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Dai X, Bui DS, Lodge C. Glutathione S-Transferase Gene Associations and Gene-Environment Interactions for Asthma. Curr Allergy Asthma Rep 2021; 21:31. [PMID: 33970355 DOI: 10.1007/s11882-021-01005-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Asthma is one of the most common chronic inflammatory airway diseases. Airway oxidative stress is defined as an imbalance between oxidative and antioxidative processes in the airways. There is evidence that chronic damage caused by oxidative stress may be involved in asthmatic inflammation and reduced lung function. Given their biological antioxidant function, the antioxidant genes in the glutathione S-transferase (GST) family are believed to be associated with development and progression of asthma. This review aims to summarize evidence on the relationship between GST gene polymorphisms and asthma and interactions with environmental exposures. RECENT FINDINGS The current evidence on the association between GST genes and asthma is still weak or inconsistent. Failure to account for environmental exposures may explain the lack of consistency. It is highly likely that environmental exposures interact with GST genes involved in the antioxidant pathway. According to current knowledge, carriers of GSTM1(rs366631)/T1(rs17856199) null genotypes and GSTP1 Val105 (rs1695) genotypes are more susceptible to environmental oxidative exposures and have a higher risk of asthma. Some doubt remains regarding the presence or absence of interactions with different environmental exposures in different study scenarios. The GST-environment interaction may depend on exposure type, asthma phenotype or endotype, ethnics, and other complex gene-gene interaction. Future studies could be improved by defining precise asthma endotypes, involving multiple gene-gene interactions, and increasing sample size and power. Although there is evidence for an interaction between GST genes, and environmental exposures in relation to asthma, results are not concordant. Further investigations are needed to explore the reasons behind the inconsistency.
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Affiliation(s)
- Xin Dai
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Level 3 207 Bouverie Street, Parkville, VIC, 3010, Australia
| | - Dinh S Bui
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Level 3 207 Bouverie Street, Parkville, VIC, 3010, Australia
| | - Caroline Lodge
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Level 3 207 Bouverie Street, Parkville, VIC, 3010, Australia.
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The intersect of genetics, environment, and microbiota in asthma-perspectives and challenges. J Allergy Clin Immunol 2021; 147:781-793. [PMID: 33678251 DOI: 10.1016/j.jaci.2020.08.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/07/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023]
Abstract
In asthma, a significant portion of the interaction between genetics and environment occurs through microbiota. The proposed mechanisms behind this interaction are complex and at times contradictory. This review covers recent developments in our understanding of this interaction: the "microbial hypothesis" and the "farm effect"; the role of endotoxin and genetic variation in pattern recognition systems; the interaction with allergen exposure; the additional involvement of host gut and airway microbiota; the role of viral respiratory infections in interaction with the 17q21 and CDHR3 genetic loci; and the importance of in utero and early-life timing of exposures. We propose a unified framework for understanding how all these phenomena interact to drive asthma pathogenesis. Finally, we point out some future challenges for continued research in this field, in particular the need for multiomic integration, as well as the potential utility of asthma endotyping.
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Antenatal steroid therapy for fetal lung maturation and the subsequent risk of childhood asthma: a longitudinal analysis. J Pregnancy 2010; 2010:789748. [PMID: 21490744 PMCID: PMC3065803 DOI: 10.1155/2010/789748] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 04/06/2010] [Indexed: 11/22/2022] Open
Abstract
This study was designed to test the hypothesis that fetal exposure to corticosteroids in the antenatal period is an independent risk factor for the development of asthma in early childhood with little or no effect in later childhood. A population-based cohort study of all pregnant women who resided in Nova Scotia, Canada, and gave birth to a singleton fetus between 1989 and 1998
was undertaken. After a priori specified exclusions, 80,448 infants were available for analysis.
Using linked health care utilization records, incident asthma cases developed after 36 months of
age were identified. Extended Cox proportional hazards models were used to estimate hazard
ratios while controlling for confounders. Exposure to corticosteroids during pregnancy was
associated with a risk of asthma in childhood between 3–5 years of age: adjusted hazard ratio of
1.19 (95% confidence interval: 1.03, 1.39), with no association noted after 5 years of age:
adjusted hazard ratio for 5–7 years was 1.06 (95% confidence interval: 0.86, 1.30)
and for 8 or greater years was 0.74 (95% confidence interval: 0.54, 1.03). Antenatal steroid therapy appears to be an independent risk factor for the development of asthma between 3 and 5 years of age.
