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Charbit AR, Liegeois MA, Raymond WW, Comhair SAA, Johansson MW, Hastie AT, Bleecker ER, Fajt M, Castro M, Sumino K, Erzurum SC, Israel E, Jarjour NN, Mauger DT, Moore WC, Wenzel SE, Woodruff PG, Levy BD, Tang MC, Fahy JV. A Novel DNase Assay Reveals Low DNase Activity in Severe Asthma. Am J Physiol Lung Cell Mol Physiol 2024. [PMID: 38651338 DOI: 10.1152/ajplung.00081.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
Secreted deoxyribonucleases (DNases), such as DNase-1 and DNase-IL3, degrade extracellular DNA, and endogenous DNases have roles in resolving airway inflammation and guarding against autoimmune responses to nucleotides. Subsets of patients with asthma have high airway DNA levels, but information about DNase activity in health and in asthma is lacking. To characterize DNase activity in health and in asthma, we developed a novel kinetic assay using a Taqman probe sequence that is quickly cleaved by DNase-I to produce a large product signal. We used this kinetic assay to measure DNase activity in sputum from participants in the Severe Asthma Research Program (SARP)-3 (n=439) and from healthy controls (n=89). We found that DNase activity was lower than normal in asthma (78.7 RFU/min vs 120.4 RFU/min, p<0.0001). Compared to asthma patients with sputum DNase activity levels in the upper tertile activity levels, those in the lower tertile of sputum DNase activity were characterized clinically by more severe disease and pathologically by airway eosinophilia and airway mucus plugging. Carbamylation of DNase-I, a post translational modification that can be mediated by eosinophil peroxidase, inactivated DNase-I. In summary, a Taqman probe-based DNase activity assay uncovers low DNase activity in the asthma airway which is associated with more severe disease and airway mucus plugging and may be caused, at least in part, by eosinophil-mediated carbamylation.
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Affiliation(s)
- Annabelle R Charbit
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Maude A Liegeois
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Wilfred W Raymond
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Suzy A A Comhair
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, United States
| | - Mats W Johansson
- Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Annette T Hastie
- Internal Medicine-Pulmonary Section, Wake Forest School of Medicine, Winston Salem, NC, United States
| | | | - Merritt Fajt
- Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Mario Castro
- Department of Medicine, University of Kansas School of Medicine, Kansas City, KS, United States
| | - Kaharu Sumino
- Washington University in St. Louis, St. Louis, MO, United States
| | - Serpil C Erzurum
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, United States
| | - Elliot Israel
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - David T Mauger
- Center for Biostatistics and Epidemiology, Pennsylvania State University School of Medicine, Hershey, PA, United States
| | - Wendy C Moore
- Department of Internal Medicine, Wake Forest University, Winston-Salem, NC, United States
| | - Sally E Wenzel
- Department of Environmental and Occupational Health, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Bruce D Levy
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Monica C Tang
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - John V Fahy
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Covar R, Lazarus SC, Krishnan JA, Blake KV, Sorkness CA, Dyer AM, Lang JE, Lugogo NL, Mauger DT, Wechsler ME, Wenzel SE, Cardet JC, Castro M, Israel E, Phipatanakul W, King TS. Association of Sputum Eosinophilia With Easily Measured Type-2 Inflammatory Biomarkers in Untreated Mild Persistent Asthma. J Allergy Clin Immunol Pract 2024; 12:960-969.e6. [PMID: 38097180 DOI: 10.1016/j.jaip.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/26/2023] [Accepted: 12/05/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A multicenter clinical trial in patients with mild persistent asthma indicated that response to inhaled corticosteroids (ICS) is limited to those with sputum eosinophilia. However, testing for sputum eosinophilia is impractical in most clinical settings. OBJECTIVE We examined associations between sputum eosinophilia and type 2 inflammatory biomarkers in untreated mild persistent asthma. METHODS Induced sputum, blood eosinophil count (BEC), fractional exhaled nitric oxide (FeNO), and serum periostin were obtained twice during the 6-week run-in period in a clinical trial that enrolled patients 12 years and older with symptomatic, mild persistent asthma without controller therapy. The optimal threshold for each biomarker was based on achieving 80% or greater sensitivity. Performance of biomarkers (area under the receiver operating characteristics curve [AUC], range 0.0-1.0) in predicting sputum eosinophilia 2% or greater was determined; AUCs of 0.8 to 0.9 and more than 0.9 define excellent and outstanding discrimination, respectively. RESULTS Of 564 participants, 27% were sputum eosinophilic, 83% were atopic, 70% had BEC of 200/uL or higher or FeNO of 25 ppb or greater; 64% of participants without sputum eosinophilia had elevated BEC or FeNO. The AUCs for BEC, FeNO, and both together in predicting sputum eosinophilia were all below the threshold for excellent discrimination (AUC 0.75, 0.78, and 0.79, respectively). Periostin (in adults) had poor discrimination (AUC 0.59; P = .02). CONCLUSIONS In untreated mild persistent asthma, there is substantial discordance between sputum eosinophilia, BEC, and FeNO. Until prospective trials test the ability of alternative biomarkers to predict ICS response, BEC or FeNO phenotyping may be an option to consider ICS through a shared decision-making process with consideration of other clinical features.
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Affiliation(s)
- Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo.
| | - Stephen C Lazarus
- Department of Medicine, University of California, San Francisco, Calif
| | - Jerry A Krishnan
- Departments of Medicine and Public Health, University of Illinois Chicago, Chicago, Ill
| | - Kathryn V Blake
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health, Jacksonville, Fla
| | - Christine A Sorkness
- Department of Medicine and School of Pharmacy, University of Wisconsin, Madison, Wis
| | - Anne-Marie Dyer
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Jason E Lang
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Njira L Lugogo
- Department of Medicine, University of Michigan, Ann Arbor, Mich
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | | | - Sally E Wenzel
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | | | - Mario Castro
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kan
| | - Elliot Israel
- Department of Medicine, Harvard Medical School Brigham & Women's Hospital, Boston, Mass
| | | | - Tonya S King
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
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3
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Hastie AT, Bishop AC, Khan MS, Bleecker ER, Castro M, Denlinger LC, Erzurum SC, Fahy JV, Israel E, Levy BD, Mauger DT, Meyers DA, Moore WC, Ortega VE, Peters SP, Wenzel SE, Steele CH. Protein-Protein interactive networks identified in bronchoalveolar lavage of severe compared to nonsevere asthma. Clin Exp Allergy 2024; 54:265-277. [PMID: 38253462 DOI: 10.1111/cea.14447] [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: 07/18/2023] [Revised: 12/04/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
INTRODUCTION Previous bronchoalveolar lavage fluid (BALF) proteomic analysis has evaluated limited numbers of subjects for only a few proteins of interest, which may differ between asthma and normal controls. Our objective was to examine a more comprehensive inflammatory biomarker panel in quantitative proteomic analysis for a large asthma cohort to identify molecular phenotypes distinguishing severe from nonsevere asthma. METHODS Bronchoalveolar lavage fluid from 48 severe and 77 nonsevere adult asthma subjects were assessed for 75 inflammatory proteins, normalized to BALF total protein concentration. Validation of BALF differences was sought through equivalent protein analysis of autologous sputum. Subjects' data, stratified by asthma severity, were analysed by standard statistical tests, principal component analysis and 5 machine learning algorithms. RESULTS The severe group had lower lung function and greater health care utilization. Significantly increased BALF proteins for severe asthma compared to nonsevere asthma were fibroblast growth factor 2 (FGF2), TGFα, IL1Ra, IL2, IL4, CCL8, CCL13 and CXCL7 and significantly decreased were platelet-derived growth factor a-a dimer (PDGFaa), vascular endothelial growth factor (VEGF), interleukin 5 (IL5), CCL17, CCL22, CXCL9 and CXCL10. Four protein differences were replicated in sputum. FGF2, PDGFaa and CXCL7 were independently identified by 5 machine learning algorithms as the most important variables for discriminating severe and nonsevere asthma. Increased and decreased proteins identified for the severe cluster showed significant protein-protein interactions for chemokine and cytokine signalling, growth factor activity, and eosinophil and neutrophil chemotaxis differing between subjects with severe and nonsevere asthma. CONCLUSION These inflammatory protein results confirm altered airway remodelling and cytokine/chemokine activity recruiting leukocytes into the airways of severe compared to nonsevere asthma as important processes even in stable status.
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Affiliation(s)
- Annette T Hastie
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Andrew C Bishop
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Mohammad S Khan
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Eugene R Bleecker
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mario Castro
- Department of Pulmonary, Critical Care and Sleep Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Loren C Denlinger
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Serpil C Erzurum
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - John V Fahy
- Department of Pulmonary and Critical Care Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Elliot Israel
- Department of Medicine, Brigham and Womens Hospital, Boston, Massachusetts, USA
| | - Bruce D Levy
- Department of Medicine, Brigham and Womens Hospital, Boston, Massachusetts, USA
| | - David T Mauger
- Center for Biostatistics and Epidemiology, Penn State School of Medicine, Hershey, Pennsylvania, USA
| | - Deborah A Meyers
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Wendy C Moore
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Victor E Ortega
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stephen P Peters
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sally E Wenzel
- The University of Pittsburgh Asthma Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chad H Steele
- Department of Microbiology and Immunology, School of Medicine, Tulane University, New Orleans, Louisiana, USA
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Leung C, Tang M, Huang BK, Fain SB, Hoffman EA, Choi J, Dunican EM, Mauger DT, Denlinger LC, Jarjour NN, Israel E, Levy BD, Wenzel SE, Sumino K, Hastie AT, Schirm J, McCulloch CE, Peters MC, Woodruff PG, Sorkness RL, Castro M, Fahy JV. A Novel Air Trapping Segment Score Identifies Opposing Effects of Obesity and Eosinophilia on Air Trapping in Asthma. Am J Respir Crit Care Med 2023. [PMID: 38113166 DOI: 10.1164/rccm.202305-0802oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 12/18/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Density thresholds in computed tomography (CT) lung scans quantify air trapping (AT) at the whole lung level but are not informative for AT in specific bronchopulmonary segments. OBJECTIVES To apply a segment-based measure of AT in asthma to investigate the clinical determinants of AT in asthma. METHODS In each of 19 bronchopulmonary segments in CT lung scans from 199 asthma patients, AT was categorized as present if lung attenuation was < -856 Hounsfield units at expiration in ≥ 15% of lung area. The resulting AT segment score (0-19) was related to patient outcomes. RESULTS AT varied at the lung segment level and tended to persist at the patient and lung segment level over 3 years. Patients with widespread AT (>10 segments) had more severe asthma (p<0.05). The mean (± SD) AT segment score in patients with a BMI > 30 was lower than in patients with a BMI < 30 (3.5 ± 4.6 vs. 5.5 ± 6.3, p=0.008), and the frequency of AT in lower lobe segments in obese patients was less than in upper and middle lobe segments (35 vs. 46%, p=0.001). The AT segment score in patients with sputum eosinophil % > 2 was higher than in patients without sputum eosinophilia (7.0 ± 6.1 vs. 3.3 ± 4.9, p<0.0001). Lung segments with AT more frequently had airway mucus plugging than lung segments without AT (48 vs. 18%, p≤0.0001). CONCLUSIONS In patients with asthma, air trapping is more severe in those with airway eosinophilia and mucus plugging whereas those who are obese have less severe trapping because their lower lobe segments are spared.
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Affiliation(s)
- Clarus Leung
- University of California San Francisco, 8785, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, San Francisco, California, United States
| | - Monica Tang
- University of California San Francisco, 8785, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, San Francisco, California, United States
| | - Brendan K Huang
- University of California San Francisco, 8785, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, San Francisco, California, United States
| | - Sean B Fain
- University of Iowa, Department of Radiology, Iowa City, Iowa, United States
| | - Eric A Hoffman
- University of Iowa Carver College of Medicine, Radiology, Iowa City, Iowa, United States
| | - Jiwoong Choi
- University of Kansas School of Medicine, 12251, Division of Pulmonary, Critical Care and Sleep Medicine, Kansas City, Kansas, United States
| | - Eleanor M Dunican
- University College Dublin, 8797, School of Medicine, Dublin, Ireland
| | - David T Mauger
- The Pennsylvania State University, 8082, Division of Biostatistics and Bioinformatics, Penn State College of Medicine, University Park, Pennsylvania, United States
| | - Loren C Denlinger
- University of Wisconsin, Medicine-Allergy, Pulmonary and Critical Care Medicine, Madison, Wisconsin, United States
| | - Nizar N Jarjour
- University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Elliot Israel
- Brigham & Women's Hospital, Pulmonary and Critical Care Division, Boston, Massachusetts, United States
| | - Bruce D Levy
- Brigham and Women's Hospital Biomedical Research Institute, 278479, Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Sally E Wenzel
- University of Pittsburgh, Division of Pulmonary, Allergy and Critical Care Medicine, Pittsburgh, Pennsylvania, United States
- Dept of EOH, Pittsburgh, Pennsylvania, United States
| | - Kaharu Sumino
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine, St. Louis, Missouri, United States
| | - Annette T Hastie
- Wake Forest University School of Medicine, 12279, Department of Internal Medicine, Section for Pulmonary, Critical Care, Allergy and Immunology, Winston-Salem, North Carolina, United States
| | - Joshua Schirm
- VIDA Diagnostics Inc., Coralville, Iowa, United States
| | - Charles E McCulloch
- University of California San Francisco, 8785, Department of Epidemiology and Biostatistics, San Francisco, California, United States
| | - Michael C Peters
- University of California San Francisco, 8785, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, San Francisco, California, United States
| | - Prescott G Woodruff
- University of California San Francisco, 8785, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, San Francisco, California, United States
- University of California San Francisco, 8785, Cardiovascular Research Institute, San Francisco, California, United States
| | - Ronald L Sorkness
- University of Wisconsin-Madison, 5228, School of Pharmacy, Madison, Wisconsin, United States
| | - Mario Castro
- University of Kansas School of Medicine, 12251, Division of Pulmonary, Critical Care and Sleep Medicine, Kansas City, Kansas, United States
| | - John V Fahy
- University of California San Francisco, 8785, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, San Francisco, California, United States
- University of California San Francisco, 8785, Cardiovascular Research Institute, San Francisco, California, United States;
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5
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Xu W, Hong YS, Hu B, Comhair SAA, Janocha AJ, Zein JG, Chen R, Meyers DA, Mauger DT, Ortega VE, Bleecker ER, Castro M, Denlinger LC, Fahy JV, Israel E, Levy BD, Jarjour NN, Moore WC, Wenzel SE, Gaston B, Liu C, Arking DE, Erzurum SC. Mitochondrial DNA Copy Number Variation in Asthma Risk, Severity, and Exacerbations. medRxiv 2023:2023.12.05.23299392. [PMID: 38106101 PMCID: PMC10723502 DOI: 10.1101/2023.12.05.23299392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Rationale Although airway oxidative stress and inflammation are central to asthma pathogenesis, there is limited knowledge of the relationship of asthma risk, severity, or exacerbations to mitochondrial dysfunction, which is pivotal to oxidant generation and inflammation. Objectives We investigated whether mitochondrial DNA copy number (mtDNA-CN) as a measure of mitochondrial function is associated with asthma diagnosis, severity, oxidative stress, and exacerbations. Methods We measured mtDNA-CN in blood in two cohorts. In the UK Biobank (UKB), we compared mtDNA-CN in mild and moderate-severe asthmatics to non-asthmatics. In the Severe Asthma Research Program (SARP), we evaluated mtDNA-CN in relation to asthma severity, biomarkers of oxidative stress and inflammation, and exacerbations. Measures and Main Results In UK Biobank, asthmatics (n = 29,768) have lower mtDNA-CN compared to non-asthmatics (n = 239,158) (beta, -0.026 [95% CI, -0.038 to -0.014], P = 2.46×10-5). While lower mtDNA-CN is associated with asthma, mtDNA-CN did not differ by asthma severity in either UKB or SARP. Biomarkers of inflammation show that asthmatics have higher white blood cells (WBC), neutrophils, eosinophils, fraction exhaled nitric oxide (FENO), and lower superoxide dismutase (SOD) than non-asthmatics, confirming greater oxidative stress in asthma. In one year follow-up in SARP, higher mtDNA-CN is associated with reduced risk of three or more exacerbations in the subsequent year (OR 0.352 [95% CI, 0.164 to 0.753], P = 0.007). Conclusions Asthma is characterized by mitochondrial dysfunction. Higher mtDNA-CN identifies an exacerbation-resistant asthma phenotype, suggesting mitochondrial function is important in exacerbation risk.
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Affiliation(s)
- Weiling Xu
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
| | - Yun Soo Hong
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bo Hu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Suzy A. A. Comhair
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
| | - Allison J. Janocha
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
| | - Joe G. Zein
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ruoying Chen
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - David T. Mauger
- Department of Public Health Sciences, Pennsylvania State University School of Medicine, Hershey, Pennsylvania
| | - Victor E. Ortega
- Department of Internal Medicine, Division of Respiratory Medicine, Mayo Clinic, Scottsdale, Arizona
| | | | - Mario Castro
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Loren C. Denlinger
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin, Madison, Wisconsin
| | - John V. Fahy
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California
| | - Elliot Israel
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Bruce D. Levy
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nizar N. Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Wendy C. Moore
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benjamin Gaston
- Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chunyu Liu
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Dan E. Arking
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Serpil C. Erzurum
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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6
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Li H, Castro M, Denlinger LC, Erzurum SC, Fahy JV, Gaston B, Israel E, Jarjour NN, Levy BD, Mauger DT, Moore WC, Wenzel SE, Zein J, Bleecker ER, Meyers DA, Chen Y, Li X. Investigations of a combination of atopic status and age of asthma onset identify asthma subphenotypes. J Asthma 2023; 60:1843-1852. [PMID: 36940238 PMCID: PMC10528448 DOI: 10.1080/02770903.2023.2193634] [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: 01/25/2023] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Subphenotypes of asthma may be determined by age onset and atopic status. We sought to characterize early or late onset atopic asthma with fungal or non-fungal sensitization (AAFS or AANFS) and non-atopic asthma (NAA) in children and adults in the Severe Asthma Research Program (SARP). SARP is an ongoing project involving well-phenotyped patients with mild to severe asthma. METHODS Phenotypic comparisons were performed using Kruskal-Wallis or chi-square test. Genetic association analyses were performed using logistic or linear regression. RESULTS Airway hyper-responsiveness, total serum IgE levels, and T2 biomarkers showed an increasing trend from NAA to AANFS and then to AAFS. Children and adults with early onset asthma had greater % of AAFS than adults with late onset asthma (46% and 40% vs. 32%; P < 0.00001). In children, AAFS and AANFS had lower % predicted FEV1 (86% and 91% vs. 97%) and greater % of patients with severe asthma than NAA (61% and 59% vs. 43%). In adults with early or late onset asthma, NAA had greater % of patients with severe asthma than AANFS and AAFS (61% vs. 40% and 37% or 56% vs. 44% and 49%). The G allele of rs2872507 in GSDMB had higher frequency in AAFS than AANFS and NAA (0.63 vs. 0.55 and 0.55), and associated with earlier age onset and asthma severity. CONCLUSIONS Early or late onset AAFS, AANFS, and NAA have shared and distinct phenotypic characteristics in children and adults. AAFS is a complex disorder involving genetic susceptibility and environmental factors.
