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Rulff H, Schmidt RF, Wei LF, Fentker K, Kerkhoff Y, Mertins P, Mall MA, Lauster D, Gradzielski M. Comprehensive Characterization of the Viscoelastic Properties of Bovine Submaxillary Mucin (BSM) Hydrogels and the Effect of Additives. Biomacromolecules 2024; 25:4014-4029. [PMID: 38832927 PMCID: PMC11238336 DOI: 10.1021/acs.biomac.4c00153] [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: 06/06/2024]
Abstract
This study presents a comprehensive characterization of the viscoelastic and structural properties of bovine submaxillary mucin (BSM), which is widely used as a commercial source to conduct mucus-related research. We conducted concentration studies of BSM and examined the effects of various additives, NaCl, CaCl2, MgCl2, lysozyme, and DNA, on its rheological behavior. A notable connection between BSM concentration and viscoelastic properties was observed, particularly under varying ionic conditions. The rheological spectra could be well described by a fractional Kelvin-Voigt model with a minimum of model parameters. A detailed proteomics analysis provided insight into the protein, especially mucin composition within BSM, showing MUC19 as the main component. Cryo-scanning electron microscopy enabled the visualization of the porous BSM network structure. These investigations give us a more profound comprehension of the BSM properties, especially those pertaining to viscoelasticity, and how they are influenced by concentration and environmental conditions, aspects relevant to the field of mucus research.
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Affiliation(s)
- Hanna Rulff
- Institute of Chemistry, Technische Universität Berlin, 10623 Berlin, Germany
| | - Robert F Schmidt
- Institute of Chemistry, Technische Universität Berlin, 10623 Berlin, Germany
| | - Ling-Fang Wei
- Institute of Pharmacy, Freie Universität Berlin, 14195 Berlin, Germany
| | - Kerstin Fentker
- Proteomics Platform, Max-Delbrück-Center for Molecular Medicine, 13125 Berlin, Germany
- Institute of Chemistry and Biochemistry, Freie Universität Berlin, 14195 Berlin, Germany
| | - Yannic Kerkhoff
- Research Center of Electron Microscopy, Institute of Chemistry and Biochemistry, Freie Universität Berlin, 14195 Berlin, Germany
| | - Philipp Mertins
- Proteomics Platform, Max-Delbrück-Center for Molecular Medicine, 13125 Berlin, Germany
- Berlin Institute of Health at Charite, Universitätsmedizin Berlin, 10178 Berlin, Germany
| | - Marcus A Mall
- Berlin Institute of Health at Charite, Universitätsmedizin Berlin, 10178 Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charite, Universitätsmedizin Berlin, 13353 Berlin, Germany
- German Centre for Lung Research (DZL), Associated Partner Site, 13353 Berlin, Germany
| | - Daniel Lauster
- Institute of Pharmacy, Freie Universität Berlin, 14195 Berlin, Germany
| | - Michael Gradzielski
- Institute of Chemistry, Technische Universität Berlin, 10623 Berlin, Germany
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2
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Chen Q, Cai P, Chang THW, Burgener E, Kratochvil MJ, Gupta A, Hargill A, Secor PR, Nielsen JE, Barron AE, Milla C, Heilshorn SC, Spakowitz A, Bollyky PL. Pf bacteriophages hinder sputum antibiotic diffusion via electrostatic binding. SCIENCE ADVANCES 2024; 10:eadl5576. [PMID: 38820163 PMCID: PMC11141622 DOI: 10.1126/sciadv.adl5576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/30/2024] [Indexed: 06/02/2024]
Abstract
Despite great progress in the field, chronic Pseudomonas aeruginosa (Pa) infections remain a major cause of mortality in patients with cystic fibrosis (pwCF), necessitating treatment with antibiotics. Pf is a filamentous bacteriophage produced by Pa and acts as a structural element in Pa biofilms. Pf presence has been associated with antibiotic resistance and poor outcomes in pwCF, although the underlying mechanisms are unclear. We have investigated how Pf and sputum biopolymers impede antibiotic diffusion using pwCF sputum and fluorescent recovery after photobleaching. We demonstrate that tobramycin interacts with Pf and sputum polymers through electrostatic interactions. We also developed a set of mathematical models to analyze the complex observations. Our analysis suggests that Pf in sputum reduces the diffusion of charged antibiotics due to a greater binding constant associated with organized liquid crystalline structures formed between Pf and sputum polymers. This study provides insights into antibiotic tolerance mechanisms in chronic Pa infections and may offer potential strategies for novel therapeutic approaches.
