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Gupta VK, Rajendraprasad S, Ozkan M, Ramachandran D, Ahmad S, Bakken JS, Laudanski K, Gajic O, Bauer B, Zec S, Freeman DW, Khanna S, Shah A, Skalski JH, Sung J, Karnatovskaia LV. Safety, feasibility, and impact on the gut microbiome of kefir administration in critically ill adults. BMC Med 2024; 22:80. [PMID: 38378568 PMCID: PMC10880344 DOI: 10.1186/s12916-024-03299-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Dysbiosis of the gut microbiome is frequent in the intensive care unit (ICU), potentially leading to a heightened risk of nosocomial infections. Enhancing the gut microbiome has been proposed as a strategic approach to mitigate potential adverse outcomes. While prior research on select probiotic supplements has not successfully shown to improve gut microbial diversity, fermented foods offer a promising alternative. In this open-label phase I safety and feasibility study, we examined the safety and feasibility of kefir as an initial step towards utilizing fermented foods to mitigate gut dysbiosis in critically ill patients. METHODS We administered kefir in escalating doses (60 mL, followed by 120 mL after 12 h, then 240 mL daily) to 54 critically ill patients with an intact gastrointestinal tract. To evaluate kefir's safety, we monitored for gastrointestinal symptoms. Feasibility was determined by whether patients received a minimum of 75% of their assigned kefir doses. To assess changes in the gut microbiome composition following kefir administration, we collected two stool samples from 13 patients: one within 72 h of admission to the ICU and another at least 72 h after the first stool sample. RESULTS After administering kefir, none of the 54 critically ill patients exhibited signs of kefir-related bacteremia. No side effects like bloating, vomiting, or aspiration were noted, except for diarrhea in two patients concurrently on laxatives. Out of the 393 kefir doses prescribed for all participants, 359 (91%) were successfully administered. We were able to collect an initial stool sample from 29 (54%) patients and a follow-up sample from 13 (24%) patients. Analysis of the 26 paired samples revealed no increase in gut microbial α-diversity between the two timepoints. However, there was a significant improvement in the Gut Microbiome Wellness Index (GMWI) by the second timepoint (P = 0.034, one-sided Wilcoxon signed-rank test); this finding supports our hypothesis that kefir administration can improve gut health in critically ill patients. Additionally, the known microbial species in kefir were found to exhibit varying levels of engraftment in patients' guts. CONCLUSIONS Providing kefir to critically ill individuals is safe and feasible. Our findings warrant a larger evaluation of kefir's safety, tolerability, and impact on gut microbiome dysbiosis in patients admitted to the ICU. TRIAL REGISTRATION NCT05416814; trial registered on June 13, 2022.
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Affiliation(s)
- Vinod K Gupta
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sanu Rajendraprasad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mahmut Ozkan
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sumera Ahmad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Johan S Bakken
- Section of Infectious Diseases, St Luke's Hospital, Duluth, MN, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brent Bauer
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Simon Zec
- Department of Anesthesiology and Perioperative Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David W Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Sahil Khanna
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jaeyun Sung
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Kanj AN, Guiance IR, Kottom TJ, Schaefbauer KJ, Choudhury M, Limper AH, Skalski JH. The intestinal commensal fungus Wallemia mellicola enhances asthma in mice through Dectin-2. Med Mycol 2024; 62:myae004. [PMID: 38331424 PMCID: PMC10898867 DOI: 10.1093/mmy/myae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/10/2024] Open
Abstract
Overgrowth of the fungus Wallemia mellicola in the intestines of mice enhances the severity of asthma. Wallemia mellicola interacts with the immune system through Dectin-2 expressed on the surface of myeloid and intestinal epithelial cells. Using Dectin-2-deficient mice, we show that the interaction of W. mellicola with Dectin-2 is essential for the gut-lung pathways, enhancing the severity of asthma in mice with W. mellicola intestinal dysbiosis. These findings offer better insight into dysbiosis-associated inflammation and highlight the role pattern recognition receptors have in immune recognition of commensal fungi in the gut, leading to alterations in immune function in the lungs.