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Thomou C, Paraskakis E, Neofytou E, Kalmanti M, Siafakas NM, Tzortzaki EG. Acquired somatic mutations in the microsatellite DNA, in children with bronchial asthma. Pediatr Pulmonol 2009; 44:1017-24. [PMID: 19728390 DOI: 10.1002/ppul.21097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES High incidence of genetic alterations at the microsatellite (MS) DNA level has been reported in asthmatic adults. WORKING HYPOTHESIS The aim of this study was to investigate whether microsatellite instability (MSI) and loss of heterozygosity (LOH) were detectable phenomena in children with asthma. METHODOLOGY DNA was extracted from sputum and blood cells of 27 children (10.8 +/- 2.5 years) with mild to moderate asthma, and from 8 healthy, never-smoked young adults. Fourteen polymorphic MS markers, namely D5S207, D5S820, D5S637, D6S344, D6S2223, D6S263, SGC35231, D11S1253, D11S1337, D11S97, USAT24G1, D13S273, D14S258, and D14S292, located on chromosomes (chr) 5q, 6p, 11q, 13q, and 14q were used to assess MSI and LOH. RESULTS None of the healthy subjects exhibited any genetic alteration. Five out of 27 children (18.5%) exhibited MSI or LOH in sputum cells versus blood samples from which 3 in the marker USAT24G1 (chr 13q14.1), 1 in the marker D14S258 (chr 14q23-q24.3), and 1 in the marker D5S637 (chr 5q12-q13). Compared to a previous study, with asthmatic adults, whereas MSI and/or LOH was exhibited in approximately 60% of the cases, the current study reported <20% of genetic alterations, at the MS DNA, in asthmatic children. CONCLUSIONS Our results showed that genetic instability in the MS DNA, is present in asthmatic children, but to less extent than in adult asthmatics from previous studies. These findings may support the hypothesis that somatic mutations may be early acquired in the natural course of asthma and could represent another contributor to the molecular pathogenesis of the disease. However, further studies are needed to clarify this hypothesis.
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Affiliation(s)
- Christina Thomou
- Department of Pediatrics, University Hospital of Heraklion, Crete, Greece
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Kim JH, Ellwood PE, Asher MI. Diet and asthma: looking back, moving forward. Respir Res 2009; 10:49. [PMID: 19519921 PMCID: PMC2703624 DOI: 10.1186/1465-9921-10-49] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Accepted: 06/12/2009] [Indexed: 01/15/2023] Open
Abstract
Asthma is an increasing global health burden, especially in the western world. Public health interventions are sought to lessen its prevalence or severity, and diet and nutrition have been identified as potential factors. With rapid changes in diet being one of the hallmarks of westernization, nutrition may play a key role in affecting the complex genetics and developmental pathophysiology of asthma. The present review investigates hypotheses about hygiene, antioxidants, lipids and other nutrients, food types and dietary patterns, breastfeeding, probiotics and intestinal microbiota, vitamin D, maternal diet, and genetics. Early hypotheses analyzed population level trends and focused on major dietary factors such as antioxidants and lipids. More recently, larger dietary patterns beyond individual nutrients have been investigated such as obesity, fast foods, and the Mediterranean diet. Despite some promising hypotheses and findings, there has been no conclusive evidence about the role of specific nutrients, food types, or dietary patterns past early childhood on asthma prevalence. However, diet has been linked to the development of the fetus and child. Breastfeeding provides immunological protection when the infant's immune system is immature and a modest protective effect against wheeze in early childhood. Moreover, maternal diet may be a significant factor in the development of the fetal airway and immune system. As asthma is a complex disease of gene-environment interactions, maternal diet may play an epigenetic role in sensitizing fetal airways to respond abnormally to environmental insults. Recent hypotheses show promise in a biological approach in which the effects of dietary factors on individual physiology and immunology are analyzed before expansion into larger population studies. Thus, collaboration is required by various groups in studying this enigma from epidemiologists to geneticists to immunologists. It is now apparent that this multidisciplinary approach is required to move forward and understand the complexity of the interaction of dietary factors and asthma.
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Affiliation(s)
- June-Ho Kim
- Department of Cancer Immunology & AIDS, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
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Pole JD, Mustard CA, To T, Beyene J, Allen AC. Antenatal steroid therapy for fetal lung maturation: is there an association with childhood asthma? J Asthma 2009; 46:47-52. [PMID: 19191137 DOI: 10.1080/02770900802262795] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study was designed to test the hypothesis that fetal exposure to corticosteroids in the antenatal period is an independent risk factor for the development of asthma in childhood. METHODS A population-based cohort study was conducted of all pregnant women who resided in Nova Scotia, Canada, and gave birth to a singleton fetus between January 1989 and December 1998 and lived to discharge. After exclusions, 79,395 infants were available for analysis. Using linked health care utilization records, incident asthma cases between 36 to 72 months of age were identified. Generalized Estimating Equations were used to estimate the odds ratio of the association between exposure to corticosteroids and asthma while controlling for confounders. RESULTS Over the 10 years of the study corticosteroid therapy increased by threefold. Exposure to corticosteroids during pregnancy was associated with a risk of asthma in childhood: adjusted odds ratio of 1.23 (95% confidence interval: 1.06, 1.44). CONCLUSIONS Antenatal steroid therapy appears to be an independent risk factor for the development of asthma between 36 and 72 months of age. Further research into the smallest possible steroid dose required to achieve the desired post-natal effect is needed to reduce the risk of developing childhood asthma.
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Affiliation(s)
- Jason D Pole
- Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada.
