1
|
Calabrese DR, Tsao T, Magnen M, Valet C, Gao Y, Mallavia B, Tian JJ, Aminian EA, Wang KM, Shemesh A, Punzalan EB, Sarma A, Calfee CS, Christenson SA, Langelier CR, Hays SR, Golden JA, Leard LE, Kleinhenz ME, Kolaitis NA, Shah R, Venado A, Lanier LL, Greenland JR, Sayah DM, Ardehali A, Kukreja J, Weigt SS, Belperio JA, Singer JP, Looney MR. NKG2D receptor activation drives primary graft dysfunction severity and poor lung transplantation outcomes. JCI Insight 2022; 7:e164603. [PMID: 36346670 PMCID: PMC9869973 DOI: 10.1172/jci.insight.164603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
Clinical outcomes after lung transplantation, a life-saving therapy for patients with end-stage lung diseases, are limited by primary graft dysfunction (PGD). PGD is an early form of acute lung injury with no specific pharmacologic therapies. Here, we present a large multicenter study of plasma and bronchoalveolar lavage (BAL) samples collected on the first posttransplant day, a critical time for investigations of immune pathways related to PGD. We demonstrated that ligands for NKG2D receptors were increased in the BAL from participants who developed severe PGD and were associated with increased time to extubation, prolonged intensive care unit length of stay, and poor peak lung function. Neutrophil extracellular traps (NETs) were increased in PGD and correlated with BAL TNF-α and IFN-γ cytokines. Mechanistically, we found that airway epithelial cell NKG2D ligands were increased following hypoxic challenge. NK cell killing of hypoxic airway epithelial cells was abrogated with NKG2D receptor blockade, and TNF-α and IFN-γ provoked neutrophils to release NETs in culture. These data support an aberrant NK cell/neutrophil axis in human PGD pathogenesis. Early measurement of stress ligands and blockade of the NKG2D receptor hold promise for risk stratification and management of PGD.
Collapse
Affiliation(s)
- Daniel R. Calabrese
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Tasha Tsao
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Mélia Magnen
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Colin Valet
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Ying Gao
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Beñat Mallavia
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | | | - Kristin M. Wang
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Avishai Shemesh
- Department of Medicine, UCSF, San Francisco, California, USA
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
| | | | - Aartik Sarma
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | | | | | - Steven R. Hays
- Department of Medicine, UCSF, San Francisco, California, USA
| | | | | | | | | | - Rupal Shah
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Aida Venado
- Department of Medicine, UCSF, San Francisco, California, USA
| | - Lewis L. Lanier
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
- Department of Microbiology and Immunology and
| | - John R. Greenland
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Medicine, UCSF, San Francisco, California, USA
| | - David M. Sayah
- Department of Medicine, UCLA, Los Angeles, California, USA
| | - Abbas Ardehali
- Department of Medicine, UCLA, Los Angeles, California, USA
| | | | | | | | | | - Mark R. Looney
- Department of Medicine, UCSF, San Francisco, California, USA
| |
Collapse
|
2
|
Santos J, Calabrese DR, Greenland JR. Lymphocytic Airway Inflammation in Lung Allografts. Front Immunol 2022; 13:908693. [PMID: 35911676 PMCID: PMC9335886 DOI: 10.3389/fimmu.2022.908693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplant remains a key therapeutic option for patients with end stage lung disease but short- and long-term survival lag other solid organ transplants. Early ischemia-reperfusion injury in the form of primary graft dysfunction (PGD) and acute cellular rejection are risk factors for chronic lung allograft dysfunction (CLAD), a syndrome of airway and parenchymal fibrosis that is the major barrier to long term survival. An increasing body of research suggests lymphocytic airway inflammation plays a significant role in these important clinical syndromes. Cytotoxic T cells are observed in airway rejection, and transcriptional analysis of airways reveal common cytotoxic gene patterns across solid organ transplant rejection. Natural killer (NK) cells have also been implicated in the early allograft damage response to PGD, acute rejection, cytomegalovirus, and CLAD. This review will examine the roles of lymphocytic airway inflammation across the lifespan of the allograft, including: 1) The contribution of innate lymphocytes to PGD and the impact of PGD on the adaptive immune response. 2) Acute cellular rejection pathologies and the limitations in identifying airway inflammation by transbronchial biopsy. 3) Potentiators of airway inflammation and heterologous immunity, such as respiratory infections, aspiration, and the airway microbiome. 4) Airway contributions to CLAD pathogenesis, including epithelial to mesenchymal transition (EMT), club cell loss, and the evolution from constrictive bronchiolitis to parenchymal fibrosis. 5) Protective mechanisms of fibrosis involving regulatory T cells. In summary, this review will examine our current understanding of the complex interplay between the transplanted airway epithelium, lymphocytic airway infiltration, and rejection pathologies.