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Affiliation(s)
- Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN USA
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
| | - Irene Riestra Guiance
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN USA
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
| | - Theodore J Kottom
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
| | - Kyle J Schaefbauer
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
| | - Malay Choudhury
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN USA
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN USA
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN USA
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Kanj AN, Kottom TJ, Schaefbauer KJ, Choudhury M, Limper AH, Skalski JH. Dysbiosis of the intestinal fungal microbiota increases lung resident group 2 innate lymphoid cells and is associated with enhanced asthma severity in mice and humans. Respir Res 2023; 24:144. [PMID: 37259076 PMCID: PMC10230676 DOI: 10.1186/s12931-023-02422-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/15/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The gut-lung axis is the concept that alterations of gut microbiota communities can influence immune function in the lungs. While studies have explored the relationship between intestinal bacterial dysbiosis and asthma development, less is understood about the impact of commensal intestinal fungi on asthma severity and control and underlying mechanisms by which this occurs. METHODS Wild-type mice were treated with Cefoperazone to deplete gut bacteria and administered Candida albicans or water through gavage. Mice were then sensitized to house dust mite (HDM) and their lungs were analyzed for changes in immune response. Humans with asthma were recruited and stool samples were analyzed for Candida abundance and associations with asthma severity and control. RESULTS Mice with intestinal Candida dysbiosis had enhanced Th2 response after airway sensitization with HDM, manifesting with greater total white cell and eosinophil counts in the airway, and total IgE concentrations in the serum. Group 2 innate lymphoid cells (ILC2) were more abundant in the lungs of mice with Candida gut dysbiosis, even when not sensitized to HDM, suggesting that ILC2 may be important mediators of the enhanced Th2 response. These effects occurred with no detectable increased Candida in the lung by culture or rtPCR suggesting gut-lung axis interactions were responsible. In humans with asthma, enhanced intestinal Candida burden was associated with the risk of severe asthma exacerbation in the past year, independent of systemic antibiotic and glucocorticoid use. CONCLUSIONS Candida gut dysbiosis may worsen asthma control and enhance allergic airway inflammation, potentially mediated by ILC2. Further studies are necessary to examine whether microbial dysbiosis can drive difficult-to-control asthma in humans and to better understand the underlying mechanisms.
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Affiliation(s)
- Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Theodore J Kottom
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Kyle J Schaefbauer
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Malay Choudhury
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
- Thoracic Disease Research Unit, Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA.
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Martin MJ, Pennington KM, Skalski JH, Yi ES, Levin DL, Durani U, Ryu JH. Emphysematous Lung Lesions Caused by Perivascular and Alveolar-Septal Deposition of Amyloid Light-Chain Amyloidosis. Chest 2021; 160:e169-e171. [PMID: 34366038 DOI: 10.1016/j.chest.2021.03.038] [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: 11/03/2020] [Revised: 03/10/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022] Open
Abstract
Pulmonary amyloidosis, whether isolated or seen as part of systemic amyloidosis, has a variety of radiographic manifestations. Known parenchymal lung findings include reticulonodular opacities, diffuse interstitial infiltrates, or cystic lesions. Here, we present a case of systemic amyloid light-chain (AL) amyloidosis presenting with severe exertional dyspnea and emphysematous lung lesions on chest CT, a finding described only once before. Although factors that influence the pattern of pulmonary amyloid deposition remain unclear, CT image findings typically reflect the histopathologic patterns of deposition. In this case, we hypothesize that the emphysematous changes in the lower lung zones are likely a manifestation of severe alveolar-septal involvement. This case suggests that radiographic findings of pulmonary amyloidosis are not limited to the more common findings of reticular opacities or interstitial infiltrates. Emphysematous changes are possible, and clinicians should maintain a broad differential when seen in the setting of dyspnea.
