Evaluation of serum eosinophilic cationic protein as a marker of disease activity in chronic asthma

Tear and Serum Eosinophil Cationic Protein Levels in Seasonal Allergic Conjunctivitis

PURPOSE

Eosinophil cationic protein (ECP) levels in tear fluid and sera of patients with seasonal allergic conjunctivitis (SAC) were measured to assess local and systemic eosinophilic activity in SAC. The correlation between ECP levels and disease activity was evaluated.

METHODS

Tears and sera were collected from 21 patients with SAC and 13 healthy control subjects. ECP levels in tears and sera were measured before and 4 weeks after treatment with 0.1% lodoxamide eyedrops. Clinical signs and symptoms of SAC were scored and the correlation of ECP levels with the clinical scores was evaluated.

RESULTS

Tear and serum levels of ECP were significantly increased (p = 0.01, p = 0.02, respectively) in patients with SAC compared with the control subjects, but ECP levels were not correlated with the severity of the disease. Following treatment with topical 0.1% lodoxamide eyedrops, the mean level of ECP in tears decreased significantly (p = 0.02), whereas no significant change was observed in serum ECP levels. Furthermore, a significant decrease in clinical signs and symptoms scores was found after treatment (both p < 0.0001).

CONCLUSIONS

Increased serum and tear ECP levels in patients with SAC confirms that both local and systemic eosinophil activation occurs in SAC. However, clinical signs and symptoms of SAC were not found to be correlated with the degree of eosinophilic activity. Thus ECP does not seem to have an important role in clinical manifestations of SAC.

Blood eosinophils as a marker of likely corticosteroid response in children with preschool wheeze: time for an eosinophil guided clinical trial?

Childhood wheezing is common particularly in children under the age of 6 years and in this age group is generally referred to as preschool wheezing. Particular diagnostic and treatment uncertainties exist in these young children due to the difficulty in obtaining objective evidence of reversible airways narrowing and inflammation. A diagnosis of asthma depends on the presence of relevant clinical signs and symptoms and the demonstration of reversible airways narrowing on lung function testing, which is difficult to perform in young children. Few treatments are available and inhaled corticosteroids are the recommended preventer treatment in most international asthma guidelines. There is, however, considerable controversy about its effectiveness in children with preschool wheeze and a corticosteroid responder phenotype has not been established. These diagnostic and treatment uncertainties in conjunction with the knowledge of corticosteroid side effects, in particular the reduction of growth velocity, have resulted in a variable approach to inhaled corticosteroid prescribing by medical practitioners and a reluctance in carers to regularly administer the treatment. Identifying children who are likely responders to corticosteroid therapy would be a major benefit in the management of this condition. Eosinophils have emerged as a promising biomarker of corticosteroid responsive airways disease, and evaluation of this biomarker in sputum has successfully been employed to direct management in adults with asthma. Obtaining sputum from young children is time consuming and difficult, and it is hard to justify more invasive procedures such as a bronchoscopy in young children routinely. Recently, in children, interest has shifted to assessing the value of less invasive biomarkers of likely corticosteroid response and the biomarker 'blood eosinophils' has emerged as an attractive candidate. The aim of this review was to summarize the evidence for blood eosinophils as a predictive biomarker for corticosteroid responsive disease with a particular focus on the difficult area of preschool wheeze.

Traditional Chinese Medicine ZHENG Identification Provides a Novel Stratification Approach in Patients with Allergic Rhinitis

Background. We aimed to apply the ZHENG identification to provide an easy and useful tool to stratify the patients with allergic rhinitis (AR) through exploring the correlation between the quantified scores of AR symptoms and the TCM ZHENGs. Methods. A total of 114 AR patients were enrolled in this observational study. All participants received the examinations of anterior rhinoscopy and acoustic rhinometry. Their blood samples were collected for measurement of total serum immunoglobulin E (IgE), blood eosinophil count (Eos), and serum eosinophil cationic protein (ECP). They also received two questionnaire to assess the severity scores of AR symptoms and quantified TCM ZHENG scores. Multiple linear regression analysis was used to determine explanatory factors for the score of AR manifestations. Results. IgE and ECP level, duration of AR, the 2 derived TCMZHENG scores of “Yin-Xu − Yang-Xu”, and “Qi-Xu + Blood-Xu” were 5 explanatory variables to predict the severity scores of AR symptoms. The patients who had higher scores of “Yin-Xu − Yang-Xu” or “Qi-Xu + Blood-Xu” tended to manifest as “sneezer and runner” or “blockers,” respectively. Conclusions. The TCM ZHENG scores correlated with the severity scores of AR symptoms and provided an easy and useful tool to stratify the AR patients.

The role of measuring airway hyperresponsiveness and inflammatory biomarkers in asthma

Asthma is characterized by inflammation and airway hyperresponsiveness, which results in episodic airflow obstruction. It is diagnosed once a compatible clinical history plus objective evidence of diurnal variability in peak expiratory flow or significant reversibility to inhaled bronchodilator is documented. In accordance with current guidelines, measures of airway calibre and symptoms allow patients and clinicians to assess the degree of asthma control and titrate pharmacotherapy. However, these parameters fail to reflect the extent of underlying endobronchial inflammation and airway hyperresponsiveness, which in turn suggests that additional measures of asthma control may be of benefit. This evidence-based review highlights ways by which inflammation and airway hyperresponsiveness can be assessed and how they may provide additional useful information in the diagnosis and management of asthmatic patients.

The relationship between asthma and allergic rhinitis in the Iraqi population

BACKGROUND

Recently, extensive research has established that epidemiologic and therapeutic links exist between allergic rhinitis and asthma. The objective of this study was to clarify this association in Iraq.

METHODS

The data included in this study were collected from five surveys for asthma and allergic rhinitis that were performed during the period from September 2000 to July 2008. These surveys were parts of Tikrit University College of Medicine PHC program.

RESULTS

The frequency of allergic rhinitis (AR) was 61.6% among individuals with asthma versus 6% among non-asthmatic (control) subjects (Odd Ratio [OR] = 25.5; P < 0.0001). All studies indicated a significant frequency of AR among asthmatic patients in comparison with non-asthmatic subjects, whether the patients were adults or children (OR for adults = 14.9 and 22.5, for children 34.7 and 48.4; P < 0.001 for all). Furthermore, the high frequency of AR in asthmatic patients was seen whether the study was a community based study (CBS)(OR = 14.9 and 48.4; P < 0.0001) or a hospital based study (HBS)(OR = 22.5 & 34.7; P < 0.0001). The frequency of current asthma was 51.8% among individuals with AR versus 5.4% among control subjects (OR = 23.1; P < 0.0001).

CONCLUSIONS

This study provided evidence that AR and asthma are strongly associated with each other and the treatment approach should consider the entire airway rather than only a part.

The efficacy of a comprehensive lifestyle modification programme based on yoga in the management of bronchial asthma: a randomized controlled trial

BACKGROUND

There is a substantial body of evidence on the efficacy of yoga in the management of bronchial asthma. Many studies have reported, as the effects of yoga on bronchial asthma, significant improvements in pulmonary functions, quality of life and reduction in airway hyper-reactivity, frequency of attacks and medication use. In addition, a few studies have attempted to understand the effects of yoga on exercise-induced bronchoconstriction (EIB) or exercise tolerance capacity. However, none of these studies has investigated any immunological mechanisms by which yoga improves these variables in bronchial asthma.

