Rakesh K Chandra

Northwestern University, Evanston, Illinois, United States

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Publications (100)260.54 Total impact

  • The Journal of allergy and clinical immunology 05/2014; 133(5):1503-1503.e4. · 12.05 Impact Factor
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    ABSTRACT: Objective: To systematically assess the prevalence of bacterial infection in adults with acute rhinosinusitis (ARS)Data Sources: PubMed and CINAHL databasesReview Methods: Electronic databases were systematically searched for relevant studies published up to June 2012.Results: 29 articles, evaluating a total of 9,595 patients with a clinical diagnosis of ARS, were included in the study. 14 (48%) studies required radiographic confirmation of sinusitis, 1 (3%) required evidence of purulence, 10 (35%) required both for inclusion in the study population, and 4 (14%) required neither. The random effects model estimate of prevalence of bacterial growth on all cultures was 53.7% (CI 48.4%-59.0%), ranging from 52.5% (CI 46.7%-58.3%) in studies requiring radiographic confirmation of sinusitis to 61.1% (CI 54.0%-68.1%) in studies requiring neither radiographic evidence nor purulence on exam. Studies which obtained cultures from antral swab had a prevalence of bacterial growth of 61.0% (CI 54.7%-67.2%), while those utilizing endoscopic meatal sampling had a prevalence of 32.9% (CI 19.0%-46.8%).Conclusion: Few studies evaluate the recovery of bacteria via culture in adults with a diagnosis of ABRS or ARS based on clinical criteria alone. With radiographic and/or endoscopic confirmation, antral puncture and endoscopically guided cultures produce positive bacterial cultures in approximately half of patients. Opportunities exist to improve diagnostic accuracy for bacterial infection in ARS.
    The Laryngoscope 04/2014; · 1.98 Impact Factor
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    ABSTRACT: Objective: Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding risk factors that increase readmission rates may help enhance patient education and set system-wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery. Study Design: This study is a retrospective analysis of the 2011 National Surgical Quality Improvement Program (NSQIP) dataset. Methods: NSQIP was reviewed for outpatients with 'Otolaryngology (ENT)' as their recorded surgical specialty. Readmission was tracked through the 'Unplanned Readmission' variable. Patient characteristics and outcomes were compared using chi-square analysis and student t-tests for categorical and continuous variables, respectively. Multivariate regression analysis investigated predictors of readmission. Results: A total of 6,788 outpatient otolaryngological surgery patients were isolated. The unplanned readmission rate was 2.01%. Multivariate regression analysis revealed superficial surgical site infection (Odds Ratio [OR] 2.672, Confidence Interval [CI] 1.133-6.304, p =.025) and work relative value units (OR.972, CI.944 - 1, p =.049) to be significant predictors of readmission. Conclusion: Outpatient otolaryngological surgery has an associated 2.01% unplanned readmission rate. Superficial surgical site infection and work relative value units proved to be significant positive and negative risk factors, respectively, for readmission. These findings will help to benchmark outpatient readmission rates and manage patient and hospital system expectations.
    The Laryngoscope 11/2013; · 1.98 Impact Factor
  • The Journal of allergy and clinical immunology 09/2013; · 12.05 Impact Factor
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    ABSTRACT: Objective: Various intranasal landmarks have been described to aid in localization of the natural sphenoid sinus ostium. The objective of this study is to identify the ostium location relative to the skull base and assess relationships between ostium location and sphenoid disease or pneumatization pattern. Study Design: Descriptive study Level of Evidence: 4 Methods: Consecutive Xoran Mini-CAT scans of patients with no prior history of sinus surgery (n=202) were evaluated. The natural sphenoid ostium was identified in axial, coronal, and sagittal planes. Distances from the planum to the ostium and from the planum to the sinus floor were calculated. Lund-Mackay score and pneumatization pattern were recorded for each sphenoid sinus. Results: The mean distance from planum to ostium was 11.2 ± 2.6 mm (range 4.4-19.2mm). This, on average, encompassed 45.5 ± 10% of the total sphenoid height. ANOVA with post hoc Tukey analysis revealed that the ostium was closer to the planum in sinuses with sellar (p=0.05) or presellar (p=0.02) pneumatization, compared to those where pneumatization was postsellar. Although minor asymmetry was observed in some patients, the ostium tended to be in a similar position on each side. There was no significant relationship between ostium location and degree of sinus disease. There was a significant difference in pneumatization pattern between males and females (p=.04). More males had postsellar pneumatization than expected and more females had sellar pneumatization than expected. Conclusions: The natural ostium of the sphenoid sinus, on average, is located at approximately the midpoint of the sphenoid face. However, significant variability between patients can be observed. Surgeons should also recognize that the ostium may be closer to the skull base when the sinus is less pneumatized.