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Affiliation(s)
- Max J Martin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic and Surgical Pathology, Department of Pathology, Mayo Clinic, Rochester, MN
| | - David L Levin
- Division of Thoracic Radiology, Department of Radiology, Mayo Clinic, Rochester, MN
| | - Urshila Durani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Limon JJ, Tang J, Li D, Wolf AJ, Michelsen KS, Funari V, Gargus M, Nguyen C, Sharma P, Maymi VI, Iliev ID, Skalski JH, Brown J, Landers C, Borneman J, Braun J, Targan SR, McGovern DPB, Underhill DM. Malassezia Is Associated with Crohn's Disease and Exacerbates Colitis in Mouse Models. Cell Host Microbe 2019; 25:377-388.e6. [PMID: 30850233 DOI: 10.1016/j.chom.2019.01.007] [Citation(s) in RCA: 238] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/19/2018] [Accepted: 01/15/2019] [Indexed: 01/09/2023]
Abstract
Inflammatory bowel disease (IBD) is characterized by alterations in the intestinal microbiota and altered immune responses to gut microbiota. Evidence is accumulating that IBD is influenced by not only commensal bacteria but also commensal fungi. We characterized fungi directly associated with the intestinal mucosa in healthy people and Crohn's disease patients and identified fungi specifically abundant in patients. One of these, the common skin resident fungus Malassezia restricta, is also linked to the presence of an IBD-associated polymorphism in the gene for CARD9, a signaling adaptor important for anti-fungal defense. M. restricta elicits innate inflammatory responses largely through CARD9 and is recognized by Crohn's disease patient anti-fungal antibodies. This yeast elicits strong inflammatory cytokine production from innate cells harboring the IBD-linked polymorphism in CARD9 and exacerbates colitis via CARD9 in mouse models of disease. Collectively, these results suggest that targeting specific commensal fungi may be a therapeutic strategy for IBD.
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Affiliation(s)
- Jose J Limon
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Jie Tang
- Genomics Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dalin Li
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrea J Wolf
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Kathrin S Michelsen
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Vince Funari
- Genomics Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Matthew Gargus
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Christopher Nguyen
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Purnima Sharma
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Viviana I Maymi
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Iliyan D Iliev
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Joseph H Skalski
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jordan Brown
- Genomics Core, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Carol Landers
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - James Borneman
- Department of Plant Pathology and Microbiology, University of California, Riverside, Riverside, CA 92521, USA
| | - Jonathan Braun
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Stephan R Targan
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dermot P B McGovern
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - David M Underhill
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
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Skalski JH, Limon JJ, Sharma P, Gargus MD, Nguyen C, Tang J, Coelho AL, Hogaboam CM, Crother TR, Underhill DM. Expansion of commensal fungus Wallemia mellicola in the gastrointestinal mycobiota enhances the severity of allergic airway disease in mice. PLoS Pathog 2018; 14:e1007260. [PMID: 30235351 PMCID: PMC6147580 DOI: 10.1371/journal.ppat.1007260] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/06/2018] [Indexed: 12/26/2022] Open
Abstract
The gastrointestinal microbiota influences immune function throughout the body. The gut-lung axis refers to the concept that alterations of gut commensal microorganisms can have a distant effect on immune function in the lung. Overgrowth of intestinal Candida albicans has been previously observed to exacerbate allergic airways disease in mice, but whether subtler changes in intestinal fungal microbiota can affect allergic airways disease is less clear. In this study we have investigated the effects of the population expansion of commensal fungus Wallemia mellicola without overgrowth of the total fungal community. Wallemia spp. are commonly found as a minor component of the commensal gastrointestinal mycobiota in both humans and mice. Mice with an unaltered gut microbiota community resist population expansion when gavaged with W. mellicola; however, transient antibiotic depletion of gut microbiota creates a window of opportunity for expansion of W. mellicola following delivery of live spores to the gastrointestinal tract. This phenomenon is not universal as other commensal fungi (Aspergillus amstelodami, Epicoccum nigrum) do not expand when delivered to mice with antibiotic-depleted microbiota. Mice with Wallemia-expanded gut mycobiota experienced altered pulmonary immune responses to inhaled aeroallergens. Specifically, after induction of allergic airways disease with intratracheal house dust mite (HDM) antigen, mice demonstrated enhanced eosinophilic airway infiltration, airway hyperresponsiveness (AHR) to methacholine challenge, goblet cell hyperplasia, elevated bronchoalveolar lavage IL-5, and enhanced serum HDM IgG1. This phenomenon occurred with no detectable Wallemia in the lung. Targeted amplicon sequencing analysis of the gastrointestinal mycobiota revealed that expansion of W. mellicola in the gut was associated with additional alterations of bacterial and fungal commensal communities. We therefore colonized fungus-free Altered Schaedler Flora (ASF) mice with W. mellicola. ASF mice colonized with W. mellicola experienced enhanced severity of allergic airways disease compared to fungus-free control ASF mice without changes in bacterial community composition.