METHODS

The present randomized controlled trial (RCT) was conducted on 57 adult subjects with mild or moderate bronchial asthma who were allocated randomly to either the yoga (intervention) group (n = 29) or the wait-listed control group (n = 28). The control group received only conventional care and the yoga group received an intervention based on yoga, in addition to the conventional care. The intervention consisted of 2-wk supervised training in lifestyle modification and stress management based on yoga followed by closely monitored continuation of the practices at home for 6-wk. The outcome measures were assessed in both the groups at 0 wk (baseline), 2, 4 and 8 wk by using Generalized Linear Model (GLM) repeated measures followed by post-hoc analysis.

RESULTS

In the yoga group, there was a steady and progressive improvement in pulmonary function, the change being statistically significant in case of the first second of forced expiratory volume (FEV1) at 8 wk, and peak expiratory flow rate (PEFR) at 2, 4 and 8 wk as compared to the corresponding baseline values. There was a significant reduction in EIB in the yoga group. However, there was no corresponding reduction in the urinary prostaglandin D2 metabolite (11beta prostaglandin F2alpha) levels in response to the exercise challenge. There was also no significant change in serum eosinophilic cationic protein levels during the 8-wk study period in either group. There was a significant improvement in Asthma Quality of Life (AQOL) scores in both groups over the 8-wk study period. But the improvement was achieved earlier and was more complete in the yoga group. The number-needed-to-treat worked out to be 1.82 for the total AQOL score. An improvement in total AQOL score was greater than the minimal important difference and the same outcome was achieved for the sub-domains of the AQOL. The frequency of rescue medication use showed a significant decrease over the study period in both the groups. However, the decrease was achieved relatively earlier and was more marked in the yoga group than in the control group.

CONCLUSION

The present RCT has demonstrated that adding the mind-body approach of yoga to the predominantly physical approach of conventional care results in measurable improvement in subjective as well as objective outcomes in bronchial asthma. The trial supports the efficacy of yoga in the management of bronchial asthma. However, the preliminary efforts made towards working out the mechanism of action of the intervention have not thrown much light on how yoga works in bronchial asthma.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00815962.

Urinary eosinophil-derived neurotoxin concentrations in patients with atopic dermatitis: a useful clinical marker for disease activity

BACKGROUND

It has been reported that measurements of eosinophil-derived neurotoxin (EDN) may be useful for identifying eosinophil activities in allergic diseases including atopic dermatitis.

METHODS

EDN concentrations in the urine were measured by enzyme-linked immunosorbent assay, and the number of eosinophils in the peripheral blood was counted in 30 patients with atopic dermatitis. The severity of atopic dermatitis was graded on the criteria proposed by Rajka and Langeland. The disease activity was assessed by each patient on a visual analogue scale (VAS).

RESULTS

Urinary concentrations of EDN in patients with atopic dermatitis showed a significant positive correlation with disease severity. Urine EDN concentrations also correlated with VAS scores for itching, skin condition, overall skin symptoms and total VAS score, but not with the VAS score for skin dryness. Urinary EDN concentrations did not correlate with the number of eosinophils in the peripheral blood.

CONCLUSIONS

The urinary EDN concentration in patients with atopic dermatitis is a useful clinical marker for monitoring disease activity.

Serum eosinophil-derived neurotoxin (EDN) in diagnosis and evaluation of severity and bronchial hyperresponsiveness in childhood asthma

This study sought to evaluate the use of serum eosinophil-derived neurotoxin (EDN), which has been proposed as a marker of airway inflammation in asthma in the diagnosis and evaluation of the severity and bronchial hyperresponsiveness in childhood asthma. We studied 72 children with atopic asthma, 36 children with nonatopic asthma, and 43 healthy controls. Skin prick tests, pulmonary function tests, and methacholine challenge tests were performed, in addition to total eosinophil count, serum ECP, and EDN being measured in all subjects. EDN levels were significantly higher in the atopic asthma group than those in the nonatopic asthma group or control group (p < 0.001), as were ECP levels (p < 0.001). EDN levels differed more significantly among groups divided by asthma severity (p < 0.001) than did ECP levels for these groups (p < 0.05). For the groups divided according to bronchial hyperresponsiveness, both EDN and ECP levels were significantly different (p < 0.005 and p < 0.01, respectively). Significant correlations were found between EDN and PC(20) (gamma = -0.281; p < 0.001), between ECP and PC(20) (gamma = -0.274; p < 0.005), and between EDN and ECP (gamma = 0.443; p < 0.001). In conclusion, serum EDN, as another marker of eosinophilic inflammation together with ECP, may aid in the diagnosis of asthma, especially atopic asthma, and in the evaluation of the severity and bronchial hyperresponsiveness in childhood asthma.

[Activated eosinophils: techniques to characterize them]

The deleterious role thought to be played by eosinophils in many situations is linked to their ability to secrete various inflammatory substances, mainly toxic proteins and lipid mediators, in body tissue. This ability is a particular feature of activated eosinophils, which have undergone numerous metabolic, functional, and phenotypic changes from their resting state. Characterizing the properties of these activated cells is an essential step in improving our understanding of their contributions to local inflammatory response, as both regulatory and effector cells. Improvements in existing methods as well as the development of new technical approaches have facilitated the ex vivo and in vitro study of activated eosinophils and their contribution to various disease states.

Bronchial responsiveness and serum eosinophil cationic protein levels in preschool children with recurrent wheezing

BACKGROUND

Bronchial hyperresponsiveness is a universally recognized phenomenon of asthma, and increased levels of eosinophil cationic protein (ECP) have been identified in the serum of patients with asthma.

OBJECTIVES

To investigate whether enhanced bronchial responsiveness and elevated serum ECP levels are associated with recurrent wheezing in preschool children and to examine the possible relationship between these 2 variables.

METHODS

We recruited 130 children aged 4 to 6 years: 59 with at least 3 episodes of wheezing in the previous year (current wheezers), 38 with a documented history of wheezing before 3 years of age but no subsequent wheezing episodes (past wheezers), and 33 who had never experienced wheezing (nonwheezers). The children underwent methacholine bronchial provocation tests using a modified auscultation method and blood sampling for the measurement of ECP levels.

RESULTS

Current wheezers showed greater bronchial responsiveness than past wheezers and nonwheezers, as demonstrated by lower provocation concentrations that caused audible wheeze and lower provocation concentrations that caused a decline in oxygen saturation of at least 5% from baseline. Likewise, current wheezers had higher serum ECP levels than the other 2 groups. Among current wheezers, ECP levels showed a significant negative correlation with provocation concentrations that caused oxygen desaturation and a marginally significant correlation with provocation concentrations that caused audible wheeze.

CONCLUSIONS

Enhanced bronchial responsiveness and elevated serum ECP levels are associated with recurrent wheezing in 4- to 6-year-old children. These results suggest that wheezing during preschool years may be phenotypically similar to wheezing in older children.

