Keywords
cystic fibrosis, modifier genes, inflammatory mediators, IL1B
This article is included in the Genomics and Genetics gateway.
This article is included in the Cell & Molecular Biology gateway.
cystic fibrosis, modifier genes, inflammatory mediators, IL1B
Version 3 of this manuscript additionally include information about age of patients classified to severe and mild phenotype of the disease. Furthermore, the reference numbered 21 and the text was added to clarify the disease severity classification of patients. We also provided information about CF genotypes among patients group in the Table 4 containing analysed polymorphisms. Additionally, the information that patients were clinically stable at the time of study recruitment was added.
See the authors' detailed response to the review by Daniel J. Smith
See the authors' detailed response to the review by Tadeusz Przybyłowski
Recent scientific outcomes confirm that the clinical phenotype of cystic fibrosis (CF) (OMIM: 219700) is determined not only by classes of mutations in the CFTR gene (cystic fibrosis transmembrane regulator) but in association with environmental factors and genetic variations in modifier genes.1–3 The hypothesis about the role of modifier genes in CF was born based on the observations, that patients with the same CFTR genotype presented diverse manifestations and course of the disease.4 Today, over 2000 different CFTR mutations have been reported and F508del is by far the most common.5 Although mutations in the CFTR gene are well known and classified, the contribution of modulatory genes in CF is currently still investigated. Among analyzed candidate genes are those involved in the inflammatory process, as well as in immunity and antioxidant molecules.6 However, the results of the majority of global research on modifier genes’ role in CF are inconclusive.
CF is a multi-organ disease, whereas chronic pulmonary inflammation and respiratory failure consist of the main cause of death in those patients. There is evidence, that the inflammatory process in the lung is associated with an imbalance between pro- and anti-inflammatory mediators.7 Among important pro-inflammatory cytokines produced during the response are tumor necrosis factor-alpha (TNF-α), interleukins (IL) 8, 6, 1, and 1B, while among cytokines inducing the opposite effect are transforming growth factor-beta 1 (TGFB1) and IL10.8–10
Proteins, IL8 and TNF-α, play a crucial role in the pathophysiology of CF lung disease due to their participation in the recruitment and activation of neutrophils on the respiratory epithelial surface, which is a primary component of the innate immune response.11 Thus, genes CXCL8 and TNF coding for those cytokines, which expression is regulated by sequence variants, are highlighted as potential modifier genes in the severity of lung disease in CF. Although numerous polymorphic variants have been described in the CXCL8 gene, the association only between polymorphisms rs4073 (c.-251T>A), rs2227306 (c.781C>T), rs2227307 (c.396T>G), pulmonary function, and clinical severity markers in CF patients was confirmed in several studies.8,12 The most often analyzed changes in the TNF gene are located in the promoter region, such as c.-238G>A (rs361525) having a variable effect on gene expression and c.-308A>G (rs1800629) associated with increased gene transcription, worst pulmonary function, and early pulmonary symptoms in patients with CF.13,14 in contrast to studies performed by Schmitt-Grohé et al.15 and Khorrami et al.16 There is also proven, that some of TNF and CXCL8 polymorphisms are associated with Pseudomonas aeruginosa (PA) chronic colonization in CF patients.14,17 Furthermore, modulating effects on the CF also have shown IL1B and IL10 genes, where the most common SNPs were associated with severe lung disease in pediatric American and Australian populations.18,19 Whereas, in French and German pediatric CF patients those results were not shared.8
Results of up to now performed studies, searching for genes that modify the course and phenotype of CF, mostly concern the association with pulmonary exacerbation. However, based on our long-term observations of CF patients we state, that around 20% of CF patients manifest a pronounced exacerbation of symptoms from the digestive system. We hypothesized, that this possibly may be predicted by polymorphic changes at immunologically relevant genes. Within this context, we have selected 12 polymorphisms located in five genes CXCL8 (rs4073, rs2227306, rs2227307, rs188378669), TNF (rs361525, rs1800629), IL1B (rs16944, rs1143634, rs1142639, rs1143627), IL6 (rs1800795), and IL10 (rs1800896) for correlation analysis, as candidate genetic modulators of the pulmonary or digestive manifestation and severity of the disease among Polish CF patients.