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Affiliation(s)
- Joseph H. Skalski
- F. Widjaja Foundation Inflammatory Bowel & Immunobiology Research Institute, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jose J. Limon
- F. Widjaja Foundation Inflammatory Bowel & Immunobiology Research Institute, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Purnima Sharma
- F. Widjaja Foundation Inflammatory Bowel & Immunobiology Research Institute, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Matthew D. Gargus
- F. Widjaja Foundation Inflammatory Bowel & Immunobiology Research Institute, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Christopher Nguyen
- F. Widjaja Foundation Inflammatory Bowel & Immunobiology Research Institute, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Jie Tang
- Genomics Core, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Ana Lucia Coelho
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Cory M. Hogaboam
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Timothy R. Crother
- Division of Pediatric Infectious Diseases, Department of Medicine, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - David M. Underhill
- F. Widjaja Foundation Inflammatory Bowel & Immunobiology Research Institute, and the Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
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Abstract
Fungi are increasingly being recognized as common members of the microbiomes found on nearly all mucosal surfaces, and interest is growing in understanding how these organisms may contribute to health and disease. In this review, we investigate recent developments in our understanding of the fungal microbiota or "mycobiota" including challenges faced in characterizing it, where these organisms are found, their diversity, and how they interact with host immunity. Growing evidence indicates that, like the bacterial microbiota, the fungal microbiota is often altered in disease states, and increasingly studies are being designed to probe the functional consequences of such fungal dysbiosis on health and disease.
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Affiliation(s)
- Jose J Limon
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA; Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Joseph H Skalski
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA; Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David M Underhill
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA; Division of Immunology, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA; Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway.
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Abstract
BACKGROUND The interview visit is an important component of residency and fellowship recruitment that requires a substantial expenditure of time and resources for both training programs and candidates. OBJECTIVE Survey aimed to study the impact of a preinterview dinner on fellowship program candidates. METHODS A single center preintervention and postintervention comparison study was conducted using an electronic survey distributed to all Pulmonary and Critical Care Fellowship candidates over 3 years (2013-2015). The interview visit in 2013 did not include a preinterview dinner (no-dinner group), while the candidates interviewing in 2014 and 2015 were invited to a preinterview dinner with current fellows on the evening before the interview day (dinner group). RESULTS The survey was distributed to all candidates (N = 70) who interviewed between 2013 and 2015 with a 59% (n = 41) completion rate. Ninety percent of respondents (37 of 41) reported that a preinterview dinner is valuable, primarily to gain more information about the program and to meet current fellows. Among candidates who attended the dinner, 88% (23 of 26) reported the dinner improved their impression of the program. The dinner group was more likely to have a positive view of current fellows in the program as desirable peers compared to candidates in the no-dinner group. CONCLUSIONS This pilot study suggests that a preinterview dinner may offer benefits for candidates and training programs and may enhance candidates' perceptions of the fellowship program relative to other programs they are considering.
