Allergy and Immunology

Annual Achievements

Recognized Excellence of Division Trainees and Faculty

The Division of Allergy and Immunology is proud of the excellence of its undergraduate, graduate, postdoctoral and clinical trainees and junior investigators. Recognition of several for their achievements throughout the year, include:

• Netali Morgenstern Ben Baruch, a binational scholar in the Rothenberg Lab, is a recipient of a Zuckerman Israeli Postdoctoral Scholarship.
• Hayley Flanagan, summer student in the Rothenberg Lab, won first place in the Infectious Disease and Immunology category at the 59th Annual National Student Research Forum (NSRF) for her summer research at Cincinnati Children's.

Eosinophil-Depleting Drug Now Being Studied for Eosinophilic Gastritis

Divisional investigators, under the leadership of Marc Rothenberg, MD, PhD, developed an investigator-initiated study aiming to examine the effect of the eosinophil-depleting drug benralizumab on patients with eosinophilic gastritis (EG), an allergic disease involving severe inflammation of the stomach. At present, there are no FDA-approved medicines for this disease. Benralizumab is a humanized monoclonal antibody directed against the alpha subunit of the interleukin 5 receptor (IL-5Rα). The binding of the antibody to IL-5Rα results in eosinophil depletion via antibody-dependent cellular cytotoxicity. Benralizumab, administered subcutaneously, is already FDA approved to treat eosinophil-associated asthma. The primary objective of the Benralizumab Eosinophilic Gastritis (BEG) study is to assess the efficacy of repeat subcutaneous doses of benralizumab, compared with placebo, to reduce eosinophilic inflammation in the gastrointestinal tract. The secondary objectives of the BEG study include assessing changes in endoscopic score, histologic features, blood eosinophil counts, clinical symptoms, and expression of genes (as assessed by whole-genome RNA sequencing). Eligible subjects are children and adults between the ages of 12-60 years with active EG.

Cadherin-like 26

One of the molecules highly increased in the stomach of patients with eosinophilic gastritis (EG) was cadherin-like 26 (CDH26). Think of cadherins as velcro between cells, with each cadherin protein acting like a hook that snags cadherin on other cells. This attaches cells to each other. CDH26 was also increased in the esophagus of patients with eosinophilic esophagitis (EoE) so it may have a common function in different types of eosinophilic gastrointestinal disorders (EGIDs). Julie Caldwell, PhD, under the mentorship of Marc Rothenberg, MD, PhD, investigated CDH26 further and found that CDH26 not only had a structural role in human gastrointestinal tissue, but also had an immunoregulatory role during allergic responses. CDH26 bound to integrins to regulate leukocyte adhesion and activation, a critical step in immune cell recruitment to tissue. By identifying and determining the involvement of how factors that are differentially regulated in EGIDs, such as CDH26, in these disorders, we may be able to develop better diagnostic tools and treatments related to these molecules in the future.

Loss of Tissue Identity

In the differentiation process, cells in the body become more specified, transitioning from less mature cells with more potential fates to more mature cells with more specialized functions and identity. An esophageal epithelial cell is a highly specified cell, but one that may explain the mystery of the tissue specificity in eosinophilic gastrointestinal disorders (EGIDs), allergic conditions of the gastrointestinal tract. Mark Rochman, PhD, under the mentorship of Marc Rothenberg, MD, PhD, investigates whether tissue identity and differentiation state were a part of the pathogenesis of eosinophilic esophagitis (EoE), the most common of the EGIDs. They found that a profound loss of differentiation or identity in esophageal epithelial tissue was a key part of EoE pathogenesis.

Eosinophilic Esophagitis Genetic Susceptibility Mediated by Synergistic Interactions Between Disease-specific and General Atopic Disease Loci

Eosinophilic esophagitis (EoE) is an esophageal inflammatory disease associated with atopic diseases. Genetic variations and environmental exposures contribute to EoE, but how identified EoE risk variants, such as those in thymic stromal lymphopoietin (TSLP) and calpain 14 (CAPN14), relate to atopy or interact is unclear. Currently, genetic risk variants for EoE have uncovered key pathways involved in disease pathogenesis but are not associated with susceptibility risk factors large enough to be useful for clinical decisions. In an original research study, Marc Rothenberg, MD, PhD, and colleagues investigated whether carrying combinations of genetic risk factors would increase disease risk, perhaps enough to be clinically useful. They explored the relationship between EoE, atopy, and genetic risk. Cohorts of patients with EoE with and without atopy and community controls used to test for whether atopy enriches in patients with EoE, what genetic variants specifically associate with risk of EoE, and how EoE-specific and atopy-related genetic variants interact. They found that enriched atopic disease in patients with EoE. Patients with atopy were more likely to carry risk alleles for the interleukin 4/kinesin family member 3A (IL4/KIF3A) locus. On the other hand, variants in TSLP and CAPN14 were specifically associated with EoE. Importantly, there was a notable interaction between genetic risk variants in IL4/KIF3A and TSLP. Having the risk allele for IL4/KIF3A or TSLP associates with modest risk of EoE but having both associated with relatively high risk of EoE (i.e., 3.6-fold increased risk). These findings support the mediation of EoE genetic susceptibility by synergistic interactions between EoE-specific and general atopic disease loci and help explain the high degree of atopic disease comorbidity in children with EoE. Identifying these effects may help to better predict disease susceptibility and bring EoE closer to benefiting from precision medicine.

Environmental Factors Could Adjust Risk for Eosinophilic Esophagitis in People with Particular Gene Variants

In collaboration with national researchers, Marc Rothenberg, MD, PhD, investigated how early-life environmental exposures interact with genetic susceptibility variants in pediatric patients with eosinophilic esophagitis (EoE). The study followed 127 subjects with EoE and 121 control subjects, all recruited from the Cincinnati Center for Eosinophilic Disorders at Cincinnati Children’s. Subjects with and without EoE were all under the age of 18 at time of enrollment and were self-reported Caucasian. They all had a DNA sample taken and their mothers asked to fill out a questionnaire describing early life experiences. The study results are notable in that the risk of developing EoE, in people with two gene variants associated with developing the disease, modification by certain environmental exposures could potentially occur. The research suggested that people with gene variants in CAPN14 or LOC283710/KLF13 breastfed or admitted to a neonatal intensive care unit were significantly less or more likely to develop the disease. Notably, breastfed people with a gene variant in the CAPN14 gene were 92% less likely to develop EoE compared to patients who had the gene variant but were not breastfed. Though the underlying mechanism for how breastfeeding and CAPN14 may interact and protect against EoE is unknown, the association ofCAPN14 with barrier function in the gut, suggesting that breastmilk’s preventive role may relate to the setting of altered barrier function. The study also suggests that admission into a neonatal intensive care unit can significantly increase the odds of developing EoE in people with a gene variant at LOC283710/KLF13. Though the evidence is preliminary, further understanding of these interactions could provide an opportunity to alter the development of EoE, as some environmental factors are modifiable in individuals harboring specific genetic variants.

Whole-exome Sequencing Uncovers Oxidoreductases and Hints at Mitochondrial Dysfunction in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic allergic disorder that presents with difficulty swallowing, vomiting, failure to thrive, and food impaction in adulthood. Even with the identification of several EoE-associated pathways the underlying genetic causes of this disorder are poorly understood. In this publication, Marc Rothenberg, MD, PhD, and colleagues used whole-exome sequencing and family-based trio analysis to identify EoE-associated variants in the mitochondrial oxidoreductases DHTKD1 and OGDHL. In T cells, loss of DHTKD1 function increased reactive oxygen species and viperin, which promotes Th2 cytokine production. Moreover, there was an increase of viperin in esophageal biopsies from patients with EoE. Together, these results implicate mitochondrial dysfunction in EoE pathogenesis. Thus, this translational research identified a series of rare genetic variants implicating the oxidoreductases DHTKD1 and OGDHL in the genetic etiology of EoE, an allergic inflammatory esophageal disorder with a complex underlying genetic etiology, and underscore a potential pathogenic role for mitochondrial dysfunction in EoE.

Division Director Gives Meaningful Keynote in Austria

Named after the visionary researcher and internationally renowned founder of neuromedicine, the Otto Loewi Research Centre for Vascular Biology, Immunology and Inflammation celebrated its official opening at the Medical University of Graz. Director of the Division of Allergy and Immunology at Cincinnati Children’s, Marc Rothenberg, MD, PhD, gave the Otto Loewi Memorial Lecture, in memory of the 1936 Nobel Laureate in Medicine, for the discovery of neuromediators (acetylcholine). In addition to Dr. Loewi’s scientific contributions, which are still impacting patients today, such as the usage of neuromediators in the allergy field (e.g., adrenaline for anaphylaxis and acetylcholine inhibitors for bronchodilation), Dr. Loewi’s plight as a Jewish person in Nazi-controlled Austria was notable. The arrest of Dr. Loewi and the stripping of his faculty position occurred despite being the Chairman of Physiology at the Medical School and the Nobel Laureate two years earlier. Released from prison only by handing over all of his assets, including his house and funds from the Nobel Prize, he was subsequently permitted to leave Austria. Prior to Dr. Rothenberg’s lecture was the dedication and ribbon-cutting ceremony of a new research building and institute that will bear Otto Loewi’s name. After the official opening of the ceremony, the Rector of the University gave his greetings and spoke about the center's namesake and Dr. Loewi’s work in Graz before his expulsion by the Nazis, delivering a most moving speech indicating that naming the building after Otto Loewi is so that the atrocities against the Jews, carried out in the very premises of the medical school, will never happen again.

Consortium for Eosinophilic Gastrointestinal Researchers CEGIR

In its fourth year, the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) received recognition by various sources for its amazing patient advocacy efforts, teamwork, and structure. CEGIR is the first large-scale collaboration between key stakeholders in the field of eosinophilic gastrointestinal disorders, including researchers, patients and the key funding agency, the National Institutes of Health (NIH), and dedicates itself to improving the lives of individuals with eosinophilic gastrointestinal disorders through innovative research, clinical expertise and education via collaborations between scientists, health care providers, patients, and professional organizations. A published summary of the formation of CEGIR, “Creating a multi-center rare disease consortium – the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR)” is in Translational Science of Rare Diseases. There are two articles featuring CEGIR publications in the Spotlight on Rare Diseases publication of the Rare Diseases Clinical Research Network: “CEGIR - Improving research of eosinophilic gastrointestinal disorders with the patient perspective” and “CEGIR - Changing the paradigm in research of eosinophilic gastrointestinal disorders”.

