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Ilmarinen P, Julkunen-Iivari A, Lundberg M, Luukkainen A, Nuutinen M, Karjalainen J, Huhtala H, Pekkanen J, Kankaanranta H, Toppila-Salmi S. Cluster Analysis of Finnish Population-Based Adult-Onset Asthma Patients. J Allergy Clin Immunol Pract 2023; 11:3086-3096. [PMID: 37268268 DOI: 10.1016/j.jaip.2023.05.034] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Phenotypes of adult asthma have been identified in previous studies but rarely in population-based settings. OBJECTIVE To identify clusters of adult-onset asthma in a Finnish population-based study on subjects born before 1967. METHODS We used population-based data from 1350 asthmatics with adult-onset asthma (Adult Asthma in Finland) from Finnish national registers. Twenty-eight covariates were selected based on literature. The number of covariates was reduced by using factor analysis before cluster analysis. RESULTS Five clusters (CLU1-CLU5) were identified, 3 clusters with late-onset adult asthma (onset ≥40 years) and 2 clusters with onset at earlier adulthood (<40 years). Subjects in CLU1 (n = 666) had late-onset asthma and were nonobese, symptomatic, and predominantly female with few respiratory infections during childhood. CLU2 (n = 36) consisted of subjects who had earlier-onset asthma, were predominantly female, obese with allergic asthma, and had recurrent respiratory infections. Subjects in CLU3 (n = 75) were nonobese, older, and predominantly men with late-onset asthma, smoking history, comorbidities, severe asthma, least allergic diseases, low education, many siblings, and childhood in rural areas. CLU4 (n = 218) was a late-onset cluster consisting of obese females with comorbidities, asthma symptoms, and low education level. Subjects in CLU5 (n = 260) had earlier onset asthma, were nonobese, and predominantly allergic females. CONCLUSIONS Our population-based adult-onset asthma clusters take into account several critical factors such as obesity and smoking, and identified clusters that partially overlap with clusters identified in clinical settings. Results give us a more profound understanding of adult-onset asthma phenotypes and support personalized management.
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Affiliation(s)
- Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anna Julkunen-Iivari
- Department of Allergy, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - Marie Lundberg
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Annika Luukkainen
- Inflammation Center, Department of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Nuutinen
- Department of Allergy, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Juha Pekkanen
- Department of Public Health, University of Helsinki, Helsinki, Finland; Environmental Health Unit, National Institute for Health and Welfare, Kuopio, Finland
| | - Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Department of Internal Medicine and Clinical Nutrition, Krefting Research Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Sanna Toppila-Salmi
- Department of Allergy, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland; Department of Pulmonary Medicine, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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2
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Helevä A, Murtomäki A, Huhtala H, Bousquet J, Luukkainen A, Karjalainen J, Lemmetyinen R, Haukka J, Torkki P, Nuutinen M, Toppila‐Salmi S. Risk factors of NSAID-exacerbated respiratory disease: A population-based study. Clin Transl Allergy 2023; 13:e12296. [PMID: 37632242 PMCID: PMC10442774 DOI: 10.1002/clt2.12296] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/28/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Asthma with NSAID-exacerbated respiratory disease (NERD) is associated with uncontrolled or severe asthma. NERD patients are more prone to severe allergic reactions and their asthma exacerbations lead to hospitalisations twice as often compared to patients with non-NERD-asthma. NERD patients are prone to recurrent nasal polyposis requiring frequent endoscopic sinus surgeries. However, the early risk factors of NERD are not fully understood. The aim was to identify risk factors of NERD among patients with adult-onset asthma. METHODS We used data from 1350 population-based adult asthmatics with adult-onset asthma from Finnish national registers. NERD was defined as self-reported wheeze or other typical respiratory symptoms after ingestion of NSAIDs. Thirty-six covariates covering several domains (personal characteristics, life-style, early life factors, asthma characteristics and multimorbidities) were selected based on literature and were studied in association with NERD using logistic regressions. RESULTS The study population included 153 (11.3%) asthmatics with NERD. Thirty-six covariates were entered in univariate logistic regression analysis, in which 23 were associated with NERD (p < 0.05). These variables were entered in a multivariable logistic regression model in which allergic respiratory symptoms, female sex, osteoarthritis, difficult asthma, nasal polyps, second-hand smoke exposure at home, having 3 or more older siblings and being overweight were significantly associated with asthma with NERD (p < 0.05). Overweight decreased the risk of NERD, other factors increased it. CONCLUSION According to our study, risk factors of NERD in part are associated with female sex, BMI, exposure to tobacco smoke, allergy, orthopaedic disorders and infection history, and their early recognition might thus be important to manage the burden of NERD.
