Asthma and cigarette smoking

Long-term multicenter comparison shows equivalent efficacy of monoclonal antibodies in severe asthma therapy

BACKGROUND

Monoclonal antibodies (biologics) drastically changed severe asthma therapy. Mepolizumab (anti-interleukin (IL) 5), benralizumab (anti-IL5 receptor alpha), and dupilumab (anti-IL4/13) are the most used biologics in this context. While all biologics are efficient individually, the choice of biologic is complicated by insufficient data on their comparative long-term treatment efficacy. Here, we compare the real-life efficacy of these biologics in asthma therapy over 12 months.

METHODS

280 severe asthma patients treated with mepolizumab (129/280, 46%), benralizumab (83/280, 30%) or dupilumab (68/280, 24%) for one year were analyzed retrospectively. Data were collected at baseline and after 6 and 12 months of therapy. Endpoints were changes pulmonary function (PF), exacerbation rate, oral corticosteroid (OCS) use and dose, asthma control test (ACT) score and fractional exhaled nitric oxide (FeNO) levels as well as responder status measured by the recently published "Biologic Asthma Response Score" (BARS).

RESULTS

All biologics led to significant improvements in PF, ACT and OCS dose. Only Mepolizumab and Benralizumab significantly decreased the exacerbation rate, while only Mepolizumab and Dupilumab significantly decreased FeNO. Responder rates measured by BARS were high across all groups: roughly half of all patients achieved full response and most of the remainder achieved at least partial responder status. Overall, outcomes were similar between groups after both 6 and 12 months.

CONCLUSIONS

All biologics showed great efficacy in individual parameters and high responder rates measured by BARS without a clinically relevant advantage for any antibody. Response was usually achieved after 6 months and retained at 12 months, emphasizing the utility of early response assessment.

Evidence for 2 clusters among patients with noneosinophilic asthma

BACKGROUND

Although asthma is often seen as an eosinophilic disease associated with atopy, patients with noneosinophilic asthma represent a substantial part of the population with asthma.

OBJECTIVE

To apply an unsupervised clustering method in a cohort of 588 patients with noneosinophilic asthma (sputum eosinophils < 3%) recruited from an asthma clinic of a secondary care center.

METHODS

Our cluster analysis of the whole cohort identified 2 subgroups as cluster 1 (n = 417) and cluster 2 (n = 171).

RESULTS

Cluster 1 comprised a predominantly female group with late disease onset, a low proportion of atopy (24%), and a substantial smoking history (53%). In this cluster, treatment burden was low (<50% of inhaled corticosteroid users); asthma control and quality of life were poor, with median Asthma Control Test, Asthma Control Questionnaire, and Asthma Quality of Life scores of 16, 1.7, and 4.5, respectively, whereas lung function was preserved with a median postbronchodilation forced expiratory volume in 1 second of 93% predicted. Cluster 2 was a predominantly male group, almost exclusively comprising patients with atopy (99%) with early disease onset and a moderate treatment burden (median inhaled corticosteroids dose 800 µg/d equivalent beclomethasone). In cluster 2, asthma was partially controlled, with median Asthma Control Test and Asthma Control Questionnaire scores reaching 18 and 1.3, respectively, and lung function well preserved with a median postbronchodilation of 95% predicted. Although systemic and airway neutrophilic inflammation was the dominant pattern in cluster 1, cluster 2 essentially comprised paucigranulocytic asthma with moderately elevated fraction exhaled nitric oxide.

CONCLUSION

Noneosinophilic asthma splits into 2 clusters distinguishing by disease onset, atopic status, smoking history, systemic and airway inflammation, and disease control and quality of life.

Nicotinic receptors in airway disease

With continued smoking of tobacco products and expanded use of nicotine delivery devices worldwide, understanding the impact of smoking and vaping on respiratory health remains a major global unmet need. Although multiple studies have shown a strong association between smoking and asthma, there is a relative paucity of mechanistic understanding of how elements in cigarette smoke impact the airway. Recognizing that nicotine is a major component in both smoking and vaping products, it is critical to understand the mechanisms by which nicotine impacts airways and promotes lung diseases such as asthma. There is now increasing evidence that α7 nicotinic acetylcholine receptors (α7nAChRs) are critical players in nicotine effects on airways, but the mechanisms by which α7nAChR influences different airway cell types have not been widely explored. In this review, we highlight and integrate the current state of knowledge regarding nicotine and α7nAChR in the context of asthma and identify potential approaches to alleviate the impact of smoking and vaping on the lungs.

Frequency and characteristics of asthma in smokers attending smoking cessation units in Spain

INTRODUCTION

The interaction between smoking and asthma impairs lung function and increases airflow obstruction severity. The identification of smoking patterns in smokers with and without asthma is crucial to provide the best care strategies. The aims of this study are to estimate asthma frequency, describe asthma features, and characterize smoking in smokers attending smoking cessation units.

MATERIAL AND METHODS

We carried out a cross-sectional study in five smoking cessation units with different geographical distribution to estimate asthma frequency in smokers, characterize asthma features in smokers, as well as smoking in asthmatic smokers.

RESULTS

Asthma frequency among smokers was 18.6%. Asthmatic smokers presented high passive exposure, low smoking self-efficacy and will to quit smoking, as well as a high exacerbation frequency, severe symptoms, and frequent use of long-acting beta agonists, inhaled steroids, and short-acting beta agonists.

DISCUSSION

Smokers with asthma constitute a high-risk group with worsened evolution of pulmonary involvement. All smokers should be regularly screened for asthma. Effective smoking cessation strategies should be proposed to smokers with asthma in order to reverse the harmful effects of smoking on the airway, together with a comprehensive and integral approach.

Caspase-8 activation by cigarette smoke induces pro-inflammatory cell death of human macrophages exposed to lipopolysaccharide

Cigarette smoking impairs the lung innate immune response making smokers more susceptible to infections and severe symptoms. Dysregulation of cell death is emerging as a key player in chronic inflammatory conditions. We have recently reported that short exposure of human monocyte-derived macrophages (hMDMs) to cigarette smoke extract (CSE) altered the TLR4-dependent response to lipopolysaccharide (LPS). CSE caused inhibition of the MyD88-dependent inflammatory response and activation of TRIF/caspase-8/caspase-1 pathway leading to Gasdermin D (GSDMD) cleavage and increased cell permeability. Herein, we tested the hypothesis that activation of caspase-8 by CSE increased pro-inflammatory cell death of LPS-stimulated macrophages. To this purpose, we measured apoptotic and pyroptotic markers as well as the expression/release of pro-inflammatory mediators in hMDMs exposed to LPS and CSE, alone or in combination, for 6 and 24 h. We show that LPS/CSE-treated hMDMs, but not cells treated with CSE or LPS alone, underwent lytic cell death (LDH release) and displayed apoptotic features (activation of caspase-8 and -3/7, nuclear condensation, and mitochondrial membrane depolarization). Moreover, the negative regulator of caspase-8, coded by CFLAR gene, was downregulated by CSE. Activation of caspase-3 led to Gasdermin E (GSDME) cleavage. Notably, lytic cell death caused the release of the damage-associated molecular patterns (DAMPs) heat shock protein-60 (HSP60) and S100A8/A9. This was accompanied by an impaired inflammatory response resulting in inhibited and delayed release of IL6 and TNF. Of note, increased cleaved caspase-3, higher levels of GSDME and altered expression of cell death-associated genes were found in alveolar macrophages of smoker subjects compared to non-smoking controls. Overall, our findings show that CSE sensitizes human macrophages to cell death by promoting pyroptotic and apoptotic pathways upon encountering LPS. We propose that while the delayed inflammatory response may result in ineffective defenses against infections, the observed cell death associated with DAMP release may contribute to establish chronic inflammation. CS exposure sensitizes human macrophages to pro-inflammatory cell death. Upon exposure to LPS, CS inhibits the TLR4/MyD88 inflammatory response, downregulating the pro-inflammatory genes TNF and IL6 and the anti-apoptotic gene CFLAR, known to counteract caspase-8 activity. CS enhances caspase-8 activation through TLR4/TRIF, with a partial involvement of RIPK1, resulting on the activation of caspase-1/GSDMD axis leading to increased cell permeability and DAMP release through gasdermin pores [19]. At later timepoints caspase-3 becomes strongly activated by caspase-8 triggering apoptotic events which are associated with mitochondrial membrane depolarization, gasdermin E cleavage and secondary necrosis with consequent massive DAMP release.

