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Beigelman A, Goss CW, Wang J, Srinivasan M, Boomer J, Zhou Y, Bram S, Casper TJ, Coverstone AM, Kanchongkittiphon W, Kuklinski C, Storch GA, Schechtman KB, Castro M, Bacharier LB. Azithromycin therapy in infants hospitalized for respiratory syncytial virus bronchiolitis: Airway matrix metalloproteinase-9 levels and subsequent recurrent wheeze. Ann Allergy Asthma Immunol 2024; 132:623-629. [PMID: 38237675 DOI: 10.1016/j.anai.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Early life respiratory syncytial virus (RSV) bronchiolitis is a significant risk factor for childhood asthma. In vitro and in vivo studies suggested that decreasing levels of airway matrix metalloproteinase (MMP)-9 during RSV bronchiolitis may be associated with clinical benefits. OBJECTIVE To investigate whether azithromycin therapy during severe RSV bronchiolitis reduces upper airway MMP-9 levels, whether upper airway MMP-9 levels correlate with upper airway interleukin IL-8 levels, and whether MMP-9 level reduction is associated with reduced post-RSV recurrent wheeze (RW). METHODS A total of 200 otherwise healthy 1- to 18-month-old infants hospitalized with RSV bronchiolitis were randomized into a double-blind, placebo-controlled trial of oral azithromycin (10 mg/kg daily for 7 days followed by 5 mg/kg daily for 7 days) or placebo. Infants were followed for 2 to 4 years for the outcome of RW (3 or more wheezing episodes). Nasal lavage samples for MMP-9 levels were obtained at baseline, day 14 (end of the study treatment), and after 6 months. RESULTS Upper airway MMP-9 levels were highly correlated with IL-8 levels at all 3 time points: randomization, day 14, and 6 months (r = 0.80; P < .0001 for all time points). MMP-9 levels were similar between treatment groups at randomization, were lower on day 14 among children treated with azithromycin (P = .0085), but no longer different after 6 months. MMP-9 levels at baseline and change from baseline to day 14 were not associated with the development of RW (P = .49, .39, respectively). CONCLUSION Azithromycin therapy in children hospitalized with RSV bronchiolitis had a short-term anti-inflammatory effect in reducing upper airway MMP-9 levels. However, the reduction in MMP-9 levels did not relate to subsequent RW post-RSV. TRIAL REGISTRATION This study is a secondary analysis of the Azithromycin to Prevent Wheezing following severe RSV bronchiolitis-II clinical trial registered at Clinicaltrials.gov (NCT02911935).
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Affiliation(s)
- Avraham Beigelman
- The Kipper Institute of Allergy and Immunology, Schneider Children's Medical Center of Israel and the Tel Aviv University, Petach Tikvah, Israel.
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Jinli Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Mythili Srinivasan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jonathan Boomer
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Sarah Bram
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Timothy J Casper
- Department of Pediatrics, Mercy Children's Hospital, St. Louis, Missouri
| | - Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Cadence Kuklinski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory A Storch
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Kenneth B Schechtman
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee
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Painter N, Monovoukas D, Delecaris AO, Coverstone AM, Zopf DA, Saba TG. Incorporating a Three-Dimensional Printed Airway into a Pediatric Flexible Bronchoscopy Curriculum. ATS Sch 2024; 5:142-153. [PMID: 38633515 PMCID: PMC11022656 DOI: 10.34197/ats-scholar.2023-0078oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/16/2023] [Indexed: 04/19/2024] Open
Abstract
Background Although hands-on simulation plays a valuable role in procedural training, there are limited tools available to teach pediatric flexible bronchoscopy (PFB). Fellowship programs rely on patient encounters, with inherent risk, or high-cost virtual reality simulators that may not be widely available and create education inequalities. Objective Our objective was to study the educational value and transferability of a novel, low-cost, three-dimensional-printed pediatric airway model (3D-AM) for PFB training. Our central hypothesis was that the 3D-AM would have high educational value and would be easily transferrable to learners at different teaching hospitals. Methods The 3D-AM was designed to teach technical bronchoscopy skills, airway anatomy, airway pathology, and bronchoalveolar lavage (BAL). The curriculum was offered to incoming fellows in pediatric pulmonology, pediatric surgery, and pediatric critical care across three different teaching institutions. After course completion, each participant assessed the simulation model(s) with a 5-point Likert scale across six domains: physical attributes, realism of experience, ability to perform tasks, value, relevance, and global impression. The expert instructors assessed the learners' competency using a modified version of the Bronchoscopy Skills and Tasks Assessment Tool. Results A total of 14 incoming fellows participated in the course. The mean scores for the 3D-AM across all six domains and across the three institutions was between 4 and 5, suggesting that learners generally had a favorable impression and a similar experience across different institutions. All learners "agreed" or "strongly agreed" that the course was a valuable use of their time, helped teach technical skills and airway anatomy, and would be useful for extra training during fellowship. Most of the learners correctly identified anatomy, bronchomalacia, and performed a BAL. Wall trauma was observed in 36% of learners. Conclusion The utility, low cost, and transferability of this model may create opportunities for PFB training across different institutions despite resource limitations in the United States and abroad.