Study Finds Absence of Key Protein May Drive Eosinophilic Esophagitis: Replacement Therapy Reversed Effects in Tissue Experiments

Absence of a specific protein in cells lining the esophagus may cause inflammation and tissue damage in people with eosinophilic esophagitis (EoE). The protein, SPINK7, was nearly absent in esophageal biopsies from people with active EoE but was prevalent in healthy esophagi, where it damped down inflammation and helped preserve tissue structure. Encouragingly, an available therapeutic reversed damaging inflammation in tissues that lacked SPINK7. Because foods we eat contain enzymes that can damage human tissue, the lining of the esophagus protects itself by producing its own enzymes that degrade the offending proteins and thus protect the lining. Nurit Azouz, PhD, under the mentorship of Marc Rothenberg, MD, PhD, found that SPINK7 is a key contributor to this protective process and was nearly absent in the esophagi of adults and children with EoE. By silencing or removing SPINK7, the gene that codes for SPINK7, in cultures derived from esophageal tissues, they discovered that large gaps formed between cells lining the esophagus and that these cells lost their normal barrier function that ordinarily helps move food along the digestive tract. Tissues that did not express SPINK7 also produced high levels of chemical messengers called cytokines that attract and activate eosinophils and produce the same type of inflammation seen in allergic diseases The researchers then treated esophageal tissue samples with alpha-1 anti-trypsin, or A1AT, a biologic drug approved to treat a genetic form of emphysema. Like SPINK7, A1AT is a natural inhibitor of tissue-damaging proteins called proteases. In the lab, A1AT reversed the damaging inflammation seen in tissues that lacked SPINK7, warranting the suggestion of further investigation to determine whether this therapeutic may also benefit people with EoE. Currently, people with EoE may take corticosteroids to relieve inflammatory symptoms, restrict their diets to avoid allergen containing foods that drive EoE or undergo periodic surgical procedures to expand the esophagus. (Listen to the podcast “Absence of Key Protein, SPINK7, May Drive Eosinophilic Esophagitis”, Marc E. Rothenberg, MD, PhD.)

Recognized Excellence of Division Trainees and Faculty

The Division of Allergy and Immunology is proud of the excellence of its undergraduate, graduate, postdoctoral and clinical trainees and junior investigators. Several received recognition for their achievements throughout the year:

• Rachel Ernst and Tarah Wagner, summer students in the Rothenberg Lab, and mentored by Mark Rochman, PhD, won the Poster of Distinction at the Nutrition Research Day Poster Session at Cincinnati Children's for their work on peanut protein levels. Ernst and Wagner went on to take first place in the Agriculture / Food Science category at their high school's capstone competition on April 28.
• Justin Wheeler, MD, a clinical fellow in the Hogan Lab, was the recipient for the award for the 2017 AAAAI / APFED Best Oral Abstract on eosinophilic gastrointestinal diseases by a fellow-in-training at the 2017 American Academy of Asthma, Allergy & Immunology (AAAAI) Annual Meeting.
• Assistant professor, Ting Wen, MD, PhD, received a Trustee Grant Award by Cincinnati Children’s to support the Wen Lab in investigating the roles of FFAR3 in Th2 cytokine production by esophageal lymphocytes.
• Assistant professor, Andrew W. Lindsley, MD, PhD, received a K08 from the National Institute of Allergy and Infectious Diseases (NIAID). This National Institutes of Health clinical scientist career development award will support the Lindsley Lab in investigating how the sphingolipid ORMDL3 regulates dendritic cells in asthma.
• Assistant professor, Patricia C. Fulkerson, MD, PhD, received an R01 from National Institute of Allergy and Infectious Diseases (NIAID). This R01 will support the Fulkerson Lab in investigating the role of the transcription factor Aiolos in eosinophilic asthma.

p65: A Step Back from Sepsis

Sepsis is a life-threatening condition caused by the body’s response to infection injuring a person’s own organs and tissues and causing endotoxic shock. Sepsis is primarily caused by Gram-negative bacteria, which trigger immune cells and cytokines. A study, published in Innate Immunity, and led by Simone Vanoni, PhD, and our division’s director of research, Simon P. Hogan, PhD, demonstrates that lack of the protein p65, a part of the NF-κB transcription complex, in macrophages caused increased mortality in mice with endotoxic shock and that there is an association with the excessive production of proinflammatory cytokines. These findings identify a new role for NF-κB in the negative regulation of myeloid cell proinflammatory activity and function in sepsis.

Cadherin 26: Adhesion and Immunomodulation During Allergic Inflammation

Cadherins mediate diverse processes critical in inflammation, including cell adhesion, migration and differentiation. A recent study, published in Mucosal Immunology and led by Julie Caldwell, PhD, and Marc E. Rothenberg, MD, PhD, reported that an uncharacterized cadherin, cadherin 26 (CDH26), is highly expressed by epithelial cells in human allergic gastrointestinal tissue, such as the stomach tissue of patients with eosinophilic gastritis (EG) and esophageal tissue of patients with eosinophilic esophagitis (EoE). In vitro characterization revealed that CDH26 not only enhanced cellular adhesion through binding catenin and integrin, but also had an interesting inhibitory role when expressed as an Fc-fusion protein, with CDH26-Fc inhibiting activation of human CD4+ T cells in vitro, including secretion of IL-2. As CDH26 regulated leukocyte adhesion and activation, it may represent a novel checkpoint for immune regulation and therapy of eosinophilic gastrointestinal disorders (e.g., EG and EoE) via CDH26-Fc. A patent concerning this work was recently granted by the USA patent office.

Memory T Cell Epigenome Encodes Rapid Recall Ability

Even though T-cell receptor (TCR) stimulation with a co-stimulation is sufficient for the activation of both naïve and memory T cells, the memory cells are capable of producing lineage-specific cytokines much more rapidly than the naïve cells. The mechanisms behind this rapid recall response of the memory cells are still not completely understood. In a study published in Scientific Reports, Artem Barski, PhD, together with colleagues from the National Institutes of Health (NIH) and New York University, epigenetically profiled human resting naïve, central and effector memory T cells using ChIP-Seq and found that unlike the naïve cells, the regulatory elements of the cytokine genes in the memory T cells marked by activating histone modifications even in the resting state. Therefore, the ability to induce expression of rapid recall genes upon activation associates with the deposition of positive histone modifications during memory T cell differentiation. The researchers propose a model of T cell memory, in which immunologic memory state encoded epigenetically, through poising and transcriptional memory.

Siglec-8: Engaging Eosinophil Cell Death

Activation of Siglec-8 receptor on human eosinophils leads to eosinophil reactive oxygen species production and cell death. A study published in Immunobiology and led by Dr. Nives Zimmermann, MD, evaluated the suspected role of Src family kinases (SFKs) in this pathway. They discovered the requirement of SFKs for the production of intracellular reactive oxygen species via this pathway and that both the reactive oxygen species and the requirement of SFKs for Siglec-8–induced cell death in activated eosinophils. Deciphering the molecular basis of eosinophil cell death may inform translational and clinical research, as accumulation of activated eosinophils can contribute to inflammation and damage in conditions such as asthma and eosinophilic gastrointestinal disorders.

Tissue Identity in Organ-specific Responses of Allergy

Despite systemic sensitization to the triggering allergens, allergic inflammation manifests in different organs—lungs, skin and esophagus for patients with asthma, atopic dermatitis and eosinophilic esophagitis (EoE), respectively. The disparity between the systemic trigger yet organ-specific response is not well understood. In a study published in The Journal of Allergy and Clinical Immunology, Mark Rochman, PhD; Jared Travers, PhD; and Marc E. Rothenberg, MD, PhD, assessed the potential role of organ-specific genes in the differential manifestation of allergy. They characterized the expression of esophagus-specific genes identified by The Human Protein Atlas Project, which maps the molecular signature of tissues, in esophageal biopsy specimens of patients with EoE, a chronic, inflammatory, food allergen–driven disorder of the esophagus. Strikingly, about 39% of esophagus-specific genes had altered expression in EoE biopsies, with the downregulation of approximately 90% of these genes. These findings reveal a profound loss of differentiation within the esophageal epithelium. The whole-exome sequencing revealed mutations in several esophagus-specific genes in EoE tissue. Notably, prior research showed that the gene most strongly associated with EoE disease risk, CAPN14, encodes an esophagus-specific protease. These collective findings suggest that the pathogenesis of EoE involves a loss of esophageal differentiation and expand our understanding of the propagation of allergic inflammation on the level of tissue molecular identity, suggesting that genetic profiling of tissue-specific genes may have diagnostic and prognostic value for EoE and potentially other allergic conditions.

2017 NIAID Addendum Guidelines for Preventing Peanut Allergy

In 2015, findings from a landmark National Institute of Allergy and Infectious Diseases (NIAID)-funded clinical trial, called the Learning Early About Peanut (LEAP) study, showed that introducing peanut-containing foods to infants at high risk for developing peanut allergy was safe, and led to an 81% relative reduction in the subsequent development of peanut allergy. Due to the strength of these results, NIAID established a coordinating committee that convened an expert panel to update the 2010 Guidelines to specifically address the prevention of peanut allergy. The division's director of clinical services, Amal H. Assa'ad, MD, contributed through service on the coordinating committee and expert panel to these Addendum Guidelines for the Prevention of Peanut Allergy in the United States published in the January 2017 issue of Annals of Allergy and Immunology along with an editorial by Amal H. Assa'ad, MD. These addendum guidelines are a major paradigm reversal by recommending early peanut introduction to infants, the importance evidenced by these guidelines published in seven prestigious journals in the fields of allergy, dermatology, nutrition and general pediatrics. Read the National Public Radio segment (by Patti Neighmond), the Reuter's article (by Rob Goodier), and a related Journal of Allergy and Clinical Immunology editorial about the LEAP study findings about early allergen consumption.

Food Allergy Desensitization and Tolerance Induction and Disparities

Clinical trials for the desensitization and induction of tolerance in children and adults with food allergy continued with the contributions of our division’s director of clinical services, Amal H. Assa’ad, MD; physicians, such as Michelle B. Lierl, MD, and Stephanie L Logsdon, MD; fellows; research nurses and coordinators; and the Shubert Clinic. Completed studies include epicutaneous immunotherapy (known as the peanut patch, and manufactured as Viaskin®), oral immunotherapy for peanut allergy and oral immunotherapy for multiple food allergens, with the last employing an anti-immunoglobulin E under the marketed name of Xolair® (omalizumab) to reduce the incidence of side effects that accompany oral immunotherapy. The peanut (LAMP-based) vaccine study was also initiated, with participants progressing from randomized, placebo-controlled trials to a higher dose phase. Furthermore, Amal H. Assa’ad, is collaborating in National Institutes of Health (NIH)-funded research to examine racial and ethnic disparities in food allergy, the FORWARD study, showed that children who were parent-identified as African American, or Hispanic, had different food allergen profiles, higher rates of associated atopic conditions, and increased rates of food allergen–associated anaphylaxis and emergency department visits than children who were parent-identified as Caucasian.

Physician Receives 2017 Clinical Care Award

The Faculty Awards Committee at Cincinnati Children's selected Michelle B. Lierle, MD, for the Clinical Care Award. This is a well-deserved honor for Dr. Lierl, who is now in her 30th anniversary year at Cincinnati Children's. In addition to her great clinical service, Dr. Lierl researches fungal allergens and has created a fungal spore photo website.

