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Shishodia S, Haloob N, Hopkins C. Antibody-based therapeutics for chronic rhinosinusitis with nasal polyps. Expert Opin Biol Ther 2024:1-12. [PMID: 38900023 DOI: 10.1080/14712598.2024.2370397] [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: 10/19/2023] [Accepted: 06/17/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Chronic rhinosinusitis with nasal polyps (CRSwNP) is a prevalent inflammatory condition with heterogenous underlying endotypes, the most common being type 2 mediated inflammation. Several biologics have been developed to target specific pro-inflammatory cytokines and their receptors with proven efficacy in both quantitative and qualitative outcomes in patients with severe uncontrolled disease. However, there is an ongoing debate on the role of biologics relative to conventional therapies for CRSwNP and their efficacy in patient subgroups with non-polyp type 2 disease. AREAS COVERED This review examines the evidence on the efficacy and safety of biologics in CRSwNP, recommendations for their use, and discusses the broader economic factors influencing their application in clinical practice. EXPERT OPINION Emerging real-life data demonstrating the variable efficacy of the available biologics for patients with CRSwNP, coupled with the high cost compared to conventional therapies such as surgery, renders biologics to be considered as an add-on therapy in the majority of cases. However, ongoing research into increasing biologic dose intervals and novel therapies targeting alternative pathways may offer a more cost-effective and sustainable option in future.
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Affiliation(s)
- Shama Shishodia
- Department of Rhinology and Skull Base Surgery, Guy's and St Thomas' Hospital NHS, Foundation Trust, London, UK
| | - Nora Haloob
- Department of Rhinology and Skull Base Surgery, Guy's and St Thomas' Hospital NHS, Foundation Trust, London, UK
| | - Claire Hopkins
- Department of Rhinology and Skull Base Surgery, Guy's and St Thomas' Hospital NHS, Foundation Trust, London, UK
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2
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Anselmo-Lima WT, Romano FR, Tamashiro E, Roithmann R, Dinarte VRP, Piltcher OB, Miyake MM, Fornazieri MA, Nakanishi M, Bezerra TFP, Dolci RLL, Mello JF, Lessa MM, Voegels RL, Kosugi EM, Sakano E, Valera FCP. Brazilian guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps ‒ 2024 update. Braz J Otorhinolaryngol 2024; 90:101394. [PMID: 38367543 PMCID: PMC10879704 DOI: 10.1016/j.bjorl.2024.101394] [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: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION Biologics targeting type 2 inflammation have revolutionized the way we treat patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Particularly in severe and difficult-to-control cases, these drugs have provided a new reality for these patients, allowing for the effective and safe treatment of extensive diseases that were not completely managed with the typical strategy of surgery and topical medications. OBJECTIVES The experience achieved with the approval of these medications by ANVISA for use in CRSwNP and the knowledge obtained regarding outcomes, adverse effects, and the ideal patient profile prompted the update of the previously published guideline, with a detailed review of the most recent scientific literature, the personal experiences of experts, and the adaptation to the reality of the Brazilian healthcare system, both public and private. RESULTS We proposed a new eligibility criterion for biologics in patients with CRSwNP based on four pillars of indication: the impact of the disease on the patient's life, whether in the presence of specific symptoms or in overall quality of life; the extent of sinonasal disease; the presence of type 2 comorbidities, considering other associated diseases that may also benefit from anti-T2 biologics, and the presence of biomarkers to define type 2 inflammation, especially those associated with worse disease prognoses. CONCLUSIONS This innovative and pioneering method has two major advantages. First, it ensures a comprehensive evaluation of patients; second, it is flexible, as advancements in our understanding of the disease and changes in cost-effectiveness can be addressed by simply adjusting the required score for indication, without the need to modify the entire evaluation scheme.
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Affiliation(s)
- Wilma T Anselmo-Lima
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Oftalmologia, Otorrinolaringologia, Cirurgia de Cabeça e Pescoço, Ribeirão Preto, SP, Brazil.
| | - Fabrizio R Romano
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Universidade de São Paulo (FMRP-USP), Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Edwin Tamashiro
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Oftalmologia, Otorrinolaringologia, Cirurgia de Cabeça e Pescoço, Ribeirão Preto, SP, Brazil
| | | | | | - Otavio B Piltcher
- Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (FAMED-UFRGS), Departamento de Oftalmologia e Otorrinolaringologia, Porto Alegre, RS, Brazil
| | - Marcel M Miyake
- Universidade de São Paulo (FMRP-USP), Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil; Santa Casa de Misericórdia, Hospital de São Paulo, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Marco A Fornazieri
- Universidade Estatual de Londrina, Londrina, PR, Brazil; Pontifícia Universidade Católica do Paraná (PUCPR), Câmpus Londrina, Londrina, PR, Brazil
| | - Marcio Nakanishi
- Universidade de Brasília, Faculdade de Medicina, Programa de Pós-Graduação, Brasilia, DF, Brazil
| | | | | | - João F Mello
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcus M Lessa
- Faculdade de Medicina da Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Richard L Voegels
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo M Kosugi
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Eulalia Sakano
- Universidade Estadual Paulista, Faculdade de Ciências Médicas, Departamento de Oftalmologia/Otorrinolaringologia, Campinas, SP, Brazil
| | - Fabiana C P Valera
- Universidade de São Paulo (FMRP-USP), Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil
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Tu Z, Liu M, Xu C, Wei Y, Lu T, Xiao Y, Li H, Zhang S, Xie X, Li J, Wen W. Functional 2D Nanoplatforms Alleviate Eosinophilic Chronic Rhinosinusitis by Modulating Eosinophil Extracellular Trap Formation. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2307800. [PMID: 38477549 PMCID: PMC11109617 DOI: 10.1002/advs.202307800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/23/2024] [Indexed: 03/14/2024]
Abstract
The therapeutic outcomes of patients with eosinophilic chronic rhinosinusitis (ECRS) remain unsatisfactory, largely because the underlying mechanisms of eosinophilic inflammation are uncertain. Here, it is shown that the nasal secretions of ECRS patients have high eosinophil extracellular trap (EET) and cell-free DNA (cfDNA) levels. Moreover, the cfDNA induced EET formation by activating toll-like receptor 9 (TLR9) signaling. After demonstrating that DNase I reduced eosinophilic inflammation by modulating EET formation, linear polyglycerol-amine (LPGA)-coated TiS2 nanosheets (TLPGA) as functional 2D nanoplatforms with low cytotoxicity, mild protein adsorption, and increased degradation rate is developed. Due to the more flexible linear architecture, TLPGA exhibited higher cfDNA affinity than the TiS2 nanosheets coated with dendritic polyglycerol-amine (TDPGA). TLPGA reduced cfDNA levels in the nasal secretions of ECRS patients while suppressing cfDNA-induced TLR9 activation and EET formation in vitro. TLPGA displayed exceptional biocompatibility, preferential nasal localization, and potent inflammation modulation in mice with eosinophilic inflammation. These results highlight the pivotal feature of the linear molecular architecture and 2D sheet-like nanostructure in the development of anti-inflammation nanoplatforms, which can be exploited for ECRS treatment.
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Affiliation(s)
- Zhaoxu Tu
- Department of OtolaryngologyThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Department of OtolaryngologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Ming Liu
- Department of OtolaryngologyThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Changyi Xu
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Department of Clinical LaboratoryThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Yi Wei
- Department of OtolaryngologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Tong Lu
- Department of OtolaryngologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Yongqiang Xiao
- ENT instituteEye & ENT HospitalFudan UniversityShanghai201114China
| | - Hongxia Li
- Department of OtolaryngologyThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Shuaiyin Zhang
- Department of OtolaryngologyThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Xinran Xie
- Department of OtolaryngologyThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Jian Li
- Department of OtolaryngologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
| | - Weiping Wen
- Department of OtolaryngologyThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Department of OtolaryngologyThe First Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
- Biomedical Innovation CenterThe Sixth Affiliated HospitalSun Yat‐sen UniversityGuangzhouGuangdong510655China
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Dekeyser A, Huart C, Hummel T, Hox V. Olfactory Loss in Rhinosinusitis: Mechanisms of Loss and Recovery. Int J Mol Sci 2024; 25:4460. [PMID: 38674045 PMCID: PMC11050448 DOI: 10.3390/ijms25084460] [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: 03/25/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Chronic rhinosinusitis (CRS) is a highly prevalent disease and up to 83% of CRS patients suffer from olfactory dysfunction (OD). Because OD is specifically seen in those CRS patients that present with a type 2 eosinophilic inflammation, it is believed that type 2 inflammatory mediators at the level of the olfactory epithelium are involved in the development of this olfactory loss. However, due to the difficulties in obtaining tissue from the olfactory epithelium, little is known about the true mechanisms of inflammatory OD. Thanks to the COVID-19 pandemic, interest in olfaction has been growing rapidly and several studies have been focusing on disease mechanisms of OD in inflammatory conditions. In this paper, we summarize the most recent data exploring the pathophysiological mechanisms underlying OD in CRS. We also review what is known about the potential capacity of olfactory recovery of the currently available treatments in those patients.
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Affiliation(s)
- Agnès Dekeyser
- Laboratory of Pneumology, ENT (Airways) and Dermatology (Skin) (LUNS), Institute of Experimental and Clinical Research (IREC), UCLouvain, 1200 Brussels, Belgium; (A.D.); (C.H.)
| | - Caroline Huart
- Laboratory of Pneumology, ENT (Airways) and Dermatology (Skin) (LUNS), Institute of Experimental and Clinical Research (IREC), UCLouvain, 1200 Brussels, Belgium; (A.D.); (C.H.)
- Department of Otorhinolaryngology, Head and Neck Surgery, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Thomas Hummel
- Smell and Taste Clinic, Department of Otorhinolaryngology, University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany;
| | - Valérie Hox
- Laboratory of Pneumology, ENT (Airways) and Dermatology (Skin) (LUNS), Institute of Experimental and Clinical Research (IREC), UCLouvain, 1200 Brussels, Belgium; (A.D.); (C.H.)
- Department of Otorhinolaryngology, Head and Neck Surgery, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
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Böscke R. [Difficult-to-treat chronic rhinosinusitis-when the standard treatment is not effective and biologics are not available]. HNO 2024; 72:231-241. [PMID: 38472346 DOI: 10.1007/s00106-024-01443-w] [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] [Accepted: 02/06/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND In recent years, significant improvements have been made in the treatment options for uncontrolled chronic rhinosinusitis (CRS) refractory to standard medical and surgical therapy. This is the result of a better understanding of the pathophysiology and the resulting development of biologicals for CRS with nasal polyps (CRSwNP). However, biologics are not (yet) available for all patients in Europe. OBJECTIVE Based on the session "Difficult-to-treat CRS, when biologics are not available" at the 29th Congress of the European Rhinologic Society (ERS) 2023 in Sofia, Bulgaria, the treatment options for uncontrolled CRS with the exclusion of biologics will be discussed. MATERIALS AND METHODS The content of the presentations "Is there a place for antibiotics?" "Indications for revision surgery," "Novel systemic treatment options," "Novel local treatment options," and "Phototherapy for nasal polyps" are outlined and supported by a review of the literature. RESULTS Various treatment options are available for managing uncontrolled CRS, even if biologic treatments are unavailable. Treatment options for type‑2 (T2) CRS include steroid rinses, repeated short-term oral steroids, steroid-eluting stents, and extended sinus surgery. In the case of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD), acetylsalicylic acid (ASA) desensitization can be considered. Non-T2 endotypes or CRS without nasal polyps (CRSsNP) may benefit from several weeks of macrolides and xylitol rinses. CONCLUSION To accurately assess the efficacy of second-line therapies for treatment of difficult-to-treat CRS within an endotype-specific framework, additional controlled clinical trials are needed that take into account the heterogeneity of CRS endotypes.
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Affiliation(s)
- Robert Böscke
- Universitätsklinik für Hals-Nasen-Ohren-Heilkunde, Evangelisches Krankenhaus Oldenburg, Medizinischer Campus der Carl-von-Ossietzky Universität Oldenburg, Steinweg 13-17, 26122, Oldenburg, Deutschland.