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Affiliation(s)
| | | | - Angela O. Delecaris
- Department of Pediatrics, Indiana
University School of Medicine, Indianapolis, Indiana; and
| | - Andrea M. Coverstone
- Department of Pediatrics, Washington
University School of Medicine, St. Louis, Missouri
| | - David A. Zopf
- Department of Otolaryngology–Head
and Neck Surgery, and
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3
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Beigelman A, Srinivasan M, Goss CW, Wang J, Zhou Y, True K, Ahrens E, Burgdorf D, Haslam MD, Boomer J, Bram S, Burnham CAD, Casper TJ, Coverstone AM, Kanchongkittiphon W, Kuklinski C, Storch GA, Wallace MA, Yin-DeClue H, Castro M, Schechtman KB, Bacharier LB. Azithromycin to Prevent Recurrent Wheeze Following Severe Respiratory Syncytial Virus Bronchiolitis. NEJM Evid 2022; 1:10.1056/evidoa2100069. [PMID: 37621674 PMCID: PMC10448891 DOI: 10.1056/evidoa2100069] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Early-life severe respiratory syncytial virus (RSV) bronchiolitis is a risk factor for childhood asthma. Because azithromycin may attenuate airway inflammation during RSV bronchiolitis, we evaluated whether it would reduce the occurrence of post-RSV recurrent wheeze. METHODS We prospectively enrolled 200 otherwise healthy 1- to 18-month-old children hospitalized with RSV bronchiolitis in this single-center, double-blind, placebo-controlled study and randomly assigned them to receive oral azithromycin (10 mg/kg daily for 7 days, followed by 5 mg/kg daily for 7 days) or placebo. Randomization was stratified by recent open-label antibiotic use. The primary outcome was the occurrence of recurrent wheeze, defined as a third episode of post-RSV wheeze over the following 2 to 4 years. RESULTS As an indication of the biologic activity of azithromycin, nasal wash interleukin-8 levels, at day 14 after randomization, were lower among azithromycin-treated participants (P<0.01). Despite evidence of biologic activity, azithromycin did not reduce the risk of post-RSV recurrent wheeze (47% in the azithromycin group vs. 36% in the placebo group; adjusted hazard ratio, 1.45; 95% confidence interval [CI], 0.92 to 2.29; P=0.11). Azithromycin also did not modify the risk of recurrent wheeze among participants already receiving other antibiotic treatment at the time of enrollment (hazard ratio, 0.94; 95% CI, 0.43 to 2.07). There was a potential signal among antibiotic-naïve participants who received azithromycin to have an increased risk of recurrent wheeze (hazard ratio, 1.79; 95% CI, 1.03 to 3.1). CONCLUSIONS Azithromycin therapy for 14 days during acute severe RSV bronchiolitis did not reduce recurrent wheeze occurrence over the following 2 to 4 years. Our data suggest no benefit of azithromycin administration with the goal of preventing recurrent wheeze in later life. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02911935.).
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Affiliation(s)
- Avraham Beigelman
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
- Kipper Institute of Allergy and Immunology, Schneider Children's Medical Center of Israel and the Tel Aviv University, Petach Tikvah, Israel
| | - Mythili Srinivasan
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis
| | - Jinli Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Kelly True
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Elizabeth Ahrens
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Dana Burgdorf
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | | | - Jonathan Boomer
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Sarah Bram
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis
| | | | - Andrea M Coverstone
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | | | - Cadence Kuklinski
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Gregory A Storch
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Meghan A Wallace
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis
| | - Huiqing Yin-DeClue
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | | | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville
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4
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Coverstone AM, Seibold MA, Peters MC. Diagnosis and Management of T2-High Asthma. J Allergy Clin Immunol Pract 2021; 8:442-450. [PMID: 32037108 DOI: 10.1016/j.jaip.2019.11.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/07/2019] [Accepted: 11/24/2019] [Indexed: 12/15/2022]
Abstract
Type 2 (T2) inflammation plays a key role in the pathogenesis of asthma. IL-4, IL-5, and IL-13, along with other inflammatory mediators, lead to increased cellular eosinophilic inflammation. It is likely that around half of all patients with asthma have evidence of T2-high inflammation. Sputum and blood eosinophils, exhaled nitric oxide, blood IgE levels, and airway gene expression markers are frequently used biomarkers of T2-high asthma. Individuals with T2-high asthma tend to have several features of increased asthma severity, including reduced lung function and increased rates of asthma exacerbations, and T2-high patients demonstrate distinct pathologic features including increased airway remodeling and alterations in airway mucus production. Several monoclonal antibodies are now available to treat individuals with T2-high asthma and these medications significantly reduce asthma exacerbation rates.
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Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Division of Allergy, Immunology and Pulmonary Medicine, Washington University School of Medicine in Saint Louis, St Louis, Mo.
| | - Max A Seibold
- National Jewish Health, Department of Pediatrics, Center for Genes, Environment, and Health, Denver, Colo
| | - Michael C Peters
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, Calif
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Abstract
Cystic fibrosis is the most common life-shortening genetic disease affecting Caucasians, clinically manifested by fat malabsorption, poor growth and nutrition, and recurrent sinopulmonary infections. Newborn screening programs for cystic fibrosis are now implemented throughout the United States and in many nations worldwide. Early diagnosis and interventions have led to improved clinical outcomes for people with cystic fibrosis. Newer cystic fibrosis transmembrane conductance regulator potentiators and correctors with mutation-specific effects have increasingly been used in children, and these agents are revolutionizing care. Indeed, it is possible that highly effective modulator therapy used early in life could profoundly affect the trajectory of cystic fibrosis lung disease, and primary prevention may be achievable.