Fellowship Director Receives 2017 AAAAI Distinguished Service Award

The American Academy of Asthma, Allergy & Immunology (AAAAI) selected the director of our Allergy / Immunology Fellowship Program, Kimberly A. Risma, MD, PhD for their 2017 Distinguished Service Award based on her leadership with the Chrysalis Project. The Chrysalis Project is a program for medical students and internal medicine and/or pediatric residents that provides them the opportunity to explore a career in allergy / immunology. Housed within the AAAAI Annual Meeting, it includes pairing the Chrysalis mentee with a fellow-in-training mentor, didactic lectures with allergy/immunology faculty, career option presentations, and free conference registration and access to the leading knowledge in the hundreds of AAAAI meeting sessions, workshops, symposia, seminars and oral abstracts. Dr. Risma has helped to propel this program to become a jewel of our society; thus greatly impacting our field and its future. Through her efforts, she has established a ‘pipeline’ of strong physicians in our field. In 2010, Dr. Risma received a nomination from the Board of AAAAI to assume the co-Chair position of the Chrysalis Program Project after a pause in the program's funding. Under her leadership, the program has expanded from 20 to 50 attendees per year. The Chrysalis Project has been extraordinarily well received as evident from the growing number of highly qualified applicants and attendees, the positive reviews, and the growing number of fellowship applicants who credit the Chrysalis Project.

Division Director Receives 2016 Faculty Award: Research Achievement Award

The Fifth Annual Faculty Awards by Cincinnati Children's recognized our division director, Marc E. Rothenberg, MD, PhD, for his dedicated efforts with a Research Achievement Award. Rothenberg is one of the most productive researchers in the field of Allergy and Immunology. The scope of his work includes basic biology, translational research, genetics and epigenetics, and clinical trials of novel agents. Rothenberg primarily focuses on molecular analysis of allergic inflammation, particularly the pathogenesis of eosinophilic gastrointestinal diseases (EGIDs). He is a pioneer in identifying, studying and treating EGIDs and has built a comprehensive program, making Cincinnati Children’s the leading site for study and treatment of these disorders. He also founded and directs the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR), a group of national leaders funded by the National Institutes of Health (NIH). Rothenberg’s research has resulted in over 300 peer-reviewed, and in some cases landmark, articles published in the highest-impact journals. His work has been cited over 17,000 times. He has received a number of prestigious national awards, and has served as a research mentor to students and colleagues around the world. Rothenberg’s research also sheds light on other atopic diseases, including asthma. His efforts in basic research, and clinical trials, contributed to the FDA approval in 2015 of the first new class of drugs in over a decade to treat severe asthma.

Recognized Excellence of Division Trainees and Faculty

The Division of Allergy and Immunology is proud of the excellence of its undergraduate, graduate, postdoctoral and clinical trainees and junior investigators. Several were recognized for their achievements throughout the year:

• Jeffrey Rymer, predoctoral fellow in the Rothenberg Lab, won the first prize for his poster at the 2016 Annual Scientific Symposium from the Digestive Health Center.
• Jared Travers, MD, and PhD predoctoral fellow in the Rothenberg Lab, will study the role of nuclear IL-33 in mucosal inflammation through an NIH F30 fellowship grant awarded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
• Allergy/immunology clinical fellow, Michael Goodman, MD, received K12 support through the NIH Pediatric Scientist Development Program.
• Artem Barski, PhD, assistant professor, received a Trustee Award from Cincinnati Children's for his research project "Epigenetic Suppression of IL4 Expression in T Cells" in the Barski Lab and a T1 Core grant by the CCTST to establish the Epigenomics Data Analysis Core.
• Patricia C. Fulkerson, MD, PhD, assistant professor, selected as a 2015 Schmidlapp Woman Scholar by the Fifth Third Bank / Charlotte R. Schmidlapp Women Scholars Program to support her career development and research in the Fulkerson Lab.
• Our division's Director of Research, Simon P. Hogan, PhD, received funding from the Cincinnati Children's Research Innovation/Pilot Funding Program in 2016. This program will support the Hogan Lab in investigating the involvement of antibiotics in antigen sensitization in food allergy.

Fostering the Future through Clinical and Research Fellowship Education

David W. Morris, MD, matriculated from our division’s Allergy/Immunology Fellowship Program in the Summer of 2015. After working further as a clinician and clinical researcher at Cincinnati Children’s, Dayton Children’s Hospital recruited him to expand the clinical allergy program. During his fellowship, he conducted research mentored by Patricia C. Fulkerson, MD, PhD. He initiated two research projects in the Fulkerson Lab: 1) evaluation of human samples for eosinophil progenitor populations in the peripheral blood of patients with eosinophilic esophagitis (EoE) and 2) the development of a murine cell model to evaluate the effect of toll-like receptor 2 stimulation on eosinophil development. The former’s results published in the Journal of Allergy and Clinical Immunology. As an indication of his excellence, his clinical and research fellowship training is supported with our division’s Allergy/Immunology T32 training award. In addition, he received a peer-reviewed grant in 2014 from the American Academy of Allergy, Asthma and Immunology (AAAAI).

Tipping the Scales: the Interplay of IL-25, CD4+ TH2 Cells and Type 2 Innate Lymphoid Cells in Promoting Food Allergy

After food sensitization occurs, a strong allergic reaction to ingested food is essential for the development of food allergy. However, the immunologic mechanisms that drive the propagation of food allergic reactions in the intestine remain elusive. A recent study, led by Yui-Hsi Wang, PhD, associate professor, shows that interleukin 25 (IL-25) enhances anaphylactic responses in a mouse model of food allergy by stimulating type 2 innate lymphoid cells (ILC2s) in the intestines. ILC2s produce IL-5 and IL-13, which promote immunoglobulin E (IgE)–mediated food allergy and drive uncontrolled type-2 immune responses. Repeated exposure to the food antigen increased the number of CD4(+) T helper type 2 (TH2) cells, which fueled further IL-13 production by IL-25–stimulated ILC2s. These findings, published in the Journal of Allergy and Clinical Immunology, suggest that the IL-25–mediated, collaborative interactions between ILCs and adaptive CD4+ TH2 cells are a pivotal step in amplifying the cascade of allergic reactions to ingested antigens and underscore the importance of understanding the mechanisms that underlie intestinal allergic responses to ingested food. Future, in-depth studies of the molecular and cellular factors composing these stepwise pathways may facilitate the discovery of biomarkers and therapeutic targets for diagnosing, preventing and treating food allergy.

Research Suggests Less Invasive Monitoring of Eosinophilic Disorder

Patricia C. Fulkerson, MD, PhD, assistant professor, led recent, preliminary research suggesting that eosinophil progenitors (EoPs) in the blood may be a potential marker for disease activity of eosinophilic esophagitis (EoE) in children. This potential method of monitoring is less invasive, sparing children with EoE the discomfort and risk of endoscopic procedures to assess whether their disease is active. The disease activity of EoE is currently monitored using peak esophageal eosinophil count, which requires invasive endoscopy to collect esophageal tissue biopsies for assessment. People with EoE, a lifelong disease, must continue monitoring disease activity, even after effective treatment with restricted diets or steroids. Treatment changes, such as reintroducing a single food, requires additional endoscopic exams to assess for disease flare-ups. Research led by the Fulkerson lab and published in the Journal of Allergy and Clinical Immunology found elevated EoP levels in the blood of pediatric patients with active EoE disease, suggesting a promising, blood-based marker. Measuring EoP blood levels to monitor disease activity has the potential to reduce discomfort, costs and side effects for patients. However, additional research is needed to validate the EoP-based marker before its routine use in clinic.

How to Stop Eosinophilic Esophagitis Tissue Damage? Target Calpain 14

Drugs that target the protein calpain 14 may someday help treat the inflammation and scarring that can occur in people with eosinophilic esophagitis (EoE), according to new research from the Cincinnati Center for Eosinophilic Disorders. Previous research, led by division director Marc E. Rothenberg, MD, PhD, has established a powerful link between EoE and the CAPN14 gene, which codes for calpain 14. In the latest findings, published in JCI Insight, Rothenberg and colleagues detail the biochemical and functional properties of calpain 14 and the disruptions in esophageal cells that occur when the expression of CAPN14 is experimentally regulated. The new information suggests that controlling the activity of calpain 14 may prevent the development of EoE, thus making the protein an important target for further drug research.

Putting the Brakes on Anaphylactic Reactions

A study, published in Immunity, Inflammation and Disease, and led by our division’s director of research, Simon P. Hogan, PhD, demonstrates that loss of the phosphatidylinositol 3-kinase (PI3K) activating signal triggered by interleukin 4 receptor alpha (IL-4R⍺) does not alter susceptibility to food-induced experimental anaphylaxis. Symptoms of experimental anaphylaxis, namely diarrhea, antigen-specific IgE and intestinal mastocytosis, are comparable between mice with, and without, functional IL-4R⍺ and PI3K signaling. However, mice without functional IL-4R⍺-mediated PI3K signaling have accelerated disease progression. This quickened anaphylactic response associates with a more rapid decrease in blood volume caused by histamine. Notably, endothelial IL-4R⍺ PI3K signaling negatively regulates the histamine-induced endothelial leak response. These results define an unanticipated role for IL-4R⍺–mediated PI3K signaling in putting the brakes on IgE-mediated anaphylactic reactions.

EoGenius Diagnostic Test for Eosinophilic Esophagitis

Research, led by division director Marc E. Rothenberg, MD, PhD, and instructor Ting Wen, PhD, yielded an RNA expression test to help diagnose eosinophilic esophagitis (EoE). Through collaboration with Miraca Life Sciences, they brought this innovation from the bench to bedside, and it is now commercially available as the EoGenius test. This achievement represents a meaningful stride forward for this often misdiagnosed condition.

Kabuki Syndrome

Kabuki syndrome is a rare developmental disorder that affects many systems of the body that associates with mutations in genes encoding histone-modifying proteins. This study, led by Andrew W. Lindsley, MD, PhD, and published in the Journal of Allergy and Clinical Immunology, characterizes the humoral immune defects of this understudied condition in patients with mutations in lysine methyltransferase 2D (KMT2D). The research showed that mutations in KMT2D associate with dysregulation of terminal B-cell differentiation. This dysregulation is what leads to the humoral immune deficiency observed in Kabuki syndrome, and the autoimmunity that sometimes develops. These findings support the importance of a change in clinical practice in that patients with Kabuki syndrome would benefit from undergoing serial clinical immune evaluations.

Food Allergy Desensitization and Tolerance Induction

Clinical trials for the desensitization and induction of tolerance in children and adults with food allergy continued with the contributions of our division’s director of Clinical Services, Amal H. Assa’ad, MD; physicians, such as Michelle B. Lierl, MD, and Stephanie L. Logsdon, MD; fellows; research nurses and coordinators; and the Shubert Clinic. Completed studies include epicutaneous immunotherapy (known as the peanut patch and marketed as Viaskin®), oral immunotherapy for peanut allergy and oral immunotherapy for multiple food allergens under the marketed name of Xolair® (omalizumab) to reduce the incidence of side effects.

Allergic Diseases and Internalizing Behaviors in Early Childhood

Research recent conducted during the fellowship of Maya Nanda, MD with the Allergy/Immunology Fellowship Program examined whether having multiple allergic diseases in early childhood associated with having internalizing disorders in the school-age years. The study was published in Pediatrics. Children who were enrolled in the Cincinnati Childhood Allergy and Air Pollution Study underwent skin testing and examinations at ages 1, 2, 3, 4, and 7 years. When the children were age 7, their parents completed the Behavior Assessment System for Children, Second Edition (BASC-2), a validated measure of childhood behavior and emotion. The study, led by Patrick H. Ryan, PhD, concluded that children with allergic rhinitis and allergic persistent wheezing at age 4 are at increased risk of internalizing behaviors at age 7. Furthermore, there was a dose-dependent association between the number of allergic diseases that a child had and the degree of elevation of the internalizing scores.