    The Laryngoscope 09/2013; · 1.98 Impact Factor
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    ABSTRACT: Current symptom criteria poorly predict a diagnosis of chronic rhinosinusitis (CRS) resulting in excessive treatment of patients with presumed CRS. The objective of this study was analyze the positive predictive value of individual symptoms, or symptoms in combination, in patients with CRS symptoms and examine the costs of the subsequent diagnostic algorithm using a decision tree-based cost analysis. We analyzed previously collected patient-reported symptoms from a cross-sectional study of patients who had received a computed tomography (CT) scan of their sinuses at a tertiary care otolaryngology clinic for evaluation of CRS symptoms to calculate the positive predictive value of individual symptoms. Classification and regression tree (CART) analysis then optimized combinations of symptoms and thresholds to identify CRS patients. The calculated positive predictive values were applied to a previously developed decision tree that compared an upfront CT (uCT) algorithm against an empiric medical therapy (EMT) algorithm with further analysis that considered the availability of point of care (POC) imaging. The positive predictive value of individual symptoms ranged from 0.21 for patients reporting forehead pain and to 0.69 for patients reporting hyposmia. The CART model constructed a dichotomous model based on forehead pain, maxillary pain, hyposmia, nasal discharge, and facial pain (C-statistic 0.83). If POC CT were available, median costs ($64-$415) favored using the upfront CT for all individual symptoms. If POC CT was unavailable, median costs favored uCT for most symptoms except intercanthal pain (-$15), hyposmia (-$100), and discolored nasal discharge (-$24), although these symptoms became equivocal on cost sensitivity analysis. The three-tiered CART model could subcategorize patients into tiers where uCT was always favorable (median costs: $332-$504) and others for which EMT was always favorable (median costs -$121 to -$275). The uCT algorithm was always more costly if the nasal endoscopy was positive. Among patients with classic CRS symptoms, the frequency of individual symptoms varied the likelihood of a CRS diagnosis marginally. Only hyposmia, the absence of facial pain, and discolored discharge sufficiently increased the likelihood of diagnosis to potentially make EMT less costly. The development of an evidence-based, multisymptom-based risk stratification model could substantially affect the management costs of the subsequent diagnostic algorithm.
    International Forum of Allergy and Rhinology 09/2013; · 1.00 Impact Factor
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    ABSTRACT: Chronic Rhinosinusitis (CRS) is accompanied by evidence of a vigorous adaptive immune response, and emerging studies demonstrate that some nasal polyps manifest a polyclonal autoantibody response. We previously found that antibodies against BP180, a component of the hemidesmosome complex and the dominant epitope in autoimmune bullous pemphigoid, were found at elevated levels in nasal polyp tissue. Given the critical role of hemidesmosomes in maintaining epithelial integrity, we sought to investigate the distribution of BP180 in nasal tissue and evaluate for evidence of systemic autoimmunity against this antigen in CRS. Case-control experimental study. The expression and distribution of BP180 in cultured nasal epithelial cells and normal nasal tissue were confirmed using real-time polymerase chain reaction (PCR), Western immunoblotting, immunofluorescence and immunohistochemistry. Sera were collected from three groups: control, CRSsNP, and CRSwNP. A commercially available ELISA was utilized to compare anti-BP180 autoantibody levels in sera. BP180 is expressed in nasal epithelium, but is not confined to the basement membrane as it is in human skin. In cultured nasal epithelial cells, confocal immunofluorescence showed a punctate distribution of BP180 along the basal surface, consistent with its distribution in epithelial keratinocytes. There are significantly higher levels of circulating nonpathologic anti-BP180 autoantibodies in CRS patients compared with normal controls (P <0.05). BP180 is more widely expressed in nasal epithelium versus skin, although it appears to play a similar role in the formation of hemidesmosomes along the basement membrane. Further investigations are ongoing to characterize the pathogenicity of the anti-epithelial antibody response in CRS.
