Neck Surgery , Northwestern University , Chicago , IL , USA
| | - Robert Kern
- a Feinberg School of Medicine, Department of Otolaryngology, Head and Neck Surgery , Northwestern University , Chicago , IL , USA
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18
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Stevens WW, Schleimer RP, Kern RC. Chronic Rhinosinusitis with Nasal Polyps. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2016; 4:565-72. [PMID: 27393770 PMCID: PMC4939220 DOI: 10.1016/j.jaip.2016.04.012] [Citation(s) in RCA: 262] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/18/2016] [Accepted: 04/21/2016] [Indexed: 12/11/2022]
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is an important clinical entity diagnosed by the presence of both subjective and objective evidence of chronic sinonasal inflammation. Symptoms include anterior or posterior rhinorrhea, nasal congestion, hyposmia, and/or facial pressure or pain that last for a duration of more than 12 weeks. Nasal polyps are inflammatory lesions that project into the nasal airway, are typically bilateral, and originate from the ethmoid sinus. Males are more likely to be affected than females, but no specific genetic or environmental factors have been strongly linked to the development of this disorder to date. CRSwNP is frequently associated with asthma and allergic rhinitis, but the cellular and molecular mechanisms that contribute to the clinical symptoms are not fully understood. Defects in the sinonasal epithelial cell barrier, increased exposure to pathogenic and colonized bacteria, and dysregulation of the host immune system are all thought to play prominent roles in disease pathogenesis. Additional studies are needed to further explore the clinical and pathophysiological features of CRSwNP so that biomarkers can be identified and novel advances can be made to improve the treatment and management of this disease.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Robert P Schleimer
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert C Kern
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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19
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Stevens WW, Lee RJ, Schleimer RP, Cohen NA. Chronic rhinosinusitis pathogenesis. J Allergy Clin Immunol 2016; 136:1442-1453. [PMID: 26654193 DOI: 10.1016/j.jaci.2015.10.009] [Citation(s) in RCA: 226] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 02/07/2023]
Abstract
There are a variety of medical conditions associated with chronic sinonasal inflammation, including chronic rhinosinusitis (CRS) and cystic fibrosis. In particular, CRS can be divided into 2 major subgroups based on whether nasal polyps are present or absent. Unfortunately, clinical treatment strategies for patients with chronic sinonasal inflammation are limited, in part because the underlying mechanisms contributing to disease pathology are heterogeneous and not entirely known. It is hypothesized that alterations in mucociliary clearance, abnormalities in the sinonasal epithelial cell barrier, and tissue remodeling all contribute to the chronic inflammatory and tissue-deforming processes characteristic of CRS. Additionally, the host innate and adaptive immune responses are also significantly activated and might be involved in pathogenesis. Recent advancements in the understanding of CRS pathogenesis are highlighted in this review, with special focus placed on the roles of epithelial cells and the host immune response in patients with cystic fibrosis, CRS without nasal polyps, or CRS with nasal polyps.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert J Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Robert P Schleimer
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Noam A Cohen
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Philadelphia Veterans Affairs Medical Center, Surgical Service, Philadelphia, Pa; Monell Chemical Senses Center, Philadelphia, Pa
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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21
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Stevens WW, Ocampo CJ, Berdnikovs S, Sakashita M, Mahdavinia M, Suh L, Takabayashi T, Norton JE, Hulse KE, Conley DB, Chandra RK, Tan BK, Peters AT, Grammer LC, Kato A, Harris KE, Carter RG, Fujieda S, Kern RC, Schleimer RP. Cytokines in Chronic Rhinosinusitis. Role in Eosinophilia and Aspirin-exacerbated Respiratory Disease. Am J Respir Crit Care Med 2015; 192:682-94. [PMID: 26067893 DOI: 10.1164/rccm.201412-2278oc] [Citation(s) in RCA: 213] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE The mechanisms that underlie the pathogenesis of chronic rhinosinusitis without nasal polyps (CRSsNP), chronic rhinosinusitis with nasal polyps (CRSwNP), and aspirin-exacerbated respiratory disease (AERD) are not clear. OBJECTIVES To first evaluate the inflammatory profiles of CRSsNP and CRSwNP tissues and then to investigate whether clinical differences observed between CRSwNP and AERD are in part secondary to differences in inflammatory mediator expression within nasal polyp (NP) tissues. METHODS Expression levels of numerous inflammatory mediators were determined by quantitative real-time polymerase chain reaction, ELISA, and multiplex immunoassay. MEASUREMENTS AND MAIN RESULTS CRSwNP NP had increased levels of type 2 mediators, including IL-5 (P < 0.001), IL-13 (P < 0.001), eotaxin-2 (P < 0.001), and monocyte chemoattractant protein (MCP)-4 (P < 0.01), compared with sinonasal tissue from subjects with CRSsNP and control subjects. Expression of IFN-γ messenger RNA or protein was low and not different among the chronic rhinosinusitis subtypes examined. Compared with CRSwNP, AERD NP had elevated protein levels of eosinophil cationic protein (ECP) (P < 0.001), granulocyte-macrophage colony-stimulating factor (GM-CSF) (P < 0.01), and MCP-1 (P = 0.01), as well as decreased gene expression of tissue plasminogen activator (tPA) (P = 0.02). Despite the higher eosinophilia in AERD, there was no associated increase in type 2 mediator protein levels observed. CONCLUSIONS CRSwNP was characterized by a predominant type 2 inflammatory environment, whereas CRSsNP did not reflect a classic type 1 milieu, as has been suggested previously. AERD can be distinguished from CRSwNP by elevated ECP levels, but this enhanced eosinophilia is not associated with elevations in traditional type 2 inflammatory mediators associated with eosinophil proliferation and recruitment. However, other factors, including GM-CSF, MCP-1, and tPA, may be important contributors to AERD pathogenesis.