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Affiliation(s)
- Alma Helevä
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- MD PhD Programme of the Faculty of MedicineUniversity of HelsinkiHelsinkiFinland
| | - Aada Murtomäki
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
| | - Heini Huhtala
- Faculty of Social SciencesTampere UniversityTampereFinland
| | - Jean Bousquet
- Institute for AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPAllergology and ImmunologyBerlinGermany
- University Hospital of MontpellierMontpellierFrance
| | - Annika Luukkainen
- Infectious Disease UnitSouth Karelia Central HospitalLappeenrantaFinland
| | - Jussi Karjalainen
- Allergy CentreTampere University HospitalTampereFinland
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Riikka Lemmetyinen
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Jari Haukka
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Paulus Torkki
- Department of Public HealthUniversity of HelsinkiHelsinkiFinland
| | - Mikko Nuutinen
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- Haartman InstituteMedicumUniversity of HelsinkiHelsinkiFinland
| | - Sanna Toppila‐Salmi
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHospital District of Helsinki and UusimaaHelsinkiFinland
- Haartman InstituteMedicumUniversity of HelsinkiHelsinkiFinland
- Department of Pulmonary MedicineHeart and Lung CenterHelsinki University Hospital and University of HelsinkiHelsinkiFinland
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3
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Riekkinen M, Kajova M, Eriksson M, Luukkainen A, Holmberg V, Aro T, Pakkanen SH, Miettinen S, Montonen R, Smura T, Lääveri T, Kantele A. Superspreading of SARS-CoV-2 Omicron BA.2.23 among vaccinated Finnish adults: symptomatic COVID-19 only contracted by those without recent infection. Epidemiol Infect 2023:1-23. [PMID: 37401478 PMCID: PMC10368952 DOI: 10.1017/s0950268823001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
An outbreak of SARS-CoV-2 was confirmed after an academic party in Helsinki, Finland, in 2022. All 70 guests were requested to fill in follow-up questionnaires; serologic analyses and whole-genome sequencing (WGS) were conducted when possible.Of those participating - all but one with ≥3 vaccine doses - 21/53 (40%) had test-confirmed symptomatic COVID-19: 7% of those with earlier episodes and 76% of those without. Half (11/21) were febrile, but none needed hospitalisation. WGS revealed subvariant BA.2.23.Compared to vaccination alone, our data suggest remarkable protection by hybrid immunity against symptomatic infection, particularly in instances of recent infections with homologous variants.
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4
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Koskinen A, Lemmetyinen R, Luukkainen A, Kankaanranta H, Ilmarinen P, Karjalainen J, Pekkanen J, Huhtala H, Haukka J, But A, Toppila-Salmi S. Season of birth affects the risk of adult-onset asthma in Finland. Allergy 2023; 78:555-558. [PMID: 36067009 PMCID: PMC10087432 DOI: 10.1111/all.15504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Anni Koskinen
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Inflammation Center, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Riikka Lemmetyinen
- Inflammation Center, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Annika Luukkainen
- Inflammation Center, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Infectious Diseases, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hannu Kankaanranta
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Department of Internal Medicine and Clinical Nutrition, Krefting Research Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pinja Ilmarinen
- Department of Respiratory Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jussi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Juha Pekkanen
- Department of Public Health, University of Helsinki, Helsinki, Finland.,Environmental Health, National Institute for Health and Welfare, Kuopio, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Anna But
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Inflammation Center, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Pulmonary Medicine, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland
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5
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Hanif T, Laulajainen-Hongisto A, Luukkainen A, Numminen J, Kääriäinen J, Myller J, Kalogjera L, Huhtala H, Kankainen M, Renkonen R, Toppila-Salmi S. Hierarchical clustering in evaluating inflammatory upper airway phenotypes; increased symptoms in adults with allergic multimorbidity. Asian Pac J Allergy Immunol 2021; 38:239-250. [PMID: 31175712 DOI: 10.12932/ap-170818-0395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inflammatory upper airway diseases cause significant morbidity. They include phenotypes with different treatment; allergic or non-allergic rhinitis (AR, nAR), and chronic rhinosinusitis with or without nasal polyps (CRSwNP, CRSsNP). In clinical practice, these phenotypes are often difficult to distinguish and may overlap. OBJECTIVE To evaluate if hierarchical clustering can be used to distinguish these phenotypes based on the presence of nasal polyps, off-seasonal allergic symptoms, and self-reported background characteristics - e.g. atopic dermatitis (AD); and to further analyse the obtained clusters. METHODS We studied a random sample of 74 CRS (chronic rhinosinusitis) patients, and a control group of 80 subjects without CRS with/without AR (tertiary hospitals, 2006-2012). All underwent interview and nasal examination, and filled a questionnaire. Variables regarding demographics, off-seasonal symptoms, and clinical findings were collected. Hierarchical clustering was performed, the obtained clusters were cross-tabulated and analysed. RESULTS Four clusters were identified; 1: "Severe symptoms and CRSwNP" (n = 29), 2: "Asymptomatic AR and controls" (n = 39), 3: "Moderate symptoms and CRSsNP" (n = 36), and 4: "Symptomatic and AD" (n = 50). Cluster 1 had most sinonasal symptoms, cluster 3 had a high prevalence of facial pain. The presence of AR did not distinguish CRS groups. Of the AR subjects, 51 % belonged to cluster 4, where AR with off-seasonal airway symptoms and AD predominated. CONCLUSIONS Hierarchical clustering can be used to distinguish inflammatory upper airway disease phenotypes. The AR phenotype was subdivided by the presence of AD. Adult AR+ AD patients could benefit from active clinical care of the upper airways also off-season.