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Sima Y, Wang X, Zhang L. Interaction of eosinophilic and neutrophilic inflammation in patients with chronic rhinosinusitis. Curr Opin Allergy Clin Immunol 2024; 24:25-31. [PMID: 37966141 DOI: 10.1097/aci.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE OF REVIEW In the past year, the endotype of chronic rhinosinusitis (CRS) has been studied from a new perspective. Eosinophilic and neutrophilic inflammation are not independent processes in the pathogenesis of CRS. In this review, we will focus on recent research on mixed eosinophilic-neutrophilic inflammation in CRS and discuss the mechanism and potential treatments. RECENT FINDINGS Traditionally, patients with eosinophilic CRS (ECRS) present with severe clinical manifestations, comorbidities, and a higher recurrence rate. Recent studies have found that approximately 40% of patients with ECRS present with neutrophilic infiltration, while patients with predominantly eosinophilic infiltration along with neutrophilic inflammation present with more complex inflammation, clinical manifestations and exhibit refractory characteristics. SUMMARY The complex inflammatory profile and refractory clinical characteristics of mixed eosinophilic-neutrophilic inflammation in CRS are current challenges for clinicians. We summarize the features of eosinophilic and neutrophilic inflammation and current studies on the mechanisms of mixed eosinophilic-neutrophilic inflammation and suggest potentially effective therapeutic methods. We hope that this review will help with determining precise treatment options for patients.
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Affiliation(s)
- Yutong Sima
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology
| | - Xiangdong Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology
- Department of Allergy, Beijing Tongren Hospital, Capital Medical University
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology
- Department of Allergy, Beijing Tongren Hospital, Capital Medical University
- Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Hatsukawa H, Ishikawa M. Clinical Utility of Machine Learning Methods Using Regression Models for Diagnosing Eosinophilic Chronic Rhinosinusitis. OTO Open 2024; 8:e122. [PMID: 38464815 PMCID: PMC10924764 DOI: 10.1002/oto2.122] [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: 01/12/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024] Open
Abstract
Objective Machine learning methods using regression models can predict actual values of histological eosinophil count from blood eosinophil levels. Therefore, these methods might be useful for diagnosing eosinophilic chronic rhinosinusitis, but their utility still remains unclear. We compared 2 statistical approaches, and investigated the utility of machine learning methods for diagnosing eosinophilic chronic rhinosinusitis. Study Design Retrospective study. Setting Medical center. Methods Data, including eosinophilic levels, obtained from blood and sinonasal samples of 264 patients with chronic rhinosinusitis (257 with and 57 without nasal polyps) were analyzed. We determined factors affecting histopathological eosinophil count in regression models. We also investigated optimal cutoff values for blood eosinophil percentages/absolute eosinophil counts (AECs) through receiver operating characteristic curves and machine-learning methods based on regression models. A histopathological eosinophil count ≥10/high-power field was defined as eosinophilic chronic rhinosinusitis. Results Blood eosinophil levels, nasal polyp presence, and comorbid asthma were factors affecting histopathological eosinophil count. Cutoffs between the 2 statistical approaches differed in the group with nasal polyps, but not in one without nasal polyps. Machine-learning methods identified blood eosinophil percentages ≥1% or AEC ≥100/μL as cut-offs for eosinophilic chronic rhinosinusitis with nasal polyps, while ≥6% or ≥400/μL for one without nasal polyps. Conclusion Cut-offs of blood eosinophil levels obtained by machine-learning methods might be useful when suspecting eosinophilic chronic rhinosinusitis prior to biopsy because of their ability to adjust covariates, dealing with overfitting, and predicting actual values of histological eosinophil count.
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Affiliation(s)
- Hiroatsu Hatsukawa
- Department of Otolaryngology, Head and Neck SurgeryHyogo Prefectural Amagasaki General Medical CenterAmgasakiJapan
| | - Masaaki Ishikawa
- Department of Otolaryngology, Head and Neck SurgeryHyogo Prefectural Amagasaki General Medical CenterAmgasakiJapan
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Chalmers JD, Kettritz R, Korkmaz B. Dipeptidyl peptidase 1 inhibition as a potential therapeutic approach in neutrophil-mediated inflammatory disease. Front Immunol 2023; 14:1239151. [PMID: 38162644 PMCID: PMC10755895 DOI: 10.3389/fimmu.2023.1239151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
Neutrophils have a critical role in the innate immune response to infection and the control of inflammation. A key component of this process is the release of neutrophil serine proteases (NSPs), primarily neutrophil elastase, proteinase 3, cathepsin G, and NSP4, which have essential functions in immune modulation and tissue repair following injury. Normally, NSP activity is controlled and modulated by endogenous antiproteases. However, disruption of this homeostatic relationship can cause diseases in which neutrophilic inflammation is central to the pathology, such as chronic obstructive pulmonary disease (COPD), alpha-1 antitrypsin deficiency, bronchiectasis, and cystic fibrosis, as well as many non-pulmonary pathologies. Although the pathobiology of these diseases varies, evidence indicates that excessive NSP activity is common and a principal mediator of tissue damage and clinical decline. NSPs are synthesized as inactive zymogens and activated primarily by the ubiquitous enzyme dipeptidyl peptidase 1, also known as cathepsin C. Preclinical data confirm that inactivation of this protease reduces activation of NSPs. Thus, pharmacological inhibition of dipeptidyl peptidase 1 potentially reduces the contribution of aberrant NSP activity to the severity and/or progression of multiple inflammatory diseases. Initial clinical data support this view. Ongoing research continues to explore the role of NSP activation by dipeptidyl peptidase 1 in different disease states and the potential clinical benefits of dipeptidyl peptidase 1 inhibition.
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Affiliation(s)
- James D. Chalmers
- Department of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Ralph Kettritz
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a Cooperation Between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin, Berlin, Germany
| | - Brice Korkmaz
- INSERM UMR-1100, Research Center for Respiratory Diseases, University of Tours, Tours, France
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Vultaggio A, Accinno M, Vivarelli E, Mecheri V, Maggiore G, Cosmi L, Parronchi P, Rossi O, Maggi E, Gallo O, Matucci A. Blood CD62L low inflammatory eosinophils are related to the severity of asthma and reduced by mepolizumab. Allergy 2023; 78:3154-3165. [PMID: 37792721 DOI: 10.1111/all.15909] [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: 05/09/2023] [Revised: 08/30/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Eosinophils have been divided into different subpopulations with distinct phenotypes based on CD62L expression. No data are available regarding the correlation between eosinophils subphenotypes and clinical severity of asthma, as well as the effect of anti-IL-5 therapy on these cells. The study investigates the correlation between blood CD62Llow inflammatory eosinophils (iEos) and clinical severity of severe eosinophilic asthma (SEA) and evaluates the impact of mepolizumab on iEos. METHODS 112 patients were screened and were divided in two groups: biological-naive (n = 51) and biological-treated patients (n = 61). The Biological-naive patients were analyzed before treatment (Group A) and 19 out of 51 patients, were longitudinally analyzed before and after treatment with mepolizumab 100 mg s.c/4 weeks (Group B); 32 patients were excluded because they were being treated with other biological therapies. Blood eosinophils were analyzed by FACS and correlated with clinical scores. In vitro effect of IL-5 and mepolizumab on CD62L expression was assessed. RESULTS A significant correlation between blood CD62Llow cells and clinical scores of asthma and nasal polyps, as well as the number of asthma exacerbations in the last year was shown in untreated patients. In longitudinally studied patients we observed a marked reduction of CD62Llow cells paralleled by an increase in the proportion of CD62Lbright cells, associated with clinical improvement of asthma control. In vitro, CD62L expression on eosinophils is modulated by IL-5 and anti-IL-5. CONCLUSION A positive correlation between CD62Llow iEos and the baseline clinical features of SEA with CRSwNP was shown. Furthermore mepolizumab restores the healthy balance among eosinophils sub-phenotypes in SEA patients.
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Affiliation(s)
- Alessandra Vultaggio
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Matteo Accinno
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Emanuele Vivarelli
- Immunology and Cellular Therapy Unit, Careggi University Hospital, Florence, Italy
| | - Valentina Mecheri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giandomenico Maggiore
- Department of Clinical and Experimental Medicine, Otolaryngology Clinic, University of Florence, Florence, Italy
| | - Lorenzo Cosmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Olivero Rossi
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Enrico Maggi
- Translational Immunology Unit, Immunology Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Oreste Gallo
- Department of Clinical and Experimental Medicine, Otolaryngology Clinic, University of Florence, Florence, Italy
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
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Zhang S, Wang Z. An Emerging Role of Extracellular Traps in Chronic Rhinosinusitis. Curr Allergy Asthma Rep 2023; 23:675-688. [PMID: 37934391 PMCID: PMC10739460 DOI: 10.1007/s11882-023-01082-1] [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] [Accepted: 04/21/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE OF REVIEW Chronic rhinosinusitis (CRS) is a complicated, heterogeneous disease likely caused by inflammatory and infectious factors. There is clear evidence that innate immune cells, including neutrophils and eosinophils, play a significant role in CRS. Multiple immune cells, including neutrophils and eosinophils, have been shown to release chromatin and granular proteins into the extracellular space in response to triggering extracellular traps (ETs). The formation of ETs remains controversial due to their critical function during pathogen clearance while being associated with harmful inflammatory illnesses. This article summarizes recent research on neutrophil extracellular traps (NETs) and eosinophil extracellular traps (EETs) and their possible significance in the pathophysiology of CRS. RECENT FINDINGS A novel type of programmed cell death called ETosis, which releases ETs, has been proposed by recent study. Significantly more NETs are presented in nasal polyps, and its granule proteins LL-37 induce NETs production in CRS with nasal polyps (CRSwNP) patients. Similar to NETs, developed in the tissue of nasal polyps, primarily in subepithelial regions with epithelial barrier defects, and are associated with linked to elevated tissue levels of IL-5 and S. aureus colonization. This article provides a comprehensive overview of NETs and EETs, as well as an in-depth understanding of the functions of these ETs in CRS.
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Affiliation(s)
- Siyuan Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenlin Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Kim DK, Yu H. Incidence Rates and Risk Ratios of Normal Tension Glaucoma in Patients with Chronic Rhinosinusitis: A Population-Based Longitudinal Follow-Up Study. Life (Basel) 2023; 13:2238. [PMID: 38137840 PMCID: PMC10745065 DOI: 10.3390/life13122238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
Several studies have investigated the association between chronic rhinosinusitis (CRS) and ophthalmological complications. However, it remains uncertain whether CRS is independently associated with the development of normal tension glaucoma (NTG). Therefore, this retrospective cohort study aimed to investigate the prospective association between CRS and the increased incidence and risk of NTG using a representative population-based dataset. The selection of both the CRS and comparison groups was meticulously conducted through the propensity scoring method. The incidence and risk ratios of NTG were measured using person-years at risk and a weighted Cox proportional hazards model. We enrolled 30,284 individuals without CRS (comparison group) and 15,142 individuals with CRS. The NTG incidence rates were 1.19 and 0.81 in the CRS and comparison groups, respectively. The CRS group showed a significantly increased risk of subsequent development for NTG (adjusted hazard ratio = 1.41, 95% confidence interval = 1.16-1.72), regardless of the CRS subtype. Additionally, the risk of developing NTG was relatively higher in the first 2 years after CRS diagnosis. Moreover, a subgroup analysis revealed a higher risk of NTG in elderly female individuals with CRS. The present findings underscore the importance of monitoring and managing NTG risk in individuals with CRS, especially in elderly female patients.
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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 24252, Republic of Korea
- Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Hyunjae Yu
- Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
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12
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Hatsukawa H, Ishikawa M, Hirai T, Endo K, Saito E, Matsumoto H, Okazaki K. Comorbidity of eosinophilic chronic rhinosinusitis in chronic eosinophilic pneumonia. Respirol Case Rep 2023; 11:e01236. [PMID: 37854459 PMCID: PMC10579627 DOI: 10.1002/rcr2.1236] [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: 08/02/2023] [Accepted: 10/07/2023] [Indexed: 10/20/2023] Open
Abstract
We aimed to elucidate details of comorbid chronic rhinosinusitis (CRS) in chronic eosinophilic pneumonia (CEP) under the collaboration between otolaryngologists and pulmonologists in a prospective study. The CEP diagnosis was performed by pulmonologists based on clinical symptoms, laboratory findings, and/or eosinophilia detected in bronchoalveolar lavage. All patients were referred to otolaryngologists before undergoing oral corticosteroid treatment for CEP. Ten CEP cases visited to otolaryngologists. All cases showed bilateral sinonasal inflammation in computed tomography (CT), indicating comorbid CRS. Nasal polyps (NPs) were observed in 50% of patients on endoscopy. Eighty percent of patients were diagnosed with eosinophilic CRS. In blood eosinophil levels and the mucosal eosinophil count, there were no significant differences between CRS without and with NPs. In Lund-Mackay CT total scores, among-individual variability was observed in CRS with NPs. The collaboration revealed blood/sinonasal eosinophilia and the variability in Lund-Mackay CT total scores as remarkable findings about the comorbid CRS.