Division Director Receives First Bunning Chair

Our division director, Marc E. Rothenberg, MD, PhD, was named the first recipient of the Denise and Dave Bunning Chair for the Division of Allergy and Immunology. Cincinnati Children’s established the chair in honor of the Bunnings, who have been generous supporters of Rothenberg’s work and the advancement of the Division of Allergy and Immunology for nearly 10 years. In particular, they have helped Cincinnati Children’s make great strides in diagnosing, understanding and treating eosinophilic gastrointestinal disease, known as eosinophilic gastrointestinal disorders (EGIDs). EGIDs cause the body to treat food like a foreign invader, causing inflammation, pain and tissue damage. Rothenberg has focused on alleviating the suffering of patients with these severe, life-altering allergies throughout his medical career. He is a pioneer in his field, leading Cincinnati Children’s as the first to form an EGID center, which stands as an example for dozens of EGID centers that have since been set up across the country. Rothenberg established and is the principal investigator of the Consortium of Eosinophil Gastrointestinal Disease Researchers, which is one of only 22 rare disease consortia supported by the NIH, through three NIH institutes (NIAID, NIDDK and NCATS). Other recent EGID achievements include Rothenberg receiving an R01 by the NIAID for his project "Genetic and Immunological Dissection of Eosinophilic Esophagitis", and the "Most Outstanding Translational Research Achievement between 2010-2015" at Cincinnati Children's for his work towards the Nature Genetics publication, "Genome-wide association analysis of eosinophilic esophagitis provides insight into the tissue specificity of this allergic disease”. The Bunning endowed chair provides an enduring way of ensuring that Cincinnati Children's will have the best faculty and outstanding research of EGIDs in perpetuity.

BioWardrobe: an Integrated "-omics" Analysis Platform

High-throughput sequencing has revolutionized biology by enhancing our ability to perform genome-wide studies. However, due to lack of bioinformatics expertise, modern technologies are still beyond the capabilities of many laboratories. Andrey Kartashov, MSc, and Artem Barski, PhD, developed the BioWardrobe platform, which allows users to store, visualize and analyze epigenomics and transcriptomics data using a biologist-friendly web interface, without the need for programming expertise. Predefined pipelines allow users to download data, visualize results on a genome browser, calculate RPKMs (reads per kilobase per million) and identify peaks. Advanced capabilities include differential gene expression and binding analysis and creation of average tag-density profiles and heatmaps. BioWardrobe was published in Genome Biology.

Division Leading the Way to Measure Eosinophilic Esophagitis Pathology

Our division director, Marc E. Rothenberg, MD, PhD, established and is the principal investigator (PI) of the Consortium of Eosinophil Gastrointestinal Disease Researchers (CEGIR), which is one of only 22 rare disease consortia supported by the NIH, through three NIH Institutes (NIAID, NIDDK and NCATS). CEGIR is pushing boundaries with much-needed research of eosinophil gastrointestinal diseases (EGIDs), and the management of that research as well. For instance, EGID researchers have developed and validated a histologic scoring system to objectively analyze pathologic features of eosinophilic esophagitis (EoE), a severe, often painful food allergy that renders children unable to eat a wide variety of foods. This study, led by Margaret Collins, MD, and other professors of pathology in the Cincinnati Center for Eosinophilic Disorders at Cincinnati Children’s was in collaboration with our national CEGIR colleagues, and published in Diseases of the Esophagus. This scoring system encourages pathologists to evaluate more than eosinophilic inflammation and reduces our dependence on a single feature for diagnosis. By having validated tools to measure other pathologic features of EoE, the reported findings provide a new opportunity for evaluating disease activity and treatments going forward. CEGIR is also implementing cloud technology involving a virtual microscope across consortium sites to improve collaboration between its network of researchers, providers, patients and organizations. From improving the interactions between researchers at nine different centers located across the country, to connecting patients with clinical studies and patient advocacy groups, CEGIR is leading the charge on bringing digital health to the clinical research field.

The Untold Story of a New Asthma Drug

The FDA approved the drug mepolizumab in November 2015 and then reslizumab in March 2016 to help treat severe asthma, which was an achievement grounded in many years of research and testing by innumerable physicians and scientists, including those at Cincinnati Children's, such as Division Director Marc E. Rothenberg, MD, PhD; our division's Director of Clinical Services, Amal H. Assa’ad, MD, and Director of Research, Simon P. Hogan, PhD. These medications target a subset of patients (ages 12 and up) with asthma whose current drug regimens are insufficient to control their condition. This is the first class of new asthma drugs approved in over a decade based on targeting the allergy-associated, inflammatory cells called eosinophils. Rothenberg and his research team are considered pioneers in the field, and Cincinnati Children’s has become a global leader in researching and treating eosinophilic conditions. The institution’s researchers characterized a critical genetic/molecular pathway (involving the protein interleukin 5) that helps fuel severe asthma, which is caused by eosinophils. Mepolizumab and reslizumab inhibit interleukin 5 and block the production of eosinophils, which drives certain types of severe asthma. In addition to basic laboratory studies that established the molecular target for this therapy, Cincinnati Children’s also helped conduct clinical trials testing the safety and efficacy of mepolizumab in patients, not only those with asthma but also those with other eosinophilic disorders such as eosinophilic esophagitis.

Research of a New Cell Type May Explain Why Some Individuals Develop Severe Allergic Reactions to Food

Yui-Hsi Wang, PhD, and his colleagues, report their discovery of a new cell type that appears to drive life-threatening food allergies, and may help explain why some people get severe allergic reactions, and others do not. Food allergy is a harmful immune reaction that occurs shortly after a person eats certain foods. For some people, the reaction to a particular food may merely be uncomfortable. For others, food allergy can trigger a severe, or life-threatening anaphylaxis, reaction. It has been perplexing why only some individuals among those with food allergy are more prone to develop life-threatening anaphylactic response to ingested food. A key study led by Dr. Wang, published in Immunity, reports the findings of a new type of mucosal mast cells, termed IL-9–producing mucosal mast cells (MMC9s), which may provide some clues to this enigma. MMC9s produce large amounts of an inflammatory immune protein called interleukin 9 (IL-9) and mast cell mediators, which amplifies anaphylactic shock in response to ingested food. Data from murine experiments support that triggering MMC9s is a key step for mice to gain susceptibility to developing food allergy. Analyzing small intestine biopsy samples from patients with food allergy, Wang’s team found significantly increased expression of the IL9 genetic transcript, and other related transcripts, suggesting a possible connection. The results obtained from these studies, published in Immunity, will likely greatly influence and improve our conceptual understandings of why some individuals may be more susceptibility to developing food allergy–induced, life-threatening anaphylaxis and thus make possible new designs for medicines to treat and/or prevent food allergy. This research will be further pursued by Dr. Wang, who received a FY 14 Peer Reviewed Medical Research Program (PRMRP) Investigator-Initiated Research Award from the United States Department of Defense (DoD) for his project "IL-9-Producing Mast Cell Precursors and Food Allergy".

Biosensors: Measuring Early Events in Cell Death

Natural killer (NK) cells are cytotoxic lymphocytes and first responders of the human immune system in identifying and eliminating tumor cells and virally infected cells. As natural killer (NK) cell–based therapy is being considered for treating human cancer, developing new tools to measure early events in cell death is critical. After recently demonstrating that protease-cleavable luciferase biosensors detect granzyme B and pro-apoptotic caspase activation within minutes of target cell recognition by murine cytotoxic lymphocytes, researchers led by Kimberly A. Risma, MD, PhD, successfully adapted the biosensor technology to assess perforin-dependent and -independent induction of death pathways in tumor cells recognized by human NK cell lines and primary cells and also developed biosensors for granzyme A and K, for which no other functional reporters are available. These studies, published in Blood, establish the sensitivity of protease-cleaved luciferase biosensors to measure previously undetectable events in live cells in real time. Further development of caspase and granzyme biosensors will allow interrogation of additional features of granzyme activity in live cells including localization, timing and specificity, which will inform NK cell–based therapy development.

Eosinophils Outside of Inflammation: Homeostatic Regulation of IgA Production

Eosinophils are a multifunctional type of white blood cell that resides in the gastrointestinal lamina propria. They are widely known for their roles in inflammatory response; however, their non-inflammatory functions remain largely unexplored. Researchers, led by division director Marc E. Rothenberg, MD, PhD, used mice with a selective deficiency of systemic eosinophils (by lineage ablation) or gastrointestinal eosinophils (eotaxin-1/2 double deficient or CC chemokine receptor 3 deficient). They found that eosinophils support immunoglobulin A (IgA) class switching, maintain intestinal mucus secretions, affect intestinal microbial composition and promote the development of Peyer's patches. Eosinophil-deficient mice showed reduced expression of mediators of secretory IgA production, including intestinal interleukin 1β (IL-1β). Gastrointestinal eosinophils expressed a relatively high level of IL-1β, and IL-1β–deficient mice manifested the altered gene expression profiles observed in eosinophil-deficient mice and decreased levels of IgA(+) cells. The study’s collective data, published in Mucosal Immunology, suggest the requirement of eosinophils for homeostatic intestinal immune responses including IgA production, and that their affect is mediated via IL-1β in the small intestine.

Neurotrophins: Another Piece in the IL-13 Inflammation Puzzle

Researchers, led by division director Marc E. Rothenberg, MD, PhD, explored the interaction of the interleukin (IL) 13 and neurotrophin pathways, which are functionally important for the pathogenesis of immune responses, particularly those involving pain such as in eosinophilic esophagitis (EoE). By interrogating IL-13–induced responses in human epithelial cells, they found an early transcriptional target of IL-13, neurotrophic tyrosine kinase receptor, type 1 (NTRK1). NTRK1 is a cognate, high-affinity receptor for nerve growth factor (NGF). NTRK1’s induction accompanied by accumulation of activating epigenetic marks in the promoter. In human EoE, an allergic inflammation disease, NTRK1 was increased in inflamed tissue and dynamically expressed as a function of disease activity, and a downstream mediator of NTRK1 signaling was elevated in allergic inflammatory tissue compared with control tissue. Unlike NTRK1, its ligand NGF was constitutively expressed in control and disease states, indicating that IL-13–stimulated NTRK1 induction is a limiting factor in pathway activation. In epithelial cells, NGF and IL-13 synergistically induced several target genes, including chemokine (C-C motif) ligand 26 (eotaxin-3). In summary, these results, published in the Journal of Clinical Investigation Insight, demonstrate that IL-13 confers epithelial cell responsiveness to NGF by regulating NTRK1 levels by a transcriptional and epigenetic mechanism and that this process likely contributes to allergic inflammation.