The study was approved by the local Ethics Committee of the University of Medical Sciences in Poznan, Poland (resolution no. 675/15), and all experiments were performed following the relevant guidelines and regulations of this Committee. Written informed consent was obtained from each patient. 55 Polish patients (20 males and 35 females) between the ages of 20-52 with diagnosed CF were enrolled for this study. The patient group was collected in 12 months (from January to December 2016) in the Department of Pulmonology, Allergology and Lung Oncology of the Clinical Hospital of Poznan University of Medical Sciences in Poland. Diagnosis of CF in all patients was performed by sweat chloride test results (> 60 mmol/L) or/and identification of CFTR gene mutations. Detailed information about each patient including sex, age, BMI, age of diagnosis, presence of F508del mutation, pulmonary function parameters, function of internal organs, complications, and hospitalizations were recorded. Additionally, a control group of 50 healthy individuals was collected. A detailed characteristics of the study cohort with clinical and demographic data are presented in Table 1.
Pulmonary function tests, using Jaeger MasterScreen system (Erich Jaeger GmbH; Würzburg, Germany) were performed to assess lung function. All spirometric examinations were carried out with the subject seated, using a nose clip and a disposable mouthpiece. Using spirometric measurements, values of expiratory forced vital capacity (FVC) and forced expiratory volume in one second (FEV1%) were obtained and were expressed as the percentage of predicted values according to European Community for Steel and Coal.20
At the same time the body plethysmography for assessing residual volume (RV), total lung capacity (TLC), and diffusing capacity of the lungs for carbon monoxide (DLCO) were performed.
Patients were divided in the context of lung function impairment, based on the FEV1% values, while they were clinically stable, 1 - within the norm (FEV1% ≥ 70) and mild pulmonary obstruction (FEV1% 40-70) (35 subjects in total), 2 - severe pulmonary obstruction (FEV1% ≤ 40) (20 subjects in total).21 The “severe” group of patients did not differ significantly in age from patients in the “mild” group (mean age was 27.11 and 30.75, respectively; p-value was 0.055).
In an attempt to analyze the correlation between the genotype and manifestation of CF, patients were divided into two subgroups depending on the dominant symptoms - the group with the manifestation primarily from the respiratory system (44 individuals) and the group of patients with prevalent gastrointestinal symptoms (11 individuals). The division was made by the specialists from the pulmonology field conducting the patients, based on the clinical data and interview. To the digestive predominant phenotype were enrolled patients with the coexistence of at least two of listed conditions: 1) diabetes or glucose metabolism impairment, 2) pancreatic insufficiency, 3) liver disease or cirrhosis, 4) nagging pain or dysfunction of the digestive system. All patients with GI predominant phenotype represented “mild” lung impairment. Specialists determining the patients phenotype were not involved in the analysis of genotype assessment. Results of genotyping did not influence the assessment of phenotypic description.
Genomic DNA of each patient was extracted from the peripheral blood samples (5 mL) using the standard method with guanidine isothiocyanate (GTC). Detection of the single nucleotide polymorphisms (SNPs) in five genes: CXCL8 (rs4073, rs2227306, rs2227307, rs188378669), TNF (rs361525, rs1800629), IL1B (rs16944, rs1143634, rs1142639, rs1143627), IL6 (rs1800795) and IL10 (rs1800896) was performed using pyrosequencing or Sanger sequencing. Primers for the pyrosequencing analysis were designed using PyroMark Assay Design Software (Biotage, Uppsala, Sweden) and for Sanger sequencing using Primer3Plus software. Primer details are shown in Table 2. Amplification of targeted DNA regions was carried out on Applied Biosystems 2720 Thermal Cycler (Applied Biosystems, Foster City, CA) on the total volume of 30 uL containing 0.75 U of FIREPol® DNA Polymerase, 2.5 μL 10× buffer, 2.0 μL dNTP mix (2.5 mM each dNTP), 1.5 mM MgCl2 solution, 80 ng DNA and 0.2 μM of each primer. All reagents were obtained from Solis BioDyne (Tartu, Estonia). The amplification products were analyzed in 1.5% agarose gels electrophoresis. Pyrosequencing was performed by the PSQ™ 96MA system (Qiagen) using PyroMark™ Gold Q96 Reagents (Qiagen GmbH, Hilden, Germany), according to the manufacturer instructions. Direct sequencing was performed using BigDye Terminator v3.1 Cycle Sequencing Kit (Thermo Fisher Scientific) on the Applied Biosystems 3500 and Series Genetic Analyzers.
