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Suikkila A, Lyly A, Savinko T, Vento SI, Saarinen R, Hafrén L. Inflammatory Cytokines in Middle Ear Effusion of Patients With Asthma, Chronic Rhinosinusitis With Nasal Polyps With or Without NSAID Intolerance. Otol Neurotol 2024; 45:765-772. [PMID: 38896805 DOI: 10.1097/mao.0000000000004230] [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: 06/21/2024]
Abstract
OBJECTIVE To measure the inflammatory cytokines of middle ear effusion (MEE) in otitis media (OM) associated with asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) with or without nonsteroidal anti-inflammatory drug (NSAID) sensitivity to strengthen our assumption that OM is part of the same inflammatory entity. The potential individual differences between MEE inflammatory cytokines could be used in clinical practice for more individual characterization of the inflammation. STUDY DESIGN Case-control study. SETTING Tertiary referral center. PATIENTS Convenience sample of 24 case patients with otitis media with effusion (OME) or chronic otitis media (COM), asthma, and CRSwNP, 14 of whom had NSAID intolerance, and 8 controls with OME but no history of asthma, CRSwNP, or NSAID intolerance. INTERVENTION Diagnostic. MAIN OUTCOME AND MEASURE Inflammatory cytokines including interleukins (IL)-4, IL-5, IL-6, IL-13, and interferon gamma (IFN-γ) in middle ear effusion. RESULTS The MEE mass fractions of IL-5 ( p = 0.003) and IFN-γ ( p = 0.048) were higher among our case patients with OME/COM than among the controls. For IL-4 and IL-13, the mass fractions were also higher among the case patients than the controls, but this difference was not statistically significant ( p = 0.199 and p = 0.617, respectively). We found no difference between the IL-6 mass fractions of the groups. We found notable heterogeneity in individual patients' cytokine levels. CONCLUSIONS According to our findings, OM, when present, should be considered part of the respiratory inflammatory process associated with asthma and CRSwNP. The individual differences in MEE cytokine levels could be useful as biomarkers.
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Affiliation(s)
- Anna Suikkila
- Department of Otorhinolaryngology-Head and Neck surgery, University of Helsinki and Helsinki University Hospital
| | | | - Terhi Savinko
- Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Seija I Vento
- Department of Otorhinolaryngology-Head and Neck surgery, University of Helsinki and Helsinki University Hospital
| | - Riitta Saarinen
- Department of Otorhinolaryngology-Head and Neck surgery, University of Helsinki and Helsinki University Hospital
| | - Lena Hafrén
- Department of Otorhinolaryngology-Head and Neck surgery, University of Helsinki and Helsinki University Hospital
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2
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Sillanpää S, Numminen J. Baseline Conservative and Surgical Management in the Treatment of NSAID-Exacerbated Respiratory Disease. FRONTIERS IN ALLERGY 2022; 2:659887. [PMID: 35387049 PMCID: PMC8974786 DOI: 10.3389/falgy.2021.659887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/27/2021] [Indexed: 11/13/2022] Open
Abstract
Non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) is a chronic medical condition that includes asthma, chronic rhinosinusitis with nasal polyposis, and hypersensitivity to aspirin and other NSAIDs. Eosinophilic inflammation in the upper and lower airways is treated with local corticosteroids, repeated antibiotics, oral corticosteroid courses, endoscopic sinus surgery, and in some cases aspirin treatment after desensitization (ATAD). Nevertheless, the disease may be uncontrolled and it has a great impact on quality of life. A better understanding of the pathomechanisms of the disease and the development of medications that target type 2 inflammation mediators may have a crucial role in achieving better disease control in patients with N-ERD.
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Affiliation(s)
- Saara Sillanpää
- Department of Ear and Oral Diseases, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jura Numminen
- Department of Ear and Oral Diseases, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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3
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Förster-Ruhrmann U, Beule AG, Becker S, Chaker AM, Huppertz T, Hagemann J, Hoffmann TK, Dazert S, Deitmer T, Wrede H, Schlenter W, Welkoborsky HJ, Wollenberg B, Olze H, Rudack C, Sperl A, Casper I, Dietz A, Wagenmann M, Zuberbier T, Bergmann KC, Bedbrook A, Bousquet J, Bachert C, Bergmann C, Klimek L. Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC). Laryngorhinootologie 2021; 100:864-872. [PMID: 34521148 DOI: 10.1055/a-1592-0316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Zusammenfassung
Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab.
Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt.
Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt.
Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.
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Affiliation(s)
- U Förster-Ruhrmann
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Charité-Universitätsmedizin, Berlin
| | - A G Beule
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätskliniken Münster
| | - S Becker
- Hals-Nasen-Ohrenklinik und Poliklinik, Universitätsklinik Tübingen
| | - A M Chaker
- Klinik für Hals-, Nasen- und Ohrenheilkunde und Zentrum für Allergie und Umwelt (ZAUM), Klinikum rechts der Isar, Technische Universität München
| | - T Huppertz
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsmedizin Mainz
| | - J Hagemann
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsmedizin Mainz
| | - T K Hoffmann
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Ulm
| | - S Dazert
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Bochum
| | - T Deitmer
- Deutsche Gesellschaft für Hals-, Nasen- und Ohrenheilkunde, Kopf- und Halschirurgie, Bonn
| | - H Wrede
- Hals-, Nasen- und Ohrenarzt, Herford
| | - W Schlenter
- Ärzteverband Deutscher Allergologen, Dreieich
| | - H J Welkoborsky
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Klinikum Nordstadt Hannover
| | - B Wollenberg
- Klinik für Hals-, Nasen- und Ohrenheilkunde und Zentrum für Allergie und Umwelt (ZAUM), Klinikum rechts der Isar, Technische Universität München
| | - H Olze
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Charité-Universitätsmedizin, Berlin
| | - C Rudack
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätskliniken Münster
| | - A Sperl
- Zentrum für Rhinologie und Allergologie, Wiesbaden
| | - I Casper
- Zentrum für Rhinologie und Allergologie, Wiesbaden
| | - A Dietz
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Leipzig
| | - M Wagenmann
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Düsseldorf
| | - T Zuberbier
- Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin
| | - K C Bergmann
- Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin
| | - A Bedbrook
- MACVIA-France, Fondation partenariale FMC VIA-LR, Montpellier, Frankreich
| | - J Bousquet
- MACVIA-France, Fondation partenariale FMC VIA-LR, Montpellier, Frankreich.,INSERM U 1168, VIMA: Ageing and Chronic Diseases Epidemiological and Public Health Approaches, Villejuif.,Université Versailles St-Quentin-en-Yvelines, UMR-S 1168, Montigny le Bretonneux, Frankreich.,Berlin Institute of Health, Comprehensive Allergy Center, Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin
| | - C Bachert
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Gent, Belgien
| | - C Bergmann
- RKM 740, HNO, Interdisziplinäre Facharztklinik, Düsseldorf
| | - L Klimek
- Zentrum für Rhinologie und Allergologie, Wiesbaden
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4
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Fernandez TD, Torres MJ, Romano A. Editorial: Drug Hypersensitivity: From Mechanisms to Improved Diagnosis and Standards of Care. Front Pharmacol 2021; 12:718928. [PMID: 34220526 PMCID: PMC8245755 DOI: 10.3389/fphar.2021.718928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- T D Fernandez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga-IBIMA, Málaga, Spain
| | - M J Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain.,Departamento de Medicina, Universidad de Málaga-IBIMA, Málaga, Spain.,Andalusian Centre for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - A Romano
- IRCCS Oasi Maria S.S., Troina, Italy.,Fondazione Mediterranea G.B. Morgagni, Catania, Italy
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Agondi RC, Dias GMFS, Assis JPD, Pacheco R, Kalil J, Giavina-Bianchi P. Hypersensitivity to dipyrone in aspirin-exacerbated respiratory disease patients is associated with urticaria. Respir Med 2020; 170:106041. [PMID: 32843172 DOI: 10.1016/j.rmed.2020.106041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/16/2020] [Accepted: 05/21/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To phenotype patients with aspirin-exacerbated respiratory disease (AERD) according to the presence of atopy, urticaria and level of peripheral eosinophils. METHODS This study included adult asthmatic patients with AERD followed up at a tertiary hospital. They were classified according to atopy and/or urticaria, assessing clinical and laboratorial differences among the groups in order to identify possible aggravating factors of the disease. RESULTS We included 73 patients, 78.1% being female with a mean age of 54.0 years. Severe asthma was observed in 68.5% and respiratory exacerbation with dipyrone in 67.1% of these patients. They had median total serum IgE of 191.6 IU/mL, mean peripheral eosinophils of 718.5 cells/mm3, and 50.7% were atopic. Urticaria was observed in 32.9% of them, and exacerbations were more often triggered by dipyrone (p = .016). Atopic patients were younger than nonatopic patients (p = .023), and had, on average, higher total serum IgE levels (p = .022). We observed a good correlation between asthma severity and peripheral eosinophils count (r2 = 026; p = .021). CONCLUSIONS In this study, severe asthma was highly prevalent in AERD patients. Likewise, urticaria was quite prevalent and its presence was associated with dipyrone induced hypersensitivity reaction. Atopy was found in half of the patients, with no association with asthma severity. Patients with higher levels of peripheral eosinophils had more severe asthma. Dypirone hypersensitivity may be a marker for concomitant respiratory and cutaneous hypersensitivity reactions.