Identification of a Genetic-Molecular Linkage for EoE Opens New Doors for Treatment

A gene called CAPN14 has been identified as a novel genetic component in epithelial tissue in the esophagus, and the gene’s interaction with the immune hormones thymic stromal lymphopoietin (TSLP) and interleukin 13 (IL-13) may explain why some patients develop eosinophilic esophagitis (EoE), a hard-to-treat food allergy marked by chronic inflammation of the esophagus. In effect, EoE turns out to develop from interplay of a patient’s underlying genetic susceptibility to allergies and a tissue-specific process dictated by the molecular aspects of the CAPN14 gene, according to Marc Rothenberg, MD, PhD, director of the Cincinnati Center for Eosinophilic Disorders and the Division of Allergy and Immunology. Rothenberg, and colleagues in the Divisions of Gastroenterology, Hepatology and Nutrition; Human Genetics; and the Center for the Genetics Autoimmune Etiology, probed millions of genetic variants in nearly 1,000 people with EoE and 9,000 people without EoE. They found several genetic linkages, with the strongest associations being at the CAPN14 and TSLP loci. EoE is triggered by allergic sensitivity to certain foods and an accumulation of eosinophils, specialized immune cells, in the esophagus. Rothenberg and his team found that CAPN14, which encodes the enzyme calpain 14 in the esophagus, is dramatically upregulated when epithelial cells in the esophagus are exposed to IL-13, a known molecular activator of EoE. The CAPN14 gene is part of the esophageal disease process of EoE. CAPN14’s upregulation, Rothenberg’s team noted, occurs in an epigenetic “hot spot” that encodes for an EoE-associated genetic variant that regulates the binding of transcription factors to the upstream region of the CAPN14 gene. This new finding “is a breakthrough for this condition and gives us a new way to develop therapeutic strategies by modifying the expression of calpain 14 and its activity,” Rothenberg says. “Our results are immediately applicable to EoE and have broader implications for understanding eosinophilic disorders, as well as allergies, in general.”

Cincinnati Children's Inaugural Member of the Food Allergy Research &
Education Clinical Network

The Food Allergy Research & Education (FARE) Clinical Network is an initiative that aims to accelerate the development of drugs for patients with food allergies, as well as improve the quality of care for this serious illness. Cincinnati Children's became a FARE Center of Excellence and an inaugural member of the FARE Clinical Network in large part through divisional efforts and the Food Allergy Program of the Division of Allergy and Immunology.

Excellence of Division Trainees and Junior Faculty

The Division of Allergy and Immunology is proud of the excellence of its undergraduate, graduate, postdoctoral, and clinical trainees and junior investigators. Several have been recognized for their achievements throughout the year. Rahul D’Mello, a MD, PhD student in the Rothenberg Lab, won first place at the 2015 Graduate Student Research Forum poster competition at the University of Cincinnati College of Medicine. Nurit Azouz, a research fellow in the Rothenberg Lab, won the first prize at the 2015 Annual Scientific Symposium of the Digestive Health Center. Masashi Yukawa, a postdoctoral fellow in the Barski Lab, and his mentor, Artem Barski, PhD, were awarded a Careers in Immunology Fellowship award by the American Association of Immunologists (AAI). Ting Wen, PhD, a Research Instructor in the division, won the first place for 2014 Outstanding Poster Presentation at the 2014 Ohio River Valley Cytometry Association meeting and was awarded a Digestive Health Center Pilot and Feasibility Award and a 2015 APFED HOPE Pilot Grant for his research investigating esophageal lymphocytes in eosinophilic esophagitis. Assistant Professor Patricia C. Fulkerson, MD, PhD, was awarded a 2015 Young Physician-Scientist Award by the American Society for Clinical Investigation Council and a Trustee Award by the Trustee Award & Procter Scholar (TAPS) Program at Cincinnati Children's.

Clinical Director Contributes to Peanut Desensitization Study

Our division and center has been one of the top enrolling centers in the multi-center peanut desensitization study using the Viaskin patch. This important clinical research could not have been accomplished without the dedicated efforts and expertise of our clinical research team, led by our division’s Director of Clinical Services, Amal H. Assa'ad, MD, and the support of the division and the individuals and families who entered the study. DBV technologies, the sponsor of the study, announced in a press release that the primary endpoint for this phase IIb clinical trial has been met. The division has conducted four clinical trials with two methods of desensitization, one oral and one by a patch applied to the skin. Both studies yielded data supporting a high rate of success and captured national and international attention.

Research Director Receives Mentoring Achievement and Research Awards

Our division's Director of Research, Simon P. Hogan, PhD, was recognized for his dedicated efforts with the Mentoring Achievement Award in the Fourth Annual Faculty Awards by Cincinnati Children's (Watch the video). His excellence in mentoring is coupled to his merit in research and collaboration. He was awarded a 2015 FARE Investigator in Food Allergy Award, a Mid-Career Investigator Award from Food Allergy Research & Education (FARE), that will support Hogan in identifying the key proteins and cells that cause the blood vessel fluid leak leading to severe anaphylaxis triggered by foods. Furthermore, divisional collaborators Hogan and Yui-Hsi Wang, PhD, and national collaborator Rodney Newberry, MD (Washington University in St. Louis) were awarded a multi-principal investigator R01 grant from the National Institute of Allergy and Infectious Diseases (NIAID) for their project investigating goblet cell antigen passages in food allergy.

Furthering Data Analysis of Next-Generation Sequencing to Facilitate Research

Assistant Professor Artem Barski, PhD and Andrey Kartashov, MS have developed a user-friendly, integrated platform for analyzing the “big data” derived from genome and epigenome sequencing, which was recently described in Genome Biology. The recent proliferation of next-generation sequencing (NGS)–based methods for analysis of gene expression, chromatin structure and protein–DNA interactions has opened new horizons for molecular biology. However, the sheer volume of the data obtained from sequencing requires computational data analysis, and the bioinformatic and programming expertise required for this analysis is usually absent in typical biomedical laboratories, resulting in data inaccessibility or delays in applying modern sequencing-based technologies to pressing questions in basic and health-related research. Barski and Kartashov collaboratively developed a new approach and platform, called “BioWardrobe”, to facilitate the analysis and utilization of both newly generated and publically available datasets. More than twenty labs at Cincinnati Children’s currently use BioWardrobe, including the Barski Lab, Fulkerson Lab, Grimes Lab, Hogan Lab, Namekawa Lab, Rothenberg Lab, and Singh Lab, as well as national colleagues at New York University School of Medicine (Cuddapah Lab) and Cedars-Sinai (Berman Lab). Primary research using the BioWardrobe platform has recently been published in several journals, including Developmental Cell and Mucosal Immunology, and more are forthcoming. Barski and Kartashov intend to continue to improve BioWardrobe using an Innovative Core Facility grant provided by the University of Cincinnati’s Center for Clinical and Translational Science and Training (CCTST) and employing BioWardrobe in their own research on epigenetic regulation in the immune system (e.g. Cincinnati Children’s 2015 Trustee Award to Barksi, "Epigenetic Suppression of IL4 Expression in T Cells”) and collaborative projects with other investigators. The work to develop BioWardrobe was supported in part by the Cincinnati Children’s Research Foundation, NHLBI NIH Career Transition Award (K22 HL098691 to Artem Barski) and the Center for Clinical and Translational Science and Training (CCTST) Innovative Core Facility grant (NIH/NCRR Institutional Clinical and Translational Science Award, 8UL1TR000077-06). (Read the press release)

Cincinnati Children’s Receives NIH Grant To Lead Multicenter Consortium on Eosinophilic Disorders

Cincinnati Children’s has received a 5-year, $6.25 million grant from the National Institutes of Health to lead a consortium of organizations from around the country that will conduct clinical research into eosinophilic gastrointestinal disorders and train investigators in how to conduct clinical research—the Consortium of Eosinophilic Gastrointestinal Disease Researchers CEGIR. This NIH grant (U54AI117804) is believed to be the first to establish a network focusing on the three distinct diseases of eosinophilic esophagitis, eosinophilic gastritis and eosinophilic colitis and is funded by the Office of Rare Diseases Research, which is part of the NIH’s National Center for Advancing Translational Sciences, as part of the Rare Disease Research Network and is funded by the NIAID, NIDDK and NCATS at the NIH. CEGIR will further research and clinical expertise, train clinical investigators, pilot clinical research projects and provide access to information related to eosinophilic disorders for basic and clinical researchers, physicians, patients and the lay public. Marc Rothenberg, MD, PhD, Director of the Division of Allergy and Immunology and the Cincinnati Center for Eosinophilic Disorders at Cincinnati Children’s, is the principal investigator. To coincide with Rare Disease Day® 2015, CEGIR launched a new Patient Contact Registry for Rare Eosinophilic Gastrointestinal Diseases. (Read the press release)

Environment Plays Bigger Role than Genetics in Food Allergic Disease Eosinophilic Esophagitis

In an international collaboration involving multiple institutions and led by Marc Rothenberg, MD, PhD, Director of the Division of Allergy and Immunology and the Cincinnati Center for Eosinophilic Disorders, researchers at Cincinnati Children’s quantified the risk associated with genes and environment on familial clustering of eosinophilic esophagitis (EoE). The researchers constructed and examined patient family pedigrees of patients with EoE and their first-degree relatives (nuclear family analysis) and of patients with EoE and their identical or fraternal twin/triplets (twin analysis). Using these two distinct analyses, they determined that 2.4% of siblings and 1.8% of first-degree relatives of patients with EoE also had EoE. This study, published in the Journal of Allergy and Clinical Immunology and first authored by Eileen S. Alexander, PhD, MS, BSN, RN, is the first EoE heritability study to analyze twins. This is a necessary step in separating the contribution of genetics from environment. It also identified a few environmental risk factors, including food allergies, high twin birth-weight difference, and self-reported penicillin allergy.

Anti–Interleukin 13 may have Clinical Utility in Treating Eosinophilic Esophagitis

Marc Rothenberg, MD, PhD, Ting Wen, PhD and national and international researchers of eosinophilic disorders have translated their pre-clinical findings by demonstrating that a humanized antibody against interleukin 13 (IL-13), called QAX576, is effective for the emerging food allergic disorder eosinophilic esophagitis (EoE). As reported in the Journal of Allergy and Clinical Immunology in 2015, adult patients received intravenous QAX576 or placebo every 4 weeks for three doses and were then followed for 6 months. The responder rate was 12.5% (90% confidence limit, 1% to 43%) with placebo, compared to 40.0% (90% confidence limit, 22% to 61%) with QAX576. Esophageal eosinophil counts decreased by 60% with QAX576 versus an increase of 23% with placebo, and the decrease was sustained up to 6 months. There was a trend for improved symptoms, particularly dysphagia. QAX576 improved expression of EoE-relevant esophageal transcripts, including eotaxin-3, periostin, and markers of mast cells and barrier function, for up to 6 months after treatment. The investigators found that QAX576 was well tolerated. Thus, this study provides proof-of-principle to support a long-standing theory of the Cincinnati Center for Eosinophilic Disorders—that anti–IL-13 may have clinical utility for the treatment of EoE and may have a persistent effect. The potential for persistent effect is especially promising as disease usually recurs after cessation of steroid or dietary treatment, the current standards of care for treatment of EoE.