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Abstract
Respiratory illness is an important cause of morbidity and mortality in patients with human immunodeficiency virus (HIV). The spectrum of pulmonary disease that can affect patients with HIV is wide and includes opportunistic infection with many fungal, viral, and parasitic organisms. This article reviews the clinical presentation; approach to diagnosis; and management of fungal, viral, and parasitic pneumonias that can develop in patients with HIV including respiratory disease caused by Aspergillus, Cryptococcus, Histoplasma, Coccidioides, Cytomegalovirus, Toxoplasma, and Strongyloides. Because clinical symptoms and radiographic patterns are often insensitive at distinguishing these pulmonary infections, this review particularly focuses on specific host risk factors and diagnostic testing to consider when approaching HIV patients with respiratory illness.
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Affiliation(s)
- Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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10
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Gilbert CR, Lee HJ, Skalski JH, Maldonado F, Wahidi M, Choi PJ, Bessich J, Sterman D, Argento AC, Shojaee S, Gorden JA, Wilshire CL, Feller-Kopman D, Amador RO, Nonyane BAS, Yarmus L. The Use of Indwelling Tunneled Pleural Catheters for Recurrent Pleural Effusions in Patients With Hematologic Malignancies: A Multicenter Study. Chest 2015; 148:752-758. [PMID: 25789576 PMCID: PMC4556125 DOI: 10.1378/chest.14-3119] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Malignant pleural effusion is a common complication of advanced malignancies. Indwelling tunneled pleural catheter (IPC) placement provides effective palliation but can be associated with complications, including infection. In particular, hematologic malignancy and the associated immunosuppressive treatment regimens may increase infectious complications. This study aimed to review outcomes in patients with hematologic malignancy undergoing IPC placement. METHODS A retrospective multicenter study of IPCs placed in patients with hematologic malignancy from January 2009 to December 2013 was performed. Inclusion criteria were recurrent, symptomatic pleural effusion and an underlying diagnosis of hematologic malignancy. Records were reviewed for patient demographics, operative reports, and pathology, cytology, and microbiology reports. RESULTS Ninety-one patients (mean ± SD age, 65.4 ± 15.4 years) were identified from eight institutions. The mean × SD in situ dwell time of all catheters was 89.9 ± 127.1 days (total, 8,160 catheter-days). Seven infectious complications were identified, all of the pleural space. All patients were admitted to the hospital for treatment, with four requiring additional pleural procedures. Two patients died of septic shock related to pleural infection. CONCLUSIONS We present, to our knowledge, the largest study examining clinical outcomes related to IPC placement in patients with hematologic malignancy. An overall 7.7% infection risk and 2.2% mortality were identified, similar to previously reported studies, despite the significant immunosuppression and pancytopenia often present in this population. IPC placement appears to remain a reasonable clinical option for patients with recurrent pleural effusions related to hematologic malignancy.
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Affiliation(s)
- Christopher R Gilbert
- Division of Pulmonary, Allergy, and Critical Care Medicine, Bronchoscopy and Interventional Pulmonology, Penn State College of Medicine-Milton S. Hershey Medical Center, Hershey, PA.
