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Nenna R, Stern DA, Carr TF, Spangenberg A, Wright AL, Martinez FD, Halonen M. Prenatal exposure to RSV season influences first-year risk of RSV lower respiratory illness and RSV-specific immune responses assessed at birth. J Virol 2023; 97:e0076723. [PMID: 37671863 PMCID: PMC10537569 DOI: 10.1128/jvi.00767-23] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/01/2023] [Indexed: 09/07/2023] Open
Abstract
Maternal-to-fetal transmission of respiratory syncytial virus (RSV) has been shown to occur but whether late prenatal exposure to RSV season influences offspring postnatal RSV-lower respiratory illness (LRI) risk in early life or RSV immune status at birth is unclear. In this study, the duration of third trimester RSV season exposure was determined for 1,094 newborns of the Tucson Children's Respiratory Study (TCRS) and found to show an inverse relation to risk for first RSV-LRI in the first year. Cord blood anti-RSV antibody is related to third trimester RSV season exposure but not to first year RSV-LRI risk. In a separate birth cohort (the Infant Immune Study), supernatants from cord blood mononuclear cells stimulated with the recall antigen, UV-inactivated RSV, were assayed for IFN-γ and IL-4. The frequency of detectable IFN-γ (but not IL-4) was increased for those with at least 2 mo of third trimester RSV season exposure, suggestive of a fetal immune response to RSV. IMPORTANCE Our study found that duration of third trimester exposure to RSV season related inversely to subsequent risk of postnatal RSV-LRI in the first year, thus implicating this exposure as an important factor in reducing risk of postnatal RSV-LRIs, a risk reduction that appears to be independent of maternally transferred anti-RSV antibody level. The increase in frequency of detectable IFN-γ and not IL-4 in response to UV-inactivated RSV in cord blood immune cells for infants with greater third trimester exposure to RSV season is suggestive of a Type-1 immune response to RSV occurring in utero.
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Affiliation(s)
- Raffaella Nenna
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
- Department of Maternal, Infantile, and Urological Services, Sapienza University of Rome, Rome, Italy
| | - Debra A. Stern
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
| | - Tara F. Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
| | - Amber Spangenberg
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
| | - Anne L. Wright
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
| | - Fernando D. Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
| | - Marilyn Halonen
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA
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Eremija J, Carr TF. New Evidence on the Development of Atopic Multimorbidity: Are Patients Marching to the Beat of Their Own Drum? J Allergy Clin Immunol Pract 2023; 11:2620-2621. [PMID: 37558364 DOI: 10.1016/j.jaip.2023.05.032] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Jelena Eremija
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, Ariz
| | - Tara F Carr
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, Ariz.
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3
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Carr TF, Fajt ML, Kraft M, Phipatanakul W, Szefler SJ, Zeki AA, Peden DB, White SR. Treating asthma in the time of COVID. J Allergy Clin Immunol 2023; 151:809-817. [PMID: 36528110 PMCID: PMC9749385 DOI: 10.1016/j.jaci.2022.12.800] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
The Precision Interventions for Severe and/or Exacerbation-Prone Asthma clinical trials network is actively assessing novel treatments for severe asthma during the coronavirus disease (COVID-19) pandemic and has needed to adapt to various clinical dilemmas posed by the COVID-19 pandemic. Pharmacologic interactions between established asthma therapies and novel drug interventions for COVID-19 infection, including antivirals, biologics, and vaccines, have emerged as a critical and unanticipated issue in the clinical care of asthma. In particular, impaired metabolism of some long-acting beta-2 agonists by the cytochrome P4503A4 enzyme in the setting of antiviral treatment using ritonavir-boosted nirmatrelvir (NVM/r, brand name Paxlovid) may increase risk for adverse cardiovascular events. Although available data have documented the potential for such interactions, these issues are largely unappreciated by clinicians who treat asthma, or those dispensing COVID-19 interventions in patients who happen to have asthma. Because these drug-drug interactions have not previously been relevant to patient care, clinicians have had no guidance on management strategies to reduce potentially serious interactions between treatments for asthma and COVID-19. The Precision Interventions for Severe and/or Exacerbation-Prone Asthma network considered the available literature and product information, and herein share our considerations and plans for treating asthma within the context of these novel COVID-19-related therapies.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | - Merritt L Fajt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh
| | - Monica Kraft
- Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, Boston
| | - Stanley J Szefler
- The University of Colorado School of Medicine and Children's Hospital Colorado, Department of Pediatrics, The Breathing Institute, Aurora
| | - Amir A Zeki
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis School of Medicine, UC Davis Lung Center, Sacramento
| | - David B Peden
- Division of Allergy and Immunology, Department of Pediatrics, University of North Carolina, Chapel Hill
| | - Steven R White
- Department of Medicine, the University of Chicago, Chicago.
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Carr TF, Stern DA, Morgan W, Guerra S, Martinez FD. Elevated Childhood Insulin-related Asthma Is a Risk Factor for Reduced Lung Function. Am J Respir Crit Care Med 2023; 207:790-792. [PMID: 36521027 PMCID: PMC10037476 DOI: 10.1164/rccm.202209-1654le] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Dixon AE, Carr TF, Que L. Advances in Asthma. Semin Respir Crit Care Med 2022; 43:593-594. [PMID: 35803267 DOI: 10.1055/s-0042-1753473] [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] [Indexed: 10/17/2022]
Affiliation(s)
- Anne E Dixon
- Department of Medicine Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Tara F Carr
- Department of Medicine Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Loretta Que
- Department of Medicine Duke University School of Medicine, Durham, North Carolina
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6
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Eremija J, Carr TF. Immunotherapy for Asthma. Semin Respir Crit Care Med 2022; 43:709-719. [PMID: 35714626 DOI: 10.1055/s-0042-1749454] [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: 10/18/2022]
Abstract
Asthma represents one of the biggest global health concerns with increasing prevalence and influence on global health. Several distinct asthma phenotypes have been identified with one of the most common, earliest recognized, and described being the allergic asthma phenotype, in which allergens trigger asthma through mechanisms involving allergen-specific immunoglobulin E (IgE). Allergen-specific immunotherapy (AIT), in the forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), has been used for many decades as a tool for reducing IgE-mediated sensitization and controlling symptoms of allergic disease, most commonly for allergic rhinitis, and it remains the only currently available disease modifying therapy in atopic patients. AIT has been studied for use in mild to moderate allergic asthma. While the data are often inconsistent, and utilize a multitude of different methods, antigens, and outcome measures, in general, AIT may have several beneficial effects on asthma disease control, quality of life, and requirement for medication. These benefits are notable when immunotherapy is used as an adjunct to pharmacologic treatment in carefully selected and monitored patients with mild to moderate persistent asthma. Patients with severe asthma are excluded from these trials. Importantly, patients with asthma, and in particular severe asthma, may have a higher rate of systemic adverse reactions to SCIT, including anaphylaxis, however, these events are overall rare. Future research in the area is needed to definitively assess the benefit of SCIT and SLIT for patients with asthma, comparing outcomes with different methods, addressing the role of AIT in severe asthma, significance of multiallergen AIT in allergic asthma, and safety concerns in asthma.
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Affiliation(s)
- Jelena Eremija
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Tara F Carr
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
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Carr TF, Peters MC. Novel potential treatable traits in asthma: Where is the research taking us? J Allergy Clin Immunol Glob 2022; 1:27-36. [PMID: 37780590 PMCID: PMC10509971 DOI: 10.1016/j.jacig.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 10/03/2023]
Abstract
Asthma is a complex, heterogeneous disease in which the underlying mechanisms are not fully understood. Patients are often grouped into phenotypes (based on clinical, biologic, and physiologic characteristics) and endotypes (based on distinct genetic or molecular mechanisms). Recently, patients with asthma have been broadly split into 2 phenotypes based on their levels of type 2 inflammation: type 2 and non-type 2 asthma. However, this approach is likely oversimplified, and our understanding of the non-type 2 mechanisms in asthma remains extremely limited. A better understanding of asthma phenotypes and endotypes may assist in development of drugs for new therapeutic targets in asthma. One approach is to identify "treatable traits," which are specific patient characteristics related to phenotypes and endotypes that can be targeted by therapies. This review will focus on emerging treatable traits in asthma and aim to describe novel patient subgroups and endotypes that may represent the next step in the search for new therapeutic approaches.