High-dose Fluticasone Effective Against Eosinophilic Esophagitis

In another finding for eosinophilic esophagitis (EoE), the results of a clinical trial led by Marc Rothenberg, MD, PhD, Director of the Division of Allergy and Immunology and the Cincinnati Center for Eosinophilic Disorders, and published in Gastroenterology showed that high doses of the corticosteroid fluticasone propionate halted the inflammation of eosinophilic esophagitis (EoE) in a number of people. The disease of some trial participants did not respond to fluticasone, however, even after six months of high-dose treatments, providing evidence that certain people have EoE that is steroid resistant. By analyzing gene expression in esophageal tissues, the scientists identified a cluster of genes that may help predict steroid responsiveness. The study was funded by a grant from the NIAID at the NIH. (Read the press release)

Parent-reported Symptoms Gauge Pathogenic Features of the Food Allergic Disease Eosinophilic Esophagitis in Children

Researchers have identified that parent-reported responses to a questionnaire called the Pediatric Eosinophilic Esophagitis Symptom Score (PEESS® v2.0) correspond to clinical and biologic features of eosinophilic esophagitis (EoE) – a severe and often painful food allergy that renders children unable to eat a wide variety of foods. This study, published online in Journal of Allergy and Clinical Immunology, was led by researchers at Cincinnati Children’s, including Marc Rothenberg, MD, PhD, Director of the Division of Allergy and Immunology and the Cincinnati Center for Eosinophilic Disorders. The current focus for evaluating treatment for eosinophilic esophagitis involves looking at changes in the tissues and cells of the esophagus. However, to improve both clinical outcomes and patients’ quality of life, there is a need to objectively measure and consider both patients’ symptoms and how they feel, according to the research team. The authors of this study recruited pediatric patients with eosinophilic esophagitis. The PEESS® v2.0 questionnaire measured symptoms and their impact. On the basis of a previous study, the authors grouped these questions into four categories that represent the major symptom types observed in eosinophilic esophagitis—dysphagia, gastrointestinal reflux disease, nausea/vomiting, and pain. The study demonstrated that these four PEESS® v2.0 symptom categories were meaningful and that each corresponded with clinical symptoms of eosinophilic esophagitis. With the PEESS® v2.0 categories, researchers can better track disease activity in clinical settings, and this instrument can be used to test the impact and benefit of new therapies. The categories will also aid diet intervention and drug trials. Long term, this work may help identify the biologic pathways to target for intervention. The investigators are now working to get this questionnaire approved by the FDA. (Read the press release)

Zeroing in on Under-recognized Allergens

Few people know as much about slime mold as Michelle Lierl, MD. Her recent study, published in the Annals of Allergy, Asthma and Immunology, suggests that myxomycete (slime mold) spores may be under-recognized as airborne allergens. However, conducting the research needed to reach this conclusion presented a significant challenge. No extracts of these spores are commercially available, so Lierl collects the spores herself and makes the experimental extracts needed for allergy skin testing. Having also discovered a lack of photographs available of these microscopic spores, she launched a website to share images of basidiomycete, ascomycete and myxomycete spores as a reference source. Now Lierl is testing methods for growing myxomycetes in bulk, a necessary step for wider-scale research.

Setting the Guidelines for Ohio’s SCID Screening Initiative

In July 2013, the state of Ohio added severe combined immune deficiency disease (SCID) screening to its list of mandatory infant screenings. This life-threatening genetic disorder causes a lack of functional T cells that makes children with SCID extremely vulnerable to infectious diseases. Kimberly Risma, MD, PhD, who developed Cincinnati Children’s guidelines for responding to an abnormal SCID screening test, worked with members of the Ohio Department of Health (ODH) Newborn Screening Laboratory and other pediatric immunologists to develop algorithms that will guide pediatricians’ response statewide. The new testing requirement is a critical improvement in newborn screening and will allow physicians to identify patients with SCID prior to them becoming ill from exposure to bacterial, viral or fungal agents or to live vaccines such as those for rotavirus. The most common treatment for SCID is bone marrow transplantation (BMT), although recent gene therapy trials are showing promise.

Developing New Diagnostics for Rare Food Allergy

A team of researchers led by Ting Wen, PhD, and Marc Rothenberg, MD, PhD, developed a molecular diagnostic panel for eosinophilic esophagitis (EoE), a severe, often painful allergy that renders children unable to eat a wide variety of foods. Their recent study, published in Gastroenterology, demonstrated that the EoE Diagnostic Panel is accurate and reliable; can quantitatively measure the degree of disease activity; can identify patients who have been exposed to topical glucocorticoids; and can be done within hours after biopsy procurement. The test was recently licensed to Diagnovus, LLC, and is now commercially available as the ENGUAGE™ GI-EoE.

Discovery of Impaired Barrier Function in Eosinophilic Esophagitis

Faculty researcher Joseph D. Sherrill, PhD,identified impaired barrier function in eosinophilic esophagitis (EoE) in a publication in Mucosal Immunology. Researchers from Cincinnati Children’s, University of North Carolina School of Medicine and Nestle Research Centre in Switzerland investigated desmosomal cadherin desmoglein 1 (DSG-1), an essential intercellular adhesion molecule that is altered in various human skin disorders. Examining esophageal biopsies from patients with EoE, the investigators observed a specific decrease in DSG-1. They further demonstrated that decreasing expression of DSG-1 weakened the barrier function of the esophageal epithelium, suggesting a potential mechanism by which patients with EoE are hypersensitized to food antigens. Additionally, they showed that reducing DSG-1 expression promoted a pro-allergic cascade. These findings may serve as a basis for new EoE therapeutics designed to improve barrier function, Sherrill was awarded a Digestive Health Center Pilot and Feasibility Award for his project “Characterization of the Antimicrobial Peptide RNase 7 in Eosinophilic Esophagitis”.

Division Clinical Director Shares Expertise in Food Allergy

Amal H. Assa'ad, MD, lectured on food allergy, eczema and eosinophilic disorders at the plenary session of the American College of Allergy, Asthma Immunology (ACAAI) and in Turkey and Mexico on the topic of dietary prevention of food allergies. Her efforts were recognized by the Donald Fournier Lectureship from Louisiana State University. In conjunction with her sharing of expertise and knowledge through lectures and mentorship, her program in food allergy research has expanded to three treatment clinical trials with high patient enrollment. Notably, she published about the food-specific serum IgE measurements in children presenting with food allergy, this novel analysis of serum IgE testing for foods in children with food allergy showed for that food-specific IgE, a commonly utilized test, has results that fall in different ranges depending on the food and that a food-specific interpretation of the test would provide a more valid clinical application than the current ‘one size fits all’ interpretation of the test.

Discovery of a Novel Mode of Biochemically Regulating Eosinophil Cell Death

Nives Zimmermann, MD, was awarded a special invited lectureship by the American Academy of Allergy, Asthma and Immunology (AAAAI), the 2014 ARTrust™ and Donald Y. M. Leung, MD, PhD, AAAAI-JACI Lecture: “Investing Together in Our Future" award, for her symposium presentation entitled "Siglec-8 engagement induces apoptotic or lytic eosinophil cell death, depending on cell activation status" at the annual AAAAI meeting. Her presented and published work has demonstrated a novel way of biochemically regulating eosinophil cell death. Death of eosinophils can have a protective role, as when removed by a non-inflammatory process such as apoptosis, or a harmful role, as when removed by lysis, a process that releases intracellular granules and cytokines, which contribute to tissue damage and inflammation. Zimmermann demonstrated that the same molecule on the cell surface of eosinophils, Siglec-8, could lead to either apoptosis (IL-5/anti-Siglec-8 costimulation) or lysis (anti-Siglec-8 stimulation). In activated eosinophils, ligation of Siglec-8 leads to reactive oxygen species–dependent enhancement of IL-5–induced ERK phosphorylation, a novel mode of biochemically regulating eosinophil cell death. Further understanding the mechanisms involved may provide new avenues for therapeutics by permitting manipulation of eosinophils to a more beneficial cell death pathway.

Excellence of Division Trainees and Junior Investigators

The Division of Allergy and Immunology is proud of the excellence of its undergraduate, graduate, postdoctorate, and clinical trainees and junior investigators. Several have been recognized for their achievements throughout the year. Abby Stein, a medical student researcher in the Fulkerson Lab, and Patrick McWeeney, a medical student researcher in the Hogan Lab, won awards at the 55th Annual National Student Research Forum (University of Texas, Medical Branch campus, Galveston, Texas). Abby’s presentation of eosinophil progenitors in experimental asthma won the best poster presentation in the Immunology category, and Patrick’s presentation won the best poster presentation in the Biochemistry and Molecular Biology section. These two medical student researchers were part of Cincinnati Children's Summer Medical Student Respiratory Research Fellowship (SMURRF) program and represented Cincinnati Children’s, the University of Cincinnati and our division well. Michael Stephens, an undergraduate researcher in the Fulkerson Lab, presented at the annual, regional meeting of the Northeast-4 district (the states of KY, OH, and MI) of the National Biological Honors Society and won the Frank G. Brooks award for ranking first place in podium presentations. He was presented with a plaque and certificate and provided funds for him to present at the national conference this year. Rahul D’Mello, MD, and PhD student in the Rothenberg Lab, spoke about his experiences about shaping the next generation of physician-scientists in a University of Cincinnati College of Medicine article. Ting Wen, PhD, a research fellow in the Rothenberg Lab, won the second-place prize at the third annual Ohio River Valley Cytometry Association's Imaging and Cytometry Research Day. David Morris, MD, a clinical fellow in the Fulkerson Lab, was awarded a 2014 ARTrust mini-grant entitled “Characterization of eosinophil progenitors (EoPs) in the peripheral blood of pediatric patients with active eosinophilic esophagitis (EoE)”. Julie Caldwell, a research associate in the Rothenberg Lab, won first at the 2014 Digestive Health Center Research Symposium for her project “CDH26: a Functional Integrin-Binding Cadherin Involve in Eosinophilic Gastrointestinal Disorders”. Nurit Azouz, a research fellow in the Rothenberg Lab, received an American Heart Association (AHA) Postdoctoral Fellowship award.

Division Director at Cincinnati Children’s Elected AAAS Fellow

Marc Rothenberg, MD, PhD, Director of the Division of Allergy and Immunology and the Cincinnati Center for Eosinophilic Disorders at Cincinnati Children’s, has been elected as a Fellow of the American Association for the Advancement of Science (AAAS). Fellows are elected by their peers and recognized for meritorious efforts to advance science and its applications. Dr. Rothenberg’s research focuses on elucidating the mechanisms of allergic responses, especially in mucosal tissues such as the gastrointestinal tract and lung. The goal of his research is to identify mechanisms of allergic inflammation, with the aim of developing and testing novel pharmaceutical targets for the treatment and cure of patients with a variety of allergic diseases, especially eosinophilic gastrointestinal disorders, such as eosinophilic esophagitis. His extensive publications include more than 300 articles on molecular mechanisms of allergic responses. He has served on various review panels for journals and grant agencies, including the Burroughs Trust, the Medical Research Council of the United Kingdom and the National Institutes of Health, where he served on the Advisory Council of the National Institute of Allergy and Infectious Disease. His research has been supported by numerous sources, including the National Institutes of Health, USA Department of Defense, Human Frontier Science Program Organization, Burroughs Wellcome Fund, Dana Foundation, Campaign Urging Research for Eosinophilic Diseases Foundation and Food Allergy Research Education, Inc. In addition to his own research, Rothenberg has mentored numerous scientists and clinicians, sees patients suffering from allergic and immunological diseases from around the world, and has helped to build a top program in pediatric allergy and immunology.