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Affiliation(s)
- Rosana Câmara Agondi
- Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil; Laboratory of Immunology (LIM19), Heart Institute (InCor), School of Medicine, University of São Paulo, São Paulo, Brazil.
| | | | - Joāo Paulo de Assis
- Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil.
| | - Rosilane Pacheco
- Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil.
| | - Jorge Kalil
- Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil; Laboratory of Immunology (LIM19), Heart Institute (InCor), School of Medicine, University of São Paulo, São Paulo, Brazil.
| | - Pedro Giavina-Bianchi
- Clinical Immunology and Allergy Division, University of Sao Paulo School of Medicine, São Paulo, Brazil.
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Wardzyńska A, Pawełczyk M, Rywaniak J, Kurowski M, Makowska JS, Kowalski ML. Circulating MicroRNAs and T-Cell Cytokine Expression Are Associated With the Characteristics of Asthma Exacerbation. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:125-136. [PMID: 31743969 PMCID: PMC6875481 DOI: 10.4168/aair.2020.12.1.125] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/25/2019] [Accepted: 08/11/2019] [Indexed: 12/15/2022]
Abstract
Purpose Immunological mechanisms underlying asthma exacerbation have not been elucidated. The aim of this study was to assess the associations of various asthma exacerbation traits with selected serum microRNA (miRNA) expression and T-cell subpopulations. Methods Twenty-one asthmatics were studied during asthma exacerbation (exacerbation visit [EV] and the follow-up visit [FV] at 6 weeks). At both visits, spirometry was performed, fractional exhaled nitric oxide (FeNO) was measured, and nasopharyngeal and blood samples were collected. In nasopharyngeal samples, respiratory viruses were assayed by multiplex polymerase chain reaction (PCR), and bacterial cultures were performed. Serum miRNAs were assayed with real-time PCR. T-cell surface markers, eosinophil progenitors and intracellular cytokines were assessed by flow cytometry. Results Two-thirds of patients had moderate or severe exacerbation and the FV, overall improvement in asthma control was observed. The mean expression of serum miRNA-126a, miRNA-16 and miRNA-21 was significantly lower at the EV than at the FV. At EV, miRNA-29b correlated with FeNO (r = 0.44, P < 0.05), and 5 of 7 miRNA tested correlated with pulmonary function tests. The number of cluster of differentiation (CD)45+CD4+interleukin (IL)4+ cells was significantly higher at the EV than at the FV, and positive correlations of T-regulatory cells and eosinophil progenitors with asthma control was found. At the EV, serum miRNAs negatively correlated with the number of T cells expressing IL-4, IL-17, IL-22 and interferon gamma, while at the FV both positive and negative correlations with T-cell subsets were observed. No association of detected pathogen (viruses and bacteria) in nasopharyngeal fluid with clinical, functional and immunological parameters was found. Conclusions Epigenetic dysregulation during asthma exacerbation could be related to respiratory function, airway inflammation and T-cell cytokine expression.
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Affiliation(s)
| | | | - Joanna Rywaniak
- Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Marcin Kurowski
- Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Joanna S Makowska
- Department of Rheumatology, Medical University of Lodz, Lodz, Poland
| | - Marek L Kowalski
- Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland.