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Affiliation(s)
- Andrea M. Coverstone
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Thomas W. Ferkol
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, MO, United States
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6
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Coverstone AM, Boomer JS, Lew D, Bacharier LB, Castro M. Type 2 inflammation in the sputum of adolescents with asthma. Ann Allergy Asthma Immunol 2020; 126:297-299. [PMID: 33276117 DOI: 10.1016/j.anai.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/06/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St Louis, Missouri.
| | - Jonathan S Boomer
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Daphne Lew
- Division of Biostatistics and Center for Population Health Informatics, Washington University School of Medicine in Saint Louis, St Louis, Missouri
| | - Leonard B Bacharier
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, Kansas City, Kansas
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7
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Coverstone AM, Bacharier LB. Airway Inflammatory Patterns in Severe Childhood Asthma-How Might This Change General Practice? J Allergy Clin Immunol Pract 2020; 7:1813-1814. [PMID: 31279464 DOI: 10.1016/j.jaip.2019.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, Saint Louis, Mo.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, Saint Louis, Mo
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8
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Coverstone AM, Bacharier LB, Wilson BS, Fitzpatrick AM, Teague WG, Phipatanakul W, Wenzel SE, Gaston BM, Bleecker ER, Moore WC, Ramratnam S, Jarjour NN, Ly NP, Fahy JV, Mauger DT, Schechtman KB, Yin-DeClue H, Boomer JS, Castro M. Clinical significance of the bronchodilator response in children with severe asthma. Pediatr Pulmonol 2019; 54:1694-1703. [PMID: 31424170 PMCID: PMC7015037 DOI: 10.1002/ppul.24473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/12/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Our objective was to determine those characteristics associated with reversibility of airflow obstruction and response to maximal bronchodilation in children with severe asthma through the Severe Asthma Research Program (SARP). METHODS We performed a cross-sectional analysis evaluating children ages 6 to 17 years with nonsevere asthma (NSA) and severe asthma (SA). Participants underwent spirometry before and after 180 µg of albuterol to determine reversibility (≥12% increase in FEV1 ). Participants were then given escalating doses up to 720 µg of albuterol to determine their maximum reversibility. RESULTS We evaluated 230 children (n = 129 SA, n = 101 NSA) from five centers across the United States in the SARP I and II cohorts. SA (odds ratio [OR], 2.08, 95% confidence interval [CI], 1.05-4.13), second-hand smoke exposure (OR, 2.81, 95%CI, 1.23-6.43), and fractional exhaled nitric oxide (FeNO; OR, 1.97, 95%CI, 1.35-2.87) were associated with increased odds of airway reversibility after maximal bronchodilation, while higher prebronchodilator (BD) FEV1 % predicted (OR, 0.91, 95%CI, 0.88-0.94) was associated with decreased odds. In an analysis using the SARP III cohort (n = 186), blood neutrophils, immunoglobulin E (IgE), and FEV1 % predicted were significantly associated with BD reversibility. In addition, children with BD response have greater healthcare utilization. BD reversibility was associated with reduced lung function at enrollment and 1-year follow-up though less decline in lung function over 1 year compared to those without reversibility. CONCLUSIONS Lung function, that is FEV1 % predicted, is a predictor of BD response in children with asthma. Additionally, smoke exposure, higher FeNO or IgE level, and low peripheral blood neutrophils are associated with a greater likelihood of BD reversibility. BD response can identify a phenotype of pediatric asthma associated with low lung function and poor asthma control.
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Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Bradley S Wilson
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - William Gerald Teague
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wanda Phipatanakul
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sally E Wenzel
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benjamin M Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - Wendy C Moore
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sima Ramratnam
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Ngoc P Ly
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - John V Fahy
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - Kenneth B Schechtman
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Huiqing Yin-DeClue
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Jonathan S Boomer
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Mario Castro
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
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9
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Coverstone AM, Wang L, Sumino K. Beyond Respiratory Syncytial Virus and Rhinovirus in the Pathogenesis and Exacerbation of Asthma: The Role of Metapneumovirus, Bocavirus and Influenza Virus. Immunol Allergy Clin North Am 2019; 39:391-401. [PMID: 31284928 PMCID: PMC7127190 DOI: 10.1016/j.iac.2019.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Respiratory viruses other than rhinovirus or respiratory syncytial virus, including human metapneumovirus, influenza virus, and human bocavirus, are important pathogens in acute wheezing illness and asthma exacerbations in young children. Whether infection with these viruses in early life is associated with recurrent wheezing and/or asthma is not fully investigated, although there are data to suggest children with human metapneumovirus lower respiratory tract infection may have a higher likelihood of subsequent and recurrent wheezing several years after initial infection.
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Affiliation(s)
- Andrea M Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 1 Children's Place, Campus Box 8116, Saint Louis, MO 63110, USA
| | - Leyao Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 425 S. Euclid Avenue, CB 8052, Saint Louis, MO 63110, USA
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 660 Euclid Avenue, Campus Box 8052, Saint Louis, MO 63110, USA.