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Affiliation(s)
- Hiroatsu Hatsukawa
- Department of Otolaryngology, Head and Neck SurgeryHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Masaaki Ishikawa
- Department of Otolaryngology, Head and Neck SurgeryHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Tomoyuki Hirai
- Department of Respiratory MedicineHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Kazuo Endo
- Department of Respiratory MedicineHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Emiko Saito
- Department of Respiratory MedicineHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Hirotaka Matsumoto
- Department of Respiratory MedicineHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Kouya Okazaki
- Department of Respiratory MedicineHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
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Cui N, Zhu X, Zhao C, Meng C, Sha J, Zhu D. A Decade of Pathogenesis Advances in Non-Type 2 Inflammatory Endotypes in Chronic Rhinosinusitis: 2012-2022. Int Arch Allergy Immunol 2023; 184:1237-1253. [PMID: 37722364 DOI: 10.1159/000532067] [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: 04/17/2023] [Accepted: 07/12/2023] [Indexed: 09/20/2023] Open
Abstract
Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by localized inflammation of the upper airways. CRS includes two main phenotypes, namely, CRS with nasal polyps and CRS without nasal polyps. The phenotype-based classification method cannot reflect the pathological mechanism. The endotype-based classification method has been paid more and more attention by researchers. It is mainly divided into type 2 and non-type 2 endotypes. The mechanism driving the pathogenesis of non-type 2 inflammation is currently unknown. In this review, the PubMed and Web of Science databases were searched to conduct a critical analysis of representative literature works on the pathogenesis of non-type 2 inflammation in CRS published in the past decade. This review summarizes the latest evidence that may lead to the pathogenesis of non-type 2 inflammation. It is the main method that analyzing the pathogenesis from the perspective of immunology. Genomics and proteomics technique provide new approaches to the study of the pathogenesis. Due to differences in race, environment, geography, and living habits, there are differences in the occurrence of non-type 2 inflammation, which increase the difficulty of understanding the pathogenesis of non-type 2 inflammation in CRS. Studies have confirmed that non-type 2 endotype is more common in Asian patients. The emergence of overlap and unclassified endotypes has promoted the study of heterogeneity in CRS. In addition, as the source of inflammatory cells and the initiation site of the inflammatory response, microvessels and microlymphatic vessels in the nasal mucosal subepithelial tissue participate in the inflammatory response and tissue remodeling. It is uncertain whether CRS patients affect the risk of infection with SARS-CoV-2. In addition, the pathophysiological mechanism of non-type 2 CRS combined with COVID-19 remains to be further studied, and it is worth considering how to select the befitting biologics for CRS patients with non-type 2 inflammation.
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Affiliation(s)
- Na Cui
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China,
| | - Xuewei Zhu
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Chen Zhao
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Cuida Meng
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jichao Sha
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Dongdong Zhu
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
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Huang GJ, Chen ZQ, Fan ZJ, Li SH. The causal association between peripheral blood eosinophils and nasal polyps: a Mendelian randomization study. Eur Arch Otorhinolaryngol 2023; 280:4285-4290. [PMID: 37466661 DOI: 10.1007/s00405-023-08129-z] [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: 05/03/2023] [Accepted: 07/12/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE Observational studies suggested that peripheral blood eosinophils were associated with the risk of nasal polyps. However, these studies did not confirm the causality. This study aims to apply Mendelian randomization (MR) method to comprehensively assess the potential causal association between peripheral blood eosinophils and nasal polyps. METHODS Genetic instrumental variables were extracted from the largest available genome-wide association study (GWAS) of European participants, which were used to investigate the relationship between peripheral blood eosinophils and nasal polyps. The inverse variance weighted method, the MR Egger method, and the weighted median method were applied for this analysis. MR-Egger intercept tests, leave-one-out analyses, and funnel plots were performed for the sensitivity analysis. RESULTS With the inverse variance weighted method, the MR analysis suggested that there was a significant difference between peripheral blood eosinophils and the risk of nasal polyps (ukb-a-97, OR 1.004, 95% CI 1.003-1.005, p < 0.001; ukb-a-541, OR 1.005, 95% CI 1.004-1.006, p < 0.001; ukb-b-7211, OR 1.004, 95% CI 1.003-1.005, p < 0.001; ukb-b-8425, OR 1.004, 95% CI 1.003-1.005, p < 0.001; finn-b-J10_NASALPOLYP, OR 3.089, 95% CI 2.537-3.761, p < 0.001). Consistent results were also proved by using the weighted median method and the MR Egger method. CONCLUSIONS Our findings reveal the causal effect of peripheral blood eosinophils on the increased risk of nasal polyps.
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Affiliation(s)
- Guan-Jiang Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, Guangdong, China
| | - Zi-Qing Chen
- Department of Otorhinolaryngology Head and Neck Surgery, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, Guangdong, China
| | - Zhi-Jun Fan
- Department of Otorhinolaryngology Head and Neck Surgery, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, Guangdong, China.
| | - Shao-Hua Li
- Department of Otorhinolaryngology Head and Neck Surgery, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, Guangdong, China.
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Gelardi M, Giancaspro R, Duda L, Quaranta VN, Pizzulli C, Maiorano E, Di Canio FM, Ruzza A, Iannuzzi L, Quaranta NAA, Parisi F, Cassano M, Marzullo A. Eosinophil-mast cell pattern of intraepithelial infiltration as a marker of severity in CRSwNP. Sci Rep 2023; 13:12101. [PMID: 37495667 PMCID: PMC10372103 DOI: 10.1038/s41598-023-39149-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/20/2023] [Indexed: 07/28/2023] Open
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is defined as a Type 2 eosinophilic disease, while CRSsNP is considered a Type 1 neutrophilic disease. Since neutrophils are also activated in eosinophilic CRSwNP, the eosinophil-neutrophil dualism has been revaluated. Among the inflammatory cells infiltrating sinus-nasal tissues, the role of mast cells (MCs) is not already recognized, although Clinical-Cytological Grading, which defines the severity of CRSwNP, attributes to mixed eosinophil-MC forms of CRSwNP a greater risk of recurrence. We aimed to examine nasal polyps from both a cytological and histopathological point of view, to evaluate the presence and localization of MCs. Cytological and histological examination of 39 samples of nasal polyps were performed. Immunohistochemistry was used to evaluate the presence of Tryptase + CD117 + MCs, which were counted both in the epithelial layer and in the lamina propria. A statistically significant correlation was found between intraepithelial MCs and CRSwNP severity (p < 0.001) and between the total eosinophil count and the total mast cell count (p < 0.001). Cytological examination and immunohistochemistry were comparable in detecting the presence of intraepithelial MCs (p = 0.002). The histological cut-off of 6 intraepithelial MCs was identified to detect severe CRSwNP (p < 0.001). MCs have been shown to be located in the lamina propria of almost all eosinophilic nasal polyps without significantly affecting their severity. Intraepithelial MCs are associated with greater severity of CRSwNP. Histopathological criteria of the eosinophil-MC form of CRSwNP in addition to the eosinophilic one, should be defined to guarantee patients effective and tailored treatments.
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Affiliation(s)
- Matteo Gelardi
- Unit of Otolaryngology, Department of Clinical and Experimental Medicine, University of Foggia, Via Luigi Pinto 1, 71122, Foggia, Italy
| | - Rossana Giancaspro
- Unit of Otolaryngology, Department of Clinical and Experimental Medicine, University of Foggia, Via Luigi Pinto 1, 71122, Foggia, Italy.
| | - Loren Duda
- Unit of Pathology, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Vitaliano Nicola Quaranta
- Section of Respiratory Disease, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Cristina Pizzulli
- Unit of Pathology, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Eugenio Maiorano
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Filomena Milena Di Canio
- Unit of Otolaryngology, Department of Clinical and Experimental Medicine, University of Foggia, Via Luigi Pinto 1, 71122, Foggia, Italy
| | - Annamaria Ruzza
- Unit of Otolaryngology, Department of Clinical and Experimental Medicine, University of Foggia, Via Luigi Pinto 1, 71122, Foggia, Italy
| | - Lucia Iannuzzi
- Otolaryngology Unit, Department of Basic Medical Science, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Bari, Italy
| | - Nicola Antonio Adolfo Quaranta
- Otolaryngology Unit, Department of Basic Medical Science, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Bari, Italy
| | | | - Michele Cassano
- Unit of Otolaryngology, Department of Clinical and Experimental Medicine, University of Foggia, Via Luigi Pinto 1, 71122, Foggia, Italy
| | - Andrea Marzullo
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari "Aldo Moro", 70124, Bari, Italy
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Huang Y, Zhang N, Bachert C. Innovative treatments for severe uncontrolled chronic rhinosinusitis with nasal polyps. Expert Rev Clin Immunol 2023; 19:837-845. [PMID: 37083285 DOI: 10.1080/1744666x.2023.2206120] [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: 02/17/2023] [Accepted: 04/19/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION In recent years, endotypes of chronic rhinosinusitis (CRS) based on the underlying immune mechanisms provided a better understanding of this heterogeneous disease and are frequently applied in diagnosis and treatment. AREAS COVERED In this manuscript, we aim to review novel treatment approaches for this often uncontrolled disease and highlight endotype-driven medical algorithms that could be beneficial in daily clinical practice. EXPERT OPINION With the development of endotyping and the mucosal inflammatory concept, several type 2-targeted biologics and surgical options are nowadays available for treating CRS. However, a better understanding based on clinical trials and real-life experience in daily practice is needed to optimize patient selection, biological drug selection, treatment duration, prediction, and long-term follow-up strategies. Indirect comparison analysis suggested that dupilumab might be the most effective biologic for treating CRS with nasal polyps, but the role and timing of surgery remain unclear. More real-life studies and comparative trials are needed for the optimal integration of biologics into clinical pathways in combination with established treatment approaches such as nasal and oral glucocorticosteroids and adequate surgery to provide long-term perspectives.
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Affiliation(s)
- Yanran Huang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - Nan Zhang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - Claus Bachert
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangzhou, China
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Muenster, Muenster, Germany
- Division of ENT diseases, Stockholm, Sweden
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17
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Sima Y, Zhao Y, Wang X, Zhang L. Precision medicine in chronic rhinosinusitis - using endotype and endotype-driven therapeutic options. Expert Rev Clin Immunol 2023; 19:949-958. [PMID: 37387541 DOI: 10.1080/1744666x.2023.2232115] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/28/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) is a heterogeneous disease, and its complex pathophysiological characteristics pose a challenge to its clinical treatment. CRS is distinguished not only by clinical phenotype but also by endotype characteristics, which are divided into type 2 CRS and non-type 2 CRS. AREAS COVERED In this review, we summarize and discuss current studies that depict the mechanisms and endotypes of CRS. In particular, inflammatory cells and the microbiome play a role in the pathophysiology of CRS. We also listed some of the biomarkers described in recent studies that may serve as a theoretical foundation for additional investigations. We have summarized the advantages and disadvantages of existing treatments and listed the available biological treatments for CRS in detail. EXPERT OPINION Endotype-driven therapeutic options face many challenges because of the complexity of the disease. Glucocorticoids, nasal endoscopic surgery, and biological therapy are the main treatments used in clinical practice, but they have limitations. This review provides advice on the clinical management and treatment options for patients with different endotypes, which will be more conducive to improving the quality of life and reducing the financial burden on patients.
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Affiliation(s)
- Yutong Sima
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otorhinolaryngology, Beijing, China
| | - Yan Zhao
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otorhinolaryngology, Beijing, China
| | - Xiangdong Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otorhinolaryngology, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Beijing Laboratory of Allergic Diseases, Beijing Municipal Education Commission and Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otorhinolaryngology, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Nakayama T, Haruna SI. A review of current biomarkers in chronic rhinosinusitis with or without nasal polyps. Expert Rev Clin Immunol 2023; 19:883-892. [PMID: 37017326 DOI: 10.1080/1744666x.2023.2200164] [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: 12/30/2022] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) is a heterogeneous disease with a variety of cellular and molecular pathophysiologic mechanisms. Biomarkers have been explored in CRS using various phenotypes, such as polyp recurrence after surgery. Recently, the presence of regiotype in CRS with nasal polyps (CRSwNP) and the introduction of biologics for the treatment of CRSwNP has indicated the importance of endotypes, and there is a need to elucidate endotype-based biomarkers. AREAS COVERED Biomarkers for eosinophilic CRS, nasal polyps, disease severity, and polyp recurrence have been identified. Additionally, endotypes are being identified for CRSwNP and CRS without nasal polyps using cluster analysis, an unsupervised learning technique. EXPERT OPINION Endotypes in CRS have still being established, and biomarkers capable of identifying endotypes of CRS are not yet clear. When identifying endotype-based biomarkers, it is necessary to first identify endotypes clarified by cluster analysis for outcomes. With the application of machine learning, the idea of predicting outcomes using a combination of multiple integrated biomarkers, rather than a single biomarker, will become mainstream.