Gene | SNP | Primer Name | Primer sequence | Product length |
---|---|---|---|---|
TNF | c.-238G > A (rs361525) | TNF_238_F* | 5’-CTCCAGGGTCCTACACACAAAT-3’ | 188 bp |
TNF_238_R | 5’-CATCTGGAGGAAGCGGTAGTG-3’ | |||
TNF_238_Seq | 5’-CCCATCCTCCCTGCT-3’ | - | ||
c.-308C > T (rs1800629) | TNF_308_F* | 5’-GCCCCTCCCAGTTCTAGTTCT-3’ | 184 bp | |
TNF_308_R | 5’-ATTCCGAGGGGGGTCTTC-3’ | |||
TNF_308_Seq | 5’-GGCTGAACCCCGTCC-3’ | - | ||
CXCL8 | c.-251T > A (rs4073) | CXCL8_251_F | 5’-ATCTTGTTCTAACACCTGCCACTC-3’ | 112 bp |
CXCL8_251_R* | 5’-AAGCTCCACAATTTGGTGAATTA-3’ | |||
CXCL8_251_Seq | 5’-TAGAAATAAAAAAGCATACA-3’ | - | ||
c.781C > T (rs2227306) | CXCL8_781_F* | 5’-GAAGGCAATTTCTATGCTGGAGAG-3’ | 225 bp | |
CXCL8_781_R | 5’-CCTGAATATTCTCCTAGCCCTTGA-3’ | |||
CXCL8_781_Seq | 5’-CATAACTGACAACATTGAAC-3’ | - | ||
c.396T > G (rs2227307) | CXCL8_396_F | 5’-GCGTTTTCCTATGTCTAAATGTGA-3’ | 357 bp | |
CXCL8_396_R* | 5’-CAAATCTGAGGCTTGTCAATGA-3’ | |||
CXCL8_396_Seq | 5’-CTGCTTTTATAATTTATACC-3’ | - | ||
c.91G > T (rs188378669) | CXCL8_91_F | 5’-ATCACTTTTTCCCCCAACAG-3’ | 246 bp | |
CXCL8_91_R | 5’-CCTAACACCTGGAACTTTCCTAAA-3’ | |||
IL1B | c.-598T > C (rs16944) | IL1B_598_F* | 5’-TGAGGGTGTGGGTCTCTACCTT-3’ | 112 bp |
IL1B_598_R | 5’-AAGCTCCACAATTTGGTGAATTA-3’ | |||
IL1B_598_Seq | 5’-TAGAAATAAAAAAGCATACA-3’ | - | ||
c.315G > A (rs1143634) | IL1B _315_F | 5’-CGTGCACATAAGCCTCGTTATC-3’ | 59 bp | |
IL1B _315_R* | 5’-GCTCCACATTTCAGAACCTATCTT-3’ | |||
IL1B _315_Seq | 5’-CATAACTGACAACATTGAAC-3’ | - | ||
c.597+76G > A (rs1142639) | IL1B _597_F* | 5’-TTGAAGGTTGCACGCAGTTAA-3’ | 143 bp | |
IL1B _597_R | 5’-TCAGCCTCCTGCTACCACTTATT-3’ | |||
IL1B _597_Seq | 5’-CAGACAACCACCTTCTC-3’ | - | ||
c.-118G > A (rs1143627) | IL1B _118_F | 5’-GTGCCTTGTGCCTCGAAGAG-3’ | 86 bp | |
IL1B _118_R* | 5’-TCAGCCTCCTACTTCTGCTTTTGA-3’ | |||
IL1B _118_Seq | 5’-CCCTCGCTGTTTTTAT-3’ | - | ||
IL6 | c.-237G > C (rs1800795) | IL6 _237_F* | 5’-TGCACTTTTCCCCCTAGTTGT-3’ | 82 bp |
IL6 _237_R | 5’-TGGGGCTGATTGGAAACCT-3’ | |||
IL6 _237_Seq | 5’-TGTGACGTCCTTTAGCA-3’ | - | ||
IL10 | c.-1117A > G (rs1800896) | IL10 _1117_F | 5’-AACTGGCTCCCCTTACCTTCTA-3’ | 151 bp |
IL10 _1117_R* | 5’-AGGCTGGATAGGAGGTCCCTTACT-3’ | |||
IL10_1117_Seq | 5’-AAGGCTTCTTTGGGA-3’ | - |
Conformance of genotypes distribution of all analyzed polymorphisms with the Hardy-Weinberg equilibrium (HWE) was assessed using Fisher’s exact test. The pair-wise linkage disequilibrium (LD) of variants located in genes TNF, CXCL8, and IL1B was evaluated by Lewontin’s D′ using Haploview software version 4.2. The correlation analyses between genotypes and clinical data were performed using the chi-square test and Fisher’s exact test.