The ECP/Eo count ratio in children with asthma

We hypothesized that the serum eosinophil eationic protein (ECP) concentration to peripheral blood eosinophil count ratio (ECP/Eo ratio), reflecting active eosinophils, could better correlate with asthma severity in asthmatic patients, than each of these parameters alone. One hundred twenty children with mild to moderate persistent stable asthma were included into the study. At the first visit, previous asthma medications were withheld and patients were administered beta-2 agonists "as needed." At the second visit peripheral blood eosinophil count, serum ECP, sIL-2R, and sICAM-1 were measured, and spirometry and histamine challenge tests were performed. During the study, patients filled daily diary cards to assess symptoms score. One hundred seventeen patients completed the study. The univariate logistic regression analysis showed that asthma severity is related to PC20H, ECP, ECP/Eo ratio, sIL-2R, and sICAM-1. In general, patients with higher level of ECP, ECP/Eo ratio, sIL-2R, sICAM-1 and with lower PC20H exhibited the higher risk of moderate asthma. Multivariate regression analysis showed that only PC20H and ECP/Eo ratio were the best predictors of asthma severity; higher PC20H (1 mg/mL change) slightly decrease (OR = 0.656; 95% CI: 0.44-0.99) and higher ECP/Eo ratio (0.1 pg/cell change) increase (OR = 1.84; 95% CI: 1.02-3.34) a risk of moderate asthma. These data show that the ECP/Eo ratio is a better and more useful marker than ECP or peripheral blood eosinophil count separately in assessing asthma in children.

The determinants of bronchial hyperresponsiveness in patients with allergic rhinitis

BACKGROUND

Patients with allergic rhinitis and bronchial hyperresponsiveness (BHR) may be at higher risk of developing asthma.

OBJECTIVE

To investigate whether reactivity to aeroallergens in skin prick testing (SPT) and serum eosinophil cationic protein levels can be used to predict BHR in allergic rhinitis patients.

METHODS

Fifty-nine consecutive patients with allergic rhinitis underwent SPTs using grass, tree, weed, parietaria, Alternaria, Aspergillus, mites, and cat and dog dander extracts. Methacholine challenge tests were performed using spirometry.

RESULTS

Methacholine-induced BHR was detected in 23 patients (39%). Of 59 patients, 14 had 1 positive SPT response, 35 had 2 to 4 positive responses, and 10 had more than 4 positive responses. There was a significant inverse correlation between methacholine provocation concentration that caused a decrease in forced expiratory volume in 1 second of 20% (PC20) and the number of positive SPT responses (r = -0.28; P = .03). The BHR-positive patients had a mean of 4 positive SPT responses, whereas BHR-negative patients had a mean of 2.6 (P = .04). Nine BHR-positive patients (39%) and only 1 BHR-negative patient (3%) had more than 4 positive SPT responses (P < .001). There was no correlation between serum eosinophil cationic protein levels and methacholine PC20 doses. There was a strong association between hyperresponsiveness to methacholine and both cat and dog dander sensitivity (P < .001 and P = .001, respectively).

CONCLUSIONS

Allergic rhinitis patients with SPT responses to a higher number of allergens are more likely to have BHR. Whether the number of positive SPT responses correlates with the risk of developing asthma in allergic rhinitis patients remains to be determined.

Clinical usefulness of inflammatory markers in asthma

Asthma is a significant and increasing health problem. Airway inflammation and hyperresponsiveness are key pathophysiological mechanisms underlying asthma. Currently, effective treatments target these two processes and can lead to clinically important improvements in disease control. At present, decisions to initiate or modify therapy are based on symptoms and measures of airway caliber, with no direct assessment of airway inflammation or hyperresponsiveness. It is now possible to measure airway inflammation using noninvasive markers such as exhaled gases, induced sputum and serum measurements. Exhaled nitric oxide (eNO) and induced sputum eosinophils show the greatest promise as clinically useful markers of airway inflammation in asthma. Induced sputum can now be applied to the diagnosis of airway diseases, based on its ability to detect eosinophilic bronchitis in cough, and to differentiate between eosinophilic and non-eosinophilic asthma. The place of induced sputum and eNO in the ongoing monitoring of patients with asthma are now being investigated in controlled trials.

Low-dose theophylline in childhood asthma: a placebo-controlled, double-blind study

Regular anti-inflammatory treatment is essential in treating persistent asthma. Most commonly, inhaled corticosteroids (ICS) are used. However, especially in children, there is concern about the long-term safety of ICS such that doses should be kept to a minimum. The use of theophylline has decreased because of frequent side-effects in therapeutic doses. In adults, there have been reports about an immunomodulatory effect of low-dose theophylline. To study the clinical and immunomodulatory effect in children, 36 patients (mean age 12.5 SD 2.4 years) with moderate, persistent asthma on regular ICS were recruited into a placebo-controlled, double-blind study. After a 6-week run-in period, patients received either theophylline 10 mg/kg bodyweight or placebo for 12 weeks. Diary cards, lung function, peripheral blood lymphocyte subpopulations and serum eosinophil cationic protein (sECP) were assessed. In the treatment group, mean serum theophylline was 7.1 mg/l. There was no change in symptoms or use of rescue medication. Mean (SD) peak expiratory flow (PEF) increased from 86% (24) to 95% (18) predicted. sECP decreased from 43.2 microg/l (32.5) to 26.5 microg/l (16.9) (p = 0.02). Lymphocyte subpopulations did not change. The study failed to show a beneficial clinical or an immunomodulatory effect of theophylline when used in low doses. These results do not support a more important role of theophylline in the long-term treatment of moderate childhood asthma.

High eosinophil cationic protein level in asthmatic patients with "heat" Zheng

In traditional Chinese medicine (TCM), the imbalance of yin and yang is one of the basic pathogeneses of a disease. Preponderance of yang leads to "heat" manifestations including thirst, dryness of the throat, dark scanty urine and constipation. Treatment of asthma in TCM is based on the differentiation of "heat" Zheng according to the manifestations. Some of the patients with allergic asthma also present typical "heat" manifestations. To investigate the essence of "heat" manifestation in asthma, we measured the serum level of eosinophil cationic protein (ECP) in asthmatic patients. ECP usually represents the activation of eosinophils which are the main effectors in late allergic reactions. Our results demonstrated that asthmatic patients with "heat" manifestations had higher serum ECP levels, compared to those without "heat" manifestations (34.3 +/- 4 microg/l versus 15.3 +/- 3 microg/l). However, total immunoglobulin B (IgE), and the eosinophil count in peripheral blood did not show any difference between the "heat" and "non-heat" groups. Therefore, we conclude that ECP in asthmatic patients plays an important role in the development of "heat" manifestations as diagnosed by TCM.

Effects of low dose fluticasone/salmeterol combination on surrogate inflammatory markers in moderate persistent asthma

BACKGROUND

Noninvasive surrogate markers provide valuable information on the asthmatic inflammatory process. We wished to examine the effects of low dose fluticasone/salmeterol combination on different commonly used inflammatory markers in moderate persistent asthma.

METHODS

Twenty-five moderate persistent atopic asthmatics were enrolled of whom 20 completed an open label study. Following an initial 4 week steroid washout period in which patients took salmeterol 50 microg dry powder inhaler 1 puff BD, they received the addition of fluticasone as fluticasone 100 microg/salmeterol 50 microg combination dry powder inhaler 1 puff BD for the next 2 weeks. Exhaled nitric oxide, spirometry, methacholine PD20, sputum/blood eosinophils and sputum/serum eosinophil cationic protein (ECP) were measured following the salmeterol only and fluticasone/salmeterol combination treatment periods.

RESULTS

Compared to salmeterol alone (i.e. after the steroid washout), the use of fluticasone/salmeterol combination conferred significant improvements (P < 0.05) in all surrogate markers of inflammation apart from serum ECP. Geometric mean fold changes were 4.3-fold/1.3-fold for sputum/blood eosinophils, 2.2-fold/1.2-fold for sputum/serum ECP, 2.3-fold for methacholine PD20 and 1.8-fold for exhaled nitric oxide.