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Affiliation(s)
- Qingquan Chen
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Pam Cai
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305, USA
| | - Tony Hong Wei Chang
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Elizabeth Burgener
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305, USA
- Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA
| | - Michael J Kratochvil
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305, USA
| | - Aditi Gupta
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Aviv Hargill
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
| | - Patrick R Secor
- Division of Biological Sciences, University of Montana, Missoula, MT 59812, USA
| | - Josefine Eilsø Nielsen
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, USA
- Department of Science and Environment, Roskilde University, 4000 Roskilde, Denmark
| | - Annelise E Barron
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, USA
| | - Carlos Milla
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305, USA
| | - Sarah C Heilshorn
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305, USA
| | - Andy Spakowitz
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305, USA
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305, USA
| | - Paul L Bollyky
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305, USA
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3
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Chen Q, Cai P, Chang THW, Burgener E, Kratochvil MJ, Gupta A, Hargil A, Secor PR, Nielsen JE, Barron AE, Milla C, Heilshorn SC, Spakowitz A, Bollyky PL. Pf bacteriophages hinder sputum antibiotic diffusion via electrostatic binding. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.10.584330. [PMID: 38496625 PMCID: PMC10942440 DOI: 10.1101/2024.03.10.584330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Despite great progress in the field, chronic Pseudomonas aeruginosa (Pa) infections remain a major cause of morbidity and mortality in patients with cystic fibrosis, necessitating treatment with inhaled antibiotics. Pf phage is a filamentous bacteriophage produced by Pa that has been reported to act as a structural element in Pa biofilms. Pf presence has been associated with resistance to antibiotics and poor outcomes in cystic fibrosis, though the underlying mechanisms are unclear. Here, we have investigated how Pf phages and sputum biopolymers impede antibiotic diffusion using human sputum samples and fluorescent recovery after photobleaching. We demonstrate that tobramycin interacts with Pf phages and sputum polymers through electrostatic interactions. We also developed a set of mathematical models to analyze the complex observations. Our analysis suggests that Pf phages in sputum reduce the diffusion of charged antibiotics due to a greater binding constant associated with organized liquid crystalline structures formed between Pf phages and sputum polymers. This study provides insights into antibiotic tolerance mechanisms in chronic Pa infections and may offer potential strategies for novel therapeutic approaches.
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Affiliation(s)
- Qingquan Chen
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Pam Cai
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305
| | - Tony Hong Wei Chang
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Elizabeth Burgener
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305
- Children’s Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027
| | - Michael J. Kratochvil
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305
| | - Aditi Gupta
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Aviv Hargil
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
| | - Patrick R. Secor
- Division of Biological Sciences, University of Montana, United States
| | - Josefine Eilsø Nielsen
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, United States
- Department of Science and Environment, Roskilde University, 4000 Roskilde, Denmark
| | - Annelise E. Barron
- Department of Bioengineering, School of Medicine & School of Engineering, Stanford University, Stanford, CA 94305, United States
| | - Carlos Milla
- Center for Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University, Stanford, CA 94305
| | - Sarah C. Heilshorn
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305
| | - Andy Spakowitz
- Department of Chemical Engineering, Stanford University, Stanford, CA, 94305
- Department of Materials Science and Engineering, Stanford University, 476 Lomita Mall, Stanford, CA 94305
| | - Paul L. Bollyky
- Division of Infectious Diseases and Geographic Medicine, Dept. of Medicine, Stanford University School of Medicine, Beckman Center, 279 Campus Drive, Stanford, CA 94305
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4
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Gold LS, Hansen RN, Mayer-Hamblett N, Nichols DP, Gifford AH, Kloster M, Goss CH, Kessler L. The cost of simplifying treatments for cystic fibrosis: Implications of the SIMPLIFY trial. J Manag Care Spec Pharm 2024; 30:26-33. [PMID: 38153868 PMCID: PMC10775778 DOI: 10.18553/jmcp.2024.30.1.26] [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] [Indexed: 12/30/2023]
Abstract
BACKGROUND Dornase alfa and hypertonic saline are mucoactive therapies that can improve respiratory symptoms in people with cystic fibrosis (CF). A recent randomized control trial showed that participants with well-preserved pulmonary function taking elexacaftor + tezacaftor + ivacaftor (ETI) who discontinued dornase alfa or hypertonic saline for 6 weeks had no clinically meaningful decline in lung function. This may prompt discussions with care providers regarding ongoing use of these medications. OBJECTIVE To compare the costs of outpatient medications between people taking ETI who continued or discontinued (1) dornase alfa or (2) hypertonic saline from 2 clinical trials and project cost differences in the US CF population if these 2 medications were used only intermittently for symptom relief instead of chronically. METHODS The SIMPLIFY study was 2 parallel multicenter trials that randomized participants 1:1 to either continue or discontinue therapy. To estimate costs, we used data from the Merative MarketScan Databases to identify people with CF from 2020 to 2021. Our primary outcomes were differences in costs of outpatient prescription drugs among those who continued vs discontinued dornase alfa and, separately, hypertonic saline. We obtained adjusted differences in median costs. To estimate the annual cost savings if the population of people with CF taking ETI used these medications only intermittently, we multiplied the proportion of people in MarketScan with CF diagnoses who were taking each of these medications by the median cost savings per year and subtracted the cost of "rescue" use. RESULTS A total of 392 participants from the dornase alfa trial and 273 from the hypertonic saline trial were included in analyses. The adjusted difference in median medication costs was not significant for the hypertonic saline trial, but we observed a significantly decreased 6-week cost of medications in the dornase alfa trial (adjusted median difference in costs between discontinue and continue of $5,860 (95% CI = $4,870-$6,850); P < 0.0001). We estimated that two-thirds of people with CF use ETI and dornase alfa in the United States; if they discontinued dornase alfa except for intermittent use, the resulting annual savings would be $1.21 billion. CONCLUSIONS Although the costs of dornase alfa and hypertonic saline are smaller compared with ETI, reduction in use would lead to substantial prescription drug cost savings and reduce the treatment burden. However, individual benefits of these therapies should be considered, and decisions regarding changes in therapy remain an important discussion between people with CF and their providers. Study registration number: NCT04378153.