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Knudsen TB, Thomsen SF, Ulrik CS, Fenger M, Nepper-Christensen S, Backer V. Season of birth and risk of atopic disease among children and adolescents. J Asthma 2007; 44:257-60. [PMID: 17530522 DOI: 10.1080/02770900701246832] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Season of birth (SOB) has been regarded as a risk factor for atopy. The aim of this study was to explore the relationship between season of birth (SOB) and later development of atopic disease in children and adolescents. METHODS A total of 1,007 randomly selected subjects, 7 to 17 years of age, who were living in urban Copenhagen, Denmark were studied. All participants were interviewed about respiratory symptoms and possible risk factors for atopic disease. Skin test reactivity, serum total immunoglobulin E (IgE), and airway responsiveness were measured using standard techniques. RESULTS The overall risk of atopy, as judged by skin test reactivity and serum total IgE, was the same regardless of SOB. On the contrary, asthma was more common in subjects born in the autumn compared with subjects born during the remaining part of the year (12.4% vs. 5.6%), OR = 2.40, 95% CI (1.56-3.94), p < 0.001. This was observed both for atopic asthma OR = 2.41, 95% CI (1.25-4.64), p = 0.007, non-atopic asthma, OR = 2.35, 95% CI (1.14-4.83), p = 0.02, and house dust mite (HDM) sensitive airway hyperresponsiveness, OR = 3.00, 95% CI (1.44-6.24), p = 0.002. Rhinitis and pollen allergy were not significantly related to SOB. CONCLUSIONS Atopy itself is independent of season of birth, whereas asthma is more prevalent among subjects born during the autumn. Regarding asthma, these results suggest that the first months of life enclose a period of particular vulnerability towards environmental risk factors, especially exposure to aeroallergens like HDM.
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Martin AC, Laing IA, Khoo SK, Zhang G, Rueter K, Teoh L, Taheri S, Hayden CM, Geelhoed GC, Goldblatt J, LeSouëf PN. Acute asthma in children: Relationships among CD14 and CC16 genotypes, plasma levels, and severity. Am J Respir Crit Care Med 2005; 173:617-22. [PMID: 16387800 DOI: 10.1164/rccm.200509-1367oc] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The majority of previous studies investigating asthma genetics have focused on cohorts with stable disease and have not defined mechanisms important during acute asthma. CD14 and CC16 each play a key role in biologically important inflammatory pathways and the gene of each has a functional promoter-region polymorphism. OBJECTIVES This study was designed to determine the influence of these polymorphisms on plasma levels of their products and clinical disease during acute asthma. We hypothesized that genotype-related differences in CD14 and CC16 production would be more marked during acute asthma and related to disease severity. METHODS We studied 148 children on presentation with acute asthma and again in convalescence. CD14 C-159T and CC16 A38G genotypes were determined, and plasma levels of soluble CD14 (sCD14) and CC16 were measured at both times. MEASUREMENTS AND MAIN RESULTS During acute asthma, plasma sCD14 levels were higher for the whole group (p = 0.003), but increases were only in subjects with CD14 -159TT (p = 0.003) and -159CT (p = 0.004), and not in those with -159CC. Plasma CC16 levels were also elevated acutely for the whole group (p = 0.013), but only in those with CC16 38GG (p = 0.043) and 38AG (p = 0.014), and not in those with CC16 38AA. Subjects with CD14 -159CC and CC16 38AA were more likely to have moderate or severe acute asthma. CONCLUSIONS Plasma levels of sCD14 and CC16 were higher during acute asthma in the subjects. Those with CD14 -159CC and CC16 38AA had no change in sCD14 and CC16 levels and more severe asthma.
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Affiliation(s)
- Andrew C Martin
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia.
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Hallstrand TS, Fischer ME, Wurfel MM, Afari N, Buchwald D, Goldberg J. Genetic pleiotropy between asthma and obesity in a community-based sample of twins. J Allergy Clin Immunol 2005; 116:1235-41. [PMID: 16337451 PMCID: PMC2014783 DOI: 10.1016/j.jaci.2005.09.016] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Revised: 09/06/2005] [Accepted: 09/07/2005] [Indexed: 01/01/2023]
Abstract
BACKGROUND Asthma and obesity are common conditions that are strongly associated. This association might be due to shared genetic or environmental causes. OBJECTIVE We sought to determine whether a shared genetic cause is responsible for the association between asthma and obesity and to estimate the magnitude of shared genetic cause. METHODS The analyses were performed with 1001 monozygotic and 383 dizygotic same-sex twin pairs within the University of Washington Twin Registry. The presence of asthma was determined by self-report of a physician diagnosis of asthma, and body mass index (BMI) was calculated by using self-reported height and weight. Obesity was defined as a BMI of 30 or greater. The association between asthma and BMI was assessed by means of mixed-effects ordinal regression. Twin correlations examined the association of asthma and obesity. Univariate and bivariate structural equation models estimated the components of variance attributable to genetic and environmental effects. RESULTS A strong association between asthma and BMI was identified in the sample population (P < .001). Substantial heritability was detected for asthma (53%) and obesity (77%), which is indicative of additive genetic influences on each disorder. The best-fitting model of shared components of variance indicated that 8% of the genetic component of obesity is shared with asthma. CONCLUSION The covariation between obesity and asthma is predominantly caused by shared genetic risk factors for both conditions.
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Affiliation(s)
- Teal S Hallstrand
- Department of Medicine, University of Washington, Seattle, 98195, USA.