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Affiliation(s)
- Huashi Li
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Loren C. Denlinger
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Serpil C. Erzurum
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John V. Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Benjamin Gaston
- Wells Center for Pediatric Research and Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nizar N. Jarjour
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David T Mauger
- Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Wendy C. Moore
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joe Zein
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Deborah A. Meyers
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Yin Chen
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Xingnan Li
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
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7
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Li X, Li H, Christenson SA, Castro M, Denlinger LC, Erzurum SC, Fahy JV, Gaston BM, Israel E, Jarjour NN, Levy BD, Mauger DT, Moore WC, Zein J, Kaminski N, Wenzel SE, Woodruff PG, Bleecker ER, Meyers DA. Genetic analyses of chr11p15.5 region identify MUC5AC- MUC5B associated with asthma-related phenotypes. J Asthma 2023; 60:1824-1835. [PMID: 36946148 PMCID: PMC10524756 DOI: 10.1080/02770903.2023.2193631] [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: 01/30/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Genome-wide association studies (GWASs) have identified single nucleotide polymorphisms (SNPs) in chr11p15.5 region associated with asthma and idiopathic interstitial pneumonias (IIPs). We sought to identify functional genes for asthma by combining SNPs and mRNA expression in bronchial epithelial cells (BEC) in the Severe Asthma Research Program (SARP). METHODS Correlation analyses of mRNA expression of six candidate genes (AP2A2, MUC6, MUC2, MUC5AC, MUC5B, and TOLLIP) and asthma phenotypes were performed in the longitudinal cohort (n = 156) with RNAseq in BEC, and replicated in the cross-sectional cohort (n = 155). eQTL (n = 114) and genetic association analysis of asthma severity (426 severe vs. 531 non-severe asthma) were performed, and compared with previously published GWASs of IIPs and asthma. RESULTS Higher expression of AP2A2 and MUC5AC and lower expression of MUC5B in BEC were correlated with asthma, asthma exacerbations, and T2 biomarkers (P < 0.01). SNPs associated with asthma and IIPs in previous GWASs were eQTL SNPs for MUC5AC, MUC5B, or TOLLIP, however, they were not in strong linkage disequilibrium. The risk alleles for asthma or protective alleles for IIPs were associated with higher expression of MUC5AC and lower expression of MUC5B. rs11603634, rs12788104, and rs28415845 associated with moderate-to-severe asthma or adult onset asthma in previous GWASs were not associated with asthma severity (P > 0.8). CONCLUSIONS SNPs associated with asthma in chr11p15.5 region are not associated with asthma severity neither with IIPs. Higher expression of MUC5AC and lower expression of MUC5B are risk for asthma but protective for IIPs.
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Affiliation(s)
- Xingnan Li
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Huashi Li
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Stephanie A. Christenson
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Loren C. Denlinger
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Serpil C. Erzurum
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John V. Fahy
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Benjamin M. Gaston
- Wells Center for Pediatric Research and Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nizar N. Jarjour
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David T Mauger
- Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Wendy C. Moore
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Joe Zein
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Naftali Kaminski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Prescott G. Woodruff
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | - Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Deborah A. Meyers
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, USA
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8
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Bochkov YA, Devries M, Tetreault K, Gangnon R, Lee S, Bacharier LB, Busse WW, Camargo CA, Choi T, Cohen R, De R, DeMuri GP, Fitzpatrick AM, Gergen PJ, Grindle K, Gruchalla R, Hartert T, Hasegawa K, Khurana Hershey GK, Holt P, Homil K, Jartti T, Kattan M, Kercsmar C, Kim H, Laing IA, Le Souëf PN, Liu AH, Mauger DT, Pappas T, Patel SJ, Phipatanakul W, Pongracic J, Seroogy C, Sly PD, Tisler C, Wald ER, Wood R, Lemanske RF, Jackson DJ, Gern JE. Rhinoviruses A and C elicit long-lasting antibody responses with limited cross-neutralization. J Med Virol 2023; 95:e29058. [PMID: 37638498 PMCID: PMC10484091 DOI: 10.1002/jmv.29058] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
Rhinoviruses (RVs) can cause severe wheezing illnesses in young children and patients with asthma. Vaccine development has been hampered by the multitude of RV types with little information about cross-neutralization. We previously showed that neutralizing antibody (nAb) responses to RV-C are detected twofold to threefold more often than those to RV-A throughout childhood. Based on those findings, we hypothesized that RV-C infections are more likely to induce either cross-neutralizing or longer-lasting antibody responses compared with RV-A infections. We pooled RV diagnostic data from multiple studies of children with respiratory illnesses and compared the expected versus observed frequencies of sequential infections with RV-A or RV-C types using log-linear regression models. We tested longitudinally collected plasma samples from children to compare the duration of RV-A versus RV-C nAb responses. Our models identified limited reciprocal cross-neutralizing relationships for RV-A (A12-A75, A12-A78, A20-A78, and A75-A78) and only one for RV-C (C2-C40). Serologic analysis using reference mouse sera and banked human plasma samples confirmed that C40 infections induced nAb responses with modest heterotypic activity against RV-C2. Mixed-effects regression modeling of longitudinal human plasma samples collected from ages 2 to 18 years demonstrated that RV-A and RV-C illnesses induced nAb responses of similar duration. These results indicate that both RV-A and RV-C nAb responses have only modest cross-reactivity that is limited to genetically similar types. Contrary to our initial hypothesis, RV-C species may include even fewer cross-neutralizing types than RV-A, whereas the duration of nAb responses during childhood is similar between the two species. The modest heterotypic responses suggest that RV vaccines must have a broad representation of prevalent types.
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Affiliation(s)
| | - Mark Devries
- University of Wisconsin-Madison, Madison, WI, United States
| | | | - Ronald Gangnon
- University of Wisconsin-Madison, Madison, WI, United States
| | - Sujin Lee
- Department of Pediatrics, Center for ViroScience and Cure, Emory University School of Medicine, Atlanta, GA, United States
| | | | | | - Carlos A. Camargo
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Timothy Choi
- University of Wisconsin-Madison, Madison, WI, United States
| | - Robyn Cohen
- Boston University, Boston, MA, United States
| | - Ramyani De
- Department of Pediatrics, Center for ViroScience and Cure, Emory University School of Medicine, Atlanta, GA, United States
| | | | - Anne M. Fitzpatrick
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Peter J. Gergen
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Rockville, MD, United States
| | | | | | - Tina Hartert
- Vanderbilt University, Nashville, TN, United States
| | - Kohei Hasegawa
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Patrick Holt
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Kiara Homil
- University of Turku and Turku University Hospital, Turku, Finland
| | - Tuomas Jartti
- University of Turku and Turku University Hospital, Turku, Finland
- PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Meyer Kattan
- Columbia University, New York, NY, United States
| | | | - Haejin Kim
- Henry Ford Health Systems, Detroit, MI, United States
| | | | | | - Andrew H. Liu
- Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | | | - Tressa Pappas
- University of Wisconsin-Madison, Madison, WI, United States
| | | | | | | | | | - Peter D. Sly
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | | | - Ellen R. Wald
- University of Wisconsin-Madison, Madison, WI, United States
| | - Robert Wood
- Johns Hopkins University, Baltimore, MD, United States
| | | | | | - James E. Gern
- University of Wisconsin-Madison, Madison, WI, United States
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9
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Fitzpatrick AM, Mauger DT. Reply to "Clinically accessible biomarkers to assess the modifiable risk of asthma/wheezing attacks in toddlers". J Allergy Clin Immunol Pract 2023; 11:1985-1986. [PMID: 37295868 DOI: 10.1016/j.jaip.2023.03.027] [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] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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10
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. J Allergy Clin Immunol Pract 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [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] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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11
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Li X, Guerra S, Ledford JG, Kraft M, Li H, Hastie AT, Castro M, Denlinger LC, Erzurum SC, Fahy JV, Gaston B, Israel E, Jarjour NN, Levy BD, Mauger DT, Moore WC, Zein J, Kaminski N, Wenzel SE, Woodruff PG, Meyers DA, Bleecker ER. Low CC16 mRNA Expression Levels in Bronchial Epithelial Cells Are Associated with Asthma Severity. Am J Respir Crit Care Med 2023; 207:438-451. [PMID: 36066606 PMCID: PMC9940145 DOI: 10.1164/rccm.202206-1230oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [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: 06/29/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: CC16 is a protein mainly produced by nonciliated bronchial epithelial cells (BECs) that participates in host defense. Reduced CC16 protein concentrations in BAL and serum are associated with asthma susceptibility. Objectives: Few studies have investigated the relationship between CC16 and asthma progression, and none has focused on BECs. In this study, we sought to determine if CC16 mRNA expression levels in BECs are associated with asthma severity. Methods: Association analyses between CC16 mRNA expression levels in BECs (242 asthmatics and 69 control subjects) and asthma-related phenotypes in Severe Asthma Research Program were performed using a generalized linear model. Measurements and Main Results: Low CC16 mRNA expression levels in BECs were significantly associated with asthma susceptibility and asthma severity, high systemic corticosteroids use, high retrospective and prospective asthma exacerbations, and low pulmonary function. Low CC16 mRNA expression levels were significantly associated with high T2 inflammation biomarkers (fractional exhaled nitric oxide and sputum eosinophils). CC16 mRNA expression levels were negatively correlated with expression levels of Th2 genes (IL1RL1, POSTN, SERPINB2, CLCA1, NOS2, and MUC5AC) and positively correlated with expression levels of Th1 and inflammation genes (IL12A and MUC5B). A combination of two nontraditional T2 biomarkers (CC16 and IL-6) revealed four asthma endotypes with different characteristics of T2 inflammation, obesity, and asthma severity. Conclusions: Our findings indicate that low CC16 mRNA expression levels in BECs are associated with asthma susceptibility, severity, and exacerbations, partially through immunomodulation of T2 inflammation. CC16 is a potential nontraditional T2 biomarker for asthma development and progression.
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Affiliation(s)
- Xingnan Li
- Division of Genetics, Genomics, and Precision Medicine, and
| | - Stefano Guerra
- Asthma and Airway Disease Research Center, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Julie G. Ledford
- Asthma and Airway Disease Research Center, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Monica Kraft
- Asthma and Airway Disease Research Center, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Huashi Li
- Division of Genetics, Genomics, and Precision Medicine, and
| | - Annette T. Hastie
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Loren C. Denlinger
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Serpil C. Erzurum
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - John V. Fahy
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Benjamin Gaston
- Wells Center for Pediatric Research and Riley Hospital for Children, Indiana University, Indianapolis, Indiana
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nizar N. Jarjour
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David T. Mauger
- Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania
| | - Wendy C. Moore
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joe Zein
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Naftali Kaminski
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; and
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Prescott G. Woodruff
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of California at San Francisco, San Francisco, California
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12
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Tattersall MC, Lee KE, Tsuchiya N, Osman F, Korcarz CE, Hansen KM, Peters MC, Fahy JV, Longhurst CA, Dunican E, Wentzel SE, Leader JK, Israel E, Levy BD, Castro M, Erzurum SC, Lempel J, Moore WC, Bleecker ER, Phillips BR, Mauger DT, Hoffman EA, Fain SB, Reeder SB, Sorkness RL, Jarjour NN, Denlinger LC, Schiebler ML. Skeletal Muscle Adiposity and Lung Function Trajectory in the Severe Asthma Research Program. Am J Respir Crit Care Med 2023; 207:475-484. [PMID: 36194556 PMCID: PMC9940151 DOI: 10.1164/rccm.202203-0597oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 03/28/2022] [Accepted: 10/04/2022] [Indexed: 01/05/2023] Open
Abstract
Rationale: Extrapulmonary manifestations of asthma, including fatty infiltration in tissues, may reflect systemic inflammation and influence lung function and disease severity. Objectives: To determine if skeletal muscle adiposity predicts lung function trajectory in asthma. Methods: Adult SARP III (Severe Asthma Research Program III) participants with baseline computed tomography imaging and longitudinal postbronchodilator FEV1% predicted (median follow-up 5 years [1,132 person-years]) were evaluated. The mean of left and right paraspinous muscle density (PSMD) at the 12th thoracic vertebral body was calculated (Hounsfield units [HU]). Lower PSMD reflects higher muscle adiposity. We derived PSMD reference ranges from healthy control subjects without asthma. A linear multivariable mixed-effects model was constructed to evaluate associations of baseline PSMD and lung function trajectory stratified by sex. Measurements and Main Results: Participants included 219 with asthma (67% women; mean [SD] body mass index, 32.3 [8.8] kg/m2) and 37 control subjects (51% women; mean [SD] body mass index, 26.3 [4.7] kg/m2). Participants with asthma had lower adjusted PSMD than control subjects (42.2 vs. 55.8 HU; P < 0.001). In adjusted models, PSMD predicted lung function trajectory in women with asthma (β = -0.47 Δ slope per 10-HU decrease; P = 0.03) but not men (β = 0.11 Δ slope per 10-HU decrease; P = 0.77). The highest PSMD tertile predicted a 2.9% improvement whereas the lowest tertile predicted a 1.8% decline in FEV1% predicted among women with asthma over 5 years. Conclusions: Participants with asthma have lower PSMD, reflecting greater muscle fat infiltration. Baseline PSMD predicted lung function decline among women with asthma but not men. These data support an important role of metabolic dysfunction in lung function decline.
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Affiliation(s)
| | | | - Nanae Tsuchiya
- Division of Cardiothoracic Imaging, Department of Radiology, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin
- Department of Radiology, School of Medicine, University of the Ryukyus, Nishihara, Japan
| | | | | | | | - Michael C. Peters
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - John V. Fahy
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Eleanor Dunican
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
- St. Vincent’s Hospital Elm Park, Dublin, Ireland
| | - Sally E. Wentzel
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, and
| | - Joseph K. Leader
- Department of Radiology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elliot Israel
- Division of Pulmonary and Critical Care and
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | | | - Jason Lempel
- Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wendy C. Moore
- Section of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Eugene R. Bleecker
- Division of Genetics and
- Division of Pharmacokinetics, Department of Medicine, College of Medicine, University of Arizona, Tucson, Arizona
| | - Brenda R. Phillips
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania; and
| | - David T. Mauger
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania; and
| | - Eric A. Hoffman
- Department of Biomedical Engineering
- Department of Radiology, and
- Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | | | | | - Nizar N. Jarjour
- Division of Pulmonary Medicine and Critical Care
- Department of Medicine
| | | | - Mark L. Schiebler
- Division of Cardiothoracic Imaging, Department of Radiology, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin
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13
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Ginebaugh SP, Hagner M, Ray A, Erzurum SC, Comhair SAA, Denlinger LC, Jarjour NN, Castro M, Woodruff PG, Christenson SA, Bleecker ER, Meyers DA, Hastie AT, Moore WC, Mauger DT, Israel E, Levy BD, Wenzel SE, Camiolo MJ. Bronchial epithelial cell transcriptional responses to inhaled corticosteroids dictate severe asthmatic outcomes. J Allergy Clin Immunol 2023:S0091-6749(23)00208-7. [PMID: 36796454 DOI: 10.1016/j.jaci.2023.01.028] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Inhaled corticosteroids (CSs) are the backbone of asthma treatment, improving quality of life, exacerbation rates, and mortality. Although effective for most, a subset of patients with asthma experience CS-resistant disease despite receiving high-dose medication. OBJECTIVE We sought to investigate the transcriptomic response of bronchial epithelial cells (BECs) to inhaled CSs. METHODS Independent component analysis was performed on datasets, detailing the transcriptional response of BECs to CS treatment. The expression of these CS-response components was examined in 2 patient cohorts and investigated in relation to clinical parameters. Supervised learning was used to predict BEC CS responses using peripheral blood gene expression. RESULTS We identified a signature of CS response that was closely correlated with CS use in patients with asthma. Participants could be separated on the basis of CS-response genes into groups with high and low signature expression. Patients with low expression of CS-response genes, particularly those with a severe asthma diagnosis, showed worse lung function and quality of life. These individuals demonstrated enrichment for T-lymphocyte infiltration in endobronchial brushings. Supervised machine learning identified a 7-gene signature from peripheral blood that reliably identified patients with poor CS-response expression in BECs. CONCLUSIONS Loss of CS transcriptional responses within bronchial epithelium was related to impaired lung function and poor quality of life, particularly in patients with severe asthma. These individuals were identified using minimally invasive blood sampling, suggesting these findings may enable earlier triage to alternative treatments.
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Affiliation(s)
- Scott P Ginebaugh
- Integrative Systems Biology, University of Pittsburgh, Pittsburgh, Pa
| | | | - Anuradha Ray
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | | | | | - Loren C Denlinger
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Mario Castro
- University of Kansas School of Medicine, Kansas City, Mo
| | - Prescott G Woodruff
- University of California, San Francisco School of Medicine, San Francisco, Calif
| | | | - Eugene R Bleecker
- Division for Genetics, Genomics and Personalized Medicine, University of Arizona College of Medicine, Tucson, Ariz
| | - Deborah A Meyers
- Division for Genetics, Genomics and Personalized Medicine, University of Arizona College of Medicine, Tucson, Ariz
| | | | - Wendy C Moore
- Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Elliot Israel
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Bruce D Levy
- Department of Medicine, Divisions of Pulmonary & Critical Care Medicine & Allergy & Immunology, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sally E Wenzel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Environmental Medicine and Occupational Health, Graduate School of Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pa
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14
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Gaffin JM, Petty CR, Sorkness RL, Denlinger LC, Phillips BR, Ly NP, Gaston B, Ross K, Fitzpatrick A, Bacharier LB, DeBoer MD, Teague WG, Wenzel SE, Ramratnam S, Israel E, Mauger DT, Phipatanakul W. Determinants of lung function across childhood in the Severe Asthma Research Program (SARP) 3. J Allergy Clin Immunol 2023; 151:138-146.e9. [PMID: 36041656 PMCID: PMC9825637 DOI: 10.1016/j.jaci.2022.08.014] [Citation(s) in RCA: 8] [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: 03/15/2022] [Revised: 07/24/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Children with asthma are at risk for low lung function extending into adulthood, but understanding of clinical predictors is incomplete. OBJECTIVE We sought to determine phenotypic factors associated with FEV1 throughout childhood in the Severe Asthma Research Program 3 pediatric cohort. METHODS Lung function was measured at baseline and annually. Multivariate linear mixed-effects models were constructed to assess the effect of baseline and time-varying predictors of prebronchodilator FEV1 at each assessment for up to 6 years. All models were adjusted for age, predicted FEV1 by Global Lung Function Initiative reference equations, race, sex, and height. Secondary outcomes included postbronchodilator FEV1 and prebronchodilator FEV1/forced vital capacity. RESULTS A total of 862 spirometry assessments were performed for 188 participants. Factors associated with FEV1 include baseline Feno (B, -49 mL/log2 PPB; 95% CI, -92 to -6), response to a characterizing dose of triamcinolone acetonide (B, -8.4 mL/1% change FEV1 posttriamcinolone; 95% CI, -12.3 to -4.5), and maximal bronchodilator reversibility (B, -27 mL/1% change postbronchodilator FEV1; 95% CI, -37 to -16). Annually assessed time-varying factors of age, obesity, and exacerbation frequency predicted FEV1 over time. Notably, there was a significant age and sex interaction. Among girls, there was no exacerbation effect. For boys, however, moderate (1-2) exacerbation frequency in the previous 12 months was associated with -20 mL (95% CI, -39 to -2) FEV1 at each successive year. High exacerbation frequency (≥3) 12 to 24 months before assessment was associated with -34 mL (95% CI, -61 to -7) FEV1 at each successive year. CONCLUSIONS In children with severe and nonsevere asthma, several clinically relevant factors predict FEV1 over time. Boys with recurrent exacerbations are at high risk of lower FEV1 through childhood.
