Pulmonary macrophage transplantation therapy.

Bone-marrow transplantation is an effective cell therapy but requires myeloablation, which increases infection risk and mortality. Recent lineage-tracing studies documenting that resident macrophage populations self-maintain independently of haematological progenitors prompted us to consider organ-targeted, cell-specific therapy. Here, using granulocyte-macrophage colony-stimulating factor (GM-CSF) receptor-ß-deficient (Csf2rb(-/-)) mice that develop a myeloid cell disorder identical to hereditary pulmonary alveolar proteinosis (hPAP) in children with CSF2RA or CSF2RB mutations, we show that pulmonary macrophage transplantation (PMT) of either wild-type or Csf2rb-gene-corrected macrophages without myeloablation was safe and well-tolerated and that one administration corrected the lung disease, secondary systemic manifestations and normalized disease-related biomarkers, and prevented disease-specific mortality. PMT-derived alveolar macrophages persisted for at least one year as did therapeutic effects. Our findings identify mechanisms regulating alveolar macrophage population size in health and disease, indicate that GM-CSF is required for phenotypic determination of alveolar macrophages, and support translation of PMT as the first specific therapy for children with hPAP.

Complete Tracheal Ring Deformity. A Translational Genomics Approach to Pathogenesis.

Rationale: Complete tracheal ring deformity (CTRD) is a rare congenital abnormality of unknown etiology characterized by circumferentially continuous or nearly continuous cartilaginous tracheal rings, variable degrees of tracheal stenosis and/or shortening, and/or pulmonary arterial sling anomaly.Objectives: To test the hypothesis that CTRD is caused by inherited or de novo mutations in genes required for normal tracheal development.Methods: CTRD and normal tracheal tissues were examined microscopically to define the tracheal abnormalities present in CTRD. Whole-exome sequencing was performed in children with CTRD and their biological parents ("trio analysis") to identify gene variants in patients with CTRD. Mutations were confirmed by Sanger sequencing, and their potential impact on structure and/or function of encoded proteins was examined using human gene mutation databases. Relevance was further examined by comparison with the effects of targeted deletion of murine homologs important to tracheal development in mice.Measurements and Main Results: The trachealis muscle was absent in all of five patients with CTRD. Exome analysis identified six de novo, three recessive, and multiple compound-heterozygous or rare hemizygous variants in children with CTRD. De novo variants were identified in SHH (Sonic Hedgehog), and inherited variants were identified in HSPG2 (perlecan), ROR2 (receptor tyrosine kinase-like orphan receptor 2), and WLS (Wntless), genes involved in morphogenetic pathways known to mediate tracheoesophageal development in mice.Conclusions: The results of the present study demonstrate that absence of the trachealis muscle is associated with CTRD. Variants predicted to cause disease were identified in genes encoding Hedgehog and Wnt signaling pathway molecules, which are critical to cartilage formation and normal upper airway development in mice.

Airway inflammation and symptoms in children following liver and heart transplantation.

OBJECTIVES: To describe the upper airway endoscopic findings of children with upper airway symptoms after liver transplantation (LT) or heart transplantation (HT). METHODS: Review of children undergoing airway endoscopy after LT or HT from 2011 to 2015 at a tertiary care pediatric hospital. Airway findings, biopsy results, immunosuppression, and Epstein-Barr virus (EBV) levels were recorded. RESULTS: Twenty-three of 158 LT (111) and HT (47) recipients underwent endoscopy. Median time from LT to endoscopy was 9 months (range 4-25) and 31 months (range 1-108) for HT. Thirteen of 23 patients presented with upper airway symptoms, and 10/23 presented with respiratory failure or for surveillance. Thirteen patients with upper airway symptoms had abnormal findings (7 LT; 6 HT), most commonly arytenoid edema (13 patients). There were five EBV-positive biopsies (four with post-transplant lymphoproliferative disorder), and six EBV-negative biopsies with lymphocytic inflammation. One biopsy demonstrated fungal infection. Immunosuppression was decreased in seven patients, and three received steroids. There were no episodes of allograft rejection. No patients had airway symptoms at last follow-up. CONCLUSIONS: In pediatric solid organ transplant recipients, symptoms of airway obstruction are not uncommon and should be evaluated with endoscopy. Endoscopy without symptoms is low-yield. Treatment with decreased immunosuppression improved airway symptoms.

Official American Thoracic Society technical standards: flexible airway endoscopy in children.