Clinical impact of vaping on cardiopulmonary function and lung cancer development: an update

The word 'vaping' is used to define the usage of electronic cigarettes or other instruments to inhale a wide variety of heated and aerosolized substances. Although proposed as a less dangerous and oncogenic alternative than standard nicotine products, e-cigarettes and vaping devices are quite far from being considered benign. In fact, although vaping devices do not generate carcinogenic agents as polycyclic aromatic hydrocarbons produced by the combustion of standard cigarettes and their liquids do not present tobacco-related carcinogens like nitrosamines, there is nowadays clear evidence that they produce dangerous products during their use. Several different molecular mechanisms have been proposed for the oncogenic impact of vaping fluids - by means of their direct chemical action or derivative products generated by pyrolysis and combustion ranging from epithelial-mesenchymal transition, redox stress and mitochondrial toxicity to DNA breaks and fragmentation. In this review we focus on vaping devices, their potential impact on lung carcinogenesis, vaping-associated lung injury and other clinical implications on cardiovascular, cerebrovascular and respiratory diseases, as well as on the psychological implication of e-cigarettes both on heavy smokers trying to quit smoking and on younger non-smokers approaching vaping devices because they are considered as a less dangerous alternative to tobacco cigarettes.

Benralizumab in severe eosinophilic asthma in real life: confirmed effectiveness and contrasted effect on sputum eosinophilia versus exhaled nitric oxide fraction - PROMISE

Background

Randomised controlled trials have shown that benralizumab, an anti-interleukin-5 receptor monoclonal antibody, reduces exacerbations and oral corticosteroid dose and improves asthma control and lung function in severe eosinophilic asthma. The aim of this study was to confirm results of randomised controlled trials in real life in a population of 73 patients with severe eosinophilic asthma treated with benralizumab for at least 12 months.

Methods

Patients underwent careful monitoring of asthma exacerbations, exhaled nitric oxide fraction, lung function, asthma control and quality of life questionnaire responses and sputum induction, and gave a blood sample at baseline, after 6 months and then every year.

Results

We found significant reductions in exacerbations (by 92%, p<0.0001) and oral corticosteroid dose (by 83%, p<0.001) after 6 months that were maintained over time, with 78% of patients able to stop oral corticosteroid therapy. Patients improved their Asthma Control Test (ACT) score (from 11.7±5.1 to 16.9±5.35, p<0.0001), Asthma Control Questionnaire (ACQ) score (from 2.88±1.26 to 1.77±1.32, p<0.0001) and Asthma Quality of Life Questionnaire score (+1.04, p<0.0001) at 6 months and this was maintained during follow-up. Only 35% and 43% of patients reached asthma control according to an ACT score ≥20 and ACQ score <1.5, respectively. We observed stable post-bronchodilation lung function over time and a significant reduction in sputum eosinophil count, with 85% of patients exhibiting sputum eosinophil counts <3% after 6 months (p<0.01) with no effect on exhaled nitric oxide fraction.

Conclusion

In our real-life study, we confirm the results published in randomised controlled trials showing a sharp reduction in exacerbations and oral corticosteroid therapy, an improvement in asthma control and quality of life, and a dramatic reduction in sputum eosinophil count.

Chronic Obstructive Pulmonary Disease, Part 5: Clinical Pearls for Comorbid COPD

Chronic obstructive pulmonary disease (COPD) is often diagnosed with other comorbid conditions. This can complicate therapy overall by contributing to adverse events leading to poor outcomes to not only COPD, but other comorbid conditions. This manuscript will discuss common comorbid conditions often seen with COPD, update vaccination recommendations for COPD patients, and provide information regarding smoking cessation in COPD. The senior care pharmacist has an important role where they can recommend medication adjustments to potentially avoid these adverse events, immunize their patients appropriately, and provide assistance with smoking cessation to improve not only COPD outcomes but outcomes associated with other comorbid conditions.

PRevalence of the Eosinophilic Phenotype Among SeveRE asthma patients in Lebanon: results of the PREPARE study

BACKGROUND

The prevalence of eosinophilic asthma in Lebanon, one of the most severe phenotypes among severe asthma, is not known. This study aimed at determining the prevalence of the eosinophilic phenotype defined as an eosinophil count ≥ 300 cells/mm3 among severe asthma patients in Lebanon.

METHODS

The Lebanese Chapter of the PREPARE study was a national, multicenter, cross-sectional observational study. Patients aged ≥ 12 years with severe asthma were identified and prospectively enrolled during clinic visits and completed the Global Initiative for Asthma (GINA) assessment of asthma control questionnaire. Patients' health characteristics were collected from medical records and blood samples were obtained for measurement of serum IgE levels and blood eosinophils count.

RESULTS

Overall, 101 patients (with mean age of 46.3 ± 17.0 years and 73.27% females) with severe asthma were included and, among them, 37% had eosinophilic phenotype, 67.3% had atopic phenotype with IgE > 100 IU/mL and 25.7% patients had overlapping atopic and eosinophilic phenotypes. Close to 80% had late-onset asthma, beyond 12 years of age, and around 85% had at least one severe exacerbation in the 12 months prior to study enrolment. The majority of participants [64.4%] had uncontrolled asthma, 24.7% had partially controlled symptoms and 10.9% had controlled symptoms. 19.8% of participants were on chronic oral corticosteroids, 78.2% had short course treatment of corticosteroids and all were prescribed a combination of inhaled corticosteroids and long-acting beta-agonist.

CONCLUSIONS

The majority of patients with severe asthma were uncontrolled of which 37% present with an eosinophilic phenotype, which should be taken into consideration for better management of these patients in view of the novel phenotype-specific therapeutic options.

Assessing the impacts of smoking cessation and resumption on back pain risk in later life

BACKGROUND

This study aimed to assess the impacts of smoking cessation and resumption over 4 years on the risk of back pain at the 6-year follow-up among older adults in England.

METHODS

We analysed 6467 men and women aged ≥50 years in the English Longitudinal Study of Aging. Self-reported smoking status, assessed in waves 4 (2008-2009) and 6 (2012-2013), was used as exposure for the study, whereas self-reported back pain of moderate or severe intensity, assessed in wave 7 (2014-2015), was used as the outcome. A targeted minimum loss-based estimator was used with longitudinal modified treatment policies to adjust for baseline and time-varying covariates.