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Affiliation(s)
| | - Carter R Petty
- Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | | | | | | | - Ngoc P Ly
- University of California San Francisco, San Francisco, Calif
| | | | - Kristie Ross
- Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - David T Mauger
- Pennsylvania State University College of Medicine, Hershey, Pa
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15
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Peters MC, Schiebler ML, Mauger DT, Fahy JV. Reply to Nie et al. and Bhammar et al. Am J Respir Crit Care Med 2023; 207:111-112. [PMID: 36029296 PMCID: PMC9952864 DOI: 10.1164/rccm.202208-1585le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | | | | | - John V. Fahy
- University of California, San FranciscoSan Francisco, California
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16
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Tang M, Mauger DT, Fahy JV, Dunican EM. Reply to Ikeda and Tomita. Am J Respir Crit Care Med 2022; 206:1299-1300. [PMID: 35876128 PMCID: PMC9746837 DOI: 10.1164/rccm.202207-1337le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Monica Tang
- University of California San FranciscoSan Francisco, California
| | | | - John V. Fahy
- University of California San FranciscoSan Francisco, California
| | - Eleanor M. Dunican
- St. Vincent’s University HospitalDublin, Ireland
- University College DublinDublin, Ireland
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17
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Peters MC, Schiebler ML, Cardet JC, Johansson MW, Sorkness R, DeBoer MD, Bleecker ER, Meyers DA, Castro M, Sumino K, Erzurum SC, Tattersall MC, Zein JG, Hastie AT, Moore W, Levy BD, Israel E, Phillips BR, Mauger DT, Wenzel SE, Fajt ML, Koliwad SK, Denlinger LC, Woodruff PG, Jarjour NN, Fahy JV. The Impact of Insulin Resistance on Loss of Lung Function and Response to Treatment in Asthma. Am J Respir Crit Care Med 2022; 206:1096-1106. [PMID: 35687105 PMCID: PMC9704842 DOI: 10.1164/rccm.202112-2745oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 12/12/2021] [Accepted: 06/09/2022] [Indexed: 02/03/2023] Open
Abstract
Rationale: The role of obesity-associated insulin resistance (IR) in airflow limitation in asthma is uncertain. Objectives: Using data in the Severe Asthma Research Program 3 (SARP-3), we evaluated relationships between homeostatic measure of IR (HOMA-IR), lung function (cross-sectional and longitudinal analyses), and treatment responses to bronchodilators and corticosteroids. Methods: HOMA-IR values were categorized as without (<3.0), moderate (3.0-5.0), or severe (>5.0). Lung function included FEV1 and FVC measured before and after treatment with inhaled albuterol and intramuscular triamcinolone acetonide and yearly for 5 years. Measurements and Main Results: Among 307 participants in SARP-3, 170 (55%) were obese and 140 (46%) had IR. Compared with patients without IR, those with IR had significantly lower values for FEV1 and FVC, and these lower values were not attributable to obesity effects. Compared with patients without IR, those with IR had lower FEV1 responses to β-adrenergic agonists and systemic corticosteroids. The annualized decline in FEV1 was significantly greater in patients with moderate IR (-41 ml/year) and severe IR (-32 ml/year,) than in patients without IR (-13 ml/year, P < 0.001 for both comparisons). Conclusions: IR is common in asthma and is associated with lower lung function, accelerated loss of lung function, and suboptimal lung function responses to bronchodilator and corticosteroid treatments. Clinical trials in patients with asthma and IR are needed to determine if improving IR might also improve lung function.
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Affiliation(s)
- Michael C. Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- Division of Endocrinology and Metabolism, Department of Medicine, and Diabetes Center, University of California San Francisco, San Francisco, California
| | - Mark L. Schiebler
- Division of Cardiothoracic Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Mats W. Johansson
- Morgridge Institute for Research, Madison, Wisconsin
- Department of Biomolecular Chemistry, and
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ronald Sorkness
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mark D. DeBoer
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine; Department of Medicine, University of Arizona, Tucson, Arizona
| | - Deborah A. Meyers
- Division of Genetics, Genomics and Precision Medicine; Department of Medicine, University of Arizona, Tucson, Arizona
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Kansas University Medical Center, Kansas City, Kansas
| | - Kaharu Sumino
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | | | - Matthew C. Tattersall
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Joe G. Zein
- Department of Pulmonary and Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Annette T. Hastie
- Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Wendy Moore
- Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elliot Israel
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brenda R. Phillips
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - David T. Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; and
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Merritt L. Fajt
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Suneil K. Koliwad
- Division of Endocrinology and Metabolism, Department of Medicine, and Diabetes Center, University of California San Francisco, San Francisco, California
| | - Loren C. Denlinger
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Nizar N. Jarjour
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John V. Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
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18
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Wang Z, Xu W, Comhair SAA, Fu X, Shao Z, Bearden R, Zein JG, Bleecker ER, Castro M, Denlinger LC, Fahy JV, Israel E, Levy BD, Jarjour NN, Moore WC, Wenzel SE, Mauger DT, Gaston B, Hazen SL, Erzurum SC. Urinary total conjugated 3-bromotyrosine, asthma severity, and exacerbation risk. Am J Physiol Lung Cell Mol Physiol 2022; 323:L548-L557. [PMID: 36126269 PMCID: PMC9602918 DOI: 10.1152/ajplung.00141.2022] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/19/2022] [Accepted: 09/08/2022] [Indexed: 11/22/2022] Open
Abstract
Asthma is an inflammatory disease of the airways characterized by eosinophil recruitment, eosinophil peroxidase release, and protein oxidation through bromination, which following tissue remodeling results in excretion of 3-bromotyrosine. Predicting exacerbations and reducing their frequency is critical for the treatment of severe asthma. In this study, we aimed to investigate whether urinary total conjugated bromotyrosine can discriminate asthma severity and predict asthma exacerbations. We collected urine from participants with severe (n = 253) and nonsevere (n = 178) asthma, and the number of adjudicated exacerbations in 1-yr longitudinal follow-up was determined among subjects enrolled in the Severe Asthma Research Program, a large-scale National Institutes of Health (NIH)-funded consortium. Urine glucuronidated bromotyrosine and total conjugated forms were quantified by hydrolysis with either glucuronidase or methanesulfonic acid, respectively, followed by liquid chromatography-tandem mass spectrometry analyses of free 3-bromotyrosine. Blood and sputum eosinophils were also counted. The majority of 3-bromotyrosine in urine was found to exist in conjugated forms, with glucuronidated bromotyrosine representing approximately a third, and free bromotyrosine less than 1% of total conjugated bromotyrosine. Total conjugated bromotyrosine was poorly correlated with blood (r2 = 0.038) or sputum eosinophils (r2 = 0.0069). Compared with participants with nonsevere asthma, participants with severe asthma had significantly higher urinary total conjugated bromotyrosine levels. Urinary total conjugated bromotyrosine was independently associated with asthma severity, correlated with the number of asthma exacerbations, and served as a predictor of asthma exacerbation risk over 1-yr of follow-up.
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Affiliation(s)
- Zeneng Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Weiling Xu
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Suzy A A Comhair
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xiaoming Fu
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zhili Shao
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rebecca Bearden
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joe G Zein
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene R Bleecker
- Department of Medicine, University of Arizona Health Sciences, Tucson, Arizona
| | - Mario Castro
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Loren C Denlinger
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin, Madison, Wisconsin
| | - John V Fahy
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California
| | - Elliot Israel
- Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Bruce D Levy
- Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Wendy C Moore
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sally E Wenzel
- Department of Environmental Medicine and Occupational Health, Graduate School of Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David T Mauger
- Center for Biostatistics and Epidemiology, Pennsylvania State University School of Medicine, Hershey, Pennsylvania
| | - Benjamin Gaston
- Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stanley L Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serpil C Erzurum
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Tang M, Elicker BM, Henry T, Gierada DS, Schiebler ML, Huang BK, Peters MC, Castro M, Hoffman EA, Fain SB, Ash SY, Choi J, Hall C, Phillips BR, Mauger DT, Denlinger LC, Jarjour NN, Israel E, Phipatanakul W, Levy BD, Wenzel SE, Bleecker ER, Woodruff PG, Fahy JV, Dunican EM. Mucus Plugs Persist in Asthma, and Changes in Mucus Plugs Associate with Changes in Airflow over Time. Am J Respir Crit Care Med 2022; 205:1036-1045. [PMID: 35104436 PMCID: PMC9851493 DOI: 10.1164/rccm.202110-2265oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/31/2022] [Indexed: 02/07/2023] Open
Abstract
Rationale: Cross-sectional analysis of mucus plugs in computed tomography (CT) lung scans in the Severe Asthma Research Program (SARP)-3 showed a high mucus plug phenotype. Objectives: To determine if mucus plugs are a persistent asthma phenotype and if changes in mucus plugs over time associate with changes in lung function. Methods: In a longitudinal analysis of baseline and Year 3 CT lung scans in SARP-3 participants, radiologists generated mucus plug scores to assess mucus plug persistence over time. Changes in mucus plug score were analyzed in relation to changes in lung function and CT air trapping measures. Measurements and Main Results: In 164 participants, the mean (range) mucus plug score was similar at baseline and Year 3 (3.4 [0-20] vs. 3.8 [0-20]). Participants and bronchopulmonary segments with a baseline plug were more likely to have plugs at Year 3 than those without baseline plugs (risk ratio, 2.8; 95% confidence interval [CI], 2.0-4.1; P < 0.001; and risk ratio, 5.0; 95% CI, 4.5-5.6; P < 0.001, respectively). The change in mucus plug score from baseline to Year 3 was significantly negatively correlated with change in FEV1% predicted (rp = -0.35; P < 0.001) and with changes in CT air trapping measures (all P values < 0.05). Conclusions: Mucus plugs identify a persistent asthma phenotype, and susceptibility to mucus plugs occurs at the subject and the bronchopulmonary segment level. The association between change in mucus plug score and change in airflow over time supports a causal role for mucus plugs in mechanisms of airflow obstruction in asthma.
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Affiliation(s)
- Monica Tang
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | | | - Travis Henry
- Duke Radiology, Department of Radiology, Duke University, Durham, North Carolina
| | - David S. Gierada
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Mark L. Schiebler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brendan K. Huang
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Michael C. Peters
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Eric A. Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Sean B. Fain
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Samuel Y. Ash
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jiwoong Choi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Chase Hall
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Brenda R. Phillips
- Center for Biostatistics and Epidemiology, Pennsylvania State University School of Medicine, Harrisburg, Pennsylvania
| | - David T. Mauger
- Division of Biostatistics and Bioinformatics, Penn State College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Loren C. Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nizar N. Jarjour
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Wanda Phipatanakul
- Asthma, Allergy, Dermatology, Rheumatology, and Immunology, Boston Children’s Hospital, Boston, Massachusetts
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eugene R. Bleecker
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Prescott G. Woodruff
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - John V. Fahy
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Eleanor M. Dunican
- Education and Research Centre, St. Vincent’s University Hospital, Dublin, Ireland; and
- UCD School of Medicine, University College Dublin, Dublin, Ireland
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20
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Trivedi AP, Hall C, Goss CW, Lew D, Krings JG, McGregor MC, Samant M, Sieren JP, Li H, Schechtman KB, Schirm J, McEleney S, Peterson S, Moore WC, Bleecker ER, Meyers DA, Israel E, Washko GR, Levy BD, Leader JK, Wenzel SE, Fahy JV, Schiebler ML, Fain SB, Jarjour NN, Mauger DT, Reinhardt JM, Newell JD, Hoffman EA, Castro M, Sheshadri A, Levy B, Cernadas M, Washko GR, Haley K, Cardet JC, Duvall M, Forth V, Le M, Fandozzi E, O'Neill A, Gentile K, Cinelli M, Tulchinsky A, Lawrance G, Czajkowski R, Lemole P, Antunes W, McGinnis A, Klokeid K, Phipatanakul W, Sheehan W, Bartnikas L, Baxi S, Crestani E, Etsy B, Gaffin J, Hauptman M, Kantor D, Lai P, Louisias M, Nelson K, Permaul P, Schneider L, Wright L, Minnicozzi S, Maciag M, Haktanir-Abul M, Gunnlaugsson S, Burke-Roberts E, Cunningham A, Ansel-Kelly E, Waskosky S, Ramsey A, Feloney L, Wenzel S, Fajt M, Celedon J, Larkin A, Di P, Chu HW, Gauthier M, Wu W, Jain S, Camiolo M, Rauscher C, Luyster F, Rebovich P, Demas J, Wunderley R, Vitari C, Ilnicki M, Srollo D, Takosky C, Lanzo R, Leader J, Lapic DM, Etling E, Rhodes D, Burger J, Glover E, Peters A, Smith C, Bonfiglio N, Trudeau J, Bang SJ, Lin Q, Liu CH, Kupul S, Jarjour N, Denlinger L, Lemanske R, Fain S, Viswanathan R, Moss M, Jackson D, Sorkness R, Ramratnam S, Tattersall M, Crisafi G, Klaus D, Wollet L, Bach J, Johansson M, Schiebler M, Esnault S, Mathur S, Yakey J, Floerke H, Guadarrama A, Maddox A, Peters B, Beaman K, Sumino K, Castro M, Bacharier L, Gierada D, Woods J, Schechtman K, Patterson B, Sheshadri A, Coverstone A, Shifren A, Quirk J, Byers D, Krings J, McGregor MC, Samant M, Tarsi J, Koch T, Curtis V, Yin-Declue H, Boomer J, Saylor M, Frei S, Rowe L, Sajol G, Kozlowski J, Hoffman E, Allard E, Atha J, Ching-Long L, Fahy J, Woodruff P, Ly N, Bhakta N, Peters M, Moreno C, Baum A, Liu D, Kalra A, Orain X, Charbit A, Njoku N, Dunican E, Teague WG, Greenwald R, DeBoer M, Wavell K, deRonde K, Erzurum S, Carl J, Khatri S, Dweik R, Comhair S, Sharp J, Lempel J, Farha S, Taliercio R, Aronica M, Zein J, Koo M, Painter TA, Hopkins K, Lawrence J, Abi-Saleh S, Labadia M, Qirjaz E, Wehrmann R, Arbruster D, Markle T, Matuska B, Baicker-McKee S, Wyszynski P, Fitzgerald K, Ross K, Gaston B, Myers R, Craven D, Roesch E, Thomas R, Logan L, Veri L, Gluvna A, Wallace J, Pryor M, Smith S, Allerton P, Emrich T, Hilliard J, Krenicky J, Smith L, Ferrebee M, Moore W, Bleecker E, Meyers D, Peters S, Li X, Hastie A, Ortega V, Hawkins G, Krings J, Ampleford E, Pippins A, Field P, Rector B, Sprissler R, Fransway B, Fitzpatrick A, Stephenson S, Mauger DT, Phillips B. Quantitative CT Characteristics of Cluster Phenotypes in the Severe Asthma Research Program Cohorts. Radiology 2022; 304:450-459. [PMID: 35471111 PMCID: PMC9340243 DOI: 10.1148/radiol.210363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Clustering key clinical characteristics of participants in the Severe Asthma Research Program (SARP), a large, multicenter prospective observational study of patients with asthma and healthy controls, has led to the identification of novel asthma phenotypes. Purpose To determine whether quantitative CT (qCT) could help distinguish between clinical asthma phenotypes. Materials and Methods A retrospective cross-sectional analysis was conducted with the use of qCT images (maximal bronchodilation at total lung capacity [TLC], or inspiration, and functional residual capacity [FRC], or expiration) from the cluster phenotypes of SARP participants (cluster 1: minimal disease; cluster 2: mild, reversible; cluster 3: obese asthma; cluster 4: severe, reversible; cluster 5: severe, irreversible) enrolled between September 2001 and December 2015. Airway morphometry was performed along standard paths (RB1, RB4, RB10, LB1, and LB10). Corresponding voxels from TLC and FRC images were mapped with use of deformable image registration to characterize disease probability maps (DPMs) of functional small airway disease (fSAD), voxel-level volume changes (Jacobian), and isotropy (anisotropic deformation index [ADI]). The association between cluster assignment and qCT measures was evaluated using linear mixed models. Results A total of 455 participants were evaluated with cluster assignments and CT (mean age ± SD, 42.1 years ± 14.7; 270 women). Airway morphometry had limited ability to help discern between clusters. DPM fSAD was highest in cluster 5 (cluster 1 in SARP III: 19.0% ± 20.6; cluster 2: 18.9% ± 13.3; cluster 3: 24.9% ± 13.1; cluster 4: 24.1% ± 8.4; cluster 5: 38.8% ± 14.4; P < .001). Lower whole-lung Jacobian and ADI values were associated with greater cluster severity. Compared to cluster 1, cluster 5 lung expansion was 31% smaller (Jacobian in SARP III cohort: 2.31 ± 0.6 vs 1.61 ± 0.3, respectively, P < .001) and 34% more isotropic (ADI in SARP III cohort: 0.40 ± 0.1 vs 0.61 ± 0.2, P < .001). Within-lung Jacobian and ADI SDs decreased as severity worsened (Jacobian SD in SARP III cohort: 0.90 ± 0.4 for cluster 1; 0.79 ± 0.3 for cluster 2; 0.62 ± 0.2 for cluster 3; 0.63 ± 0.2 for cluster 4; and 0.41 ± 0.2 for cluster 5; P < .001). Conclusion Quantitative CT assessments of the degree and intraindividual regional variability of lung expansion distinguished between well-established clinical phenotypes among participants with asthma from the Severe Asthma Research Program study. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Verschakelen in this issue.
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21
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Mutic AD, Mauger DT, Grunwell JR, Opolka C, Fitzpatrick AM. Social Vulnerability Is Associated with Poorer Outcomes in Preschool Children With Recurrent Wheezing Despite Standardized and Supervised Medical Care. The Journal of Allergy and Clinical Immunology: In Practice 2022; 10:994-1002. [PMID: 35123099 PMCID: PMC9007879 DOI: 10.1016/j.jaip.2021.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/13/2021] [Accepted: 12/31/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Social determinants of health are associated with disparate asthma outcomes in school-age children. Social determinants have not been studied in preschool children with recurrent wheezing. OBJECTIVE We hypothesized that preschool children with recurrent wheezing at highest risk of social vulnerability would have more frequent symptoms and exacerbations when followed over 1 year, despite receiving standardized and supervised asthma care. METHODS A multicenter population of adherent preschool children receiving standardized and supervised care for wheezing was stratified by a composite measure of social vulnerability based on individual-level variables. Primary outcomes included days with upper respiratory infections and days with asthma symptom flares. Other outcomes included symptom scores during upper respiratory infections and respiratory symptom flare days, exacerbation occurrence, quality of life during the exacerbation, and hospitalization. RESULTS Preschool children at highest risk of social vulnerability did not have more frequent upper respiratory infections, respiratory symptoms, or exacerbations, but instead had more severe symptoms during upper respiratory infections and respiratory flare days, as well as more severe exacerbations with significantly poorer caregiver quality of life. Children at highest risk of social vulnerability also lived in poorer housing conditions with differing exposures and self-reported triggers. CONCLUSIONS Individual-level social determinants of health reflecting social vulnerability are associated with poorer outcomes in preschool children with recurrent wheezing despite access to supervised and standardized care. Comprehensive assessment of social determinants of health is warranted in even the youngest children with wheezing, because mitigation of these social inequities is an essential first step toward improving outcomes in pediatric patients.
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Affiliation(s)
- Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Pennsylvania State University, Hershey, Pa
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Cydney Opolka
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Ga.
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22
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Krings JG, Goss CW, Lew D, Samant M, McGregor MC, Boomer J, Bacharier LB, Sheshadri A, Hall C, Brownell J, Schechtman KB, Peterson S, McEleney S, Mauger DT, Fahy JV, Fain SB, Denlinger LC, Israel E, Washko G, Hoffman E, Wenzel SE, Castro M. Quantitative CT metrics are associated with longitudinal lung function decline and future asthma exacerbations: Results from SARP-3. J Allergy Clin Immunol 2021; 148:752-762. [PMID: 33577895 PMCID: PMC8349941 DOI: 10.1016/j.jaci.2021.01.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 08/07/2020] [Revised: 12/02/2020] [Accepted: 01/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Currently, there is limited knowledge regarding which imaging assessments of asthma are associated with accelerated longitudinal decline in lung function. OBJECTIVES We aimed to assess whether quantitative computed tomography (qCT) metrics are associated with longitudinal decline in lung function and morbidity in asthma. METHODS We analyzed 205 qCT scans of adult patients with asthma and calculated baseline markers of airway remodeling, lung density, and pointwise regional change in lung volume (Jacobian measures) for each participant. Using multivariable regression models, we then assessed the association of qCT measurements with the outcomes of future change in lung function, future exacerbation rate, and changes in validated measurements of morbidity. RESULTS Greater baseline wall area percent (β = -0.15 [95% CI = -0.26 to -0.05]; P < .01), hyperinflation percent (β = -0.25 [95% CI = -0.41 to -0.09]; P < .01), and Jacobian gradient measurements (cranial-caudal β = 10.64 [95% CI = 3.79-17.49]; P < .01; posterior-anterior β = -9.14, [95% CI = -15.49 to -2.78]; P < .01) were associated with more severe future lung function decline. Additionally, greater wall area percent (rate ratio = 1.06 [95% CI = 1.01-1.10]; P = .02) and air trapping percent (rate ratio =1.01 [95% CI = 1.00-1.02]; P = .03), as well as lower decline in the Jacobian determinant mean (rate ratio = 0.58 [95% CI = 0.41-0.82]; P < .01) and Jacobian determinant standard deviation (rate ratio = 0.52 [95% CI = 0.32-0.85]; P = .01), were associated with a greater rate of future exacerbations. However, imaging metrics were not associated with clinically meaningful changes in scores on validated asthma morbidity questionnaires. CONCLUSIONS Baseline qCT measures of more severe airway remodeling, more small airway disease and hyperinflation, and less pointwise regional change in lung volumes were associated with future lung function decline and asthma exacerbations.