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Affiliation(s)
- Tanzeela Hanif
- Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland
| | - Anu Laulajainen-Hongisto
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Otorhinolaryngology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Luukkainen
- Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland
| | - Jura Numminen
- Department of Ear and Oral diseases, Tampere University Hospital, Tampere, Finland
| | - Janne Kääriäinen
- Department of Ear and Oral diseases, Tampere University Hospital, Tampere, Finland
| | - Jyri Myller
- Department of Otorhinolaryngology, Hospital District of P?ij?t-H?me, Lahti, Finland
| | - Livije Kalogjera
- Department of Otolaryngology-Head and Neck Surgery, Zagreb School of Medicine, University Hospital Centre "Sestre milosrdnice", Zagreb, Croatia
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Matti Kankainen
- Finnish Institute of Molecular Medicine, University of Helsinki, Helsinki, Finland.,HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Risto Renkonen
- Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland.,HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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6
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Lew ZZR, Liu J, Ong HH, Tan VJ, Luukkainen A, Ong YK, Thong M, Puan KJ, Chow VTK, Tan KS, Wang DY. Contact-Free Co-Culture Model for the Study of Innate Immune Cell Activation During Respiratory Virus Infection. J Vis Exp 2021. [PMID: 33720120 DOI: 10.3791/62115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The early interactions between the nasal epithelial layer and the innate immune cells during viral infections remains an under-explored area. The significance of innate immunity signaling in viral infections has increased substantially as patients with respiratory infections who exhibit high innate T cell activation show a better disease outcome. Hence, dissecting these early innate immune interactions allows the elucidation of the processes that govern them and may facilitate the development of potential therapeutic targets and strategies for dampening or even preventing early progression of viral infections. This protocol details a versatile model that can be used to study early crosstalk, interactions, and activation of innate immune cells from factors secreted by virally infected airway epithelial cells. Using an H3N2 influenza virus (A/Aichi/2/1968) as the representative virus model, innate cell activation of co-cultured peripheral blood mononuclear cells (PBMCs) has been analyzed using flow cytometry to investigate the subsets of cells that are activated by the soluble factors released from the epithelium in response to the viral infection. The results demonstrate the gating strategy for differentiating the subsets of cells and reveal the clear differences between the activated populations of PBMCs and their crosstalk with the control and infected epithelium. The activated subsets can then be further analyzed to determine their functions as well as molecular changes specific to the cells. Findings from such a crosstalk investigation may uncover factors that are important for the activation of vital innate cell populations, which are beneficial in controlling and suppressing the progression of viral infection. Furthermore, these factors can be universally applied to different viral diseases, especially to newly emerging viruses, to dampen the impact of such viruses when they first circulate in naïve human populations.