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Affiliation(s)
- Tsuguhisa Nakayama
- Department of Otorhinolaryngology and Head & Neck Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Shin-Ichi Haruna
- Department of Otorhinolaryngology and Head & Neck Surgery, Dokkyo Medical University, Tochigi, Japan
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Haloob N, Karamali K, Hopkins C. The Role of Biologics in the Treatment of Chronic Rhinosinusitis. BioDrugs 2023:10.1007/s40259-023-00602-9. [PMID: 37318659 DOI: 10.1007/s40259-023-00602-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/16/2023]
Abstract
The last decade has seen significant developments in the field of biologics for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP). Translational research borne from knowledge of the pathophysiology of type 2 inflammatory disease of the lower airways and the strong association with CRSwNP, has led to major therapeutic breakthroughs, with phase 3 trials of four biologics completed at the time of writing, and more underway. This article explores the evidence behind biologics for CRSwNP, the guidance on their use and the health economic factors influencing their position amongst the established therapeutic options for this common chronic condition.
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Affiliation(s)
- Nora Haloob
- Department of Rhinology and Skull Base Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK.
| | - Katerina Karamali
- Department of Rhinology and Skull Base Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Claire Hopkins
- Department of Rhinology and Skull Base Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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Guo CL, Lu RY, Wang CS, Zhao JF, Pan L, Liu HC, Liao B, Liu Z. Identification of Inflammatory Endotypes by Clinical Characteristics and Nasal Secretion Biomarkers in Chronic Rhinosinusitis with Nasal Polyps. Int Arch Allergy Immunol 2023; 184:955-965. [PMID: 37253337 PMCID: PMC10614570 DOI: 10.1159/000530193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/03/2023] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION The emergency of biologics and surgical techniques targeting the specific inflammatory endotype in chronic rhinosinusitis with nasal polyps (CRSwNP) asks for efficient identification of patients with different endotypes. Although mucosal IL-4, IL-5, IL-13, and IgE have been used to define type 2 (T2) inflammation, the optimal one remains unclear. In this study, we aimed to determine the optimal anchor for T2 inflammation and identify clinical characteristics and nasal secretion biomarkers predicting different endotypes in CRSwNP. METHODS Six mediators in sinonasal tissue and 36 mediators in nasal secretion samples were detected by the Bio-Plex suspension array system. Mucosal IFN-γ and IL-17A levels were used to define the T1 and T3 endotype, respectively. The efficacy of mucosal IL-4, IL-5, IL-13, and IgE to define the T2 endotype was compared. The power of clinical characteristics and nasal secretion biomarkers to predict the T1, T2, and T3 endotype was analyzed. RESULTS Among mucosal IL-4, IL-5, IL-13, and IgE, IL-13 was the best one to coincide with the expression of other T2 biomarkers. A combination of atopy, facial pain symptom score, ethmoid/maxillary computed tomography score ratio, and blood eosinophil percentage had a moderate predictive performance for T2 endotype (area under the receiver operating curve [AUC] = 0.815), comparable to that of nasal secretion IL-5 (AUC = 0.819). For the T3 endotype, nasal secretion IL-1Rα identified it with an AUC value of 0.756. No efficient marker for the T1 endotype was found. CONCLUSION IL-13 is a primary anchor for the T2 endotype in CRSwNP. Clinical characteristics and nasal secretion biomarkers are helpful for identifying the T2 and T3 endotype of CRSwNP.
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Affiliation(s)
- Cui-Lian Guo
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Ruo-Yu Lu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Chong-Shu Wang
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Jie-Fang Zhao
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Li Pan
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Hui-Cheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Bo Liao
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
| | - Zheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Insititue of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
- Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, PR China
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Kotas ME, Patel NN, Cope EK, Gurrola JG, Goldberg AN, Pletcher SD, Seibold MA, Moore CM, Gordon ED. IL-13-associated epithelial remodeling correlates with clinical severity in nasal polyposis. J Allergy Clin Immunol 2023; 151:1277-1285. [PMID: 36736797 PMCID: PMC10243183 DOI: 10.1016/j.jaci.2022.12.826] [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: 10/04/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Epithelial remodeling is a histopathologic feature of chronic inflammatory airway diseases including chronic rhinosinusitis (CRS). Cell-type shifts and their relationship to CRS endotypes and severity are incompletely described. OBJECTIVE We sought to understand the relationship of epithelial cell remodeling to inflammatory endotypes and disease outcomes in CRS. METHODS Using cell-type transcriptional signatures derived from epithelial single-cell sequencing, we analyzed bulk RNA-sequencing data from sinus epithelial brushings obtained from patients with CRS with and without nasal polyps in comparison to healthy controls. RESULTS The airway epithelium in nasal polyposis displayed increased tuft cell transcripts and decreased ciliated cell transcripts along with an IL-13 activation signature. In contrast, CRS without polyps showed an IL-17 activation signature. IL-13 activation scores were associated with increased tuft cell, goblet cell, and mast cell scores and decreased ciliated cell scores. Furthermore, the IL-13 score was strongly associated with a previously reported activated ("polyp") tuft cell score and a prostaglandin E2 activation signature. The Lund-Mackay score, a computed tomographic metric of sinus opacification, correlated positively with activated tuft cell, mast cell, prostaglandin E2, and IL-13 signatures and negatively with ciliated cell transcriptional signatures. CONCLUSIONS These results demonstrate that cell-type alterations and prostaglandin E2 stimulation are key components of IL-13-induced epithelial remodeling in nasal polyposis, whereas IL-17 signaling is more prominent in CRS without polyps, and that clinical severity correlates with the degree of IL-13-driven epithelial remodeling.
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Affiliation(s)
- Maya E Kotas
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, Calif
| | - Neil N Patel
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, Calif
| | - Emily K Cope
- Center for Applied Microbiome Sciences, the Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Ariz
| | - Jose G Gurrola
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, Calif
| | - Andrew N Goldberg
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, Calif
| | - Steven D Pletcher
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, Calif; Surgical Service, ENT Section, San Francisco VA Medical Center, San Francisco, Calif
| | - Max A Seibold
- Center for Genes, Environment, and Health, National Jewish Health, Denver, Colo; Department of Pediatrics, National Jewish Health, Denver, Colo; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, Colo
| | - Camille M Moore
- Center for Genes, Environment, and Health, National Jewish Health, Denver, Colo; Department of Biostatistics and Informatics, University of Colorado, Aurora, Colo.
| | - Erin D Gordon
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco, Calif.
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22
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Sousa-Pinto B, Sá-Sousa A, Vieira RJ, Amaral R, Pereira AM, Anto JM, Klimek L, Czarlewski W, Mullol J, Pfaar O, Bedbrook A, Brussino L, Kvedariene V, Larenas-Linnemann DE, Okamoto Y, Ventura MT, Ansotegui IJ, Bosnic-Anticevich S, Canonica GW, Cardona V, Cecchi L, Chivato T, Cingi C, Costa EM, Cruz AA, Del Giacco S, Devillier P, Fokkens WJ, Gemicioglu B, Haahtela T, Ivancevich JC, Kuna P, Kaidashev I, Kraxner H, Laune D, Louis R, Makris M, Monti R, Morais-Almeida M, Mösges R, Niedoszytko M, Papadopoulos NG, Patella V, Pham-Thi N, Regateiro FS, Reitsma S, Rouadi PW, Samolinski B, Sheikh A, Sova M, Taborda-Barata L, Toppila-Salmi S, Sastre J, Tsiligianni I, Valiulis A, Yorgancioglu A, Zidarn M, Zuberbier T, Fonseca JA, Bousquet J. Cutoff Values of MASK-air Patient-Reported Outcome Measures. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 10:2438-2447.e9. [PMID: 36566778 DOI: 10.1016/j.jaip.2022.04.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 05/09/2023]
Abstract
BACKGROUND In clinical and epidemiological studies, cutoffs of patient-reported outcome measures can be used to classify patients into groups of statistical and clinical relevance. However, visual analog scale (VAS) cutoffs in MASK-air have not been tested. OBJECTIVE To calculate cutoffs for VAS global, nasal, ocular, and asthma symptoms. METHODS In a cross-sectional study design of all MASK-air participants, we compared (1) approaches based on the percentiles (tertiles or quartiles) of VAS distributions and (2) data-driven approaches based on clusters of data from 2 comparators (VAS work and VAS sleep). We then performed sensitivity analyses for individual countries and for VAS levels corresponding to full allergy control. Finally, we tested the different approaches using MASK-air real-world cross-sectional and longitudinal data to assess the most relevant cutoffs. RESULTS We assessed 395,223 days from 23,201 MASK-air users with self-reported allergic rhinitis. The percentile-oriented approach resulted in lower cutoff values than the data-driven approach. We obtained consistent results in the data-driven approach. Following the latter, the proposed cutoff differentiating "controlled" and "partly-controlled" patients was similar to the cutoff value that had been arbitrarily used (20/100). However, a lower cutoff was obtained to differentiate between "partly-controlled" and "uncontrolled" patients (35 vs the arbitrarily-used value of 50/100). CONCLUSIONS Using a data-driven approach, we were able to define cutoff values for MASK-air VASs on allergy and asthma symptoms. This may allow for a better classification of patients with rhinitis and asthma according to different levels of control, supporting improved disease management.