For all calculations, STATISTICA 12.0 software (Stat Soft, 2014) was used. The level of significance was set at p < 0.05.
A total of 55 CF Polish patients and 50 healthy controls were successfully genotyped for selected 12 polymorphisms located in genes CXCL8, TNF, IL1B, IL6, and IL10. Genotypes distribution for all SNPs met the requirements of HWE. No relevant differences in variant allele frequency between both groups were demonstrated. Only TNF c.-308C > T variant was observed significantly less often in the patient group (2.7%) compared to controls (15%), where the p-value was 0.001. All obtained frequencies of each genotype and allele are presented in Table 3.
SNP | Genotype | Group of CF patients (n = 55) | Control group (n = 50) | 1000 Genomes database | Allele frequency CF patients vs control group | ||||
---|---|---|---|---|---|---|---|---|---|
Number (%) | HWE** (p-value) | Variant allele freq. | Number (%) | HWE** (p-value) | Variant allele freq. | Variant allele freq. (EU population) | |||
TNF c.-238G > A (rs361525) | GG | 48 (87.3) | 0.614 | 6.4% | 44 (88) | 0.1 | 7% | 6% | p = 0.853 |
GA | 7 (12.7) | 5 (10) | |||||||
AA | 0 (0.0) | 1 (2) | |||||||
TNF c.-308C > T (rs1800629) | CC | 52 (94.5) | 0.835 | 2.7% | 36 (72) | 0.889 | 15% | 13% | p = 0.001 |
CT | 3 (5.5) | 13 (26) | |||||||
TT | 0 (0.0) | 1 (2) | |||||||
CXCL8 c.-251T > A (rs4073) | TT | 16 (29.1) | 0.419 | 43.6% | 17 (34) | 0.916 | 42% | 42% | p = 0.810 |
TA | 30 (54.5) | 24 (48) | |||||||
AA | 9 (16.4) | 9 (18) | |||||||
CXCL8 c.781C > T (rs2227306) | CC | 16 (29.1) | 0.419 | 43.6% | 17 (34) | 0.916 | 42% | 39% | p = 0.810 |
CT | 30 (54.5) | 24 (48) | |||||||
TT | 9 (16.4) | 9 (18) | |||||||
CXCL8 c.396T > G (rs2227307) | TT | 16 (29.1) | 0.419 | 43.6% | 17 (34) | 0.916 | 42% | 42% | p = 0.810 |
TG | 30 (54.5) | 24 (48) | |||||||
GG | 9 (16.4) | 9 (18) | |||||||
CXCL8 c.91G > T (rs188378669) | GG | 54 (98.2) | 0.945 | 0.9% | 50 (100) | - | 0% | 0% | p = 1.290 |
GT | 1 (1.8) | 0 (0) | |||||||
TT | 0 (0.0) | 0 (0) | |||||||
IL1B c.315G > A (rs1143634) | GG | 34 (61.8) | 0.311 | 20% | 35 (70) | 0.578 | 17% | 25% | p = 0.576 |
GA | 20 (36.4) | 13 (26) | |||||||
AA | 1 (1.8) | 2 (4) | |||||||
IL1B c.-598T > C (rs16944) | TT | 5 (9.1) | 0.536 | 73% | 5 (10) | 0.736 | 70% | 65% | p = 0.662 |
TC | 20 (36.4) | 20 (40) | |||||||
CC | 30 (54.5) | 25 (50) | |||||||
IL1B c.597+76G > A (rs1143639) | GG | 34 (61.8) | 0.311 | 20% | 35 (70) | 0.578 | 17% | 24% | p = 0.576 |
GA | 20 (36.4) | 13 (26) | |||||||
AA | 1 (1.8) | 2 (4) | |||||||
IL1B c.-118G > A (rs1143627) | GG | 5 (9.1) | 0.974 | 70% | 4 (8) | 0.594 | 69% | 65% | p = 0.875 |
GA | 23 (41.8) | 23 (46) | |||||||
AA | 27 (49.1) | 23 (46) | |||||||
IL6 c.-237G > C (rs1800795) | GG | 16 (29.1) | 0.701 | 47% | 20 (40) | 0.406 | 39% | 42% | p = 0.226 |
GC | 26 (47.3) | 21 (42) | |||||||
CC | 13 (23.6) | 9 (18) | |||||||
IL10 c.1117A > G (rs1800896) | AA | 16 (29) | 0.185 | 43% | 20 (40) | 0.238 | 40% | 45% | p = 0.688 |
AG | 31 (56.5) | 20 (40) | |||||||
GG | 8 (14.5) | 10 (20) |
Our haplotype analysis confirmed a strong LD (D' = 1, r2 = 0.928) between variants c.-251T > A (rs4073), c.781C > T (rs2227306) and c.396T > G (rs2227307) in the CXCL8 gene, forming four haplotypes: TCT, ATG, TCG and ACG observed in our CF patient group with frequency 54.6%, 41.8%, 1,8% and 1,8%, respectively. Furthermore, two polymorphic changes located in the promoter region of IL1B gene, c.-118G > A (rs1143627) and c.-598T > C (rs16944) were observed in high LD (D’ = 0.904, r2 = 0.75), constructing a haploblock, where haplotypes AC, GT, GC, AT frequency was 68.1%, 26.3%, 3.7% and 1.9%, respectively. Both haploblocks are presented on the Figure 1.