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Affiliation(s)
- Laura S. Gold
- Department of Radiology, University of Washington, Seattle
| | - Ryan N. Hansen
- School of Pharmacy, University of Washington, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Nicole Mayer-Hamblett
- Seattle Children’s Research Institute, WA
- Department of Biostatistics, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
| | | | - Alex H. Gifford
- Department of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | | | - Christopher H. Goss
- Seattle Children’s Research Institute, WA
- Department of Pediatrics, University of Washington, Seattle
| | - Larry Kessler
- Department of Health Systems and Population Health, University of Washington, Seattle
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5
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Islam MM, Takeyama N. Role of Neutrophil Extracellular Traps in Health and Disease Pathophysiology: Recent Insights and Advances. Int J Mol Sci 2023; 24:15805. [PMID: 37958788 PMCID: PMC10649138 DOI: 10.3390/ijms242115805] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Neutrophils are the principal trouper of the innate immune system. Activated neutrophils undergo a noble cell death termed NETosis and release a mesh-like structure called neutrophil extracellular traps (NETs) as a part of their defensive strategy against microbial pathogen attack. This web-like architecture includes a DNA backbone embedded with antimicrobial proteins like myeloperoxidase (MPO), neutrophil elastase (NE), histones and deploys in the entrapment and clearance of encountered pathogens. Thus NETs play an inevitable beneficial role in the host's protection. However, recent accumulated evidence shows that dysregulated and enhanced NET formation has various pathological aspects including the promotion of sepsis, pulmonary, cardiovascular, hepatic, nephrological, thrombotic, autoimmune, pregnancy, and cancer diseases, and the list is increasing gradually. In this review, we summarize the NET-mediated pathophysiology of different diseases and focus on some updated potential therapeutic approaches against NETs.
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Affiliation(s)
- Md Monirul Islam
- Department of Emergency and Critical Care Medicine, Aichi Medical University, Aichi 480-1195, Japan
- Department of Biochemistry and Biotechnology, University of Science and Technology Chittagong (USTC), Chattogram 4202, Bangladesh
| | - Naoshi Takeyama
- Department of Emergency and Critical Care Medicine, Aichi Medical University, Aichi 480-1195, Japan
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6
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Neutrophil Extracellular Traps in Airway Diseases: Pathological Roles and Therapeutic Implications. Int J Mol Sci 2023; 24:ijms24055034. [PMID: 36902466 PMCID: PMC10003347 DOI: 10.3390/ijms24055034] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Neutrophils are important effector cells of the innate immune response that fight pathogens by phagocytosis and degranulation. Neutrophil extracellular traps (NETs) are released into the extracellular space to defend against invading pathogens. Although NETs play a defensive role against pathogens, excessive NETs can contribute to the pathogenesis of airway diseases. NETs are known to be directly cytotoxic to the lung epithelium and endothelium, highly involved in acute lung injury, and implicated in disease severity and exacerbation. This review describes the role of NET formation in airway diseases, including chronic rhinosinusitis, and suggests that targeting NETs could be a therapeutic strategy for airway diseases.
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7
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Klosinska K, Reece E, Kenny E, Renwick J. Reducing human DNA bias in cystic fibrosis airway specimens for microbiome analysis. J Microbiol Methods 2022; 200:106540. [PMID: 35853495 DOI: 10.1016/j.mimet.2022.106540] [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: 05/26/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/27/2022]
Abstract
Next generation sequencing (NGS) has transformed our understanding of airway microbiology, however there are methodology limitations that require consideration. The presence of high concentrations of human DNA in clinical specimens can significantly impact sequencing of the microbiome, especially in low biomass samples. Here we compared three different methods (0.025% saponin, NEBNext Microbiome DNA enrichment kit, QIAamp DNA microbiome kit) for the reduction of human DNA from six CF sputum samples and determined the impact on the microbiome detected using 16S rRNA gene sequencing. Human DNA in undepleted CF sputum accounted for 94.3% of the total DNA. Saponin, the NEBNext kit and the QIAamp kit reduced human DNA levels by an average of 38.7%, 61.8% and 94.8%, respectively. None of the depletion methods reduced total bacterial DNA concentrations. QIAamp depletion did not influence taxa richness or alpha diversity however alterations to the core genera were noted following depletion. While all methods reduced human DNA in the CF sputum samples, the QIAamp DNA microbiome kit reduced Human DNA levels significantly while leaving bacterial DNA levels unchanged. Human DNA depletion in low biomass, human DNA-dense CF sputum samples is vital for improving bacterial resolution in the CF airway microbiome.