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Affiliation(s)
| | | | | | | | | | - Lydia Suh
- 1 Division of Allergy/Immunology, Department of Medicine, and
| | | | - James E Norton
- 1 Division of Allergy/Immunology, Department of Medicine, and
| | - Kathryn E Hulse
- 1 Division of Allergy/Immunology, Department of Medicine, and
| | - David B Conley
- 2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rakesh K Chandra
- 3 Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee; and
| | - Bruce K Tan
- 2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anju T Peters
- 1 Division of Allergy/Immunology, Department of Medicine, and
| | | | - Atsushi Kato
- 1 Division of Allergy/Immunology, Department of Medicine, and
| | | | | | - Shigeharu Fujieda
- 4 Division of Otorhinolaryngology Head and Neck Surgery, Department of Sensory and Locomotor Medicine, University of Fukui, Fukui, Japan
| | - Robert C Kern
- 2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert P Schleimer
- 1 Division of Allergy/Immunology, Department of Medicine, and.,2 Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Hong CJ, Tsang AC, Quinn JG, Bonaparte JP, Stevens A, Kilty SJ. Anti-IgE monoclonal antibody therapy for the treatment of chronic rhinosinusitis: a systematic review. Syst Rev 2015; 4:166. [PMID: 26581392 PMCID: PMC4652338 DOI: 10.1186/s13643-015-0157-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 11/09/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Several options are available for the treatment of chronic rhinosinusitis (CRS), but disease control remains elusive for many patients. Recently, literature has emerged describing anti-IgE monoclonal antibody as a potential therapy for CRS. However, its effectiveness and safety are not well known. The purpose of this systematic review was to assess the effectiveness and safety of anti-IgE therapy and to identify evidence gaps that will guide future research for the management of CRS. METHODS Methodology was registered with PROSPERO (No. CRD42014007600). A comprehensive search was performed of standard bibliographic databases, Google Scholar, and clinical trials registries. Only randomized controlled trials assessing anti-IgE therapy in adult patients for the treatment of CRS were included. Two independent reviewers extracted data using a pre-defined extraction form and performed quality assessment using the Cochrane risk of bias tool and the GRADE framework. RESULTS Two studies met our inclusion criteria. When comparing anti-IgE therapy to placebo, there was a significant difference in Lund-McKay score (p = 0.04) while no difference was seen for percent opacification on computed tomography (CT). At 16 weeks, treatment led to a decrease in clinical polyp score. No significant difference was seen with regard to quality of life (Total Nasal Symptom Severity (TNSS), p < 0.21; Sinonasal Outcome Test 20 (SNOT-20), p < 0.60), and no serious complications were reported in either trial. Based on the quality assessment, studies were deemed to be of moderate risk of bias and a low overall quality of evidence. CONCLUSIONS There is currently insufficient evidence to determine the effectiveness of anti-IgE monoclonal antibody therapy for the treatment of CRS.
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Affiliation(s)
- Chris J Hong
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Adrian C Tsang
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Jason G Quinn
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, NS, Canada.
| | - James P Bonaparte
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, The Ottawa Hospital, 737 Parkdale Ave., Room 459, Ottawa, Ontario, K1Y 1J8, Canada.
| | - Adrienne Stevens
- Center for Practice Changing Research, Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada. .,Department of Clinical Epidemiology, University of Ottawa, Ottawa, ON, Canada.
| | - Shaun J Kilty
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, The Ottawa Hospital, 737 Parkdale Ave., Room 459, Ottawa, Ontario, K1Y 1J8, Canada.