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Affiliation(s)
- Zhe Zhang Ryan Lew
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Jing Liu
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Hsiao Hui Ong
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Vivian Jiayi Tan
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore
| | | | - Yew Kwang Ong
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore; Department of Otolaryngology, Head and Neck Surgery, National University Hospital, National University Health System
| | - Mark Thong
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore; Department of Otolaryngology, Head and Neck Surgery, National University Hospital, National University Health System
| | - Kia Joo Puan
- Agency for Science, Technology and Research (A*STAR), Singapore Immunology Network (SIgN)
| | - Vincent Tak Kwong Chow
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore; NUHS Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore
| | - Kai Sen Tan
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore; Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore; NUHS Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore;
| | - De Yun Wang
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore; NUHS Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore;
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7
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Toppila-Salmi S, Julkunen-Iivari A, Luukkainen A, Vento S, Apajalahti S, Saat R, Lehtinen A, Jarnstedt J, Numminen J, Markkola A, Huhtala H, Geneid A, Heikkinen A, Meurman J. Radiologic periodontal findings in paranasal sinus computed tomography scans of chronic rhinosinusitis patients. RHINOL 2020. [DOI: 10.4193/rhinol/20.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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8
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Laulajainen-Hongisto A, Toppila-Salmi SK, Luukkainen A, Kern R. Airway Epithelial Dynamics in Allergy and Related Chronic Inflammatory Airway Diseases. Front Cell Dev Biol 2020; 8:204. [PMID: 32292784 PMCID: PMC7118214 DOI: 10.3389/fcell.2020.00204] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/10/2020] [Indexed: 12/12/2022] Open
Abstract
Allergic rhinitis, chronic rhinosinusitis, and asthma are highly prevalent, multifactorial chronic airway diseases. Several environmental and genetic factors affect airway epithelial dynamics leading to activation of inflammatory mechanisms in the airways. This review links environmental factors to host epithelial immunity in airway diseases. Understanding altered homeostasis of the airway epithelium might provide important targets for diagnostics and therapy of chronic airway diseases.
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Affiliation(s)
- Anu Laulajainen-Hongisto
- Department of Otorhinolaryngology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Prague, Czechia
| | - Sanna Katriina Toppila-Salmi
- Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Annika Luukkainen
- Haartman Institute, Medicum, University of Helsinki, Helsinki, Finland
| | - Robert Kern
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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9
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Luukkainen A, Puan KJ, Yusof N, Lee B, Tan KS, Liu J, Yan Y, Toppila-Salmi S, Renkonen R, Chow VT, Rotzschke O, Wang DY. A Co-culture Model of PBMC and Stem Cell Derived Human Nasal Epithelium Reveals Rapid Activation of NK and Innate T Cells Upon Influenza A Virus Infection of the Nasal Epithelium. Front Immunol 2018; 9:2514. [PMID: 30467502 PMCID: PMC6237251 DOI: 10.3389/fimmu.2018.02514] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 10/11/2018] [Indexed: 12/30/2022] Open
Abstract
Background: We established an in vitro co-culture model involving H3N2-infection of human nasal epithelium with peripheral blood mononuclear cells (PBMC) to investigate their cross-talk during early H3N2 infection. Methods: Nasal epithelium was differentiated from human nasal epithelial stem/progenitor cells and cultured wtih fresh human PBMC. PBMC and supernatants were harvested after 24 and 48 h of co-culture with H3N2-infected nasal epithelium. We used flow cytometry and Luminex to characterize PBMC subpopulations, their activation and secretion of cytokine and chemokines. Results: H3N2 infection of the nasal epithelium associated with significant increase in interferons (IFN-α, IFN-γ, IL-29), pro-inflammatory cytokines (TNF-α, BDNF, IL-3) and viral-associated chemokines (IP-10, MCP-3, I-TAC, MIG), detectable already after 24 h. This translates into rapid activation of monocytes, NK-cells and innate T-cells (MAIT and γδ T cells), evident with CD38+ and/or CD69+ upregulation. Conclusions: This system may contribute to in vitro mechanistic immunological studies bridging systemic models and possibly enable the development of targeted immunomodulatory therapies.