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Takeuchi K, Suzuki S, Yagawa M, Yuta A, Majima Y. A CD14 gene polymorphism is associated with the IgE level for Dermatophagoides pteronyssinus. Acta Otolaryngol 2005; 125:966-71. [PMID: 16109674 DOI: 10.1080/00016480510044197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
CONCLUSION CD14/-159 plays a role in sensitization to Dermatophagoides pteronyssinus in Japanese patients with allergic rhinitis. OBJECTIVE An association between a polymorphism in the 5'-flanking region of the CD14 gene and atopic phenotypes has been identified in a pediatric American population and an adult Dutch population. The aim of this study was to determine whether the CD14/-159 polymorphism is associated with specific IgE levels in allergic rhinitis patients in a Japanese population. MATERIAL AND METHODS The CD14/-159 genotypes of 81 unrelated patients with allergic rhinitis and 78 healthy subjects were determined and compared. The total IgE level and the specific IgE levels for three aeroallergens were determined. The IgE levels for each genotype were compared. RESULTS The frequencies of CD14/-159 genotypes did not differ between the two groups. Among the allergic rhinitis patients, TT homozygotes had significantly fewer positive CAP-radioallergosorbent tests (CAP-RASTs) than CC homozygotes and CT heterozygotes, suggesting that the C allele is dominant. TT homozygotes also had significantly lower CAP-RAST scores for Dermatophagoides pteronyssinus, but not for Cryptomeria japonica or Dactylis glomerata, than CC homozygotes and CT heterozygotes. There was no significant association between total serum IgE levels and CD14/-159 genotypes in the allergic rhinitis patients.
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Affiliation(s)
- Kazuhiko Takeuchi
- Department of Otorhinolaryngology, Mie University School of Medicine, Mie, Japan.
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Samara K, Zervou M, Siafakas NM, Tzortzaki EG. Microsatellite DNA instability in benign lung diseases. Respir Med 2005; 100:202-11. [PMID: 16005622 DOI: 10.1016/j.rmed.2005.05.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Accepted: 05/23/2005] [Indexed: 02/02/2023]
Abstract
Recently DNA mismatch repair system (MMR) has been extensively investigated in molecular medicine. Microsatellite (MS) DNA alterations are considered as indicating an ineffective MMR system. MS loss of heterozygosity (LOH) and microsatellite instability (MSI) have been reported in a number of human malignancies. LOH and MSI have recently been detected in benign diseases, such as actinic keratosis, pterygium and atherosclerosis. In addition, MSI and LOH have been detected in asthma, chronic obstructive pulmonary disease, sarcoidosis and idiopathic pulmonary fibrosis. This is a review of MSI in benign lung diseases. It is concluded that detecting genetic alterations at the MS DNA level could be a useful technique to identify locus of potential altered genes that may play a key role in the pathogenesis of these diseases. In addition, MSI and LOH could be used as a genetic screening tool in molecular epidemiology.
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Affiliation(s)
- Katerina Samara
- Department of Thoracic Medicine, Medical School, University of Crete, Heraklion 71110, Crete, Greece
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Turner SW, Khoo SK, Laing IA, Palmer LJ, Gibson NA, Rye P, Landau LI, Goldblatt J, Le Souëf PN. beta2 adrenoceptor Arg16Gly polymorphism, airway responsiveness, lung function and asthma in infants and children. Clin Exp Allergy 2004; 34:1043-8. [PMID: 15248848 DOI: 10.1111/j.1365-2222.2004.02001.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We have previously reported a relationship between increased airway responsiveness (AR) in infancy and reduced childhood lung function. OBJECTIVE The current study aimed to determine whether the Arg16Gly polymorphism of the beta2 adrenoceptor (beta2AR) gene was important to this relationship. METHODS A cohort that initially numbered 253 individuals underwent assessments of AR and lung function aged 1 month, 6 and 11 years; genotyping for polymorphisms of the beta(2)AR was performed. RESULTS At 1 month of age, the genotype homozygous Arg16 (n=24) was associated with a mean increase in log dose-response slope (AR) of 0.27 [95% confidence interval (CI) 0.07, 0.49] compared with the genotype homozygous Gly16 (n=58), P=0.01. At 11 years of age, the genotype homozygous Arg16 (n=35) was associated with a mean reduction in the percentage of forced expiratory volume in 1 s of 5.3% [95% CI 0.3, 10.2] compared with the genotype homozygous Gly16 (n=65), P=0.03. There was no association between the Arg16Gly polymorphism and atopy or diagnosed asthma. However, nine of 69 individuals with the genotype homozygous Gly16 were admitted to hospital with asthma compared with five out of 111 individuals with the remaining genotypes (P<0.05). CONCLUSION The Arg16Gly polymorphism may be important to the association between increased AR in infancy and reduced lung function in childhood and may also be a determinant of asthma severity in children but not asthma per se.
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Affiliation(s)
- S W Turner
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.
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Wallace AM, Sandford AJ. Therapeutic response to asthma medications: genotype predictors. ACTA ACUST UNITED AC 2004; 3:161-71. [PMID: 15219175 DOI: 10.2165/00151829-200403030-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Asthma is a major social and economic burden. Studies have shown that genetic polymorphisms can influence drug efficacy and/or toxicity. The understanding of the pharmacogenetics of asthma will allow therapeutic regimens to be tailored on an individual basis. It is hoped that linkage and association studies will define new therapeutic targets for asthma but until then, studies have focused on improving response to beta(2)-adrenoceptor agonist and leukotriene modifier therapy. Genetic polymorphism may account for interindividual differences in toxicity and efficacy of asthma medications. To date, single nucleotide polymorphism and limited haplotype analysis have provided inconclusive evidence as to how genotype predictors can be used to optimize current asthma therapies based on each patient's genetic profile.