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Affiliation(s)
- James G Krings
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, St Louis, Mo
| | - Charles W Goss
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Daphne Lew
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Maanasi Samant
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, St Louis, Mo
| | - Mary Clare McGregor
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, St Louis, Mo
| | - Jonathan Boomer
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas City, Kan
| | - Leonard B Bacharier
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Ajay Sheshadri
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Tex
| | - Chase Hall
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas City, Kan
| | - Joshua Brownell
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, Wis
| | - Ken B Schechtman
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, Mo
| | | | | | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, the University of California San Francisco, San Francisco, Calif
| | - Sean B Fain
- Department of Radiology and Biomedical Engineering, University of Wisconsin, Madison, Wis
| | - Loren C Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, Wis
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - George Washko
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Eric Hoffman
- Department of Radiology, Biomedical Engineering, and Medicine, University of Iowa, Iowa City, IA
| | - Sally E Wenzel
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, the University of Pittsburgh, Pittsburgh, Pa
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas City, Kan.
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23
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Zein JG, McManus JM, Sharifi N, Erzurum SC, Marozkina N, Lahm T, Giddings O, Davis MD, DeBoer MD, Comhair SA, Bazeley P, Kim HJ, Busse W, Calhoun W, Castro M, Chung KF, Fahy JV, Israel E, Jarjour NN, Levy BD, Mauger DT, Moore WC, Ortega VE, Peters M, Bleecker ER, Meyers DA, Zhao Y, Wenzel SE, Gaston B. Benefits of Airway Androgen Receptor Expression in Human Asthma. Am J Respir Crit Care Med 2021; 204:285-293. [PMID: 33779531 DOI: 10.1164/rccm.202009-3720oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Androgens are potentially beneficial in asthma, but AR (androgen receptor) has not been studied in human airways.Objectives: To measure whether AR and its ligands are associated with human asthma outcomes.Methods: We compared the effects of AR expression on lung function, symptom scores, and fractional exhaled nitric oxide (FeNO) in adults enrolled in SARP (Severe Asthma Research Program). The impact of sex and of androgens on asthma outcomes was also evaluated in the SARP with validation studies in the Cleveland Clinic Health System and the NHANES (U.S. National Health and Nutrition Examination Survey).Measurements and Main Results: In SARP (n = 128), AR gene expression from bronchoscopic epithelial brushings was positively associated with both FEV1/FVC ratio (R2 = 0.135, P = 0.0002) and the total Asthma Quality of Life Questionnaire score (R2 = 0.056, P = 0.016) and was negatively associated with FeNO (R2 = 0.178, P = 9.8 × 10-6) and NOS2 (nitric oxide synthase gene) expression (R2 = 0.281, P = 1.2 × 10-10). In SARP (n = 1,659), the Cleveland Clinic Health System (n = 32,527), and the NHANES (n = 2,629), women had more asthma exacerbations and emergency department visits than men. The levels of the AR ligand precursor dehydroepiandrosterone sulfate correlated positively with the FEV1 in both women and men.Conclusions: Higher bronchial AR expression and higher androgen levels are associated with better lung function, fewer symptoms, and a lower FeNO in human asthma. The role of androgens should be considered in asthma management.
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Affiliation(s)
- Joe G Zein
- Lerner Research Institute and.,Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Serpil C Erzurum
- Lerner Research Institute and.,Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Suzy A Comhair
- Lerner Research Institute and.,Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Peter Bazeley
- Lerner Research Institute and.,Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hyun Jo Kim
- Department of Systems Biology and Bioinformatics, Case Western Reserve University, Cleveland, Ohio
| | - William Busse
- Department of Medicine, School of Medicine, University of Wisconsin, Madison, Wisconsin
| | - William Calhoun
- Department of Medicine, University of Texas Medical Branch, University of Texas, Galveston, Texas
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of Kansas, Kansas City, Kansas
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - John V Fahy
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of Kansas, Kansas City, Kansas.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Nizar N Jarjour
- Department of Medicine, School of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - David T Mauger
- Center for Biostatistics and Epidemiology, School of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Wendy C Moore
- Section on Pulmonary, Critical Care, Allergic, and Immunologic Disease, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Victor E Ortega
- Section on Pulmonary, Critical Care, Allergic, and Immunologic Disease, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michael Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Eugene R Bleecker
- Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Deborah A Meyers
- Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Yi Zhao
- Department of Biostatistics and Health Science Data, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Sally E Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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24
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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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25
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Jolliffe DA, Camargo CA, Sluyter JD, Aglipay M, Aloia JF, Ganmaa D, Bergman P, Bischoff-Ferrari HA, Borzutzky A, Damsgaard CT, Dubnov-Raz G, Esposito S, Gilham C, Ginde AA, Golan-Tripto I, Goodall EC, Grant CC, Griffiths CJ, Hibbs AM, Janssens W, Khadilkar AV, Laaksi I, Lee MT, Loeb M, Maguire JL, Majak P, Mauger DT, Manaseki-Holland S, Murdoch DR, Nakashima A, Neale RE, Pham H, Rake C, Rees JR, Rosendahl J, Scragg R, Shah D, Shimizu Y, Simpson-Yap S, Trilok-Kumar G, Urashima M, Martineau AR. Vitamin D supplementation to prevent acute respiratory infections: a systematic review and meta-analysis of aggregate data from randomised controlled trials. Lancet Diabetes Endocrinol 2021; 9:276-292. [PMID: 33798465 DOI: 10.1016/s2213-8587(21)00051-6] [Citation(s) in RCA: 226] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND A 2017 meta-analysis of data from 25 randomised controlled trials (RCTs) of vitamin D supplementation for the prevention of acute respiratory infections (ARIs) revealed a protective effect of this intervention. We aimed to examine the link between vitamin D supplementation and prevention of ARIs in an updated meta-analysis. METHODS For this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and the ClinicalTrials.gov registry for studies listed from database inception to May 1, 2020. Double-blind RCTs of vitamin D3, vitamin D2, or 25-hydroxyvitamin D (25[OH]D) supplementation for any duration, with a placebo or low-dose vitamin D control, were eligible if they had been approved by a research ethics committee, and if ARI incidence was collected prospectively and prespecified as an efficacy outcome. Studies reporting results of long-term follow-up of primary RCTs were excluded. Aggregated study-level data, stratified by baseline 25(OH)D concentration and age, were obtained from study authors. Using the proportion of participants in each trial who had one or more ARIs, we did a random-effects meta-analysis to obtain pooled odds ratios (ORs) and 95% CIs to estimate the effect of vitamin D supplementation on the risk of having one or more ARIs (primary outcome) compared with placebo. Subgroup analyses were done to estimate whether the effects of vitamin D supplementation on the risk of ARI varied according to baseline 25(OH)D concentration (<25 nmol/L vs 25·0-49·9 nmol/L vs 50·0-74·9 nmol/L vs >75·0 nmol/L), vitamin D dose (daily equivalent of <400 international units [IU] vs 400-1000 IU vs 1001-2000 IU vs >2000 IU), dosing frequency (daily vs weekly vs once per month to once every 3 months), trial duration (≤12 months vs >12 months), age at enrolment (<1·00 years vs 1·00-15·99 years vs 16·00-64·99 years vs ≥65·00 years), and presence versus absence of airway disease (ie, asthma only, COPD only, or unrestricted). Risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool. The study was registered with PROSPERO, CRD42020190633. FINDINGS We identified 1528 articles, of which 46 RCTs (75 541 participants) were eligible. Data for the primary outcome were obtained for 48 488 (98·1%) of 49 419 participants (aged 0-95 years) in 43 studies. A significantly lower proportion of participants in the vitamin D supplementation group had one or more ARIs (14 332 [61·3%] of 23 364 participants) than in the placebo group (14 217 [62·3%] of 22 802 participants), with an OR of 0·92 (95% CI 0·86-0·99; 37 studies; I2=35·6%, pheterogeneity=0·018). No significant effect of vitamin D supplementation on the risk of having one or more ARIs was observed for any of the subgroups defined by baseline 25(OH)D concentration. However, protective effects of supplementation were observed in trials in which vitamin D was given in a daily dosing regimen (OR 0·78 [95% CI 0·65-0·94]; 19 studies; I2=53·5%, pheterogeneity=0·003), at daily dose equivalents of 400-1000 IU (0·70 [0·55-0·89]; ten studies; I2=31·2%, pheterogeneity=0·16), for a duration of 12 months or less (0·82 [0·72-0·93]; 29 studies; I2=38·1%, pheterogeneity=0·021), and to participants aged 1·00-15·99 years at enrolment (0·71 [0·57-0·90]; 15 studies; I2=46·0%, pheterogeneity=0·027). No significant interaction between allocation to the vitamin D supplementation group versus the placebo group and dose, dose frequency, study duration, or age was observed. In addition, no significant difference in the proportion of participants who had at least one serious adverse event in the vitamin supplementation group compared with the placebo group was observed (0·97 [0·86-1·07]; 36 studies; I2=0·0%, pheterogeneity=0·99). Risk of bias within individual studies was assessed as being low for all but three trials. INTERPRETATION Despite evidence of significant heterogeneity across trials, vitamin D supplementation was safe and overall reduced the risk of ARI compared with placebo, although the risk reduction was small. Protection was associated with administration of daily doses of 400-1000 IU for up to 12 months, and age at enrolment of 1·00-15·99 years. The relevance of these findings to COVID-19 is not known and requires further investigation. FUNDING None.
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Affiliation(s)
- David A Jolliffe
- Barts and The London School of Medicine and Dentistry, and Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK.
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Sluyter
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Mary Aglipay
- Department of Pediatrics, St Michael's Hospital, Toronto, ON, Canada
| | - John F Aloia
- Bone Mineral Research Center, Winthrop University Hospital, Mineola, NY, USA
| | - Davaasambuu Ganmaa
- Department of Nutrition, Harvard TH Chan Shool of Public Health, Boston, MA, USA
| | - Peter Bergman
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Heike A Bischoff-Ferrari
- Department of Geriatric Medicine and Aging Research, University Hospital Zurich, Zurich, Switzerland
| | - Arturo Borzutzky
- Department of Pediatric Infectious Diseases and Immunology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Camilla T Damsgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Gal Dubnov-Raz
- Exercise, Lifestyle and Nutrition Clinic, Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Susanna Esposito
- Paediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Clare Gilham
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Inbal Golan-Tripto
- Saban Pediatric Medical Center, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Emma C Goodall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Cameron C Grant
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Christopher J Griffiths
- Barts and The London School of Medicine and Dentistry, and Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | | | | | - Ilkka Laaksi
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland; Centre for Military Medicine, Helsinki, Finland
| | - Margaret T Lee
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York, NY USA
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Paweł Majak
- Department of Pediatric Pulmonology, Medical University of Lodz, Lodz, Poland
| | - David T Mauger
- Department of Statistics, The Pennsylvania State University, Hershey, PA, USA
| | - Semira Manaseki-Holland
- Department of Public Health, Epidemiology and Biostatistics, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - David R Murdoch
- Department of Pathology, University of Otago, Christchurch, New Zealand
| | | | - Rachel E Neale
- Population Health Department, QIMR Berghofer Medical Research Institute, QLD, Australia
| | - Hai Pham
- Population Health Department, QIMR Berghofer Medical Research Institute, QLD, Australia
| | - Christine Rake
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Judy R Rees
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jenni Rosendahl
- Children's Hospital, Pediatric Research Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Robert Scragg
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Dheeraj Shah
- Department of Paediatrics, University College of Medical Sciences, Delhi, India
| | - Yoshiki Shimizu
- FANCL Research Institute, FANCL Corporation, Yokohama, Japan
| | - Steve Simpson-Yap
- Neuroepidemiology Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | | | | | - Adrian R Martineau
- Barts and The London School of Medicine and Dentistry, and Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK.
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Hastie AT, Mauger DT, Denlinger LC, Coverstone A, Castro M, Erzurum S, Jarjour N, Levy BD, Meyers DA, Moore WC, Phillips BR, Wenzel SE, Fahy JV, Israel E, Bleecker ER. Mixed Sputum Granulocyte Longitudinal Impact on Lung Function in the Severe Asthma Research Program. Am J Respir Crit Care Med 2021; 203:882-892. [PMID: 33545021 DOI: 10.1164/rccm.202009-3713oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Rationale: Some reports indicate longitudinal variability in sputum differential cell counts, whereas others describe stability. Highly variable sputum eosinophil percentages are associated with greater lung function loss than persistently elevated eosinophil percentages, but elevated neutrophils are linked to more severe asthma.Objectives: To examine sputum granulocyte stability or variability longitudinally and associations with important clinical characteristics.Methods: The SARP III (Severe Asthma Research Program III) cohort underwent comprehensive phenotype characterization at baseline and annually over 3 years. Adult subjects with acceptable sputum levels were assigned to one of three longitudinal sputum groups: eosinophils predominantly <2%, eosinophils predominantly ≥2%, or highly variable eosinophil percentages (>2 SDs determined from independent, repeated baseline eosinophil percentages). Subjects were similarly assigned to one of three longitudinal neutrophil groups with a 50% cut point.Measurements and Main Results: The group with predominantly <2% sputum eosinophils had the highest lung function (prebronchodilator FEV1% predicted, P < 0.01; FEV1/FVC ratio, P < 0.001) at baseline and throughout 3 years compared with other eosinophil groups. Healthcare use did not differ, although the highly variable eosinophil group reported more asthma exacerbations at Year 3. Longitudinal neutrophil groups showed few differences. However, a combination of predominantly ≥2% eosinophil and ≥50% neutrophil groups resulted in the lowest prebronchodilator FEV1% predicted (P = 0.049) compared with the combination with predominantly <2% eosinophils and<50% neutrophils.Conclusions: Subjects with predominantly ≥2% sputum eosinophils in combination with predominantly ≥50% neutrophils showed greater loss of lung function, whereas those with highly variable sputum eosinophils had greater healthcare use.
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Affiliation(s)
- Annette T Hastie
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - David T Mauger
- Penn State College of Medicine, Penn State University, Hershey, Pennsylvania
| | | | | | - Mario Castro
- School of Medicine, Washington University, St. Louis, Missouri
| | | | | | - Bruce D Levy
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Wendy C Moore
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Brenda R Phillips
- Penn State College of Medicine, Penn State University, Hershey, Pennsylvania
| | | | - John V Fahy
- University of California-San Francisco, San Francisco, California
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Denlinger LC, Phillips BR, Sorkness RL, Bleecker ER, Castro M, DeBoer MD, Fitzpatrick AM, Hastie AT, Gaffin JM, Moore WC, Peters MC, Peters SP, Phipatanakul W, Cardet JC, Erzurum SC, Fahy JV, Fajt ML, Gaston B, Levy BD, Meyers DA, Ross K, Teague WG, Wenzel SE, Woodruff PG, Zein J, Jarjour NN, Mauger DT, Israel E. Responsiveness to Parenteral Corticosteroids and Lung Function Trajectory in Adults with Moderate-to-Severe Asthma. Am J Respir Crit Care Med 2021; 203:841-852. [PMID: 33290668 DOI: 10.1164/rccm.202002-0454oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rationale: It is unclear why select patients with moderate-to-severe asthma continue to lose lung function despite therapy. We hypothesized that participants with the smallest responses to parenteral corticosteroids have the greatest risk of undergoing a severe decline in lung function.Objectives: To evaluate corticosteroid-response phenotypes as longitudinal predictors of lung decline.Methods: Adults within the NHLBI SARP III (Severe Asthma Research Program III) who had undergone a course of intramuscular triamcinolone at baseline and at ≥2 annual follow-up visits were evaluated. Longitudinal slopes were calculated for each participant's post-bronchodilator FEV1% predicted. Categories of participant FEV1 slope were defined: severe decline, >2% loss/yr; mild decline, >0.5-2.0% loss/yr; no change, 0.5% loss/yr to <1% gain/yr; and improvement, ≥1% gain/yr. Regression models were used to develop predictors of severe decline.Measurements and Main Results: Of 396 participants, 78 had severe decline, 91 had mild decline, 114 had no change, and 113 showed improvement. The triamcinolone-induced difference in the post-bronchodilator FEV1% predicted (derived by baseline subtraction) was related to the 4-year change in lung function or slope category in univariable models (P < 0.001). For each 5% decrement in the triamcinolone-induced difference the FEV1% predicted, there was a 50% increase in the odds of being in the severe decline group (odds ratio, 1.5; 95% confidence interval, 1.3-1.8), when adjusted for baseline FEV1, exacerbation history, blood eosinophils and body mass index.Conclusions: Failure to improve the post-bronchodilator FEV1 after a challenge with parenteral corticosteroids is an evoked biomarker for patients at risk for a severe decline in lung function.
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Affiliation(s)
- Loren C Denlinger
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Brenda R Phillips
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Ronald L Sorkness
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, KU School of Medicine, The University of Kansas, Kansas City, Kansas
| | - Mark D DeBoer
- Divisions of Pediatric Diabetes and Endocrinology and Pediatric Respiratory Medicine, Allergy, Immunology and Sleep, Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Anne M Fitzpatrick
- Division of Pulmonary, Allergy and Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Annette T Hastie
- Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Jonathan M Gaffin
- Divisions of Pulmonary Medicine and Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, and
| | - Wendy C Moore
- Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michael C Peters
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, UCSF School of Medicine, University of California, San Francisco, San Francisco, California
| | - Stephen P Peters
- Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Wanda Phipatanakul
- Divisions of Pulmonary Medicine and Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, and
| | - Juan Carlos Cardet
- Divisions of Pulmonary Medicine and Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, and
| | - Serpil C Erzurum
- Lerner Research Institute and the Respiratory Institute, The Cleveland Clinic, Cleveland, Ohio
| | - John V Fahy
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, UCSF School of Medicine, University of California, San Francisco, San Francisco, California
| | - Merritt L Fajt
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Benjamin Gaston
- Division of Pediatric Pulmonary, Allergy and Sleep Medicine, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana; and
| | - Bruce D Levy
- Divisions of Pulmonary Medicine and Allergy and Immunology, Department of Pediatrics, Boston Children's Hospital, and
| | - Deborah A Meyers
- Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Kristie Ross
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - W Gerald Teague
- Divisions of Pediatric Diabetes and Endocrinology and Pediatric Respiratory Medicine, Allergy, Immunology and Sleep, Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Sally E Wenzel
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Prescott G Woodruff
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, UCSF School of Medicine, University of California, San Francisco, San Francisco, California
| | - Joe Zein
- Lerner Research Institute and the Respiratory Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Nizar N Jarjour
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Elliot Israel
- Divisions of Pulmonary and Critical Care and of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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Choi T, Devries M, Bacharier LB, Busse W, Camargo CA, Cohen R, Demuri GP, Evans MD, Fitzpatrick AM, Gergen PJ, Grindle K, Gruchalla R, Hartert T, Hasegawa K, Khurana Hershey GK, Holt P, Homil K, Jartti T, Kattan M, Kercsmar C, Kim H, Laing IA, LeBeau P, Lee KE, Le Souëf PN, Liu A, Mauger DT, Ober C, Pappas T, Patel SJ, Phipatanakul W, Pongracic J, Seroogy C, Sly PD, Tisler C, Wald ER, Wood R, Gangnon R, Jackson DJ, Lemanske RF, Gern JE, Bochkov YA. Enhanced Neutralizing Antibody Responses to Rhinovirus C and Age-Dependent Patterns of Infection. Am J Respir Crit Care Med 2021; 203:822-830. [PMID: 33357024 PMCID: PMC8017585 DOI: 10.1164/rccm.202010-3753oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/23/2020] [Indexed: 01/10/2023] Open
Abstract
Rationale: Rhinovirus (RV) C can cause asymptomatic infection and respiratory illnesses ranging from the common cold to severe wheezing.Objectives: To identify how age and other individual-level factors are associated with susceptibility to RV-C illnesses.Methods: Longitudinal data from the COAST (Childhood Origins of Asthma) birth cohort study were analyzed to determine relationships between age and RV-C infections. Neutralizing antibodies specific for RV-A and RV-C (three types each) were determined using a novel PCR-based assay. Data were pooled from 14 study cohorts in the United States, Finland, and Australia, and mixed-effects logistic regression was used to identify factors related to the proportion of RV-C versus RV-A detection.Measurements and Main Results: In COAST, RV-A and RV-C infections were similarly common in infancy, whereas RV-C was detected much less often than RV-A during both respiratory illnesses and scheduled surveillance visits (P < 0.001, χ2) in older children. The prevalence of neutralizing antibodies to RV-A or RV-C types was low (5-27%) at the age of 2 years, but by the age of 16 years, RV-C seropositivity was more prevalent (78% vs. 18% for RV-A; P < 0.0001). In the pooled analysis, the RV-C to RV-A detection ratio during illnesses was significantly related to age (P < 0.0001), CDHR3 genotype (P < 0.05), and wheezing illnesses (P < 0.05). Furthermore, certain RV types (e.g., C2, C11, A78, and A12) were consistently more virulent and prevalent over time.Conclusions: Knowledge of prevalent RV types, antibody responses, and populations at risk based on age and genetics may guide the development of vaccines or other novel therapies against this important respiratory pathogen.