BACKGROUND: Flexible airway endoscopy (FAE) is an accepted and frequently performed procedure in the evaluation of children with known or suspected airway and lung parenchymal disorders. However, published technical standards on how to perform FAE in children are lacking. METHODS: The American Thoracic Society (ATS) approved the formation of a multidisciplinary committee to delineate technical standards for performing FAE in children. The committee completed a pragmatic synthesis of the evidence and used the evidence synthesis to answer clinically relevant questions. RESULTS: There is a paucity of randomized controlled trials in pediatric FAE. The committee developed recommendations based predominantly on the collective clinical experience of our committee members highlighting the importance of FAE-specific airway management techniques and anesthesia, establishing suggested competencies for the bronchoscopist in training, and defining areas deserving further investigation. CONCLUSIONS: These ATS-sponsored technical standards describe the equipment, personnel, competencies, and special procedures associated with FAE in children.

Use of induced pluripotent stem cells to recapitulate pulmonary alveolar proteinosis pathogenesis.

RATIONALE: In patients with pulmonary alveolar proteinosis (PAP) syndrome, disruption of granulocyte/macrophage colony-stimulating factor (GM-CSF) signaling is associated with pathogenic surfactant accumulation from impaired clearance in alveolar macrophages. OBJECTIVES: The aim of this study was to overcome these barriers by using monocyte-derived induced pluripotent stem (iPS) cells to recapitulate disease-specific and normal macrophages. METHODS: We created iPS cells from two children with hereditary PAP (hPAP) caused by recessive CSF2RA(R217X) mutations and three normal people, differentiated them into macrophages (hPAP-iPS-Mφs and NL-iPS-Mφs, respectively), and evaluated macrophage functions with and without gene-correction to restore GM-CSF signaling in hPAP-iPS-Mφs. MEASUREMENTS AND MAIN RESULTS: Both hPAP and normal iPS cells had human embryonic stem cell-like morphology, expressed pluripotency markers, formed teratomas in vivo, had a normal karyotype, retained and expressed mutant or normal CSF2RA genes, respectively, and could be differentiated into macrophages with the typical morphology and phenotypic markers. Compared with normal, hPAP-iPS-Mφs had impaired GM-CSF receptor signaling and reduced GM-CSF-dependent gene expression, GM-CSF- but not M-CSF-dependent cell proliferation, surfactant clearance, and proinflammatory cytokine secretion. Restoration of GM-CSF receptor signaling corrected the surfactant clearance abnormality in hPAP-iPS-Mφs. CONCLUSIONS: We used patient-specific iPS cells to accurately reproduce the molecular and cellular defects of alveolar macrophages that drive the pathogenesis of PAP in more than 90% of patients. These results demonstrate the critical role of GM-CSF signaling in surfactant homeostasis and PAP pathogenesis in humans and have therapeutic implications for hPAP.

Obstructive lung disease is common in children with syndromic and congenital scoliosis: a preliminary study.

BACKGROUND: It is well known that restrictive lung disease (RLD) is associated with scoliosis. This study identifies that obstructive lung disease (OLD) is associated with syndromic scoliosis and congenital scoliosis. METHODS: We searched a local database for patients with scoliosis who underwent a pulmonary function testing (PFT) from 2004 to 2009. All patients with congenital scoliosis or syndromic thoracolumbar scoliosis with a Cobb angle of ≥40 degrees and acceptable and repeatable PFT testing were included in the study. OLD was defined as an forced expiratory volume in the first second/forced vital capacity ratio below 95% confidence interval. Bronchoscopy videos and computed tomography scans or magnetic resonance images were reviewed to identify anatomic causes of lower airway disease. RESULTS: A total of 18 patients met the criteria for inclusion. The median age at diagnosis was 11.3 years. The median primary Cobb angle was 60 degrees. The prevalence of OLD was 33% and RLD was 57%. The 6 children with OLD underwent preoperative bronchoscopy and chest computed tomography or magnetic resonance imaging to identify anatomic causes of lower airway obstruction. The 4 children with OLD and right-sided major thoracic curves had compression of the right mainstem bronchus between the spine (posterior) and the right pulmonary artery (anterior). The 2 children with OLD and left-sided major thoracic curves had compression of the left mainstem bronchus between the spine (posterior) and the descending aorta (anterior) or the left atrium (anterior). CONCLUSIONS: In our study, the prevalence of OLD in children with congenital scoliosis or syndromic scoliosis was 33%, which was elevated when compared with the population prevalence of 2% to 5%. Mainstem airway compression from spine rotation was discovered to be the potential mechanism of disease. LEVEL OF EVIDENCE: Level IV, prognostic study investigating the effect of a patient characteristic on the outcome of disease.

Improvement of tracheal compression after pectus excavatum repair.