Collapse
Affiliation(s)
- Jesse Santos
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R. Calabrese
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
- *Correspondence: Daniel Calabrese, ; John R. Greenland,
| | - John R. Greenland
- Department of Medicine University of California, San Francisco, San Francisco, CA, United States
- Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
- *Correspondence: Daniel Calabrese, ; John R. Greenland,
| |
Collapse
|
3
|
Abstract
Chronic lung allograft dysfunction (CLAD) is a syndrome of progressive lung function decline, subcategorized into obstructive, restrictive, and mixed phenotypes. The trajectory of CLAD is variable depending on the phenotype, with restrictive and mixed phenotypes having more rapid progression and lower survival. The mechanisms driving CLAD development remain unclear, though allograft injury during primary graft dysfunction, acute cellular rejection, antibody-mediated rejection, and infections trigger immune responses with long-lasting effects that can lead to CLAD months or years later. Currently, retransplantation is the only effective treatment.
Collapse
Affiliation(s)
- Aida Venado
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, 505 Parnassus Ave, M1093A, San Francisco, CA 94143-2204, USA.
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, Univeristy of California, San Francisco, 500 Parnassus Ave, MU 405W Suite 305, San Francisco, CA 94143, USA
| | - John R Greenland
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, SF VAHCS Building 2, Room 453 (Mail stop 111D), 4150 Clement St, San Francisco CA 94121, USA
| |
Collapse
|
4
|
Pandoraea pnomenusa Superinfection in a Patient with SARS-CoV-2 Pneumonia: First Case in the Literature. Infect Dis Rep 2022; 14:205-212. [PMID: 35314655 PMCID: PMC8938804 DOI: 10.3390/idr14020025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 12/12/2022] Open
Abstract
Pandoraea pnomenusa is a Gram-negative bacterium of the Pandoraea genus and is mainly associated with the colonization of structurally abnormal airways. During the COVID-19 pandemic, many microorganisms have been associated with coinfection and superinfection in SARS-CoV-2 pneumonia, but so far, no coinfection or superinfection by P. pnomenusa has been reported. We present the first case describing this association in a previously healthy patient. Clinical manifestations, treatment, and outcomes are shown.
Collapse
|
5
|
Dugger DT, Calabrese DR, Gao Y, Deiter F, Tsao T, Maheshwari J, Hays SR, Leard L, Kleinhenz ME, Shah R, Golden J, Kukreja J, Gordon ED, Singer JP, Greenland JR. Lung Allograft Epithelium DNA Methylation Age Is Associated With Graft Chronologic Age and Primary Graft Dysfunction. Front Immunol 2021; 12:704172. [PMID: 34691018 PMCID: PMC8528961 DOI: 10.3389/fimmu.2021.704172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/09/2021] [Indexed: 02/04/2023] Open
Abstract
Advanced donor age is a risk factor for poor survival following lung transplantation. However, recent work identifying epigenetic determinants of aging has shown that biologic age may not always reflect chronologic age and that stressors can accelerate biologic aging. We hypothesized that lung allografts that experienced primary graft dysfunction (PGD), characterized by poor oxygenation in the first three post-transplant days, would have increased biologic age. We cultured airway epithelial cells isolated by transbronchial brush at 1-year bronchoscopies from 13 subjects with severe PGD and 15 controls matched on age and transplant indication. We measured epigenetic age using the Horvath epigenetic clock. Linear models were used to determine the association of airway epigenetic age with chronologic ages and PGD status, adjusted for recipient PGD risk factors. Survival models assessed the association with chronic lung allograft dysfunction (CLAD) or death. Distributions of promoter methylation within pathways were compared between groups. DNA methyltransferase (DNMT) activity was quantified in airway epithelial cells under hypoxic or normoxic conditions. Airway epigenetic age appeared younger but was strongly associated with the age of the allograft (slope 0.38 per year, 95% CI 0.27–0.48). There was no correlation between epigenetic age and recipient age (P = 0.96). Epigenetic age was 6.5 years greater (95% CI 1.7–11.2) in subjects who had experienced PGD, and this effect remained significant after adjusting for donor and recipient characteristics (P = 0.03). Epigenetic age was not associated with CLAD-free survival risk (P = 0.11). Analysis of differential methylation of promoters of key biologic pathways revealed hypomethylation in regions related to hypoxia, inflammation, and metabolism-associated pathways. Accordingly, airway epithelial cells cultured in hypoxic conditions showed suppressed DNMT activity. While airway methylation age was primarily determined by donor chronologic age, early injury in the form of PGD was associated with increased allograft epigenetic age. These data show how PGD might suppress key promoter methylation resulting in long-term impacts on the allograft.