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Affiliation(s)
- Annika Luukkainen
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Haartman Institute, University of Helsinki, Helsinki, Finland
| | - Kia Joo Puan
- Singapore Immunology Network (SIgN), ASTAR (Agency for Science, Technology and Research), Singapore, Singapore
| | - Nurhashikin Yusof
- Singapore Immunology Network (SIgN), ASTAR (Agency for Science, Technology and Research), Singapore, Singapore
| | - Bernett Lee
- Singapore Immunology Network (SIgN), ASTAR (Agency for Science, Technology and Research), Singapore, Singapore
| | - Kai Sen Tan
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jing Liu
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yan Yan
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sanna Toppila-Salmi
- Haartman Institute, University of Helsinki, Helsinki, Finland.,Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Risto Renkonen
- Haartman Institute, University of Helsinki, Helsinki, Finland.,HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Vincent T Chow
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Olaf Rotzschke
- Singapore Immunology Network (SIgN), ASTAR (Agency for Science, Technology and Research), Singapore, Singapore
| | - De Yun Wang
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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10
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Toppila‐Salmi S, Luukkainen A, Lemmetyinen R, Karjalainen J, Huhtala H, Renkonen R, Wang DY, Mäkelä MJ, Pekkanen J. Birth decade affects the sensitization pattern and asthma risk in Finnish adult population. Allergy 2017; 72:1791-1795. [PMID: 28444953 DOI: 10.1111/all.13194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2017] [Indexed: 11/26/2022]
Abstract
We have previously shown that sensitizations to several types of allergens distinguish subjects with and without adult-onset asthma in Finland. The aim was to analyze how age affects sensitization and asthma risk. We used previous population-based case-control data (N=456) from Finnish adult asthma patients with one or two matched controls. Asthma was diagnosed based on a typical history of asthmatic symptoms and lung function tests. Allergic sensitization was determined by skin prick test (SPT) to 17 aeroallergens. Information on demographics was obtained by a questionnaire. Sensitization to more than one allergen type and the number of positive SPT reactions associated with younger age and asthma. Atopic subjects aged 65 and above were characterized by sensitization to only one to two allergens, with very few animal danders and without an association with asthma. Multiple sensitizations and animal dander sensitization are more common among Finnish asthmatic adults aged under 56 than among older asthmatics. Cohort studies are needed to understand timing of host-environmental interactions behind this.
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Affiliation(s)
- S. Toppila‐Salmi
- Haartman Institute University of Helsinki Helsinki Finland
- Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - A. Luukkainen
- Haartman Institute University of Helsinki Helsinki Finland
- Department of Otolaryngology Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - R. Lemmetyinen
- Haartman Institute University of Helsinki Helsinki Finland
| | - J. Karjalainen
- Allergy Centre Tampere University Hospital Tampere Finland
| | - H. Huhtala
- Faculty of Social Sciences University of Tampere Tampere Finland
| | - R. Renkonen
- Haartman Institute University of Helsinki Helsinki Finland
- HUSLAB Helsinki University Hospital Helsinki Finland
| | - D. Y. Wang
- Department of Otolaryngology Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - M. J. Mäkelä
- Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - J. Pekkanen
- Department of Public Health University of Helsinki Helsinki Finland
- Department of Health Protection National Institute for Health and Welfare Kuopio Finland
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Ådjers K, Luukkainen A, Pekkanen J, Hurme M, Huhtala H, Renkonen R, Wang DY, Mäkelä MJ, Karjalainen J, Toppila-Salmi S. Self-Reported Allergic Rhinitis and/or Allergic Conjunctivitis Associate with IL13 rs20541 Polymorphism in Finnish Adult Asthma Patients. Int Arch Allergy Immunol 2017; 172:123-128. [PMID: 28273659 DOI: 10.1159/000456009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/11/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Our aim was to observe factors associated with IL13 rs20541 polymorphism and other factors with or without allergic comorbidities such as subject-reported allergic rhinitis (AR) and/or allergic conjunctivitis (AC) symptoms in adult asthmatics. METHODS A population-based sample of Finnish adult asthma patients (n = 1,156) and matched controls (n = 1,792) filled in a questionnaire. Asthma was diagnosed based on a typical history of asthma symptoms and lung function tests. Skin prick tests with 17 aeroallergens and blood tests including analysis of interleukin 13 (IL13) rs20541 (G/A) genotypes were performed for a subsample (n = 193). RESULTS The proportion of asthmatics reporting AR was 61.9% and reporting AC was 40.7%. After adjustments, the presence of the IL13 rs20541A- allele (OR 3.06, 95% CI 1.42-6.58, p = 0.004) or multisensitization (adjusted OR 4.59, 95% CI 1.48-14.26, p = 0.008) was associated with AR/AC asthma. Nasal polyps and acetylsalicylic acid-exacerbated respiratory disease was also associated with AR/AC asthma. CONCLUSIONS Adult AR/AC asthma could putatively be a phenotype, characterized by the presence of atopic and/or eosinophilic factors and a high prevalence of the IL13 rs20541A- allele. Studies on the mechanisms behind this and in other populations are needed.
