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Fuchs T, Zlamy M, Zöggeler T, Appelt D, Niedermayr K, Siedl A, Gasser V, Eder J, Ellemunter H. Detection of cytokines in nasal lavage samples of patients with cystic fibrosis: comparison of two different cytokine detection assays. BMC Pulm Med 2024; 24:286. [PMID: 38890643 PMCID: PMC11186286 DOI: 10.1186/s12890-024-03103-9] [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: 11/20/2023] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Cystic fibrosis (CF) is a genetic multisystem disorder. Inflammatory processes, which presumably begin early in infancy, play a crucial role in the progression of the disease. The detection of inflammatory biomarkers, especially in the airways, has therefore gained increasing attention. Due to improved treatment options, patients with CF produce less sputum. Nasal lavage samples therefore represent a promising alternative to induced sputum or bronchoalveolar lavage specimens. However, methodology of cytokine measurements is not standardised and comparisons of results are therefore often difficult. The aim of this study was to identify suitable detection methods of cytokines in nasal lavage samples by comparison of two different assays. METHODS Nasal lavage samples were obtained from the same patient at the same time by trained respiratory physiotherapists using a disposable syringe and 10 ml of 0.9% sodium chloride per nostril during outpatient visits. The cytokines IL-17 A, IL-2, IL-6 and IL-10 were measured using two different assays (BD™ and Milliplex®), which have already been applied in sputum and nasal lavage samples, despite different lower detection limits. RESULTS 22 participants were included in the study. In 95.5% of measurements, values were below the limit of detection with respect to the BD™ assay. Only IL-6 could be detected in approximately half of the patients. Individual cytokine levels were considerably higher when measured with Milliplex®, which is also reflected in a statistically significant manner (p = < 0.01). CONCLUSION The right choice of analysis method is crucial for measuring inflammatory markers in nasal lavage samples. Compared to the literature, Milliplex® showed higher detection rates and similar concentrations to other studies. TRIAL REGISTRATION Ethics approval was obtained from the ethics committee at Medical University of Innsbruck (EK Nr: 1055/2022).
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Affiliation(s)
- Teresa Fuchs
- Department of Pediatrics III, Cystic Fibrosis Centre Innsbruck, Medical University of Innsbruck, Innsbruck, Austria.
| | - Manuela Zlamy
- Tiroler Gesundheitsfond, Amt der Tiroler Landesregierung, Innsbruck, Austria
| | - Thomas Zöggeler
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Dorothea Appelt
- Department of Pediatrics III, Cystic Fibrosis Centre Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
| | - Katharina Niedermayr
- Department of Pediatrics I, Cystic Fibrosis Centre Innsbruck, Tirol Kliniken, Innsbruck, Austria
| | - Anja Siedl
- Department of Pediatrics I, Cystic Fibrosis Centre Innsbruck, Tirol Kliniken, Innsbruck, Austria
| | - Verena Gasser
- Department of Pediatrics I, Cystic Fibrosis Centre Innsbruck, Tirol Kliniken, Innsbruck, Austria
| | - Johannes Eder
- Department of Pediatrics I, Cystic Fibrosis Centre Innsbruck, Tirol Kliniken, Innsbruck, Austria
| | - Helmut Ellemunter
- Department of Pediatrics III, Cystic Fibrosis Centre Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
- Medical University of Innsbruck, Austria, Medical Research Affiliate, Innsbruck, Austria
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Jarosz-Griffiths HH, Gillgrass L, Caley LR, Spoletini G, Clifton IJ, Etherington C, Savic S, McDermott MF, Peckham D. Anti-inflammatory effects of elexacaftor/tezacaftor/ivacaftor in adults with cystic fibrosis heterozygous for F508del. PLoS One 2024; 19:e0304555. [PMID: 38820269 PMCID: PMC11142445 DOI: 10.1371/journal.pone.0304555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 05/14/2024] [Indexed: 06/02/2024] Open
Abstract