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10
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Lachowicz-Scroggins ME, Dunican EM, Charbit AR, Raymond W, Looney MR, Peters MC, Gordon ED, Woodruff PG, Lefrançais E, Phillips BR, Mauger DT, Comhair SA, Erzurum SC, Johansson MW, Jarjour NN, Coverstone AM, Castro M, Hastie AT, Bleecker ER, Fajt ML, Wenzel SE, Israel E, Levy BD, Fahy JV. Extracellular DNA, Neutrophil Extracellular Traps, and Inflammasome Activation in Severe Asthma. Am J Respir Crit Care Med 2019; 199:1076-1085. [PMID: 30888839 PMCID: PMC6515873 DOI: 10.1164/rccm.201810-1869oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/15/2019] [Indexed: 12/30/2022] Open
Abstract
Rationale: Extracellular DNA (eDNA) and neutrophil extracellular traps (NETs) are implicated in multiple inflammatory diseases. NETs mediate inflammasome activation and IL-1β secretion from monocytes and cause airway epithelial cell injury, but the role of eDNA, NETs, and IL-1β in asthma is uncertain. Objectives: To characterize the role of activated neutrophils in severe asthma through measurement of NETs and inflammasome activation. Methods: We measured sputum eDNA in induced sputum from 399 patients with asthma in the Severe Asthma Research Program-3 and in 94 healthy control subjects. We subdivided subjects with asthma into eDNA-low and -high subgroups to compare outcomes of asthma severity and of neutrophil and inflammasome activation. We also examined if NETs cause airway epithelial cell damage that can be prevented by DNase. Measurements and Main Results: We found that 13% of the Severe Asthma Research Program-3 cohort is "eDNA-high," as defined by sputum eDNA concentrations above the upper 95th percentile value in health. Compared with eDNA-low patients with asthma, eDNA-high patients had lower Asthma Control Test scores, frequent history of chronic mucus hypersecretion, and frequent use of oral corticosteroids for maintenance of asthma control (all P values <0.05). Sputum eDNA in asthma was associated with airway neutrophilic inflammation, increases in soluble NET components, and increases in caspase 1 activity and IL-1β (all P values <0.001). In in vitro studies, NETs caused cytotoxicity in airway epithelial cells that was prevented by disruption of NETs with DNase. Conclusions: High extracellular DNA concentrations in sputum mark a subset of patients with more severe asthma who have NETs and markers of inflammasome activation in their airways.
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Affiliation(s)
- Marrah E Lachowicz-Scroggins
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Eleanor M Dunican
- 3 School of Medicine and St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Annabelle R Charbit
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Wilfred Raymond
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Mark R Looney
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Michael C Peters
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Erin D Gordon
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Prescott G Woodruff
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Emma Lefrançais
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Brenda R Phillips
- 4 Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - David T Mauger
- 4 Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - Suzy A Comhair
- 5 Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Nizar N Jarjour
- 7 Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Andrea M Coverstone
- 8 Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Mario Castro
- 8 Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Annette T Hastie
- 9 Pulmonary Section, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Eugene R Bleecker
- 10 Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Merritt L Fajt
- 11 Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;and
| | - Sally E Wenzel
- 11 Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;and
| | - Elliot Israel
- 12 Division of Pulmonary and Critical Care Medicine, Brigham Research Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bruce D Levy
- 12 Division of Pulmonary and Critical Care Medicine, Brigham Research Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John V Fahy
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
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11
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Schaefer N, Li X, Seibold MA, Jarjour NN, Denlinger LC, Castro M, Coverstone AM, Teague WG, Boomer J, Bleecker ER, Meyers DA, Moore WC, Hawkins GA, Fahy J, Phillips BR, Mauger DT, Dakhama A, Gellatly S, Pavelka N, Berman R, Di YP, Wenzel SE, Chu HW. The effect of BPIFA1/SPLUNC1 genetic variation on its expression and function in asthmatic airway epithelium. JCI Insight 2019; 4:127237. [PMID: 30996135 DOI: 10.1172/jci.insight.127237] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/14/2019] [Indexed: 11/17/2022] Open
Abstract
Bacterial permeability family member A1 (BPIFA1), also known as short palate, lung, and nasal epithelium clone 1 (SPLUNC1), is a protein involved in the antiinflammatory response. The goal of this study was to determine whether BPIFA1 expression in asthmatic airways is regulated by genetic variations, altering epithelial responses to type 2 cytokines (e.g., IL-13). Nasal epithelial cells from patients with mild to severe asthma were collected from the National Heart, Lung, and Blood Institute Severe Asthma Research Program centers, genotyped for rs750064, and measured for BPIFA1. To determine the function of rs750064, cells were cultured at air-liquid interface and treated with IL-13 with or without recombinant human BPIFA1 (rhBPIFA1). Noncultured nasal cells with the rs750064 CC genotype had significantly less BPIFA1 mRNA expression than the CT and TT genotypes. Cultured CC versus CT and TT cells without stimulation maintained less BPIFA1 expression. With IL-13 treatment, CC genotype cells secreted more eotaxin-3 than CT and TT genotype cells. Also, rhBPIFA1 reduced IL-13-mediated eotaxin-3. BPIFA1 mRNA levels negatively correlated with serum IgE and fractional exhaled nitric oxide. Baseline FEV1% levels were lower in the asthma patients with the CC genotype (n = 1,016). Our data suggest that less BPIFA1 in asthma patients with the CC allele may predispose them to greater eosinophilic inflammation, which could be attenuated by rhBPIFA1 protein therapy.