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Affiliation(s)
- Bernardo Sousa-Pinto
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal; RISE-Health Research Network, University of Porto, Porto, Portugal
| | - Ana Sá-Sousa
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal; RISE-Health Research Network, University of Porto, Porto, Portugal
| | - Rafael José Vieira
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal; RISE-Health Research Network, University of Porto, Porto, Portugal
| | - Rita Amaral
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal; RISE-Health Research Network, University of Porto, Porto, Portugal
| | - Ana Margarida Pereira
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal; RISE-Health Research Network, University of Porto, Porto, Portugal
| | - Josep M Anto
- Department of Research & Development, ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain; Department of Medical Research & Environment, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Epidemiology of Asthma, Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Ludger Klimek
- Department of Otolaryngology, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, Germany; Center for Rhinology and Allergology, Wiesbaden, Germany
| | | | - Joaquim Mullol
- Rhinology Unit and Smell Clinic, ENT Department, Hospital Clínic, Clinical and Experimental Respiratory Immunoallergy, IDIBAPS, CIBERES, University of Barcelona, Barcelona, Spain
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Anna Bedbrook
- Department of Allergy, ARIA & MASK-air, Montpellier, France
| | - Luisa Brussino
- Department of Medical Sciences, Allergy and Clinical Immunology Unit, University of Torino and Mauriziano Hospital, Torino, Italy
| | - Violeta Kvedariene
- Department of Pathology, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Institute of Clinical Medicine, Clinic of Chest Diseases and Allergology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Desirée E Larenas-Linnemann
- Center of Excellence in Asthma and Allergy, Médica Sur Clinical Foundation and Hospital, México City, Mexico
| | - Yoshitaka Okamoto
- Department of Otorhinolaryngology, Chiba University Hospital and Chiba Rosai Hospital, Chiba, Japan
| | - Maria Teresa Ventura
- Unit of Geriatric Immunoallergology, University of Bari Medical School and Institute of Sciences of Food Production, National Research Council (Ispa-Cnr), Bari, Italy
| | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
| | - Sinthia Bosnic-Anticevich
- Quality Use of Respiratory Medicines Group, Woolcock Institute of Medical Research, Sydney, Sydney Pharmacy School, The University of Sydney, Sydney Local Health District, Sydney, NSW, Australia
| | - G Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron & ARADyAL research network, Barcelona, Spain
| | - Lorenzo Cecchi
- SOS Allergology and Clinical Immunology, USL Toscana Centro, Prato, Italy
| | - Tomas Chivato
- School of Medicine, University CEU San Pablo, Madrid, Spain
| | - Cemal Cingi
- ENT Department, Eskisehir Osmangazi University, Medical Faculty, Eskisehir, Turkey
| | - Elísio M Costa
- UCIBIO, REQUINTE, Faculty of Pharmacy and Competence Center on Active and Healthy Ageing of University of Porto (Porto4Ageing), Porto, Portugal
| | - Alvaro A Cruz
- Fundaçao ProAR, Federal University of Bahia and GARD/WHO Planning Group, Salvador, Bahia, Brazil
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital "Duilio Casula", University of Cagliari, Cagliari, Italy
| | - Philippe Devillier
- VIM Suresnes, UMR 0892, Pôle des Maladies des Voies Respiratoires, Hôpital Foch, Université Paris-Saclay, Suresnes, France
| | - Wytske J Fokkens
- Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, the Netherlands
| | - Bilun Gemicioglu
- Department of Pulmonary Diseases, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | - Igor Kaidashev
- Department of Internal Medicine, Poltava State Medical University, Poltava, Ukraine
| | - Helga Kraxner
- Department of Otorhinolaryngology, Head and Neck Surgery, Semmelweis University, Budapest, Hungary
| | - Daniel Laune
- Department Recherches & Développement, KYomed INNOV, Montpellier, France
| | - Renaud Louis
- Department of Pulmonary Medicine, CHU Liege, and GIGA I3 research group, University of Liege, Liege, Belgium
| | - Michael Makris
- Allergy Unit "D Kalogeromitros", 2nd Department of Dermatology and Venereology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Riccardo Monti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Ralph Mösges
- IMSB, Medical Faculty, University at Cologne, and ClinCompetence Cologne GmbH, Cologne, Germany
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, Gdansk, Poland
| | | | - Vincenzo Patella
- Division of Allergy and Clinical Immunology, Department of Medicine, Agency of Health ASL Salerno, "Santa Maria della Speranza" Hospital, Battipaglia, Salerno, Italy
| | - Nhân Pham-Thi
- Ecole Polytechnique Palaiseau, IRBA (Institut de Recherche bio-Médicale des Armées), Bretigny, France
| | - Frederico S Regateiro
- Allergy and Clinical Immunology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (ICBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Sietze Reitsma
- Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, the Netherlands
| | - Philip W Rouadi
- Department of Otolaryngology-Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon; Department of Otolaryngology-Head and Neck Surgery, Dar Al Shifa Hospital, Salmiya, Kuwait
| | - Boleslaw Samolinski
- Department of Prevention of Environmental Hazards, Allergology and Immunology, Medical University of Warsaw, Poland
| | - Aziz Sheikh
- Usher Institute, the University of Edinburgh, Edinburgh, UK
| | - Milan Sova
- Department of Respiratory Medicine and Tuberculosis, University Hospital, Brno, Czech Republic
| | - Luis Taborda-Barata
- UBIAir-Clinical & Experimental Lung Centre, University of Beira Interior, Covilhã and CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal; Department of Immunoallergology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - Sanna Toppila-Salmi
- Skin and Allergy Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Joaquin Sastre
- Fundacion Jimenez Diaz, CIBERES, Faculty of Medicine, Autonoma University of Madrid, Madrid, Spain
| | - Ioanna Tsiligianni
- Health Planning Unit, Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece; International Primary Care Respiratory Group IPCRG, Aberdeen, Scotland
| | - Arunas Valiulis
- Institute of Clinical Medicine and Institute of Health Sciences, Vilnius, Lithunia; Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Arzu Yorgancioglu
- Department of Pulmonary Diseases, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Mihaela Zidarn
- University Clinic of Respiratory and Allergic Diseases, Golnik & University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia
| | - Torsten Zuberbier
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Joao A Fonseca
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal; RISE-Health Research Network, University of Porto, Porto, Portugal
| | - Jean Bousquet
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; Department of Pneumology, University Hospital, Montpellier, France.
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23
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Alvarez L, Querubin J, Bedoya J, Mejia A, Sánchez J. Cost-utility analysis of dupilumab compared with endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyps. Evaluation in Colombia, a developing country. Expert Rev Pharmacoecon Outcomes Res 2023; 23:571-578. [PMID: 36976904 DOI: 10.1080/14737167.2023.2196407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Chronic rhinosinusitis with nasal polyps (CRSwNP) compromise's respiratory function, sleep, concentration, work capacity and quality of life, generating high costs for patient and health systems. The aim of the study was to analyze the cost-utility of Dupilumab compared to endoscopic sinus surgery for patients with CRSwNP. RESEARCH DESIGN AND METHODS We developed a model-based cost-utility analysis from the perspective of the Colombian health system to compare Dupilumab vs endoscopic nasal surgery in patients with difficult-to-treat CRSwNP. Transition probabilities were extracted from the published literature about CRSwNP and costing was based on local tariffs. We performed probabilistic sensitivity analysis for outcomes, probabilities, and costs (10.000 Monte Carlo simulations). RESULTS The cost of dupilumab ($ 142.919) was 7.8 times higher than nasal endoscopic sinus surgery ($ 18.347). In terms of QALYs, surgery generates better results than Dupilumab: 11.78 vs. 9.05 QALYs. CONCLUSIONS From the perspective of the health system, endoscopic sinus surgery for the management of CRSwNP is a dominant alternative in all the analyzed scenarios compared to the use of Dupilumab. From a cost-utility point of view, the use of dupilumab should be considered when the patient requires multiple surgeries or when there is a contraindication for surgeries performance.
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Affiliation(s)
- Leidy Alvarez
- Program in Health Economics Evaluation, Faculty of Medicine and Economics, University of Antioquia, Medellín Colombia
| | - Juan Querubin
- Program in Health Economics Evaluation, Faculty of Medicine and Economics, University of Antioquia, Medellín Colombia
| | - Juan Bedoya
- Otorhinolaryngology Service, University of Antioquia, Medellín Colombia
| | - Aurelio Mejia
- Program in Health Economics Evaluation, Faculty of Medicine and Economics, University of Antioquia, Medellín Colombia
| | - Jorge Sánchez
- Group of Clinical and Experimental Allergy, Hospital "Alma Mater de Antioquia", Universidad de Antioquia, Medellín, Colombia
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24
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Yao Y, Zhu HY, Zeng M, Liu Z. Immunological mechanisms and treatable traits of chronic rhinosinusitis in Asia: A narrative review. Clin Otolaryngol 2023; 48:363-370. [PMID: 36317525 DOI: 10.1111/coa.14001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/23/2022] [Accepted: 10/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To review the current literature on immunological mechanisms and treatable traits of chronic rhinosinusitis (CRS) in Asia. DESIGN This is a narrative review of published data on the immunological mechanisms and treatable traits of CRS in Asia. Published English literature on CRS in Asian and Western countries was reviewed. Where available, the data extracted included epidemiology, immunology, bacterium, phenotype, endotype and treatment. RESULTS AND CONCLUSION CRS is a heterogeneous disease characterised by persistent locoregional mucosal inflammation of the paranasal sinuses. The inflammatory signatures of CRS vary across patients with distinct racial and ethnic backgrounds and geographic areas. Compared to CRS patients in Western countries, Asian CRS patients display less eosinophilic and Type 2 inflammation, which is associated with lower asthma and allergic rhinitis comorbidities. In contrast, Asian patients with CRS have more prominent non-eosinophilic inflammation than those in Western countries. In addition, Asian CRS patients may have different bacterial colonisation than patients in Western countries. Our review suggests that the distinct immunological mechanisms between Asian and Western CRS patients may influence the clinical phenotype, responses to treatment and outcomes. The treatable trait is a new strategy and therapeutic target identified by phenotype or endotype and has been proposed as a new paradigm for the management of diseases. Improved understanding of CRS phenotypic and endotypic heterogeneity and incorporation of treatable traits into clinical care pathways may facilitate more effective selections of therapeutic interventions, including surgery and biologics.
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Affiliation(s)
- Yin Yao
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China.,Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, Hubei, People's Republic of China
| | - Hong-Yu Zhu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Ming Zeng
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China.,Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, Hubei, People's Republic of China
| | - Zheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China.,Hubei Clinical Research Center for Nasal Inflammatory Diseases, Wuhan, Hubei, People's Republic of China
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25
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Chen CC, Buchheit KM. Endotyping Chronic Rhinosinusitis with Nasal Polyps: Understanding Inflammation Beyond Phenotypes. Am J Rhinol Allergy 2023; 37:132-139. [PMID: 36848270 DOI: 10.1177/19458924221149003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogenous group of inflammatory conditions impacting the nose and paranasal sinuses. Our understanding of the underlying pathobiology of CRSwNP has substantially improved due to ongoing translational research efforts. Advances in treatment options, including targeted respiratory biologic therapy for CRSwNP, allow for more personalized approaches for CRSwNP patient care. Patients with CRSwNP are typically classified to one or more endotype based on the presence of type 1, type 2, and type 3 inflammation. This review will discuss recent advances in our understanding of CRSwNP and how this may impact current and future treatment approaches for patients with CRSwNP.
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Affiliation(s)
- Chongjia C Chen
- Department of Medicine, Harvard Medical School, the Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, MA, USA
| | - Kathleen M Buchheit
- Department of Medicine, Harvard Medical School, the Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, MA, USA
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26
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Delemarre T, Bachert C. Neutrophilic inflammation in chronic rhinosinusitis. Curr Opin Allergy Clin Immunol 2023; 23:14-21. [PMID: 36539379 DOI: 10.1097/aci.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Over the last years, extensive research has been done on neutrophils and their contribution in chronic rhinosinusitis (CRS), and made it clear that they are more than just a bystander in this disease. In this article, we will review all recent publications on this topic and look to what the future hold regarding therapeutics targeting the neutrophilic inflammation in CRS. RECENT FINDINGS Evidence is growing that the presence of neutrophils are associated with a worse disease outcome in certain CRS patient groups. They are highly activated in type 2 inflammations and exhibit damaging properties through their proteases, contributing to the chronicity of the disease. Several recent studies identified useful biomarkers and targets for future therapeutics. SUMMARY The findings we review in this manuscript are of utmost importance in unraveling the complexity of CRS and provide us with the necessary knowledge for future clinical practices.
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Affiliation(s)
- Tim Delemarre
- Upper Airways Research Laboratory, Faculty of Medicine, Ghent University, Ghent, Belgium
| | - Claus Bachert
- Upper Airways Research Laboratory, Faculty of Medicine, Ghent University, Ghent, Belgium
- Division of ENT Diseases, CLINTEC, Karolinska Institute, Stockholm, Sweden
- First Affiliated Hospital, Sun Yat-Sen University, International Airway Research Center, Guangzhou, China
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27
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Tai J, Shin JM, Park J, Han M, Kim TH. Oxidative Stress and Antioxidants in Chronic Rhinosinusitis with Nasal Polyps. Antioxidants (Basel) 2023; 12:antiox12010195. [PMID: 36671057 PMCID: PMC9854928 DOI: 10.3390/antiox12010195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Oxidative stress results from an imbalance between the production of reactive oxygen species and the body's antioxidant defense system. It plays an important role in the regulation of the immune response and can be a pathogenic factor in various diseases. Chronic rhinosinusitis (CRS) is a complex and heterogeneous disease with various phenotypes and endotypes. Recently, an increasing number of studies have proposed that oxidative stress (caused by both environmental and intrinsic stimuli) plays an important role in the pathogenesis and persistence of CRS. This has attracted the attention of several researchers. The relationship between the presence of reactive oxygen species composed of free radicals and nasal polyp pathology is a key topic receiving attention. This article reviews the role of oxidative stress in respiratory diseases, particularly CRS, and introduces potential therapeutic antioxidants that may offer targeted treatment for CRS.