Inflammation is a key driver in the pathogenesis of cystic fibrosis (CF). We assessed the effectiveness of elexacaftor/tezacaftor/ivacaftor (ETI) therapy on downregulating systemic and immune cell-derived inflammatory cytokines. We also monitored the impact of ETI therapy on clinical outcome. Adults with CF, heterozygous for F508del (n = 19), were assessed at baseline, one month and three months following ETI therapy, and clinical outcomes were measured, including sweat chloride, lung function, weight, neutrophil count and C-reactive protein (CRP). Cytokine quantifications were measured in serum and following stimulation of peripheral blood mononuclear cells (PBMCs) with lipopolysaccharide (LPS) and adenosine triphosphate and analysed using LEGEND plex™ Human Inflammation Panel 1 by flow cytometry (n = 19). ASC specks were measured in serum and caspase-1 activity and mRNA levels determined from stimulated PBMCs were determined. Patients remained stable over the study period. ETI therapy resulted in decreased sweat chloride concentrations (p < 0.0001), CRP (p = 0.0112) and neutrophil count (p = 0.0216) and increased percent predicted forced expiratory volume (ppFEV1) (p = 0.0399) from baseline to three months, alongside a trend increase in weight. Three months of ETI significantly decreased IL-18 (p< 0.0011, p < 0.0001), IL-1β (p<0.0013, p = 0.0476), IL-6 (p = 0.0109, p = 0.0216) and TNF (p = 0.0028, p = 0.0033) levels in CF serum and following PBMCs stimulation respectively. The corresponding mRNA levels were also found to be reduced in stimulated PBMCs, as well as reduced ASC specks and caspase-1 levels, indicative of NLRP3-mediated production of pro-inflammatory cytokines, IL-1β and IL-18. While ETI therapy is highly effective at reducing sweat chloride and improving lung function, it also displays potent anti-inflammatory properties, which are likely to contribute to improved long-term clinical outcomes.
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Affiliation(s)
| | - Lindsey Gillgrass
- Adult Cystic Fibrosis Unit, St James’s University Hospital, Leeds, United Kingdom
| | - Laura R. Caley
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Giulia Spoletini
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
- Adult Cystic Fibrosis Unit, St James’s University Hospital, Leeds, United Kingdom
| | - Ian J. Clifton
- Adult Cystic Fibrosis Unit, St James’s University Hospital, Leeds, United Kingdom
| | | | - Sinisa Savic
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Michael F. McDermott
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Daniel Peckham
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
- Adult Cystic Fibrosis Unit, St James’s University Hospital, Leeds, United Kingdom
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3
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Abrami M, Biasin A, Tescione F, Tierno D, Dapas B, Carbone A, Grassi G, Conese M, Di Gioia S, Larobina D, Grassi M. Mucus Structure, Viscoelastic Properties, and Composition in Chronic Respiratory Diseases. Int J Mol Sci 2024; 25:1933. [PMID: 38339210 PMCID: PMC10856136 DOI: 10.3390/ijms25031933] [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: 12/31/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
The respiratory mucus, a viscoelastic gel, effectuates a primary line of the airway defense when operated by the mucociliary clearance. In chronic respiratory diseases (CRDs), such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF), the mucus is overproduced and its solid content augments, changing its structure and viscoelastic properties and determining a derangement of essential defense mechanisms against opportunistic microbial (virus and bacteria) pathogens. This ensues in damaging of the airways, leading to a vicious cycle of obstruction and infection responsible for the harsh clinical evolution of these CRDs. Here, we review the essential features of normal and pathological mucus (i.e., sputum in CF, COPD, and asthma), i.e., mucin content, structure (mesh size), micro/macro-rheology, pH, and osmotic pressure, ending with the awareness that sputum biomarkers (mucins, inflammatory proteins and peptides, and metabolites) might serve to indicate acute exacerbation and response to therapies. There are some indications that old and novel treatments may change the structure, viscoelastic properties, and biomarker content of sputum; however, a wealth of work is still needed to embrace these measures as correlates of disease severity in association with (or even as substitutes of) pulmonary functional tests.