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Affiliation(s)
- Tara F. Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Michael C. Peters
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Calif
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8
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Carr TF, Granell R, Stern DA, Guerra S, Wright A, Halonen M, Henderson J, Martinez FD. High Insulin in Early Childhood Is Associated with Subsequent Asthma Risk Independent of Body Mass Index. J Allergy Clin Immunol Pract 2022; 10:785-792.e5. [PMID: 34656798 PMCID: PMC9059620 DOI: 10.1016/j.jaip.2021.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Asthma and obesity are major, interconnected public health challenges that usually have their origins in childhood, and for which the relationship is strengthened among those with insulin resistance. OBJECTIVE To determine whether high insulin in early life confers increased longitudinal risk for asthma independent of body mass index. METHODS The study used data from the Tucson Children's Respiratory Study (TCRS) and the Avon Longitudinal Study of Parents and Children (ALSPAC). Nonfasting insulin was measured in TCRS participants at age 6 years and fasting insulin in ALSPAC participants at age 8 years. Physician-diagnosed active asthma was determined at baseline and at subsequent assessments up to age 36 years in TCRS and 17 years in ALSPAC. RESULTS In TCRS, high insulin (upper quartile) at age 6 years was associated with increased odds of having active asthma from ages 8 to 36 years compared with low insulin (odds ratio,1.98; 95% CI, 1.28-3.05; P = .002). Similarly, in ALSPAC, high insulin was associated with a significantly higher risk of active asthma from ages 11 to 17 years compared with low insulin (odds ratio, 1.59; 95% CI, 1.12-2.27; P = .009). These findings were independent of baseline body mass index in both cohorts, and were not related to other demographic and asthma risk factors nor other tested markers of systemic inflammation and metabolic syndrome. CONCLUSIONS In 2 separate birth cohorts, higher blood insulin level in early childhood was associated with increased risk of active asthma through adolescence and adulthood, independent of body mass index. High insulin indicates a novel mechanism for asthma development, which may be a target for intervention.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz.
| | | | - Debra A Stern
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Stefano Guerra
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Anne Wright
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Marilyn Halonen
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | | | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
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9
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Georas SN, Wright RJ, Ivanova A, Israel E, LaVange LM, Akuthota P, Carr TF, Denlinger LC, Fajt ML, Kumar R, O'Neal WK, Phipatanakul W, Szefler SJ, Aronica MA, Bacharier LB, Burbank AJ, Castro M, Crotty Alexander L, Bamdad J, Cardet JC, Comhair SAA, Covar RA, DiMango EA, Erwin K, Erzurum SC, Fahy JV, Gaffin JM, Gaston B, Gerald LB, Hoffman EA, Holguin F, Jackson DJ, James J, Jarjour NN, Kenyon NJ, Khatri S, Kirwan JP, Kraft M, Krishnan JA, Liu AH, Liu MC, Marquis MA, Martinez F, Mey J, Moore WC, Moy JN, Ortega VE, Peden DB, Pennington E, Peters MC, Ross K, Sanchez M, Smith LJ, Sorkness RL, Wechsler ME, Wenzel SE, White SR, Zein J, Zeki AA, Noel P. The Precision Interventions for Severe and/or Exacerbation-Prone (PrecISE) Asthma Network: An overview of Network organization, procedures, and interventions. J Allergy Clin Immunol 2022; 149:488-516.e9. [PMID: 34848210 PMCID: PMC8821377 DOI: 10.1016/j.jaci.2021.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/24/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022]
Abstract
Asthma is a heterogeneous disease, with multiple underlying inflammatory pathways and structural airway abnormalities that impact disease persistence and severity. Recent progress has been made in developing targeted asthma therapeutics, especially for subjects with eosinophilic asthma. However, there is an unmet need for new approaches to treat patients with severe and exacerbation-prone asthma, who contribute disproportionately to disease burden. Extensive deep phenotyping has revealed the heterogeneous nature of severe asthma and identified distinct disease subtypes. A current challenge in the field is to translate new and emerging knowledge about different pathobiologic mechanisms in asthma into patient-specific therapies, with the ultimate goal of modifying the natural history of disease. Here, we describe the Precision Interventions for Severe and/or Exacerbation-Prone Asthma (PrecISE) Network, a groundbreaking collaborative effort of asthma researchers and biostatisticians from around the United States. The PrecISE Network was designed to conduct phase II/proof-of-concept clinical trials of precision interventions in the population with severe asthma, and is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Using an innovative adaptive platform trial design, the PrecISE Network will evaluate up to 6 interventions simultaneously in biomarker-defined subgroups of subjects. We review the development and organizational structure of the PrecISE Network, and choice of interventions being studied. We hope that the PrecISE Network will enhance our understanding of asthma subtypes and accelerate the development of therapeutics for severe asthma.
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Affiliation(s)
- Steve N Georas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, NY.
| | | | - Anastasia Ivanova
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Lisa M LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Praveen Akuthota
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Merritt L Fajt
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | | | - Wanda K O'Neal
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | | | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Mark A Aronica
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Allison J Burbank
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Mo
| | - Laura Crotty Alexander
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Julie Bamdad
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Md
| | | | | | | | | | - Kim Erwin
- Institute for Healthcare Delivery Design, University of Illinois at Chicago, Chicago, Ill
| | | | - John V Fahy
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | | | - Benjamin Gaston
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Ind
| | - Lynn B Gerald
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Daniel J Jackson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - John James
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Nicholas J Kenyon
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Sumita Khatri
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Kirwan
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, La
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Andrew H Liu
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Mark C Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Md
| | - M Alison Marquis
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jacob Mey
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, La
| | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - James N Moy
- Rush University Medical Center, Chicago, Ill
| | - Victor E Ortega
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - David B Peden
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | | | - Michael C Peters
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Kristie Ross
- The Cleveland Clinic, Cleveland, Ohio; UH Rainbow Babies and Children's Hospitals, Cleveland, Ohio
| | - Maria Sanchez
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | | | - Ronald L Sorkness
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Michael E Wechsler
- Children's Hospital Colorado, Aurora, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Joe Zein
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Md
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Affiliation(s)
- Tara F Carr
- Department of Medicine University of Arizona Tucson, Arizona
| | - Monica Kraft
- Department of Medicine University of Arizona Tucson, Arizona
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11
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, Department of Medicine; University of Arizona, Tucson AZ.
| | - Monica Kraft
- Asthma and Airway Disease Research Center, Department of Medicine; University of Arizona, Tucson AZ.
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Carr TF. Treatment approaches for the patient with T2 low asthma. Ann Allergy Asthma Immunol 2021; 127:530-535. [PMID: 34688426 DOI: 10.1016/j.anai.2021.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify treatment approaches that can be used in the management of patients with asthma who lack significant type 2 inflammation, also called T2 low asthma. DATA SOURCES Recent expert guideline updates on the management of asthma, recent journal articles and review articles, and foundational journal articles are referenced. STUDY SELECTIONS This review cites clinical cohort studies of highly characterized patients with asthma, clinical interventional trials of high impact, mechanistic studies relevant to T2 low asthma, and emerging work in this area. RESULTS T2 low asthma accounts for approximately one-third to one-half of individuals with asthma. Characteristics of participants with T2 low asthma include higher body mass index, cigarette smoking/smoke exposure, relative lack of responsiveness to steroids, less bronchodilator reversibility, and often the presence of neutrophilic inflammation. Multiple available interventions target these characteristics, including standard inhalers, azithromycin, and lifestyle interventions of weight loss and smoking cessation. CONCLUSION Treatment of T2 low asthma should involve currently available approaches and will benefit from improved definition and understanding of disease pathobiology.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona.
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13
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Snider JM, You JK, Wang X, Snider AJ, Hallmark B, Zec MM, Seeds MC, Sergeant S, Johnstone L, Wang Q, Sprissler R, Carr TF, Lutrick K, Parthasarathy S, Bime C, Zhang HH, Luberto C, Kew RR, Hannun YA, Guerra S, McCall CE, Yao G, Del Poeta M, Chilton FH. Group IIA secreted phospholipase A2 is associated with the pathobiology leading to COVID-19 mortality. J Clin Invest 2021; 131:e149236. [PMID: 34428181 PMCID: PMC8483752 DOI: 10.1172/jci149236] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [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: 03/04/2021] [Accepted: 08/12/2021] [Indexed: 12/15/2022] Open
Abstract
There is an urgent need to identify the cellular and molecular mechanisms responsible for severe COVID-19 that results in death. We initially performed both untargeted and targeted lipidomics as well as focused biochemical analyses of 127 plasma samples and found elevated metabolites associated with secreted phospholipase A2 (sPLA2) activity and mitochondrial dysfunction in patients with severe COVID-19. Deceased COVID-19 patients had higher levels of circulating, catalytically active sPLA2 group IIA (sPLA2-IIA), with a median value that was 9.6-fold higher than that for patients with mild disease and 5.0-fold higher than the median value for survivors of severe COVID-19. Elevated sPLA2-IIA levels paralleled several indices of COVID-19 disease severity (e.g., kidney dysfunction, hypoxia, multiple organ dysfunction). A decision tree generated by machine learning identified sPLA2-IIA levels as a central node in the stratification of patients who died from COVID-19. Random forest analysis and least absolute shrinkage and selection operator-based (LASSO-based) regression analysis additionally identified sPLA2-IIA and blood urea nitrogen (BUN) as the key variables among 80 clinical indices in predicting COVID-19 mortality. The combined PLA-BUN index performed significantly better than did either one alone. An independent cohort (n = 154) confirmed higher plasma sPLA2-IIA levels in deceased patients compared with levels in plasma from patients with severe or mild COVID-19, with the PLA-BUN index-based decision tree satisfactorily stratifying patients with mild, severe, or fatal COVID-19. With clinically tested inhibitors available, this study identifies sPLA2-IIA as a therapeutic target to reduce COVID-19 mortality.