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Affiliation(s)
- Junhu Tai
- Department of Otorhinolaryngology—Head & Neck Surgery, College of Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Jae-Min Shin
- Department of Otorhinolaryngology—Head & Neck Surgery, College of Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Jaehyung Park
- Department of Otorhinolaryngology—Head & Neck Surgery, College of Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Munsoo Han
- Department of Otorhinolaryngology—Head & Neck Surgery, College of Medicine, Korea University, Seoul 02841, Republic of Korea
- Mucosal Immunology Institute, College of Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Tae Hoon Kim
- Department of Otorhinolaryngology—Head & Neck Surgery, College of Medicine, Korea University, Seoul 02841, Republic of Korea
- Mucosal Immunology Institute, College of Medicine, Korea University, Seoul 02841, Republic of Korea
- Correspondence: ; Tel.: +82-02-920-5486
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28
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Backer V, Cardell LO, Lehtimäki L, Toppila-Salmi S, Bjermer L, Reitsma S, Hellings PW, Weinfeld D, Aanæs K, Ulrik CS, Braunstahl GJ, Aarli BB, Danielsen A, Kankaanranta H, Steinsvåg S, Bachert C. Multidisciplinary approaches to identifying and managing global airways disease: Expert recommendations based on qualitative discussions. FRONTIERS IN ALLERGY 2023; 4:1052386. [PMID: 36895864 PMCID: PMC9989256 DOI: 10.3389/falgy.2023.1052386] [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: 09/23/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Abstract
Background Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma frequently co-exist and share pathologic features. Taking a "global" treatment approach benefits diagnosis and treatment of both, but care is often siloed by specialty: joined-up clinics are uncommon. Our objectives were to explore expert opinion to give practical suggestions to identify adults needing global airways care; enhance cross-specialty working; and widen knowledge to support diagnosis and management, integrate with existing care pathways, and supplement existing guidelines. Methods Sixteen practicing physicians from northern Europe were invited for their national and/or international standing in treating asthma and/or chronic rhinosinusitis. Appreciative Inquiry techniques were used to guide their discussions. Results Key themes arising were screening and referral, collaboration on management, awareness and education, and research. Provided are screening criteria and suggestions for specialist referrals, and pointers for physicians to optimize their knowledge of global airways disease. Collaborative working is underscored, and practical suggestions are given for multidisciplinary teamworking within global airways clinics. Research gaps are identified. Conclusion This initiative provides practical suggestions for optimizing the care of adults with CRSwNP and asthma. Discussion of the role of allergy and drug exacerbations on these conditions, and care for patients with other global airways diseases were beyond scope; however, we expect some principles of our discussion will likely benefit patients with related conditions. The suggestions bridge asthma and CRSwNP management guidelines, envisioning interdisciplinary, global airway clinics relevant to various clinical settings. They highlight the value of joint screening for early recognition and referral of patients.
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Affiliation(s)
- Vibeke Backer
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Lars Olaf Cardell
- Division of ENT Diseases, CLINTEC, Karolinska Institute, Stockholm, Sweden.,Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sanna Toppila-Salmi
- Department of Allergology, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Sietze Reitsma
- Department of Otorhinolaryngology - Head and Neck Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands
| | - Peter W Hellings
- Department of Otorhinolaryngology - Head and Neck Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, Netherlands.,Department of Otorhinolaryngology, University Hospitals Leuven, Leuven, Belgium.,Department of Otorhinolaryngology, Upper Airways Disease Research Group, University of Ghent, Ghent, Belgium
| | - Dan Weinfeld
- Asthma and Allergy Clinic Outpatient Unit (Adults), Department of Internal Medicine, South Alvsborgs Central Hospital, Boras, Sweden
| | - Kasper Aanæs
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gert-Jan Braunstahl
- Department of Pulmonology, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands.,Department of Pulmonology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Bernt Bøgvald Aarli
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Arild Danielsen
- Department of ENT & Allergy, The Multidisciplinary Clinic "BestHelse", Oslo, Norway
| | - Hannu Kankaanranta
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sverre Steinsvåg
- Department of Otolaryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen and Sørlandet Sykehus, Kristiandsand, Norway
| | - Claus Bachert
- Division of ENT Diseases, CLINTEC, Karolinska Institute, Stockholm, Sweden.,Department of Otorhinolaryngology, Upper Airways Disease Research Group, University of Ghent, Ghent, Belgium.,Department of Otorhinolaryngology, International Airway Research Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Oka SI, Kanai K, Oka A, Kitamura H, Furutate S, Oyamada S, Takahashi M, Iwasaki S, Koike T, Mochizuki T, Okano M. A case of intractable chronic rhinosinusitis without nasal polyps leading remission after treatment switching from anti-IL-5 to anti-IL-4Rα monoclonal antibody. OTOLARYNGOLOGY CASE REPORTS 2023. [DOI: 10.1016/j.xocr.2023.100512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Olfaction in nasal polyp patients after Reboot surgery: an endotype-based prospective study. Eur Arch Otorhinolaryngol 2022; 280:2821-2830. [PMID: 36571613 PMCID: PMC9791624 DOI: 10.1007/s00405-022-07813-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE To report biomarkers present in the olfactory mucosa in chronic rhinosinusitis with nasal polyps (CRSwNP) in comparison with nasal polyps and to nasal mucosal tissues from control patients. To evaluate the kinetics of smell over 6 months in patients who underwent Reboot surgery. METHODS Cohort study from May 2021 to May 2022. We collected samples of olfactory mucosa and nasal polyps from 16 CRSwNP patients and inferior turbinate samples from 20 control subjects. The study was not randomized for surgical and/or medical treatment. Samples were analyzed by Luminex and Unicap 100 to measure biomarkers of inflammation (IL1-β, IL4, IL5, IL6, IL17, CCL3, CCL4, G-CSF, SE-IgE, total IgE and ECP). 12 of the CRSwNP patients underwent Extended Sniffin'tests at timepoints 1-4 days pre-surgery, and 1, 3 and 6 months after Reboot surgery. RESULTS Type-2 markers were significantly elevated in OM and polyp tissue in CRSwNP (n = 16) vs. controls (n = 20), P < 0.05. TDI scores improved already 1 month (P < 0.05) after surgery and remained stable for 6 months. Type-2 inflammation in nasal polyps was associated with decreased sense of smell and taste before surgery, but improved after surgery (P = 0.048). Type-3 inflammation was present in the olfactory mucosa and was associated with a better sense of smell before surgery, but a smaller improvement of smell afterward. CONCLUSIONS Type-2 inflammation is present in the olfactory mucosa in CRSwNP patients and is associated with smell loss. Reboot surgery, aiming to completely remove inflamed sinus mucosa, significantly improves the smell in this group of patients.
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Pongdee T, Bielinski SJ, Decker PA, Kita H, Larson NB. White blood cells and chronic rhinosinusitis: a Mendelian randomization study. Allergy Asthma Clin Immunol 2022; 18:98. [PMID: 36419128 PMCID: PMC9682667 DOI: 10.1186/s13223-022-00739-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Risk factors for the pathogenesis of chronic rhinosinusitis (CRS) remain largely undetermined, which is likely due to the heterogeneity of the disease. White blood cell counts have been largely unexplored as a risk factor for CRS even though different types of white blood cells are involved in the inflammatory process of CRS. OBJECTIVE To investigate causal associations between different types of white blood cells on risk of CRS utilizing a Mendelian randomization (MR) analysis. METHODS A two-sample MR analysis was performed using respective GWAS summary statistics for the exposure traits (neutrophil count, eosinophil count, basophil count, lymphocyte count, and monocyte count) and outcome trait (CRS). For the exposure traits, the European Bioinformatics Institute database of complete GWAS summary data was used. For the outcome trait, summary statistics for CRS GWAS were obtained from FinnGen. Primary analysis for MR was performed using inverse-variance weighted two-sample MR. Sensitivity analyses included weighted median, MR-Egger, and MR-PRESSO (raw and outlier-corrected). RESULTS Eosinophils were associated with CRS (OR = 1.55 [95% CI 1.38, 1.73]; p = 4.3E-14). Eosinophil results were similar across additional MR methods. MR results did not demonstrate significant causal relationships between neutrophils, lymphocytes, monocytes, or basophils with CRS. No significant pleiotropic bias was observed. CONCLUSIONS In a two-sample MR analysis, a potential causal link between blood eosinophil counts and CRS has been demonstrated. In addition, causal relationships between blood counts among other white blood cell types and CRS were not found. Further studies involving genetic variation in CRS are needed to corroborate genetic causal effects for CRS.
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Affiliation(s)
- Thanai Pongdee
- grid.66875.3a0000 0004 0459 167XDivision of Allergic Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Suzette J. Bielinski
- grid.66875.3a0000 0004 0459 167XDivision of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN USA
| | - Paul A. Decker
- grid.66875.3a0000 0004 0459 167XDivision of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN USA
| | - Hirohito Kita
- grid.417468.80000 0000 8875 6339Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, AZ USA ,grid.66875.3a0000 0004 0459 167XDepartment of Immunology, Mayo Clinic, Rochester, MN USA
| | - Nicholas B. Larson
- grid.66875.3a0000 0004 0459 167XDivision of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN USA
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Gevaert P, Han JK, Smith SG, Sousa AR, Howarth PH, Yancey SW, Chan R, Bachert C. The roles of eosinophils and interleukin-5 in the pathophysiology of chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol 2022; 12:1413-1423. [PMID: 35243803 PMCID: PMC9790271 DOI: 10.1002/alr.22994] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/10/2022] [Accepted: 03/01/2022] [Indexed: 12/30/2022]
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is generally associated with eosinophilic tissue infiltration linked to type 2 inflammation and characterized by elevated levels of interleukin (IL)-5 and other type 2 inflammatory mediators. Although distinct and overlapping contributions of eosinophils and IL-5 to CRSwNP pathology are still being explored, they are both known to play an important role in NP inflammation. Eosinophils secrete numerous type 2 inflammatory mediators including granule proteins, enzymes, cytokines, chemokines, growth factors, lipids, and oxidative products. IL-5 is critical for the differentiation, migration, activation, and survival of eosinophils but is also implicated in the biological functions of mast cells, basophils, innate lymphoid cells, B cells, and epithelial cells. Results from clinical trials of therapeutics that target type 2 inflammatory mediators (including but not limited to anti-IL-5, anti-immunoglobulin-E, and anti-IL-4/13) may provide further evidence of how eosinophils and IL-5 contribute to CRSwNP. Finally, the association between eosinophilia/elevated IL-5 and greater rates of NP recurrence after endoscopic sinus surgery (ESS) suggests that these mediators may have utility as biomarkers of NP recurrence in diagnosing and assessing the severity of CRSwNP. This review provides an overview of eosinophil and IL-5 biology and explores the literature regarding the role of these mediators in CRSwNP pathogenesis and NP recurrence following ESS. Based on current published evidence, we suggest that although eosinophils play a key role in CRSwNP pathophysiology, IL-5, a cytokine that activates these cells, also represents a pertinent and effective treatment target in patients with CRSwNP.
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Affiliation(s)
- Philippe Gevaert
- Upper Airway Research LaboratoryDepartment of OtorhinolaryngologyGhent University HospitalGhentBelgium
| | | | - Steven G. Smith
- Respiratory Medical Franchise, GSKResearch Triangle ParkNorth CarolinaUSA
| | - Ana R. Sousa
- Clinical Sciences, Respiratory, GSKBrentfordMiddlesexUK
| | - Peter H. Howarth
- Clinical and Experimental SciencesFaculty of Medicine, University of Southampton and NIHR Respiratory Biomedical Research UnitSouthampton General HospitalSouthamptonUK,Global Respiratory Franchise, GSKBrentfordMiddlesexUK
| | - Steven W. Yancey
- Respiratory Medical Franchise, GSKResearch Triangle ParkNorth CarolinaUSA
| | - Robert Chan
- Clinical Sciences, Respiratory, GSKBrentfordMiddlesexUK
| | - Claus Bachert
- Upper Airway Research LaboratoryDepartment of OtorhinolaryngologyGhent University HospitalGhentBelgium,Division of ENT DiseasesCLINTECKarolinska InstituteStockholmSweden
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Shamil E, Hopkins C. Unified Airway Disease. Otolaryngol Clin North Am 2022; 56:157-168. [DOI: 10.1016/j.otc.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Could Chronic Rhinosinusitis Increase the Risk of Ulcerative Colitis? A Nationwide Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12102344. [PMID: 36292033 PMCID: PMC9600918 DOI: 10.3390/diagnostics12102344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/29/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease of the sinonasal mucosa with an inflammatory or infectious etiology. Inflammatory bowel disease (IBD) causes chronic intestinal inflammation. Thus, both diseases share innate immune and epithelial barrier dysfunctions of the mucosa. However, the association between sinusitis and IBD is not well-known. We aimed to determine the association between CRS and the risk for IBDs, such as Crohn’s disease (CD) and ulcerative colitis (UC). In this long-term retrospective cohort study, 15,175 patients with CRS and 30,350 patients without CRS (comparison group) were enrolled after 1:2 propensity score matching. The incidence rates of CD and UC were 0.22 and 0.51 (1000 person-years), respectively. The adjusted hazard ratio (HR) for developing CD and UC in CRS patients was 1.01 (95% confidence interval (CI), 0.66–1.54) and 1.72 (95% CI, 1.26–2.36), respectively. Additionally, in the subgroup analysis using the CRS phenotype, the adjusted HRs of UC were significantly increased in patients with CRS without nasal polyps (adjusted HR = 1.71; 95% CI, 1.24–2.35), but not in those with CRS with nasal polyps. CRS without nasal polyps is associated with an increased incidence of UC but not CD. Therefore, clinicians should pay attention to the early detection of UC when treating patients with CRS without nasal polyps.