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Affiliation(s)
- Timothy Choi
- University of Wisconsin-Madison, Madison, Wisconsin
| | - Mark Devries
- University of Wisconsin-Madison, Madison, Wisconsin
| | | | | | | | | | | | | | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Peter J Gergen
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Rockville, Maryland
| | | | | | | | | | | | - Patrick Holt
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Tuomas Jartti
- University of Turku, Turku, Finland
- Universities of Oulu, Oulu, Finland
| | | | | | - Haejin Kim
- Henry Ford Health Systems, Detroit, Michigan
| | - Ingrid A Laing
- University of Western Australia, Perth, Western Australia, Australia
| | | | | | - Peter N Le Souëf
- University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Liu
- University of Colorado, Denver, Colorado
| | | | | | | | | | | | | | | | - Peter D Sly
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia; and
| | | | - Ellen R Wald
- University of Wisconsin-Madison, Madison, Wisconsin
| | - Robert Wood
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - James E Gern
- University of Wisconsin-Madison, Madison, Wisconsin
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Sheehan WJ, Paul IM, Mauger DT, Moy JN, Szefler SJ, Jackson DJ, Fitzpatrick AM, Cabana MD, Covar R, Robison RG, Phipatanakul W. Adherence rates during a randomized controlled trial evaluating the use of blinded acetaminophen and ibuprofen in children with asthma. Contemp Clin Trials 2021; 104:106334. [PMID: 33652129 DOI: 10.1016/j.cct.2021.106334] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND/AIMS When conducting clinical trials comparing over-the-counter (OTC) medications, the wide availability of these treatments are a potential challenge to maintaining study integrity. We seek to describe adherence to a study protocol involving widely available OTC medications. METHODS To prospectively evaluate associations between acetaminophen use and asthma in 300 children aged 1-5 years, we conducted a double blind, randomized, controlled trial where parents administered blinded forms of either acetaminophen or ibuprofen as needed to their children over a 48 week period. Written and verbal instructions encouraged the exclusive use of the blinded study medication and discouraged OTC use. Adherence was determined by evaluating the frequency of use of per-protocol blinded study medication compared to off-protocol use of OTC medications. RESULTS 4195 doses of acetaminophen or ibuprofen were received by children during the study which included 3664 doses (87.3%) of blinded study medication adhering to the protocol and 531 doses (12.7%) of OTC products deviating from the protocol with better adherence among those randomized to ibuprofen as compared to acetaminophen (89.5% vs. 85.5% of doses, p < 0.01). Individually, 227 participants (75.7%) remained fully adherent by not receiving any OTC medications. Pre-study preference for either acetaminophen or ibuprofen by the participants' families was not associated with differential rates of adherence to the blinded medication. CONCLUSION This parallel study demonstrated greater than 85% of acetaminophen or ibuprofen doses were blinded study medications adhering to the protocol while less than 15% were OTC deviations from the protocol. This successfully implemented study design provides a template to comparatively evaluate these and other OTC medications.
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Affiliation(s)
- William J Sheehan
- Boston Children's Hospital, Division of Allergy and Immunology, Harvard Medical School, Boston, MA, United States of America; Children's National Hospital, Division of Allergy and Immunology, George Washington University School of Medicine and Health Sciences, Washington DC, United States of America
| | - Ian M Paul
- Penn State College of Medicine, Department of Pediatrics, Hershey, PA, United States of America
| | - David T Mauger
- Penn State College of Medicine, Department of Public Health Sciences, Hershey, PA, United States of America
| | - James N Moy
- Stroger Hospital of Cook County, Department of Pediatrics, Rush University Medical Center, Chicago, IL, United States of America
| | - Stanley J Szefler
- Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Section of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Madison, WI, United States of America
| | - Anne M Fitzpatrick
- Emory University, Department of Pediatrics, Atlanta, GA, United States of America
| | - Michael D Cabana
- University of California, San Francisco, Department of Pediatrics, San Francisco, CA, United States of America
| | - Ronina Covar
- National Jewish Health, Department of Pediatrics, Denver, CO, United States of America
| | - Rachel G Robison
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Allergy and Immunology, Chicago, IL, United States of America
| | - Wanda Phipatanakul
- Boston Children's Hospital, Division of Allergy and Immunology, Harvard Medical School, Boston, MA, United States of America.
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30
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Phipatanakul W, Mauger DT, Guilbert TW, Bacharier LB, Durrani S, Jackson DJ, Martinez FD, Fitzpatrick AM, Cunningham A, Kunselman S, Wheatley LM, Bauer C, Davis CM, Geng B, Kloepfer KM, Lapin C, Liu AH, Pongracic JA, Teach SJ, Chmiel J, Gaffin JM, Greenhawt M, Gupta MR, Lai PS, Lemanske RF, Morgan WJ, Sheehan WJ, Stokes J, Thorne PS, Oettgen HC, Israel E. Preventing asthma in high risk kids (PARK) with omalizumab: Design, rationale, methods, lessons learned and adaptation. Contemp Clin Trials 2021; 100:106228. [PMID: 33242697 PMCID: PMC7887056 DOI: 10.1016/j.cct.2020.106228] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 07/22/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 11/27/2022]
Abstract
Asthma remains one of the most important challenges to pediatric public health in the US. A large majority of children with persistent and chronic asthma demonstrate aeroallergen sensitization, which remains a pivotal risk factor associated with the development of persistent, progressive asthma throughout life. In individuals with a tendency toward Type 2 inflammation, sensitization and exposure to high concentrations of offending allergens is associated with increased risk for development of, and impairment from, asthma. The cascade of biological responses to allergens is primarily mediated through IgE antibodies and their production is further stimulated by IgE responses to antigen exposure. In addition, circulating IgE impairs innate anti-viral immune responses. The latter effect could magnify the effects of another early life exposure associated with increased risk of the development of asthma - viral infections. Omalizumab binds to circulating IgE and thus ablates antigen signaling through IgE-related mechanisms. Further, it has been shown restore IFN-α response to rhinovirus and to reduce asthma exacerbations during the viral season. We therefore hypothesized that early blockade of IgE and IgE mediated responses with omalizumab would prevent the development and reduce the severity of asthma in those at high risk for developing asthma. Herein, we describe a double-blind, placebo-controlled trial of omalizumab in 2-3 year old children at high risk for development of asthma to prevent the development and reduce the severity of asthma. We describe the rationale, methods, and lessons learned in implementing this potentially transformative trial aimed at prevention of asthma.
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Affiliation(s)
- Wanda Phipatanakul
- Boston Children's Hospital, Division of Allergy and Immunology, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - David T Mauger
- Pennsylvania State University, Hershey, PA, United States of America
| | - Theresa W Guilbert
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Leonard B Bacharier
- Washington University and St. Louis Children's Hospital, St. Louis, MO, United States of America
| | - Sandy Durrani
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | | | - Fernando D Martinez
- Asthma and Airway Research Center, University of Arizona, Tucson, AZ, United States of America
| | | | - Amparito Cunningham
- Boston Children's Hospital, Division of Allergy and Immunology, United States of America
| | - Susan Kunselman
- Pennsylvania State University, Hershey, PA, United States of America
| | - Lisa M Wheatley
- NIH/National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States of America
| | - Cindy Bauer
- Phoenix Children's Hospital, Phoenix, AZ, United States of America
| | - Carla M Davis
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America
| | - Bob Geng
- Rady Children's Hospital, UC San Diego, San Diego, CA, United States of America
| | - Kirsten M Kloepfer
- Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Craig Lapin
- Connecticut Children's Medical Center, Division of Pulmonary Hartford, CT, United States of America
| | - Andrew H Liu
- Children's Hospital Colorado, University of Colorado, Aurora, CO, United States of America
| | - Jacqueline A Pongracic
- Ann and Robert Lurie Children's Hospital of Chicago, Chicago, IL, United States of America
| | - Stephen J Teach
- Children's National Hospital, Washington, DC, United States of America
| | - James Chmiel
- NIH/National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States of America
| | - Jonathan M Gaffin
- Harvard Medical School, Boston, MA, United States of America; Boston Children's Hospital, Division of Pulmonary Medicine, Boston, MA, United States of America
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado, Aurora, CO, United States of America
| | - Meera R Gupta
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America
| | - Peggy S Lai
- Harvard Medical School, Boston, MA, United States of America; Massachusetts General Hospital, Division of Pulmonary and Critical Care, Boston, MA, United States of America
| | | | - Wayne J Morgan
- Asthma and Airway Research Center, University of Arizona, Tucson, AZ, United States of America
| | - William J Sheehan
- Children's National Hospital, Washington, DC, United States of America
| | - Jeffrey Stokes
- Washington University and St. Louis Children's Hospital, St. Louis, MO, United States of America
| | - Peter S Thorne
- University of Iowa, College of Public Health, Department of Occupational and Environmental Health, Iowa City, IA, United States of America
| | - Hans C Oettgen
- Boston Children's Hospital, Division of Allergy and Immunology, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elliot Israel
- Harvard Medical School, Boston, MA, United States of America; Brigham and Women's Hospital, Divisions of Pulmonary and Critical Care Medicine and Allergy and Immunology, Boston, MA, United States of America
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31
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Jolliffe DA, Camargo CA, Sluyter JD, Aglipay M, Aloia JF, Ganmaa D, Bergman P, Borzutzky A, Damsgaard CT, Dubnov-Raz G, Esposito S, Gilham C, Ginde AA, Golan-Tripto I, Goodall EC, Grant CC, Griffiths CJ, Hibbs AM, Janssens W, Khadilkar AV, Laaksi I, Lee MT, Loeb M, Maguire JL, Majak P, Mauger DT, Manaseki-Holland S, Murdoch DR, Nakashima A, Neale RE, Pham H, Rake C, Rees JR, Rosendahl J, Scragg R, Shah D, Shimizu Y, Simpson-Yap S, Kumar GT, Urashima M, Martineau AR. Vitamin D supplementation to prevent acute respiratory infections: systematic review and meta-analysis of aggregate data from randomised controlled trials. medRxiv 2020:2020.07.14.20152728. [PMID: 33269357 PMCID: PMC7709175 DOI: 10.1101/2020.07.14.20152728] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A 2017 meta-analysis of data from 25 randomised controlled trials of vitamin D supplementation for the prevention of acute respiratory infections revealed a protective effect of the intervention. Since then, 20 new RCTs have been completed. METHODS Systematic review and meta-analysis of data from randomised controlled trials (RCTs) of vitamin D for ARI prevention using a random effects model. Pre-specified sub-group analyses were done to determine whether effects of vitamin D on risk of ARI varied according to baseline 25-hydroxyvitamin D (25[OH]D) concentration or dosing regimen. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and the ClinicalTrials.gov registry from inception to 1st May 2020. Double-blind RCTs of supplementation with vitamin D or calcidiol, of any duration, were eligible if they were approved by a Research Ethics Committee and if ARI incidence was collected prospectively and pre-specified as an efficacy outcome. Aggregate data, stratified by baseline 25(OH)D concentration, were obtained from study authors. The study was registered with PROSPERO (no. CRD42020190633). FINDINGS We identified 45 eligible RCTs (total 73,384 participants). Data were obtained for 46,331 (98.0%) of 47,262 participants in 42 studies, aged 0 to 95 years. For the primary comparison of vitamin D supplementation vs. placebo, the intervention reduced risk of ARI overall (Odds Ratio [OR] 0.91, 95% CI 0.84 to 0.99; P for heterogeneity 0.01). No statistically significant effect of vitamin D was seen for any of the sub-groups defined by baseline 25(OH)D concentration. However, protective effects were seen for trials in which vitamin D was given using a daily dosing regimen (OR 0.75, 95% CI 0.61 to 0.93); at daily dose equivalents of 400-1000 IU (OR 0.70, 95% CI 0.55 to 0.89); and for a duration of ≤12 months (OR 0.82, 95% CI 0.72 to 0.93). No significant interaction was seen between allocation to vitamin D vs. placebo and dose frequency, dose size, or study duration. Vitamin D did not influence the proportion of participants experiencing at least one serious adverse event (OR 0.97, 95% CI 0.86 to 1.09). Risk of bias within individual studies was assessed as being low for all but three trials. A funnel plot showed left-sided asymmetry (P=0.008, Egger's test). INTERPRETATION Vitamin D supplementation was safe and reduced risk of ARI, despite evidence of significant heterogeneity across trials. Protection was associated with administration of daily doses of 400-1000 IU vitamin D for up to 12 months. The relevance of these findings to COVID-19 is not known and requires investigation. FUNDING None.
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Affiliation(s)
- David A Jolliffe
- Institute for Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Sluyter
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Mary Aglipay
- Department of Pediatrics, St Michael’s Hospital, Toronto, Ontario, Canada
| | - John F Aloia
- Bone Mineral Research Center, Winthrop University Hospital, Mineola, NY, USA
| | - Davaasambuu Ganmaa
- Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - Peter Bergman
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Arturo Borzutzky
- Department of Pediatric Infectious Diseases and Immunology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Camilla T Damsgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Gal Dubnov-Raz
- Exercise, Lifestyle and Nutrition Clinic, Edmond and Lily Safra Children’s Hospital, Tel Hashomer, Israel
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Clare Gilham
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Inbal Golan-Tripto
- Saban Pediatric Medical Center, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Emma C Goodall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Cameron C Grant
- Department of Paediatrics: Child & Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Christopher J Griffiths
- Institute for Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | | | | | - Ilkka Laaksi
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Margaret T Lee
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, NY USA
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathon L Maguire
- Department of Pediatrics, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Paweł Majak
- Department of Pediatric Pulmonology, Medical University of Lodz, Lodz, Poland
| | - David T Mauger
- Department of Statistics, The Pennsylvania State University, Hershey, PA, USA
| | - Semira Manaseki-Holland
- Department of Public Health, Epidemiology and Biostatistics, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - David R Murdoch
- Department of Pathology, University of Otago, Christchurch, New Zealand
| | | | - Rachel E Neale
- Population Health Department, QIMR Berghofer Medical Research Institute, Queensland, Australia
| | - Hai Pham
- Population Health Department, QIMR Berghofer Medical Research Institute, Queensland, Australia
| | - Christine Rake
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Judy R Rees
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jenni Rosendahl
- Children’s Hospital, Pediatric Research Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Robert Scragg
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Dheeraj Shah
- Department of Paediatrics, University College of Medical Sciences, Delhi, India
| | - Yoshiki Shimizu
- FANCL Research Institute, FANCL Corporation, Yokohama, Japan
| | - Steve Simpson-Yap
- Neuroepidemiology Unit, Melbourne School of Population & Global Health, The University of Melbourne, Melbourne, VIC, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | | | | | - Adrian R Martineau
- Institute for Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
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Ivanova A, Israel E, LaVange LM, Peters MC, Denlinger LC, Moore WC, Bacharier LB, Marquis MA, Gotman NM, Kosorok MR, Tomlinson C, Mauger DT, Georas SN, Wright RJ, Noel P, Rosner GL, Akuthota P, Billheimer D, Bleecker ER, Cardet JC, Castro M, DiMango EA, Erzurum SC, Fahy JV, Fajt ML, Gaston BM, Holguin F, Jain S, Kenyon NJ, Krishnan JA, Kraft M, Kumar R, Liu MC, Ly NP, Moy JN, Phipatanakul W, Ross K, Smith LJ, Szefler SJ, Teague WG, Wechsler ME, Wenzel SE, White SR. The precision interventions for severe and/or exacerbation-prone asthma (PrecISE) adaptive platform trial: statistical considerations. J Biopharm Stat 2020; 30:1026-1037. [PMID: 32941098 PMCID: PMC7954787 DOI: 10.1080/10543406.2020.1821705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 12/24/2022]
Abstract
The Precision Interventions for Severe and/or Exacerbation-prone Asthma (PrecISE) study is an adaptive platform trial designed to investigate novel interventions to severe asthma. The study is conducted under a master protocol and utilizes a crossover design with each participant receiving up to five interventions and at least one placebo. Treatment assignments are based on the patients' biomarker profiles and precision health methods are incorporated into the interim and final analyses. We describe key elements of the PrecISE study including the multistage adaptive enrichment strategy, early stopping of an intervention for futility, power calculations, and the primary analysis strategy.
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Affiliation(s)
| | - Elliot Israel
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Patricia Noel
- Division of Lung Diseases, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD
| | | | - Praveen Akuthota
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | - Dean Billheimer
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | | | | | | | | | | | | | - Merritt L. Fajt
- Wells Center for Pediatric Research, Indiana University, Indianapolis
| | | | | | | | | | - Jerry A. Krishnan
- Asthma and Airway Disease Research Center, University of Arizona, Tucson
| | | | | | | | - Ngoc P. Ly
- Rush University Medical Center, Chicago, IL
| | - James N. Moy
- Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Wanda Phipatanakul
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristie Ross
- UH Rainbow Babies and Children’s Hospitals, Cleveland, OH
| | | | - Stanley J. Szefler
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | | | | | - Sally E. Wenzel
- National Jewish Health, Denver, CO, and University of Colorado School of Medicine, Aurora, CO
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Peters MC, Sajuthi S, Deford P, Christenson S, Rios CL, Montgomery MT, Woodruff PG, Mauger DT, Erzurum SC, Johansson MW, Denlinger LC, Jarjour NN, Castro M, Hastie AT, Moore W, Ortega VE, Bleecker ER, Wenzel SE, Israel E, Levy BD, Seibold MA. COVID-19-related Genes in Sputum Cells in Asthma. Relationship to Demographic Features and Corticosteroids. Am J Respir Crit Care Med 2020; 202:83-90. [PMID: 32348692 PMCID: PMC7328313 DOI: 10.1164/rccm.202003-0821oc] [Citation(s) in RCA: 307] [Impact Index Per Article: 76.8] [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: 03/27/2020] [Accepted: 04/29/2020] [Indexed: 01/18/2023] Open
Abstract
Rationale: Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). ACE2 (angiotensin-converting enzyme 2), and TMPRSS2 (transmembrane protease serine 2) mediate viral infection of host cells. We reasoned that differences in ACE2 or TMPRSS2 gene expression in sputum cells among patients with asthma may identify subgroups at risk for COVID-19 morbidity.Objectives: To determine the relationship between demographic features and sputum ACE2 and TMPRSS2 gene expression in asthma.Methods: We analyzed gene expression for ACE2 and TMPRSS2, and for ICAM-1 (intercellular adhesion molecule 1) (rhinovirus receptor as a comparator) in sputum cells from 330 participants in SARP-3 (Severe Asthma Research Program-3) and 79 healthy control subjects.Measurements and Main Results: Gene expression of ACE2 was lower than TMPRSS2, and expression levels of both genes were similar in asthma and health. Among patients with asthma, male sex, African American race, and history of diabetes mellitus were associated with higher expression of ACE2 and TMPRSS2. Use of inhaled corticosteroids (ICS) was associated with lower expression of ACE2 and TMPRSS2, but treatment with triamcinolone acetonide did not decrease expression of either gene. These findings differed from those for ICAM-1, where gene expression was increased in asthma and less consistent differences were observed related to sex, race, and use of ICS.Conclusions: Higher expression of ACE2 and TMPRSS2 in males, African Americans, and patients with diabetes mellitus provides rationale for monitoring these asthma subgroups for poor COVID-19 outcomes. The lower expression of ACE2 and TMPRSS2 with ICS use warrants prospective study of ICS use as a predictor of decreased susceptibility to SARS-CoV-2 infection and decreased COVID-19 morbidity.