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Affiliation(s)
- Justin M. Snider
- School of Nutritional Sciences and Wellness, College of Agriculture and Life Sciences, University of Arizona, Tucson, Arizona, USA
| | - Jeehyun Karen You
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, New York, USA
| | - Xia Wang
- School of Biomedical Engineering, Anhui Medical University, Hefei, China
- Department of Molecular and Cellular Biology and
| | - Ashley J. Snider
- School of Nutritional Sciences and Wellness, College of Agriculture and Life Sciences, University of Arizona, Tucson, Arizona, USA
| | - Brian Hallmark
- BIO5 Institute, University of Arizona, Tucson, Arizona, USA
| | - Manja M. Zec
- School of Nutritional Sciences and Wellness, College of Agriculture and Life Sciences, University of Arizona, Tucson, Arizona, USA
| | | | - Susan Sergeant
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Qiuming Wang
- School of Nutritional Sciences and Wellness, College of Agriculture and Life Sciences, University of Arizona, Tucson, Arizona, USA
| | - Ryan Sprissler
- Center for Applied Genetics and Genomic Medicine
- Department of Health Sciences
| | | | - Karen Lutrick
- Family and Community Medicine, College of Medicine – Tucson
| | | | - Christian Bime
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine
| | - Hao Helen Zhang
- Department of Mathematics, and
- Statistics Interdisciplinary Program, University of Arizona, Tucson, Arizona, USA
| | - Chiara Luberto
- Department of Physiology and Biophysics, Stony Brook University, Stony Brook, New York, USA
- Stony Brook Cancer Center, Stony Brook, New York, USA
| | - Richard R. Kew
- Stony Brook Cancer Center, Stony Brook, New York, USA
- Department of Pathology
| | - Yusuf A. Hannun
- Stony Brook Cancer Center, Stony Brook, New York, USA
- Department of Pathology
- Department of Medicine, and
- Department of Biochemistry and Cell Biology, Stony Brook University, Stony Brook, New York, USA
- Veterans Affairs Medical Center, Northport, New York, USA
| | | | - Charles E. McCall
- Departments of Internal Medicine, Microbiology, and Immunology and Translational Sciences Institute, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Guang Yao
- Department of Molecular and Cellular Biology and
- Arizona Cancer Center, University of Arizona, Tucson, Arizona, USA
| | - Maurizio Del Poeta
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, New York, USA
- Veterans Affairs Medical Center, Northport, New York, USA
- Division of Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
| | - Floyd H. Chilton
- School of Nutritional Sciences and Wellness, College of Agriculture and Life Sciences, University of Arizona, Tucson, Arizona, USA
- BIO5 Institute, University of Arizona, Tucson, Arizona, USA
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14
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Israel E, Denlinger LC, Bacharier LB, LaVange LM, Moore WC, Peters MC, Georas SN, Wright RJ, Mauger DT, Noel P, Akuthota P, Bach J, Bleecker ER, Cardet JC, Carr TF, Castro M, Cinelli A, Comhair SAA, Covar RA, Alexander LC, DiMango EA, Erzurum SC, Fahy JV, Fajt ML, Gaston BM, Hoffman EA, Holguin F, Jackson DJ, Jain S, Jarjour NN, Ji Y, Kenyon NJ, Kosorok MR, Kraft M, Krishnan JA, Kumar R, Liu AH, Liu MC, Ly NP, Marquis MA, Martinez FD, Moy JN, O'Neal WK, Ortega VE, Peden DB, Phipatanakul W, Ross K, Smith LJ, Szefler SJ, Teague WG, Tulchinsky AF, Vijayanand P, Wechsler ME, Wenzel SE, White SR, Zeki AA, Ivanova A. PrecISE: Precision Medicine in Severe Asthma: An adaptive platform trial with biomarker ascertainment. J Allergy Clin Immunol 2021; 147:1594-1601. [PMID: 33667479 PMCID: PMC8113113 DOI: 10.1016/j.jaci.2021.01.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 12/08/2020] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
Severe asthma accounts for almost half the cost associated with asthma. Severe asthma is driven by heterogeneous molecular mechanisms. Conventional clinical trial design often lacks the power and efficiency to target subgroups with specific pathobiological mechanisms. Furthermore, the validation and approval of new asthma therapies is a lengthy process. A large proportion of that time is taken by clinical trials to validate asthma interventions. The National Institutes of Health Precision Medicine in Severe and/or Exacerbation Prone Asthma (PrecISE) program was established with the goal of designing and executing a trial that uses adaptive design techniques to rapidly evaluate novel interventions in biomarker-defined subgroups of severe asthma, while seeking to refine these biomarker subgroups, and to identify early markers of response to therapy. The novel trial design is an adaptive platform trial conducted under a single master protocol that incorporates precision medicine components. Furthermore, it includes innovative applications of futility analysis, cross-over design with use of shared placebo groups, and early futility analysis to permit more rapid identification of effective interventions. The development and rationale behind the study design are described. The interventions chosen for the initial investigation and the criteria used to identify these interventions are enumerated. The biomarker-based adaptive design and analytic scheme are detailed as well as special considerations involved in the final trial design.
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Affiliation(s)
- Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Lisa M LaVange
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael C Peters
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Steve N Georas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - David T Mauger
- Pennsylvania State University School of Medicine, Hershey, Pa
| | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Praveen Akuthota
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Julia Bach
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Eugene R Bleecker
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | | | - Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Kan
| | | | | | | | - Laura Crotty Alexander
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | | | | | - John V Fahy
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Merritt L Fajt
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Benjamin M Gaston
- Wells Center for Pediatric Research, Indiana University, Indianapolis, Ind
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Daniel J Jackson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Sonia Jain
- Pulmonary Division, Department of Medicine, University of California-San Diego, La Jolla, Calif
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Yuan Ji
- Department of Health Studies, University of Chicago, Chicago, Ill
| | - Nicholas J Kenyon
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Michael R Kosorok
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Jerry A Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | | | - Andrew H Liu
- University of Colorado School of Medicine, Aurora, Colo; Children's Hospital Colorado, Aurora, Colo
| | - Mark C Liu
- Pulmonary and Critical Care Medicine, Department of Medicine, the Johns Hopkins University, Baltimore, Md
| | - Ngoc P Ly
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | - M Alison Marquis
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - James N Moy
- Rush University Medical Center, Chicago, Ill
| | - Wanda K O'Neal
- Center for Environmental Medicine, Asthma, and Lung Biology, University of North Carolina, Chapel Hill, NC
| | - Victor E Ortega
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - David B Peden
- Marsico Lung Institute, UNC CF Research Center, University of North Carolina, Chapel Hill, NC
| | | | - Kristie Ross
- UH Rainbow Babies and Children's Hospitals, Cleveland, Ohio
| | | | - Stanley J Szefler
- University of Colorado School of Medicine, Aurora, Colo; Children's Hospital Colorado, Aurora, Colo
| | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, Va
| | | | | | - Michael E Wechsler
- National Jewish Health, Denver, Colo; University of Colorado School of Medicine, Aurora, Colo
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Ill
| | - Amir A Zeki
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, Calif
| | - Anastasia Ivanova
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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15
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Vickery BP, Vereda A, Nilsson C, du Toit G, Shreffler WG, Burks AW, Jones SM, Fernández-Rivas M, Blümchen K, O'B Hourihane J, Beyer K, Anagnostou A, Assa'ad AH, Ben-Shoshan M, Bird JA, Carr TF, Carr WW, Casale TB, Chong HJ, Ciaccio CE, Dorsey MJ, Fineman SM, Fritz SB, Greiner AN, Greos LS, Hampel FC, Ibáñez MD, Jeong DK, Johnston DT, Kachru R, Kim EH, Lanser BJ, Leonard SA, Maier MC, Mansfield LE, Muraro A, Ohayon JA, Oude Elberink JNG, Petroni DH, Pongracic JA, Portnoy JM, Rachid R, Rupp NT, Sanders GM, Sharma HP, Sharma V, Sher ER, Sher L, Sindher SB, Siri D, Spergel JM, Sprikkelman AB, Sussman GL, Tsoumani M, Varshney P, Vitalpur G, Wang J, Yang WH, Zubeldia JM, Smith A, Ryan R, Adelman DC. Continuous and Daily Oral Immunotherapy for Peanut Allergy: Results from a 2-Year Open-Label Follow-On Study. J Allergy Clin Immunol Pract 2020; 9:1879-1889.e13. [PMID: 33359589 DOI: 10.1016/j.jaip.2020.12.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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: 09/18/2020] [Revised: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The randomized, controlled PALISADE trial demonstrated the benefit of daily oral immunotherapy with Peanut (Arachis Hypogaea) allergen powder-dnfp (PTAH, formerly AR101) in peanut-allergic children and adolescents. OBJECTIVE ARC004, the open-label follow-on study to PALISADE, used 5 dosing cohorts to explore PTAH treatment beyond 1 year and alternative dosing regimens in peanut-allergic individuals. METHODS Active arm (PTAH-continuing) PALISADE participants who tolerated 300-mg peanut protein at the exit double-blind placebo-controlled food challenge and placebo arm (PTAH-naive) participants could enter ARC004. PTAH-continuing participants were assigned to receive daily (cohorts 1 and 3A) or non-daily (cohorts 2, 3B, and 3C) dosing regimens; PTAH-naive participants were built up to 300 mg/d PTAH, followed by maintenance dosing. At study completion, participants underwent an exit double-blind placebo-controlled food challenge with doses up to 2000 mg peanut protein. Data were assessed using descriptive statistics. RESULTS Overall, 358 (87.5%) eligible participants (4-17 years) entered ARC004 (PTAH-continuing, n = 256; PTAH-naive, n = 102). Among PTAH-continuing participants, exposure-adjusted adverse event rates were 12.94 to 17.54/participant-year and 25.95 to 42.49/participant-year in daily and non-daily dosing cohorts, respectively; most participants (83%) experienced mild or moderate adverse events. Daily dosing cohorts appeared to have higher desensitization rates than non-daily dosing cohorts. Of all PTAH-continuing cohorts, cohort 3A had the longest daily dosing duration and the highest desensitization rates. Changes in immune markers with PTAH continuation demonstrated ongoing immunomodulation. Outcomes in PTAH-naive participants mirrored those of the PALISADE active arm. CONCLUSIONS Continued daily PTAH treatment beyond 1 year showed sustained safety and efficacy. Ongoing immunomodulation was observed during the second year of treatment.