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35
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Hao D, Wu Y, Li P, Li C, Jiang T, Zhang Q, Liu S, Shi L. An Integrated Analysis of Inflammatory Endotypes and Clinical Characteristics in Chronic Rhinosinusitis with Nasal Polyps. J Inflamm Res 2022; 15:5557-5565. [PMID: 36185639 PMCID: PMC9518682 DOI: 10.2147/jir.s377301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Chronic rhinosinusitis with nasal polyps (CRSwNP) is mainly characterised by type 1 (T1), type 2 (T2) and type 3 (T3) inflammatory endotypes. However, correlations between inflammatory endotypes and clinical features in CRSwNP have not been demonstrated sufficiently. This study aimed to determine the endotype-phenotype associations in CRSwNP. Methods Clinical data of 31 control subjects and 106 CRSwNP patients were analysed. Interferon (IFN)-γ (T1), Charcot-Leyden crystal galectin (CLC) (T2) and Interleukin (IL)-17A (T3) were used as biomarkers to identify the inflammatory endotypes. Results The mRNA expression level of IFN-γ was positively correlated with IL-17A (r = 0.817; P < 0.0001). Headache/facial pain (P = 0.039) was associated with T1 endotype. Smell loss (P = 0.025) was associated with T2 endotype. Purulent rhinorrhea (P = 0.001) was associated with T3 endotype. Atopy (P = 0.030), asthma (P = 0.005) and recurrence (P = 0.022) were more frequent in T2 endotype. Total Symptom Scores (TSS) of T2 (P < 0.001) and T3 (P = 0.009) endotype were higher than non-T2 and non-T3, respectively. Sino Nasal Outcome Test-22 (SNOT-22) total scores of T3 (P = 0.054) endotype were higher than non-T3. Conclusion Identifications of endotype-phenotype associations are useful in clinical diagnoses and targeted therapies for patients with CRSwNP.
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Affiliation(s)
- Dingqian Hao
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Yisha Wu
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Ping Li
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Chunhao Li
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Tianjiao Jiang
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Qian Zhang
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Shengyang Liu
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Li Shi
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, People’s Republic of China
- Correspondence: Li Shi; Shengyang Liu, Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, 250000, People’s Republic of China, Email ;
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XBP1 Regulates the Transcription of HIF-1a in BALB/c Mice with Chronic Rhinosinusitis without Polyps. Anal Cell Pathol (Amst) 2022; 2022:3066456. [PMID: 35915851 PMCID: PMC9338878 DOI: 10.1155/2022/3066456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/25/2022] [Accepted: 05/26/2022] [Indexed: 12/03/2022] Open
Abstract
X-box binding protein 1 (XBP1) is a transcription factor that recognizes the CRE-like element in enhancers of human T-cell leukemia virus and MHC class II gene and induces their transcription. This study was performed to characterize the function of XBP1, which was identified to be a differentially expressed gene via GEO database, in chronic rhinosinusitis (CRS) without nasal polyps (CRSsNP). XBP1 expression was significantly elevated in both CRSsNP patients and mice who were accompanied with mucosal thickening, goblet cell hyperplasia and chemosis, glandular hyperplasia, and dense infiltration of inflammatory cells. Silencing of XBP1 suppressed the development of CRSsNP in mice. Mechanistically, knockdown of XBP1 downregulated the expression of hypoxia-inducible factor 1-alpha (HIF-1a), and overexpression of XBP1 led to the opposite result. Silencing of HIF-1a inhibited β-catenin expression and impaired the Wnt/β-catenin pathway. Further overexpression of HIF-1a in XBP1-silenced CRSsNP mice exacerbated pathological changes in mouse nasal mucosal tissues, promoted inflammation, and activated the Wnt/β-catenin pathway. Taken together, overexpression of XBP1 may be associated with increased expression of HIF-1a and possibly contribute to the Wnt/β-catenin pathway activation and the development of CRSsNP.
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Maspero J, Adir Y, Al-Ahmad M, Celis-Preciado CA, Colodenco FD, Giavina-Bianchi P, Lababidi H, Ledanois O, Mahoub B, Perng DW, Vazquez JC, Yorgancioglu A. Type 2 inflammation in asthma and other airway diseases. ERJ Open Res 2022; 8:00576-2021. [PMID: 35923421 PMCID: PMC9339769 DOI: 10.1183/23120541.00576-2021] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/22/2022] [Indexed: 11/24/2022] Open
Abstract
Chronic inflammatory airway diseases, including asthma, chronic rhinosinusitis, eosinophilic COPD and allergic rhinitis are a global health concern. Despite the coexistence of these diseases and their common pathophysiology, they are often managed independently, resulting in poor asthma control, continued symptoms and poor quality of life. Understanding disease pathophysiology is important for best treatment practice, reduced disease burden and improved patient outcomes. The pathophysiology of type 2 inflammation is driven by both the innate immune system triggered by pollutants, viral or fungal infections involving type 2 innate lymphoid cells (ILC2) and the adaptive immune system, triggered by contact with an allergen involving type 2 T-helper (Th2) cells. Both ILC2 and Th2 cells produce the type-2 cytokines (interleukin (IL)-4, IL-5 and IL-13), each with several roles in the inflammation cascade. IL-4 and IL-13 cause B-cell class switching and IgE production, release of pro-inflammatory mediators, barrier disruption and tissue remodelling. In addition, IL-13 causes goblet-cell hyperplasia and mucus production. All three interleukins are involved in trafficking eosinophils to tissues, producing clinical symptoms characteristic of chronic inflammatory airway diseases. Asthma is a heterogenous disease; therefore, identification of biomarkers and early targeted treatment is critical for patients inadequately managed by inhaled corticosteroids and long-acting β-agonists alone. The Global Initiative for Asthma guidelines recommend add-on biological (anti IgE, IL-5/5R, IL-4R) treatments for those not responding to standard of care. Targeted therapies, including omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab and tezepelumab, were developed on current understanding of the pathophysiology of type 2 inflammation. These therapies offer hope for improved management of type 2 inflammatory airway diseases. Asthma is a heterogenous disease. Targeted therapies have been developed based on the pathophysiology of type 2 inflammation. These therapies offer hope for improved management of type 2 inflammatory airway diseases.https://bit.ly/3HCkrvQ
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Chronic Rhinosinusitis, S. aureus Biofilm and Secreted Products, Inflammatory Responses, and Disease Severity. Biomedicines 2022; 10:biomedicines10061362. [PMID: 35740385 PMCID: PMC9220248 DOI: 10.3390/biomedicines10061362] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/06/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a persistent inflammation of the nasal cavity and paranasal sinuses associated with tissue remodelling, dysfunction of the sinuses’ natural defence mechanisms, and induction of different inflammatory clusters. The etiopathogenesis of CRS remains elusive, and both environmental factors, such as bacterial biofilms and the host’s general condition, are thought to play a role. Bacterial biofilms have significant clinical relevance due to their potential to cause resistance to antimicrobial therapy and host defenses. Despite substantial medical advances, some CRS patients suffer from recalcitrant disease that is unresponsive to medical and surgical treatments. Those patients often have nasal polyps with tissue eosinophilia, S. aureus-dominant mucosal biofilm, comorbid asthma, and a severely compromised quality of life. This review aims to summarise the contemporary knowledge of inflammatory cells/pathways in CRS, the role of bacterial biofilm, and their impact on the severity of the disease. Here, an emphasis is placed on S. aureus biofilm and its secreted products. A better understanding of these factors might offer important diagnostic and therapeutic perceptions for recalcitrant disease.
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Hopkins C, Lee SE, Klimek L, Soler ZM. Clinical Assessment of Chronic Rhinosinusitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1406-1416. [PMID: 35183784 DOI: 10.1016/j.jaip.2022.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 12/15/2022]
Abstract
Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.
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Affiliation(s)
| | - Stella E Lee
- Division of Otolaryngology-Head & Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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Heffernan A, Phulka J, Thamboo A. Improving predictability of IgE-high type 2 chronic sinusitis with nasal polyps in the biologic era. J Otolaryngol Head Neck Surg 2022; 51:22. [PMID: 35606866 PMCID: PMC9128111 DOI: 10.1186/s40463-022-00580-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 05/12/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is an inflammatory disease that may require biological therapy. Omalizumab is an anti-IgE biologic that was recently approved by the FDA and Health Canada for use in severe CRS with nasal polyps (CRSwNP) recalcitrant to intranasal corticosteroids. Dosing is based on weight and pre-treatment serum IgE, with elevated levels of the latter being an indication for biologic treatment according to EPOS and EUFOREA guidelines. The goal of this study was to identify variables that predict IgE-high type 2 inflammation and serve as indicators for biologic treatment in CRS. METHODS Patients ≥ 19 yo diagnosed with CRS undergoing functional endoscopic sinus surgery were included retrospectively. Demographics, past medical history, preoperative blood work, Lund-Mackay (LM), Lund Kennedy (LK), and SNOT-22 scores were extracted. Descriptive statistics and binary logistic regression analyses were conducted. Model superiority was based on Nagelkerke R2 scores and receiver operating characteristic curves. RESULTS Sixty-five patients, average age 49.96 ± 13.59 years, were included. Sixty-one binary logistic regression models for elevated serum IgE were created. Among the top 3 models, the best model had sensitivity, specificity, positive predictive value and negative predictive values of 82.1, 69.2, 80.0, and 72.0. All performance measures except sensitivity exceeded the Canadian Biologics Guideline model. Serum eosinophils ≥ 300 cell/uL, CRSwNP and LM ≥ 17 increased the odds of elevated IgE. CONCLUSIONS IgE-high type-2 inflammation can be predicted by a model that includes eosinophil ≥ 300 cell/uL, CRSwNP, LM ≥ 17, asthma diagnosis and SNOT-22 ≥ 40. Patients meeting these parameters have a high pretest probability for elevated IgE and would benefit from IgE serology to determine qualification for omalizumab. This could reduce unwarranted IgE serology in patients with CRSwNP but also target a patient population for further workup that will lead to optimization of resource allocation and improve healthcare equity in rural and remote areas within Canada.
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Affiliation(s)
- Austin Heffernan
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of British Columbia, 2775 Laurel Street, 4th Floor, Vancouver, BC, V5Z 1M9, Canada
| | - Jobanjit Phulka
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of British Columbia, 2775 Laurel Street, 4th Floor, Vancouver, BC, V5Z 1M9, Canada
| | - Andrew Thamboo
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of British Columbia, 2775 Laurel Street, 4th Floor, Vancouver, BC, V5Z 1M9, Canada.
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.
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41
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Calabrese C, Seccia V, Pelaia C, Spinelli F, Morini P, Rizzi A, Detoraki A. S. aureus and IgE-mediated diseases: pilot or copilot? A narrative review. Expert Rev Clin Immunol 2022; 18:639-647. [PMID: 35507006 DOI: 10.1080/1744666x.2022.2074402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION S. aureus is a major opportunistic pathogen that has been implicated in the pathogenesis of several chronic inflammatory diseases including bronchial asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), chronic spontaneous urticaria (CSU), and atopic dermatitis. S. aureus can induce the production of both polyclonal and specific IgE that can elicit an inflammatory cascade. AREAS COVERED The link between the sensitization to S. aureus enterotoxins and the severity of several chronic inflammatory diseases is reviewed in detail, as well as its therapeutic implications. EXPERT OPINION An anti-IgE strategy to inhibit S. aureus enterotoxins would be a valid approach to treat several endotypes of severe asthma, CRSwNP and CSU in which IgE against S. aureus enterotoxins should represent, not only a marker of severity of the diseases but also a target of a treatment.