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Affiliation(s)
- Alison M Wallace
- University of British Columbia, James Hogg iCapture Centre, St Paul's Hospital, Vancouver, British Columbia, Canada
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Polk S, Sunyer J, Muñoz-Ortiz L, Barnes M, Torrent M, Figueroa C, Harris J, Vall O, Antó JM, Cullinan P. A prospective study of Fel d1 and Der p1 exposure in infancy and childhood wheezing. Am J Respir Crit Care Med 2004; 170:273-8. [PMID: 15117746 DOI: 10.1164/rccm.200310-1348oc] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The impact of domestic exposure to cat allergen (Fel d1) and house dust mite (Der p1) on wheezing from birth to the age of 4 years was investigated in a multicenter prospective birth cohort; 1,611 mothers were recruited before delivery in Ashford, England, and Barcelona and Menorca, Spain. Exposures were gathered via dust sample collection at children's home in their first year of life. Families provided complete outcome data (wheezing status in all 4 years) for 1,289 children. Domestic allergen levels varied substantially between centers. Six hundred three (47%) children never wheezed during their first 4 years of life. Der p1 did not correlate with any type of wheezing outcome. Fel d1 significantly increased the risk of wheezing in 3- and 4-year-olds in comparison to 1-year-olds. Distinct risk profiles were found for wheezing at different ages. Multivariate analysis revealed an interaction between Fel d1 and maternal asthma among children who wheeze in Year 4 (relative risk = 2.77; 95% confidence interval = 1.19-6.46). Our data support the idea that several patterns of wheezing with different risk profiles exist among young children. The effect of Fel d1 exposure varied according to age and maternal asthma.
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Affiliation(s)
- Sarah Polk
- Unitat Recerca Respiratòria i Ambietal, Institut Municipal Investigació Mèdica, Barcelona, Spain
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Arnaiz NO, Kaufman JD, Daroowalla FM, Quigley S, Farin F, Checkoway H. Genetic factors and asthma in aluminum smelter workers. ACTA ACUST UNITED AC 2003; 58:197-200. [PMID: 14655898 DOI: 10.3200/aeoh.58.4.197-200] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An asthma-like condition has been reported among aluminum smelter potroom workers. The pathophysiologic mechanisms and the causative agent involved are unknown. Inasmuch as gene polymorphisms are associated with asthma in the general population, the authors of this case-control study examined whether polymorphisms were associated with the development of potroom asthma. Genotyping was performed for the beta2-adrenoreceptor, high-affinity Ig (immunoglobulin) E receptor, and Tumor Necrosis Factor on potroom workers who developed a new asthma-like condition and on individuals who did not develop respiratory problems. No associations were found between potroom asthma case status and genotype. The asthma-like condition associated with potroom work remains poorly understood. Future investigations of genetic susceptibility and occupational asthma may provide pathophysiologic insights into these work-related conditions, but larger numbers of subjects will be required.
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Affiliation(s)
- Nilo O Arnaiz
- Department of Environmental and Occupational Health Sciences, University of Washington Seattle, Washington 98195, USA
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Somech R, Amariglio N, Spirer Z, Rechavi G. Genetic predisposition to infectious pathogens: a review of less familiar variants. Pediatr Infect Dis J 2003; 22:457-61. [PMID: 12792391 DOI: 10.1097/01.inf.0000068205.82627.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The susceptibility and clinical manifestations of infectious diseases in human populations are influenced by a variety of factors, among them host genetics. Obvious examples for the effect of host genetics on predisposition to unique infections are the primary immunodeficiency diseases. Minor gene variants that influence the host immune system are much more common. The iceberg model can be used to illustrate the epidemiology of immunodeficiency states. Accordingly only a few individuals have known and severe recognized primary immunodeficiencies, whereas many more patients have mild immunodeficiencies that may remain undiagnosed and are predisposed to a unique infectious disease. We review some of the less common variants that influence the host defense and predispose to certain infectious agents or change their outcome.
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Affiliation(s)
- Raz Somech
- Pediatric Hemato-Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel
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El-Sharif N, Abdeen Z, Barghuthy F, Nemery B. Familial and environmental determinants for wheezing and asthma in a case-control study of school children in Palestine. Clin Exp Allergy 2003; 33:176-86. [PMID: 12580909 DOI: 10.1046/j.1365-2222.2003.01598.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Our prevalence study on Palestinian school children aged 6-12 years showed lower rates for asthma and asthma symptoms than economically developed and industrialized countries. Reasons for such differences are largely unknown, and could possibly be related to different environmental and lifestyle factors. OBJECTIVE To investigate familial, early life exposures and indoor environmental determinants for asthma in children in Palestine. METHODS From the population of our previous study, a group of 273 children with wheeze in the past 12 months (of whom 99 children had physician-diagnosed asthma) were matched with an equal number of non-wheezing controls. This case-control study involved a parental questionnaire; skin prick testing (SPT) with mixed house dust mites, cat and dog dander, mixed grass, mixed trees pollen, Alternaria tenuis, olive tree and cockroach extracts; and serum for total and specific IgE for the same eight allergens. RESULTS Paternal asthma and maternal hayfever significantly tripled the risk for their children to have wheezing. Previous diagnoses of bronchial allergy, bronchitis, pneumonia, or whooping cough, and positive SPT for house dust mites and cockroaches were significantly more likely among wheezing and asthmatic children than controls. Specific IgE levels for house dust mites and cat allergens showed significantly higher risk for reported wheezing. After adjustment for several environmental and sociodemographic factors using multivariate logistic regression analysis, paternal asthma, maternal hayfever, damp houses, cat and cockroach SPT positivity proved to be strong predictors for wheezing symptoms. CONCLUSION Our study confirmed that familial 'atopic' diseases are significant predictors of childhood asthma in Palestinian children. Moreover, indoor environment such as presence of cats and domestic moulds also appear to play a role. Our findings are consistent with studies in Canada, New Zealand, Estonia and Sweden, and show promise to explore further gene-environment interaction in the genesis of asthma.