CONCLUSIONS

Surrogate markers apart from serum ECP may be used as a guide to evaluate the anti-inflammatory effects of low dose inhaled corticosteroids. Sputum markers tend to be more sensitive than blood when assessing the anti-inflammatory response.

Comparison of different activity parameters in atopic dermatitis: correlation with clinical scores

BACKGROUND

Several laboratory markers have been described to correlate positively with disease activity of atopic dermatitis (AD). These include soluble adhesion molecules and eosinophil granular proteins. Although the correlation of these parameters with the severity and extent of skin involvement has been repeatedly studied in the past, no systematic investigation has been performed over a lengthy period of time. In addition, no subjective disease parameters recorded by the patient have been included in studies dealing with disease activity.

OBJECTIVES

To assess the validity of different objective and subjective parameters [soluble E-selectin (sE-selectin), soluble vascular cell adhesion molecule-1 (sVCAM-1), eosinophil cationic protein (ECP), urinary nitrate excretion (reflecting endogenous nitric oxide formation) and the patients' impressions of pruritus, sleeplessness and skin status] as markers of AD disease activity.

METHODS

Twenty patients were examined for 1 year and their skin status was evaluated by an established score (SCORAD). sE-selectin, sVCAM-1 and ECP were analysed by commercial test kits. Urinary nitrate concentration was measured by gas chromatography-mass spectrometry. The subjective parameters, pruritus, sleeplessness and impression of skin status, were recorded by the patients on a visual analogue scale.

RESULTS

In this long-term trial, only sE-selectin and the subjective parameters showed a statistically significant correlation with the SCORAD score.

CONCLUSIONS

Our data indicate that basic clinical scoring remains a most effective and relevant method of recording skin disease activity in AD.

Serum ECP levels and methacholine challenge in infants with recurrent wheezing

BACKGROUND

High levels of serum eosinophil cationic protein (sECP) as a marker of eosinophilic airway inflammation have been described as a predictor of childhood asthma. Bronchial hyperreactivity (BHR) appears to be secondary to the release of inflammatory mediators.

OBJECTIVE

We investigated the possible correlation between eosinophilic inflammation and BHR in 72 infants with recurrent wheezing.

METHODS

To determine bronchial reactivity, lung function measurements with methacholine challenge were performed in 72 infants, aged 12 to 30 months, and the degree of BHR to methacholine was compared with sECP values. Patients were grouped according to low (group 1, <10 microg/L, n = 22), medium (group 2, 10 to 20 microg/L, n = 23), and high (group 3, >20 microg/L, n = 27) sECP values.

RESULTS

In group 1, sECP levels ranged from 3.1 to 9.9 microg/L, mean 6.6 microg/L +/- standard deviation [SD] 2.3, in group 2, from 10.3 to 19.8 microg/L, mean 14.3 microg/L +/- SD 2.8, and in group 3 from 23.0 to 66.7 microg/L, mean 34.5 microg/L +/- SD 9.5. Distribution of provocative methacholine concentration among groups was as follows: group 1, 30 to 976 microg, mean 350.9 microg +/- SD 258.3; group 2, 36 to 752 microg, mean 340.7 microg +/- SD 226.3; group 3, 41 to 848 microg, mean 301.3 microg +/- SD 189.8 methacholine.

CONCLUSION

There was no significant correlation between sECP levels and bronchial reactivity in all groups (r = -0.076, P = 0.6), indicating that these parameters reflect two independent pathogenic mechanisms in the etiology of childhood asthma.

Evaluation of serum eosinophil cationic protein as a predictive marker for asthma exacerbation in patients with persistent disease

BACKGROUND

Eosinophilic inflammation is a feature of asthma. However, serological markers to indicate eosinophil activation in this process are not fully defined.

OBJECTIVE

To evaluate the relationship of serum eosinophil cationic protein (ECP) to asthma worsening and a marker for treatment effectiveness, 26 adult patients with an asthma exacerbation were identified.

METHODS

Identified asthma subjects were treated with oral corticosteroids (prednisone) for 14 days. The lung function variables, forced expiratory volume in one second (FEV1) and peak expiratory flow (PEF), were determined as percentage of predicted and the blood total eosinophil count and serum ECP levels were measured. Patients were re-evaluated after 14 days of corticosteroid treatment and then every 3 months thereafter during a 12-month period.

RESULTS

Eighteen patients responded to prednisone treatment, whereas eight did not, assessed as improvement of their lung function parameters. Different serum ECP patterns could be seen in the responders compared with the non-responders. All 18 responders had considerably increased serum ECP at the time of exacerbation, whereas the non-responders had lower serum ECP levels. The serum ECP levels decreased to a greater extent in the responder patient group than in the non-responder patients following prednisone treatment. This difference in patterns was not seen with total blood eosinophil counts.

CONCLUSION

Our findings suggest that serum ECP may be used to predict a response to corticosteroid therapy in adult patients with asthma.

Treatment of asthma patients with herbal medicine TJ-96: a randomized controlled trial

Alternative medicine use has increased at a remarkable pace all over the world in recent years. Although herbal medicine for the treatment of asthma is becoming the focus of public attention, randomized studies had not been performed, even in Eastern countries including Japan. This study was designed to investigate whether one of the Japanese government approved herbal complexes Saiboku-to (TJ-96) is effective for the treatment of atopic asthma, and to investigate whether this protective activity is associated with a reduction in eosinophilic inflammation. A double-blind, randomized, crossover design was used. Subjects received 2.5 g of TJ-96 or placebo orally 3 times daily for 4 weeks and then, after a washout period of at least 4 weeks, crossed over to receive the alternative treatment. We assessed the effects of pretreatment with TJ-96 on bronchoconstriction precipitated by inhalation of methacholine. Furthermore, eosinophil counts and measurement of eosinophilic cationic protein (ECP) were performed. After 4 weeks of treatment with TJ-96, values of PC20 -methacholine significantly improved in the treatment with TJ-96. Also, patients' symptoms, blood eosinophils, serum ECP, sputum eosinophils, and sputum ECP were significantly decreased. Our results suggest that TJ-96 has an antiinflammatory effect on bronchial eosinophilic infiltration. This study raises further interesting therapeutic possibilities and argues for further trials of new approaches to the treatment of asthma.

Challenges to treatment goals and outcomes in pediatric asthma

To achieve long-term control in pediatric asthma, it is essential to establish treatment goals acceptable to both the patient and care giver and to choose appropriate outcome measures that will show the benefits of the treatment. Differences between the perceptions of patients and care givers of what constitutes a desirable treatment goal, and poor perception of asthma control by both patient and physician, hinder optimal treatment of asthma. The use of objective outcome measures in pediatric asthma generally can provide a good evaluation of asthma severity as well as a basis for setting treatment goals that are acceptable to patients and care givers alike. Objective measurements that assess airway inflammation, which is the fundamental pathophysiology in asthma and the underlying mechanism for chronic airway remodeling, may be the most useful means for gauging pediatric asthma control and evaluating response to treatment. Techniques such as exhaled nitric oxide analysis, bronchoalveolar lavage, and sputum analysis, although used primarily in research, have successfully identified the level of airway inflammation in children. Furthermore, the association of meaningful outcome measures with education about the long-term effects of uncontrolled asthma and the need for anti-inflammatory treatment should help in developing treatment goals and strategies that will be acceptable to both patient and care giver.