A 4-year-old girl with pectus excavatum (PE), multiple prior respiratory infections, tracheomalacia and tracheal compression due to the innominate artery was referred for surgical evaluation. Aortopexy was deemed unlikely to improve airway diameter due to her chest concavity. Thoracoscopy-assisted PE repair was performed, resulting in marked improvement in the anteroposterior diameter of the trachea and resolution of her respiratory symptoms. Durability of the PE correction at 2 and 7 years following bar removal was demonstrated radiographically.

Forensic odontology in DVI-A path forward.

Dental identification is a pillar of disaster victim identification (DVI). Dental identification is accurate, efficient, inexpensive, and accepted in courts of law. The (known) antemortem (AM) dental charts and radiographic images acquired from the dentist of the missing person are evaluated, processed, and compared to post mortem (PM) findings present in the dentition or fragments of the dentition of the deceased individual. These comparisons evaluate and assess individuating restorative dental work, dental anatomical areas of concordance, spatial relationships of teeth one to another, and occasionally calculate the degree of "uniqueness" of either or both of the AM and PM dentition compared to known population databases. In a multiple fatality incident, odontologists may utilize age stratification to assist other means of identification. Computer comparison algorithms using recorded data can indicate possible matches between AM and PM data sets. Following clinical assessment, collection of post mortem tooth specimens for DNA profiling generation may be undertaken. This paper will highlight modern and efficient use of these tools. The framework for how dental identification in these incidents is currently managed is presented. The authors propose a change to this approach that moves away from interpretive subjective assessment toward comparisons based largely on objective data. The aim of this paper is to highlight the benefits of minimizing subjective decisions and maximizing objective data in the dental DVI process while simultaneously reducing risk to clinical personnel and minimizing costs by reducing the number of clinicians required onsite.

Hereditary pulmonary alveolar proteinosis: pathogenesis, presentation, diagnosis, and therapy.

RATIONALE: We identified a 6-year-old girl with pulmonary alveolar proteinosis (PAP), impaired granulocyte-macrophage colony-stimulating factor (GM-CSF) receptor function, and increased GM-CSF. OBJECTIVES: Increased serum GM-CSF may be useful to identify individuals with PAP caused by GM-CSF receptor dysfunction. METHODS: We screened 187 patients referred to us for measurement of GM-CSF autoantibodies to diagnose autoimmune PAP. Five were children with PAP and increased serum GM-CSF but without GM-CSF autoantibodies or any disease causing secondary PAP; all were studied with family members, subsequently identified patients, and controls. MEASUREMENT AND MAIN RESULTS: Eight children (seven female, one male) were identified with PAP caused by recessive CSF2RA mutations. Six presented with progressive dyspnea of insidious onset at 4.8 ± 1.6 years and two were asymptomatic at ages 5 and 8 years. Radiologic and histopathologic manifestations were similar to those of autoimmune PAP. Molecular analysis demonstrated that GM-CSF signaling was absent in six and severely reduced in two patients. The GM-CSF receptor ß chain was detected in all patients, whereas the α chain was absent in six and abnormal in two, paralleling the GM-CSF signaling defects. Genetic analysis revealed multiple distinct CSF2RA abnormalities, including missense, duplication, frameshift, and nonsense mutations; exon and gene deletion; and cryptic alternative splicing. All symptomatic patients responded well to whole-lung lavage therapy. CONCLUSIONS: CSF2RA mutations cause a genetic form of PAP presenting as insidious, progressive dyspnea in children that can be diagnosed by a combination of characteristic radiologic findings and blood tests and treated successfully by whole-lung lavage.

Patient-derived granulocyte/macrophage colony-stimulating factor autoantibodies reproduce pulmonary alveolar proteinosis in nonhuman primates.

RATIONALE: Granulocyte/macrophage colony-stimulating factor (GM-CSF) autoantibodies (GMAb) are strongly associated with idiopathic pulmonary alveolar proteinosis (PAP) and are believed to be important in its pathogenesis. However, levels of GMAb do not correlate with disease severity and GMAb are also present at low levels in healthy individuals. OBJECTIVES: Our primary objective was to determine whether human GMAb would reproduce PAP in healthy primates. A secondary objective was to determine the concentration of GMAb resulting in loss of GM-CSF signaling in vivo (i.e., critical threshold). METHODS: Nonhuman primates (Macaca fascicularis) were injected with highly purified, PAP patient-derived GMAb in dose-ranging (2.2-50 mg) single and multiple administration studies, and after blocking antihuman immunoglobulin immune responses, in chronic administration studies maintaining serum levels greater than 40 microg/ml for up to 11 months. MEASUREMENTS AND MAIN RESULTS: GMAb blocked GM-CSF signaling causing (1) a milky-appearing bronchoalveolar lavage fluid containing increased surfactant lipids and proteins; (2) enlarged, foamy, surfactant-filled alveolar macrophages with reduced PU.1 and PPARgamma mRNA, and reduced tumor necrosis factor-alpha secretion; (3) pulmonary leukocytosis; (4) increased serum surfactant protein-D; and (5) impaired neutrophil functions. GM-CSF signaling varied inversely with GMAb concentration below a critical threshold of 5 microg/ml, which was similar in lungs and blood and to the value observed in patients with PAP. CONCLUSIONS: GMAb reproduced the molecular, cellular, and histopathologic features of PAP in healthy primates, demonstrating that GMAb directly cause PAP. These results have implications for therapy of PAP and help define the therapeutic window for potential use of GMAb to treat other disorders.