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Affiliation(s)
- Michela Abrami
- Department of Engineering and Architecture, University of Trieste, Via Valerio 6/A, I-34127 Trieste, Italy; (M.A.); (A.B.); (M.G.)
| | - Alice Biasin
- Department of Engineering and Architecture, University of Trieste, Via Valerio 6/A, I-34127 Trieste, Italy; (M.A.); (A.B.); (M.G.)
| | - Fabiana Tescione
- Institute of Polymers, Composites and Biomaterials, National Research Council of Italy, P.le E. Fermi 1, I-80055 Portici, Italy; (F.T.); (D.L.)
| | - Domenico Tierno
- Clinical Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, University of Trieste, Strada di Fiume 447, I-34149 Trieste, Italy; (D.T.); (G.G.)
| | - Barbara Dapas
- Department of Chemical and Pharmaceutical Sciences, University of Trieste, Via L. Giorgieri 1, I-34127 Trieste, Italy;
| | - Annalucia Carbone
- Department of Clinical and Experimental Medicine, University of Foggia, Via Napoli 121, I-71122 Foggia, Italy; (A.C.); (S.D.G.)
| | - Gabriele Grassi
- Clinical Department of Medical, Surgical and Health Sciences, Cattinara University Hospital, University of Trieste, Strada di Fiume 447, I-34149 Trieste, Italy; (D.T.); (G.G.)
| | - Massimo Conese
- Department of Clinical and Experimental Medicine, University of Foggia, Via Napoli 121, I-71122 Foggia, Italy; (A.C.); (S.D.G.)
| | - Sante Di Gioia
- Department of Clinical and Experimental Medicine, University of Foggia, Via Napoli 121, I-71122 Foggia, Italy; (A.C.); (S.D.G.)
| | - Domenico Larobina
- Institute of Polymers, Composites and Biomaterials, National Research Council of Italy, P.le E. Fermi 1, I-80055 Portici, Italy; (F.T.); (D.L.)
| | - Mario Grassi
- Department of Engineering and Architecture, University of Trieste, Via Valerio 6/A, I-34127 Trieste, Italy; (M.A.); (A.B.); (M.G.)
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Bacalhau M, Camargo M, Lopes-Pacheco M. Laboratory Tools to Predict CFTR Modulator Therapy Effectiveness and to Monitor Disease Severity in Cystic Fibrosis. J Pers Med 2024; 14:93. [PMID: 38248793 PMCID: PMC10820563 DOI: 10.3390/jpm14010093] [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: 12/11/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
The implementation of cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator drugs into clinical practice has been attaining remarkable therapeutic outcomes for CF, a life-threatening autosomal recessive genetic disease. However, there is elevated CFTR allelic heterogeneity, and various individuals carrying (ultra)rare CF genotypes remain without any approved modulator therapy. Novel translational model systems based on individuals' own cells/tissue are now available and can be used to interrogate in vitro CFTR modulator responses and establish correlations of these assessments with clinical features, aiming to provide prediction of therapeutic effectiveness. Furthermore, because CF is a progressive disease, assessment of biomarkers in routine care is fundamental in monitoring treatment effectiveness and disease severity. In the first part of this review, we aimed to focus on the utility of individual-derived in vitro models (such as bronchial/nasal epithelial cells and airway/intestinal organoids) to identify potential responders and expand personalized CF care. Thereafter, we discussed the usage of CF inflammatory biomarkers derived from blood, bronchoalveolar lavage fluid, and sputum to routinely monitor treatment effectiveness and disease progression. Finally, we summarized the progress in investigating extracellular vesicles as a robust and reliable source of biomarkers and the identification of microRNAs related to CFTR regulation and CF inflammation as novel biomarkers, which may provide valuable information for disease prognosis.