| | - Hans J Lee
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Fabien Maldonado
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Momen Wahidi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Philip J Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Jamie Bessich
- Division of Pulmonary, Allergy, and Critical Care Medicine, Interventional Pulmonology and Thoracic Oncology, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Daniel Sterman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Interventional Pulmonology and Thoracic Oncology, University of Pennsylvania Medical Center, Philadelphia, PA
| | - A Christine Argento
- Division of Pulmonary, Allergy, and Critical Care Medicine, Emory University Medical Center, Atlanta, GA
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Jed A Gorden
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
| | - Candice L Wilshire
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ricardo O Amador
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, The Johns Hopkins University School of Medicine, Baltimore, MD
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Skalski JH, Kottom TJ, Limper AH. Pathobiology of Pneumocystis pneumonia: life cycle, cell wall and cell signal transduction. FEMS Yeast Res 2015; 15:fov046. [PMID: 26071598 DOI: 10.1093/femsyr/fov046] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 12/28/2022] Open
Abstract
Pneumocystis is a genus of ascomycetous fungi that are highly morbid pathogens in immunosuppressed humans and other mammals. Pneumocystis cannot easily be propagated in culture, which has greatly hindered understanding of its pathobiology. The Pneumocystis life cycle is intimately associated with its mammalian host lung environment, and life cycle progression is dependent on complex interactions with host alveolar epithelial cells and the extracellular matrix. The Pneumocystis cell wall is a varied and dynamic structure containing a dominant major surface glycoprotein, β-glucans and chitins that are important for evasion of host defenses and stimulation of the host immune system. Understanding of Pneumocystis cell signaling pathways is incomplete, but much has been deduced by comparison of the Pneumocystis genome with homologous genes and proteins in related fungi. In this mini-review, the pathobiology of Pneumocystis is reviewed, with particular focus on the life cycle, cell wall components and cell signal transduction.
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Affiliation(s)
- Joseph H Skalski
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Theodore J Kottom
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Andrew H Limper
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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12
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Skalski JH, Elrashidi M, Reed DA, McDonald FS, Bhagra A. Using Standardized Patients to Teach Point-of-Care Ultrasound-Guided Physical Examination Skills to Internal Medicine Residents. J Grad Med Educ 2015. [PMID: 26217431 PMCID: PMC4507938 DOI: 10.4300/jgme-d-14-00178.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Point-of-care (POC) ultrasound has been shown to improve procedural outcomes and physical examination accuracy in multiple settings. There are limited data regarding the optimal way to train nonradiologists in POC ultrasound. This is a primary barrier to more widespread use of ultrasound in the physical examination. OBJECTIVE We created a workshop to instruct postgraduate year (PGY)-2 and PGY-3 internal medicine residents in POC ultrasound imaging of the abdominal aorta and kidneys. METHODS A half-day simulation center workshop was created to review ultrasound operations and teach residents to independently obtain ultrasound images of the abdominal aorta and kidneys on standardized patients with normal anatomy. The workshop incorporated didactic instruction and hands-on ultrasound practice in small groups. Each resident's ability to independently obtain ultrasound images was assessed using a preworkshop and postworkshop skills examination with a standardized patient. Resident knowledge and attitudes toward POC ultrasound were also assessed using a preworkshop and postworkshop test and survey. RESULTS A total of 58 residents completed the workshop, and 84% were able to independently obtain high-quality images of the abdominal aorta and kidney after workshop completion, compared with 16% on the preworkshop test. Residents demonstrated a statistically significant increase in their self-reported confidence with ultrasound operation and image acquisition. CONCLUSIONS Training using standardized patients can prepare residents to independently obtain POC ultrasound images of the aorta and kidneys. Training resulted in increased resident confidence with POC ultrasound and self-reported likelihood of future use.
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Abstract
The burden of pleural diseases continues to rise and affects an increasingly complex and aging patient population. As such, thoracentesis is one of the most common procedures performed by respiratory physicians, as pleural fluid analysis can establish the diagnosis of pleural effusions in approximately 75% of the cases. When a diagnosis is not reached, options include image-guided biopsies, only possible when focal pleural lesions can be identified by computed tomography or ultrasound; closed pleural biopsies, associated with a relatively low diagnostic yield; and surgical pleural biopsies, which typically require general anesthesia and a hospital stay. Medical thoracoscopy addresses some of the limitations of these techniques, allows a comprehensive pleural examination and targeted pleural biopsies, and offers the possibility of treatment of recurrence in the same setting. As such, medical thoracoscopy is ideally positioned as a valuable tool in the diagnosis of unexplained exudative pleural effusions.