RESULTS

Regarding the estimation of the effects of changes in smoking status on the risk of back pain, during the follow-up, individuals who resumed smoking within 4 years had a higher risk of back pain than those who avoided smoking for over 4 years, and the relative risk (RR) (95% confidence interval [CI]) was 1.536 (1.214-1.942). Regarding the estimation of effects of smoking cessation on the risk of back pain, smoking cessation over 4 years was associated with a significantly lower risk of back pain, as indicated by the originally observed data, and the RR (95% CI) was 0.955 (0.912-0.999).

CONCLUSIONS

Older adults who avoided smoking for over 4 years had a lower risk of back pain. However, those who resumed smoking within 4 years had a higher risk of back pain.

SIGNIFICANCE

Older adults who avoided smoking for over 4 years had a lower risk of back pain. However, those who resumed smoking within 4 years had a higher risk of back pain. Our study data suggest the importance of maintaining smoking cessation to reduce the risk of back pain in the older population.

The Role of Long-Acting Antimuscarinic Agents in the Treatment of Asthma

The journey of using anticholinergics in the treatment of asthma started with anticholinergic-containing plants such as Datura stramonium and Atropa belladonna, followed by ipratropium bromide and continued with tiotropium, glycopyrronium, and umeclidinium. Although antimuscarinics were used in the maintenance treatment of asthma over a century ago, after a long time (since 2014), it has been recommended to be used as an add-on long-acting antimuscarinic agent (LAMA) therapy in the maintenance treatment of asthma. The airway tone controlled by the vagus nerve is increased in asthma. Allergens, toxins, or viruses cause airway inflammation and inflammation-related epithelial damage, increased sensory nerve stimulation, ganglionic and postganglionic acetylcholine (ACh) release by inflammatory mediators, intensification of ACh signaling at M1 and M3 muscarinic ACh receptors (mAChRs), and dysfunction of M2 mAChR. Optimal anticholinergic drug for asthma should effectively block M3 and M1 receptors, but have minimal effect on M2 receptors. Tiotropium, umeclidinium, and glycopyrronium are anticholinergic agents with this feature. Tiotropium has been used in a separate inhaler as an add-on treatment to inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA), and glycopyrronium and umeclidinium have been used in a single inhaler as a combination of ICS/LABA/LAMA in asthma in recent years. Guidelines recommend this regimen as an optimization step for patients with severe asthma before initiating any biologic or systemic corticosteroid therapy. In this review, the history of antimuscarinic agents, their effectiveness and safety in line with randomized controlled trials, and real-life studies in asthma treatment will be discussed according to the current data.

Calpeptin may reverse glucocorticoid-resistance of allergic rhinitis associated with cigarette smoke exposure by down-regulating interferon regulatory factor 1

Cigarette smoke exposure is an important factor in chronic inflammation in patients with allergic rhinitis (AR); however, the relationship between cigarette smoke and AR-related glucocorticoid resistance requires further study. In mice, calpeptin significantly reduces inflammation of the lower respiratory tract caused by cigarette smoke, but whether it can treat glucocorticoid-resistant AR caused by cigarette smoke requires further research. In this study, we confirmed that cigarette smoke exposure can aggravate the Th2 inflammatory response in AR leading to glucocorticoid resistance. The underlying mechanism may be related to decreased expression of DNA methyltransferase 3a (Dnmt3a), and increased expression of interferon regulatory factor 1 (IRF1). In addition, we found that calpeptin can inhibit the expression of IRF1 and thus treat AR-associated glucocorticoid resistance in rats exposed to cigarette smoke. These data suggest that calpeptin may downregulate IRF1 and therefore treat glucocorticoid resistance in AR-associated with cigarette smoke exposure.

Modulation of Alveolar Macrophage Activity by Eugenol Attenuates Cigarette-Smoke-Induced Acute Lung Injury in Mice

This study investigates the role of eugenol (EUG) on CS-induced acute lung injury (ALI) and how this compound is able to modulate macrophage activity. C57BL/6 mice were exposed to 12 cigarettes/day/5days and treated 15 min/day/5days with EUG. Rat alveolar macrophages (RAMs) were exposed to CSE (5%) and treated with EUG. In vivo, EUG reduced morphological changes inflammatory cells, oxidative stress markers, while, in vitro, it induced balance in the oxidative stress and reduced the pro-inflammatory cytokine release while increasing the anti-inflammatory one. These results suggest that eugenol reduced CS-induced ALI and acted as a modulator of macrophage activity.

Longitudinal associations between exclusive, dual, and polytobacco use and asthma among US youth

Little is known about the respiratory health effects of dual (two products) and polytobacco (three or more products) use among youth in the United States. Thus, we followed a longitudinal cohort of youth into adulthood using data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, examining incident asthma at each follow-up (Waves 2-5). We classified past 30-day tobacco use as 1) no products (never/former use), 2) exclusive cigarettes, 3) exclusive electronic nicotine delivery systems (ENDS), 4) exclusive other combustible (OC) tobacco products (cigars, hookah, pipe), 5) dual cigarettes/OC and ENDS, 6) dual cigarettes and OCs, and 7) polytobacco use (cigarettes, OCs, and ENDS). Using discrete time survival models, we analyzed the incidence of asthma across Waves 2-5, predicted by time-varying tobacco use lagged by one wave, and adjusted for potential baseline confounders. Asthma was reported by 574 of the 9141 respondents, with an average annual incidence of 1.44% (range 0.35% to 2.02%, Waves 2-5). In adjusted models, exclusive cigarette use (HR: 1.71, 95% CI: 1.11-2.64) and dual cigarette and OC use (HR: 2.78, 95% CI: 1.65-4.70) were associated with incident asthma compared to never/former use, while exclusive ENDS use (HR: 1.50, 95% CI: 0.92-2.44) and polytobacco use (HR: 1.95, 95% CI: 0.86-4.44) were not. To conclude, youth who use cigarettes with or without OCs had higher risk of incident asthma. Further longitudinal studies on the respiratory health effects of ENDS and dual/polytobacco use are needed as products continue to evolve.

Challenges and perspectives of tobacco cessation in special groups of patients and populations

During the first 2 years of the coronavirus disease 2019 pandemic, health systems worldwide were put under extreme pressure, and healthcare professionals had to manage unprecedented health crises as well as provide healthcare services to an increased number of patients. Therefore, public health policies with respect to smoking and education of the general population regarding the harmful effects of active and second-hand smoking may not have received adequate attention during this period. More specifically, certain subpopulations suffering from chronic diseases may not have received adequate information about the effects of smoking on the course and outcome of their disease; high-level, evidence-based pharmaceutical therapies; and the potential for follow-up. However, adequate education and awareness regarding short- and long-term health benefits from smoking cessation for the general population as well as special subgroups remains of utmost importance. Healthcare professionals should understand that it is only through high-quality evidence and results from independent studies that they will be able to provide their expertise and scientific knowledge concerning newer tobacco products and their effects on human health.