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Affiliation(s)
- Mafalda Bacalhau
- Biosystems & Integrative Sciences Institute (BioISI), Faculty of Sciences, University of Lisbon, 1749-016 Lisbon, Portugal;
| | - Mariana Camargo
- Department of Surgery, Division of Urology, Sao Paulo Federal University, Sao Paulo 04039-060, SP, Brazil
| | - Miquéias Lopes-Pacheco
- Biosystems & Integrative Sciences Institute (BioISI), Faculty of Sciences, University of Lisbon, 1749-016 Lisbon, Portugal;
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5
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Hisert KB, Birket SE, Clancy JP, Downey DG, Engelhardt JF, Fajac I, Gray RD, Lachowicz-Scroggins ME, Mayer-Hamblett N, Thibodeau P, Tuggle KL, Wainwright CE, De Boeck K. Understanding and addressing the needs of people with cystic fibrosis in the era of CFTR modulator therapy. THE LANCET. RESPIRATORY MEDICINE 2023; 11:916-931. [PMID: 37699420 DOI: 10.1016/s2213-2600(23)00324-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/07/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
Cystic fibrosis is a multiorgan disease caused by impaired function of the cystic fibrosis transmembrane conductance regulator (CFTR). Since the introduction of the CFTR modulator combination elexacaftor-tezacaftor-ivacaftor (ETI), which acts directly on mutant CFTR to enhance its activity, most people with cystic fibrosis (pwCF) have seen pronounced reductions in symptoms, and studies project marked increases in life expectancy for pwCF who are eligible for ETI. However, modulator therapy has not cured cystic fibrosis and the success of CFTR modulators has resulted in immediate questions about the new state of cystic fibrosis disease and clinical challenges in the care of pwCF. In this Series paper, we summarise key questions about cystic fibrosis disease in the era of modulator therapy, highlighting state-of-the-art research and clinical practices, knowledge gaps, new challenges faced by pwCF and the potential for future health-care challenges, and the pressing need for additional therapies to treat the underlying genetic or molecular causes of cystic fibrosis.
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Affiliation(s)
| | - Susan E Birket
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - John F Engelhardt
- Department of Anatomy and Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Isabelle Fajac
- Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Robert D Gray
- Institution of Regeneration and Repair, Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | | | - Nicole Mayer-Hamblett
- Department of Pediatrics, Department of Biostatistics, Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
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6
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Lepissier A, Bonnel AS, Wizla N, Weiss L, Mittaine M, Bessaci K, Kerem E, Houdouin V, Reix P, Marguet C, Sermet-Gaudelus I. Moving the Dial on Airway Inflammation in Response to Trikafta in Adolescents with Cystic Fibrosis. Am J Respir Crit Care Med 2023; 207:792-795. [PMID: 36599047 PMCID: PMC10037474 DOI: 10.1164/rccm.202210-1938le] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
| | - Anne Sophie Bonnel
- Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Hôpital André Mignot, Le Chesnay, France
| | | | | | | | | | - Eitan Kerem
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Philippe Reix
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- UMR 5558 CNRS Equipe EMET Université Claude Bernard Lyon 1, Lyon, France
| | - Christophe Marguet
- CHU de Rouen, Rouen, France
- UMR 1311, Université de Normandie, Rouen, France
| | - Isabelle Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Paris, France
- Hôpital Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
- Université Paris Cité, Paris, France
- European Respiratory Network-Lung, Frankfurt, Germany
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7
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Barr HL, Bihouee T, Zwitserloot AM. A year in review: Real world evidence, functional monitoring and emerging therapeutics in 2021. J Cyst Fibros 2022; 21:191-196. [PMID: 35272931 PMCID: PMC8900606 DOI: 10.1016/j.jcf.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 12/20/2022]
Affiliation(s)
- H L Barr
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Nottingham Respiratory Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.