Blood eosinophil counts for the prediction of the severity of exercise-induced bronchospasm in asthma

It has been suggested that airway eosinophilic inflammation is associated with the severity of exercise-induced bronchospasm (EIB). Blood eosinophils are known to be an indirect marker of airway inflammation in asthma. The aim of this study is to investigate that a simple and easy blood test for blood eosinphil counts may predict the severity of EIB in asthma. Seventy-seven men with perennial asthma (age range 18-23 years) were included. Lung function test, skin prick test, and blood tests for eosinophils counts and total IgE levels were performed. Methacholine bronchial provocation test and, 24 h later, free running test were carried out. EIB was defined as a 15% reduction or more in post-exercise FEV1 compared with pre-exercise FEV1 value. Atopy score was defined as a sum of mean wheal diameters to allergens. EIB was observed in 60 (78%) of 77 subjects. Asthmatics with EIB showed significantly increased percentages of eosinophils (P<0.01), log eosinophil counts (P<0.001), and atopy scores (P<0.05) and decreased log PC20 values (P < 0.05) compared with asthmatics without EIB. Asthmatics with eosinophils of > 700 microl(-1) (36.9 +/- 12.7%) had significantly greater maximal % fall in FEV1 after exercise than asthmatics with eosinophils of < 350 microl(-1) (24.7 +/- 16.6%, P <0.05). Blood eosinophil counts > 350 microl(-1) yielded the specificity of 88% and positive predictive value of 93% for the presence of EIB. When a multiple regression analysis of maximal % fall in FEV1 according to log eosinophil counts, log PC20, log IgE and atopy score was performed, only blood eosinophil counts were significant factor contributing to the maximal % fall in FEV1 after exercise. These findings not only suggest that a simple blood test for eosinophils may be useful in the prediction of the severity of EIB, but also reinforce the view that airway eosinophilic inflammation may play a major role in EIB in asthma.

Which factors predict success after discontinuation of inhaled budesonide therapy in children with asthma?

Urinary eosinophil protein X (UEPX) concentration, lung function, and nonspecific bronchial hyperreactivity were determined in 40 asthmatic children (asymptomatic for 6.4 +/- 3.0 months) (mean age 9.8 +/- 2.9 years) receiving inhaled budesonide, in order to establish whether measurement of these parameters is useful in determining discontinuation of inhaled corticosteroid therapy. After the discontinuation of therapy, patients were asked to come to the Outpatient Clinic if symptoms recurred and did not respond to beta2 mimetic usage in 24 hr. Otherwise they were to be seen 2-3 months later for a follow-up visit. UEPX concentration was determined and spirometry was performed on this visit. While UEPX concentrations had increased (p < 0.0001), FEV1, FEF 25-75 and PEF had decreased significantly 2.3 +/- 0.53 months after the cessation of inhaled budesonide therapy in all children (p = 0.004, p = 0.02, p = 0.02, respectively). Due to clinical deterioration, inhaled corticosteroid therapy had to be restarted in 19 (48%) of the children (Group I), while the remaining 21 (52%) (Group II) continued to be asymptomatic during the 2.3 +/- 0.5 months follow-up period. Although the initial UEPX concentrations, spirometer variables, and methacholine PC20 values of these two groups were not statistically different, the duration of clinical remission before discontinuation of budesonide prophylaxis was significantly longer in group II (p = 0.0037). We concluded that, in determining discontinuation of inhaled corticosteroid prophylaxis, duration of clinical remission seems to be a more useful criterion than measurement of UEPX levels, lung function test, and assessment of bronchial hyperreactivity.

Markers of allergic inflammation in peripheral blood of children with asthma after treatment with inhaled triamcinolone acetonide

BACKGROUND

It is important to monitor inflammation regularly in asthma in addition to clinical symptoms, and there is a great need for noninvasive tests that could routinely be used in clinical practice.

OBJECTIVE

Our hypothesis was that the improvement of clinical parameters, together with decreased airway responsiveness, could be correlated with changes in the levels of serum markers of inflammation after a 4-week treatment with triamcinolone.

METHODS

In this double-blind, randomized, placebo-controlled trial, 48 children, aged 6 to 18 years, with mild to moderate atopic asthma, were randomly allocated to receive triamcinolone or matching placebo for 4 weeks. The following parameters were measured: the symptom score, forced expiratory volume in 1 second (FEV1), provocative concentration of histamine causing a 20% fall in FEV1 (PC20) for histamine and peripheral blood eosinophil count, serum levels of the inflammatory markers eosinophil cationic protein (ECP), soluble receptor of interleukin-2 (sIL-2R), interleukin-4, soluble intercellular adhesion molecule-1 before and after treatment.

RESULTS

The clinical parameters significantly improved after treatment with triamcinolone; the mean value of FEV1 changed from 74% of predicted value before, to 90% of predicted after treatment (P < 0.001). PC20 for histamine after treatment with triamcinolone increased significantly from the mean value 2.5 mg/mL to 4.7 mg/mL (P < 0.001). Treatment with triamcinolone significantly (P < 0.05) decreased serum levels of all the measured inflammatory markers. The mean concentration of eosinophil blood count was 380 and 261 cells/mm3; ECP, 83 and 58 ng/mL; serum sIL-2R, 734 and 487 pg/mL; soluble intercellular adhesion molecule-1, 266 and 210 ng/mL, before and after treatment, respectively. The values of interleukin-4 were low and close to the sensitivity of the assay. A significant correlation was found between ECP and sIL-2R levels before and after treatment with triamcinolone.

CONCLUSIONS

A significant decrease of all the measured serum parameters was observed after treatment with triamcinolone; however, no significant correlation was found among any of those parameters and clinical markers of disease severity (such as FEV1 or PC20H).

Serum eosinophil cationic protein levels measured during exacerbation of asthma: characteristics of patients with low titres

BACKGROUND

Serum eosinophil cationic protein (ECP) levels reflect ongoing eosinophilic airway inflammation and are used as a marker for asthma activity. ECP levels, however, may not be elevated in some asthmatic patients, even when they are symptomatic.

OBJECTIVE

To clarify the characteristics of patients with 'low' ECP titres despite asthma exacerbation.

METHODS

Serum ECP levels were measured in 113 asthmatic patients during exacerbation. Patients were divided into two groups according to ECP titre: a high ECP group (H; ECP > or = 16.0 microg/L) and a low ECP group (L; ECP <16.0 microg/L). Twenty-two patients who had recently received systemic steroids were excluded and the clinical features of the remaining patients in H (n = 54) and L (n = 37 were compared.

RESULTS

Gender, atopic or smoking status, disease severity, inhaled steroid or theophylline usage, peak expiratory flow (% personal best) and forced expiratory volume in 1 s (FEV1) (% predicted) did not significantly differ between the two groups. Patients in L were significantly older and had longer disease duration and lower serum IgE levels than those in H. Multivariate analysis combining age, disease duration and IgE levels showed that age and disease duration were independently associated with ECP level. Airway wall thickness, assessed in a subset of patients using computed tomography, was significantly larger in L.

CONCLUSION

Serum ECP levels in asthmatic patients may not be elevated during exacerbation and thus may not be a useful marker in patients who are older, have longer disease duration or possibly have thicker airway walls. Mechanisms other than eosinophilic inflammation, such as airway remodelling, may be involved in asthma exacerbation in these patients.

Cromolyn sodium suppresses eosinophilic inflammation in patients with aspirin-intolerant asthma

BACKGROUND

Although administration of cromolyn sodium is one of the most useful drugs for the treatment of aspirin-intolerant asthma (AIA), both its pharmacologic mechanism of action and association with the pathogenesis remain obscure.