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Affiliation(s)
| | | | - Caroline Nilsson
- Clinical Science and Education, Karolinska Institutet, Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - George du Toit
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - A Wesley Burks
- Department of Pediatrics, University of North Carolina Food Allergy Initiative, Division of Allergy and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stacie M Jones
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | | | - Katharina Blümchen
- Adolescent Medicine, Division of Allergology, Pneumology and Cystic Fibrosis, Goethe University Frankfurt, Frankfurt, Germany
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, Royal College of Surgeons in Ireland, Dublin, Ireland; Infant Centre and Pediatrics and Child Health, University College Cork, HRB Clinical Research Facility-Cork, Cork, Ireland
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité Universtãtsmedizin Berlin, Berlin, Germany
| | | | - Amal H Assa'ad
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Moshe Ben-Shoshan
- McGill University Health Centre - Montreal Children's Hospital, Montreal, Quebec, Canada
| | | | - Tara F Carr
- Banner University of Arizona Medical Center, Tucson, Ariz 647
| | - Warner W Carr
- Allergy & Asthma Associates of Southern California dba Southern California Research, Mission Viejo, Calif
| | - Thomas B Casale
- University of South Florida, Asthma, Allergy & Immunology Clinical Research Unit, Tampa, Fla
| | - Hey Jin Chong
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pa
| | | | - Morna J Dorsey
- University of California, San Francisco, San Francisco, Calif
| | | | | | | | - Leon S Greos
- Colorado Allergy and Asthma Centers, PC, Denver, Colo
| | | | - Maria Dolores Ibáñez
- Hospital Clínico San Carlos, Hospital Universitario Niño Jesús, Alergology Department, Madrid, Spain
| | | | | | - Rita Kachru
- UCLA Medical Center, Santa Monica, Santa Monica, Calif
| | - Edwin H Kim
- University of North Carolina at Chapel Hill CTRC, Chapel Hill, NC
| | | | | | - Mary C Maier
- Baker Allergy, Asthma and Dermatology Research Center, LLC, Portland, Ore
| | | | - Antonella Muraro
- Azienda Ospedaliera di Padova e UOSD Allergie Alimentari, Padova, Italy
| | | | - Joanna N G Oude Elberink
- University Medical Center Groningen, Department of Internal Medicine, Division of Allergology, Groningen, Netherlands
| | | | | | | | | | - Ned T Rupp
- National Allergy and Asthma Research, LLC, N. Charleston, SC
| | | | | | - Vibha Sharma
- Central Manchester University Hospitals NHS Foundation Trust, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | | | - Lawrence Sher
- Peninsula Research Associates, Inc., Rolling Hills Estates, Calif
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research, LPCH at El Camino Hospital, Mountain View, Calif
| | - Dareen Siri
- Sneeze, Wheeze, & Itch Associates, LLC, Normal, Ill
| | | | - Aline B Sprikkelman
- University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology & Allergology, Groningen, Netherlands
| | - Gordon L Sussman
- Gordon Sussman Clinical Research, Inc., Toronto, Ontario, Canada
| | - Marina Tsoumani
- Manchester University NHS Foundation Trust eWythenshawe Hospital, Manchester, United Kingdom
| | - Pooja Varshney
- Specially for Children Allergy, Asthma, and Immunology Clinic, Austin, Texas
| | - Girish Vitalpur
- Indiana University North Hospital, Riley Children's Specialists, Carmel, Ind
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, Clinical Research Unit, New York, NY
| | - William H Yang
- Ottawa Allergy Research Corporation, Ottawa, Ontario, Canada
| | - José Manuel Zubeldia
- Hospital General Universitario Gregorio Marañón, Alergology Department, Madrid, Spain
| | | | - Robert Ryan
- Aimmune Therapeutics, London, United Kingdom
| | - Daniel C Adelman
- Aimmune Therapeutics, Brisbane, Calif; Department of Medicine, University of California San Francisco, San Francisco, Calif.
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16
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Aggarwal A, Balogun R, Carr TF, Desai AP, Jie T, Pan JJ. Transfer of peanut allergy from donor to recipient after liver transplant. Ann Hepatol 2020; 18:508-513. [PMID: 31031165 DOI: 10.1016/j.aohep.2018.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 08/07/2018] [Revised: 09/06/2018] [Accepted: 10/02/2018] [Indexed: 02/04/2023]
Abstract
31 years old female with a history of contact dermatitis, eczema, allergic rhinitis, pernicious anemia, alopecia areata and latent tuberculosis was treated concurrently with methotrexate along with isoniazid and pyridoxine. Five months into the therapy she developed acute onset jaundice progressing into fulminant liver failure with altered mentation and worsening liver function tests. Extensive workup including serological and histopathological evaluation revealed drug-induced liver injury as the etiology of her liver failure and she underwent a successful orthotropic liver transplant. On post-transplant follow-up at four months, she was noted to have an allergic reaction consisting of a perioral rash and swelling (without anaphylaxis) after receiving a kiss from her significant other who had just eaten a peanut butter chocolate. She denied any history of allergic reaction to peanuts prior to the transplant. Percutaneous skin testing revealed immediate hypersensitivity to peanut, hazelnut, and pecan believed to be acquired newly post-transplant. Further investigation revealed that the organ donor had a documented history of systemic anaphylaxis from the peanut allergy and a positive peanut-specific IgE level. Also, another parallel solid organ recipient (lung transplant) from the same organ donor experienced a serious anaphylactic reaction after peanut exposure. This is a case of food (peanut) allergy transfer from the donor to the recipient after the liver transplant. This case highlights the importance of incorporating known donor allergies as a part of pre-transplant screening, given the potentially serious consequences from the transfer of allergies to a previously anergic recipient.
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Affiliation(s)
- Avin Aggarwal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Rilwan Balogun
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Tara F Carr
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Archita P Desai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Tun Jie
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Jen-Jung Pan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Tucson, AZ, USA
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17
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Grossman NL, Ortega VE, King TS, Bleecker ER, Ampleford EA, Bacharier LB, Cabana MD, Cardet JC, Carr TF, Castro M, Denlinger LC, Denson JL, Fandino N, Fitzpatrick AM, Hawkins GA, Holguin F, Krishnan JA, Lazarus SC, Nyenhuis SM, Phipatanakul W, Ramratnam SK, Wenzel S, Peters SP, Meyers DA, Wechsler ME, Israel E. Exacerbation-prone asthma in the context of race and ancestry in Asthma Clinical Research Network trials. J Allergy Clin Immunol 2019; 144:1524-1533. [PMID: 31520679 DOI: 10.1016/j.jaci.2019.08.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/27/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Minority groups of African descent experience disproportionately greater asthma morbidity compared with other racial groups, suggesting that genetic variation from a common ancestry could influence exacerbation risk. OBJECTIVE We evaluated clinical trial measures in the context of self-reported race and genetic ancestry to identify risk factors for asthma exacerbations. METHODS One thousand eight hundred forty multiethnic subjects from 12 Asthma Clinical Research Network and AsthmaNet trials were analyzed for incident asthma exacerbations with Poisson regression models that included clinical measures, self-reported race (black, non-Hispanic white, and other), and estimates of global genetic African ancestry in a subgroup (n = 760). RESULTS Twenty-four percent of 1840 subjects self-identified as black. Black and white subjects had common risk factors for exacerbations, including a history of 2 or more exacerbations in the previous year and FEV1 percent predicted values, whereas chronic sinusitis, allergic rhinitis, and gastroesophageal reflux disease were only associated with increased exacerbation risk in black subjects. In the combined multiethnic cohort, neither race (P = .30) nor percentage of genetic African ancestry as a continuous variable associated with exacerbation risk (adjusted rate ratio [RR], 1.26 [95% CI, 0.94-1.70; P = .13]; RR per 1-SD change [32% ancestry], 0.97 [95% CI, 0.78-1.19; P = .74]). However, in 161 black subjects with genetic data, those with African ancestry greater than the median (≥82%) had a significantly greater risk of exacerbation (RR, 3.06 [95% CI, 1.09-8.6; P = .03]). CONCLUSION Black subjects have unique risk factors for asthma exacerbations, of which global African genetic ancestry had the strongest effect.
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Affiliation(s)
- Nicole L Grossman
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Lahey Hospital and Medical Center, Burlington, Mass
| | - Victor E Ortega
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Tonya S King
- Department of Public Health Sciences, Pennsylvania State University School of Medicine, Hershey, Pa
| | - Eugene R Bleecker
- Department of Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, Ariz
| | | | - Leonard B Bacharier
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Michael D Cabana
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Juan C Cardet
- Deparment of Internal Medicine, Divison of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Tara F Carr
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona, Tucson, AZ
| | - Mario Castro
- Department of Internal Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Kansas, Kansas City, Kan
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wis
| | - Joshua L Denson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, Colo
| | - Nicolas Fandino
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | | | - Gregory A Hawkins
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC
| | - Fernando Holguin
- Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, Colo
| | - Jerry A Krishnan
- Department of Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Ill
| | - Stephen C Lazarus
- Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Sharmilee M Nyenhuis
- Department of Medicine, University of Illinois Hospital & Health Sciences System, Chicago, Ill
| | - Wanda Phipatanakul
- Division of Pediatric Allergy and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sima K Ramratnam
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison, Wis
| | - Sally Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa
| | - Stephen P Peters
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Deborah A Meyers
- Department of Medicine, Division of Genetics, Genomics, and Precision Medicine, University of Arizona College of Medicine, Tucson, Ariz
| | - Michael E Wechsler
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, Colo
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
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18
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Affiliation(s)
- Tara F Carr
- 1 Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Amir A Zeki
- 2 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis School of Medicine, Davis, California
| | - Monica Kraft
- 1 Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona; and
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19
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O'B. Hourihane J, Lieberman JA, Bird JA, Carr TF, Griffin NM, Brown KR, Zawadzki R, Abbas A, Matthews J, Jones SM. Accidental Exposures to Peanut and Other Food Allergens: Results from a Phase 3, Randomized, Double-Blind, Placebo-Controlled Trial (PALISADE). J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Abstract
The lung and gut microbiome are factors in asthma risk or protection. Relevant elements of the microbiome within both niches include the importance of the early life window for microbiome establishment, the diversity of bacteria, richness of bacteria, and effect of those bacteria on the local epithelium and immune system. Mechanisms of protection include direct anti-inflammatory action or induction of non-type 2 inflammation by certain bacterial colonies. The gut microbiome further impacts asthma risk through the contribution of metabolic products. This article reviews the mechanisms that connect the lung and gut microbiota to asthma development and severity.