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Affiliation(s)
| | - Xingnan Li
- University of Arizona, Tucson, Arizona, USA
| | | | | | | | - Mario Castro
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | | | - Jonathan Boomer
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | | | - Wendy C Moore
- Wake Forest University, Winston-Salem, North Carolina, USA
| | | | - John Fahy
- UCSF, San Francisco, California, USA
| | | | - David T Mauger
- Pennsylvania State University, Centre County, Pennsylvania, USA
| | | | | | | | | | - Y Peter Di
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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12
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DeBoer MD, Phillips BR, Mauger DT, Zein J, Erzurum SC, Fitzpatrick AM, Gaston BM, Myers R, Ross KR, Chmiel J, Lee MJ, Fahy JV, Peters M, Ly NP, Wenzel SE, Fajt ML, Holguin F, Moore WC, Peters SP, Meyers D, Bleecker ER, Castro M, Coverstone AM, Bacharier LB, Jarjour NN, Sorkness RL, Ramratnam S, Irani AM, Israel E, Levy B, Phipatanakul W, Gaffin JM, Gerald Teague W. Effects of endogenous sex hormones on lung function and symptom control in adolescents with asthma. BMC Pulm Med 2018; 18:58. [PMID: 29631584 PMCID: PMC5891903 DOI: 10.1186/s12890-018-0612-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 03/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although pre-puberty asthma is more prevalent in males, after puberty through middle-age, asthma is more prevalent in females. The surge of sex hormones with puberty might explain this gender switch. METHODS To examine the effects of sex hormones on lung function and symptoms with puberty, Tanner stage was assessed in 187 children 6-18 years of age (59% severe) enrolled in the NIH/NHLBI Severe Asthma Research Program (SARP). The effects of circulating sex hormones (n = 68; testosterone, dehydroepiandrosterone sulfate (DHEA-S), estrogen, and progesterone) on lung function and 4 week symptom control (ACQ6) in cross-section were tested by linear regression. RESULTS From pre-/early to late puberty, lung function did not change significantly but ACQ6 scores improved in males with severe asthma. By contrast females had lower post-BD FEV1% and FVC% and worse ACQ6 scores with late puberty assessed by breast development. In males log DHEA-S levels, which increased by Tanner stage, associated positively with pre- and post-BD FEV1%, pre-BD FVC %, and negatively (improved) with ACQ6. Patients treated with high-dose inhaled corticosteroids had similar levels of circulating DHEA-S. In females, estradiol levels increased by Tanner stage, and associated negatively with pre-BD FEV1% and FVC %. CONCLUSIONS These results support beneficial effects of androgens on lung function and symptom control and weak deleterious effects of estradiol on lung function in children with asthma. Longitudinal data are necessary to confirm these cross-sectional findings and to further elucidate hormonal mechanisms informing sex differences in asthma features with puberty. TRIAL REGISTRATION ClinicalTrials.gov registration number: NCT01748175 .
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Affiliation(s)
- Mark D DeBoer
- University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | | | - David T Mauger
- Pennsylvania State University School of Medicine, Hershey, USA
| | - Joe Zein
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - Serpil C Erzurum
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, USA
| | | | | | - Ross Myers
- Rainbow Babies and Children's Hospital, Cleveland, USA
| | | | - James Chmiel
- Rainbow Babies and Children's Hospital, Cleveland, USA
| | - Min Jie Lee
- Emory University School of Medicine, Atlanta, USA
| | - John V Fahy
- San Francisco School of Medicine, University of California, San Francisco, USA
| | - Michael Peters
- San Francisco School of Medicine, University of California, San Francisco, USA
| | - Ngoc P Ly
- San Francisco School of Medicine, University of California, San Francisco, USA
| | - Sally E Wenzel
- University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Merritt L Fajt
- University of Pittsburgh School of Medicine, Pittsburgh, USA
| | | | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, USA
| | | | - Deborah Meyers
- Wake Forest University School of Medicine, Winston-Salem, USA
| | | | - Mario Castro
- Washington University School of Medicine, St. Louis, USA
| | | | | | | | | | - Sima Ramratnam
- University of Wisconsin School of Medicine, Madison, USA
| | - Anne-Marie Irani
- Virginia Commonwealth University School of Medicine, Richmond, USA
| | | | - Bruce Levy
- Harvard University School of Medicine, Boston, USA
| | | | | | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
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13
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Ricklefs I, Barkas I, Duvall MG, Cernadas M, Grossman NL, Israel E, Bleecker ER, Castro M, Erzurum SC, Fahy JV, Gaston BM, Denlinger LC, Mauger DT, Wenzel SE, Comhair SA, Coverstone AM, Fajt ML, Hastie AT, Johansson MW, Peters MC, Phillips BR, Levy BD. ALX receptor ligands define a biochemical endotype for severe asthma. JCI Insight 2018; 3:120932. [PMID: 29563345 DOI: 10.1172/jci.insight.120932] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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14
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Peters MC, Kerr S, Dunican EM, Woodruff PG, Fajt ML, Levy BD, Israel E, Phillips BR, Mauger DT, Comhair SA, Erzurum SC, Johansson MW, Jarjour NN, Coverstone AM, Castro M, Hastie AT, Bleecker ER, Wenzel SE, Fahy JV. Refractory airway type 2 inflammation in a large subgroup of asthmatic patients treated with inhaled corticosteroids. J Allergy Clin Immunol 2018. [PMID: 29524537 DOI: 10.1016/j.jaci.2017.12.1009] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Airway type 2 inflammation is usually corticosteroid sensitive, but the role of type 2 inflammation as a mechanism of asthma in patients receiving high-dose inhaled corticosteroids (ICSs) is uncertain. OBJECTIVE We sought to determine whether airway type 2 inflammation persists in patients treated with ICSs and to evaluate the clinical features of patients with steroid-resistant airway type 2 inflammation. METHODS We used quantitative PCR to generate a composite metric of type 2 cytokine gene expression (type 2 gene mean [T2GM]) in induced sputum cells from healthy control subjects, patients with severe asthma receiving ICSs (n = 174), and patients with nonsevere asthma receiving ICSs (n = 85). We explored relationships between asthma outcomes and T2GM values and the utility of noninvasive biomarkers of airway T2GM. RESULTS Sputum cell T2GM values in asthmatic patients were significantly increased and remained high after treatment with intramuscular triamcinolone. We used the median T2GM value as a cutoff to classify steroid-treated type 2-low and steroid-resistant type 2-high (srT2-high) subgroups. Compared with patients with steroid-treated type 2-low asthma, those with srT2-high asthma were older and had more severe asthma. Blood eosinophil cell counts predicted srT2-high asthma when body mass index was less than 40 kg/m2 but not when it was 40 kg/m2 or greater, whereas blood IgE levels strongly predicted srT2-high asthma when age was less than 34 years but not when it was 34 years or greater. CONCLUSION Despite ICS therapy, many asthmatic patients have persistent airway type 2 inflammation (srT2-high asthma), and these patients are older and have more severe disease. Body weight and age modify the performance of blood-based biomarkers of airway type 2 inflammation.