OBJECTIVE

This study was designed to investigate the protective effect of cromolyn sodium on airway responsiveness to the sulpyrine provocation test, and to examine whether its activity is associated with a reduction in eosinophilic inflammation.

METHODS

Patients were randomly assigned to receive cromolyn sodium (20 mg/2 mL, or 1 ampoule; Fujisawa, Osaka, Japan) or matching placebo (2 mL of saline) four times daily for 1 week. We evaluated the effects of pretreatment with cromolyn sodium on bronchoconstriction precipitated by inhalation of sulpyrine in 16 adult patients with mild or moderate AIA; those who were in stable clinical condition were allocated to this study. A double-blind, randomized, crossover design was used. Blood and sputum samples were taken in the morning on the sulpyrine provocation testing day. Eosinophil counting and measurement of eosinophilic cationic protein (ECP) were performed.

RESULTS

Inhaled cromolyn sodium protect against aspirin-induced attacks of asthma through mechanisms not related to the bronchodilator property, but related to the improvement of the bronchial hypersensitivity, almost completely in all patients (P < 0.001). After 1 week's treatment with cromolyn sodium, patients' symptoms, blood and sputum eosinophils counts, and sputum ECP levels were significantly decreased compared with both placebo and baseline.

CONCLUSIONS

Cromolyn sodium has a bronchial anti-inflammatory effect associated with decreased eosinophilic infiltration. This is the first report that cromolyn sodium reduces blood and sputum eosinophils counts and sputum ECP levels in AIA.

A comparison of allergen and polycation induced cutaneous responses in the rabbit

Allergic inflammatory responses contribute to the symptoms of a number of diseases including atopic dermatitis, asthma and rhinitis. Cationic proteins are released from inflammatory cells and levels are known to be raised in disease states. Using an in vivo model of acute inflammation, we investigated the characteristics of cutaneous responses to antigen (Alternaria tenuis, AT) and poly-L-lysine (PLL, used as a paradigm for cationic proteins). We aimed to compare the inflammatory profile of cationic polypeptides and the allergic response and to identify similarities and differences between these responses. Responses to intradermal injection of the polycation, PLL and antigen were compared using radiolabelled protein ((125)I-bovine serum albumin, BSA) and cells ((111)In-neutrophils, PMN) to study plasma exudation (PE) and PMN accumulation (PMNA) in the skin of AT sensitized rabbits. Both PLL and antigen caused dose-related increases in PE and PMNA. PE (and PMNA) responses to PLL were prolonged (up to 3 h), as were those to antigen. This is in contrast to PE responses to fMLP which were maximal at 45 min. In immunized animals, treated with colchicine (1 mg kg(-1) i.v.), PE responses to the directly acting mediator, bradykinin (BK), were not affected, whereas PE responses to the neutrophil dependent mediator, f-met-leu-phe (fMLP), were significantly (P<0.01) reduced. Antigen-induced PE responses were significantly (50, 500 (P<0.05); 200 (P<0.01) p.n.u. site(-1)) inhibited by colchicine, but PLL-induced responses were not significantly affected. We conclude that although PLL-induced responses had a similar time course to those of antigen, some differences were observed between responses, which indicate that although polycations may contribute to allergic responses, these two responses are produced by distinct mechanisms.

Serum levels of eosinophil cationic protein and eosinophils in asthmatic children during a course of prednisolone therapy

Eosinophils play an important role in the inflammatory events of allergic asthma. Serum eosinophil cationic protein (ECP) is a marker of disease activity and of treatment efficacy in bronchial asthma. To understand the role of ECP concentrations in disease activity of acute asthma, we determined changes in serum concentrations of ECP elaborated by activated eosinophil before and after prednisolone therapy. Circulating levels of ECP in 15 normal control subjects, and in sera of 20 asthmatic children who were allergic to house dust mites, were measured during an acute exacerbation and when the children were in stable condition, using commercially available assay kits. The mean concentrations of serum ECP were significantly higher during an acute asthma exacerbation than when the children were stable (26.41 +/- 21.66 microg/L vs 15.74 +/- 11.36 microg/L P < 0.01) or when compared to control subjects (7.50 +/- 1.42 microg/L; P < 0.001). The mean eosinophil counts (EC) during acute asthma attacks (575 +/- 286/mm3) and when stable (467 +/- 204/mm3) were higher than in the control group (181 +/- 164/mm3). The differences were statistically significant among the three groups (P < 0.05). A significant correlation was found between serum levels of ECP and EC (r = 0.788, P = 0.001) in asthmatic children; there were also significant correlations between ECP and EC in nonallergic normal control subjects (r = 0.662; P = 0.007). In conclusion, this study provides further evidence that changes in serum ECP may serve as an objective indicator for clinical activity and results of treatment in allergic asthmatics.

Eosinophil cationic protein (ECP) in school children living in a mountainous area of Norway: a population-based study of ECP as a tool for diagnosing asthma in children with reference values

BACKGROUND

Most previous studies on eosinophil cationic protein (ECP) have been performed on carefully selected groups of asthmatic patients. Few studies based upon population cohorts have been reported. The primary objective of the present study was to assess the usefulness of serum eosinophil cationic protein (s-ECP) in the diagnosis of asthma in schoolchildren and determine reference values based on measurements in healthy children.

METHODS

The population consisted of 216 schoolchildren (aged 7-16 years) who in a previous questionnaire had reported asthma or asthma-like symptoms and a control group. The questionnaire study comprised the entire population of schoolchildren in Upper Hallingdal. After clinical assessment, blood samples, and skin prick tests, these subjects were then reclassified into four groups: atopic and nonatopic asthmatic and nonasthmatics. S-ECP was assessed in relation to atopy, asthma severity, allergen exposure, and sex.

RESULTS

The asthma group (n = 105) had significantly higher mean s-ECP level than the nonasthma group (n = 111) (13.3 vs 8.3 microg/l, P < 0.001), with no significant difference between atopic asthmatics and atopic nonasthmatics. Mean s-ECP levels in children with mild, moderate, or severe asthma were 12.1, 18.5, and 12.2 microg/l, respectively. The children with animal dander allergy demonstrated higher levels of s-ECP than children without this allergy (12.9 vs 9.1 microg/l, P = 0.001). The upper reference limit (determined as the 95th percentile in healthy children) of 19.1 microg/l, showed low sensitivity (24%) and high specificity (93%) for the diagnosis of asthma. The positive and negative likelihood ratios for the asthma diagnosis were found to be 3.2 and 0.83, respectively.

CONCLUSIONS

The highest s-ECP values were found among children with moderate asthma. Animal dander allergy resulted in elevated s-ECP. However, mean values were still below the reference value of 19.1 microg/l, and the sensitivity was low, suggesting that s-ECP is not a useful parameter for diagnosing asthma in population-based studies.

Induced sputum in children: feasibility, repeatability, and relation of findings to asthma severity

BACKGROUND

The collection of induced sputum provides a non-invasive method of investigating airway inflammation. Few studies have been performed in children, so a study was undertaken to determine the feasibility of sputum induction, the repeatability of eosinophil counts and sputum eosinophil cationic protein (ECP) levels, and the relation of these to current asthma severity. For comparison, serum ECP levels were also measured.

METHODS

In a cross sectional study of children aged 5-15 years, 27 healthy children and 60 with asthma underwent sputum induction using inhaled nebulised hypertonic saline. The whole sputum sample was used for analysis. Ten children with stable asthma repeated the procedure within 10 days.