    The Laryngoscope 09/2013; 123(9):2104-11. · 1.98 Impact Factor
  • The Journal of allergy and clinical immunology 08/2013; · 12.05 Impact Factor
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    ABSTRACT: To diagnose chronic rhinosinusitis (CRS), current guidelines require either endoscopic or computed tomography (CT) findings of sinus disease. To a primary care physician, this means a referral to an otolaryngologist or obtaining a CT scan. Unfortunately, the sensitivity of endoscopy for detecting CRS is low, and examination by the Otolaryngologist may not yield a definitive diagnosis. This leaves CT scanning. However, this is contradicted by recommendations to limit CT scanning for only preoperative planning purposes due to cost concerns. This study aims to provide an evidence-based cost-efficient recommendation for primary care practice. Health care economics-based decision analysis model. A cost-based decision analysis based on literature-reported probabilities and Medicare costs was constructed for two scenarios: 1) primary care physicians who are comfortable initiating first-line treatment for chronic rhinosinusitis, rhinitis, and atypical facial pain; and 2) primary care physicians who are less comfortable with medical management of these conditions. Under both scenarios and the extremes of sensitivity analysis, upfront CT scanning provides cost-efficient diagnosis over presuming a diagnosis of chronic rhinosinusitis. Primary care physicians who attempt first-line treatment can expect $503 (range = $296-$761) saved per patient. Meanwhile, primary care physicians who prefer to refer may expect $326 (range = $299-$353) saved per patient. In all scenarios, confirming diagnosis with CT scanning prior to treatment or referral is more cost-efficient than presuming a diagnosis of CRS based on symptoms alone. 2c. Laryngoscope, 2013.
    The Laryngoscope 08/2013; · 1.98 Impact Factor
  • The Journal of allergy and clinical immunology 07/2013; · 12.05 Impact Factor
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    ABSTRACT: Chronic rhinosinusitis (CRS) is one of the most common chronic diseases and is associated with a high socioeconomic burden from direct and indirect costs. Its estimated prevalence ranges widely, from 2 to 16%. It is more common in female subjects, aged 18-64 years, and in southern and midwestern regions of the United States. CRS is more prevalent in patients with comorbid diseases such as asthma, chronic obstructive pulmonary disease, and environmental allergies. Few studies examine patient ethnicity, socioeconomic status, geographic location, and cultural factors in CRS populations. This article provides an overview of the epidemiology, racial variations, and economic burden of CRS.
    Allergy and Asthma Proceedings 07/2013; 34(4):328-34. · 2.19 Impact Factor
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    ABSTRACT: BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is associated with TH2-dominant inflammation. Thymic stromal lymphopoietin (TSLP) is a cytokine that triggers dendritic cell-mediated TH2 inflammatory responses and that enhances IL-1-dependent TH2 cytokine production in mast cells. Although increased TSLP mRNA levels have been found in nasal polyps (NPs), expression of TSLP protein and its function in patients with chronic rhinosinusitis (CRS) have not been fully explored. OBJECTIVES: The objective of this study was to investigate the role of TSLP in patients with CRS. METHODS: We investigated the presence and stability of TSLP protein in NPs using ELISA and Western blotting and investigated the function of TSLP in nasal tissue extracts with a bioassay based on activation of human mast cells. RESULTS: Although TSLP mRNA levels were significantly increased in NP tissue from patients with CRSwNP compared with uncinate tissue from patients with CRS or control subjects, TSLP protein was significantly decreased in NP tissue, as detected by using the commercial ELISA kit. We found that recombinant TSLP was time-dependently degraded by NP extracts, and this degradation was completely inhibited by a protease inhibitor cocktail, suggesting that TSLP is sensitive to tissue proteases. Interestingly, NP extract-treated TSLP had higher activity in mast cells, although the amount of full-length TSLP was reduced up to 85%. NP extracts significantly enhanced IL-1β-dependent IL-5 production in mast cells compared with uncinate tissue homogenates, and responses were significantly inhibited by anti-TSLP, suggesting that NPs contain biologically relevant levels of TSLP activity. CONCLUSION: TSLP and its metabolic products might play an important role in the inflammation seen in patients with CRSwNP.