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Affiliation(s)
- Karolina Klosinska
- Clinical Microbiology Department, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin, Ireland
| | - Emma Reece
- Clinical Microbiology Department, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin, Ireland
| | - Elaine Kenny
- ELDA Biotech, Naas, Kildare, Ireland; TrinSeq, Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
| | - Julie Renwick
- Clinical Microbiology Department, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin, Ireland.
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8
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Kratochvil MJ, Kaber G, Demirdjian S, Cai PC, Burgener EB, Nagy N, Barlow GL, Popescu M, Nicolls MR, Ozawa MG, Regula DP, Pacheco-Navarro AE, Yang S, de Jesus Perez VA, Karmouty-Quintana H, Peters AM, Zhao B, Buja ML, Johnson PY, Vernon RB, Wight TN, Milla CE, Rogers AJ, Spakowitz AJ, Heilshorn SC, Bollyky PL. Biochemical, biophysical, and immunological characterization of respiratory secretions in severe SARS-CoV-2 infections. JCI Insight 2022; 7:152629. [PMID: 35730564 PMCID: PMC9309048 DOI: 10.1172/jci.insight.152629] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 05/10/2022] [Indexed: 01/27/2023] Open
Abstract
Thick, viscous respiratory secretions are a major pathogenic feature of COVID-19, but the composition and physical properties of these secretions are poorly understood. We characterized the composition and rheological properties (i.e., resistance to flow) of respiratory secretions collected from intubated COVID-19 patients. We found the percentages of solids and protein content were greatly elevated in COVID-19 compared with heathy control samples and closely resembled levels seen in cystic fibrosis, a genetic disease known for thick, tenacious respiratory secretions. DNA and hyaluronan (HA) were major components of respiratory secretions in COVID-19 and were likewise abundant in cadaveric lung tissues from these patients. COVID-19 secretions exhibited heterogeneous rheological behaviors, with thicker samples showing increased sensitivity to DNase and hyaluronidase treatment. In histologic sections from these same patients, we observed increased accumulation of HA and the hyaladherin versican but reduced tumor necrosis factor-stimulated gene-6 staining, consistent with the inflammatory nature of these secretions. Finally, we observed diminished type I interferon and enhanced inflammatory cytokines in these secretions. Overall, our studies indicated that increases in HA and DNA in COVID-19 respiratory secretion samples correlated with enhanced inflammatory burden and suggested that DNA and HA may be viable therapeutic targets in COVID-19 infection.
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Affiliation(s)
- Michael J. Kratochvil
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Department of Materials Science and Engineering and
| | - Gernot Kaber
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sally Demirdjian
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Pamela C. Cai
- Department of Chemical Engineering, Stanford University, Stanford, California, USA
| | | | - Nadine Nagy
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Graham L. Barlow
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Medeea Popescu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark R. Nicolls
- Department of Pulmonology, Allergy and Critical Care Medicine
| | | | | | | | - Samuel Yang
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Harry Karmouty-Quintana
- Department of Biochemistry and Molecular Biology;,Divisions of Critical Care Medicine and Pulmonary and Sleep Medicine, Department of Internal Medicine
| | | | - Bihong Zhao
- Department of Pathology and Laboratory Medicine; and,Department of Internal Medicine, University of Texas Health Science Center — McGovern Medical School, Houston, Texas, USA
| | - Maximilian L. Buja
- Department of Pathology and Laboratory Medicine; and,Department of Internal Medicine, University of Texas Health Science Center — McGovern Medical School, Houston, Texas, USA
| | - Pamela Y. Johnson
- Matrix Biology Program, Benaroya Research Institute, Seattle, Washington, USA
| | - Robert B. Vernon
- Matrix Biology Program, Benaroya Research Institute, Seattle, Washington, USA
| | - Thomas N. Wight
- Matrix Biology Program, Benaroya Research Institute, Seattle, Washington, USA
| | | | - Carlos E. Milla
- Center for Excellence in Pulmonary Biology, Department of Pediatrics
| | | | - Andrew J. Spakowitz
- Department of Chemical Engineering, Stanford University, Stanford, California, USA
| | | | - Paul L. Bollyky
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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9