RESULTS

A satisfactory sample (>500 non-squamous cells) was obtained in 61% of children with asthma and in 60% of healthy controls. The limits of agreement within subjects ranged from a 0.68 to 2.8 fold difference for eosinophil differential counts and from 0.38 to 4.4 fold for sputum ECP. Despite a median of 42% squamous cells, significant differences were found between asthma and healthy controls for the eosinophil differential count (p = 0.0004), total eosinophil counts (p = 0.03), and sputum ECP level (p = 0.0001). Overall, there was no correlation between any marker of airway inflammation and asthma severity, however expressed, including lung function.

CONCLUSIONS

Sputum induction is only possible in a proportion of children. The repeatability of sputum cell counts and ECP levels, measured in a small number of children, was similar to that reported in adults. Sputum analysis revealed no evidence of airway inflammation in a number of highly symptomatic children with asthma.

Effect of pranlukast on bronchial inflammation in patients with asthma

BACKGROUND

Pranlukast (8-[p-(4-phenylbutyloxy) benzol] amino-2-[tetrazol-5-yl]-4-oxo-4H-1-benzopyran hemihydrate), a selective cysteinyl leukotriene receptor antagonist, has been reported to exhibit not only antileukotrine activity but also pharmacological activity including antieosinophilic effects.

OBJECTIVE

This study was designed to investigate whether the antiasthmatic activity of pranlukast is associated with a reduction in eosinophilic inflammation.

METHODS

A double-blind, randomized, crossover design was used. Subjects received 225 mg of pranlukast or placebo orally twice daily for 4 weeks and then, after a washout period of at least 4 weeks, crossed over to receive the alternative treatment. We assessed the effects of pretreatment with pranlukast on bronchoconstriction precipitated by inhalation of methacholine in 32 adult patients with mild or moderate bronchial asthma; those who were in stable clinical condition were allocated to this study. Blood and sputum samples were taken the morning of the methacholine provocation test. Eosinophil counts and measurement of eosinophilic cationic protein (ECP) were performed.

RESULTS

After the 4 weeks of treatment with pranlukast, patients' symptoms, blood eosinophils, serum ECP, sputum eosinophils, and sputum ECP were significantly decreased. Furthermore, values of PC20-methacholine significantly improved in the treatment with pranlukast.

CONCLUSION

Our results suggest that pranlukast has an anti-inflammatory effect on bronchial eosinophilic infiltration. This study raises further interesting therapeutic possibilities and argues for further trials of new approaches to the treatment of bronchial asthma.

Clarithromycin suppresses bronchial hyperresponsiveness associated with eosinophilic inflammation in patients with asthma

BACKGROUND

Although long-term administration of 14-membered macrolide antibiotics is a therapeutic alternative in asthma, both its pharmacologic mechanism of action and association with the pathogenesis of asthma remain obscure.

OBJECTIVE

This study investigated the suppressive effect of clarithromycin on airway responsiveness to methacholine provocation testing and examined whether chrarithromycin's antiasthmatic activity is associated with a reduction in eosinophilic inflammation.

METHODS

For 8 weeks, patients received 200 mg of clarithromycin or identical-appearing placebo twice daily. We assessed the effects of treatment with clarithromycin on bronchoconstriction precipitated by inhalation of methacholine in 17 adults with mild or moderate bronchial asthma who were in stable clinical condition. A double-blind, randomized, crossover design was used. Eosinophil counts and eosinophilic cationic protein (ECP) levels were determined in blood and sputum samples obtained on the morning of the methacholine provocation testing day.

RESULTS

After 8 weeks of treatment with clarithromycin, patients' symptoms, blood and sputum eosinophils counts and sputum ECP levels were significantly decreased compared with both placebo and baseline. Furthermore, values of PC20 methacholine improved in all patients after clarithromycin treatment.

CONCLUSIONS

Clarithromycin has a bronchial anti-inflammatory effect associated with decreased eosinophilic infiltration. This study suggests interesting therapeutic possibilities for bronchial asthma that warrant further trials.

Issues in understanding childhood asthma

Asthma and related allergic disorders in childhood have increased considerably in prevalence over the last few decades. During the same period of increasing morbidity from childhood asthma in the community, there have been dramatic advances in understanding of the basic immunopathologic features of the disease and consequently the development of a far more rational approach to its treatment. The immunopathologic condition of eosinophil-mediated airway inflammation is established very early in the evolution of asthma in childhood. It may even antedate the onset of symptoms. The present state of the art dictates that early intervention with potent therapies cannot be justified on the basis of symptoms alone and may in any case have no influence on the natural history of the condition. This means that current cautious therapeutic guidelines should continue to be followed. However, with the development of more accurate markers predicting ongoing disease, it will be possible to evaluate a whole range of early interventions in the future. Much evidence, though indirect, points to the possibility that the only true prophylaxis that will affect the natural history of asthma will need to be commenced before clinical features are manifest.

Intracellular expression and serum levels of eosinophil peroxidase (EPO) and eosinophil cationic protein in asthmatic children

BACKGROUND

Eosinophils are involved in the chronic inflammatory response in asthma and their basic proteins are thought to play a major pathophysiological role in this process. While serum levels of basic proteins have been used to monitor the ongoing allergic disease, little is known about the intracellular expression of these proteins in clinical situations.

OBJECTIVE

The aim of the study was to determine the intracellular expression of eosinophil cationic protein (ECP) and eosinophil peroxidase (EPO) in asthmatic children and control subjects and relate it to serum levels of both proteins, lung function tests and immunoglobulin (Ig)E levels.

METHODS

Serum ECP and EPO concentrations were determined by immunoassays in 13 asthmatic children (mean age: 9 +/- 1 years, mean FEV1: 92 +/- 10% predicted, geometric mean PC20 histamine 0.5 mg/mL) and 10 age-matched, healthy control subjects. A flow cytometric single cell assay was employed to detect intracellular ECP and EPO in peripheral blood eosinophils.

RESULTS

While serum concentrations of both ECP (asthma: median 15.0 microg/L [range 3.6-57.7] vs control: 5.9 microg/L [2.7-9.1]; P = 0.02) and EPO (22.9 microg/L [5.2-82.5] vs 7. 2 microg/L [2.5-12.7]; P = 0.008) were significantly elevated in asthmatics, the intracellular expression of ECP and EPO (measured as mean fluorescence intensity) was decreased (EG1: 55.3 [17.7-120.8] vs 100.3 [46.5-264.4]; P = 0.01; EG2: 80.2 [24.1-135.3] vs 133.7 [32. 1-244.9]; P = 0.04 and EPO: 49.7 [23.1-155.8] vs 94.9 [28.8-115.2]; P = 0.03). In asthmatics there was a significant correlation of FEV1 with intracellular ECP and of bronchial hyperresponsiveness with serum EPO and ECP. Furthermore, total IgE levels were positively correlated with serum EPO only.

CONCLUSION

We conclude that in asthmatics the intracellular content of ECP and EPO in peripheral eosinophils is reduced possibly due to degranulation. Epitope masking in activated eosinophils or a shift to early bone marrow-derived progenitors with less granule proteins are further possible explanations.

Serum eosinophil cationic protein (sECP) in subjects with a history of asthma symptoms with or without rhinitis

BACKGROUND

Serum eosinophil cationic protein (sECP) has been proposed as a marker of disease activity in bronchial asthma. The study aimed to evaluate the role of sECP in screening asthmatics in a group of subjects with asthma and rhinitis symptoms, and the relationship between sECP and clinical and functional parameters of asthma.