Inhibitory Receptor LILRB3 in Inflammatory Bowel Disease

Simon P. Hogan, PhD, (Principal Investigator), in collaboration with Artem Barski PhD, Lee A. Denson, MD and Yael Haberman Ziv, MD, recently received a Crohn’s Colitis Foundation of America Senior Research Award to study the contribution of the inhibitory receptor LILRB3 in pediatric inflammatory bowel disease (IBD). Inhibitory receptors act as “brakes” and restrain or inhibit inflammatory signals in an attempt to prevent an uncontrolled and/or exaggerated inflammatory response. Consistent with this idea, in mouse-based studies, Hogan and colleagues have shown that loss of the inhibitory receptor LILRB3 causes an immune cell called macrophages to produce excessive amounts of proinflammatory proteins (i.e. IL-6, TNF-a and IL-1b), which cause intestinal inflammation and IBD. In new preliminary studies, these researchers have identified a new form of LILRB3 that appears to be expressed differently in IBD patients. This variant of LILRB3 has lost the part of the protein that is critical for activating the “brakes signal” and thus this protein’s ability to restrain inflammation. Hogan and his collaborators hypothesize that the protein LILRB3 is important in applying the “brakes” on intestinal immune signals and prevents intestinal inflammation and that the LILRB3 isoforms expressed in IBD cause a loss of this braking mechanism, causing exaggerated inflammation and more severe IBD. Successful completion of the proposed studies will provide a new and substantive departure from the current understanding of the underlying immune pathways that lead to exaggerated intestinal inflammation in IBD and will identify innovative therapeutic targets focused around LILRB3 for the treatment and prevention of IBD by blocking immune signals and inflammation.

STARD7 in Food Allergy and Anaphylaxis

Simon P. Hogan, PhD, in collaboration with Timothy E. Weaver, MS, PhD, (Principal Investigator), was recently awarded a Digestive Health Center Pilot and Feasibility Award to study the involvement of StAR-related lipid transfer domain containing 7 (STARD7) in food allergy and anaphylaxis. In preliminary studies, Weaver and Hogan have identified a strong link between intestinal, epithelial-specific deletion of STARD7, epithelial barrier dysfunction and food sensitization and that STARD7 regulates epithelial barrier gene expression via a novel interaction of STARD7 and phosphatidylcholine (PC) with the ligand-activated transcription factor peroxisome proliferator-activated receptor (PPAR). In this study, the investigators will define the importance of intestinal, epithelial-specific STARD7 in maintaining the protective epithelial barrier function and, in turn, food tolerance. They also expect to delineate the importance of PC:PPAR signaling in nuclear STARD7 modulation of the expression of barrier proteins and intestinal epithelial barrier function. Successful completion of the proposed studies will provide important, new insight into this protective pathway by identifying cells, signaling pathway(s) and target genes that mediate the putative cell-specific, barrier-enhancing and anti-inflammatory functions of STARD7.

Collaborative Modeling of the Epigenetics of Environmental Enteropathy

Simon P. Hogan, PhD, in collaboration with Sean R. Moore, MS, MD (Principal Investigator), was recently awarded a Bill & Melinda Gates Foundation Phase II Grand Challenges Exploration application entitled, "Bad water, bad diet, bad stem cells: Epigenetic modeling of environmental enteropathy in mice". Environmental enteropathy (EE) describes subclinical pathologic changes to the mucosal lining of the small intestine in individuals who lack access to safe water and good diets in settings of global poverty. EE is the single most important barrier to achieving healthy growth and development for children worldwide. In this study, the investigators will define the relationship between microbiome and diet in intestinal stem cell dysfunction and development of EE. The Grand Challenges Explorations is an initiative that encourages bold and unconventional ideas for global health in order to foster innovation in global health research.

Study Identifies Regulators of Eosinophilic Inflammation in Inflammatory Bowel Disease

Simon P. Hogan, PhD, Research Director for our Division, identified a new role for the innate inflammatory cell macrophage and NFkB signaling pathway in the regulation of eosinophilic inflammation in inflammatory bowel disease (IBD). Employing a murine model of colitis and mice with NFkB signaling deleted selectively in macrophages, Hogan identified a requirement for NFkB signaling in inflammatory macrophages for secretion of the eosinophil-selective chemokine CCL11, eosinophilic inflammation and the histopathology of experimental colitis (DSS-induced model). Molecular and cellular analyses revealed a link between expression of calprotectin (S100a8/S100a9), Ccl11expression and eosinophil numbers in the DSS-treated colon. The results indicate that myeloid cell–specific NF-kB-dependent pathways play an unexpected role in CCL11 expression and maintenance of eosinophilic inflammation in experimental colitis. These data were published in the Journal of Immunology and indicate that targeting myeloid cells and NFkB-dependent pathways may be of therapeutic benefit for the treatment of eosinophilic inflammation and histopathology in IBD.

Method Developed to Directly Evaluate Eosinophil Tracking In Vivo

Most in vivo studies of granulocytes draw conclusions about their trafficking based on examination of their steady-state tissue/blood levels, which result from a combination of tissue homing, survival and egress rather than direct examination of cellular trafficking. Ting Wen, PhD, and Marc E. Rothenberg, MD, PhD, Division Director, developed a unique cell transfer system involving the adoptive transfer of a genetically labeled, bone-marrow-derived unique granulocyte population (eosinophils) into an elicited inflammatory site, the allergic lung. As published in the Proceedings of the National Academy of Sciences, a dual polychromatic FACS-based biomarker-labeling system based on the IL4-eGFP transgene (4get) or Cd45.1 allele was used to track IV-transferred eosinophils into the airway following allergen or T(H)2-associated stimuli in the lung in multiple mouse strains. The system was amenable to reverse tagging of recipients, thus allowing transfer of nonlabeled eosinophils and competitive tracking of multiple populations of eosinophils in vivo. This unique eosinophil transfer system provides an unprecedented opportunity to examine airway eosinophil migration without the need for extensive efforts to acquire donor source and time-consuming genetic crossing and has already been used to identify a long eosinophil half-life in the allergic lung and a definite role for ST2 in regulating eosinophil trafficking.

Faculty Recognized For Research Endeavors

The American College of Allergy, Asthma & Immunology (ACAAI) unanimously voted Amal H. Assa'ad, MD, the Clinical Director, to receive the ACAAI Woman in Allergy Award for 2013. This prestigious award recognizes her dedication in advancing the specialty by her work in food allergy and science. Recently appointed faculty member Patricia Fulkerson, MD, PhD, was awarded a 2013 ARTrustTM Faculty Development Award by the American Academy of Allergy, Asthma and Immunology (AAAAI) for her eosinophil progenitor research. This is the academy’s most prestigious award. The funding supports Fulkerson’s research investigating the regulation of eosinophil progenitors by Toll-like receptors, which may support development of therapeutics for eosinophil-associated disorders such as asthma and eosinophilic gastrointestinal disorders. Recently appointed faculty member Joseph Sherrill, PhD, was awarded the Thrasher Research Fund Early Career Award in recognition of his promise as an investigator. His work employs a functional genomics approach to understand the genetic etiology of inflammatory diseases such as eosinophilic gastrointestinal disorders.

New Leadership for Division Research

Simon P. Hogan, PhD was recently appointed as the Director of Research of the Division of Allergy/Immunology. He joins the Division Director, Marc E. Rothenberg, MD, PhD, and Amal H. Assa'ad, MD, Associate Division Director and Division Clinical Director, in leading the division to new heights to improve the health of children with allergic and immune conditions through innovative research, outstanding clinical care and education of the current and next generation of leaders in healthcare and research.

New Leadership for Allergy/Immunology Fellowship Program

Kimberly A. Risma, MD, PhD has assumed the role of Fellowship Director of the Allergy/Immunology Fellowship Program. Risma is dedicated to teaching our future allergists in this combined pediatric and adult fellowship program (via partnership with the University of Cincinnati). This program is an integral part of our division's mission to improve the health of children with allergic and immune conditions through the education of the current and next generation of leaders in healthcare and research.

New Leadership for Advancing Mechanistic Allergy and Asthma Research

Nives Zimmermann, MD has assumed the position of Vice Chair of the Mechanism of Allergy and Asthma interest section of the American Academy of Allergy, Asthma and Immunology (AAAAI). In this position, she will provide leadership to the constituents with an interest in mechanistic research and a central role in the planning of the AAAAI annual conference.

Division Researcher Appointed President at the University of Cincinnati

University of Cincinnati President Santa J. Ono, PhD, Professor within the Division of Allergy and Immunology, was appointed as the 28^th President at the University of Cincinnati. Prior to his presidency, Ono served for two years as the Senior Vice President for Academic Affairs and Provost. In addition to his institutional leadership and service, Ono leads an active research program. His principal research interests focus on transcriptional regulation in the human immune system, mechanisms of mast-cell dependent inflammation on the ocular surface, and the immune component of age-related macular degeneration.

Director, Registry for Eosinophilic Disorders (REGID)

J. Pablo Abonia, MD assesses the clinical biology and regulation of mast cells and their role in diseases, such as eosinophilic esophagitis, eosinophilic gastrointestinal disorders and primary mast cell disease. He conducts translational research and clinical trials in conjunction with developing patient databanks and bioinformatic approaches to further understand allergic disease. A member of the Cincinnati Center for Eosinophilic Disorders, Abonia was recently appointed the Director of the Registry for Eosinophilic Gastrointestinal Disorders (REGID), a national not-for-profit collaboration of medical centers, professionals, families and individuals dedicated to improving the knowledge, research and outcomes for people living with eosinophilic gastrointestinal disorders.

Division Director Discovers miRNAs Controlling Eosinophilopoeisis

Marc E. Rothenberg, MD, PhD has identified roles for two miRNAs, miR-21 and miR-223, in controlling eosinophilopoiesis, the generation of eosinophils. miR-21 has previously been shown to regulate T-cell polarization and activation in preclinical models and to be dysregulated in an miRNA signature that correlates with disease activity for eosinophilic esophagitis (EoE), a severe food allergy. miR-21 is one of the most upregulated miRNAs in multiple allergic diseases associated with eosinophilia and has long been shown to positively correlate with eosinophil levels. Using a murine interleukin-5 (IL-5)-driven eosinophil differentiation model and gene expression microarray analysis, Rothenberg showed that targeted ablation of miR-21 in decreased eosinophil progenitor cell growth. In a related study, Rothenberg demonstrated a similarly important role for miR-223 in regulating eosinophil progenitor growth and differentiation, with miR-223 deficiency increasing eosinophil progenitor proliferation. Identification of the role miRNAs in eosinophilopoiesis and the specific miRNAs involved are critical advancements for the development of biomarkers, therapies and eventual cures for allergic disease.

Division Research Director Furthers Understanding of Intestinal Epithelial Barrier Homeostasis

Simon P. Hogan, PhD identified a role for the mast cell–derived serine protease chymase in the regulation of intestinal epithelial barrier homeostasis. As published in the American Journal of Physiology - Gastrointestinal and Liver Physiology, Hogan employed in vitro model systems to delineate the molecular pathways involved in chymase-mediated intestinal epithelial barrier dysfunction and demonstrated that chymase-mediated modulation of intestinal epithelial barrier was characterized by chymase-induced protease-activated receptor (PAR)-2 activation and matrix metalloproteinase (MMP)-2 expression and activation. Importantly, pharmacological and small interfering RNA-mediated antagonism of PAR-2 and MMP-2 significantly attenuated chymase-stimulated barrier dysfunction. Collectively, these results suggest that mast cell/chymase-mediated intestinal epithelial barrier function is mediated by PAR-2/MMP-2-dependent pathways.'