Healthy Cities, A comprehensive dataset for environmental determinants of health in England cities

This paper presents a fine-grained and multi-sourced dataset for environmental determinants of health collected from England cities. We provide health outcomes of citizens covering physical health (COVID-19 cases, asthma medication expenditure, etc.), mental health (psychological medication expenditure), and life expectancy estimations. We present the corresponding environmental determinants from four perspectives, including basic statistics (population, area, etc.), behavioural environment (availability of tobacco, health-care services, etc.), built environment (road density, street view features, etc.), and natural environment (air quality, temperature, etc.). To reveal regional differences, we extract and integrate massive environment and health indicators from heterogeneous sources into two unified spatial scales, i.e., at the middle layer super output area (MSOA) and the city level, via big data processing and deep learning. Our data holds great promise for diverse audiences, such as public health researchers and urban designers, to further unveil the environmental determinants of health and design methodology for a healthy, sustainable city.

Serum YKL-40 Levels in Patients with Asthma or COPD: A Pilot Study

Background and Objectives: Bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD) are not only common obstructive respiratory conditions but also major causes of morbidity and mortality worldwide. There is, however, a surprising lack of blood-based biomarkers for separating between these pulmonary disorders. The aim of this study was to assess the practical relevance of using serum YKL-40, single or combined, for this purpose. Materials and Methods: Subjects included Romanian patients with BA (n = 24) or COPD (n = 27). YKL-40, fibrinogen, pre-treatment C-reactive protein (CRP), post-treatment CRP, erythrocyte sedimentation rate, interleukin 6 (IL-6), procalcitonin (PCT), absolute neutrophil count, neutrophil percentage, absolute lymphocyte count, lymphocyte percentage, absolute eosinophil count, and eosinophil percentage were measured and compared between these patients. Results: This is the first study investigating the clinical significance of serum YKL-40 in delineating between COPD and BA in Caucasian populations. Only fibrinogen and YKL-40 levels were different between COPD and BA, with the measured values being significantly elevated. These patients exhibited distinct inflammatory profiles. Using the upper quartiles of these variables for the pooled study population (YKL-40: 5100 pg/mL; fibrinogen: 552 mg/dL) as cut-off values, subjects were classified into high or low groups. High YKL-40 adults revealed significantly increased PCT levels. High fibrinogen subjects, by contrast, showed significantly elevated IL-6 concentrations and pre-treatment CRP levels. Low YKL-40 and fibrinogen patients showed the absence of COPD. Conclusions: Combined use of serum YKL-40 and fibrinogen may be useful for identifying the absence of COPD.

How does cigarette smoking affect airway remodeling in asthmatics?

Asthma is a prevalent chronic airway inflammatory disease involving multiple cells, and the prolonged course of the disease can cause airway remodeling, resulting in irreversible or partial irreversible airflow limitation and persistent airway hyperresponsiveness (AHR) in asthmatics. Therefore, we must ascertain the factors that affect the occurrence and development of airway remodeling in asthmatics. Smokers are not uncommon in asthmatics. However, there is no systematic description of how smoking promotes airway remodeling in asthmatics. This narrative review summarizes the effects of smoking on airway remodeling in asthmatics, and the progress of the methods for evaluating airway remodeling.

Asthma Exacerbations: Patient Features and Potential Long-Term Implications

Asthma exacerbations occur in the context of a complex interplay between external exposures and host factors. Respiratory tract viral infections, in particular rhinovirus, are dominant initiators of exacerbations, with allergens and other inhalation exposures as additional key contributors. The presence of underlying type II inflammation, with associated biomarker elevations, is a major driver of exacerbation risk and mechanism, as evidenced by the consistent reduction of exacerbations seen with biologics targeting these pathways. Several genetic polymorphisms are associated with exacerbations, and while they may individually have small effects, they are cumulatively important and magnified by environmental exposures. A history of exacerbations predicts future exacerbations with potentially negative implications on long-term lung health.

The impact of Medicaid expansion on asthma-related health care services utilization and expenditure

OBJECTIVE

The purpose of this study was to examine the effect of Medicaid expansion on asthma-related health care services utilization and expenditures among low-income adult patients with asthma aged 26-64.

METHODS

Using a pooled dataset from 2007 to 2018 Medical Expenditures Panel Surveys (MEPS), we implemented a multivariate difference-in-differences analysis, which compared changes in utilization and expenditures for asthma-related health care services among adult patients with asthma with income below 133% Federal Poverty Level (FPL) vs. above 133%-400% FPL, before and after Medicaid expansion in 2014. We used negative binomial models to analyze utilization outcomes. Expenditures were estimated using two-part models with logit as the first part and generalized linear models as the second part. Estimates were weighted for the complex multi-stage sampling design of MEPS.

RESULTS

Medicaid expansion was associated with increases in both utilization and expenditures for asthma-related prescription drugs among low-income patients with asthma, by 1.8 prescription fills (p < 0.05) and $233 (p < 0.05) per year, respectively. No statistically significant association was detected for other asthma-related health care services.

CONCLUSION

Medicaid expansion led to an increase in accessibility of prescription drugs among low-income asthma patients, but had no effect on other asthma-related health care services.

Causal risk factors for asthma in Mendelian randomization studies: A systematic review and meta-analysis

BACKGROUND

Several risk factors for asthma have been proposed; however, the causality of these associations is sometimes unclear. Mendelian randomization is a powerful epidemiological approach that can help elucidate the causality of risk factors. The aim of the present study was to identify causal risk factors for asthma through Mendelian Randomization studies.

METHODS

A systematic search of PubMed and EMBASE was conducted, to identify studies investigating risk factors for asthma or respiratory allergies through Mendelian Randomization. When two or more studies investigated the same risk factor a meta-analysis was conducted. Of 239 studies initially identified, 41 were included.

RESULTS

A causal association between adiposity and adult asthma risk was found in 10 out of 12 studies with a summary risk ratio of 1.05 per kg/m² increase in BMI (95% CI: 1.03-1.07). Puberty timing (n = 3), alcohol (n = 2), and linoleic acid (n = 1) had causal effects on asthma risk, while vitamins/minerals (n = 6) showed no consistent effect on asthma. The effect of smoking on adult asthma conflicted between studies. Several of the significant associations of asthma with immune related proteins (n = 5) and depression (n = 2) investigated through multiple traits analyses could generally benefit from replications in independent datasets.

CONCLUSION

This systematic review and meta-analysis found evidence for causal effects of adiposity, puberty timing, linoleic acid, alcohol, immune related proteins, and depression on risk of asthma.

A retrospective evaluation of the effectiveness of a targeted medicines use review service in improving asthma and COPD control provided by community pharmacists in England

Objective

Medicines Use Reviews (MUR) may benefit asthma and chronic obstructive pulmonary disease (COPD) control. The present study evaluates the effect of respiratory-targeted MUR-plus (MUR+) services delivered by community pharmacists on disease control.

Methods

A retrospective analysis of MUR+ data in the PharmOutcomes database was conducted. All patients receiving respiratory-targeted MUR+ in Milton Keynes were included. Changes in asthma control test (ACT) and COPD assessment test (CAT) scores were analysed.

Key findings

A total of 191 asthma and 81 COPD patients received MUR+. Asthma and COPD control improved as shown by the increase in mean ACT [+1.2 (95% CI, 0.6–1.8)] and decrease in mean CAT [−0.2 (95% CI, −1.4 to 1.0)]. Baseline ACT, smoking cessation, absence of change in drug therapy, patient education, healthcare professional referral, device training and baseline ACT score ≤19 were associated with change in ACT, but only smoking cessation was related to CAT change. A multivariable regression model comprising the aforementioned variables explained 19% of the variance in ACT change (P &lt; 0.001). Only baseline ACT was associated with ACT change (beta = −0.34, P &lt; 0.01). Baseline CAT, absence of change in drug therapy, smoking cessation and baseline CAT score &gt;20 accounted for 12% of the variance in changes in CAT (P = 0.046). No variable was significantly associated with CAT change.