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Kratochvil MJ, Kaber G, Demirdjian S, Cai PC, Burgener EB, Nagy N, Barlow GL, Popescu M, Nicolls MR, Ozawa MG, Regula DP, Pacheco-navarro AE, Yang S, de Jesus Perez VA, Karmouty-quintana H, Peters AM, Zhao B, Buja ML, Johnson PY, Vernon RB, Wight TN, Milla CE, Rogers AJ, Spakowitz AJ, Heilshorn SC, Bollyky PL, Stanford COVID-19 Biobank Study Group. Biochemical, Biophysical, and Immunological Characterization of Respiratory Secretions in Severe SARS-CoV-2 (COVID-19) Infections.. [PMID: 35411348 PMCID: PMC8996635 DOI: 10.1101/2022.03.28.22272848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thick, viscous respiratory secretions are a major pathogenic feature of COVID-19 disease, but the composition and physical properties of these secretions are poorly understood. We characterized the composition and rheological properties (i.e. resistance to flow) of respiratory secretions collected from intubated COVID-19 patients. We find the percent solids and protein content are greatly elevated in COVID-19 compared to heathy control samples and closely resemble levels seen in cystic fibrosis, a genetic disease known for thick, tenacious respiratory secretions. DNA and hyaluronan (HA) are major components of respiratory secretions in COVID-19 and are likewise abundant in cadaveric lung tissues from these patients. COVID-19 secretions exhibit heterogeneous rheological behaviors with thicker samples showing increased sensitivity to DNase and hyaluronidase treatment. In histologic sections from these same patients, we observe increased accumulation of HA and the hyaladherin versican but reduced tumor necrosis factor–stimulated gene-6 (TSG6) staining, consistent with the inflammatory nature of these secretions. Finally, we observed diminished type I interferon and enhanced inflammatory cytokines in these secretions. Overall, our studies indicate that increases in HA and DNA in COVID-19 respiratory secretion samples correlate with enhanced inflammatory burden and suggest that DNA and HA may be viable therapeutic targets in COVID-19 infection.
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10
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Conte G, Costabile G, Baldassi D, Rondelli V, Bassi R, Colombo D, Linardos G, Fiscarelli EV, Sorrentino R, Miro A, Quaglia F, Brocca P, d’Angelo I, Merkel OM, Ungaro F. Hybrid Lipid/Polymer Nanoparticles to Tackle the Cystic Fibrosis Mucus Barrier in siRNA Delivery to the Lungs: Does PEGylation Make the Difference? ACS APPLIED MATERIALS & INTERFACES 2022; 14:7565-7578. [PMID: 35107987 PMCID: PMC8855343 DOI: 10.1021/acsami.1c14975] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 01/19/2022] [Indexed: 06/01/2023]
Abstract
Inhaled siRNA therapy has a unique potential for treatment of severe lung diseases, such as cystic fibrosis (CF). Nevertheless, a drug delivery system tackling lung barriers is mandatory to enhance gene silencing efficacy in the airway epithelium. We recently demonstrated that lipid-polymer hybrid nanoparticles (hNPs), comprising a poly(lactic-co-glycolic) acid (PLGA) core and a lipid shell of dipalmitoyl phosphatidylcholine (DPPC), may assist the transport of the nucleic acid cargo through mucus-covered human airway epithelium. To study in depth the potential of hNPs for siRNA delivery to the lungs and to investigate the hypothesized benefit of PEGylation, here, an siRNA pool against the nuclear factor-κB (siNFκB) was encapsulated inside hNPs, endowed with a non-PEGylated (DPPC) or a PEGylated (1,2-distearoyl-sn-glycero-3-phosphoethanolamine-poly(ethylene glycol) or DSPE-PEG) lipid shell. Resulting hNPs were tested for their stability profiles and transport properties in artificial CF mucus, mucus collected from CF cells, and sputum samples from a heterogeneous and representative set of CF patients. Initial information on hNP properties governing their interaction with airway mucus was acquired by small-angle X-ray scattering (SAXS) studies in artificial and cellular CF mucus. The diffusion profiles of hNPs through CF sputa suggested a crucial role of lung colonization of the corresponding donor patient, affecting the mucin type and content of the sample. Noteworthy, PEGylation did not boost mucus penetration in complex and sticky samples, such as CF sputa from patients with polymicrobial colonization. In parallel, in vitro cell uptake studies performed on mucus-lined Calu-3 cells grown at the air-liquid interface (ALI) confirmed the improved ability of non-PEGylated hNPs to overcome mucus and cellular lung barriers. Furthermore, effective in vitro NFκB gene silencing was achieved in LPS-stimulated 16HBE14o- cells. Overall, the results highlight the potential of non-PEGylated hNPs as carriers for pulmonary delivery of siRNA for local treatment of CF lung disease. Furthermore, this study provides a detailed understanding of how distinct models may provide different information on nanoparticle interaction with the mucus barrier.