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Affiliation(s)
- Tara F Carr
- Department of Medicine, University of Arizona, 1501 North Campbell Avenue, Tucson, AZ 85724-5030, USA.
| | - Rhonda Alkatib
- Department of Medicine, University of Arizona, 1501 North Campbell Avenue, Tucson, AZ 85724-5030, USA
| | - Monica Kraft
- Department of Medicine, University of Arizona, 1501 North Campbell Avenue, Tucson, AZ 85724-5030, USA
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21
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Vickery BP, Vereda A, Casale TB, Beyer K, du Toit G, Hourihane JO, Jones SM, Shreffler WG, Marcantonio A, Zawadzki R, Sher L, Carr WW, Fineman S, Greos L, Rachid R, Ibáñez MD, Tilles S, Assa’ad AH, Nilsson C, Rupp N, Welch MJ, Sussman G, Chinthrajah S, Blumchen K, Sher E, Spergel JM, Leickly FE, Zielen S, Wang J, Sanders GM, Wood RA, Cheema A, Bindslev-Jensen C, Leonard S, Kachru R, Johnston DT, Hampel FC, Kim EH, Anagnostou A, Pongracic JA, Ben-Shoshan M, Sharma HP, Stillerman A, Windom HH, Yang WH, Muraro A, Zubeldia JM, Sharma V, Dorsey MJ, Chong HJ, Ohayon J, Bird JA, Carr TF, Siri D, Fernández-Rivas M, Jeong DK, Fleischer DM, Lieberman JA, Dubois AEJ, Tsoumani M, Ciaccio CE, Portnoy JM, Mansfield LE, Fritz SB, Lanser BJ, Matz J, Oude Elberink HNG, Varshney P, Dilly SG, Adelman DC, Burks AW. AR101 Oral Immunotherapy for Peanut Allergy. N Engl J Med 2018; 379:1991-2001. [PMID: 30449234 DOI: 10.1056/nejmoa1812856] [Citation(s) in RCA: 417] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Peanut allergy, for which there are no approved treatment options, affects patients who are at risk for unpredictable and occasionally life-threatening allergic reactions. METHODS In a phase 3 trial, we screened participants 4 to 55 years of age with peanut allergy for allergic dose-limiting symptoms at a challenge dose of 100 mg or less of peanut protein (approximately one third of a peanut kernel) in a double-blind, placebo-controlled food challenge. Participants with an allergic response were randomly assigned, in a 3:1 ratio, to receive AR101 (a peanut-derived investigational biologic oral immunotherapy drug) or placebo in an escalating-dose program. Participants who completed the regimen (i.e., received 300 mg per day of the maintenance regimen for approximately 24 weeks) underwent a double-blind, placebo-controlled food challenge at trial exit. The primary efficacy end point was the proportion of participants 4 to 17 years of age who could ingest a challenge dose of 600 mg or more, without dose-limiting symptoms. RESULTS Of the 551 participants who received AR101 or placebo, 496 were 4 to 17 years of age; of these, 250 of 372 participants (67.2%) who received active treatment, as compared with 5 of 124 participants (4.0%) who received placebo, were able to ingest a dose of 600 mg or more of peanut protein, without dose-limiting symptoms, at the exit food challenge (difference, 63.2 percentage points; 95% confidence interval, 53.0 to 73.3; P<0.001). During the exit food challenge, the maximum severity of symptoms was moderate in 25% of the participants in the active-drug group and 59% of those in the placebo group and severe in 5% and 11%, respectively. Adverse events during the intervention period affected more than 95% of the participants 4 to 17 years of age. A total of 34.7% of the participants in the active-drug group had mild events, as compared with 50.0% of those in the placebo group; 59.7% and 44.4% of the participants, respectively, had events that were graded as moderate, and 4.3% and 0.8%, respectively, had events that were graded as severe. Efficacy was not shown in the participants 18 years of age or older. CONCLUSIONS In this phase 3 trial of oral immunotherapy in children and adolescents who were highly allergic to peanut, treatment with AR101 resulted in higher doses of peanut protein that could be ingested without dose-limiting symptoms and in lower symptom severity during peanut exposure at the exit food challenge than placebo. (Funded by Aimmune Therapeutics; PALISADE ClinicalTrials.gov number, NCT02635776 .).
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Carr TF, Stern DA, Halonen M, Wright AL, Martinez FD. Non-atopic rhinitis at age 6 is associated with subsequent development of asthma. Clin Exp Allergy 2018; 49:35-43. [PMID: 30220097 DOI: 10.1111/cea.13276] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/24/2018] [Accepted: 09/01/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND It has been postulated that the association between allergic rhinitis and asthma is attributable to the progressive clinical expression of respiratory inflammation during childhood. The role of non-allergic rhinitis in early life in relation to subsequent asthma has not been extensively explored. OBJECTIVE We sought to determine whether rhinitis in early life was associated with risk of asthma development into adulthood, and whether this relationship is independent of allergic sensitization. METHODS Participants were identified from the Tucson Children's Respiratory Study, a non-selected birth cohort. Allergy skin prick testing was performed at age 6 years using house dust mix, Bermuda, mesquite, olive, mulberry, careless weed, and Alternaria aeroallergens. Atopy was defined as ≥1 positive tests. Physician-diagnosed active asthma from age 6 to 32 and physician-diagnosed rhinitis at age 6 were determined by questionnaire. Participants with asthma or active wheezing at age 6 were excluded from analyses. Risk estimates were obtained with Cox regression. RESULTS There were 521 participants who met inclusion criteria. The hazard ratio for subsequently acquiring a diagnosis of asthma between the ages of 8 and 32 for those with non-atopic rhinitis was 2.1 (95% CI: 1.2, 3.4, P = 0.005), compared with the non-atopic no rhinitis group, after adjusting for sex, ethnicity, maternal asthma, maternal education and smoking, and history of 4+ colds per year at age 6. Among the atopic participants, both the active and no rhinitis groups were more likely to develop and have asthma through age 32. The relation between non-atopic rhinitis and asthma was independent of total serum IgE levels at age 6. CONCLUSION AND CLINICAL RELEVANCE Childhood rhinitis, even in the absence of atopy, confers significant risk for asthma development through adulthood. These findings underscore the importance of non-allergic mechanisms in the development of asthma.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Debra A Stern
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Marilyn Halonen
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Anne L Wright
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
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Carr TF, Kraft M. Use of biomarkers to identify phenotypes and endotypes of severeasthma. Ann Allergy Asthma Immunol 2018; 121:414-420. [PMID: 30059792 DOI: 10.1016/j.anai.2018.07.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/19/2018] [Accepted: 07/22/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Severe asthma can be classified into phenotypes and endotypes, which may inform clinicians about inflammatory pathways leading to disease and ultimately guide optimal therapeutic strategy. Biomarkers, objectively measurable characteristics of the disease, are of increasing interest to clinicians and researchers as powerful tools to distinguish among the severe asthma phenotypes and endotypes. The objective of this review is to highlight current knowledge of biomarker applications to identify phenotypes and endotypes of severe asthma. DATA SOURCES Sources used include observational cohorts, clinical trials, translational studies, comprehensive reviews, and expert/taskforce statements. STUDY SELECTIONS Included studies were selected for their relevance to the topic and for strength of data or study design. RESULTS In severe asthma, biomarkers can be used for diagnosis of phenotype or endotype, can also be predictive of clinical outcomes or response to therapy, and may be dynamic with time or therapy. Fully determining phenotype or endotype of severe asthma will require interpretation of combinations of commercially available biomarkers. CONCLUSION Biomarkers have multiple potential clinical applications in severe asthma. Novel biomarkers may add accuracy to this field.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona.
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
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Gaefke CL, Borgstrom M, Bime C, Carr TF. Disparities in Risk of Hospitalization for Food Anaphylaxis in the United States. J Allergy Clin Immunol 2018. [DOI: 10.1016/j.jaci.2017.12.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Carr TF, Kraft M. Management of Severe Asthma before Referral to the Severe Asthma Specialist. J Allergy Clin Immunol Pract 2018; 5:877-886. [PMID: 28689838 DOI: 10.1016/j.jaip.2017.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 12/26/2022]
Abstract
Severe asthma is associated with significant morbidity and can be challenging to assess and control, due to heterogeneity of disease, complexity of diagnosis, and impact of comorbidities. A structured approach to the assessment and management of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. In patients who are either not responding to treatment, or who require high doses of medication to control symptoms, it is highly possible that disease mimickers or comorbidities are present and can inhibit therapeutic responsiveness. The assessment and management of common comorbidities of asthma may dramatically impact disease control and thus medication requirement. Determining medication adherence and optimizing drug dose and delivery may separate out truly severe asthmatics from those not using medications regularly or properly. Next, although true personalized medicine for severe asthma is not yet realized, for those individuals with severe asthma, phenotypic characteristics of each patient may guide which therapeutic options may be most effective for that patient. Finally, evaluation and management of severe asthma at a referral center can add additional phenotyping, therapeutic, and diagnostic strategies.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz.