Collapse
Affiliation(s)
- Daniel T Dugger
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel R Calabrese
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| | - Ying Gao
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Fred Deiter
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Tasha Tsao
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Julia Maheshwari
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Steven R Hays
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Lorriana Leard
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Mary Ellen Kleinhenz
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Rupal Shah
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jeff Golden
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco, San Francisco, CA, United States
| | - Erin D Gordon
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jonathan P Singer
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - John R Greenland
- Pulmonary, Critical Care, Allergy and Sleep Medicine Division, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Medical Service, Veterans Affairs Health Care System, San Francisco, CA, United States
| |
Collapse
|
6
|
Hoover J, Mintz MA, Deiter F, Aminian E, Chen J, Hays SR, Singer JP, Calabrese DR, Kukreja J, Greenland JR. Rapid molecular detection of airway pathogens in lung transplant recipients. Transpl Infect Dis 2021; 23:e13579. [PMID: 33523538 PMCID: PMC8325716 DOI: 10.1111/tid.13579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 01/16/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Airway infections are difficult to distinguish from acute rejection in lung transplant recipients. Traditional culture techniques take time that may delay treatment. We hypothesized that a rapid multiplex molecular assay could improve time to diagnosis and appropriate clinical decision making. METHODS In a prospective observational study of recipients undergoing bronchoscopy, we assessed the BioFire® FilmArray® Pneumonia Panel (BFPP) in parallel to standard of care (SOC) diagnostics. Research clinicians performed shadow (research only) clinical decision making in real time. Time to report and interpretation were reported as median and interquartile ranges and compared by Wilcoxon signed-ranked test. Agreement was defined based on detection of any species targeted in the molecular assay. RESULTS For the 150 enrolled subjects, BFPP results were available 3.8 hours (IQR 2.8-5.1) following bronchoscopy, compared to 13 hours for viral SOC (IQR 10-34, P < .001) results and 48 hours for bacterial SOC (IQR 46-70, P < .001) results. Positive BFPP results were interpreted in 9 hours (IQR 5-20) following bronchoscopy, compared to 74 hours for SOC (IQR 37-110, P < .001). Assays agreed for 138 (92%) of the 150 subjects. Of 22 BFPP diagnoses, five (23%) resulted in a shadow antibiotic recommendation. Notable BFPP deficiencies included fungal species and H parainfluenzae, accounting for 15 (27%) and 13 (23%) of the 56 actionable SOC results, respectively. CONCLUSIONS This molecular diagnostic including bacterial targets has the potential to shorten time to diagnosis and augment current clinical decision making but cannot replace SOC culture methods.
Collapse
Affiliation(s)
- Jonathan Hoover
- Department of Medicine, University of California, San Francisco CA
| | | | - Fred Deiter
- Department of Medicine, University of California, San Francisco CA
| | - Emily Aminian
- Department of Medicine, University of California, San Francisco CA
| | - Joy Chen
- Department of Surgery, University of California, San Francisco CA
| | - Steven R. Hays
- Department of Medicine, University of California, San Francisco CA
| | | | - Daniel R Calabrese
- Department of Medicine, University of California, San Francisco CA
- Medical Service, San Francisco VA Health Care System, San Francisco CA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco CA
| | - John R Greenland
- Department of Medicine, University of California, San Francisco CA
- Medical Service, San Francisco VA Health Care System, San Francisco CA
| |
Collapse
|
7
|
Vos R, Van Herck A. Pseudomonas aeruginosa and chronic lung allograft dysfunction: does evading an iceberg prevent the ship from sinking? Eur Respir J 2021; 58:13993003.00041-2021. [PMID: 34326173 DOI: 10.1183/13993003.00041-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/09/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Robin Vos
- Dept of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium .,Dept CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Anke Van Herck
- Dept of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Mitchell AB, Glanville AR. The Impact of Resistant Bacterial Pathogens including Pseudomonas aeruginosa and Burkholderia on Lung Transplant Outcomes. Semin Respir Crit Care Med 2021; 42:436-448. [PMID: 34030205 DOI: 10.1055/s-0041-1728797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Pseudomonas and Burkholderia are gram-negative organisms that achieve colonization within the lungs of patients with cystic fibrosis, and are associated with accelerated pulmonary function decline. Multidrug resistance is a hallmark of these organisms, which makes eradication efforts difficult. Furthermore, the literature has outlined increased morbidity and mortality for lung transplant (LTx) recipients infected with these bacterial genera. Indeed, many treatment centers have considered Burkholderia cepacia infection an absolute contraindication to LTx. Ongoing research has delineated different species within the B. cepacia complex (BCC), with significantly varied morbidity and survival profiles. This review considers the current evidence for LTx outcomes between the different subspecies encompassed within these genera as well as prophylactic and management options. The availability of meta-genomic tools will make differentiation between species within these groups easier in the future, and will allow more evidence-based decisions to be made regarding suitability of candidates colonized with these resistant bacteria for LTx. This review suggests that based on the current evidence, not all species of BCC should be considered contraindications to LTx, going forward.