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Affiliation(s)
- Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Philippe J Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely, France
| | - Fabien Maldonado
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Abstract
Spontaneous coronary artery dissection is an uncommon cause of chest pain and acute myocardial infarction, occurring most classically in young women without cardiovascular risk factors. We present a case of a man presenting with chest pain and arrhythmia found to have multivessel spontaneous coronary artery dissection and hyperhomocysteinemia and we raise the possibility of a potential link between the two conditions.
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Affiliation(s)
- JJ Liang
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - JH Skalski
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - R Mankad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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15
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Butts MJ, Skalski JH, Wittich CM. 85-year-old man with epistaxis. Mayo Clin Proc 2011; 86:344-7. [PMID: 21454736 PMCID: PMC3068895 DOI: 10.4065/mcp.2010.0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Matthew J. Butts
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Joseph H. Skalski
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Christopher M. Wittich
- Adviser to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN
- Individual reprints of this article are not available. Address correspondence to Christopher M. Wittich, MD, PharmD, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Sweitzer NK, Skalski JH, Eggleston KL, Wagner CA, Velez M, Mitchell GF. Impact of Reductions in Aortic Pressure Augmentation on Stroke Volume and Diastolic Function in Elderly Subjects. J Card Fail 2008. [DOI: 10.1016/j.cardfail.2008.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Skalski JH, Kuch J. Polish thread in the history of circulatory physiology. J Physiol Pharmacol 2006; 57 Suppl 1:5-41. [PMID: 16766800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
A review of the most outstanding achievements in physiology of circulation done by scientists and physicians from Poland and evaluation of their contribution to the world knowledge in this matter is presented in the paper. The authors associate the beginnings of the Polish history of studying heart and its diseases with the brilliant physician from the XIV(th) century - Thomas of Wrocław, and then in the XVI(th) century, with the most eminent physician of Polish Renaissance, the expert on pulse, Joseph Struś. The attempts to address the issues related to the circulatory system over historical period of early ages, through baroque and the blooming period in medicine of the XIX(th), up to our times, were presented. The memories of the exceptional and the more or less known in the world cardiologic ancestors, associated with Poland, were recalled, such as: Adam.Ch. Thebesius, Robert Remak, Edward Korczyński, Oscar Widmann, Napoleon Cybulski, Joseph Pawiński, Andrew Klisiecki, Adolph Beck, Leon Popielski, Wiesław Hołobut and many others. The analysis of Polish achievements in the field of diagnosing and treatment of the ischaemic heart disease, starting from beginnings of the XIX(th) century, was performed. The authors also tried to recapitulate the achievements of the last 50 years in cardiological diagnostics, modern interventional cardiology, cardiac surgery along with transplantology and the scientific programmes concerning these issues. The examples of the greatest scientific achievements related to the circulatory system and to myocardial physiology and pathology over the period of recent decade were described.
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Affiliation(s)
- J H Skalski
- Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Disease, 2 Szpitalna str., 41-800 Zabrze, Poland
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Skalski JH, Sievers HH, Funda J, Regensburger D, Bernhard A. Truncus arteriosus communis associated with interrupted aortic arch: a report on two uncommon cases. Thorac Cardiovasc Surg 1992; 40:92-5. [PMID: 1631880 DOI: 10.1055/s-2007-1020121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The paper presents two infants with the A-4 type of truncus arteriosus communis (according to Van Praagh's classification). One patient who survived a surgical procedure demonstrated a rare variant of aortic arch interruption to the left off the left subclavian artery (type A according to Celoria and Patton), whereas the second presented an uncommon anomaly in which the right subclavian artery originated from the descending aorta with associated severe truncal valve incompetency. The authors describe the clinical picture along with the surgical treatment of the first infant who being six days old was subjected to a correction employing the wide patent ductus arteriosus to reconstruct the aortic arch, following the method described by Gomes and McGoon. Subsequently an aortic homograft was implanted in order to connect the right ventricle and the pulmonary artery.
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Affiliation(s)
- J H Skalski
- Department of Cardiovascular Surgery, University of Kiel, Germany
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