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Affiliation(s)
- Cecilia Calabrese
- Department of Translational Medical Sciences, Institute of Respiratory Diseases, University of Campania "L. Vanvitelli", Naples, Italy
| | - Veronica Seccia
- Otolaryngology Audiology, and Phoniatric Operative Unit, Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Corrado Pelaia
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
| | | | | | | | - Aikaterini Detoraki
- Division of Internal Medicine and Clinical Immunology, Department of Internal Medicine, Clinical Immunology, Clinical Pathology and Infectious Diseases, Azienda Ospedaliera Universitaria Federico II, Naples, Italy
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42
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Andiappan AK, Asad M, Chua C, Sehanobish E, Ren Z, Chan XY, Lum J, Ang N, Duan K, Gersten A, Abuzeid WM, Akbar N, Gibber M, Howland S, Lee B, Rotzschke O, Porcelli SA, Jerschow E. Neutrophilic inflammation and epithelial barrier disruption in nasal polyps characterize non-steroidal anti-inflammatory drug exacerbated respiratory disease. Allergy 2022; 77:1297-1299. [PMID: 34921681 DOI: 10.1111/all.15198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/28/2021] [Accepted: 12/11/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Anand Kumar Andiappan
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Mohammad Asad
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
| | - Celine Chua
- Department of Biological Science National University of Singapore Singapore City Singapore
| | - Esha Sehanobish
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
| | - Zhen Ren
- Division of Allergy and Immunology Department of Medicine Washington University School of Medicine St Louis Missouri USA
| | - Xue Ying Chan
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Josephine Lum
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Nicholas Ang
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Kaibo Duan
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Adam Gersten
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
| | - Waleed M. Abuzeid
- Rhinology and Endoscopic Skull Base Surgery Department of Otolaryngology – Head and Neck Surgery University of Washington Seattle Washington USA
| | - Nadeem Akbar
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
| | - Marc Gibber
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
| | - Shanshan Howland
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Bernett Lee
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Olaf Rotzschke
- Singapore Immunology Network Agency for Science, Technology and Research Singapore City Singapore
| | - Steven A. Porcelli
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
| | - Elina Jerschow
- Albert Einstein College of Medicine/Montefiore Medical Center Bronx New York USA
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Chegini Z, Didehdar M, Khoshbayan A, Karami J, Yousefimashouf M, Shariati A. The role of Staphylococcus aureus enterotoxin B in chronic rhinosinusitis with nasal polyposis. Cell Commun Signal 2022; 20:29. [PMID: 35264183 PMCID: PMC8905720 DOI: 10.1186/s12964-022-00839-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/05/2022] [Indexed: 02/05/2023] Open
Abstract
CRS with nasal polyps (CRSwNP) is a multifactorial disease, and various etiological factors like bacterial superantigens are known to develop this disease. Recent studies reported that Staphylococcus aureus nasal colonization was detected in 67% of the patients with CRSwNP. Moreover, it was reported that specific IgE against S. aureus enterotoxins are discovered in almost half of the nasal tissue homogenates from nasal polyps. Thus, investigations have highlighted the role of staphylococcal enterotoxins, especially enterotoxin B (SEB), in pathogenesis of CRSwNP. The destruction of mucosal integrity was reported as a main SEB-related pathogenic mechanisms in CRSwNP. SEB activates Toll Like Receptor 2 and triggers the production of pro-inflammatory cytokines; furthermore, it induces reactive oxygen species and endoplasmic reticulum stress-induced inflammation that may cause epithelial cell integrity disruption and enhance their permeability. SEB-induced Type 2/Th2 pathway results in degranulation of eosinophils, cationic proteins production, and localized eosinophilic inflammation. Furthermore, SEB may be involved in the expression of RORC and HIF-1α in Tregs and by maintaining the inflammation in sinonasal mucosa that could have a main role in the pathogenesis of nasal polyposis. Different in vitro findings were confirmed in animal studies; however, in vivo analysis of SEB-induced nasal polyps and CRS remains unfulfilled due to the lack of appropriate animal models. Finally, after elucidating different aspects of SEB pathogenesis in CRSwNP, therapeutic agents have been tested in recent studies with some encouraging results. The purpose of this article is to summarize the most important findings regarding SEB-induced CRS and nasal polyposis. Video Abstract
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Affiliation(s)
- Zahra Chegini
- Department of Microbiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mojtaba Didehdar
- Department of Medical Parasitology and Mycology, Arak University of Medical Sciences, Arak, Iran
| | - Amin Khoshbayan
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Jafar Karami
- Molecular and Medicine Research Center, Khomein University of Medical Sciences, Khomein, Iran.,Department of Medical Laboratory Sciences, Khomein University of Medical Sciences, Khomein, Iran
| | - Milad Yousefimashouf
- Department of Medical Laboratory Sciences, Faculty of Paramedical, Borujerd Branch, Islamic Azad University, Borujerd, Iran
| | - Aref Shariati
- Molecular and Medicine Research Center, Khomein University of Medical Sciences, Khomein, Iran. .,Department of Medical Laboratory Sciences, Khomein University of Medical Sciences, Khomein, Iran.
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44
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Janson C, Bjermer L, Lehtimäki L, Kankaanranta H, Karjalainen J, Altraja A, Yasinska V, Aarli B, Rådinger M, Hellgren J, Lofdahl M, Howarth PH, Porsbjerg C. Eosinophilic airway diseases: basic science, clinical manifestations and future challenges. Eur Clin Respir J 2022; 9:2040707. [PMID: 35251534 PMCID: PMC8896196 DOI: 10.1080/20018525.2022.2040707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Eosinophils have a broad range of functions, both homeostatic and pathological, mediated through an array of cell surface receptors and specific secretory granules that promote interactions with their microenvironment. Eosinophil development, differentiation, activation, survival and recruitment are closely regulated by a number of type 2 cytokines, including interleukin (IL)-5, the key driver of eosinophilopoiesis. Evidence shows that type 2 inflammation, driven mainly by interleukin (IL)-4, IL-5 and IL-13, plays an important role in the pathophysiology of eosinophilic airway diseases, including asthma, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Several biologic therapies have been developed to suppress type 2 inflammation, namely mepolizumab, reslizumab, benralizumab, dupilumab, omalizumab and tezepelumab. While these therapies have been associated with clinical benefits in a range of eosinophilic diseases, their development has highlighted several challenges and directions for future research. These include the need for further information on disease progression and identification of treatable traits, including clinical characteristics or biomarkers that will improve the prediction of treatment response. The Nordic countries have a long tradition of collaboration using patient registries and Nordic asthma registries provide unique opportunities to address these research questions. One example of such a registry is the NORdic Dataset for aSThmA Research (NORDSTAR), a longitudinal population-based dataset containing all 3.3 million individuals with asthma from four Nordic countries (Denmark, Finland, Norway and Sweden). Large-scale, real-world registry data such as those from Nordic countries may provide important information regarding the progression of eosinophilic asthma, in addition to clinical characteristics or biomarkers that could allow targeted treatment and ensure optimal patient outcomes.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skane University Hospital, Lund, Sweden
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Hannu Kankaanranta
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Alan Altraja
- Department of Pulmonology, University of Tartu and Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Valentyna Yasinska
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge, Sweden
| | - Bernt Aarli
- Department of Clinical Science, University of Bergen and Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Madeleine Rådinger
- Krefting Research Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Johan Hellgren
- Department of Otorhinolaryngology, University of Gothenburg, Gothenburg, Sweden
| | | | - Peter H Howarth
- Respiratory Medical Franchise, GSK, Brentford, Middlesex, UK
| | - Celeste Porsbjerg
- Department of Respiratory Medicine, Bispebjerg Hospital and Copenhagen University, Copenhagen, Denmark
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45
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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: 83] [Impact Index Per Article: 41.5] [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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46
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Van Nevel S, Declercq J, Holtappels G, Lambrecht BN, Bachert C. Granulocyte Colony-Stimulating Factor: Missing Link for Stratification of Type 2-high and Type 2-low Chronic Rhinosinusitis Patients. J Allergy Clin Immunol 2022; 149:1655-1665.e5. [DOI: 10.1016/j.jaci.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/08/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
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47
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Mueller SK. The Role of Exosomes in the Pathophysiology of Chronic Rhinosinusitis. Front Cell Infect Microbiol 2022; 11:812920. [PMID: 35155273 PMCID: PMC8837187 DOI: 10.3389/fcimb.2021.812920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022] Open
Abstract
Non-invasive biomarker analysis has made repetitive and painless sampling over time possible. Exosomes are being released from a parent cell and their cargo mirrors the cell micromilieu of the parent cell. Therefore, exosomes are promising surrogates for their parent cells. That is also why exosomes provide an improved signal-to-noise ratio. Current studies have identified valid non-invasive biomarkers that may be able to monitor disease severity. Exosomes are suggested to play an important role in interepithelial communication and are suggested to play a role in the initiation and maintenance of inflammation in CRS. They are, however, also involved simultaneously in several immunological processes including immune protection and immunosuppression. As the isolation of exosomes is time-consuming their value in everyday routine diagnostics has yet to be determined.
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Gevaert P, Bachert C, Maspero JF, Cuevas M, Steele D, Acharya S, Altman P. Phase 3b randomized controlled trial of fevipiprant in patients with nasal polyposis with asthma (THUNDER). J Allergy Clin Immunol 2022; 149:1675-1682.e3. [DOI: 10.1016/j.jaci.2021.12.759] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
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Xu Z, Huang Y, Delemarre T, Cavaliere C, Zhang N, Bachert C. Advances in chronic rhinosinusitis in 2020 and 2021. J Allergy Clin Immunol 2021; 149:854-866. [PMID: 34973298 DOI: 10.1016/j.jaci.2021.12.782] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 01/11/2023]
Abstract
Major progress has been achieved in the understanding and clinical practice of chronic rhinosinusitis, with or without nasal polyps. These advances resulted in a better understanding of the pathophysiology, the distribution into subgroups, and consequently in a better management perspective using classical approaches and biologics. Pathomechanisms, endotypes and biomarkers, and finally innovative therapeutic approaches are themes especially for the more severe forms of chronic rhinosinusitis, those with uncontrolled severe nasal polyps. Biologicals against key type 2 cytokines are gaining ground in the long-term treatment approaches of often recurrent nasal polyps, and should be integrated in care pathways making use of classical and innovative treatment pathways. These areas of interest show a fast development and will profoundly change our disease management within a decade.
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Affiliation(s)
- Zhaofeng Xu
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium; Sun Yat-sen Medical University, First Affiliated Hospital, Guangzhou, China
| | - Yanran Huang
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium; Department of ORLHNS, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Tim Delemarre
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium
| | - Carlo Cavaliere
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Nan Zhang
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium
| | - Claus Bachert
- Upper Airways Research Laboratory, Ghent University, Ghent, Belgium; Sun Yat-sen Medical University, First Affiliated Hospital, Guangzhou, China; Division of ENT Diseases, CLINTEC, Karolinska Institute, Stockholm, Sweden.
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50
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Jiang L, Zeng Y, Huang Z, Tang Y, Zeng Q, Liu W, Shi J. Immunopathologic characteristics of Chinese pediatric patients with chronic rhinosinusitis. World Allergy Organ J 2021; 14:100616. [PMID: 34934474 PMCID: PMC8654981 DOI: 10.1016/j.waojou.2021.100616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/21/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background The histopathology of pediatric chronic rhinosinusitis with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) is rarely reported due to low prevalence or the unavailability of tissue samples. Hence, we aimed to characterize and compare the histologic features and protein expression of Th1/Th2/Th17-related cytokines in pediatric CRSsNP and CRSwNP. Methods The histologic characteristics of 15 children with CRSsNP, 52 children with CRSwNP, and 12 control participants were analyzed using hematoxylin and eosin staining. The expression of Th1/Th2/Th17-related cytokines were examined using immunohistochemistry and the enzyme-linked immunosorbent assay. Results Pediatric subjects with CRSwNP had more intact epithelium and less submucosal mucous glands compared to those with CRSsNP. Tissue eosinophils were more prevalent in the younger CRSwNP group compared to the older CRSwNP or the CRSsNP groups. The protein concentrations of Th2 cytokines were significantly higher in the CRSwNP group than the CRSsNP group or the control group. Moreover, the protein concentrations of Th17 cytokines were significantly higher in the younger CRSwNP group than the older CRSwNP group or the CRSsNP and control groups. The protein concentrations of Th1 and Th17 cytokines were also significantly higher in the CRSsNP group than the control group. Compared with non-eosinophilic CRSwNP, eosinophilic CRSwNP presented with elevated protein concentrations of Th1 and Th17 cytokines. Conclusion For the first time, we showed that pediatric CRSwNP presents as eosinophilic with Th2/Th17 inflammation, whereas CRSsNP presents as Th1/Th17 inflammation. Our study may provide a theoretical basis for the precise treatment of pediatric CRS in the future.
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Affiliation(s)
- Lijie Jiang
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Yinhui Zeng
- Department of Otolaryngology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zhaoqi Huang
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Yiquan Tang
- Department of Otolaryngology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qingxiang Zeng
- Department of Otolaryngology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenlong Liu
- Department of Otolaryngology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jianbo Shi
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
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