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Affiliation(s)
- Michael C Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, Calif
| | - Sheena Kerr
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, Calif
| | - Eleanor M Dunican
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, Calif
| | - Prescott G Woodruff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, Calif
| | - Merritt L Fajt
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Brenda R Phillips
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Suzy A Comhair
- Department of Pathobiology, Cleveland Clinic Cleveland, Cleveland, Ohio
| | - Serpil C Erzurum
- Department of Pathobiology, Cleveland Clinic Cleveland, Cleveland, Ohio
| | - Mats W Johansson
- Department of Biomolecular Chemistry, University of Wisconsin School of Medicine, Madison, Wis
| | - Nizar N Jarjour
- Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine, Madison, Wis
| | - Andrea M Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Pediatrics, Washington University, St Louis, Mo
| | - Annette T Hastie
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Sally E Wenzel
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, Calif.
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15
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Coverstone AM, Wilson B, Burgdorf D, Schechtman KB, Storch GA, Holtzman MJ, Castro M, Bacharier LB, Sumino K. Recurrent wheezing in children following human metapneumovirus infection. J Allergy Clin Immunol 2018; 142:297-301.e2. [PMID: 29481834 DOI: 10.1016/j.jaci.2018.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/16/2018] [Accepted: 02/12/2018] [Indexed: 10/17/2022]
Affiliation(s)
| | - Brad Wilson
- Washington University School of Medicine in St Louis, St Louis, Mo
| | - Dana Burgdorf
- Washington University School of Medicine in St Louis, St Louis, Mo
| | | | - Gregory A Storch
- Washington University School of Medicine in St Louis, St Louis, Mo
| | | | - Mario Castro
- Washington University School of Medicine in St Louis, St Louis, Mo
| | | | - Kaharu Sumino
- Washington University School of Medicine in St Louis, St Louis, Mo.
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16
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Ricklefs I, Barkas I, Duvall MG, Cernadas M, Grossman NL, Israel E, Bleecker ER, Castro M, Erzurum SC, Fahy JV, Gaston BM, Denlinger LC, Mauger DT, Wenzel SE, Comhair SA, Coverstone AM, Fajt ML, Hastie AT, Johansson MW, Peters MC, Phillips BR, Levy BD. ALX receptor ligands define a biochemical endotype for severe asthma. JCI Insight 2017; 2:93534. [PMID: 28724795 DOI: 10.1172/jci.insight.93534] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/01/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In health, inflammation resolution is an active process governed by specialized proresolving mediators and receptors. ALX/FPR2 receptors (ALX) are targeted by both proresolving and proinflammatory ligands for opposing signaling events, suggesting pivotal roles for ALX in the fate of inflammatory responses. Here, we determined if ALX expression and ligands were linked to severe asthma (SA). METHODS ALX expression and levels of proresolving ligands (lipoxin A4 [LXA4], 15-epi-LXA4, and annexin A1 [ANXA1]), and a proinflammatory ligand (serum amyloid A [SAA]) were measured in bronchoscopy samples collected in Severe Asthma Research Program-3 (SA [n = 69], non-SA [NSA, n = 51] or healthy donors [HDs, n = 47]). RESULTS Bronchoalveolar lavage (BAL) fluid LXA4 and 15-epi-LXA4 were decreased and SAA was increased in SA relative to NSA. BAL macrophage ALX expression was increased in SA. Subjects with LXA4loSAAhi levels had increased BAL neutrophils, more asthma symptoms, lower lung function, increased relative risk for asthma exacerbation, sinusitis, and gastroesophageal reflux disease, and were assigned more frequently to SA clinical clusters. SAA and aliquots of LXA4loSAAhi BAL fluid induced IL-8 production by lung epithelial cells expressing ALX receptors, which was inhibited by coincubation with 15-epi-LXA4. CONCLUSIONS Together, these findings have established an association between select ALX receptor ligands and asthma severity that define a potentially new biochemical endotype for asthma and support a pivotal functional role for ALX signaling in the fate of lung inflammation. TRIAL REGISTRATION Severe Asthma Research Program-3 (SARP-3; ClinicalTrials.gov NCT01606826)FUNDING Sources. National Heart, Lung and Blood Institute, the NIH, and the German Society of Pediatric Pneumology.