Conclusions

Respiratory-targeted MUR+ service by community pharmacists was associated with improvements in asthma control among patients with poorer baseline ACT, but not in patients with COPD. Several potentially modifiable factors such as education were associated with changes in control.

Expression of Major Lipid Raft Protein Raftlin in Chronic Rhinosinusitis with Nasal Polyps in Smoking and Non-Smoking Patients Correlated with Interleukin-17 and Tumor Necrosis Factor-α Levels

Raftlin, as an inflammatory biomarker, has been previously reported in chronic inflammatory diseases. This study investigates the expression of Raftlin in cigarette smokers and in chronic rhinosinusitis with nasal polyps (CRSwNP), as well as evaluating its correlation with interleukin-17 (IL-17) and tumor necrosis factor-α (TNF-α) levels. A total of 30 CRSwNP non-smoking and 16 CRSwNP + SK (smoking) patients undergoing endoscopic sinus surgery were enrolled, while 20 middle turbinate tissue pieces were examined and performed as the control group. In nasal mucosa epithelial staining, Raftlin levels were elevated in the columnar cells and were stained much more intensely in the CRSwNP and CRSwNP + SK groups. Raftlin was located more closely to the apical region of the epithelium in the CRSwNP + SK group; however, the Raftlin levels from whole nasal tissue pieces, according to ELISA data, showed that there was no significant difference between the three different study groups. A positive relationship by Pearson correlation was found between IL-17 or TNF-α levels and Raftlin levels. Taken together, these data indicate that increasing Raftlin expression in columnar cells might involve nasal epithelial remodeling in smokers with CRSwNP.

Early transcriptional responses of bronchial epithelial cells to whole cigarette smoke mirror those of in-vivo exposed human bronchial mucosa

BACKGROUND

Despite the well-known detrimental effects of cigarette smoke (CS), little is known about the complex gene expression dynamics in the early stages after exposure. This study aims to investigate early transcriptomic responses following CS exposure of airway epithelial cells in culture and compare these to those found in human CS exposure studies.

METHODS

Primary bronchial epithelial cells (PBEC) were differentiated at the air-liquid interface (ALI) and exposed to whole CS. Bulk RNA-sequencing was performed at 1 h, 4 h, and 24 h hereafter, followed by differential gene expression analysis. Results were additionally compared to data retrieved from human CS studies.

RESULTS

ALI-PBEC gene expression in response to CS was most significantly changed at 4 h after exposure. Early transcriptomic changes (1 h, 4 h post CS exposure) were related to oxidative stress, xenobiotic metabolism, higher expression of immediate early genes and pro-inflammatory pathways (i.e., Nrf2, AP-1, AhR). At 24 h, ferroptosis-associated genes were significantly increased, whereas PRKN, involved in removing dysfunctional mitochondria, was downregulated. Importantly, the transcriptome dynamics of the current study mirrored in-vivo human studies of acute CS exposure, chronic smokers, and inversely mirrored smoking cessation.

CONCLUSION

These findings show that early after CS exposure xenobiotic metabolism and pro-inflammatory pathways were activated, followed by activation of the ferroptosis-related cell death pathway. Moreover, significant overlap between these transcriptomic responses in the in-vitro model and human in-vivo studies was found, with an early response of ciliated cells. These results provide validation for the use of ALI-PBEC cultures to study the human lung epithelial response to inhaled toxicants.

Exposure to Cigarette Smoke and Daily Physical Activity Associated with Asthma

Background: Asthmatic sufferers complain of sudden relapse when performing daily activities. exposure to cigarette smoke makes asthmatics where the longer the exposure is experienced by the patient, the more frequent asthma exacerbations are experienced. For people with asthma, avoiding excessive physical activity and exposure to cigarette smoke is very necessary to prevent recurrence of symptoms. So it is necessary to control the level of asthma, which is influenced by factors that trigger asthma recurrence.   Aim: The purpose of the study was to determine the relationship between daily physical activity and exposure to cigarette smoke on asthma recurrence in asthmatic patients   Methods: This type of research uses observational analytic using a cross sectional approach. Sampling in this study using purposive sampling obtained the number of respondents 358 with a vulnerable age of 18-45 years. This research was conducted for 6 months. The measuring instrument for exposure to cigarette smoke uses a questionnaire containing the categories of exposure to cigarette smoke less than 1 hour, exposure to cigarette smoke 1-4 hours and exposure to cigarette smoke more than 4 hours. Physical activity measurement tool using the International Physical Activity Questionnaire (IPAQ). Asthma recurrence was measured by using a questionnaire that refers to the Asthma Control Test (ACT). The research procedure was carried out by researchers by ensuring that respondents were in good health and signed the informed consent provided. Data analysis using Chi-Square test.   Result: The results of the Chi Square test with a significance value of = 0.05, p value = 0.000, which means p < then there is a relationship between daily physical activity and exposure to cigarette smoke on asthma recurrence in asthmatic patients.   Conclusions: There is a relationship between exposure to cigarette smoke and daily physical activity on asthma relapse in asthmatic patients. It is expected that asthmatics should avoid triggering factors for asthma relapse to achieve controlled asthma levels.    

Exposure to Sodium Hypochlorite or Cigarette Smoke Induces Lung Injury and Mechanical Impairment in Wistar Rats

Pulmonary irritants, such as cigarette smoke (CS) and sodium hypochlorite (NaClO), are associated to pulmonary diseases in cleaning workers. We examined whether their association affects lung mechanics and inflammation in Wistar rats. Exposure to these irritants alone induced alterations in the lung mechanics, inflammation, and remodeling. The CS increased airway cell infiltration, acid mucus production, MMP-12 expression, and alveolar enlargement. NaClO increased the number of eosinophils and macrophages in the bronchoalveolar lavage fluid, with cells expressing IL-13, MMP-12, MMP-9, TIMP-1, and iNOS in addition to increased IL-1β and TNF-α levels. Co-exposure to both irritants increased epithelial and smooth muscle cell area, acid mucus production, and IL-13 expression in the airways, while it reduced the lung inflammation. In conclusion, the co-exposure of CS with NaClO reduced the pulmonary inflammation, but increased the acidity of mucus, which may protect lungs from more injury. A cross-resistance in people exposed to multiple lung irritants should also be considered.

Epidemiology of Asthma-Chronic Obstructive Pulmonary Disease Overlap

Asthma COPD Overlap has consistently reported to be associated with an increase burden of disease but the impact on lung function decline and mortality varies by study. The prevalence increases with age but the relationship with gender also varies with the study population. The variability in the prevalence and clinical characteristics of ACO is linked to differences in how chronic obstructive pulmonary disease (COPD) and asthma are defined, including diagnostic criteria (spirometry-based vs. clinical or symptom-based diagnoses vs. claims data), the population studied, the geographic region and environment and a consensus approach to the diagnosis of ACO is needed to allow meaningful and consistent epidemiologic information to be generated about this condition.