Use of dental CBCT software for evaluation of medical CT-acquired images in a multiple fatality incident: Proof of principles.

Comparison of post-mortem dental findings to ante mortem dental records is a well-established, frequently used scientific means of human identification. Dentistry has adapted a form of CT scanning that uses a cone-shaped beam and is thus termed cone beam computed tomography (CBCT). CBCT is presently being used in many aspects of dentistry including osseointegrated implant planning, orthodontics, endodontics, investigation of pathology, and assessment prior to complex dental extractions. The identification of seven individuals from multiple fatality incident was undertaken using a simple technique for completing comparative radiographic dental identifications using post-mortem medical computed tomographic (CT) image-acquisition techniques and commercially available dental software normally used in clinical care. The authors will show the means by which the harvesting of anatomically important data from medical CTs and conversion of these files was undertaken to provide crisp, clear post-mortem dental images for forensic comparison to assist in the identification of two adults and provide age stratification of three juveniles. The use of this technique has shown to be beneficial for expediting efficient identification of deceased individuals, helping to isolate which cases may need additional scientific methods of identification, saving time and money to the organization and eliminating biological/body substance or radiation exposure to the operator. The application of this software for use in forensic dental identification cases is presented, and the methodology to create post-mortem images suitable for comparison is detailed.

Radiograph prescription practices of dentists in Ontario, Canada.

BACKGROUND: With the advent of new ionizing radiation technologies, consideration must be given to the use of radiography in clinical practice. The authors aimed to determine how general dentists obtain oral and maxillofacial images and whether dentists' demographic characteristics and practice environments affect imaging decisions. METHODS: The authors conducted a cross-sectional study using an electronic survey to collect information from general dentists in Ontario, Canada's most populous province. RESULTS: The authors received 1,332 responses from 9,052 general dentists registered to practice in Ontario. A total of 57.2% of dentists used a nonindividualized approach to obtaining images for new adult dentate patients. Using clinical case scenarios, the authors found that 18.8% through 55.1% of dentists did not follow evidence-based guidelines when obtaining images. Overprescribing imaging was 5.8 times more common than underprescribing. Seeing patients after images were obtained (odds ratio [OR], 5.5), owning a panoramic and a cone-beam computed tomography imaging system (OR, 4.4), and the belief that images should be obtained to screen for occult pathoses (OR, 3.5) were the factors most strongly associated with overprescription. CONCLUSIONS: Radiography prescription practices varied considerably among general dentists in Ontario and did not conform to established guidelines. Factors other than patient needs appeared to influence imaging practices. PRACTICAL IMPLICATIONS: Overprescription of imaging by general dentists can result in unnecessary radiation exposure and financial costs to patients. To mitigate this, changes are needed in dental education, continuing education courses, and regulatory requirements.

The use of radiographic imaging technologies by general dentists in Ontario, Canada.

OBJECTIVE: The aim of this study was to determine the prevalence of 2-dimensional and 3-dimensional digital imaging technologies, the methods used by general dentists to limit patient exposure to ionizing radiation, and the impact of dentists' education on imaging technologies and patient dose-reducing techniques. STUDY DESIGN: A cross-sectional, web-based survey of all general dentists in Ontario was conducted. RESULTS: Responses from 1332 (14.7%) of the 9052 registered general dentists in Ontario were included in the analysis. Approximately 89% reported using digital intraoral technology, 81.1% reported owning panoramic imaging systems, 71.2% reported making referrals for cone beam computed tomography (CBCT), and 9.5% reported including CBCT in their practices. CBCT was most commonly used for dental implant treatment planning (85.8%), followed by endodontics (45.4%), evaluation of pathology (39.6%), and surgical assessment for impacted teeth or difficult extractions (36.8%). Approximately 32.7% used only collimators with a long focal point-receptor distance and 8% used only rectangular collimation; 86.9% reported using a thyroid collar when imaging patients. Differences in educational backgrounds correlated with differences in the use of imaging and dose-reducing techniques. CONCLUSIONS: There is widespread adoption of digital imaging technologies by general dentists in Ontario, including CBCT. Greater implementation of long and/or rectangular collimation could markedly reduce the ionizing radiation dose to patients. Changes in dental education curricula and continuing education course offerings may address these issues.