    The Journal of allergy and clinical immunology 05/2013; · 12.05 Impact Factor
  • Eric K Meen, Rakesh K Chandra
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    ABSTRACT: BACKGROUND: Sleep-disordered breathing (SDB) is a spectrum of airway collapse, ranging from primary snoring to profound obstructive sleep apnea (OSA). Studies have shown an association between impaired nasal breathing and SDB; consequently, treatments of nasal obstruction are often used in an attempt to improve disease severity. The authors performed a review of the literature to determine the impact of nasal obstruction and the effectiveness of nonsurgical and surgical interventions on SDB. METHODS: Relevant literature up to 2012 on the association between nasal obstruction and SDB and effectiveness of nonsurgical and surgical treatment of the nose in SDB were reviewed. RESULTS: The literature is mostly limited to uncontrolled case series in which patient groups, interventions, disease definitions, and outcome measures are not standardized. Nasal medications, including intranasal steroids and nasal decongestants, have not been shown to improve either snoring or OSA. Nasal dilators have no impact on OSA but may improve snoring. Surgery for nasal obstruction does not improve objective indicators of SDB but can improve subjective elements of disease, such as snoring, sleepiness, and quality of life. Nasal surgery can facilitate continuous positive airway pressure use in cases where nasal obstruction is the factor limiting compliance. CONCLUSION: Nasal obstruction plays a modulating, but not causative, role in SDB. Nasal interventions may improve subjective aspects of snoring and OSA but do not improve objective indicators of disease. Standardization of methods and higher evidence level studies will further clarify the benefit of nasal interventions in the treatment of SDB.
    American Journal of Rhinology and Allergy 05/2013; 27(3):213-220.
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    ABSTRACT: BACKGROUND: Chronic rhinosinusitis (CRS) is a prevalent condition with underexplored risk factors. OBJECTIVES: We sought to determine CRS incidence and evaluate associations with a range of premorbid medical conditions for chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) using real-world clinical practice data. METHODS: Electronic health records data from 446,480 Geisinger Clinic primary care patients were used for a retrospective longitudinal cohort study for data from 2001-2010. By using logistic regression, newly diagnosed CRS cases between 2007 and 2009 were compared with frequency-matched control subjects on premorbid factors in the immediate (0-6 months), intermediate (7-24 months), and entire observed timeframes before diagnosis. RESULTS: The average incidence of CRS was 83 ± 13 CRSwNP cases per 100,000 person-years and 1048 ± 78 CRSsNP cases per 100,000 person-years. Between 2007 and 2009, 595 patients with incident CRSwNP and 7523 patients with incident CRSsNP were identified and compared with 8118 control subjects. Compared with control subjects and patients with CRSsNP, patients with CRSwNP were older and more likely to be male. Before diagnosis, patients with CRS had a higher prevalence of acute rhinosinusitis, allergic rhinitis, chronic rhinitis, asthma, gastroesophageal reflux disease, adenotonsillitis, sleep apnea, anxiety, and headaches (all P < .001). Patients with CRSsNP had a higher premorbid prevalence of infections of the upper and lower airway, skin/soft tissue, and urinary tract (all P < .001). In the immediate and intermediate timeframes analyzed, patients with CRS had more outpatient encounters and antibiotic prescriptions (P < .001), but guideline-recommended diagnostic testing was performed in a minority of cases. CONCLUSIONS: Patients who are given a diagnosis of CRS have a higher premorbid prevalence of anxiety, headaches, gastroesophageal reflux disease, sleep apnea, and infections of the respiratory system and some nonrespiratory sites, which results in higher antibiotic, corticosteroid, and health care use. The use of guideline-recommended diagnostic testing for confirmation of CRS remains poor.