Cigarette smoke aggravates asthma by inducing memory-like type 3 innate lymphoid cells

Although cigarette smoking is known to exacerbate asthma, only a few clinical asthma studies have been conducted involving smokers. Here we show, by comparing paired sputum and blood samples from smoking and non-smoking patients with asthma, that smoking associates with significantly higher frequencies of pro-inflammatory, natural-cytotoxicity-receptor-non-expressing type 3 innate lymphoid cells (ILC3) in the sputum and memory-like, CD45RO-expressing ILC3s in the blood. These ILC3 frequencies positively correlate with circulating neutrophil counts and M1 alveolar macrophage frequencies, which are known to increase in uncontrolled severe asthma, yet do not correlate with circulating eosinophil frequencies that characterize allergic asthma. In vitro exposure of ILCs to cigarette smoke extract induces expression of the memory marker CD45RO in ILC3s. Cigarette smoke extract also impairs the barrier function of airway epithelial cells and increases their production of IL-1β, which is a known activating factor for ILC3s. Thus, our study suggests that cigarette smoking increases local and circulating frequencies of activated ILC3 cells, plays a role in their activation, thereby aggravating non-allergic inflammation and the severity of asthma.

Cigarette smoking may exacerbate asthma, but the underlying mechanisms have not been studied extensively in human patients. Here authors show that type 3 innate lymphoid cells with activated phenotypes are found in the sputum and blood of smokers in higher frequencies, which might result in the aggravation of asthma.

Association Between E-Cigarettes and Asthma in Adolescents: A Systematic Review and Meta-Analysis

INTRODUCTION

Numerous studies have revealed the relationship between E-cigarettes and asthma but have shown inconsistent results. This study systematically evaluated the potential association between E-cigarette use and asthma in adolescents.

METHODS

PubMed, Embase (Ovid), Cochrane Library, and the China Biological Medicine Database were searched for relevant articles published between database inception and February 28, 2021. The quality of included studies was evaluated using the Agency for Healthcare Research and Quality assessment, and a quantitative meta-analysis was conducted to pool outcomes of ORs with 95% CIs.

RESULTS

A total of 10 cross-sectional studies incorporating a total of 483,948 participants were included. All the study participants were middle- and high-school students with a mean age of 15-16 years. The median prevalence of ever E-cigarette use was 11.2% (range=2.2%, 45%), and that of current use was 7.5% (range=2.7%, 25%). Overall, E-cigarette use was associated with significantly higher odds of having asthma (pooled OR=1.31, 95% CI=1.22, 1.42) than nonuse, and both current use (OR=1.36, 95% CI=1.26, 1.48) and ever use (OR=1.20, 95% CI=1.12, 1.28) showed similar associations.

DISCUSSION

This study shows that both current and ever E-cigarette use have significant associations with asthma in adolescents. This knowledge might provide potential evidence for developing primary prevention strategies and serve as a reference for public health policy.

State-specific Prevalence and Factors Associated With Current Marijuana, ENDS, and Cigarette use Among US Adults With Asthma

Background

The use of marijuana (MJ), combustible cigarettes (hereafter cigarettes), and electronic nicotine delivery systems (ENDS) is widespread among United States (US) adults and linked to worsening respiratory symptoms, especially among adults with asthma. This study examined state-specific prevalence and factors associated with MJ, ENDS, and cigarette use among US adults with asthma.

Methods

We analyzed data of 41 974 adults aged ≥18 years having self-reported current asthma from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). We reported weighted prevalence to account for complex survey design and performed multivariable logistic regression models to examine factors associated with current use of MJ, ENDS, and cigarettes.

Results

Overall prevalence of current MJ, ENDS, and cigarette use among adults with asthma was 14.5%, 6.6%, and 27.2%, respectively. Our results showed the US states and territories with highest and lowest use prevalence for MJ (California: 23.6% vs Guam: 3.2%), ENDS (Indiana: 12.8% vs North Dakota: 4.0%), and cigarettes (West Virginia: 42.1% vs Guam: 12.3%). Both MJ and ENDS users were more likely to be male, younger, and live in an urban area, but MJ users were more likely and ENDS users less likely to be Non-Hispanic (NH) American Indian/Alaskan Native. Cigarette users were more likely to be older, have at least 1 health condition, and were less likely to be NH Black or Hispanic and college-educated.

Conclusion

Many US adults with asthma use MJ, ENDS, and cigarettes. Our findings provide insights for clinicians about the urgent need for effective interventions to reduce tobacco and MJ use among adults with asthma.

Paucigranulocytic Asthma: Potential Pathogenetic Mechanisms, Clinical Features and Therapeutic Management

Asthma is a heterogeneous disease usually characterized by chronic airway inflammation, in which several phenotypes have been described, related to the age of onset, symptoms, inflammatory characteristics and treatment response. The identification of the inflammatory phenotype in asthma is very useful, since it allows for both the recognition of the asthmatic triggering factor as well as the optimization of treatment The paucigranulocytic phenotype of asthma (PGA) is characterized by sputum eosinophil levels <1−3% and sputum neutrophil levels < 60%. The precise characteristics and the pathobiology of PGA are not fully understood, and, in some cases, it seems to represent a previous eosinophilic phenotype with a good response to anti-inflammatory treatment. However, many patients with PGA remain uncontrolled and experience asthmatic symptoms and exacerbations, irrespective of the low grade of airway inflammation. This observation leads to the hypothesis that PGA might also be either a special phenotype driven by different kinds of cells, such as macrophages or mast cells, or a non-inflammatory phenotype with a low grade of eosinophilic inflammation. In this review, we aim to describe the special characteristics of PGA and the potential therapeutic interventions that could be offered to these patients.

Cigarette Smoking and Asthma

Globally, around half the adult asthma population are current or former cigarette smokers. Cigarette smoking and asthma interact to induce an "asthma-smoking phenotype(s)," which has important implications for diagnosis, pathogenic mechanisms, and management. The lack of progress in understanding the effects of smoking on adults with asthma is due in part to their exclusion from most investigative studies and large clinical trials. In this review, we summarize the adverse clinical outcomes associated with cigarette smoking in asthma, highlight challenges in diagnosing asthma among cigarette smokers with chronic respiratory symptoms, particularly in older individuals with a long-standing smoking history, and review pathogenic mechanisms involving smoking- and asthma-related airway inflammation, tissue remodeling, corticosteroid insensitivity, and low-grade systemic inflammation. We discuss the key components of management including the importance of smoking cessation strategies, evidence for the effectiveness of the Global Initiative for Asthma recommendations on treatment in cigarette smokers, and the role of treatable traits such as type 2 eosinophilic airway inflammation. Lastly, we provide an algorithm to aid clinicians to manage current and former smokers with asthma. In the future, controlled and pragmatic trials in real-world populations should include cigarette smokers with asthma to provide an evidence base for treatment recommendations.

Asthma-COPD Overlap Syndrome: Recent Insights and Unanswered Questions

The term asthma-COPD overlap (ACO) has been used to identify a heterogeneous condition in which patients present with airflow limitation that is not completely reversible and clinical and inflammatory features of both asthma and chronic obstructive pulmonary disease (COPD). ACO diagnosis may be difficult in clinical practice, while controversy still exists regarding its definition, pathophysiology, and impact. Patients with ACO experience a greater disease burden compared to patients with asthma or COPD alone, but in contrast they show better response to inhaled corticosteroid treatment than other COPD phenotypes. Current management recommendations focus on defining specific and measurable treatable clinical traits, according to disease phenotypes and underlying biological mechanisms for every single patient. In this publication, we review the current knowledge on definition, pathophysiology, clinical characteristics, and management options of ACO.

