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Lavoie G, Lemière C. Impact of Ongoing Treatment With Inhaled Corticosteroids During Specific Inhalation Challenges for Diagnosing Occupational Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2977-2982. [PMID: 39094943 DOI: 10.1016/j.jaip.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/15/2024] [Accepted: 07/20/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Specific inhalation challenge (SIC) tests are still the reference test for diagnosing sensitizer-induced occupational asthma (SIOA). The European Respiratory Society recommends the cessation of inhaled corticosteroids (ICS) 72 hours before SIC. OBJECTIVE To assess the effect of an ongoing ICS treatment during SIC on the maximum fall in forced expiratory volume in 1 second (FEV1), the change in methacholine provocative concentration of methacholine inducing a 20% fall in FEV1 (PC20), and sputum eosinophil counts after exposure to the suspected agent. METHODS We performed a retrospective analysis using a database of cases referred to our center for suspected SIOA from 1999 to 2022. The results of the SIC were compared between subjects treated with ICS during SIC and steroid-naïve subjects. RESULTS Six hundred and seventy-one individuals underwent SIC in the laboratory. Three hundred and eighteen were treated with ICS, whereas 353 were steroid naïve. The proportion of subjects with a positive SIC was greater among ICS-treated subjects (39. 6%) compared with steroid-naïve subjects (27.5%, P < .001). A treatment with ICS did not influence the outcome of the SIC. There was no difference in the change in PC20 or the percentage of sputum eosinophils after SIC between steroid-treated and steroid-naïve subjects. CONCLUSIONS An ongoing ICS treatment during an SIC did not affect the occurrence of an asthmatic reaction, the change in airway responsiveness, or eosinophilic inflammation after exposure to the suspected agent in subjects who have been treated with ICS for a long period of time.
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Affiliation(s)
- Gabriel Lavoie
- Chest Department, CIUSSS du Nord-de-l'île-de-Montréal, Montréal, QC, Canada; Chest Department, Université de Montréal, Montréal, QC, Canada
| | - Catherine Lemière
- Chest Department, CIUSSS du Nord-de-l'île-de-Montréal, Montréal, QC, Canada; Chest Department, Université de Montréal, Montréal, QC, Canada.
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Owen JJ, Edgar SL, Elliott S, Kerley S, Jones TL, Neville D, Fogg C, Brown TP, Chauhan AJ, Shute JK. Urinary fibrinopeptide-A as a predictive biomarker of exacerbation in asthma. RESPIRATORY MEDICINE: X 2020. [DOI: 10.1016/j.yrmex.2020.100021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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de Groot LES, Liu D, Dierdorp BS, Fens N, van de Pol MA, Sterk PJ, Kulik W, Gerlofs-Nijland ME, Cassee FR, Pinelli E, Lutter R. Ex vivo innate responses to particulate matter from livestock farms in asthma patients and healthy individuals. Environ Health 2020; 19:78. [PMID: 32620109 PMCID: PMC7333268 DOI: 10.1186/s12940-020-00632-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/24/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Asthma patients suffer from periodic acute worsening of symptoms (i.e. loss of asthma control or exacerbations), triggered by a variety of exogenous stimuli. With the growing awareness that air pollutants impact respiratory diseases, we investigated whether particulate matter (PM) derived from various livestock farms (BioPM) differentially affected innate and oxidative stress responses in asthma and health. METHODS Peripheral blood mononuclear cells (PBMCs), collected from patients sequentially before and during loss of asthma control and from healthy individuals, were exposed to BioPM collected from chicken, goat and pig farms (1 and 5 μg/ml), with or without pre-treatment with antioxidants. Cytokine release and oxidative stress were assessed. RESULTS PBMCs produced IFNγ, IL-1β, IL-10 and TNFα upon stimulation with BioPM, with that from pig farms inducing the highest cytokine levels. Overall, cytokine production was irrespective of the presence or state of disease. However, PBMCs from stable asthma patients upon exposure to the three BioPM showed more extreme TNFα responses than those from healthy subjects. Furthermore, PBMCs obtained during loss of asthma control that were exposed to BioPM from pig farms showed enhanced IFNγ release as well as decreased oxidative stress levels upon pre-treatment with N-acetylcysteine (NAC) compared to stable disease. NAC, but not superoxide dismutase and catalase, also counteracted BioPM-induced cytokine release, indicating the importance of intracellular reactive oxygen species in the production of cytokines. CONCLUSIONS BioPM triggered enhanced pro-inflammatory responses by PBMCs from both healthy subjects and asthma patients, with those from patients during loss of asthma control showing increased susceptibility to BioPM from pig farms in particular.