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Affiliation(s)
- Michael C. Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | | | | | - Stephanie Christenson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | | | | | - Prescott G. Woodruff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - David T. Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | | | | | - Loren C. Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nizar N. Jarjour
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mario Castro
- Division of Allergy, Immunology, and Pulmonary Medicine, University of Kansas, Kansas City, Kansas
| | - Annette T. Hastie
- Department of Internal Medicine, Pulmonary Section, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Wendy Moore
- Department of Internal Medicine, Pulmonary Section, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Victor E. Ortega
- Department of Internal Medicine, Pulmonary Section, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Eugene R. Bleecker
- Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Sally E. Wenzel
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Max A. Seibold
- Center for Genes, Environment, and Health and
- Department of Pediatrics, National Jewish Health, Denver, Colorado
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado–Anschutz Medical Campus, Aurora, Colorado
| | - on behalf of the NHLBI Severe Asthma Research Program-3 Investigators
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
- Center for Genes, Environment, and Health and
- Department of Pediatrics, National Jewish Health, Denver, Colorado
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
- Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio
- Department of Biomolecular Chemistry and
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Division of Allergy, Immunology, and Pulmonary Medicine, University of Kansas, Kansas City, Kansas
- Department of Internal Medicine, Pulmonary Section, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
- Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado–Anschutz Medical Campus, Aurora, Colorado
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34
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Durack J, Christian LS, Nariya S, Gonzalez J, Bhakta NR, Ansel KM, Beigelman A, Castro M, Dyer AM, Israel E, Kraft M, Martin RJ, Mauger DT, Peters SP, Rosenberg SR, Sorkness CA, Wechsler ME, Wenzel SE, White SR, Lynch SV, Boushey HA, Huang YJ. Distinct associations of sputum and oral microbiota with atopic, immunologic, and clinical features in mild asthma. J Allergy Clin Immunol 2020; 146:1016-1026. [PMID: 32298699 DOI: 10.1016/j.jaci.2020.03.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/06/2020] [Accepted: 03/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Whether microbiome characteristics of induced sputum or oral samples demonstrate unique relationships to features of atopy or mild asthma in adults is unknown. OBJECTIVE We sought to determine sputum and oral microbiota relationships to clinical or immunologic features in mild atopic asthma and the impact on the microbiota of inhaled corticosteroid (ICS) treatment administered to ICS-naive subjects with asthma. METHODS Bacterial microbiota profiles were analyzed in induced sputum and oral wash samples from 32 subjects with mild atopic asthma before and after inhaled fluticasone treatment, 18 atopic subjects without asthma, and 16 nonatopic healthy subjects in a multicenter study (NCT01537133). Associations with clinical and immunologic features were examined, including markers of atopy, type 2 inflammation, immune cell populations, and cytokines. RESULTS Sputum bacterial burden inversely associated with bronchial expression of type 2 (T2)-related genes. Differences in specific sputum microbiota also associated with T2-low asthma phenotype, a subgroup of whom displayed elevations in lung inflammatory mediators and reduced sputum bacterial diversity. Differences in specific oral microbiota were more reflective of atopic status. After ICS treatment of patients with asthma, the compositional structure of sputum microbiota showed greater deviation from baseline in ICS nonresponders than in ICS responders. CONCLUSIONS Novel associations of sputum and oral microbiota to immunologic features were observed in this cohort of subjects with or without ICS-naive mild asthma. These findings confirm and extend our previous report of reduced bronchial bacterial burden and compositional complexity in subjects with T2-high asthma, with additional identification of a T2-low subgroup with a distinct microbiota-immunologic relationship.
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Affiliation(s)
- Juliana Durack
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, Calif
| | - Laura S Christian
- Department of Microbiology & Immunology and Sandler Asthma Basic Research Center, San Francisco, Calif
| | - Snehal Nariya
- Department of Medicine, Division of Pulmonary/Critical Care Medicine, University of California, San Francisco, Calif
| | - Jeanmarie Gonzalez
- Department of Microbiology & Immunology and Sandler Asthma Basic Research Center, San Francisco, Calif
| | - Nirav R Bhakta
- Department of Medicine, Division of Pulmonary/Critical Care Medicine, University of California, San Francisco, Calif
| | - K Mark Ansel
- Department of Microbiology & Immunology and Sandler Asthma Basic Research Center, San Francisco, Calif
| | - Avraham Beigelman
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo; Kipper Institute of Allergy and Immunology, Schneider Children's Medical Center of Israel, Tel Aviv University, Tel Aviv, Israel
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Mo
| | - Anne-Marie Dyer
- Department of Public Health Sciences, Penn State University, Hershey, Pa
| | - Elliot Israel
- Department of Medicine, Brigham & Women's Hospital, Boston, Mass
| | - Monica Kraft
- University of Arizona, Health Sciences, Tucson, Ariz
| | | | - David T Mauger
- Department of Public Health Sciences, Penn State University, Hershey, Pa
| | | | | | | | | | - Sally E Wenzel
- University of Pittsburgh Asthma Institute at UPMC/UPSOM, Pittsburgh, Pa
| | - Steven R White
- Department of Medicine, University of Chicago, Chicago, Ill
| | - Susan V Lynch
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, Calif
| | - Homer A Boushey
- Department of Medicine, Division of Pulmonary/Critical Care Medicine, University of California, San Francisco, Calif
| | - Yvonne J Huang
- Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine, University of Michigan, Ann Arbor, Mich.
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Fitzpatrick AM, Bacharier LB, Jackson DJ, Szefler SJ, Beigelman A, Cabana M, Covar R, Guilbert T, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Raissy HH, Zeiger RS, Mauger DT. Heterogeneity of Mild to Moderate Persistent Asthma in Children: Confirmation by Latent Class Analysis and Association with 1-Year Outcomes. J Allergy Clin Immunol Pract 2020; 8:2617-2627.e4. [PMID: 32156610 DOI: 10.1016/j.jaip.2020.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Compared with adults, phenotypic characterization of children with asthma is still limited and it remains difficult to predict which children with asthma are at highest risk for poor outcomes. OBJECTIVE To identify latent classes in a large population of treatment-adherent children with mild to moderate asthma enrolled in clinical trials and determine whether latent class assignment predicts future lung function abnormalities and exacerbation rate. METHODS Latent class analysis was performed on 2593 children with mild to moderate asthma aged 5 18 years, with 19 variables encompassing demographic characteristics, medical history, symptoms, lung function, allergic sensitization, and type 2 inflammation. Outcomes included lung function and the annualized exacerbation rate at 12 months of follow-up. RESULTS Five latent classes were identified with differing demographic features, asthma control, sensitization, type 2 inflammatory markers, and lung function. Exacerbation rates were 1.30 ± 0.12 for class 1 (multiple sensitization with partially reversible airflow limitation), 0.90 ± 0.05 for class 2 (multiple sensitization with reversible airflow limitation), 0.87 ± 0.08 for class 3 (lesser sensitization with reversible airflow limitation), 0.87 ± 0.05 for class 4 (multiple sensitization with normal lung function), and 0.71 ± 0.06 for class 5 (lesser sensitization with normal lung function). Lung function abnormalities persisted in class 1 at 12 months. CONCLUSIONS Children with mild to moderate asthma are a heterogeneous group. Allergic sensitization and lung function may be particularly useful in identifying children at the greatest risk for future exacerbation. Additional studies are needed to determine whether latent classes correspond to meaningful phenotypes for the purpose of personalized treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Daniel J Jackson
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stanley J Szefler
- Children's Hospital Colorado and Department of Pediatrics, University of Colorado, Aurora, Colo
| | - Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Michael Cabana
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York, NY
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Theresa Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | | | - Robert F Lemanske
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Wayne Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital and Harvard Medical School Department of Pediatrics, Boston, Mass
| | | | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region and Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Public Health Sciences, Penn State University, Hershey, Pa
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36
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Zein J, Gaston B, Bazeley P, DeBoer MD, Igo RP, Bleecker ER, Meyers D, Comhair S, Marozkina NV, Cotton C, Patel M, Alyamani M, Xu W, Busse WW, Calhoun WJ, Ortega V, Hawkins GA, Castro M, Chung KF, Fahy JV, Fitzpatrick AM, Israel E, Jarjour NN, Levy B, Mauger DT, Moore WC, Noel P, Peters SP, Teague WG, Wenzel SE, Erzurum SC, Sharifi N. HSD3B1 genotype identifies glucocorticoid responsiveness in severe asthma. Proc Natl Acad Sci U S A 2020; 117:2187-2193. [PMID: 31932420 PMCID: PMC6995013 DOI: 10.1073/pnas.1918819117] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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] [Indexed: 01/10/2023] Open
Abstract
Asthma resistance to glucocorticoid treatment is a major health problem with unclear etiology. Glucocorticoids inhibit adrenal androgen production. However, androgens have potential benefits in asthma. HSD3B1 encodes for 3β-hydroxysteroid dehydrogenase-1 (3β-HSD1), which catalyzes peripheral conversion from adrenal dehydroepiandrosterone (DHEA) to potent androgens and has a germline missense-encoding polymorphism. The adrenal restrictive HSD3B1(1245A) allele limits conversion, whereas the adrenal permissive HSD3B1(1245C) allele increases DHEA metabolism to potent androgens. In the Severe Asthma Research Program (SARP) III cohort, we determined the association between DHEA-sulfate and percentage predicted forced expiratory volume in 1 s (FEV1PP). HSD3B1(1245) genotypes were assessed, and association between adrenal restrictive and adrenal permissive alleles and FEV1PP in patients with (GC) and without (noGC) daily oral glucocorticoid treatment was determined (n = 318). Validation was performed in a second cohort (SARP I&II; n = 184). DHEA-sulfate is associated with FEV1PP and is suppressed with GC treatment. GC patients homozygous for the adrenal restrictive genotype have lower FEV1PP compared with noGC patients (54.3% vs. 75.1%; P < 0.001). In patients with the homozygous adrenal permissive genotype, there was no FEV1PP difference in GC vs. noGC patients (73.4% vs. 78.9%; P = 0.39). Results were independently confirmed: FEV1PP for homozygous adrenal restrictive genotype in GC vs. noGC is 49.8 vs. 63.4 (P < 0.001), and for homozygous adrenal permissive genotype, it is 66.7 vs. 67.7 (P = 0.92). The adrenal restrictive HSD3B1(1245) genotype is associated with GC resistance. This effect appears to be driven by GC suppression of 3β-HSD1 substrate. Our results suggest opportunities for prediction of GC resistance and pharmacologic intervention.
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Affiliation(s)
- Joe Zein
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Benjamin Gaston
- Herman Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Peter Bazeley
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, VA 22904
| | - Robert P Igo
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH 44106
| | - Eugene R Bleecker
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ 85721
| | - Deborah Meyers
- Department of Medicine, University of Arizona Health Sciences, Tucson, AZ 85721
| | - Suzy Comhair
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Nadzeya V Marozkina
- Department of Pediatrics, Rainbow Babies and Children's Hospital, and Case Western Reserve University, Cleveland, OH 44106
| | - Calvin Cotton
- Department of Pediatrics, Rainbow Babies and Children's Hospital, and Case Western Reserve University, Cleveland, OH 44106
| | - Mona Patel
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Mohammad Alyamani
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Weiling Xu
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - William W Busse
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706
| | - William J Calhoun
- Department of Medicine, University of Texas Medical Branch, TX 77555
| | - Victor Ortega
- Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27587
| | - Gregory A Hawkins
- Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27587
| | - Mario Castro
- Department of Medicine, University of Kansas School of Medicine, Kansas City, KS 66160
| | - Kian Fan Chung
- The National Heart & Lung Institute, Imperial College London, London SW7 2AZ, United Kingdom
| | - John V Fahy
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, CA 94143
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322
| | - Elliot Israel
- Department of Medicine, Harvard Medical School, Boston, MA 02115
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706
| | - Bruce Levy
- Department of Medicine, Harvard Medical School, Boston, MA 02115
| | - David T Mauger
- Center for Biostatistics and Epidemiology, Pennsylvania State University School of Medicine, Hershey, PA 16802
| | - Wendy C Moore
- Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27587
| | - Patricia Noel
- Severe Asthma Research Program (SARP), National Heart, Lung, and Blood Institute, NIH, Bethesda, MD 20892
| | - Stephen P Peters
- Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27587
| | - W Gerald Teague
- Department of Pediatrics, University of Virginia, Charlottesville, VA 22904
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute, University of Pittsburgh Medical Center-University of Pittsburgh School of Medicine, Pittsburgh, PA 15261
| | - Serpil C Erzurum
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Nima Sharifi
- Lerner Research Institute and the Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195;
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37
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Coverstone AM, Bacharier LB, Wilson BS, Fitzpatrick AM, Teague WG, Phipatanakul W, Wenzel SE, Gaston BM, Bleecker ER, Moore WC, Ramratnam S, Jarjour NN, Ly NP, Fahy JV, Mauger DT, Schechtman KB, Yin-DeClue H, Boomer JS, Castro M. Clinical significance of the bronchodilator response in children with severe asthma. Pediatr Pulmonol 2019; 54:1694-1703. [PMID: 31424170 PMCID: PMC7015037 DOI: 10.1002/ppul.24473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/12/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Our objective was to determine those characteristics associated with reversibility of airflow obstruction and response to maximal bronchodilation in children with severe asthma through the Severe Asthma Research Program (SARP). METHODS We performed a cross-sectional analysis evaluating children ages 6 to 17 years with nonsevere asthma (NSA) and severe asthma (SA). Participants underwent spirometry before and after 180 µg of albuterol to determine reversibility (≥12% increase in FEV1 ). Participants were then given escalating doses up to 720 µg of albuterol to determine their maximum reversibility. RESULTS We evaluated 230 children (n = 129 SA, n = 101 NSA) from five centers across the United States in the SARP I and II cohorts. SA (odds ratio [OR], 2.08, 95% confidence interval [CI], 1.05-4.13), second-hand smoke exposure (OR, 2.81, 95%CI, 1.23-6.43), and fractional exhaled nitric oxide (FeNO; OR, 1.97, 95%CI, 1.35-2.87) were associated with increased odds of airway reversibility after maximal bronchodilation, while higher prebronchodilator (BD) FEV1 % predicted (OR, 0.91, 95%CI, 0.88-0.94) was associated with decreased odds. In an analysis using the SARP III cohort (n = 186), blood neutrophils, immunoglobulin E (IgE), and FEV1 % predicted were significantly associated with BD reversibility. In addition, children with BD response have greater healthcare utilization. BD reversibility was associated with reduced lung function at enrollment and 1-year follow-up though less decline in lung function over 1 year compared to those without reversibility. CONCLUSIONS Lung function, that is FEV1 % predicted, is a predictor of BD response in children with asthma. Additionally, smoke exposure, higher FeNO or IgE level, and low peripheral blood neutrophils are associated with a greater likelihood of BD reversibility. BD response can identify a phenotype of pediatric asthma associated with low lung function and poor asthma control.
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Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Bradley S Wilson
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - William Gerald Teague
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wanda Phipatanakul
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sally E Wenzel
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benjamin M Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - Wendy C Moore
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sima Ramratnam
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Ngoc P Ly
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - John V Fahy
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - Kenneth B Schechtman
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Huiqing Yin-DeClue
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Jonathan S Boomer
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Mario Castro
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
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Krishnamoorthy N, Douda DN, Brüggemann TR, Ricklefs I, Duvall MG, Abdulnour REE, Martinod K, Tavares L, Wang X, Cernadas M, Israel E, Mauger DT, Bleecker ER, Castro M, Erzurum SC, Gaston BM, Jarjour NN, Wenzel S, Dunican E, Fahy JV, Irimia D, Wagner DD, Levy BD. Neutrophil cytoplasts induce T H17 differentiation and skew inflammation toward neutrophilia in severe asthma. Sci Immunol 2019; 3:3/26/eaao4747. [PMID: 30076281 DOI: 10.1126/sciimmunol.aao4747] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 03/09/2018] [Accepted: 07/05/2018] [Indexed: 01/01/2023]
Abstract
Severe asthma is a debilitating and treatment refractory disease. As many as half of these patients have complex neutrophil-predominant lung inflammation that is distinct from milder asthma with type 2 eosinophilic inflammation. New insights into severe asthma pathogenesis are needed. Concomitant exposure of mice to an aeroallergen and endotoxin during sensitization resulted in complex neutrophilic immune responses to allergen alone during later airway challenge. Unlike allergen alone, sensitization with allergen and endotoxin led to NETosis. In addition to neutrophil extracellular traps (NETs), enucleated neutrophil cytoplasts were evident in the lungs. Surprisingly, allergen-driven airway neutrophilia was decreased in peptidyl arginine deiminase 4-deficient mice with defective NETosis but not by deoxyribonuclease treatment, implicating the cytoplasts for the non-type 2 immune responses to allergen. Neutrophil cytoplasts were also present in mediastinal lymph nodes, and the cytoplasts activated lung dendritic cells in vitro to trigger antigen-specific interleukin-17 (IL-17) production from naïve CD4+ T cells. Bronchoalveolar lavage fluid from patients with severe asthma and high neutrophil counts had detectable NETs and cytoplasts that were positively correlated with IL-17 levels. Together, these translational findings have identified neutrophil cytoplast formation in asthmatic lung inflammation and linked the cytoplasts to T helper 17-mediated neutrophilic inflammation in severe asthma.