Division Researcher Investigates Epigenomics of Immunology

Artem Barski, PhD is interested in the epigenetic and transcriptional regulation of gene expression and contributed to the development of ChIP-Seq, a revolutionary method that combines chromatin immunoprecipitation (ChIP) with the next-generation sequencing (Seq). Epigenomics is a cutting-edge field that elucidates the importance of how reversible modifications of DNA or histones can alter expression of genes or genetic variants during homeostasis or disease. Using ChIP-Seq and other sequencing-based genome-wide methods, Barski investigates the role of chromatin modifications in gene regulation, including his recent work with chromatin regulation of genes transcribed by RNA polymerase III and the discovery of gene poising in T cells. He is currently researching the epigenetic basis of T-cell activation, memory and tolerance.

Division Researcher Discovers Mechanism of Eosinophil Cell Death

Nives Zimmermann, MD was the senior author for “Mechanism of Siglec-8-mediated cell death in IL-5-activated eosinophils: role for reactive oxygen species-enhanced MEK/ERK activation”, which was recently published in the Journal of Allergy and Clinical Immunology. This study, led by Gen Kano, MD, PhD and performed in collaboration with Dr. Bruce Bochner from Johns Hopkins University, discovered a novel mechanism of cell death in activated eosinophils. This finding is significant because eosinophil cell death, accompanied by release of toxic granule content in tissue, contributes to the pathophysiology of multiple diseases, including allergic diseases. The ability to inhibit this novel pathway of regulated necrosis could lead to improved therapies for these diseases. As a result of this study and its potential impact, Zimmermann was awarded a grant from the American Heart Association to study the molecular mechanisms of eosinophil cell death, in collaboration with Dr. Margaret Collins, Department of Pathology.

Division Clinician Researcher Pursues Development of High-Throughput Screening Assay for Hemophagocytic Lymphohistiocytosis Therapeutics

Kimberly A. Risma, MD, PhD developed and executed the first known microplate assay screen for small-molecule enhancers of natural killer (NK) cell and cytotoxic T lymphocyte function. This study provided critical preliminary data that will permit adaptation and execution of a much larger high-throughput screen this year, in collaboration with the NIH Molecular Libraries Program. Using patient-derived primary NK cells, Risma will screen a library of FDA-approved compounds for cytotoxic enhancers of NK cell function in an attempt to repurpose drugs already in clinical use. This research effort has great potential to ultimately change the outcome for children with inherited defects in cytotoxic function associated with the potentially fatal disorder, hemophagocytic lymphohistiocytosis (HLH). More broadly, the results of this research may eventually provide alternative treatments in cancer and/or chronic viral infections.

Division Clinician Researcher Dedicated to Fungal Spore Research

Michelle B. Lierl, MD is conducting a study investigating the role of outdoor fungal and myxomycete spores as aeroallergens; this study involves allergy skin testing with myxomycete and basidiomycete spore extracts to identify whether they are previously unrecognized aeroallergens. As no extracts of these spores were commercially available, Lierl collects the spores herself and makes the extracts for the allergy skin testing. Having discovered the lack of photographs available of these microscopic spores, she also maintains a website to share photographs of spores of basidiomycetes, ascomycetes, and myxomycetes as a reference source for others for fungal species identification.

Division Clinical Director Supports Cincinnati Children's National and Global Mission

Amal H. Assa'ad, MD has exemplified the national and global mission of Cincinnati Children’s through her far-reaching dedication and valued efforts to improve child health. She has represented Cincinnati Children’s as an invited speaker at plenary sessions and international symposia at four international meetings, in Israel, Italy, Mexico, and India. In addition, she serves as an elected member of the American Academy of Allergy, Asthma and Immunology (AAAAI) Board of Directors; chaired and organized the 2012 American College of Allergy, Asthma & Immunology (ACAAI) Food Allergy Symposium; and co-authored a well-received publication in the Journal of Allergy and Clinical Immunology about preventing allergic disease through nutritional interventions. Her efforts abroad are coupled with her local leadership in clinical care and clinical research trials, with her work in food allergy being recognized with the prestigious Luisa Businco Lectureship and Award by the ACAAI.

Positive Results from Monoclonal Antibody Clinical Trial

Amal Assa’ad, MD, clinical director, was lead author for “Antibody Against IL-5 Reduces Numbers of Esophageal Intraepithelial Eosinophils in Children with Eosinophilic Esophagitis,” published in Gastroenterology. This multicenter, international project showed positive results using an anti-IL-5 antibody to treat eosinophilic esophagitis in children and was the first clinical trial to document the use of a monoclonal antibody in children as young as two years of age. This is promising news for the treatment of eosinophilic disorders as these conditions are chronic and often present at an early age. This clinical trial was based on basic and translational work by Marc Rothenberg, MD, PhD, division director.

New Faculty Member Targets Home Environment in Asthma Outcomes

Recently appointed faculty member Terri Moncrief, MD, researches the impact of single parenthood, family routines and allergic sensitizations on asthma outcomes. Moncrief, under the direction of Robert Kahn, MD, MPH, is executing a multidimensional analysis of the home environment and its effect on asthma morbidity in disadvantaged populations. Several of her studies were presented at national conferences, and her research will help develop tools to identify at-risk children and guide intervention strategies.

MicroRNA Biomarkers and Regulators of Allergic Disease

Rothenberg has identified a dysregulated microRNA signature that correlates with disease activity for eosinophilic esophagitis (EoE), a severe food allergy. Promisingly, the most elevated microRNA in the signature, miR-21, regulates T cell polarization and activation in preclinical models. Rothenberg also identified a microRNA, miR-375, that regulates interleukin-13, a key immune hormone in allergic reactions. These findings are proof of principle that microRNAs are involved in fine-tuning interleukin-13-mediated immune responses and show promise for use of microRNAs, such as miR-21 and miR-375, as noninvasive biomarkers and therapeutic targets for allergic disease. The ability to detect and measure the status of EoE with a noninvasive blood test would be a significant benefit to individuals and families.

Division Clinical Director Supports Cincinnati Children's National and Global Mission

Amal H. Assa’ad, MD has exemplified the national and global mission of Cincinnati Children’s through her far-reaching dedication and valued efforts to improve child health. She has represented Cincinnati Children’s as an invited speaker at plenary sessions and international symposia at two national meetings in the USA and three international meetings in South America, Europe and the Middle East. In addition, she was the 2011 Ghory Lecturer at Cincinnati Children’s; serves as an elected member of the AAAAI Board of Directors and the chair of the ACAAI Food Allergy Committee; and has published several sequels to the NIH Expert Panel on Food Allergy Guidelines.

Division Researcher Dedicated to Fungal Spore Research

Michelle B. Lierl, MD is conducting a study investigating the role of outdoor fungal and myxomycete spores as aeroallergens; this study involves allergy skin testing with myxomycete and basidiomycete spore extracts to identify whether they are previously unrecognized aeroallergens. As no extracts of these spores were commercially available, Lierl collects the spores herself and makes the extracts for the allergy skin testing. Having discovered the lack of photographs available of these microscopic spores, she also maintains a website to share photographs of spores of basidiomycetes, ascomycetes, and myxomycetes as a reference source for others for fungal species identification. In addition to the fungal research, Lierl is researching the association of exhaled nitric oxide levels with the development of asthma in a birth cohort of children from families with allergies, having completed the final study visits in Fall of 2011, and presented “Problem-based Learning Seminar on Pediatric Anaphylaxis” at the 2012 AAAAI Annual Meeting.

Division Researcher Forwards Knowledge of Mechanisms of Aeroallergen-Induced Airway Responses

Ariel Munitz, PhD furthered knowledge of IL-13 and resistin-like molecule alpha (RELM-α) in mechanisms of aeroallergen-induced airway responses. He presented "OpITIMixing Eosinophil Activation in Mucosal Inflammation" at the 2012 Research Conferences at the Vall d'Hebron Institut de Recerca and "Eosinophil Receptors and Receptor-Mediated Inhibition" at the 7th International Eosinophil Society Biannual Meeting. He published in the Journal of Allergy and Clinical Immunology, the Journal of Immunology, and the American Journal of Respiratory Cell and Molecular Biology and was awarded funding from the Bi-National U.S.-Israel Science Foundation, the Israel Science Foundation, and Israel Cancer Research Fund. The Editor-in-Chief of the Journal of Allergy and Clinical Immunology officially nominated him to the journals' reviewer board in recognition of his excellent record of reviewing manuscripts. 

Division Researcher Identifies Mechanisms and Biomarkers in Ocular Diseases

Santa Ono, PhD contributed several significant research findings this year through his investigations on the transcriptional regulation in the human immune system, mechanisms of mast-cell dependent inflammation on the ocular surface and immune component of age-related macular degeneration. He published his studies in Experimental and Molecular Pathology and the British Journal of Ophthalmology: “Identification of anti-retinal antibodies in patients with age-related macular degeneration”, “Serum autoantibody biomarkers for age-related macular degeneration and possible regulators of neovascularization”, “Identification of genes and proteins specifically regulated by costimulation of mast cell Fce Receptor I and chemokine receptor 1”, and “The effect of perioperative allergic conjunctivitis on corneal lymphangiogenesis after corneal transplantation”. Ono was the invited plenary speaker for the 2012 Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting. In addition to his research, Ono continues to serve as the Senior Vice President for Academic Affairs and University Provost at the University of Cincinnati.

Division Researcher Committed to Asthma Morbidity Research

Terri M. Moncrief, MD forwarded her research to critically analyze the components of the social home environment that contribute to poor asthma morbidity among disadvantaged populations. Her work entitled “Prevalence of Cockroach and Mouse Sensitization among Children Hospitalized for Wheezing and Asthma”, was presented at the 2011 Pediatric Hospitalist Medicine Conference and the 2011 World Allergy Congress; "Single-parenthood: Possible Mechanisms of Increase Pediatric Asthma-Related Morbidity" at the 2011 American College of Allergy, Asthma and Immunology (ACAAI) National Scientific Meeting; and "Effect of a "Home Away from Home' on Children's Adherence to Asthma Medicine" at the 2012 Pediatric Academic Society Scientific Meeting. She published a related research study, “Mouse Sensitization as an Independent Risk Factor for Asthma Morbidity”, in the peer-reviewed journal Annals of Allergy, Asthma & Immunology. These studies and her ongoing research will serve as the foundation for forming clinically relevant tools for successful identification of at-risk children and instituting effective intervention strategies. She presented at the 2011 Pediatric Hospitalist Medicine Conference and the 2011 World Allergy Congress; "Single-parenthood: Possible Mechanisms of Increase Pediatric Asthma-Related Morbidity" at the 2011 American College of Allergy, Asthma and Immunology (ACAAI) National Scientific Meeting; and "Effect of a "Home Away from Home' on Children's Adherence to Asthma Medicine" at the 2012 Pediatric Academic Society Scientific Meeting. She published a related research study, “Mouse Sensitization as an Independent Risk Factor for Asthma Morbidity”, in the peer-reviewed journal Annals of Allergy, Asthma & Immunology. These studies and her ongoing research will serve as the foundation for forming clinically relevant tools for successful identification of at-risk children and instituting effective intervention strategies.