| | - T Bihouee
- Chronic Childhood Diseases unit, Pediatric Department, Nantes University Hospital, Nantes, France
| | - A M Zwitserloot
- University of Groningen, Department of Pediatric Pulmonology and Pediatric Allergy, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
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8
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Landini N, Ciet P, Janssens HM, Bertolo S, Ros M, Mattone M, Catalano C, Majo F, Costa S, Gramegna A, Lucca F, Parisi GF, Saba L, Tiddens HAWM, Morana G. Management of respiratory tract exacerbations in people with cystic fibrosis: Focus on imaging. Front Pediatr 2022; 10:1084313. [PMID: 36814432 PMCID: PMC9940849 DOI: 10.3389/fped.2022.1084313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/28/2022] [Indexed: 02/09/2023] Open
Abstract
Respiratory tract exacerbations play a crucial role in progressive lung damage of people with cystic fibrosis, representing a major determinant in the loss of functional lung tissue, quality of life and patient survival. Detection and monitoring of respiratory tract exacerbations are challenging for clinicians, since under- and over-treatment convey several risks for the patient. Although various diagnostic and monitoring tools are available, their implementation is hampered by the current definition of respiratory tract exacerbation, which lacks objective "cut-offs" for clinical and lung function parameters. In particular, the latter shows a large variability, making the current 10% change in spirometry outcomes an unreliable threshold to detect exacerbation. Moreover, spirometry cannot be reliably performed in preschool children and new emerging tools, such as the forced oscillation technique, are still complementary and need more validation. Therefore, lung imaging is a key in providing respiratory tract exacerbation-related structural and functional information. However, imaging encompasses several diagnostic options, each with different advantages and limitations; for instance, conventional chest radiography, the most used radiological technique, may lack sensitivity and specificity in respiratory tract exacerbations diagnosis. Other methods, including computed tomography, positron emission tomography and magnetic resonance imaging, are limited by either radiation safety issues or the need for anesthesia in uncooperative patients. Finally, lung ultrasound has been proposed as a safe bedside option but it is highly operator-dependent and there is no strong evidence of its possible use during respiratory tract exacerbation. This review summarizes the clinical challenges of respiratory tract exacerbations in patients with cystic fibrosis with a special focus on imaging. Firstly, the definition of respiratory tract exacerbation is examined, while diagnostic and monitoring tools are briefly described to set the scene. This is followed by advantages and disadvantages of each imaging technique, concluding with a diagnostic imaging algorithm for disease monitoring during respiratory tract exacerbation in the cystic fibrosis patient.
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Affiliation(s)
- Nicholas Landini
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Pierluigi Ciet
- Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia, Rotterdam, Netherlands.,Department of Radiology, University Cagliari, Cagliari, Italy.,Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Silvia Bertolo
- Department of Radiology, S. Maria Ca'Foncello Regional Hospital, Treviso, Italy
| | - Mirco Ros
- Department of Pediatrics, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Monica Mattone
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Fabio Majo
- Pediatric Pulmonology & Cystic Fibrosis Unit Bambino Gesú Children's Hospital, IRCCS Rome, Rome, Italy
| | - Stefano Costa
- Department of Pediatrics, Gaetano Martino Hospital, Messina, Italy
| | - Andrea Gramegna
- Department of Pathophisiology and Transplantation, University of Milan, Milan, Italy.,Respiratory Disease and Adult Cystic Fibrosis Centre, Internal Medicine Department, IRCCS Ca' Granda, Milan, Italy
| | - Francesca Lucca
- Regional Reference Cystic Fibrosis Center, University Hospital of Verona, Verona, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Luca Saba
- Department of Radiology, University Cagliari, Cagliari, Italy
| | - Harm A W M Tiddens
- Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia, Rotterdam, Netherlands.,Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Giovanni Morana
- Department of Radiology, S. Maria Ca'Foncello Regional Hospital, Treviso, Italy
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