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Affiliation(s)
- Linsey E S de Groot
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Dingyu Liu
- Centre for Sustainability, Environment and Health, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Barbara S Dierdorp
- Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Niki Fens
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianne A van de Pol
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wim Kulik
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Miriam E Gerlofs-Nijland
- Centre for Sustainability, Environment and Health, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Flemming R Cassee
- Centre for Sustainability, Environment and Health, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Elena Pinelli
- Centre for Immunology of Infectious Diseases and Vaccines, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - René Lutter
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Deng Z, Xie H, Cheng W, Zhang M, Liu J, Huo Y, Liao Y, Cheng Y. Dabigatran ameliorates airway smooth muscle remodeling in asthma by modulating Yes-associated protein. J Cell Mol Med 2020; 24:8179-8193. [PMID: 32542982 PMCID: PMC7348141 DOI: 10.1111/jcmm.15485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/02/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
Accumulating evidence indicates that thrombin, the major effector of the coagulation cascade, plays an important role in the pathogenesis of asthma. Interestingly, dabigatran, a drug used in clinical anticoagulation, directly inhibits thrombin activity. The aim of this study was to investigate the effects and mechanisms of dabigatran on airway smooth muscle remodeling in vivo and in vitro. Here, we found that dabigatran attenuated inflammatory pathology, mucus production, and collagen deposition in the lungs of asthmatic mice. Additionally, dabigatran suppressed Yes‐associated protein (YAP) activation in airway smooth muscle of asthmatic mice. In human airway smooth muscle cells (HASMCs), dabigatran not only alleviated thrombin‐induced proliferation, migration and up‐regulation of collagen I, α‐SMA, CTGF and cyclin D1, but also inhibited thrombin‐induced YAP activation, while YAP activation mediated thrombin‐induced HASMCs remodeling. Mechanistically, thrombin promoted actin stress fibre polymerization through the PAR1/RhoA/ROCK/MLC2 axis to activate YAP and then interacted with SMAD2 in the nucleus to induce downstream target genes, ultimately aggravating HASMCs remodeling. Our study provides experimental evidence that dabigatran ameliorates airway smooth muscle remodeling in asthma by inhibiting YAP signalling, and dabigatran may have therapeutic potential for the treatment of asthma.