Sex-Specific Association between Environmental Tobacco Smoke Exposure and Asthma Severity among Adults with Current Asthma

Background: Tobacco smoke has been associated with negative health outcomes, including those with chronic respiratory illnesses, such as asthma. This study aimed to assess the relationship between exposure to environmental tobacco smoke (ETS), as well as tobacco use (cigarette and electronic cigarettes), on asthma severity among adults with current asthma, with stratification by sex to understand potential biological sex differences. Methods: The study population consisted of Californian adults 18 years or older with self-reported physician/health care diagnosis of asthma and still having current asthma from 2020 California Health Interview Survey. All descriptive statistics and analyses were sex-stratified and survey-weighted. Crosstabulations were used to understand the association between asthma attack and ETS or firsthand smoke exposure, while binary logistic regression models were used to assess the effect of ETS exposure, current smoking status, and control variables on asthma attack in the past 12 months, with a sub-analysis among non-smoking adults with asthma. Results: Among the primary variable of interest, 35% of males and 30% of females reported ETS exposure in the past 12 months, while 13% of males and 6% of females reported being a current smoker. Past year asthma attack was reported among 43% and 55% of males and females, respectively. Among males, after adjusting for all control variables, asthma attack was significantly higher among those with ETS exposure (OR: 1.75, 95% CI: 1.01–3.02) and among current smokers (OR: 3.82, 95% CI: 1.49, 9.81). Male non-smokers with ETS exposure had a 109% higher odds of asthma attack, compared to non-exposure individuals. Conclusion: Using a population-based survey, our results highlight the ongoing burden of tobacco use and exposure particularly among males with current asthma, further corroborate the literature on the relationship between tobacco and asthma, and highlight putative sex-specific outcomes.

How E-cigarettes and vaping can affect asthma in children and adolescents

PURPOSE OF REVIEW

Electronic nicotine delivery systems such as e-cigarettes are commonly felt to be harmless devices when compared to traditional cigarettes. However, an increasing number of studies support the biological plausibility for the potential detrimental effects of vaping on the respiratory mucosa. To date, few human studies have been carried out on adult vapers showing a reduction in lung function testing, especially in those with asthma, whereas the effects of vaping on children and adolescents have not been elucidated so far.

RECENT FINDINGS

Several cross-sectional, national, population-based studies on large groups of adolescents have been carried out showing an association between vape exposure and self-reported asthma diagnosis and/or respiratory symptoms in this age group. The effects of second and third-hand exposure together with those of active and passive exposure in pregnancy, are almost completely unknown.

SUMMARY

This review outlines recent data on the potential effects of vaping on asthma, focusing on vape composition, reported effects on the respiratory mucosa, available data in adolescents, and reasons behind the current vaping epidemic. The evidence so far available both in animals and humans suggests that vaping is not harmless, and its exposure should be limited in children and adolescents, especially when affected by asthma.

European Respiratory Society Guidelines for the Diagnosis of Asthma in Adults

Although asthma is very common affecting 5-10% of the population, the diagnosis of asthma in adults remains a challenge in the real world that results in both over- and under-diagnosis. A task force (TF) was set up by the European Respiratory Society to systematically review the literature on the diagnostic accuracy of tests used to diagnose asthma in adult patients and provide recommendation for clinical practice.The TF defined eight PICO (Population, Index, Comparator, and Outcome) questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, The TF utilised the outcomes to develop an evidenced-based diagnostic algorithm, with recommendations for a pragmatic guideline for everyday practice that was directed by real-life patient experiences.The TF support the initial use of spirometry followed, and if airway obstruction is present, by bronchodilator reversibility testing. If initial spirometry fails to show obstruction, further tests should be performed in the following order: FeNO, PEF variability or in secondary care, bronchial challenge. We present the thresholds for each test that are compatible with a diagnosis of asthma in the presence of current symptoms.The TF reinforce the priority to undertake spirometry and recognise the value of measuring blood eosinophils and serum IgE to phenotype the patient. Measuring gas trapping by body plethysmography in patients with preserved FEV1/FVC ratio deserves further attention. The TF draw attention on the difficulty of making a correct diagnosis in patients already receiving inhaled corticosteroids, the comorbidities that may obscure the diagnosis, the importance of phenotyping, and the necessity to consider the patient experience in the diagnostic process.

Upsides and downsides of a telecounselling model of integrated asthma management between general practitioners and specialists

Background

Asthma control, one of the most important goals in the management of asthmatic patients, requires good adherence to guidelines and support at a territorial level, in particular on the part of general practitioners (GPs). A territorial hospital alliance can become a strength in asthma management, where control by GPs can also be carried out through a spirometric examination.

Methods

The realisation of a telecounselling model management of asthma between GPs and specialists was the aim of this study, to understand how to obtain good asthma control. A specific digital platform, the PneumoApp platform, was used for the insertion of clinical data and flow volume (F‐V) curves, performed in asthmatic patients by GPs, and for the subsequent evaluation of these data by specialists.

Results

GPs have shown to be able to perform a check‐up of respiratory function well using a portable spirometer, but the analysis of the collected data showed that GP assessment of the severity level of asthma is incorrect in patients with moderate‐severe asthma.

Conclusions

The effectiveness of a telecounselling collaboration between hospital and territory in the management of asthma patients can be improved by greater diffusion of the use of Global Initiative for Asthma (GINA) guidelines at a local level.

TH17 cells and corticosteroid insensitivity in severe asthma

Asthma is classically described as having either a type 2 (T2) eosinophilic phenotype or a non-T2 neutrophilic phenotype. T2 asthma usually responds to classical bronchodilation therapy and corticosteroid treatment. Non-T2 neutrophilic asthma is often more severe. Patients with non-T2 asthma or late-onset T2 asthma show poor response to the currently available anti-inflammatory therapies. These therapeutic failures result in increased morbidity and cost associated with asthma and pose a major health care problem. Recent evidence suggests that some non-T2 asthma is associated with elevated T_H17 cell immune responses. T_H17 cells producing Il-17A and IL-17F are involved in the neutrophilic inflammation and airway remodeling processes in severe asthma and have been suggested to contribute to the development of subsets of corticosteroid-insensitive asthma. This review explores the pathologic role of T_H17 cells in corticosteroid insensitivity of severe asthma and potential targets to treat this endotype of asthma.

Association of quality of life and disease control with cigarette smoking in patients with severe asthma

More information is needed on asthma control and health-related quality of life (HRQoL) in smokers with severe asthma. The main study objective was to characterize the association of HRQoL and disease control with cigarette smoking in individuals with severe asthma. A secondary objective was to analyze subject characteristics according to asthma onset: asthma that developed before smoking initiation versus asthma that developed after smoking initiation. This cross-sectional study included subjects with severe asthma aged 18-65 years. HRQoL was assessed using the Asthma Quality of Life Questionnaire (AQLQ) and asthma control was assessed using the Asthma Control Test (ACT) and Global Initiative for Asthma (GINA) criteria. Of the 87 patients studied, 58 (66.7%) were classified as asthmatics who had never smoked and 29 (33.3%) as asthmatics with smoking exposure. The proportion of subjects with uncontrolled asthma was higher in the asthma and smoking group (GINA criteria: P=0.032 and ACT criteria: P=0.003. There were no between-group differences in overall AQLQ score (P=0.475) or AQLQ domain scores (P>0.05). Fifty-eight subjects (66.7%) were nonsmokers, 20 (23%) had asthma onset before smoking, and 9 (10.3%) had asthma onset after smoking. Asthma onset before smoking was associated with uncontrolled asthma (P=0.013). In subjects with severe asthma, smoking was associated with a higher rate of uncontrolled disease but not with HRQoL scores.