METHODS

A total of 185 subjects with asthma symptoms, 149 of them with rhinitis as well, underwent skin tests, spirometry, methacholine (MCH) test, blood sampling for eosinophil percentage (bEOS%) and sECP determination, and nasal secretions smear for eosinophil percentage (nEOS%) determination; PEF values, symptoms, and medication over a period of 4 weeks after sampling for sECP quantitation were recorded on a diary.

RESULTS

A total of 99 (53%) subjects received a diagnosis of asthma (asthmatics), and 86 did not (nonasthmatics). In asthmatics, neither sECP nor bEOS% was significantly different from nonasthmatics. In asthmatics, sECP was higher in subjects with increased than in those with normal daily PEF variability (16.4, 6.8-24.4 vs 5.3, 3.9-8.4 microg/l; P<0.001). sECP was higher in moderate persistent asthma than in intermittent asthma (24.8, 10.6-53 vs 8.4, 5.6-14.1; P<0.05). In nonasthmatics (73 with a history of rhinitis), both sECP and bEOS% correlated with nEOS% (rho=0.35; P<0.01 and rho=0.53; P<0.001).

CONCLUSIONS

In adults with asthma symptoms with or without rhinitis, sECP did not distinguish asthmatics from nonasthmatics. In asthmatics, sECP was associated with PEF variability and symptom severity. In subjects with asthma and rhinitis, as well as in subjects with only rhinitis, sECP levels are possibly influenced by nasal inflammation.

Serum eosinophil cationic protein and bronchial responsiveness in pediatric and adolescent asthma patients

BACKGROUND

Serum eosinophil cationic protein (ECP) has been promoted as a marker of inflammatory activity in bronchial asthma. Bronchial responsiveness, measured either by inhaling pharmacologically active substances such as histamine or methacholine, or by applying physical stimuli such as the hyperventilation of cold dry air, is also considered to be an indirect marker of bronchial inflammation.

OBJECTIVES

In this study, we investigated the possible relationship between serum ECP and bronchial responsiveness to both cold dry air and histamine in presently symptom- and medication-free pediatric and adolescent asthma patients.

SUBJECTS

Thirty-six children and adolescents with atopic asthma were studied.

METHODS

On 2 consecutive days, bronchial responsiveness was assessed nonpharmacologically by cold dry air and pharmacologically by histamine in random order. Blood samples for determination of ECP were collected before each challenge.

RESULTS

Serum ECP levels correlated with neither cold dry air-induced changes in FEV1 nor the provocation concentrations of histamine causing a 20% fall in FEV1. Subjects with bronchial hyperresponsiveness to cold dry air and histamine had somewhat higher levels of serum ECP than subjects with normal responses, but these differences were insignificant.

CONCLUSIONS

Our results indicate a lack of relationship both between serum ECP and bronchial responsiveness to cold dry air and between serum ECP and bronchial responsiveness to histamine.

Serum measurement of eosinophil cationic protein in the management of asthma

Asthma is a disease characterized by chronic eosinophilic inflammation of the airways. Serum eosinophil cationic protein (ECP) has been increasingly used as a noninvasive inflammatory marker in asthma. The serum ECP level seems to reflect, although indirectly, the intensity of ongoing eosinophilic inflammation of the airways and respond sensitively to intervention, whereas it is unlikely to be useful for establishing the diagnosis of asthma in an individual patient. Monitoring of serum ECP could be of utility in the long-term follow-up of asthmatic patients. However, further longitudinal studies are required to establish the role of serum ECP measurement in the treatment modulation in asthma.

Inflammatory mechanisms in childhood asthma

There is now a reasonable body of data that would suggest that the immunopathology of asthma is similar, if not identical, in childhood asthmatics compared with adult asthmatics. Indeed, we now have evidence that much of the immunopathology is established within the airways of asthmatics very early after the onset of symptoms and, given the lack of correlation with duration of symptoms, may even antedate the first manifestations. There are, however, some differences with neutrophil recruitment being somewhat more prominent than has been recorded from adult observations. The utility of any inflammation parameter in identifying the real future asthmatics has yet to be studied in sufficient detail to define sensitivity, specificity and predictive value. Such studies will be an essential prerequisite to establishing very early intervention strategies, particularly if these involve the use of inhaled and/or oral corticosteroid.

Comparison between eosinophilic markers in induced sputum and blood in asthmatic patients

BACKGROUND

The usefulness and safety of the analysis of blood inflammatory markers in asthma are widely recognized. Recently, the analysis of induced sputum has been proposed as a safe, non-invasive tool in the study of airway inflammation in asthma.

OBJECTIVE

Our aim was to test whether sputum analysis is more useful than blood analysis in the evaluation of airway inflammation in untreated and treated asthmatic patients.

METHODS

Twelve untreated patients with mild to moderate asthma underwent a methacholine challenge test, sputum induction and blood sampling. A group of 14 normal subjects was also evaluated for baseline comparison. The same evaluation was repeated after 3 months of budesonide treatment. Before and after treatment, we tested the relationship of eosinophilic markers in induced sputum and blood with clinical and functional data. We also compared eosinophilic markers in induced sputum with the same markers in blood.

RESULTS

Untreated patients showed a significant relationship between sputum eosinophils and symptom score, and between sputum eosinophilic cationic protein and symptom score, FEV1 and PD20FEV1. No relationship between blood eosinophilic markers and clinical or functional data was observed. In budesonide-treated patients, both sputum and blood eosinophils were significantly lower than in untreated patients, but eosinophil decrease was greater in sputum than in blood. Sputum eosinophilic proteins were also significantly lower in treated patients, whereas serum eosinophilic proteins were low at baseline and remained unchanged after treatment. Sputum eosinophilic markers were lower in normal subjects than in both untreated and treated patients, while blood eosinophils, but not serum eosinophilic cationic protein, were lower in normals than in untreated patients.

CONCLUSIONS

The analysis of induced sputum is more useful than the analysis of blood in the evaluation of asthma severity and of the effect of glucocorticoid treatment in patients with mild to moderate asthma.

Effects of fluticasone propionate and beclomethasone dipropionate on parameters of inflammation in peripheral blood of patients with asthma

Bronchial inflammation plays a central role in asthma. We investigated whether parameters of inflammation were increased in peripheral blood. Furthermore, we tested whether fluticasone propionate (FP), a new inhaled corticosteroid (ICS), and beclomethasone dipropionate (BDP) affected these parameters. FP 750 microg/day and BDP 1500 microg/day were compared in a randomized, crossover study consisting of two 6-week treatment periods, each preceded by a 3-week placebo period. Twenty-one patients with symptomatic asthma completed the study. The results were compared with those of six normal subjects (controls). Immunophenotyping of inflammatory cells was performed in whole blood, and serum eosinophil cationic protein (ECP) was measured. With regard to clinical efficacy, ICS increased PC20 histamine by more than 1.9 doubling doses and FEV1 by more than 0.34 l. The number of CD3/HLA-DR+ lymphocytes was significantly increased in asthmatics compared to the normal subjects, both after placebo (P<0.01) and after therapy (P<0.05). The CD3/HLA-DR+ lymphocytes decreased significantly after treatment with FP (P<0.05). Serum ECP was elevated in patients without ICS and decreased after treatment with BDP (P<0.001). In conclusion, the number of CD3/HLA-DR+ lymphocytes and serum ECP levels were raised in the peripheral blood of symptomatic asthmatics, and decreased by clinically effective doses of ICS. In this respect, FP 750 microg/day was at least as effective as BDP 1500 microg/day.