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Affiliation(s)
- Zhenan Deng
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Haojun Xie
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Weiying Cheng
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Meihong Zhang
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Jie Liu
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Yating Huo
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Yulin Liao
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuanxiong Cheng
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
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de Groot LES, van de Pol MA, Fens N, Dierdorp BS, Dekker T, Kulik W, Majoor CJ, Hamann J, Sterk PJ, Lutter R. Corticosteroid Withdrawal-Induced Loss of Control in Mild to Moderate Asthma Is Independent of Classic Granulocyte Activation. Chest 2019; 157:16-25. [PMID: 31622588 DOI: 10.1016/j.chest.2019.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/03/2019] [Accepted: 09/23/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Loss of asthma control and asthma exacerbations are associated with increased sputum eosinophil counts. However, whether eosinophils, or the also present neutrophils, actively contribute to the accompanying inflammation has not been extensively investigated. METHODS Twenty-three patients with mild to moderate asthma were included in a standardized prospective inhaled corticosteroid (ICS) withdrawal study; 22 of the patients experienced loss of asthma control. The study assessed various immune, inflammatory, and oxidative stress parameters, as well as markers of eosinophil and neutrophil activity, in exhaled breath condensate, plasma, and sputum collected at three phases (baseline, during loss of control, and following recovery). RESULTS Loss of asthma control was characterized by increased sputum eosinophils, whereas no differences were detected between the three phases for most inflammatory and oxidative stress responses. There were also no differences detected for markers of activated eosinophils (eosinophil cationic protein and bromotyrosine) and neutrophils (myeloperoxidase and chlorotyrosine). However, free eosinophilic granules and citrullinated histone H3, suggestive of eosinophil cytolysis and potentially eosinophil extracellular trap formation, were enhanced. Baseline blood eosinophils and changes in asymmetric dimethylarginine (an inhibitor of nitric oxide synthase) in plasma were found to correlate with the decrease in FEV1 percent predicted upon ICS withdrawal (both, rs = 0.46; P = .03). CONCLUSIONS The clinical effect in mild to moderate asthma upon interruption of ICS therapy is not related to the classic inflammatory activation of eosinophils and neutrophils. It may, however, reflect another pathway underlying the onset of loss of disease control and asthma exacerbations. TRIAL REGISTRY The Netherlands Trial Register; No.: NTR3316; URL: trialregister.nl/trial/3172.
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Affiliation(s)
- Linsey E S de Groot
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Marianne A van de Pol
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Niki Fens
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Barbara S Dierdorp
- Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tamara Dekker
- Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wim Kulik
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christof J Majoor
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jörg Hamann
- Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - René Lutter
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Experimental Immunology (Amsterdam Infection & Immunity Institute), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Licari A, Marseglia G, De Amici M, Ciprandi G. Pentraxin 3 and D-dimer in children with asthma: A real-world study. Clin Exp Allergy 2019; 49:550-551. [PMID: 30723958 DOI: 10.1111/cea.13364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Amelia Licari
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gianluigi Marseglia
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Mara De Amici
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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Shi G, Zhao JW, Sun XX, Ma JF, Wang P, He FC, Ming L. TIPE2 is negatively correlated with tissue factor and thrombospondin-1 expression in patients with bronchial asthma. Exp Ther Med 2018; 15:3449-3454. [PMID: 29545867 PMCID: PMC5840926 DOI: 10.3892/etm.2018.5870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 11/16/2017] [Indexed: 12/16/2022] Open
Abstract
The interaction between inflammatory processes and a hypercoagulant state may aggravate the severity of asthma and stimulate the airway remodeling of asthma. The aim of the current study was to evaluate the association between the negative inflammatory regulator tumor necrosis factor α induced protein-8 like-2 (TIPE2) and the coagulating substances tissue factor (TF) and thrombospondin-1 (TSP-1) in patients with bronchial asthma. Compared with healthy controls, TIPE2 expression was significantly downregulated, whereas TF expression was upregulated in the peripheral blood mononuclear cells (PBMCs) of patients with bronchial asthma. In addition, levels of TF and TSP-1 in the sera were up-regulated in patients with asthma compared with healthy controls. TIPE2 expression was negatively correlated with TF in the PBMCs and sera and was negatively correlated with TSP-1 levels in the sera of patients with bronchial asthma. The results of the current study indicated that anti-inflammatory TIPE2 levels are associated with levels of the coagulation substances TF and TSP-1. However, further studies are required to determine whether TIPE2 participates in the pathogenesis of asthma by interacting with the coagulation substances TF and TSP-1.