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Affiliation(s)
- Isabell Ricklefs
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and
| | - Ioanna Barkas
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and
| | - Melody G Duvall
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and.,Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Manuela Cernadas
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and
| | - Nicole L Grossman
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and
| | - Elliot Israel
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Pediatrics, Washington University, St. Louis, Missouri, USA
| | - Serpil C Erzurum
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, UCSF, San Francisco, California, USA
| | - Benjamin M Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Loren C Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Sally E Wenzel
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Suzy A Comhair
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrea M Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Merritt L Fajt
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Annette T Hastie
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Mats W Johansson
- Department of Biomolecular Chemistry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael C Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, UCSF, San Francisco, California, USA
| | - Brenda R Phillips
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Bruce D Levy
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, and
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17
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Duvall MG, Barnig C, Cernadas M, Ricklefs I, Krishnamoorthy N, Grossman NL, Bhakta NR, Fahy JV, Bleecker ER, Castro M, Erzurum SC, Gaston BM, Jarjour NN, Mauger DT, Wenzel SE, Comhair SA, Coverstone AM, Fajt ML, Hastie AT, Johansson MW, Peters MC, Phillips BR, Israel E, Levy BD. Natural killer cell-mediated inflammation resolution is disabled in severe asthma. Sci Immunol 2017; 2:2/9/eaam5446. [PMID: 28783702 DOI: 10.1126/sciimmunol.aam5446] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/27/2017] [Indexed: 12/24/2022]
Abstract
Severe asthma is typically characterized by chronic airway inflammation that is refractory to corticosteroids and associated with excess morbidity. Patients were recruited into the National Heart, Lung, and Blood Institute-sponsored Severe Asthma Research Program and comprehensively phenotyped by bronchoscopy. Bronchoalveolar lavage (BAL) cells were analyzed by flow cytometry. Compared with healthy individuals (n = 21), patients with asthma (n = 53) had fewer BAL natural killer (NK) cells. Patients with severe asthma (n = 29) had a marked increase in the ratios of CD4+ T cells to NK cells and neutrophils to NK cells. BAL NK cells in severe asthma were skewed toward the cytotoxic CD56dim subset, with significantly increased BAL fluid levels of the cytotoxic mediator granzyme A. The numbers of BAL CD56dim NK cells and CCR6-CCR4- T helper 1-enriched CD4+ T cells correlated inversely with lung function [forced expiratory volume in 1 s (FEV1) % predicted] in asthma. Relative to cells from healthy controls, peripheral blood NK cells from asthmatic patients had impaired killing of K562 myeloid target cells despite releasing more cytotoxic mediators. Ex vivo exposure to dexamethasone markedly decreased blood NK cell lysis of target cells and cytotoxic mediator release. NK cells expressed airway lipoxin A4/formyl peptide receptor 2 receptors, and in contrast to dexamethasone, lipoxin A4-exposed NK cells had preserved functional responses. Together, our findings indicate that the immunology of the severe asthma airway is characterized by decreased NK cell cytotoxicity with increased numbers of target leukocytes, which is exacerbated by corticosteroids that further disable NK cell function. These failed resolution mechanisms likely contribute to persistent airway inflammation in severe asthma.
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Affiliation(s)
- Melody G Duvall
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Cindy Barnig
- Department of Chest Diseases, University Hospital of Strasbourg, Strasbourg, France
| | - Manuela Cernadas
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Isabell Ricklefs
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Nandini Krishnamoorthy
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Nicole L Grossman
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Nirav R Bhakta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Pediatrics, Washington University, St. Louis, MO 63110, USA
| | - Serpil C Erzurum
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Benjamin M Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Nizar N Jarjour
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA 17033, USA
| | - Sally E Wenzel
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Suzy A Comhair
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Andrea M Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Merritt L Fajt
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Annette T Hastie
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Mats W Johansson
- Department of Biomolecular Chemistry, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
| | - Michael C Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Brenda R Phillips
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA 17033, USA
| | - Elliot Israel
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bruce D Levy
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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18
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Peters MC, McGrath KW, Hawkins GA, Hastie AT, Levy BD, Israel E, Phillips BR, Mauger DT, Comhair SA, Erzurum SC, Johansson MW, Jarjour NN, Coverstone AM, Castro M, Holguin F, Wenzel SE, Woodruff PG, Bleecker ER, Fahy JV. Plasma interleukin-6 concentrations, metabolic dysfunction, and asthma severity: a cross-sectional analysis of two cohorts. Lancet Respir Med 2016; 4:574-584. [PMID: 27283230 DOI: 10.1016/s2213-2600(16)30048-0] [Citation(s) in RCA: 327] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/25/2016] [Accepted: 04/08/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Severe asthma is a complex heterogeneous disease associated with older age and obesity. The presence of eosinophilic (type 2) inflammation in some but not all patients with severe asthma predicts responsiveness to current treatments, but new treatment approaches will require a better understanding of non-type 2 mechanisms of severe asthma. We considered the possibility that systemic inflammation, which arises in subgroups of obese and older patients, increases the severity of asthma. Interleukin-6 (IL-6) is a biomarker of systemic inflammation and metabolic dysfunction, and we aimed to explore