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Affiliation(s)
- N El-Sharif
- Laboratorium voor Pneumologie (Eenheid voor Longtoxicologie), K.U. Leuven, Belgium
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20
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Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax 2003; 58:81-8. [PMID: 12511728 PMCID: PMC1746457 DOI: 10.1136/thorax.58.1.81] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Most deaths from acute asthma occur outside hospital, but the at-risk patient may be recognised on the basis of prior ICU admission and asthma medication history. Patients who fail to improve significantly in the emergency department should be admitted to an HDU or ICU for observation, monitoring, and treatment. Hypoxia, dehydration, acidosis, and hypokalaemia render the severe acute asthmatic patient vulnerable to cardiac dysrrhythmia and cardiorespiratory arrest. Mechanical ventilation may be required for a small proportion of patients for whom it may be life saving. Aggressive bronchodilator (continuous nebulised beta agonist) and anti-inflammatory therapy must continue throughout the period of mechanical ventilation. Recognised complications of mechanical ventilation include hypotension, barotrauma, and nosocomial pneumonia. Low ventilator respiratory rates, long expiratory times, and small tidal volumes help to prevent hyperinflation. Volatile anaesthetic agents may produce bronchodilation in patients resistant to beta agonists. Fatalities in acute asthmatics admitted to HDU/ICU are rare.
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Affiliation(s)
- P Phipps
- Intensive Care Unit, John Radcliffe Hospital, Oxford OX3 9DU, UK
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21
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Schoepf UJ. [Thoracic molecular imaging]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2002; 58:1429-32. [PMID: 12469022 DOI: 10.6009/jjrt.kj00000921488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- U Joseph Schoepf
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, USA
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22
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Le Souëf PN. Risk factors and epidemiology. Med J Aust 2002; 177:S40-1. [PMID: 12225254 DOI: 10.5694/j.1326-5377.2002.tb04812.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2002] [Accepted: 07/22/2002] [Indexed: 11/17/2022]
Abstract
What we know: No one gene is a major cause of asthma. Some racial groups are more at risk of asthma than others. Early exposure to domestic animals appears to reduce the chance of developing asthma. Good hygiene may increase the likelihood of asthma. Impaired early airway function predisposes to asthma. What we need to know: How do several minor genetic factors combine to increase the risk of asthma in individuals and in population groups? Does early exposure to allergens promote sensitisation or tolerance? How do viruses precipitate asthma? Can acute asthma be treated by treating viral respiratory infections? Does impaired early airway function predispose to asthma throughout childhood?
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Affiliation(s)
- Peter N Le Souëf
- Department of Paediatrics, University of Western Australia, Crawley.
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23
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Gilliland FD, Li YF, Dubeau L, Berhane K, Avol E, McConnell R, Gauderman WJ, Peters JM. Effects of glutathione S-transferase M1, maternal smoking during pregnancy, and environmental tobacco smoke on asthma and wheezing in children. Am J Respir Crit Care Med 2002; 166:457-63. [PMID: 12186820 DOI: 10.1164/rccm.2112064] [Citation(s) in RCA: 204] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The rise in childhood asthma prevalence suggests a role for environmental factors in the etiology of this evolving epidemic; however, genetics also influence the occurrence of asthma. Glutathione S-transferase (GST) M1 may play a role in asthma and wheezing occurrence among those exposed to tobacco smoke, as it functions in pathways involved in asthma pathogenesis such as xenobiotic metabolism and antioxidant defenses. Effects of GSTM1 genotype, maternal smoking during pregnancy, and childhood environmental tobacco smoke (ETS) exposure on asthma and wheezing were investigated in 2,950 children enrolled in 4th, 7th, and 10th grade classrooms in 12 Southern California communities. The effects of in utero exposure to maternal smoking on asthma and wheezing occurrence were largely restricted to children with GSTM1 null genotype. Among GSTM1 null children, in utero exposure was associated with increased prevalence of early onset asthma (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.0-2.5), asthma with current symptoms (OR 1.7, 95% CI 1.1-2.8), persistent asthma (OR 1.6, 95% CI 1.1-2.4), lifetime history of wheezing (OR 1.8, 95% CI 1.3-2.5), wheezing with exercise (OR 2.1, 95% CI 1.3-3.3), wheezing requiring medication (OR 2.2, 95% CI 1.4-3.4), and emergency room visits in the past year (OR 3.7, 95% CI 1.9-7.3). Among children with GSTM1 (+) genotype, in utero exposure was not associated with asthma or wheezing. Our findings indicate that there are important long-term effects of in utero exposure in a genetically susceptible group of children.
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Affiliation(s)
- Frank D Gilliland
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, 1540 Alcazar Street, CHP 236, Los Angeles, CA 90033, USA.