Collapse
Affiliation(s)
- Alicia B Mitchell
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Allan R Glanville
- Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
9
|
Dugger DT, Fung M, Hays SR, Singer JP, Kleinhenz ME, Leard LE, Golden JA, Shah RJ, Lee JS, Deiter F, Greenland NY, Jones KD, Langelier CR, Greenland JR. Chronic lung allograft dysfunction small airways reveal a lymphocytic inflammation gene signature. Am J Transplant 2021; 21:362-371. [PMID: 32885581 PMCID: PMC8009189 DOI: 10.1111/ajt.16293] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/27/2020] [Accepted: 08/16/2020] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) is the major barrier to long-term survival following lung transplantation, and new mechanistic biomarkers are needed. Lymphocytic bronchitis (LB) precedes CLAD and has a defined molecular signature. We hypothesized that this LB molecular signature would be associated with CLAD in small airway brushings independent of infection. We quantified RNA expression from small airway brushings and transbronchial biopsies, using RNAseq and digital RNA counting, respectively, for 22 CLAD cases and 27 matched controls. LB metagene scores were compared across CLAD strata by Wilcoxon rank sum test. We performed unbiased host transcriptome pathway and microbial metagenome analysis in airway brushes and compared machine-learning classifiers between the two tissue types. This LB metagene score was increased in CLAD airway brushes (p = .002) and improved prediction of graft failure (p = .02). Gene expression classifiers based on airway brushes outperformed those using transbronchial biopsies. While infection was associated with decreased microbial alpha-diversity (p ≤ .04), neither infection nor alpha-diversity was associated with LB gene expression. In summary, CLAD was associated with small airway gene expression changes not apparent in transbronchial biopsies in this cohort. Molecular analysis of airway brushings for diagnosing CLAD merits further examination in multicenter cohorts.
Collapse
Affiliation(s)
- Daniel T. Dugger
- Department of Medicine, University of California, San Francisco, CA 94143,Veterans Affairs Health Care System, San Francisco, CA 94121
| | - Monica Fung
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Steven R. Hays
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Jonathan P. Singer
- Department of Medicine, University of California, San Francisco, CA 94143
| | | | - Lorriana E. Leard
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Jeffrey A. Golden
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Rupal J. Shah
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Joyce S. Lee
- Department of Medicine, University of Colorado, Denver, CO 80045
| | - Fred Deiter
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Nancy Y. Greenland
- Veterans Affairs Health Care System, San Francisco, CA 94121,Department of Anatomic Pathology, University of California, San Francisco, CA 94143
| | - Kirk D. Jones
- Department of Anatomic Pathology, University of California, San Francisco, CA 94143
| | | | - John R. Greenland
- Department of Medicine, University of California, San Francisco, CA 94143,Veterans Affairs Health Care System, San Francisco, CA 94121
| |
Collapse
|
10
|
Morrell ED, Lease ED. Host-Pathogen Interactions after Lung Transplant: Are Cystic Fibrosis Patients Unique? CELL REPORTS MEDICINE 2020; 1:100061. [PMID: 33205066 PMCID: PMC7659561 DOI: 10.1016/j.xcrm.2020.100061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The impact of Pseudomonas aeruginosa airway colonization on lung allografts is not entirely clear. In this issue of Cell Reports Medicine, Dugger et al.1 identify distinct clinical outcomes and lung allograft biology in recipients with and without cystic fibrosis.
Collapse
Affiliation(s)
- Eric D Morrell
- VA Puget Sound Heath Care System, Seattle, WA 98109, USA.,Harborview Medical Center, Seattle, WA 98109, USA.,University of Washington Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA 98195, USA
| | - Erika D Lease
- University of Washington Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA 98195, USA
| |
Collapse
|