the association between IL-6 concentrations, metabolic dysfunction, and asthma severity. METHODS In this cross-sectional analysis, patients were recruited from two cohorts: mainly non-severe asthmatics from the University of California San Francisco (UCSF) and mainly severe asthmatics from the Severe Asthma Research Program (SARP). We generated a reference range for plasma IL-6 in a cohort of healthy control patients. We compared the clinical characteristics of asthmatics with plasma IL-6 concentrations above (IL-6 high) and below (IL-6 low) the upper 95% centile value for plasma IL-6 concentration in the healthy cohort. We also compared how pulmonary function, frequency of asthma exacerbations, and frequency of severe asthma differed between IL-6 low and IL-6 high asthma populations in the two asthma cohorts. FINDINGS Between Jan 1, 2005, and Dec 31, 2014, we recruited 249 patients from UCSF and between Nov 1, 2012, and Oct 1, 2014, we recruited 387 patients from SARP. The upper 95th centile value for plasma IL-6 concentration in the healthy cohort (n=93) was 3·1 pg/mL, and 14% (36/249) of UCSF cohort and 26% (102/387) of the SARP cohort had plasma IL-6 concentrations above this upper limit. The IL-6 high patients in both asthma cohorts had a significantly higher average BMI (p<0·0001) and a higher prevalence of hypertension (p<0·0001) and diabetes (p=0·04) than the IL-6 low patients. IL-6 high patients also had significantly worse lung function and more frequent asthma exacerbations than IL-6 low patients (all p values <0·0001). Although 80% (111/138) of IL-6 high asthmatic patients were obese, 62% (178/289) of obese asthmatic patients were IL-6 low. Among obese patients, the forced expiratory volume in 1 s (FEV1) was significantly lower in IL-6 high than in IL-6 low patients (mean percent predicted FEV1=70·8% [SD 19·5] vs 78·3% [19·7]; p=0·002), and the percentage of patients reporting an asthma exacerbation in the past 1-2 years was higher in IL-6 high than in IL-6 low patients (66% [73/111] vs 48% [85/178]; p=0·003). Among non-obese asthmatics, FEV1 values and the frequency of asthma exacerbations within the past 1-2 years were also significantly worse in IL-6 high than in IL-6 low patients (mean FEV1 66·4% [SD 23·1] vs 83·2% [20·4] predicted; p<0·0001; 59% [16/27] vs 34% [108/320]; p=0·01). INTERPRETATION Systemic IL-6 inflammation and clinical features of metabolic dysfunction, which occur most commonly in a subset of obese asthma patients but also in a small subset of non-obese patients, are associated with more severe asthma. These data provide strong rationale to undertake clinical trials of IL-6 inhibitors or treatments that reduce metabolic dysfunction in a subset of patients with severe asthma. Plasma IL-6 is a biomarker that could guide patient stratification in these trials. FUNDING NIH and the Parker B Francis Foundation.
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Affiliation(s)
- Michael C Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Kelly Wong McGrath
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Gregory A Hawkins
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University Winston-Salem, NC, USA
| | - Annette T Hastie
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University Winston-Salem, NC, USA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Brenda R Phillips
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, USA
| | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, USA
| | - Suzy A Comhair
- Department of Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Serpil C Erzurum
- Department of Pathobiology, Cleveland Clinic, Cleveland, OH, USA
| | - Mats W Johansson
- Department of Biomolecular Chemistry, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Nizar N Jarjour
- Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Andrea M Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Pediatrics, Washington University, St Louis, MO, USA
| | - Fernando Holguin
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sally E Wenzel
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Prescott G Woodruff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University Winston-Salem, NC, USA
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA.
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Coverstone AM, Bird M, Sicard M, Tao Y, Grange DK, Cleveland C, Molter D, Kemp JS. Overnight pulse oximetry for evaluation of sleep apnea among children with trisomy 21. J Clin Sleep Med 2014; 10:1309-15. [PMID: 25325597 DOI: 10.5664/jcsm.4286] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 07/09/2014] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES For children with trisomy 21, polysomnography at age 4 to assess obstructive sleep disordered breathing (OSDB) is the standard of care. Oximetry alone has been used to screen for disease among children without trisomy 21. This study evaluates the potential usefulness of oximetry scoring in diagnosing OSDB among children with trisomy 21. METHODS A McGill oximetry score from 1 to 4 was derived from a full overnight PSG done on 119 consecutive pediatric subjects with trisomy 21. Most were referred to the sleep laboratory because of suspicion for OSDB. Oximetry scorers were blinded to the child's full PSG and clinical course. Results of the complete PSG were then compared to oximetry scores. RESULTS Obstructive apnea-hypopnea index (OAHI) was ≥ 2.5 for 50% of all subjects. Fifty-nine subjects (49.6%) had McGill Score 1 ("inconclusive"); median OAHI was 1.0 (IQR 0.4-3.3). McGill Score was 2 for 43 subjects (36.1%); median OAHI was 4.5 (IQR 1.3-8.8). Seventeen subjects (14.3%) had McGill Scores of 3 or 4; median OAHI was 16.1 (IQR 9.3-45.5, range 2.1 to 101.1). Ten percent of subjects had a considerable number of central events (≥ 2.5 respiratory events/h but OAHI < 2.5), including 7 with McGill Score 2. CONCLUSIONS In a retrospective cohort of children with trisomy 21, McGill oximetry scores of 3 or 4 reliably identified patients with marked OSDB. The possibility of central apneas causing hypoxemia must be considered in those with McGill Score 2. With these caveats, oximetry screening should be considered when developing streamlined protocols for early intervention to treat OSDB in this population.
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Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Merielle Bird
- Sleep Medicine, St. Louis Children's Hospital, St. Louis, MO
| | - Melissa Sicard
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Yu Tao
- Department of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Dorothy K Grange
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | | | - David Molter
- Department of Otolaryngology/Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO
| | - James S Kemp
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
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