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
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Abstract
BACKGROUND Numerous aeroallergens have been associated with the development of asthma, including Alternaria, house-dust mite, and pet dander. Tucson, Arizona, is located in the Sonoran Desert, which has the highest diversity of vegetation of any desert in the world. Given the unique pollen profile in this region, we sought to identify the most common aeroallergens associated with rhinitis and asthma diagnosis in the local adult population. OBJECTIVE To identify the prevalence of aeroallergen sensitivity in the Tucson adult population and to identify which aeroallergens are associated with a diagnosis of asthma. METHODS We conducted a retrospective electronic chart review of 226 consecutive adult patients who underwent aeroallergen skin-prick testing for rhinitis at The University of Arizona Adult Allergy and Immunology Clinic over the course of 1 year. All the subjects were tested to a standard panel of tree, grass, weed, mold, house-dust mite, animal dander, cockroach, and feather extracts. Asthma was diagnosed by using the Expert Panel Report 3 guidelines. RESULTS Skin testing results were most commonly positive to mesquite (54%), Bermuda (48%), palo verde (47%), olive tree (43%), and chenopodium (43%). Compared with the subjects without asthma, those subjects with asthma were more often sensitized to molds (odds ratio [OR] 2.25 [95% confidence interval {CI}, 1.22-4.14]; p = 0.005), including Alternaria alternata (OR 2.58 [95% CI, 1.23-5.39]; p = 0.011), and cat hair and/or pelt (OR 2.13 [95% CI, 1.24-3.69]; p = 0.006). CONCLUSION Regional pollens contributed significantly to allergic disease in this unique climate. Sensitization to Alternaria and other nonregional aeroallergens were related to asthma, which supported the current practice of testing and treating patients for allergy to both locally significant and ubiquitous aeroallergens.
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Berry CE, Billheimer D, Jenkins IC, Lu ZJ, Stern DA, Gerald LB, Carr TF, Guerra S, Morgan WJ, Wright AL, Martinez FD. A Distinct Low Lung Function Trajectory from Childhood to the Fourth Decade of Life. Am J Respir Crit Care Med 2017; 194:607-12. [PMID: 27585385 DOI: 10.1164/rccm.201604-0753oc] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Low maximally attained lung function increases the risk of chronic obstructive pulmonary disease irrespective of the subsequent rate of lung function decline. OBJECTIVES We aimed to determine if there were individuals with a distinct, persistently low lung function trajectory in the CRS (Tucson Children's Respiratory Study). METHODS The CRS, an ongoing birth cohort study, enrolled 1,246 participants between 1980 and 1984. Latent class linear mixed effects modeling of the ratio of FEV1 to FVC was used to identify distinct lung function trajectories among participants with two or more spirometry measurements between ages 11 and 32 years. MEASUREMENTS AND MAIN RESULTS Among 599 participants with 2,142 observations, a model with two distinct trajectories (a low trajectory [n = 56; 9.3%] and a normal trajectory) fit the data significantly better than a model with only one trajectory (P = 0.0007). As compared with those with a normal trajectory, participants with a persistently low trajectory were more likely to have a history of maternal asthma (20.0% vs. 9.9%; P = 0.02); early life lower respiratory illness caused by respiratory syncytial virus (41.2% vs. 21.4%; P = 0.001); and physician-diagnosed active asthma at age 32 years (43.9% vs. 16.2%; P < 0.001). Individuals with a persistently low trajectory also demonstrated lower lung function as measured by average maximal expiratory flow at functional residual capacity during infancy and at age 6 years. CONCLUSIONS A distinct group of individuals in a nonselected population demonstrates a persistently low lung function trajectory that may be partly established at birth and predisposes them to chronic obstructive pulmonary disease later in life.
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Affiliation(s)
| | - Dean Billheimer
- 3 BIO5 Institute, University of Arizona, Tucson, Arizona.,4 Department of Epidemiology and Biostatistics and
| | - Isaac C Jenkins
- 5 Fred Hutchinson Cancer Research Center, Seattle, Washington; and
| | - Zhenqiang J Lu
- 3 BIO5 Institute, University of Arizona, Tucson, Arizona
| | | | - Lynn B Gerald
- 2 Arizona Respiratory Center and.,6 Department of Health Promotion Sciences, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona
| | - Tara F Carr
- 1 Department of Medicine and.,2 Arizona Respiratory Center and
| | - Stefano Guerra
- 1 Department of Medicine and.,2 Arizona Respiratory Center and.,7 CREAL Center, Pompeu Fabra University, Barcelona, Spain
| | - Wayne J Morgan
- 8 Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona.,2 Arizona Respiratory Center and
| | - Anne L Wright
- 8 Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona.,2 Arizona Respiratory Center and
| | - Fernando D Martinez
- 8 Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona.,2 Arizona Respiratory Center and.,3 BIO5 Institute, University of Arizona, Tucson, Arizona
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Abstract
The small airways of the lungs are commonly affected in pediatric and adult asthma. Small airways disease has been related to asthma control, severity, and risk of exacerbation. Diagnosis of small airways disease can be best made through evaluation of surgical lung specimens. Noninvasive techniques including spirometry, plethysmography, nitrogen washout, impulse oscillometry, and cross-sectional imaging have been utilized to assess and infer the extent of small airways disease in asthma and can be used longitudinally to assess response to treatment. Patients with small airways disease seem to benefit from inhaled asthma medications that have improved capacity to reach the distal lung compartment. This is especially important for patients with severe asthma, who rely upon high doses of inhaled corticosteroid and bronchodilators for asthma control. This review will describe the techniques which may be utilized to assess small airways disease, discuss the prevalence and characteristics of small airways disease in severe asthma, and highlight how small airway disease may complicate severe asthma treatment.
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Affiliation(s)
- Tara F Carr
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona USA
| | - Roula Altisheh
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona USA
| | - Myron Zitt
- Division of Allergy/Immunology, Department of Medicine, State University of New York, Stonybrook, NY, USA
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Abstract
BACKGROUND Sinusitis is a common disorder associated with significant patient symptomatology that adversely affects quality of life. Sinusitis can cause further morbidity and mortality through its impact on comorbid disorders, progression of inflammation, and extension of infection. OBJECTIVE This review highlights common complications of acute bacterial rhinosinusitis (ABRS) and chronic rhinosinusitis (CRS). RESULTS ABRS is complicated by orbital infections, such as pre- or postseptal cellulitis, and by intracranial infections, including abscesses of the epidural and subdural spaces. CRS can contribute to asthma, sleep disordered breathing, and smell disorders. CRS can be complicated by development of allergic fungal rhinosinusitis or deformity of surrounding bony structures. Fungal complications contribute to morbidity and mortality. CONCLUSION Complications of ABRS, although relatively rare, can cause significant morbidity and mortality, and must be promptly recognized. CRS commonly complicates or drives comorbid diseases, which adversely impacts quality of life. Treatment of these complications often requires coordinated multidisciplinary care.
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Affiliation(s)
- Tara F Carr
- Department of Medicine, University of Arizona, Tucson, Arizona, USA
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Patel S, Carr TF, Daines MO. ORAI1 Mutation in a Child with Primary Immunodeficiency-9. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Carr TF, Beamer PI, Rothers J, Stern DA, Gerald LB, Rosales CB, Van Horne YO, Pivniouk ON, Vercelli D, Halonen M, Gameros M, Martinez FD, Wright AL. Prevalence of Asthma in School Children on the Arizona-Sonora Border. J Allergy Clin Immunol Pract 2017; 5:114-120.e2. [PMID: 27544711 PMCID: PMC5222738 DOI: 10.1016/j.jaip.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Mexican-born children living in the United States have a lower prevalence of asthma than other US children. Although children of Mexican descent near the Arizona (AZ)-Sonora border are genetically similar, differences in environmental exposures might result in differences in asthma prevalence across this region. OBJECTIVE The objective of this study was to determine if the prevalence of asthma and wheeze in these children varies across the AZ-Sonora border. METHODS The International Study of Asthma and Allergy in Children written and video questionnaires were administered to 1753 adolescents from 5 middle schools: Tucson (school A), Nogales, AZ (schools B, C), and Nogales, Sonora, Mexico (schools D, E). The prevalence of asthma and symptoms was compared, with analyses in the AZ schools limited to self-identified Mexican American students. RESULTS Compared with the Sonoran reference school E, the adjusted odds ratio (OR) for asthma was significantly higher in US schools A (OR 4.89, 95% confidence interval [CI] 2.72-8.80), B (OR 3.47, 95% CI 1.88-6.42), and C (OR 4.12, 95% CI 1.78-9.60). The adjusted OR for wheeze in the past year was significantly higher in schools A (OR 2.19, 95% CI 1.20-4.01) and B (OR 2.67, 95% CI 1.42-5.01) on the written questionnaire and significantly higher in A (OR 2.13, 95% CI 1.22-3.75), B (OR 1.95, 95% CI 1.07-3.53), and Sonoran school D (OR 2.34, 95% CI 1.28-4.30) on the video questionnaire compared with school E. CONCLUSIONS Asthma and wheeze prevalence differed significantly between schools and was higher in the United States. Environmental factors that may account for these differences could provide insight into mechanisms of protection from asthma.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz.
| | - Paloma I Beamer
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz; Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Ariz
| | - Janet Rothers
- College of Nursing, University of Arizona, Tucson, Ariz
| | - Debra A Stern
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Lynn B Gerald
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz; Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Ariz
| | - Cecilia B Rosales
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Ariz
| | | | | | - Donata Vercelli
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz; Bio5 Institute, University of Arizona, Tucson, Ariz
| | | | - Mercedes Gameros
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Ariz
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
| | - Anne L Wright
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
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Abstract
OBJECTIVE The aim of this paper was to review the classification of adverse drug reactions, highlight the known pathophysiology of immediate hypersensitivity reactions, and discuss the utility of diagnostic testing for immunologically mediated immediate reactions to gadolinium-based contrast agents (GBCAs). METHODS Current literature on immediate reactions to GBCA was reviewed and summarized. RESULTS Adverse drug reactions to GBCA are rare, and can be attributed to physiologic, immunologic, and nonimmunologic processes. When immunologic reaction is suspected, particularly in the case of severe reactions, skin testing may be useful to confirm allergy and identify alternative agents for subsequent studies. CONCLUSION As GBCAs are widely used for the diagnosis and monitoring of disease, the incidence of adverse drug reactions to GBCA warrants ongoing development of approaches to diagnosis and avoidance of these adverse events.