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24
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Abstract
There has been a dramatic increase in the prevalence of asthma over the last quarter century, particularly in the industrialized world. Although our understanding of asthma continues to improve, there is no cure for the disease. Primary prevention of asthma is the focus of this review. Asthma is a disease with multiple gene-environment interactions. Candidate genes for asthma are considered, and potential interaction between one of those genes, CD14, and an environmental factor, endotoxin, is reviewed as it relates to the hygiene hypothesis. Environmental risk factors for asthma including allergens, pollutants, infectious factors, and dietary modifications are considered, particularly their potential for primary prevention of asthma. Ongoing cohort studies including the Canadian Allergy and Asthma Prevention Study, the Manchester Allergy and Asthma Study, the Children's Asthma Prevention Study from Australia, and the Prevention and Incidence of Asthma and Mite Allergy Study from the Netherlands are briefly reviewed. A more definitive understanding of genetic background and environmental triggers and their interactions is required before any specific approach to the primary prevention of asthma can be championed aggressively.
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Affiliation(s)
- Allan B Becker
- Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.
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25
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Affiliation(s)
- Aziz Sheikh
- Department of Primary Health Care and General Practice, Imperial College of Science, Technology and Medicine: Charing Cross Campus, St Dunstan's Road, London W6 8RP, UK
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26
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Affiliation(s)
- Aziz Sheikh
- Department of Primary Health Care and General Practice, Imperial College of Science, Technology and Medicine: Charing Cross Campus, St Dunstan's Road, London W6 8RP, UK
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27
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Affiliation(s)
- M J Tobin
- Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine and Edward Hines, Jr., Veterans Affairs Hospital, Hines, Illinois 6041, USA.
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28
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Dolganov GM, Woodruff PG, Novikov AA, Zhang Y, Ferrando RE, Szubin R, Fahy JV. A novel method of gene transcript profiling in airway biopsy homogenates reveals increased expression of a Na+-K+-Cl- cotransporter (NKCC1) in asthmatic subjects. Genome Res 2001; 11:1473-83. [PMID: 11544191 DOI: 10.1101/gr.191301] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Comprehensive and systematic analysis of airway gene expression represents a strategy for addressing the multiple, complex, and largely untested hypotheses that exist for disease mechanisms, including asthma. Here, we report a novel real-time PCR-based method specifically designed for quantification of multiple low-abundance transcripts using as little as 2.5 fg of total RNA per gene. This method of gene expression profiling has the same specificity and sensitivity as RT-PCR and a throughput level comparable to low-density DNA microarray hybridization. In this two-step method, multiplex RT-PCR is successfully combined with individual gene quantification via real-time PCR on generated cDNA product. Using this method, we measured the expression of 75 genes in bronchial biopsies from asthmatic versus healthy subjects and found expected increases in expression levels of Th2 cytokines and their receptors in asthma. Surprisingly, we also found increased gene expression of NKCC1--a Na+-K+-Cl- cotransporter. Using immunohistochemical method, we confirmed increased protein expression for NKCC1 in the asthmatic subject with restricted localization to goblet cells. These data validate the new transcriptional profiling method and implicate NKCC1 in the pathophysiology of mucus hypersecretion in asthma. Potential applications for this method include transcriptional profiling in limited numbers of laser captured cells and validation of DNA microarray data in clinical specimens.
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Affiliation(s)
- G M Dolganov
- Genelabs Technologies, Inc., Redwood City, California 94063, USA.
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29
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Noguchi E, Shibasaki M, Inudou M, Kamioka M, Yokouchi Y, Yamakawa-Kobayashi K, Hamaguchi H, Matsui A, Arinami T. Association between a new polymorphism in the activation-induced cytidine deaminase gene and atopic asthma and the regulation of total serum IgE levels. J Allergy Clin Immunol 2001; 108:382-6. [PMID: 11544457 DOI: 10.1067/mai.2001.117456] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Activation-induced cytidine deaminase (AICDA) is a recently identified RNA-editing deaminase that plays an important role in class-switching. Defects in AICDA result in a hyper-IgM phenotype and lack of IgG, IgA, and IgE in both human beings and mice. OBJECTIVE The aim of this study was to determine whether the AICDA gene is related to regulation of total serum IgE and development of atopic asthma. METHODS We screened for polymorphisms in the 5;-flanking and coding regions of the AICDA gene in subjects with atopic asthma and analyzed the effect of these polymorphisms on the development of atopic asthma and on total serum IgE levels in Japanese asthmatic families. RESULTS We identified 3 novel polymorphisms (5923A/G, 7888C/T, and 8578A/C) and 1 rare variant (Arg25Cys) in the AICDA gene. Transmission disequilibrium testing showed that the 7888C allele was transmitted preferentially to asthma-affected children (P =.007). Mean log [total serum IgE] levels of parents with the 7888C/7888C, 7888C/7888T, and 7888T/7888T genotypes were 2.12, 1.99, and 1.77, respectively, and a significant association was observed between the genotypes (P =.02). In RT-PCR experiments, we found 2 novel splice variants of AICDA, one lacking all of exon 4 (variant 1; 367 base pairs) and the other lacking the first 30 base pairs of exon 4 (variant 2; 453 base pairs). These variants were not associated with the 7888C/T polymorphism. CONCLUSION The 7888C/T polymorphism might be associated with the pathogenesis of atopic asthma and the regulation of total serum IgE levels.