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Affiliation(s)
- Kati Ådjers
- Department of Ophthalmology, Hatanpää Hospital, Tampere, Finland
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Luukkainen A, Seppala M, Renkonen J, Hagstrom J, Huhtala H, Rautiainen M, Myller J, Paavonen T, Ranta A, Torkkeli T, Toppila-Salmi S. Low lymphatic vessel density associates with chronic rhinosinusitis with nasal polyps. Rhinology 2017; 55:181-191. [DOI: 10.4193/rhin16.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Terna E, Luukkainen A, Seppälä M, Renkonen R, Huhtala H, Tommola S, Paavonen T, Kauppi P, Tynninen O, Jeskanen L, Toppila-Salmi S. The expression of cancerous inhibitor protein phosphatase 2A in chronic rhinosinusitis with nasal polyps. Acta Otolaryngol 2016; 136:1173-1179. [PMID: 27348236 DOI: 10.1080/00016489.2016.1195918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
CONCLUSION The study suggests that cancerous inhibitor of protein phosphatase 2A (CIP2A) expression and eosinophilia associate with chronic rhinosinusitis with nasal polyps with aspirin exacerbated respiratory disease (CRSwNP + AERD). Further studies with a larger sample size are needed to evaluate further the role of CIP2A and related pathways in CRSwNP + AERD. OBJECTIVES Low prostaglandin E2 levels putatively associate with CRSwNP + AERD and decreased c-Myc levels. The aim of this study was to evaluate the expression and revision-predictive role of oncoprotein CIP2A, another c-Myc modulator, in CRSwNP with/without AERD, and in antrochoanal polyps. METHOD Ninety retrospective archival objective glasses of nasal polyp tissue from CRSwNP or ACP patients were used for assessing mucosal eosinophilia. Of this population, 90 archival nasal polyp specimens were available for immunohistochemical staining with a polyclonal anti-CIP2A antibody, together with 19 control nasal mucosa specimens. CIP2A staining intensity and tissue eosinophilia were assessed by two blinded observers with a light microscope. Subject characteristics from 90 patients and 19 controls were obtained from patient records and additionally by a questionnaire from controls. The follow-up data was available from patient records of 84 patients and 16 controls. RESULTS The expression of epithelial CIP2A was detected both in control inferior turbinate mucosa and nasal polyps. The expression was significantly lower in the CRSwNP + AERD group compared to controls and CRSwNP without AERD (p < 0.01). High mucosal eosinophilia associated with CRSwNP (p < 0.01). Neither CIP2A nor eosinophilia predicted the need for revision surgery (p > 0.05), whereas previous surgery, allergic rhinitis, and use of corticosteroids did predict the need for revision surgery (p < 0.05).
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Seppälä M, Halme E, Tiilikainen L, Luukkainen A, Laranne J, Rautiainen M, Huhtala H, Paavonen T, Toppila-Salmi S. The expression and prognostic relevance of indoleamine 2,3-dioxygenase in tongue squamous cell carcinoma. Acta Otolaryngol 2016; 136:729-35. [PMID: 26982018 DOI: 10.3109/00016489.2016.1152631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Conclusion IDO might be useful for predicting progression of primary tumor stage T2 and T3 in tongue squamous cell carcinoma (TSCC), but does not seem like a specific biomarker for diagnosing TSCC and predicting patient survival. Objectives Indoleamine 2,3-dioxygenase (IDO) is expressed in many cells and it catabolises the essential amino acid tryptophan to kynurenine. IDO acts as an immune modulator through suppression of T-cell immunity and other pathways. In cancer cells, IDO has been proposed to promote tumor progression by enabling malignant cells to escape from the immune system. The aim of this study was to evaluate the association and prognostic relevance of IDO expression in TSCC. Method One hundred and eight retrospective tongue and lymph node specimens were stained immunohistochemically with monoclonal antibody anti-indoleamine 2,3-dioxygenase. The relative abundance of IDO positive epithelial cells, IDO staining intensity, and inflammation were assessed semi-quantitatively with light microscopy. Results IDO was expressed stronger in tongue hyperplasia than in TSCC. However, IDO expression associated with poor survival in the sub-groups with primary tumor stage T2-T4 and in the sub-group with strong inflammation in tumors' invasive front.