    The Journal of allergy and clinical immunology 03/2013; · 12.05 Impact Factor
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    ABSTRACT: BACKGROUND: Profound edema or formation of a pseudocyst containing plasma proteins is a prominent characteristic of nasal polyps (NP). However, the mechanisms underlying NP retention of plasma proteins in the submucosa remain unclear. Recently, we reported that impairment of fibrinolysis causes excessive fibrin deposition in NP and this might be involved in the retention of plasma proteins. Although the coagulation cascade plays a critical role in fibrin clot formation at extravascular sites, the expression and role of coagulation factors in NP remain unclear. OBJECTIVE: The objective of this study was to investigate the expression of coagulation factors in patients with chronic rhinosinusitis (CRS). METHODS: Sinonasal tissues were collected from patients with CRS and control subjects. We assayed mRNA for factor XIII-A (FXIII-A) by using real-time PCR and measured FXIII-A protein by means of ELISA, immunohistochemistry, and immunofluorescence. RESULTS: FXIII-A mRNA levels were significantly increased in NP tissue from patients with CRS with NP (P < .001) compared with uncinate tissue from patients with CRS or control subjects. Similarly, FXIII-A protein levels were increased in NP. Immunofluorescence analysis revealed that FXIII-A expression in inflammatory cells and FXIII-A(+) cell numbers were significantly increased in NP. Most FXIII-A staining was observed within CD68(+)/CD163(+) M2 macrophages in NP. Levels of FXIII-A correlated with markers of M2 macrophages, suggesting that M2 macrophages are major FXIIIA-producing cells in NP. CONCLUSION: Overproduction of FXIII-A by M2 macrophages might contribute to the excessive fibrin deposition in the submucosa of NP, which might contribute to the tissue remodeling and pathogenesis of CRS with NP.
    The Journal of allergy and clinical immunology 03/2013; · 12.05 Impact Factor
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    ABSTRACT: Objective To identify variations in antibiotic treatment of acute rhinosinusitis (ARS) on a national level.Study DesignCross-sectional study of a national database.SettingOtolaryngology and primary care ambulatory settings.Subjects and MethodsA nationally representative sample of adult outpatient visits was extracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey data for 2006 to 2009. Antibiotic prescriptions associated with ARS were tabulated. Statistical analyses were conducted to identify variations in antibiotic prescribing by patient and physician characteristics.ResultsAntibiotics were prescribed in 82.3% ± 2.6% of 18.7 million visits for ARS (mean age, 46.2 years; 65.9% female). The ratio of primary care physician (PCP) to otolaryngologist (ENT) ARS visits was 18.6:1. Antibiotic prescription rates were inversely related to increasing age groups of 18 to 39, 40 to 64, and ≥65 years (87.8%, 81.2%, and 71.0%, respectively; P = .02). Physicians in general medicine outpatient departments, internal medicine, and family medicine were more likely to prescribe antibiotics compared with ENTs (adjusted odds ratio [OR], 7.9 [95% confidence interval (CI), 3.5-17.8]; 6.9 [2.5-19.2]; and 3.9 [2.0-7.7], respectively). The most commonly prescribed antibiotics were azithromycin, amoxicillin, and amoxicillin/clavulanate acid (27.5%, 15.5%, and 14.6%, respectively). The ENTs selected broad-spectrum antibiotics more often than PCPs (94.3% vs 75.7% of visits with antibiotics were broad-spectrum agents; P = .01).Conclusion Antibiotics were prescribed frequently despite recent consensus guidelines that discourage antibiotic use in mild cases. Furthermore, antibiotic prescription was more likely for younger patients and in primary care settings. This highlights the need to promote awareness of practice guidelines.