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Affiliation(s)
- Tara F Carr
- Department of Medicine, Banner-University of Arizona Medical Center, Tucson, AZ
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Abstract
Asthma is a common, chronic inflammatory airways disease characterized by a clinical syndrome of bronchial hyperresponsiveness, inflammation, and reversible airflow obstruction. Individuals with asthma can vary widely in clinical presentation, severity, and pathobiology. The incident factors, pathogenesis, prognosis, and treatment of asthma remain incompletely understood. Utilizing measurable characteristics of asthmatic patients, including demographic, physiologic, and biologic markers, can however identify meaningful phenotypic categories in asthma. Identification of these phenotypes may help improve precision therapeutics targeted toward an individual’s’ disease, and may identify strategies for preventing progression of disease severity.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724-5030 USA
| | - Eugene Bleecker
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC USA
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Carr TF, Berdnikovs S, Simon HU, Bochner BS, Rosenwasser LJ. Eosinophilic bioactivities in severe asthma. World Allergy Organ J 2016; 9:21. [PMID: 27386041 PMCID: PMC4924237 DOI: 10.1186/s40413-016-0112-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [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: 03/29/2016] [Accepted: 06/15/2016] [Indexed: 12/17/2022] Open
Abstract
Asthma is clearly related to airway or blood eosinophilia, and asthmatics with significant eosinophilia are at higher risk for more severe disease. Eosinophils actively contribute to innate and adaptive immune responses and inflammatory cascades through the production and release of diverse chemokines, cytokines, lipid mediators and other growth factors. Eosinophils may persist in the blood and airways despite guidelines-based treatment. This review details eosinophil effector mechanisms, surface markers, and clinical outcomes associated with eosinophilia and asthma severity. There is interest in the potential of eosinophils or their products to predict treatment response with biotherapeutics and their usefulness as biomarkers. This is important as monoclonal antibodies are targeting cytokines and eosinophils in different lung environments for treating severe asthma. Identifying disease state-specific eosinophil biomarkers would help to refine these strategies and choose likely responders to biotherapeutics.
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Affiliation(s)
| | - Sergejs Berdnikovs
- />Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
| | - Hans-Uwe Simon
- />Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Bruce S. Bochner
- />Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
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Parsa NA, Alkatib R, Carr TF. Retrospective Analysis of Allergy Skin Testing Results and Relationship to Chronic Sinusitis in the Tucson Adult Population. J Allergy Clin Immunol 2016. [DOI: 10.1016/j.jaci.2015.12.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Carr TF, Hill JL, Chiu A, Chang EH. Alteration in Bacterial Culture After Treatment With Topical Mupirocin for Recalcitrant Chronic Rhinosinusitis. JAMA Otolaryngol Head Neck Surg 2016; 142:138-42. [DOI: 10.1001/jamaoto.2015.3059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Tara F. Carr
- Department of Otolaryngology, University of Arizona, Tucson
| | - Jennifer L. Hill
- Division of Allergy/Immunology, National Jewish Health, Denver, Colorado
| | - Alex Chiu
- Department of Otolaryngology, University of Arizona, Tucson
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Willis AL, Calton JB, Carr TF, Chiu AG, Chang EH. Dead or alive: Deoxyribonuclease I sensitive bacteria and implications for the sinus microbiome. Am J Rhinol Allergy 2015; 30:94-8. [PMID: 26715059 DOI: 10.2500/ajra.2016.30.4278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recently, there has been tremendous interest in the sinus microbiome and how it relates to disease. However, a lack of a standardized sample collection and DNA extraction methods makes comparison of results across studies nearly impossible. Furthermore, current techniques fail to identify which components of the microbiome are actually alive within the host at the time of sampling. OBJECTIVE To develop and optimize a method to differentiate which bacterial species in the human sinus microbiome are live versus dead. METHODS Duplicate samples from the middle meatus of patients with healthy sinus tissue and those patients with chronic rhinosinusitis were collected by using brushes (n = 12), swabs (n = 27), and tissue biopsy (n = 8) methods. One sample from each pair was either deoxyribonuclease I- or control-treated before DNA extraction. The relative bacterial versus human composition of each sample was determined. A 16S ribosomal RNA gene analysis was performed on a six-paired sample from patients with healthy sinus tissue. RESULTS We found that swabs and brushes collected a higher percentage of bacterial DNA than did tissue biopsy. We also determined that as much as 50% of the bacteria collected in these samples was already dead at the time of collection. The 16S ribosomal RNA gene analysis found significant changes in the relative abundance of taxa identified in the live versus dead bacterial communities of healthy human sinuses. CONCLUSIONS Our findings indicated that swabs provided the best quality microbiome samples and that a large portion of the bacteria identified in the sinus were deoxyribonuclease I sensitive. These results highlighted the need for improved techniques such as those presented here, which can differentiate between living and dead bacteria in a sample, a potentially critical distinction when examining changes in sinus innate immune function because both components play important, but distinct, functions. Further studies will determine how these living and dead bacterial populations shift in different disease states and after clinical intervention.
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Affiliation(s)
- Amanda L Willis
- Department of Otolaryngology, University of Arizona, Tucson, Arizona, USA
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Affiliation(s)
- Tara F Carr
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Monica Kraft
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona
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Gerald JK, Carr TF, Wei CY, Holbrook JT, Gerald LB. Albuterol Overuse: A Marker of Psychological Distress? J Allergy Clin Immunol Pract 2015; 3:957-62. [PMID: 26341049 DOI: 10.1016/j.jaip.2015.06.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/16/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Albuterol overuse, 3 or more canisters per year, is associated with poor asthma control and frequent exacerbations. OBJECTIVE To describe albuterol use on symptom and symptom-free days and identify predictors of albuterol overuse and controller medication underuse. METHODS Secondary analyses of data from adults with mild asthma from the Trial of Asthma Patient Education were carried out. Based on albuterol use of 80% or more on symptom days and less than 20% on symptom-free days, participants were characterized as expected users, overusers, or underusers of albuterol. Good controller medication adherence was defined as 80% or more of prescribed doses. Data included demographic characteristics, diary data, spirometry, and scores from standardized questionnaires. Bivariate associations were examined between categorization of medication use and measured characteristics. RESULTS Of the 416 participants, 212 (51%) were expected users, 114 (27%) were overusers, and 90 (22%) were underusers of albuterol. No differences were observed among the user groups by demographic characteristics or lung function. Expected users demonstrated the highest asthma-related knowledge, attitudes, and efficacy. Overusers reported the greatest symptom burden, worst asthma control, and highest frequency of symptom days. Overusers also had the highest burden of depression symptoms. More frequent symptom days accounted for 15% of overuse, greater use on symptom days accounted for 31%, and greater use on symptom free days accounted for 54% of overuse. Mean controller adherence was high across all groups, and there were no differences between the groups. CONCLUSIONS Although overusers experienced more frequent symptom days and used more albuterol on those days, most overuse was attributable to unexpected use on symptom-free days. High levels of comorbid depression were observed, particularly among overusers and among those nonadherent to controller medication.
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Affiliation(s)
- Joe K Gerald
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Ariz; Arizona Respiratory Center, The University of Arizona, Tucson, Ariz.
| | - Tara F Carr
- Arizona Respiratory Center, The University of Arizona, Tucson, Ariz
| | - Christine Y Wei
- Johns Hopkins University Bloomberg School of Public Health for the American Lung Association-Asthma Clinical Research Centers, Baltimore, Md
| | - Janet T Holbrook
- Johns Hopkins University Bloomberg School of Public Health for the American Lung Association-Asthma Clinical Research Centers, Baltimore, Md
| | - Lynn B Gerald
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Ariz; Arizona Respiratory Center, The University of Arizona, Tucson, Ariz
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Carr TF. Editorial: Innovative steps toward understanding sinonasal disease, improving diagnostics and optimizing patient care. Am J Rhinol Allergy 2015; 28:359-60. [PMID: 25198018 DOI: 10.2500/ajra.2014.28.4108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kashani S, Carr TF, Grammer LC, Schleimer RP, Hulse KE, Kato A, Kern RC, Conley DB, Chandra RK, Tan BK, Peters AT. Clinical characteristics of adults with chronic rhinosinusitis and specific antibody deficiency. J Allergy Clin Immunol Pract 2014; 3:236-42. [PMID: 25609325 DOI: 10.1016/j.jaip.2014.09.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 09/21/2014] [Accepted: 09/22/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Specific antibody deficiency (SAD) involves a deficient response to a polysaccharide vaccine in the setting of normal immunoglobulin G (IgG) levels and chronic infections. Patients with chronic rhinosinusitis (CRS) are often evaluated for SAD. There are limited data that describe patients with CRS and SAD. OBJECTIVE The objective of this study was to better characterize the role of SAD in CRS. METHODS We reviewed electronic records of adults with CRS who were evaluated for immunodeficiency with quantitative Ig levels and pre- and postantibody titers to a pneumococcal polysaccharide vaccine (PPV). RESULTS Fourteen pneumococcal serotypes were determined in 239 subjects from 2002 to 2009. Of these subjects, 64 had adequate protective titers of 1.3 μg/mL or higher in 7 or more serotypes of the 14 serotypes checked; 56 (23%) had less than 7 protective titers post-PPV and were diagnosed with SAD; and 119 had an adequate response to the vaccine with 7 or more serotypes being higher than 1.3 μg/mL (>50% response) and were characterized as "responders." Subjects with SAD received more antibiotic courses relative to responders in the 2 years after immunization (3.19 ± 2.64 vs 2.19 ± 2.24, P < .05). Of 56 subjects with SAD, 10 (17.9%) received Ig replacement therapy. Subjects who received Ig had fewer numbers of protective pneumococcal titers post-PPV and had more pneumonia (40.0%) versus subjects with SAD who did not receive Ig (10.9%). CONCLUSIONS Of the 239 patients with CRS with normal IgG levels evaluated for immunodeficiency, 56 (23.4%) had SAD. A majority of patients with SAD may not need Ig replacement; however, a subset of patients with SAD benefit from Ig replacement.