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Affiliation(s)
- Miia Seppälä
- a Haartman Institute, University of Helsinki , Helsinki , Finland
| | - Elina Halme
- b Department of Otorhinolaryngology , Tampere University Hospital, Tampere , Finland
| | - Lauri Tiilikainen
- c Department of Pathology , University of Tampere , Tampere , Finland
| | | | - Jussi Laranne
- b Department of Otorhinolaryngology , Tampere University Hospital, Tampere , Finland
| | - Markus Rautiainen
- b Department of Otorhinolaryngology , Tampere University Hospital, Tampere , Finland
| | - Heini Huhtala
- d School of Health Sciences, University of Tampere , Tampere , Finland
| | - Timo Paavonen
- c Department of Pathology , University of Tampere , Tampere , Finland
- e Fimlab Laboratories Ltd , Tampere , Finland
| | - Sanna Toppila-Salmi
- a Haartman Institute, University of Helsinki , Helsinki , Finland
- f Department of Allergy , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Luukkainen A, Karjalainen J, Hurme M, Paavonen T, Huhtala H, Toppila-Salmi S. Relationships of indoleamine 2,3-dioxygenase activity and cofactors with asthma and nasal polyps. Am J Rhinol Allergy 2015; 28:e5-10. [PMID: 24717869 DOI: 10.2500/ajra.2014.28.4013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Asthma and chronic rhinosinusitis with nasal polyps (CRSwNPs) are coexisting diseases that are multifactorial. The rural environment seems to protect from atopy, but its relation with nonatopic airway inflammations has been less investigated. Indoleamine 2,3-dioxygenase (IDO) is an enzyme involved in the catabolism of the essential amino acid tryptophan (Trp) to kynurenine (Kyn). Low IDO activity has been previously observed in atopy and asthma. The objective was to investigate the relationships of IDO activity, eosinophils, and cofactors during asthma and/or CRSwNPs. METHODS A Finnish population-based cohort of adult asthmatic patients (n = 245) and nonasthmatic patients (n = 405) was used. The presence of asthma and atopy were based on patient history and standardized diagnostic tests. The presence of acetyl salicylic acid intolerance, doctor-diagnosed NPs, and countryside environment during childhood were based on a questionnaire report. Serum IDO activity was evaluated by assessing the Kyn/Trp ratio by liquid chromatography. RESULTS Low IDO activity was associated significantly with atopy, CRSwNPs, and an urban background. IDO activity did not correlate with pulmonary function. As expected, CRSwNPs was more frequent among asthmatic patients. A rural background has a protective effect from atopy and atopic asthma but it did not affect the prevalence of CRSwNPs or nonatopic asthma. CONCLUSION Low IDO activity might result from the urban environment and influence the development of the atopic phenotype. On the other hand, low IDO activity, found in CRSwNPs, does not seem to be related to the urban background and thus may result from other, still unknown, factors.
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Affiliation(s)
- Annika Luukkainen
- Department of Clinical Medicine, Finn-Medi III, University of Tampere, Tampere, Finland
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Luukkainen A, Myller J, Torkkeli T, Rautiainen M, Toppila-Salmi S. Endoscopic sinus surgery with antrostomy has better early endoscopic recovery in comparison to the ostium-preserving technique. ISRN Otolaryngol 2012; 2012:189383. [PMID: 23724267 PMCID: PMC3658570 DOI: 10.5402/2012/189383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 04/19/2012] [Indexed: 06/02/2023]
Abstract
Background. Endoscopic sinus surgery (ESS) is considered for chronic rhinosinusitis (CRS) after failure of conservative therapy. Objective. The aim of this study was to evaluate endoscopically ostium patency and mucosal recovery after ESS, with either maxillary sinus ostium-preserving or -enlarging techniques. Materials and Methods. Thirty patients with non-polypous CRS were enrolled. Uncinectomy-only and additional middle meatal antrostomy were randomly and single-blindly performed for each side. Pre- and postoperative endoscopic scores were semi-quantitatively determined according to findings in the ostiomeatal complex area. Adhesions, maxillary sinus mucosal swelling, secretions, and ostium obstruction were also endoscopically evaluated. In addition, symptoms were asked and computed tomography scans were taken preoperatively and 9 months postoperatively. Results. At 16 days postoperatively, a better endoscopic score and a less obstructed ostium were found with antrosomy. At 9 months postoperatively the endoscopic score improved significantly and identically with both procedures, however, obstructed ostia and sinus mucosal swelling/secretions were insignificantly more frequently found on the uncinectomy-only side. Endoscopic and radiologic findings of the maxillary sinus mucosa and ostium correlated significantly 9 months postoperatively. Conclusion. There was a good long-term mucosal recovery with both surgical procedures. In terms of early mucosal recovery and ostium patency, antrostomy might be slighly superior.