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Affiliation(s)
- Guang Shi
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Key Clinical Laboratory of Henan Province, Zhengzhou, Henan 450052, P.R. China
- Department of Laboratory Medicine of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jun-Wei Zhao
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Key Clinical Laboratory of Henan Province, Zhengzhou, Henan 450052, P.R. China
- Department of Laboratory Medicine of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xiao-Xu Sun
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Key Clinical Laboratory of Henan Province, Zhengzhou, Henan 450052, P.R. China
| | - Jun-Fen Ma
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Key Clinical Laboratory of Henan Province, Zhengzhou, Henan 450052, P.R. China
- Department of Laboratory Medicine of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Pan Wang
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Fu-Cheng He
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Key Clinical Laboratory of Henan Province, Zhengzhou, Henan 450052, P.R. China
- Department of Laboratory Medicine of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Liang Ming
- Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Key Clinical Laboratory of Henan Province, Zhengzhou, Henan 450052, P.R. China
- Department of Laboratory Medicine of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
- Correspondence to: Professor Liang Ming, Clinical Laboratory, The First Affiliated Hospital of Zhengzhou University, 1E Jianshe Road, Zhengzhou, Henan 450052, P.R. China, E-mail:
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Brinkman P, van de Pol MA, Gerritsen MG, Bos LD, Dekker T, Smids BS, Sinha A, Majoor CJ, Sneeboer MM, Knobel HH, Vink TJ, de Jongh FH, Lutter R, Sterk PJ, Fens N. Exhaled breath profiles in the monitoring of loss of control and clinical recovery in asthma. Clin Exp Allergy 2017. [PMID: 28626990 DOI: 10.1111/cea.12965] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Asthma is a chronic inflammatory airway disease, associated with episodes of exacerbations. Therapy with inhaled corticosteroids (ICS) targets airway inflammation, which aims to maintain and restore asthma control. Clinical features are only modestly associated with airways inflammation. Therefore, we hypothesized that exhaled volatile metabolites identify longitudinal changes between clinically stable episodes and loss of asthma control. OBJECTIVES To determine whether exhaled volatile organic compounds (VOCs) as measured by gas-chromatography/mass-spectrometry (GC/MS) and electronic nose (eNose) technology discriminate between clinically stable and unstable episodes of asthma. METHODS Twenty-three patients with (partly) controlled mild to moderate persistent asthma using ICS were included in this prospective steroid withdrawal study. Exhaled metabolites were measured at baseline, during loss of control and after recovery. Standardized sampling of exhaled air was performed, after which samples were analysed by GC/MS and eNose. Univariate analysis of covariance (ANCOVA), followed by multivariate principal component analysis (PCA) was used to reduce data dimensionality. Next paired t tests were utilized to analyse within-subject breath profile differences at the different time-points. Finally, associations between exhaled metabolites and sputum inflammation markers were examined. RESULTS Breath profiles by eNose showed 95% (21/22) correct classification for baseline vs loss of control and 86% (19/22) for loss of control vs recovery. Breath profiles using GC/MS showed accuracies of 68% (14/22) and 77% (17/22) for baseline vs loss of control and loss of control vs recovery, respectively. Significant associations between exhaled metabolites captured by GC/MS and sputum eosinophils were found (Pearson r≥.46, P<.01). CONCLUSIONS & CLINICAL RELEVANCE Loss of asthma control can be discriminated from clinically stable episodes by longitudinal monitoring of exhaled metabolites measured by GC/MS and particularly eNose. Part of the uncovered biomarkers was associated with sputum eosinophils. These findings provide proof of principle for monitoring and identification of loss of asthma control by breathomics.
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Affiliation(s)
- P Brinkman
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - M A van de Pol
- Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - M G Gerritsen
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - L D Bos
- Department of Intensive Care, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - T Dekker
- Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - B S Smids
- Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - A Sinha
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - C J Majoor
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - M M Sneeboer
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - H H Knobel
- Philips Research, Eindhoven, The Netherlands
| | - T J Vink
- Philips Research, Eindhoven, The Netherlands
| | - F H de Jongh
- Department of Pulmonary Function, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R Lutter
- Department of Experimental Immunology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - P J Sterk
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - N Fens
- Department of Respiratory Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
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