First, we have analyzed all 12 variants in designated, based on clinical data, groups of patients - with different manifestations of CF (with pulmonary or digestive dominant symptoms) and with variable courses of disease (mild or severe) to examine possible association.
Our study demonstrated that the presence of two polymorphisms, c.-598T > C (rs16944) and c.-118G > A (rs1143627), in IL1B gene significantly correlate with character of disease (Table 4). Higher frequency of variant allele c.-598C was observed in patients with severe character of CF, compared to patients with mild course of disease (87.5% and 64.3%, respectively, χ2 = 6.92; p = 0.008). Similarly, variant allele c.-118A occurred with higher frequency in subjects presented severe character of CF versus those with mild course of disease (82.5% vs. 62.8%, respectively, χ2 = 4.68; p < 0.05).
Considering the fact, that analyzed changes formed in our study two haploblocks (in CXCL8 and IL1B genes), an analysis of the haplotypes in the context of the course and manifestation of disease was performed. We proved, that only haplotype AC created by changes c.-118G > A and c.-598T > C in IL1B gene is significantly more often observed in group with severe course of CF in comparison with mild course (80% and 61.4%, respectively; χ2 = 4.055; p = 0.03).
Because CF is a multifactorial, life-shortening disorder, the determination of SNPs that would affect the general phenotype or course of the disease is essential, but also challenging due to previous inconclusive results. So far, most of the CF studies were focused on searching modifier genes responsible for the severe pulmonary phenotype of the disease. In our investigation we have analyzed the impact of selected 12 potential candidates of modulator changes, rs4073, rs2227306, rs2227307 and rs188378669 in CXCL8 gene, rs361525 and rs1800629 in TNF gene, rs16944, rs1143634, rs1142639 and rs1143627 in IL1B gene, rs1800795 in IL6 gene and rs1800896 in IL10 gene on CF phenotype in Polish patients, taking into account the severity of symptoms on the side of the digestive, but also, respiratory system. Our hypothesis was that candidate modulator changes may predict digestive character of CF.
We observed, that in most of our group of patients (80%) the dominating symptoms occurred from the respiratory system and only in 20% of CF patients from the digestive system. Severe character of lung disease, diagnosed based on the FEV1% values, was noted in 20 patients (36%) and mild in 35 individuals (64%). In those subgroups of patients, we have performed a correlation analysis with DNA changes. Obtained variant allele frequencies of analyzed genetic variants, did not much differ from reference values for European population in 1000 Genomes database, except change TNF c.-308C > T (rs1800629) which occurred in our patients group less often (2,7%) than in the database (13%). Also interesting is, that variant CXCL8 c.91G > T, p.Glu31Ter (rs188378669) globally noted with variant allele frequency < 0.1%, was detected in our CF patients at level 0.9% (one heterozygote detected in a cohort of 55 individuals). In our previous study, we proved, that this variant is significantly more common in patients with inflammatory bowel disease (MAF = 2.12%, 15 heterozygotes detected in a cohort of 353 patients) compared to healthy Polish population (MAF = 0.25%, 1 heterozygote identified in a cohort of 200 individuals of Polish population), what may suggest its association with inflammatory diseases (unpublished data). Therefore, studies on a larger group of patients are undoubtedly necessary to verify the participation of this variant in CF, especially since there are no data on the relationship with this disease.