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Affiliation(s)
- Sara Kashani
- Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Tara F Carr
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Ariz
| | - Leslie C Grammer
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Robert P Schleimer
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Kathryn E Hulse
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Atsushi Kato
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Robert C Kern
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - David B Conley
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Bruce K Tan
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Anju T Peters
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill.
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Abstract
The goals of treatment are prevention of fatalities, hospitalizations, and emergency department visits, along with achieving good long-term control of asthma, with reduction of symptoms, maintenance of normal activity level, prevention of exacerbations, and accelerated loss of pulmonary function (forced expiratory volume in 1 second [FEV(1)]) as well as avoiding harm from therapies. Treatment often is initiated based on severity of symptoms, physical examination findings, and, for some patients, the FEV(1) or peak expiratory flow rates. Comorbidities such as gastroesophageal reflux disease and laryngopharyngeal reflux, rhinitis or rhinosinusitis, sleep apnea, recurrent infections, smoking, and substance abuse should be addressed. Two treatment modalities are indicated only for individuals with allergic asthma: allergen-specific immunotherapy, commonly known as allergy shots, and omalizumab. Allergen immunotherapy is effective in decreasing symptoms and medication use in selected patients with mild-to-moderate allergic asthma. In addition, patients receiving allergen immunotherapy for allergic rhinitis may have a decreased risk of developing asthma. Omalizumab, a recombinant humanized monoclonal anti-IgE antibody indicated for persistent moderate-to-severe allergic asthma, has been shown to improve asthma-related quality of life, decrease clinically significant exacerbation rates, number of courses of oral corticosteroids, and reduce the severity of exacerbations. It is administered every 2-4 weeks subcutaneously, and improvement should be ascertained after 4-6 months.
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Abstract
Skin tests are used in addition to a directed history and physical exam to exclude or confirm IgE-mediated diseases such as allergic rhinitis, asthma, and anaphylaxis to aeroallergens, foods, insect venoms, and certain drugs. There are two types of skin testing used in clinical practice. These include percutaneous testing (prick or puncture) and intracutaneous testing (intradermal). Prick testing involves introducing a needle into the upper layers of the skin through a drop of allergen extract and gently lifting the epidermis up. Other devices are available for prick testing. Intracutaneous (intradermal) testing involves injecting a small amount of allergen (0.01-0.02 mL) into the dermis. The release of preformed histamine from mast cells causes increased vascular permeability via smooth muscle contraction and development of a wheal; inflammatory mediators initiate a neural reflex causing vasodilatation, leading to erythema (the flare). Prick testing methods are the initial technique for detecting the presence of IgE. They may correlate better with clinical sensitivity and are more specific but less sensitive than intradermal testing. Sites of skin testing include the back and the volar aspect of the arm. Although the back is more reactive, the difference is minimal. By skin testing on the arm, the patient can witness the emergence and often sense the pruritus of the skin test reaction. Because more patients are sensitized (have IgE antibodies and positive skin test reactions) than have current symptoms, the diagnosis of allergy can be made only by correlating skin testing results with the presence of clinical symptoms.
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Abstract
Urticaria, also known as hives, may affect up to 20% of the population at some time in their lives. Urticaria is characterized by extreme pruritus and described as erythematous, raised, circumscribed lesions with central pallor that blanch with pressure. The pathogenesis of urticaria involves mast cell activation, with subsequent release of histamine and other vasoactive mediators, leading to increased vascular permeability of postcapillary venules and development of edema, erythema, and pruritus. Urticaria is closely associated with angioedema in 40% of individuals; ∼10% of patients experience angioedema without urticaria. Urticarial lesions often are generalized with multiple lesions in no specific distribution; angioedema tends to be localized, commonly affecting the face (periorbital and perioral regions), tongue, uvula, soft palate or larynx, extremities, and genitalia. Urticaria is subdivided into acute and chronic urticaria based on duration of symptoms. Acute urticaria lasts <6 weeks and an identifiable cause may be discovered such as food products, medications (aspirin, nonsteroidal anti-inflammatory drugs, and antibiotics), or insect stings. Urticaria lasting >6 weeks is designated as chronic urticaria, and an etiology is seldom identified and thus considered idiopathic. Chronic urticaria may have an autoimmune basis. There is a well-documented association between autoimmune hypothyroidism (Hashimoto's disease) and urticaria and angioedema with higher incidence of antithyroid (antithyroglobulin and antiperoxidase) antibodies in these usually euthyroid patients. Furthermore, studies have revealed a circulating IgG antibody directed against the IgE receptor (F(Cε)RIα) or IgE in 40-60% of patients with chronic urticaria. Histamine 1-receptor antagonists (antihistamines) are initial therapy.
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Carr TF, Koterba AP, Chandra R, Grammer LC, Conley DB, Harris KE, Kern R, Schleimer RP, Peters AT. Characterization of specific antibody deficiency in adults with medically refractory chronic rhinosinusitis. Am J Rhinol Allergy 2011; 25:241-4. [PMID: 21819760 PMCID: PMC3387730 DOI: 10.2500/ajra.2011.25.3653] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Specific antibody deficiency may predispose patients to recurrent respiratory tract infections. There is limited literature assessing specific antibody deficiency in chronic rhinosinusitis (CRS). This study evaluated the role of specific antibody deficiency in patients with CRS who have failed medical therapy. METHODS We performed a retrospective chart review of patients with CRS who underwent functional endoscopic sinus surgery and had prior assessment for humoral immunodeficiency. Each patient's record was reviewed for serum quantitative immunoglobulin G (IgG) and IgA and anti-Streptococcus pneumoniae antibody titers measured at baseline and 6 weeks postvaccination with the 23-valent unconjugated pneumococcal vaccine. Clinical characteristics, including asthma, atopy, and nasal polyps, were recorded. RESULTS Of the 129 CRS patients who met inclusion criteria, 93 (72%) had low baseline antipneumococcal titers. Fifteen (11.6%) patients were diagnosed with specific antibody deficiency based on an inadequate response to the pneumococcal polysaccharide vaccine. The group of patients with specific antibody deficiency had significantly lower serum IgA levels when compared with those patients with normal preimmunization titers (138 ± 67.3 versus 330 ± 356; p < 0.05). Patients with specific antibody deficiency had a significantly lower number of preimmunization protective antipneumococcal titers when compared with vaccine responders (1.41 versus 2.72; p < 0.0005). CONCLUSION This retrospective study indicates that patients with medically refractory CRS may have a high prevalence of low preimmunization antipneumococcal titers and specific antibody deficiency. Furthermore, lower serum IgA levels identified in these specific antibody deficiency patients suggests that a prospective study to further characterize this relationship is warranted.
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Affiliation(s)
- Tara F Carr
- Division of Allergy/Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kumar S, Carr TF, Evans DI, Morris-Jones P, Hann IM. Prognostic significance of cell surface markers in childhood acute lymphoblastic leukaemia. Clin Lab Haematol 2008; 1:121-8. [PMID: 317037 DOI: 10.1111/j.1365-2257.1979.tb00459.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Examination of surface markers on leukaemic blasts from 51 children with ALL revealed that ALL is a heterogeneous disease. The majority (68%) of patients with ALL lack surface markers (null leukaemia); 28% could be classed as T cell as they form rosettes with sheep RBC and 4% have been shown to possess surface immunoglobulins and hence are classed as B cells. The children with null cell leukaemia have a better prognosis than T and B cell types.
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Nicholson JAT, Wynn RF, Carr TF, Will AM. Sequential reduced- and full-intensity allografting using same donor in a child with chronic granulomatous disease and coexistent, significant comorbidity. Bone Marrow Transplant 2005; 34:1009-10. [PMID: 15489863 DOI: 10.1038/sj.bmt.1704729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Wynn RF, Grainger JD, Carr TF, Eden OB, Stevens RF, Will AM. Failure of allogeneic bone marrow transplantation to correct Diamond-Blackfan anaemia despite haemopoietic stem cell engraftment. Bone Marrow Transplant 1999; 24:803-5. [PMID: 10516686 DOI: 10.1038/sj.bmt.1701982] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We report the case of a 10-year-old boy with congenital pure red cell aplasia (Diamond-Blackfan anaemia) who received an allogeneic bone marrow transplant (BMT) from his HLA-identical sister. The transplant was complicated by moderate veno-occlusive disease (VOD). Despite cytogenetic evidence of complete donor haemopoietic stem cell engraftment there was selective failure of red cell engraftment and he remains red cell transfusion-dependent. This is the first case of a stem cell transplant failing to correct the defect in this condition despite engraftment.
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Affiliation(s)
- R F Wynn
- Royal Children's Hospital, Manchester, UK
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Affiliation(s)
- G D Osweiler
- Veterinary Diagnostic Laboratory, Iowa State University, Ames 50011, USA
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Carr TF, Stevens RF, Burton C, Harrison CJ. An interstitial deletion in the rearranged T-cell receptor gamma chain locus in a case of T-cell acute lymphoblastic leukaemia. Br J Haematol 1995; 89:688-9. [PMID: 7734387 DOI: 10.1111/j.1365-2141.1995.tb08397.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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