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Lam K, Schleimer R, Kern RC. The Etiology and Pathogenesis of Chronic Rhinosinusitis: a Review of Current Hypotheses. Curr Allergy Asthma Rep 2015; 15:41. [PMID: 26143392 PMCID: PMC4874491 DOI: 10.1007/s11882-015-0540-2] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Chronic rhinosinusitis (CRS) is a broad clinical syndrome that is characterized by prolonged mucosal inflammation of the nose and paranasal sinuses, and is typically divided into two subtypes based on the presence or absence of nasal polyps. The etiology and pathogenesis of both forms remain areas of active research. Over the last 15 years, a number of hypotheses have been proposed to explain all or part of the clinical CRS spectrum. These hypotheses reflect the concept that CRS results from a dysfunctional interplay between individual host characteristics and factors exogenous to the host. Six broad theories on CRS etiology and pathogenesis are discussed as follows: (1) the "fungal hypothesis," (2) the "superantigen hypothesis," (3) the "biofilm hypothesis," and (4) the "microbiome hypothesis," all of which emphasize key environmental factors, and (5) the "eicosanoid hypothesis" and (6) the "immune barrier hypothesis," which describe specific host factors. These theories are reviewed, and the evidence supporting them is critically appraised.
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Affiliation(s)
- Kent Lam
- Department of Otolaryngology—Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, 676 N St. Clair, Suite 1325, Chicago, IL 60611, USA
| | - Robert Schleimer
- Department of Medicine, Division of Allergy-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert C. Kern
- Department of Otolaryngology—Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, 676 N St. Clair, Suite 1325, Chicago, IL 60611, USA
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24
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Poposki JA, Peterson S, Welch K, Schleimer RP, Hulse KE, Peters AT, Norton J, Suh LA, Carter R, Harris KE, Grammer LC, Tan BK, Chandra RK, Conley DB, Kern RC, Kato A. Elevated presence of myeloid dendritic cells in nasal polyps of patients with chronic rhinosinusitis. Clin Exp Allergy 2015; 45:384-93. [PMID: 25469646 PMCID: PMC4467201 DOI: 10.1111/cea.12471] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Revised: 11/23/2014] [Accepted: 11/28/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by Th2 inflammation, the mechanism underlying the onset and amplification of this inflammation has not been fully elucidated. Dendritic cells (DCs) are major antigen-presenting cells, central inducers of adaptive immunity and critical regulators of many inflammatory diseases. However, the presence of DCs in CRS, especially in nasal polyps (NPs), has not been extensively studied. OBJECTIVE The objective of this study was to characterize DC subsets in CRS. METHODS We used real-time PCR to assess the expression of mRNA for markers of myeloid DCs (mDCs; CD1c), plasmacytoid DCs (pDCs; CD303) and Langerhans cells (LCs; CD1a, CD207) in uncinate tissue (UT) from controls and patients with CRS as well as in NP. We assayed the presence of DCs by immunohistochemistry and flow cytometry. RESULTS Compared to UT from control subjects (n = 15) and patients with CRS without NP (CRSsNP) (n = 16) and CRSwNP (n = 17), mRNAs for CD1a and CD1c were significantly elevated in NPs (n = 29). In contrast, CD207 mRNA was not elevated in NPs. Immunohistochemistry showed that CD1c(+) cells but not CD303(+) cells were significantly elevated in NPs compared to control subjects or patients with CRSsNP. Flow cytometric analysis showed that CD1a(+) cells in NPs might be a subset of mDC1s and that CD45(+) CD19(-) CD1c(+) CD11c(+) CD141(-) CD303(-) HLA-DR(+) mDC1s and CD45(+) CD19(-) CD11c(+) CD1c(-) CD141(high) HLA-DR(+) mDC2s were significantly elevated in NPs compared to UT from controls and CRSsNP, but CD45(+) CD11c(-) CD303(+) HLA-DR(+) pDCs were only elevated in NPs compared to control UT. CONCLUSION AND CLINICAL RELEVANCE Myeloid DCs are elevated in CRSwNP, especially in NPs. Myeloid DCs thus may indirectly contribute to the inflammation observed in CRSwNP.
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Affiliation(s)
- Julie A. Poposki
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Sarah Peterson
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Kate Welch
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Robert P. Schleimer
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Kathryn E. Hulse
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Anju T. Peters
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - James Norton
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Lydia A. Suh
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Roderick Carter
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Kathleen E. Harris
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Leslie C. Grammer
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Bruce K. Tan
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Rakesh K. Chandra
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - David B. Conley
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Robert C. Kern
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Atsushi Kato
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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25
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Suppressor of cytokine signaling 3 expression is diminished in sinonasal tissues from patients with chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol 2013; 133:275-277.e1. [PMID: 24084073 DOI: 10.1016/j.jaci.2013.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 08/08/2013] [Accepted: 08/13/2013] [Indexed: 11/21/2022]
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