Our study revealed, that among all analyzed genetic changes two of them, c.-598T > C (rs16944) and c.-118G > A (rs1143627) located in the IL1B gene, are significantly associated with the severe character of lung disease in polish CF subjects. Allele C in locus -598 was observed with frequency of 87.5% in patients with severe lung disease compared to patients with mild lung dysfunction (64.3%, p = 0.008, OR = 3.88, C.I. = [1.351-11.190]), while allele A in locus -118 was observed with frequency 82.5% and 62.8% in both groups, respectively (p = 0.03, OR = 2.78, C.I. = [1.079-7.194]). We confirmed high LD between both changes (rs1143627 and rs16944) creating haplotypes AC, GT, GC and AT, where AC was significantly more often observed in subjects with severe course of CF in comparison to mild.
Our findings concerning the impact of polymorphism rs16944 on CF phenotype are consistent with those obtained by de Vries et al.18 They also proved a significant correlation of the variant allele c.-598C of IL1B gene with severe pulmonary dysfunction in total of 152 Australian CF patients. Similarly, Levy et al.19 have reported that IL1B constitutes a clinically relevant modulator of CF lung disease in the study conducted among American patients. However, in their research other SNPs, rs1143634 and rs1143639 demonstrated a consistent association with severe pulmonary phenotype.
In contrast to those results, Corvol et al.8 did not find any correlation between variants c.-598T > C and c.-118G > A in IL1B gene and lung function assessed by spirometry in 329 Caucasian CF children from France and Germany. Additionally, they did not confirm any linkage disequilibrium between those polymorphisms.
Studies mainly highlight the relationship between lung disease in CF and CXCL8 gene polymorphism.22–24 IL8 plays a crucial role in the pathophysiology of inflammation of the airways in CF patients caused by a deficiency or absence of the CFTR protein.25 Our study did not confirm this association among Polish patients.
We are aware of several limitations of our research. Our study cohort included only 55 patients and 50 controls. In the next step, verification of our results should be performed on a larger group of patients. This may be crucial in the case of rare variants, as c.91G > T, p.Glu31Ter (rs188378669) in CXCL8 gene, candidate as a modifier of CF. Furthermore, other factors such as BMI, gender, or age of diagnosis was not taken into account in our statistical analyzes.
We should also highlight the strengths of our study. First, the study cohort was represented by detailed characterized patients and homogenous controls group. What is important, the effect of CFTR mutation F508del on the manifestation and course of CF in the studied patients was excluded because the frequency of mutations in the subgroups was similar.
Although this study does not indicate any modulators of digestive manifestation of CF, it constitutes the first report of genes predicting the course of this disease in the Polish population.
Recent studies indicate the important role of the microbiome in the course and manifestation of cystic fibrosis. Scientists underline that both, genotype and microbiome profiles are crucial interconnected factors in disease progression.26
Our data have shown, that from all analyzed pro-inflammatory cytokine genes, only IL1B, but not TNF, CXCL8, IL6, or IL10 clearly play a crucial role in CF manifestation, determining the severe character of lung disease. This is a confirmation of major global results, as well as the first report concerning modulator genes of CF manifestation among Polish patients. Unfortunately, none of the analyzed genetic variants was found as predictors of digestive manifestation of CF disease, which may suggest the participation of also other modulator genes in the final phenotype of the disease.
All data underlying the results are available as part of the article and no additional source data are required.
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Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
References
1. Schluchter M, Konstan M, Drumm M, Yankaskas J, et al.: Classifying Severity of Cystic Fibrosis Lung Disease Using Longitudinal Pulmonary Function Data. American Journal of Respiratory and Critical Care Medicine. 2006; 174 (7): 780-786 Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Cystic Fibrosis Physician. Published in the field of CF modifier genes during PhD studies.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Lung diseases
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