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Affiliation(s)
- Annika Luukkainen
- Department of Otorhinolaryngology, University of Tampere, Finn Medi III, 4th Floor (Biokatu 10), 33520 Tampere, Finland
| | - Jyri Myller
- Department of Otorhinolaryngology, University of Tampere, Finn Medi III, 4th Floor (Biokatu 10), 33520 Tampere, Finland
- Department of Otorhinolaryngology, Paijat-Hame Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Tommi Torkkeli
- Department of Otorhinolaryngology, Mikkeli Central Hospital, Porrassalmenkatu 35-37, 50100 Mikkeli, Finland
| | - Markus Rautiainen
- Department of Otorhinolaryngology, University of Tampere, Finn Medi III, 4th Floor (Biokatu 10), 33520 Tampere, Finland
- Department of Otorhinolaryngology, Tampere University Hospital, PL 2000, Teiskontie 35, 33521 Tampere, Finland
| | - Sanna Toppila-Salmi
- Department of Allergy, Skin and Allergy Hospital, Helsinki University Central Hospital, P.O. Box 160 (Meilahdentie 2), 00029 Hospital District of Helsinki and Uusimaa, Helsinki, Finland
- Transplantation Laboratory, Haartman Institute, University of Helsinki, FIN-00014 Helsinki, Finland
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Luukkainen A, Karjalainen J, Honkanen T, Lehtonen M, Paavonen T, Toppila-Salmi S. Indoleamine 2,3-dioxygenase expression in patients with allergic rhinitis: a case-control study. Clin Transl Allergy 2011; 1:17. [PMID: 22410120 PMCID: PMC3299587 DOI: 10.1186/2045-7022-1-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 12/12/2011] [Indexed: 02/08/2023] Open
Abstract
Background Indoleamine 2,3-dioxygenase (IDO) is a tryptophan catalyzing enzyme. It has been suggested that it has a role in lower airway allergic inflammations, but its role in allergic rhinitis has not been investigated. Objective Our aim was to evaluate the expression of IDO in the nasal mucosa of allergic rhinitis patients allergic to birch pollen during peak exposure to birch pollen allergen and compare it to non-atopic patients. Methods IDO expression was immunohistochemically evaluated from nasal specimens obtained in- and off-season from otherwise healthy non-smoking volunteers both allergic to birch pollen (having mild or moderate allergic rhinoconjunctivitis) and non-allergic controls. Results: The IDO expression levels were low in healthy controls and remained low also in patients allergic to birch pollen. There were no differences in the expression of IDO in- and off-season in either healthy or allergic subjects. Conclusions There is a controversy in the role of IDO in upper and lower airways during allergic airway disease. It seems that IDO is associated to allergic inflammations of the lower airways, but does not have a local role in the nasal cavity at least in mild or moderate forms of allergic rhinitis.
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Affiliation(s)
- Annika Luukkainen
- Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland.
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Honkanen T, Luukkainen A, Lehtonen M, Paavonen T, Karjalainen J, Hurme M, Myller J, Huhtala H, Rautiainen M, Toppila-Salmi S. Indoleamine 2,3-dioxygenase expression is associated with chronic rhinosinusitis with nasal polyps and antrochoanal polyps. Rhinology 2011; 49:356-63. [PMID: 21858269 DOI: 10.4193/rhino10.191] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic rhinosinusitis without and with nasal polyps (CRSwNP and CRSsNP), and antrochoanal polyps are different phenotypes with different pathomechanisms. Indoleamine 2,3-dioxygenase (IDO) is an enzyme expressed in many cells involved in the catabolism of the essential amino acid tryptophan to kynurenine. IDO might have a role in allergic airway inflammation. The aim was to evaluate if IDO expression is associated with CRSsNP, CRSwNP, or ACP. One hundred fifty specimens from the nasal cavity and sinus mucosa were immunohistochemically stained with mAb anti-IDO. The expression of epithelial and leukocyte IDO was associated with CRSwNP and ACP. The presence of ASA intolerance, asthma, atopy, smoking and use of medication did not significantly change the results. The different expression of IDO could putatively indicate the differences in the pathomechanisms of CRSsNP, CRSwNP and ACP. Further studies on the role of IDO in upper airways pathologies are required.
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Affiliation(s)
- T Honkanen
- Department of Pathology, University of Tampere, Tampere, Finland
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Keinonen J, Karttunen V, Räisänen J, Bergmeister F, Luukkainen A, Tikkanen P. Annealing behavior of hydrogen traps in Ne-implanted Ta. Phys Rev B Condens Matter 1986; 34:8981-8984. [PMID: 9939636 DOI: 10.1103/physrevb.34.8981] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
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Luukkainen A, Keinonen J, Erola M. Density and size of neon bubbles in molybdenum, tantalum, and tantalum oxide. Phys Rev B Condens Matter 1985; 32:4814-4817. [PMID: 9937681 DOI: 10.1103/physrevb.32.4814] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
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Keinonen J, Luukkainen A, Anttila A, Erola M. Local density change of a metal backing due to implanted ions: Effect on nuclear lifetimes obtained with the DSA method. ACTA ACUST UNITED AC 1983. [DOI: 10.1016/0167-5087(83)90357-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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