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Affiliation(s)
- Gemma Conte
- Di.S.T.A.Bi.F., University of Campania Luigi Vanvitelli, Caserta 81100, Italy
| | - Gabriella Costabile
- Department
of Pharmacy, University of Napoli Federico
II, Napoli 80131, Italy
| | - Domizia Baldassi
- Department
of Pharmacy, Pharmaceutical Technology and Biopharmacy, Ludwig-Maximilians-Universität, München, Munich 81377, Germany
| | - Valeria Rondelli
- Department
of Medical Biotechnologies and Translational Medicine, University of Milano, Segrate (MI) 20090, Italy
| | - Rosaria Bassi
- Department
of Medical Biotechnologies and Translational Medicine, University of Milano, Segrate (MI) 20090, Italy
| | - Diego Colombo
- Department
of Medical Biotechnologies and Translational Medicine, University of Milano, Segrate (MI) 20090, Italy
| | | | | | - Raffaella Sorrentino
- Department
of Molecular Medicine and Medical Biotechnologies, University of Napoli Federico II, Napoli 80131, Italy
| | - Agnese Miro
- Department
of Pharmacy, University of Napoli Federico
II, Napoli 80131, Italy
| | - Fabiana Quaglia
- Department
of Pharmacy, University of Napoli Federico
II, Napoli 80131, Italy
| | - Paola Brocca
- Department
of Medical Biotechnologies and Translational Medicine, University of Milano, Segrate (MI) 20090, Italy
| | - Ivana d’Angelo
- Di.S.T.A.Bi.F., University of Campania Luigi Vanvitelli, Caserta 81100, Italy
| | - Olivia M. Merkel
- Department
of Pharmacy, Pharmaceutical Technology and Biopharmacy, Ludwig-Maximilians-Universität, München, Munich 81377, Germany
| | - Francesca Ungaro
- Department
of Pharmacy, University of Napoli Federico
II, Napoli 80131, Italy
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11
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Singhal A, Kumar S. Neutrophil and remnant clearance in immunity and inflammation. Immunology 2021; 165:22-43. [PMID: 34704249 DOI: 10.1111/imm.13423] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/18/2021] [Accepted: 10/21/2021] [Indexed: 12/13/2022] Open
Abstract
Neutrophil-centred inflammation and flawed clearance of neutrophils cause and exuberate multiple pathological conditions. These most abundant leukocytes exhibit very high daily turnover in steady-state and stress conditions. Various armours including oxidative burst, NETs and proteases function against pathogens, but also dispose neutrophils to spawn pro-inflammatory responses. Neutrophils undergo death through different pathways upon ageing, infection, executing the intruder's elimination. These include non-lytic apoptosis and other lytic deaths including NETosis, necroptosis and pyroptosis with distinct disintegration of the cellular membrane. This causes release and presence of different intracellular cytotoxic, and tissue-damaging content as cell remnants in the extracellular environment. The apoptotic cells and apoptotic bodies get cleared with non-inflammatory outcomes, while lytic deaths associated remnants including histones and cell-free DNA cause pro-inflammatory responses. Indeed, the enhanced frequencies of neutrophil-associated proteases, cell-free DNA and autoantibodies in diverse pathologies including sepsis, asthma, lupus and rheumatoid arthritis, imply disturbed neutrophil resolution programmes in inflammatory and autoimmune diseases. Thus, the clearance mechanisms of neutrophils and associated remnants are vital for therapeutics. Though studies focused on clearance mechanisms of senescent or apoptotic neutrophils so far generated a good understanding of the same, clearance of neutrophils undergoing distinct lytic deaths, including NETs, are being the subjects of intense investigations. Here, in this review, we are providing the current updates in the clearance mechanisms of apoptotic neutrophils and focusing on not so well-defined recognition, uptake and degradation of neutrophils undergoing lytic death and associated remnants that may provide new therapeutic approaches in inflammation and autoimmunity.