    Otolaryngology Head and Neck Surgery 03/2013; · 1.73 Impact Factor
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    ABSTRACT: BACKGROUND: Despite the high prevalence and morbidity of chronic rhinosinusitis (CRS), little is known about the mechanisms that underlie its pathogenesis. Recent studies have suggested that B cells might play an important role in CRS. OBJECTIVE: We sought to thoroughly characterize B lineage cells within sinus tissues of patients with CRS and healthy control subjects and to determine whether levels of EBV-induced protein 2, which is known to play an important role in the development of B-cell responses, were increased in patients with CRS. METHODS: Cells isolated from sinus tissues of patients with CRS and healthy control subjects were characterized by means of flow cytometry and immunohistochemistry. Local production of antibodies was measured in tissue extracts, nasal lavage fluid, and sera by using multiplex bead arrays and ELISA. Quantitative RT-PCR, ELISA, and Western blotting were used to assess gene and protein expression from tissue extracts. RESULTS: Nasal polyps (NPs) from patients with CRS had increased levels of both B cells and plasma cells compared with uncinate tissue from healthy control subjects (P < .05). NPs also contained significantly increased levels of several antibody isotypes compared with normal uncinate tissue (P < .05), but no differences in circulating antibody levels were found. Interestingly, levels of EBV-induced protein 2 were also increased in NPs (P < .05) and were positively correlated with expression of plasma cell markers (CD138 and B lymphocyte-induced maturation protein) in sinus tissue. CONCLUSION: B cells and plasma cells are enriched in NPs, actively produce antibodies locally, and might contribute to chronic inflammation in patients with CRS. Elucidating the mechanisms that underlie this excessive local B-cell response might provide novel insights for the development of improved therapeutic strategies.
    The Journal of allergy and clinical immunology 03/2013; · 12.05 Impact Factor
  • Source
    Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 01/2013; 34(1):6-7. · 1.44 Impact Factor
  • The Annals of otology, rhinology, and laryngology 01/2013; 122(1):1-2. · 1.21 Impact Factor
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    ABSTRACT: RATIONALE: Nasal polyps (NP) are characterized by intense edema or formation of pseudocysts filled with plasma proteins, mainly albumin. However, the mechanisms underlying NP retention of plasma proteins in their submucosa remain unclear. OBJECTIVES: We hypothesized that formation of a fibrin mesh retains plasma proteins in NP. We assessed the fibrin deposition and expression of the components of the fibrinolytic system in patients with chronic rhinosinusitis (CRS). METHODS: We assessed fibrin deposition in nasal tissue from patients with CRS and control subjects by means of immunofluorescence. Fibrinolytic components, d-dimer and plasminogen activators were measured using ELISA, real-time PCR, and immunohistochemistry. We also performed gene expression and protein quantification analysis in cultured airway epithelial cells. MEASUREMENTS AND MAIN RESULTS: Immunofluorescence data showed profound fibrin deposition in NP compared with uncinate tissue (UT) from CRS and control subjects. Levels of the cross linked fibrin cleavage product protein, d-dimer, were significantly decreased in NP compared with UT from CRS and control, suggesting reduced fibrinolysis (P < .05). Expression levels of tissue plasminogen activator (t-PA) mRNA and protein were significantly decreased in NP compared with UT from CRS and control (P < .001). Immunohistochemistry demonstrated clear reduction of t-PA in NP, primarily in the epithelium and glands. Th2 cytokine stimulated cultured airway epithelial cells showed downregulation of t-PA, suggesting a potential Th2 mechanism in NP. CONCLUSIONS: A Th2-mediated reduction of t-PA might lead to excessive fibrin deposition in the submucosa of NP, which might contribute to the tissue remodeling and pathogenesis of CRS with nasal polyps (CRSwNP).
    American Journal of Respiratory and Critical Care Medicine 11/2012; · 11.04 Impact Factor

Publication Stats

554 Citations
260.54 Total Impact Points

Institutions

  • 2001–2014
    • Northwestern University
      • • Division of Allergy-Immunology
      • • Department of Medicine
      • • Department of Otolaryngology - Head and Neck Surgery
      Evanston, Illinois, United States
  • 2013
    • University of Fukui
      • Division of Otorhinolaryngology Head & Neck Surgery
      Hukui, Fukui, Japan
    • University of Toronto
      • Department of Otolaryngology - Head and Neck Surgery
      Toronto, Ontario, Canada
  • 2012
    • Northwestern Memorial Hospital
      Chicago, Illinois, United States
  • 2011
    • The Australian Society of Otolaryngology Head & Neck Surgery
      Evans Head, New South Wales, Australia
  • 2008–2011
    • University of Illinois at Chicago
      • Department of Otolaryngology (Chicago)
      Chicago, Illinois, United States
  • 2009
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 2004–2009
    • The University of Tennessee Health Science Center
      • Department of Otolaryngology
      Memphis, TN, United States
  • 2004–2005
    • University of Tennessee
      • Otolaryngology - Head and Neck Surgery
      Knoxville, TN, United States