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Affiliation(s)
- E Noguchi
- Department of Medical Genetics, Institute of Basic Medical Sciences, Institute of Clinical Medicine, University of Tsukuba
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30
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London SJ, James Gauderman W, Avol E, Rappaport EB, Peters JM. Family history and the risk of early-onset persistent, early-onset transient, and late-onset asthma. Epidemiology 2001; 12:577-83. [PMID: 11505179 PMCID: PMC1618803 DOI: 10.1097/00001648-200109000-00019] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Family history of asthma and allergies strongly influences asthma risk in children, but the association may differ for early-onset persistent, early-onset transient, and late-onset asthma. We analyzed the relation between family history and these types of asthma using cross-sectional data from a school-based study of 5,046 Southern California children. Parental and/or sibling history of asthma and allergy were generally more strongly associated with early-onset persistent asthma compared with early-onset transient or late-onset asthma. For children with two asthmatic parents relative to those with none, the prevalence ratio for early-onset persistent asthma was 12.1 [95% confidence interval (CI) = 7.91-18.7] compared with 7.51 (95% CI = 2.62-21.5) for early-onset transient asthma and 5.38 (95% CI = 3.40-8.50) for late-onset asthma. Maternal smoking in pregnancy was predominantly related to the risk of early-onset persistent asthma in the presence of parental history of allergy and asthma, and the joint effects were more than additive (interaction contrast ratio = 3.10, 95% CI = 1.45-4.75). Our results confirm earlier data that parental history of asthma and allergy is most strongly associated with early-onset persistent asthma and suggest that among genetically predisposed children, an early-life environmental exposure, maternal smoking during pregnancy, favors the development of early-onset asthma that persists into later early childhood.
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Affiliation(s)
- S J London
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
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31
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Hunt CE. Sudden infant death syndrome and other causes of infant mortality: diagnosis, mechanisms, and risk for recurrence in siblings. Am J Respir Crit Care Med 2001; 164:346-57. [PMID: 11500332 DOI: 10.1164/ajrccm.164.3.9910045] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- C E Hunt
- Department of Pediatrics, Medical College of Ohio, Toledo, Ohio, USA.
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32
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Cameron L, Hamid Q. Regulation of allergic airways inflammation by cytokines and glucocorticoids. Curr Allergy Asthma Rep 2001; 1:153-63. [PMID: 11899298 DOI: 10.1007/s11882-001-0083-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cytokines mediate the allergic inflammatory response of the airways, and glucocorticosteroids ameliorate allergy symptoms by regulating cytokine expression. Recent studies provide insight into the manner by which cytokines work together to mediate allergic airway disease. Real progress has also been gained in our understanding of subcellular mechanisms of allergic inflammation, particularly the role of transcription factors in regulating the expression of specific cytokine profiles and the differentiation of the TH2 subset. This article provides an update of recently reported findings in this field and highlights emerging concepts of allergic inflammation.
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Affiliation(s)
- L Cameron
- Respiratory Sciences Center, University of Arizona, Tucson, AZ, USA
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33
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Winchester EC, Millwood IY, Rand L, Penny MA, Kessling AM. Association of the TNF-alpha-308 (G-->A) polymorphism with self-reported history of childhood asthma. Hum Genet 2000; 107:591-6. [PMID: 11153913 DOI: 10.1007/s004390000410] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Asthma is a complex disease involving genetic and environmental aetiology. The tumour necrosis factor-alpha (TNF-alpha) and angiotensin-converting enzyme (ACE) genes have been implicated in asthma pathogenesis. This study investigated the association of a G-308A variant of TNF-alpha and an insertion/deletion (I/D) variant of ACE with a self-reported history of childhood asthma, in two population groups. At Northwick Park Hospital, London, 1,811 pregnant women attending for antenatal care were recruited. Participants with a self-reported history of childhood asthma, determined by a researcher-administered questionnaire, and controls with no personal or family history of asthma, of UK/Irish (cases n=20; controls n=416) and South Asian (cases n=6; controls n=275) origin were used in this study. Participants were genotyped for the TNF-alpha-308 and ACE I/D variants by a PCR-RFLP and PCR approach. The TNF-alpha-308 allele 2 (-308A) was significantly associated with self-reported childhood asthma in the UK/Irish (Odds ratios (OR): 2.6; 95% confidence intervals (CI): 1.1-6.2; P=0.03) but not in the South Asian population. The ACE DD genotype was not associated with childhood asthma in either population group. Gametic phase disequilibrium between the TNF-alpha-308 and ACE I/D variants was significantly different from zero in UK/Irish cases (delta=0.09; P=0.034). The TNF-alpha308 allele 2 or a linked major histocompatibility complex (MHC) variant may be a genetic risk factor for childhood asthma in the UK/Irish sample.
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Affiliation(s)
- E C Winchester
- Department of Medical and Community Genetics, Imperial College School of Medicine, Kennedy Galton Centre, Northwest London Hospitals NHS Trust, Harrow, UK
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34
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Hauck FR, Hunt CE. Sudden infant death syndrome in 2000. CURRENT PROBLEMS IN PEDIATRICS 2000; 30:237-61. [PMID: 11041024 DOI: 10.1067/mpp.2000.109512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- F R Hauck
- Department of Family Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
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