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Affiliation(s)
- Apurwa Singhal
- Pharmacology Division, CSIR-Central Drug Research Institute, Lucknow, Uttar Pradesh, India
| | - Sachin Kumar
- Pharmacology Division, CSIR-Central Drug Research Institute, Lucknow, Uttar Pradesh, India.,Academy of Scientific and Innovative Research (AcSIR), Postal Staff College Area, Ghaziabad, Uttar Pradesh, India
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12
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Vendrusculo FM, Piva TC, Luft C, Antunes KH, Donadio MVF. Aerobic fitness is associated with extracellular DNA levels in the sputum of patients with cystic fibrosis. Int J Clin Pract 2021; 75:e14616. [PMID: 34235820 DOI: 10.1111/ijcp.14616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS Patients with cystic fibrosis (CF) develop with progressive loss of lung function and aerobic fitness. However, the precise mechanisms of exercise intolerance are still controversial and appear to be influenced by several factors. This study aimed to evaluate the association of aerobic fitness with free DNA levels in the sputum of patients with CF. METHODS This cross-sectional study included patients with CF older than 6 years, free from active exacerbations, but who were able to produce spontaneously expectorated sputum. Extracellular DNA in the sputum was quantified. Lung function (spirometry) and aerobic fitness (cardiopulmonary exercise testing [CPET]) were performed. In addition, demographic, anthropometric and clinical data were collected. RESULTS Sixteen patients with a mean age of 19.4 ± 6.9 years and mean forced expiratory volume in the first second (FEV1 ) of 51.8 ± 28.1 (% of predicted) were included. Mean peak oxygen consumption (VO2 peak) was 32.8 ± 5.2 mL• kg-1 • min-1 , oxygen saturation at the end of the test was 90.6% ± 6.3% and mean extracellular DNA levels was 305.3 ± 153.6 μg/mL. Individuals with a VO2 peak ≤ 30 mL• kg-1 • min-1 (P = .03) and a SpO2 ≤ 90% at the end of the test (P = .03) had a greater amount of extracellular DNA in the sputum. The proportion of patients with reduced VO2 peak in the group of patients with the lowest concentration of DNA in the sputum (<243 μg/mL) was significantly lower (0% vs 100%; P = .04). CONCLUSION There is an association between the presence of free DNA in sputum and aerobic fitness in patients with CF.
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Affiliation(s)
- Fernanda Maria Vendrusculo
- Laboratory of Pediatric Physical Activity, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Taila Cristina Piva
- Laboratory of Pediatric Physical Activity, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Carolina Luft
- Laboratory of Pediatric Physical Activity, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Krist Helen Antunes
- Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Márcio Vinícius Fagundes Donadio
- Laboratory of Pediatric Physical Activity, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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13
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Abstract
The healthy lung was long thought of as sterile, but recent advances using molecular sequencing approaches have detected bacteria at low levels. Healthy lung bacteria largely reflect communities present in the upper respiratory tract that enter the lung via microaspiration, which is balanced by mechanical and immune clearance and likely involves limited local replication. The nature and dynamics of the lung microbiome, therefore, differ from those of ecological niches with robust self-sustaining microbial communities. Aberrant populations (dysbiosis) have been demonstrated in many pulmonary diseases not traditionally considered microbial in origin, and potential pathways of microbe-host crosstalk are emerging. The question now is whether and how dysbiotic microbiota contribute to initiation or perpetuation of injury. The fungal microbiome and virome are less well studied. This Review highlights features of the lung microbiome, unique considerations in studying it, examples of dysbiosis in selected disease, emerging concepts in lung microbiome-host interactions, and critical areas for investigation.
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14
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Mucus, Microbiomes and Pulmonary Disease. Biomedicines 2021; 9:biomedicines9060675. [PMID: 34199312 PMCID: PMC8232003 DOI: 10.3390/biomedicines9060675] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/31/2021] [Accepted: 06/09/2021] [Indexed: 12/20/2022] Open
Abstract
The respiratory tract harbors a stable and diverse microbial population within an extracellular mucus layer. Mucus provides a formidable defense against infection and maintaining healthy mucus is essential to normal pulmonary physiology, promoting immune tolerance and facilitating a healthy, commensal lung microbiome that can be altered in association with chronic respiratory disease. How one maintains a specialized (healthy) microbiome that resists significant fluctuation remains unknown, although smoking, diet, antimicrobial therapy, and infection have all been observed to influence microbial lung homeostasis. In this review, we outline the specific role of polymerizing mucin, a key functional component of the mucus layer that changes during pulmonary disease. We discuss strategies by which mucin feed and spatial orientation directly influence microbial behavior and highlight how a compromised mucus layer gives rise to inflammation and microbial dysbiosis. This emerging field of respiratory research provides fresh opportunities to examine mucus, and its function as predictors of infection risk or disease progression and severity across a range of chronic pulmonary disease states and consider new perspectives in the development of mucolytic treatments.