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Affiliation(s)
- Nandini Krishnamoorthy
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - David N Douda
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Thayse R Brüggemann
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Isabell Ricklefs
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Melody G Duvall
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Raja-Elie E Abdulnour
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Kimberly Martinod
- Program in Cellular and Molecular Medicine, Division of Hematology and Oncology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Luciana Tavares
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Xiao Wang
- BioMEMS Resource Center, Massachusetts General Hospital, Harvard Medical School, MA 02129, USA
| | - Manuela Cernadas
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Elliot Israel
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - David T Mauger
- Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, PA 17033, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, School of Medicine, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Pediatrics, Washington University, St. Louis, MO 63110, USA
| | - Serpil C Erzurum
- Department of Pathobiology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Benjamin M Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Nizar N Jarjour
- Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine, Madison, WI 53792, USA
| | - Sally Wenzel
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Eleanor Dunican
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Daniel Irimia
- BioMEMS Resource Center, Massachusetts General Hospital, Harvard Medical School, MA 02129, USA
| | - Denisa D Wagner
- Program in Cellular and Molecular Medicine, Division of Hematology and Oncology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Bruce D Levy
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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Ross KR, Gupta R, DeBoer MD, Zein J, Phillips BR, Mauger DT, Li C, Myers RE, Phipatanakul W, Fitzpatrick AM, Ly NP, Bacharier LB, Jackson DJ, Celedón JC, Larkin A, Israel E, Levy B, Fahy JV, Castro M, Bleecker ER, Meyers D, Moore WC, Wenzel SE, Jarjour NN, Erzurum SC, Teague WG, Gaston B. Severe asthma during childhood and adolescence: A longitudinal study. J Allergy Clin Immunol 2019; 145:140-146.e9. [PMID: 31622688 DOI: 10.1016/j.jaci.2019.09.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Morbidity and mortality associated with childhood asthma are driven disproportionately by children with severe asthma. However, it is not known from longitudinal studies whether children outgrow severe asthma. OBJECTIVE We sought to study prospectively whether well-characterized children with severe asthma outgrow their asthma during adolescence. METHODS Children with asthma were assessed at baseline with detailed questionnaires, allergy tests, and lung function tests and were reassessed annually for 3 years. The population was enriched for children with severe asthma, as assessed by the American Thoracic Society/European Respiratory Society guidelines, and subject classification was reassessed annually. RESULTS At baseline, 111 (59%) children had severe asthma. Year to year, there was a decrease in the proportion meeting the criteria for severe asthma. After 3 years, only 30% of subjects met the criteria for severe asthma (P < .001 compared with enrollment). Subjects experienced improvements in most indices of severity, including symptom scores, exacerbations, and controller medication requirements, but not lung function. Surprisingly, boys and girls were equally likely to has resolved asthma (33% vs 29%). The odds ratio in favor of resolution of severe asthma was 2.75 (95% CI, 1.02-7.43) for those with a peripheral eosinophil count of greater than 436 cells/μL. CONCLUSIONS In longitudinal analysis of this well-characterized cohort, half of the children with severe asthma no longer had severe asthma after 3 years; there was a stepwise decrease in the proportion meeting severe asthma criteria. Surprisingly, asthma severity decreased equally in male and female subjects. Peripheral eosinophilia predicted resolution. These data will be important for planning clinical trials in this population.
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Affiliation(s)
- Kristie R Ross
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Ritika Gupta
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Joe Zein
- Department of Pathobiology, Lerner Research Institute, and the Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brenda R Phillips
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Chun Li
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Ross E Myers
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Wanda Phipatanakul
- Department of Pediatrics, Harvard University School of Medicine, Boston, Mass
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Ngoc P Ly
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, Calif
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Juan C Celedón
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pa
| | - Allyson Larkin
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pa
| | - Elliot Israel
- Department of Pediatrics, Harvard University School of Medicine, Boston, Mass
| | - Bruce Levy
- Department of Pediatrics, Harvard University School of Medicine, Boston, Mass
| | - John V Fahy
- Department of Pediatrics, San Francisco School of Medicine, University of California, San Francisco, Calif
| | - Mario Castro
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Eugene R Bleecker
- Department of Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Deborah Meyers
- Department of Medicine, University of Arizona Health Sciences, Tucson, Ariz
| | - Wendy C Moore
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute at the University of Pittsburgh Medical Center-University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Nizar N Jarjour
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Serpil C Erzurum
- Department of Pathobiology, Lerner Research Institute, and the Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - W Gerald Teague
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Benjamin Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.
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40
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Fitzpatrick AM, Szefler SJ, Mauger DT, Phillips BR, Denlinger LC, Moore WC, Sorkness RL, Wenzel SE, Gergen PJ, Bleecker ER, Castro M, Erzurum SC, Fahy JV, Gaston BM, Israel E, Levy BD, Meyers DA, Teague WG, Bacharier LB, Ly NP, Phipatanakul W, Ross KR, Zein J, Jarjour NN. Development and initial validation of the Asthma Severity Scoring System (ASSESS). J Allergy Clin Immunol 2019; 145:127-139. [PMID: 31604088 DOI: 10.1016/j.jaci.2019.09.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tools for quantification of asthma severity are limited. OBJECTIVE We sought to develop a continuous measure of asthma severity, the Asthma Severity Scoring System (ASSESS), for adolescents and adults, incorporating domains of asthma control, lung function, medications, and exacerbations. METHODS Baseline and 36-month longitudinal data from participants in phase 3 of the Severe Asthma Research Program (NCT01606826) were used. Scale properties, responsiveness, and a minimally important difference were determined. External replication was performed in participants enrolled in the Severe Asthma Research Program phase 1/2. The utility of ASSESS for detecting treatment response was explored in participants undergoing corticosteroid responsiveness testing with intramuscular triamcinolone and participants receiving biologics. RESULTS ASSESS scores ranged from 0 to 20 (8.78 ± 3.9; greater scores reflect worse severity) and differed among 5 phenotypic groups. Measurement properties were acceptable. ASSESS was responsive to changes in quality of life with a minimally important difference of 2, with good specificity for outcomes of asthma improvement and worsening but poor sensitivity. Replication analyses yielded similar results, with a 2-point decrease (improvement) associated with improvements in quality of life. Participants with a 2-point or greater decrease (improvement) in ASSESS scores also had greater improvement in lung function and asthma control after triamcinolone, but these differences were limited to phenotypic clusters 3, 4, and 5. Participants treated with biologics also had a 2-point or greater decrease (improvement) in ASSESS scores overall. CONCLUSIONS The ASSESS tool is an objective measure that might be useful in epidemiologic and clinical research studies for quantification of treatment response in individual patients and phenotypic groups. However, validation studies are warranted.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Brenda R Phillips
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | | | - Wendy C Moore
- Department of Internal Medicine, Wake Forest University, Winston-Salem, NC
| | | | - Sally E Wenzel
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Peter J Gergen
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | | | - Mario Castro
- Department of Internal Medicine, Washington University, St Louis, Mo
| | | | - John V Fahy
- Department of Medicine, San Francisco, Calif
| | - Benjamin M Gaston
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Bruce D Levy
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - W Gerald Teague
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | | | - Ngoc P Ly
- Department of Pediatrics, University of California San Francisco, Cleveland, Ohio
| | | | - Kristie R Ross
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Joe Zein
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin, Madison, Wis
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41
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Ash SY, Sanchez-Ferrero GV, Schiebler ML, Rahaghi FN, Rai A, Come CE, Ross JC, Colon AG, Cardet JC, Bleecker ER, Castro M, Fahy JV, Fain SB, Gaston BM, Hoffman EA, Jarjour NN, Lempel JK, Mauger DT, Tattersall MC, Wenzel SE, Levy BD, Washko GR, Israel E, San Jose Estepar R. Estimated Ventricular Size, Asthma Severity, and Exacerbations: The Severe Asthma Research Program III Cohort. Chest 2019; 157:258-267. [PMID: 31521672 DOI: 10.1016/j.chest.2019.08.2185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/25/2019] [Accepted: 08/11/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Relative enlargement of the pulmonary artery (PA) on chest CT imaging is associated with respiratory exacerbations in patients with COPD or cystic fibrosis. We sought to determine whether similar findings were present in patients with asthma and whether these findings were explained by differences in ventricular size. METHODS We measured the PA and aorta diameters in 233 individuals from the Severe Asthma Research Program III cohort. We also estimated right, left, and total epicardial cardiac ventricular volume indices (eERVVI, eELVVI, and eETVVI, respectively). Associations between the cardiac and PA measures (PA-to-aorta [PA/A] ratio, eERVVI-to-eELVVI [eRV/eLV] ratio, eERVVI, eELVVI, eETVVI) and clinical measures of asthma severity were assessed by Pearson correlation, and associations with asthma severity and exacerbation rate were evaluated by multivariable linear and zero-inflated negative binomial regression. RESULTS Asthma severity was associated with smaller ventricular volumes. For example, those with severe asthma had 36.1 mL/m2 smaller eETVVI than healthy control subjects (P = .003) and 14.1 mL/m2 smaller eETVVI than those with mild/moderate disease (P = .011). Smaller ventricular volumes were also associated with a higher rate of asthma exacerbations, both retrospectively and prospectively. For example, those with an eETVVI less than the median had a 57% higher rate of exacerbations during follow-up than those with eETVVI greater than the median (P = .020). Neither PA/A nor eRV/eLV was associated with asthma severity or exacerbations. CONCLUSIONS In patients with asthma, smaller cardiac ventricular size may be associated with more severe disease and a higher rate of asthma exacerbations. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01761630; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Samuel Y Ash
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA.
| | | | - Mark L Schiebler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Ashish Rai
- Department of Medicine, North Shore Medical Center, Salem, MA
| | - Carolyn E Come
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - James C Ross
- Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Alysha G Colon
- College of Medicine, University of Florida, Gainesville, FL
| | - Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Medicine, University of South Florida, Tampa, FL
| | - Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, AZ
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, MO
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA
| | - Sean B Fain
- Departments of Medical Physics, Radiology, and Biomedical Engineering, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Benjamin M Gaston
- Division of Pulmonology, Allergy, and Immunology, and Pediatric Pulmonology, Rainbow Babies and Children's Hospital and Cleveland Medical Center, Cleveland, OH
| | - Eric A Hoffman
- Departments of Radiology, Biomedical Engineering, and Medicine, University of Iowa, Iowa City, IA
| | - Nizar N Jarjour
- Division of Pulmonary and Critical Care Medicine (Dr Jarjour), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason K Lempel
- Department of Radiology, Cleveland Clinic, Cleveland, OH
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Penn State Eberly College of Science, University Park, PA
| | - Matthew C Tattersall
- Division of Cardiovascular Medicine (Dr Tattersall), University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sally E Wenzel
- Division of Pulmonary, Allergy and Critical Care, University of Pittsburgh, Pittsburgh, PA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Applied Chest Imaging Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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Wu W, Bang S, Bleecker ER, Castro M, Denlinger L, Erzurum SC, Fahy JV, Fitzpatrick AM, Gaston BM, Hastie AT, Israel E, Jarjour NN, Levy BD, Mauger DT, Meyers DA, Moore WC, Peters M, Phillips BR, Phipatanakul W, Sorkness RL, Wenzel SE. Multiview Cluster Analysis Identifies Variable Corticosteroid Response Phenotypes in Severe Asthma. Am J Respir Crit Care Med 2019; 199:1358-1367. [PMID: 30682261 PMCID: PMC6543720 DOI: 10.1164/rccm.201808-1543oc] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [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: 08/20/2018] [Accepted: 01/23/2019] [Indexed: 01/15/2023] Open
Abstract
Rationale: Corticosteroids (CSs) are the most effective asthma therapy, but responses are heterogeneous and systemic CSs lead to long-term side effects. Therefore, an improved understanding of the contributing factors in CS responses could enhance precision management. Although several factors have been associated with CS responsiveness, no integrated/cluster approach has yet been undertaken to identify differential CS responses. Objectives: To identify asthma subphenotypes with differential responses to CS treatment using an unsupervised multiview learning approach. Methods: Multiple-kernel k-means clustering was applied to 100 clinical, physiological, inflammatory, and demographic variables from 346 adult participants with asthma in the Severe Asthma Research Program with paired (before and 2-3 weeks after triamcinolone administration) sputum data. Machine-learning techniques were used to select the top baseline variables that predicted cluster assignment for a new patient. Measurements and Main Results: Multiple-kernel clustering revealed four clusters of individuals with asthma and different CS responses. Clusters 1 and 2 consisted of young, modestly CS-responsive individuals with allergic asthma and relatively normal lung function, separated by contrasting sputum neutrophil and macrophage percentages after CS treatment. The subjects in cluster 3 had late-onset asthma and low lung function, high baseline eosinophilia, and the greatest CS responsiveness. Cluster 4 consisted primarily of young, obese females with severe airflow limitation, little eosinophilic inflammation, and the least CS responsiveness. The top 12 baseline variables were identified, and the clusters were validated using an independent Severe Asthma Research Program test set. Conclusions: Our machine learning-based approaches provide new insights into the mechanisms of CS responsiveness in asthma, with the potential to improve disease treatment.
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Affiliation(s)
- Wei Wu
- Computational Biology Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Seojin Bang
- Computational Biology Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | | | | | | | - John V. Fahy
- University of California San Francisco, San Francisco, California
| | | | | | - Annette T. Hastie
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Elliot Israel
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Bruce D. Levy
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - David T. Mauger
- Pennsylvania State University, University Park, Pennsylvania
| | | | - Wendy C. Moore
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michael Peters
- University of California San Francisco, San Francisco, California
| | | | - Wanda Phipatanakul
- Brigham and Women’s Hospital, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts; and
| | | | - Sally E. Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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43
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Fitzpatrick AM, Gillespie SE, Mauger DT, Phillips BR, Bleecker ER, Israel E, Meyers DA, Moore WC, Sorkness RL, Wenzel SE, Bacharier LB, Castro M, Denlinger LC, Erzurum SC, Fahy JV, Gaston BM, Jarjour NN, Larkin A, Levy BD, Ly NP, Ortega VE, Peters SP, Phipatanakul W, Ramratnam S, Teague WG. Racial disparities in asthma-related health care use in the National Heart, Lung, and Blood Institute's Severe Asthma Research Program. J Allergy Clin Immunol 2019; 143:2052-2061. [PMID: 30635198 PMCID: PMC6556425 DOI: 10.1016/j.jaci.2018.11.022] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [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: 03/23/2018] [Revised: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite advances in asthma care, disparities persist. Black patients are disproportionally affected by asthma and also have poorer outcomes compared with white patients. OBJECTIVE We sought to determine associations between black and white patients and asthma-related health care use, accounting for complex relationships. METHODS This study was completed as part of the National Heart, Lung, and Blood Institute's Severe Asthma Research Program, a prospective observational cohort. Between November 2012 and February 2015, it enrolled 579 participants 6 years and older with 1 year of observation time and complete data. Inverse probability of treatment weighting was used to balance racial groups with respect to community and family socioeconomic variables and environmental exposure variables. The primary outcome was emergency department (ED) use for asthma. Secondary outcomes included inhaled corticosteroid use, outpatient physician's office visits for asthma, and asthma-related hospitalization. RESULTS Black patients had greater odds of ED use over 1 year (odds ratio, 2.19; 95% CI, 1.43-3.35) but also differed in the majority (>50%) of baseline variables measured. After statistical balancing of the racial groups, the difference between black and white patients with respect to ED use no longer reached the level of significance. Instead, in secondary analyses black patients were less likely to see an outpatient physician for asthma management (adjusted odds ratio, 0.57; 95% CI, 0.38-0.85). CONCLUSIONS The disparity in ED use was eliminated after consideration of multiple variables. Social and environmental policies and interventions tailored to black populations with a high burden of asthma are critical to reduction (or elimination) of these disparities.
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Affiliation(s)
| | | | - David T Mauger
- Pennsylvania State University, Department of Public Health Sciences, Hershey, Pa
| | - Brenda R Phillips
- Pennsylvania State University, Department of Public Health Sciences, Hershey, Pa
| | | | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Department of Medicine, Boston, Mass
| | | | - Wendy C Moore
- Wake Forest University, Department of Medicine, Winston-Salem, NC
| | | | - Sally E Wenzel
- University of Pittsburgh, Department of Medicine, Pittsburgh, Pa
| | | | - Mario Castro
- Washington University, Departments of Medicine and Pediatrics, St Louis, Mo
| | | | | | - John V Fahy
- University of California, San Francisco, Departments of Medicine and Pediatrics, Calif
| | - Benjamin M Gaston
- Case Western Reserve University, Department of Pediatrics, Cleveland, Ohio
| | | | - Allyson Larkin
- University of Pittsburgh, Department of Medicine, Pittsburgh, Pa
| | - Bruce D Levy
- Brigham and Women's Hospital, Harvard Medical School, Department of Medicine, Boston, Mass
| | - Ngoc P Ly
- University of California, San Francisco, Departments of Medicine and Pediatrics, Calif
| | - Victor E Ortega
- Wake Forest University, Department of Medicine, Winston-Salem, NC
| | - Stephen P Peters
- Wake Forest University, Department of Medicine, Winston-Salem, NC
| | - Wanda Phipatanakul
- Boston Children's Hospital, Harvard Medical School, Department of Pediatrics, Boston, Mass
| | - Sima Ramratnam
- University of Wisconsin, Department of Medicine, Madison
| | - W Gerald Teague
- University of Virginia, Department of Pediatrics, Charlottesville, Va
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Lazarus SC, Krishnan JA, King TS, Lang JE, Blake KV, Covar R, Lugogo N, Wenzel S, Chinchilli VM, Mauger DT, Dyer AM, Boushey HA, Fahy JV, Woodruff PG, Bacharier LB, Cabana MD, Cardet JC, Castro M, Chmiel J, Denlinger L, DiMango E, Fitzpatrick AM, Gentile D, Hastie A, Holguin F, Israel E, Jackson D, Kraft M, LaForce C, Lemanske RF, Martinez FD, Moore W, Morgan WJ, Moy JN, Myers R, Peters SP, Phipatanakul W, Pongracic JA, Que L, Ross K, Smith L, Szefler SJ, Wechsler ME, Sorkness CA. Mometasone or Tiotropium in Mild Asthma with a Low Sputum Eosinophil Level. N Engl J Med 2019; 380:2009-2019. [PMID: 31112384 PMCID: PMC6711475 DOI: 10.1056/nejmoa1814917] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In many patients with mild, persistent asthma, the percentage of eosinophils in sputum is less than 2% (low eosinophil level). The appropriate treatment for these patients is unknown. METHODS In this 42-week, double-blind, crossover trial, we assigned 295 patients who were at least 12 years of age and who had mild, persistent asthma to receive mometasone (an inhaled glucocorticoid), tiotropium (a long-acting muscarinic antagonist), or placebo. The patients were categorized according to the sputum eosinophil level (<2% or ≥2%). The primary outcome was the response to mometasone as compared with placebo and to tiotropium as compared with placebo among patients with a low sputum eosinophil level who had a prespecified differential response to one of the trial agents. The response was determined according to a hierarchical composite outcome that incorporated treatment failure, asthma control days, and the forced expiratory volume in 1 second; a two-sided P value of less than 0.025 denoted statistical significance. A secondary outcome was a comparison of results in patients with a high sputum eosinophil level and those with a low level. RESULTS A total of 73% of the patients had a low eosinophil level; of these patients, 59% had a differential response to a trial agent. However, there was no significant difference in the response to mometasone or tiotropium, as compared with placebo. Among the patients with a low eosinophil level who had a differential treatment response, 57% (95% confidence interval [CI], 48 to 66) had a better response to mometasone, and 43% (95% CI, 34 to 52) had a better response to placebo (P = 0.14). In contrast 60% (95% CI, 51 to 68) had a better response to tiotropium, whereas 40% (95% CI, 32 to 49) had a better response to placebo (P = 0.029). Among patients with a high eosinophil level, the response to mometasone was significantly better than the response to placebo (74% vs. 26%) but the response to tiotropium was not (57% vs. 43%). CONCLUSIONS The majority of patients with mild, persistent asthma had a low sputum eosinophil level and had no significant difference in their response to either mometasone or tiotropium as compared with placebo. These data provide equipoise for a clinically directive trial to compare an inhaled glucocorticoid with other treatments in patients with a low eosinophil level. (Funded by the National Heart, Lung, and Blood Institute; SIENA ClinicalTrials.gov number, NCT02066298.).