The effect of pamidronate delivery in bisphosphonate-naïve patients on neutrophil chemotaxis and oxidative burst.

The pathogenesis of medication-related osteonecrosis of the jaw (MRONJ), a morbid condition associated with bisphosphonate administration, has not been fully elucidated. Recent research utilizing a murine model has revealed that the neutrophil becomes dysfunctional following exposure to bisphosphonates. Accordingly, the impairment of neutrophil function could play an important role in the pathogenesis of MRONJ via an infectious mechanism mediated by the suppression of the innate immune system. Currently, the existing human data are insufficient to substantiate this theory. To investigate, we isolated neutrophils from blood and oral rinse samples from bisphosphonate-naïve patients who were recently diagnosed with multiple myeloma both prior to and one month following their initial infusion of pamidronate, an intravenous bisphosphonate agent. Stimulated blood and oral neutrophil superoxide production and chemotactic capabilities were found to be impaired relative to baseline values. These results suggest that impaired neutrophil function may partially contribute to the aetiology underlying the pathophysiological processes linked to the development of MRONJ. Further, as the functional status of circulating neutrophils was reflected in the oral cavity where sampling can be accomplished in a non-invasive fashion, it is conceivable that neutrophil function could serve as a potential biomarker for MRONJ prognostication.

Interaction between self-efficacy and initial performance in predicting the complexity of task chosen.

Research on motivation has confirmed the predictive power of cognitive-affective variables on performance in complex tasks. However, less attention has been given to the determinants of task choice in situations where there is discretion about which task is to be undertaken. An experimental study was designed to analyze the role of dispositional variables (goal orientations and need for cognition) and self-regulatory variables (self-efficacy, intrinsic satisfaction, and task involvement) in the complexity of task chosen. 117 students participated in a complex decision-making task with different levels of difficulty. Results indicated that the avoidance performance goal orientation can predict the difficulty of the task chosen. Self-efficacy beliefs contribute to explaining the range of difficulty people consider feasible to attempt when initial performance is controlled. Individuals with high self-efficacy chose tasks that maximized their learning opportunities.

Error affect inoculation for a complex decision-making task.

Individuals bring knowledge, implicit theories, and goal orientations to group meetings. Group decisions arise out of the exchange of these orientations. This research explores how a trainee's exploratory and deliberate process (an incremental theory and learning goal orientation) impacts the effectiveness of individual and group decision-making processes. The effectiveness of this training program is compared with another program that included error affect inoculation (EAI). Subjects were 40 Spanish Policemen in a training course. They were distributed in two training conditions for an individual and group decision-making task. In one condition, individuals received the Self-Guided Exploration plus Deliberation Process instructions, which emphasised exploring the options and testing hypotheses. In the other condition, individuals also received instructions based on Error Affect Inoculation (EAI), which emphasised positive affective reactions to errors and mistakes when making decisions. Results show that the quality of decisions increases when the groups share their reasoning. The AIE intervention promotes sharing information, flexible initial viewpoints, and improving the quality of group decisions. Implications and future directions are discussed.

Outcome measures for pediatric laryngotracheal reconstruction: International consensus statement.

OBJECTIVES: Develop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies. METHODS: Standard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site-specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria. RESULTS: Thirty-three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative-/intraoperative-/procedure-related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site-specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable. CONCLUSION: This consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta-analyses, quality improvement, transfer of information, and surgeon self-assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient. LEVEL OF EVIDENCE: 5 Laryngoscope, 129:244-255, 2019.

Evaluation of the upper airway in children.

PURPOSE OF REVIEW: To summarize the current state of the art in upper-airway evaluation, focusing on endoscopic techniques, and especially to make a comparison between rigid and flexible instrumentation. RECENT FINDINGS: 'Noninvasive' techniques such as computed tomography or magnetic resonance imaging (especially cine-magnetic resonance imaging) can yield useful information, but endoscopy remains the gold standard. There is increasing understanding of the limitations and special advantages of rigid and flexible techniques for airway endoscopy; neither yields the entire picture in every patient. SUMMARY: The combination of both rigid and flexible endoscopic techniques, together with a carefully orchestrated approach to sedation/anesthesia, will yield the most accurate, complete, and useful information.