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15
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Abdo M, Uddin M, Goldmann T, Marwitz S, Bahmer T, Holz O, Kirsten AM, Trinkmann F, von Mutius E, Kopp M, Hansen G, Rabe KF, Watz H, Pedersen F. Raised sputum extracellular DNA confers lung function impairment and poor symptom control in an exacerbation-susceptible phenotype of neutrophilic asthma. Respir Res 2021; 22:167. [PMID: 34082773 PMCID: PMC8173872 DOI: 10.1186/s12931-021-01759-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Extracellular DNA (e-DNA) and neutrophil extracellular traps (NETs) are linked to asthmatics airway inflammation. However, data demonstrating the characterization of airway inflammation associated with excessive e-DNA production and its impact on asthma outcomes are limited. Objective To characterize the airway inflammation associated with excessive e-DNA production and its association with asthma control, severe exacerbations and pulmonary function, particularly, air trapping and small airway dysfunction. Methods We measured e-DNA concentrations in induced sputum from 134 asthma patients and 28 healthy controls. We studied the correlation of e-DNA concentrations with sputum neutrophils, eosinophils and macrophages and the fractional exhaled nitric oxide (FeNO). Lung function was evaluated using spirometry, body plethysmography, impulse oscillometry and inert gas multiple breath washout. We stratified patients with asthma into low-DNA and high-DNA to compare lung function impairments and asthma outcomes. Results Patients with severe asthma had higher e-DNA concentration (54.2 ± 42.4 ng/µl) than patients with mild-moderate asthma (41.0 ± 44.1 ng/µl) or healthy controls (26.1 ± 16.5 ng/µl), (all p values < 0.05). E-DNA concentrations correlated directly with sputum neutrophils (R = 0.49, p < 0.0001) and negatively with sputum macrophages (R = − 0.36, p < 0.0001), but neither with sputum eosinophils (R = 0.10, p = 0.26), nor with FeNO (R = − 0.10, p = 0.22). We found that 29% of asthma patients (n = 39) had high e-DNA concentrations above the upper 95th percentile value in healthy controls (55.6 ng /μl). High-DNA was associated with broad lung function impairments including: airflow obstruction of the large (FEV1) and small airways (FEF50%, FEF25–75), increased air trapping (RV, RV/TLC), increased small airway resistance (R5-20, sReff), decreased lung elasticity (X5Hz) and increased ventilation heterogeneity (LCI), (all P values < 0.05). We also found that high e-DNA was associated with nearly three-fold greater risk of severe exacerbations (OR 2·93 [95% CI 1.2–7.5]; p = 0·012), worse asthma control test (p = 0.03), worse asthma control questionnaire scores (p = 0.01) and higher doses of inhaled corticosteroids (p = 0.026). Conclusion Increased production of extracellular DNA in the airway characterizes a subset of neutrophilic asthma patients who have broad lung function impairments, poor symptom control and increased risk of severe exacerbations.
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Affiliation(s)
- Mustafa Abdo
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany
| | - Mohib Uddin
- Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Torsten Goldmann
- Research Center Borstel, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Sebastian Marwitz
- Research Center Borstel, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
| | - Thomas Bahmer
- Department for Internal Medicine I, Airway Research Center North (ARCN), German Center for Lung Research (DZL), University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Olaf Holz
- Fraunhofer ITEM, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research, Hannover, Germany
| | - Anne-Marie Kirsten
- Pulmonary Research Institute at the LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Frederik Trinkmann
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Biomedical Informatics, Heinrich-Lanz-Center, University Medical Center Mannheim, Mannheim, Germany
| | - Erika von Mutius
- Dr Von Hauner Children's Hospital, Ludwig Maximilians University of Munich, Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Matthias Kopp
- Department of Pediatric Pneumology, Inselspital, University Children's Hospital of Bern, University of Bern, Bern, Switzerland.,Division of Pediatric Pneumology and Allergology, University Hospital Schleswig-Holstein-Campus Luebeck, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Luebeck, Germany
| | - Gesine Hansen
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Klaus F Rabe
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany
| | - Henrik Watz
- Pulmonary Research Institute at the LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Frauke Pedersen
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany. .,Pulmonary Research Institute at the LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany.
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Kaber G, Kratochvil MJ, Burgener EB, Peltan EL, Barlow G, Yang S, Nicolls MR, de Jesus Perez V, Rosser JI, Wardle AJ, Kalinowski A, Ozawa MG, Regula DP, Nagy N, Heilshorn SC, Milla CE, Rogers AJ, Bollyky PL. Hyaluronan is abundant in COVID-19 respiratory secretions. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32935110 DOI: 10.1101/2020.09.11.20191692] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
COVID-19 respiratory infections are associated with copious, adherent respiratory secretions that prolong chronic ventilation and contribute to the morbidity and mortality caused by the disease. We hypothesized that hyaluronan, an extracellular matrix glycosaminoglycan produced at sites of active inflammation that promotes edema in other settings, might be a component of these secretions. To interrogate this, we examined the respiratory secretions collected from eight intubated patients with COVID-19, six control patients with cystic fibrosis (CF), a different respiratory disease also associated with thick adherent secretions, and eight healthy controls. In this sample set we found that hyaluronan content is increased approximately 20-fold in both CF and COVID-19 patients compared to healthy controls. The hyaluronan in COVID-19 samples was comprised of low-molecular weight fragments, the hyaluronan form most strongly linked with pro-inflammatory functions. Hyaluronan is similarly abundant in histologic sections from cadaveric lung tissue from COVID-19 patients. These findings implicate hyaluronan in the thick respiratory secretions characteristic of COVID-19 infection. Therapeutic strategies targeting hyaluronan should be investigated further for potential use in patients with COVID-19.
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