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Affiliation(s)
- Stephen C Lazarus
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Jerry A Krishnan
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Tonya S King
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Jason E Lang
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Kathryn V Blake
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Ronina Covar
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Njira Lugogo
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Sally Wenzel
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Vernon M Chinchilli
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - David T Mauger
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Anne-Marie Dyer
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Homer A Boushey
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - John V Fahy
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Prescott G Woodruff
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Leonard B Bacharier
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Michael D Cabana
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Juan C Cardet
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Mario Castro
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - James Chmiel
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Loren Denlinger
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Emily DiMango
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Anne M Fitzpatrick
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Deborah Gentile
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Annette Hastie
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Fernando Holguin
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Elliot Israel
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Daniel Jackson
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Monica Kraft
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Craig LaForce
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Robert F Lemanske
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Fernando D Martinez
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Wendy Moore
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Wayne J Morgan
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - James N Moy
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Ross Myers
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Stephen P Peters
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Wanda Phipatanakul
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Jacqueline A Pongracic
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Loretta Que
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Kristie Ross
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Lewis Smith
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Stanley J Szefler
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Michael E Wechsler
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
| | - Christine A Sorkness
- From the Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute (S.C.L., H.A.B., J.V.F., P.G.W.) and the Department of Pediatrics, Epidemiology, and Biostatistics (M.D.C.), University of California, San Francisco, San Francisco; the University of Illinois at Chicago (J.A.K.), the Department of Pediatrics, Rush University Medical Center (J.N.M.), Ann and Robert Lurie Children's Hospital of Chicago (J.A.P.), and Northwestern University, Feinberg School of Medicine (L.S.) - all in Chicago; the Department of Public Health Sciences, Penn State University, Hershey (T.S.K., V.M.C., D.T.M., A.-M.D.), and the University of Pittsburgh Asthma Institute (S.W., F.H.) and Allegheny General Hospital (D.G.), Pittsburgh - all in Pennsylvania; Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando (J.E.L., K.V.B.), and Nemours Children's Health System, Jacksonville (J.E.L., K.V.B.) - both in Florida; the Department of Pediatrics and Medicine, National Jewish Health, Denver (R.C., S.J.S., M.E.W.), and Children's Hospital Colorado, Aurora (R.C., S.J.S., M.E.W.) - both in Colorado; Duke Allergy, Asthma, and Airway Center, Duke University School of Medicine, Durham (N.L., M.K., L.Q.), Wake Forest University School of Medicine, Winston-Salem (A.H., W.M., S.P.P.), and North Carolina Clinical Research, Raleigh (C.L.) - all in North Carolina; the Departments of Pediatrics and Medicine, Washington University in St. Louis School of Medicine, St. Louis (L.B.B., M.C.); Brigham and Women's Hospital and Harvard Medical School (J.C.C., E.I.) and Boston Children's Hospital (W.P.) - all in Boston; Rainbow Babies and Children's Hospital, Cleveland (J.C., R.M., K.R.); the University of Wisconsin, Madison (L.D., D.J., R.F.L., C.A.S.); Columbia University, New York (E.D.); the Department of Pediatrics, Emory University, Atlanta (A.M.F.); and the Arizona Respiratory Center, University of Arizona, Tucson (F.D.M., W.J.M.)
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Lachowicz-Scroggins ME, Dunican EM, Charbit AR, Raymond W, Looney MR, Peters MC, Gordon ED, Woodruff PG, Lefrançais E, Phillips BR, Mauger DT, Comhair SA, Erzurum SC, Johansson MW, Jarjour NN, Coverstone AM, Castro M, Hastie AT, Bleecker ER, Fajt ML, Wenzel SE, Israel E, Levy BD, Fahy JV. Extracellular DNA, Neutrophil Extracellular Traps, and Inflammasome Activation in Severe Asthma. Am J Respir Crit Care Med 2019; 199:1076-1085. [PMID: 30888839 PMCID: PMC6515873 DOI: 10.1164/rccm.201810-1869oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/15/2019] [Indexed: 12/30/2022] Open
Abstract
Rationale: Extracellular DNA (eDNA) and neutrophil extracellular traps (NETs) are implicated in multiple inflammatory diseases. NETs mediate inflammasome activation and IL-1β secretion from monocytes and cause airway epithelial cell injury, but the role of eDNA, NETs, and IL-1β in asthma is uncertain. Objectives: To characterize the role of activated neutrophils in severe asthma through measurement of NETs and inflammasome activation. Methods: We measured sputum eDNA in induced sputum from 399 patients with asthma in the Severe Asthma Research Program-3 and in 94 healthy control subjects. We subdivided subjects with asthma into eDNA-low and -high subgroups to compare outcomes of asthma severity and of neutrophil and inflammasome activation. We also examined if NETs cause airway epithelial cell damage that can be prevented by DNase. Measurements and Main Results: We found that 13% of the Severe Asthma Research Program-3 cohort is "eDNA-high," as defined by sputum eDNA concentrations above the upper 95th percentile value in health. Compared with eDNA-low patients with asthma, eDNA-high patients had lower Asthma Control Test scores, frequent history of chronic mucus hypersecretion, and frequent use of oral corticosteroids for maintenance of asthma control (all P values <0.05). Sputum eDNA in asthma was associated with airway neutrophilic inflammation, increases in soluble NET components, and increases in caspase 1 activity and IL-1β (all P values <0.001). In in vitro studies, NETs caused cytotoxicity in airway epithelial cells that was prevented by disruption of NETs with DNase. Conclusions: High extracellular DNA concentrations in sputum mark a subset of patients with more severe asthma who have NETs and markers of inflammasome activation in their airways.
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Affiliation(s)
- Marrah E Lachowicz-Scroggins
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Eleanor M Dunican
- 3 School of Medicine and St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Annabelle R Charbit
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Wilfred Raymond
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Mark R Looney
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Michael C Peters
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Erin D Gordon
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Prescott G Woodruff
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Emma Lefrançais
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Brenda R Phillips
- 4 Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - David T Mauger
- 4 Division of Statistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - Suzy A Comhair
- 5 Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Nizar N Jarjour
- 7 Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Andrea M Coverstone
- 8 Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Mario Castro
- 8 Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Annette T Hastie
- 9 Pulmonary Section, Department of Internal Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Eugene R Bleecker
- 10 Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
| | - Merritt L Fajt
- 11 Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;and
| | - Sally E Wenzel
- 11 Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;and
| | - Elliot Israel
- 12 Division of Pulmonary and Critical Care Medicine, Brigham Research Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bruce D Levy
- 12 Division of Pulmonary and Critical Care Medicine, Brigham Research Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John V Fahy
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
- 2 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
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Schaefer N, Li X, Seibold MA, Jarjour NN, Denlinger LC, Castro M, Coverstone AM, Teague WG, Boomer J, Bleecker ER, Meyers DA, Moore WC, Hawkins GA, Fahy J, Phillips BR, Mauger DT, Dakhama A, Gellatly S, Pavelka N, Berman R, Di YP, Wenzel SE, Chu HW. The effect of BPIFA1/SPLUNC1 genetic variation on its expression and function in asthmatic airway epithelium. JCI Insight 2019; 4:127237. [PMID: 30996135 DOI: 10.1172/jci.insight.127237] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/14/2019] [Indexed: 11/17/2022] Open
Abstract
Bacterial permeability family member A1 (BPIFA1), also known as short palate, lung, and nasal epithelium clone 1 (SPLUNC1), is a protein involved in the antiinflammatory response. The goal of this study was to determine whether BPIFA1 expression in asthmatic airways is regulated by genetic variations, altering epithelial responses to type 2 cytokines (e.g., IL-13). Nasal epithelial cells from patients with mild to severe asthma were collected from the National Heart, Lung, and Blood Institute Severe Asthma Research Program centers, genotyped for rs750064, and measured for BPIFA1. To determine the function of rs750064, cells were cultured at air-liquid interface and treated with IL-13 with or without recombinant human BPIFA1 (rhBPIFA1). Noncultured nasal cells with the rs750064 CC genotype had significantly less BPIFA1 mRNA expression than the CT and TT genotypes. Cultured CC versus CT and TT cells without stimulation maintained less BPIFA1 expression. With IL-13 treatment, CC genotype cells secreted more eotaxin-3 than CT and TT genotype cells. Also, rhBPIFA1 reduced IL-13-mediated eotaxin-3. BPIFA1 mRNA levels negatively correlated with serum IgE and fractional exhaled nitric oxide. Baseline FEV1% levels were lower in the asthma patients with the CC genotype (n = 1,016). Our data suggest that less BPIFA1 in asthma patients with the CC allele may predispose them to greater eosinophilic inflammation, which could be attenuated by rhBPIFA1 protein therapy.
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Affiliation(s)
| | - Xingnan Li
- University of Arizona, Tucson, Arizona, USA
| | | | | | | | - Mario Castro
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | | | - Jonathan Boomer
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | | | - Wendy C Moore
- Wake Forest University, Winston-Salem, North Carolina, USA
| | | | - John Fahy
- UCSF, San Francisco, California, USA
| | | | - David T Mauger
- Pennsylvania State University, Centre County, Pennsylvania, USA
| | | | | | | | | | - Y Peter Di
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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47
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Sorkness CA, King TS, Dyer AM, Chinchilli VM, Mauger DT, Krishnan JA, Blake K, Castro M, Covar R, Israel E, Kraft M, Lang JE, Lugogo N, Peters SP, Wechsler ME, Wenzel SE, Lazarus SC. Adapting clinical trial design to maintain meaningful outcomes during a multicenter asthma trial in the precision medicine era. Contemp Clin Trials 2019; 77:98-103. [PMID: 30593883 PMCID: PMC6425934 DOI: 10.1016/j.cct.2018.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/19/2018] [Accepted: 12/25/2018] [Indexed: 11/23/2022]
Abstract
Precision medicine is expected to impact the care of people with asthma, given its high disease prevalence, heterogeneity of pathophysiologic mechanisms, and consequent clinical phenotypes. A novel phenotype-stratified clinical trial conducted by the NHLBI AsthmaNet Consortium, titled Steroids in Eosinophil Negative Asthma (SIENA), was a randomized, multicenter, clinical trial that prospectively stratified individuals according to their baseline level of sputum inflammation during a screening period. Two phenotypic strata were assigned based on an a priori defined extent of sputum eosinophilia (Eos Low versus Eos High). This article describes: the scientific premise for the trial design, including assumptions used for power calculations; modifications to the analysis plan implemented after the trial started due to a higher than expected prevalence of one phenotypic stratum which impacted the ability to accrue sufficient subjects within the planned budget and study period; investigator alternatives to address the strata imbalance weighing scientific impact and study feasibility; and the final modified SIENA study design and analysis plan. SIENA was successfully completed in a manner that maintained meaningful outcomes. We conclude with recommendations for incorporation of pre-specified contingency plans into phenotype-directed protocols, to address the potential for differences in observed compared to estimated prevalence of different phenotypes in a study population. These approaches can be applied to precision medicine trials for the future.
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Affiliation(s)
- Christine A Sorkness
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, United States.
| | - Tonya S King
- Penn State University, Hershey, PA, United States
| | | | | | | | | | - Kathryn Blake
- Nemours Children's Health System, Jacksonville, FL, United States
| | - Mario Castro
- Washington University, School of Medicine, St Louis, MO, United States
| | - Ronina Covar
- National Jewish Health, Denver, CO, United States
| | - Elliot Israel
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Monica Kraft
- Department of Medicine, University of Arizona, Tucson, AZ, United States
| | - Jason E Lang
- Department of Pediatrics, Duke University, Durham, NC, United States
| | - Njira Lugogo
- University of Michigan, Ann Arbor, MI, United States
| | - Stephen P Peters
- Wake Forest School of Medicine, Winston-Salem, NC, United States
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48
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Guilbert TW, Bacharier LB, Mauger DT, Phipatanakul W, Szefler SJ, Boehmer S, Beigelman A, Fitzpatrick AM, Jackson DJ, Baxi SN, Benson M, Burnham CAD, Cabana MD, Castro M, Chmiel JF, Covar R, Daines M, Gaffin JM, Gentile DA, Holguin F, Israel E, Kelly HW, Lazarus SC, Lemanske RF, Ly N, Meade K, Morgan W, Moy J, Olin JT, Peters SP, Pongracic JA, Raissy HH, Ross K, Sheehan WJ, Sorkness C, Teague WG, Thyne S, Martinez FD. Challenges in assessing the efficacy of systemic corticosteroids for severe wheezing episodes in preschool children. J Allergy Clin Immunol 2019; 143:1934-1937.e4. [PMID: 30660645 DOI: 10.1016/j.jaci.2018.10.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Theresa W Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Mo
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Wanda Phipatanakul
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | | | - Susan Boehmer
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pa
| | - Avraham Beigelman
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Mo
| | | | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Sachin N Baxi
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | | | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University in St Louis School of Medicine, St Louis, Mo
| | - Michael D Cabana
- Departments of Medicine and Pediatrics, University of California, San Francisco, San Francisco, Calif
| | - Mario Castro
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Mo
| | | | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Michael Daines
- Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - Jonathan M Gaffin
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Mass
| | - Deborah A Gentile
- Department of Pediatrics, Allegheny General Hospital, Pittsburgh, Pa
| | | | | | - H William Kelly
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
| | - Stephen C Lazarus
- Departments of Medicine and Pediatrics, University of California, San Francisco, San Francisco, Calif
| | - Robert F Lemanske
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Ngoc Ly
- Airway Clinical Research Center, University of California, San Francisco, San Francisco, Calif
| | | | - Wayne Morgan
- Arizona Respiratory Center, University of Arizona, Tucson, Ariz
| | - James Moy
- Stroger Hospital of Cook County Pediatric Services, Chicago, Ill
| | - J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | | | | | - Hengameh H Raissy
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
| | - Kristie Ross
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - William J Sheehan
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | | | - W Gerald Teague
- University of Virginia School of Medicine, Charlottesville, Va
| | - Shannon Thyne
- Department of Pediatrics, San Francisco General Hospital, San Francisco, Calif
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49
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Fitzpatrick AM, Bacharier LB, Guilbert TW, Jackson DJ, Szefler SJ, Beigelman A, Cabana MD, Covar R, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Zeiger RS, Mauger DT. Phenotypes of Recurrent Wheezing in Preschool Children: Identification by Latent Class Analysis and Utility in Prediction of Future Exacerbation. J Allergy Clin Immunol Pract 2018; 7:915-924.e7. [PMID: 30267890 DOI: 10.1016/j.jaip.2018.09.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recurrent preschool wheezing is a heterogeneous disorder with significant morbidity, yet little is known about phenotypic determinants and their impact on clinical outcomes. OBJECTIVE Latent class analysis (LCA) was used to identify latent classes of recurrent preschool wheeze and their association with future exacerbations and inhaled corticosteroid (ICS) treatment response. METHODS Data from 5 clinical trials of 1708 children aged 12 to 71 months with recurrent wheezing were merged. LCA was performed on 10 demographic, exposure, and sensitization variables to determine the optimal number of latent classes. The primary outcome was the annualized rate of wheezing exacerbations requiring systemic corticosteroids during the study intervention period; the secondary outcome was the time to first exacerbation. Exploratory analyses examined the effect of daily ICS treatment on exacerbation outcomes. RESULTS Four latent classes of recurrent wheezing were identified; these were not distinguished by current symptoms or historical exacerbations but differed with regard to allergen sensitization and/or exposures. Annualized exacerbation rates (mean ± SEM/year) were 0.65 ± 0.06 for class 1 ("minimal sensitization"), 0.93 ± 0.10 for class 2 ("sensitization with indoor pet exposure"), 0.60 ± 0.07 for class 3 ("sensitization with tobacco smoke exposure"), and 0.81 ± 0.10 for class 4 ("multiple sensitization and eczema") (P < .001). In a research setting of high adherence, daily ICS treatment improved exacerbation rates in classes 2 and 4 but not the other groups. CONCLUSIONS Sensitization and exposure assessments are useful in the prediction of future exacerbation and may identify children most likely to respond favorably to daily ICS treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | | | - Theresa W Guilbert
- Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | | | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado, Aurora, Colo
| | | | - Michael D Cabana
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Fernando Holguin
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pa
| | | | | | - Wayne Morgan
- Department of Pediatrics, University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region, San Diego, Calif; Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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50
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Ash SY, Rahaghi FN, Come CE, Ross JC, Colon AG, Cardet-Guisasola JC, Dunican EM, Bleecker ER, Castro M, Fahy JV, Fain SB, Gaston BM, Hoffman EA, Jarjour NN, Mauger DT, Wenzel SE, Levy BD, San Jose Estepar R, Israel E. Pruning of the Pulmonary Vasculature in Asthma. The Severe Asthma Research Program (SARP) Cohort. Am J Respir Crit Care Med 2018; 198:39-50. [PMID: 29672122 PMCID: PMC6034125 DOI: 10.1164/rccm.201712-2426oc] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/19/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Loss of the peripheral pulmonary vasculature, termed vascular pruning, is associated with disease severity in patients with chronic obstructive pulmonary disease. OBJECTIVES To determine if pulmonary vascular pruning is associated with asthma severity and exacerbations. METHODS We measured the total pulmonary blood vessel volume (TBV) and the blood vessel volume of vessels less than 5 mm2 in cross-sectional area (BV5) and of vessels less than 10 mm2 (BV10) in cross-sectional area on noncontrast computed tomographic scans of participants from the Severe Asthma Research Program. Lower values of the BV5 to TBV ratio (BV5/TBV) and the BV10 to TBV ratio (BV10/TBV) represented vascular pruning (loss of the peripheral pulmonary vasculature). MEASUREMENTS AND MAIN RESULTS Compared with healthy control subjects, patients with severe asthma had more pulmonary vascular pruning. Among those with asthma, those with poor asthma control had more pruning than those with well-controlled disease. Pruning of the pulmonary vasculature was also associated with lower percent predicted FEV1 and FVC, greater peripheral and sputum eosinophilia, and higher BAL serum amyloid A/lipoxin A4 ratio but not with low-attenuation area or with sputum neutrophilia. Compared with individuals with less pruning, individuals with the most vascular pruning had 150% greater odds of reporting an asthma exacerbation (odds ratio, 2.50; confidence interval, 1.05-5.98; P = 0.039 for BV10/TBV) and reported 45% more asthma exacerbations during follow-up (incidence rate ratio, 1.45; confidence interval, 1.02-2.06; P = 0.036 for BV10/TBV). CONCLUSIONS Pruning of the peripheral pulmonary vasculature is associated with asthma severity, control, and exacerbations, and with lung function and eosinophilia.
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Affiliation(s)
- Samuel Y. Ash
- Division of Pulmonary and Critical Care Medicine and
- Applied Chest Imaging Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Farbod N. Rahaghi
- Division of Pulmonary and Critical Care Medicine and
- Applied Chest Imaging Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Carolyn E. Come
- Division of Pulmonary and Critical Care Medicine and
- Applied Chest Imaging Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James C. Ross
- Applied Chest Imaging Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alysha G. Colon
- College of Medicine, University of Florida, Gainesville, Florida
| | | | - Eleanor M. Dunican
- St. Vincent’s University Hospital, University College Dublin, Dublin, Ireland
| | - Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, Arizona
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - John V. Fahy
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, California
| | - Sean B. Fain
- Department of Medical Physics
- Department of Radiology
- Department of Biomedical Engineering, and
| | - Benjamin M. Gaston
- Division of Pediatric Allergy/Immunology and
- Division of Pediatric Pulmonology, Rainbow Babies and Children’s Hospital and Cleveland Medical Center, Cleveland, Ohio
| | - Eric A. Hoffman
- Department of Radiology
- Department of Biomedical Engineering, and
- Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Nizar N. Jarjour
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin, Madison, Wisconsin
| | - David T. Mauger
- Division of Biostatistics and Bioinformatics, Eberly College of Science, Penn State University, University Park, Pennsylvania; and
| | - Sally E. Wenzel
- Division of Pulmonary, Allergy and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine and
| | - Raul San Jose Estepar
- Applied Chest Imaging Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine and
| | - SARP Investigators
- Division of Pulmonary and Critical Care Medicine and
- Applied Chest Imaging Laboratory, Brigham and Women’s Hospital, Boston, Massachusetts
- College of Medicine, University of Florida, Gainesville, Florida
- Division of Allergy and Immunology, Department of Medicine, University of South Florida, Tampa, Florida
- St. Vincent’s University Hospital, University College Dublin, Dublin, Ireland
- Division of Genetics, Genomics and Precision Medicine, University of Arizona, Tucson, Arizona
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, California
- Department of Medical Physics
- Department of Radiology
- Department of Biomedical Engineering, and
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin, Madison, Wisconsin
- Division of Pediatric Allergy/Immunology and
- Division of Pediatric Pulmonology, Rainbow Babies and Children’s Hospital and Cleveland Medical Center, Cleveland, Ohio
- Department of Radiology
- Department of Biomedical Engineering, and
- Department of Medicine, University of Iowa, Iowa City, Iowa
- Division of Biostatistics and Bioinformatics, Eberly College of Science, Penn State University, University Park, Pennsylvania; and
- Division of Pulmonary, Allergy and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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