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7
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Tyrak KE, Kupryś-Lipińska I, Czarnobilska E, Jakieła B, Pajdzik K, Ćmiel A, Plutecka H, Koziej M, Gawrońska A, Konduracka E, Kuna P, Sanak M, Mastalerz L. Sputum biomarkers during aspirin desensitization in nonsteroidal anti-inflammatory drugs exacerbated respiratory disease. Respir Med 2019; 152:51-59. [PMID: 31128610 DOI: 10.1016/j.rmed.2019.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/10/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aspirin desensitization (AD) is an effective and safe therapeutic option for patients with nonsteroidal anti-inflammatory drugs (NSAIDs)-exacerbated respiratory disease (N-ERD). The mechanisms driving its beneficial effects remain poorly understood. OBJECTIVE To investigate the effect of long-term AD on clinical, biochemical and radiological changes in N-ERD patients. METHODS The study group consisted of twenty-three individuals with N-ERD who underwent AD, followed by ingestion of 325 mg aspirin twice daily. Twenty patients completed the 52 weeks of AD. The following evaluations were conducted at baseline and in the 52nd week of AD: (i) clinical: asthma exacerbations, Asthma Control Test (ACT), Visual Analogue Scale (VAS) for the assessment of nasal symptoms; (ii) blood and induced sputum supernatant (ISS) periostin, (iii) phenotypes based on induced sputum (IS) cells, (iiii) ISS and nasal lavage (NL) concentration of prostaglandin D2 (PGD2), prostaglandin E2 (PGE2), tetranor-PGD-M, tetranor-PGE-M, 8-iso-PGE2, leukotriene B4 (LTB4), LTC4, LTD4 and LTE4, and urine LTE4. RESULTS A significant improvement was observed in ACT (P = 0.02) and VAS score (P = 0.008) in the 52nd week of AD. ISS periostin and IS eosinophil count decreased significantly in the 52nd week of AD (P = 0.04 and P = 0.01, respectively). ISS and NL eicosanoid concentrations did not change following long-term AD. CONCLUSION and Clinical Relevance: AD is associated with a decrease in sputum periostin biosynthesis, which may prevent the recruitment of eosinophils into respiratory tissue and be one of explanation of the clinical benefits of AD. Long-term aspirin administration does not lead to an imbalance between pro- and anti-inflammatory ISS eicosanoids.
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Affiliation(s)
- Katarzyna Ewa Tyrak
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Izabela Kupryś-Lipińska
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Ewa Czarnobilska
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Cracow, Poland
| | - Bogdan Jakieła
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Kinga Pajdzik
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Adam Ćmiel
- Department of Applied Mathematics, AGH University of Science and Technology, Cracow, Poland
| | - Hanna Plutecka
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Aleksandra Gawrońska
- Department of Radiology/Diagnostic Imaging, University Hospital in Cracow, Cracow, Poland
| | - Ewa Konduracka
- Coronary and Heart Failure Department, Jagiellonian University School of Medicine, John Paul II Hospital, Cracow, Poland
| | - Piotr Kuna
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Marek Sanak
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Lucyna Mastalerz
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland.
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Massoth L, Anderson C, McKinney KA. Asthma and Chronic Rhinosinusitis: Diagnosis and Medical Management. Med Sci (Basel) 2019; 7:E53. [PMID: 30934800 PMCID: PMC6524348 DOI: 10.3390/medsci7040053] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 12/17/2022] Open
Abstract
Asthma is a prevalent inflammatory condition of the lower airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchial hyperresponsiveness (BHR). Symptomatically, these patients may demonstrate wheezing, breathlessness, chest tightness, and coughing. This disease is a substantial burden to a growing population worldwide that currently exceeds 300 million individuals. This is a condition that is frequently encountered, but often overlooked in the field of otolaryngology. In asthma, comorbid conditions are routinely present and contribute to respiratory symptoms, decreased quality of life, and poorer asthma control. It is associated with otolaryngic diseases of the upper airways including allergic rhinitis (AR) and chronic rhinosinusitis (CRS). These conditions have been linked epidemiologically and pathophysiologically. Presently, they are considered in the context of the unified airway theory, which describes the upper and lower airways as a single functional unit. Thus, it is important for otolaryngologists to understand asthma and its complex relationships to comorbid diseases, in order to provide comprehensive care to these patients. In this article, we review key elements necessary for understanding the evaluation and management of asthma and its interrelatedness to CRS.
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Affiliation(s)
- Landon Massoth
- College of Medicine, University of Oklahoma, Oklahoma City, OK 73104, USA.
| | - Cody Anderson
- College of Medicine, University of Oklahoma, Oklahoma City, OK 73104, USA.
| | - Kibwei A McKinney
- College of Medicine, University of Oklahoma, Oklahoma City, OK 73104, USA.
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