Association of genetic variants of oxidative stress responsive kinase 1 (OXSR1) with asthma exacerbations in non-smoking asthmatics

BACKGROUND

Asthma exacerbation threatens patient's life. Several genetic studies have been conducted to determine the risk factors for asthma exacerbation, but this information is still lacking. We aimed to determine whether genetic variants of Oxidative Stress Responsive Kinase 1 (OXSR1), a gene with functions of salt transport, immune response, and oxidative stress, are associated with exacerbation of asthma.

METHODS

Clinical data were obtained from 1454 asthmatics and single nucleotide polymorphisms (SNPs) of OXSR1 were genotyped. Genetic associations with annual exacerbation rate were analyzed depending on smoking status.

RESULTS

Eleven SNPs were selected using Asian data in the International HapMap database. The common allele of rs1384006 C > T of OXSR1 showed a significantly higher annual exacerbation rate than the rare allele in non-smoking asthmatics (CC vs. CT vs. TT: 0.43 ± 0.04 vs. 0.28 ± 0.03 vs. 0.31 ± 0.09, P = 0.004, Pcorr = 0.039). The frequent exacerbators had a significantly higher frequency of the common allele of rs1384006 C > T than did the infrequent exacerbators (74.4% vs. 55.2%, P = 0.004, Pcorr = 0.038).

CONCLUSION

The common allele of rs1384006 C > T of OXSR1 was associated with the asthma exacerbation rate and a higher risk of being a frequent exacerbator, indicating that non-smoking asthmatics who carry common alleles may be vulnerable to asthma exacerbations.

Tobacco Smoking Could Accentuate Epithelial-Mesenchymal Transition and Th2-Type Response in Patients With Chronic Rhinosinusitis With Nasal Polyps

Tobacco smoking (TS) has been known as one of the most potent risk factors for airway inflammatory diseases. However, there has been a paucity of information regarding the immunologic alteration mediated by TS in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). To identify the effect of TS, we harvested human tissue samples (never smoker: n=41, current smoker: n=22, quitter: n=23) and analyzed the expression of epithelial-derived cytokines (EDCs) such as IL-25, IL-33, and thymic stromal lymphopoietin. The expressions of Th2 cytokines and total serum IgE showed a type-2 inflammatory alteration by TS. In addition, the epithelial marker E-cadherin and epithelial-mesenchymal transition (EMT)-associated markers (N-cadherin, α-SMA, and vimentin) were evaluated. Histological analysis showed that EDC expressions were upregulated in the current smoker group and downregulated in the quitter group. These expression patterns were consistent with mRNA and protein expression levels. We also found that the local Th2 cytokine expression and IgE class switching, as well as serum IgE levels, were elevated in the current smoker group and showed normal levels in the quitter group. Furthermore, the expressions of E-cadherin decreased while those of N-cadherin, α-SMA, and vimentin increased in the current smoker group compared those in the never smoker group. Taken together, these results indicate that TS contributes to the deterioration of pathogenesis by releasing local EDCs and Th2 cytokines, resulting in EMT in patients with CRSwNP. We verified that alterations of immunological response by TS in sinonasal epithelium can play a vital role in leading to CRSwNP.

Effects of Cigarette Smoking on Influenza Virus/Host Interplay

Cigarette smoking has been shown to increase the risk of respiratory infection, resulting in the exacerbation of infectious disease outcomes. Influenza viruses are a major respiratory viral pathogen, which are responsible for yearly epidemics that result in between 20,000 and 50,000 deaths in the US alone. However, there are limited general summaries on the impact of cigarette smoking on influenza pathogenic outcomes. Here, we will provide a systematic summarization of the current understanding of the interplay of smoking and influenza viral infection with a focus on examining how cigarette smoking affects innate and adaptive immune responses, inflammation levels, tissues that contribute to systemic chronic inflammation, and how this affects influenza A virus (IAV) disease outcomes. This summarization will: (1) help to clarify the conflict in the reports on viral pathogenicity; (2) fill knowledge gaps regarding critical anti-viral defenses such as antibody responses to IAV; and (3) provide an updated understanding of the underlying mechanism behind how cigarette smoking influences IAV pathogenicity.

Treatment response among asthmatic patients with and without reversible airflow limitations

Objectives

Asthma is a chronic airway disorder associated with variable airflow limitations, which are triggered by different stimuli. The reversibility of airflow limitations reflects patients' responses to the therapy with bronchodilators and improvements in airflow. This study aims to determine the treatment outcomes (improvements in forced expiratory volume in the first second (FEV1) and the number of asthma exacerbations) associated with the presence of airflow reversibility.

Methods

This retrospective cohort study included 154 adults (>18 years) who were diagnosed with asthma and had pulmonary function testing (PFT) at a tertiary care centre in KSA between January 1st, 2014 and May 31st, 2019. Smokers and patients with comorbidities or medications that could affect PFT were excluded from the analysis. Patients were classified as having a reversible airflow limitation when they exhibited a post-bronchodilator FEV1 increase of 12% and 200 mL. Exacerbations were defined as the need to use oral corticosteroids. Chi-square tests were used for comparative analyses.

Results

From our cohort, 42 patients exhibited reversibility. In contrast, 112 patients did not show any sign of reversibility. Asthmatics with baseline reversible airflow limitations experienced significant worsening of FEV1 during the follow-up period compared with those with no reversibility, showing a mean difference of 19.96 mL (p = 0.0206). There was no significant association between asthma reversibility and exacerbations (p = 0.23).

Conclusion

In our study, during the follow-up of patients with asthma, we found that the reversibility of airflow was associated with significantly worse FEV1, although this did not have a significant effect on exacerbations. Therefore, we recommend regular spirometry follow-ups, particularly for patients with significant airway reversibility.

Differential effects of dexamethasone and roflumilast on asthma in mice with or without short cigarette smoke exposure

Appropriate drug treatment for smoking asthmatics is uncertain because most smokers with asthma are less sensitive to treatment with glucocorticoids compared with non-smokers with asthma. We hypothesized that roflumilast (Rof), a selective phosphodiesterases-4 inhibitor regarded as an add-on therapy for chronic obstructive pulmonary disease, might be more effective than glucocorticoids for improving asthma in smokers. To investigate this hypothesis, we compared the therapeutic effects of dexamethasone (Dex) and Rof in a mouse model of ovalbumin-induced asthma with or without concurrent cigarette smoke (CS) exposure for 2 weeks. We found that recurrent asthma attacks increased lung tissue resistance. CS exposure in asthmatic mice decreased the central airway resistance, increased lung compliance, and attenuated airway hyper-responsiveness (AHR). CS exposure in asthmatic mice also increased the number of neutrophils and macrophages in the bronchoalveolar fluid. Treatment with Dex in asthmatic mice without CS exposure reduced airway resistance, AHR and airway eosinophilia. In asthmatic mice with CS exposure, however, Dex treatment unexpectedly increased lung tissue resistance and restored AHR that had been otherwise suppressed. Dex treatment in asthmatic mice with CS exposure inhibited eosinophilic inflammation but conversely exacerbated neutrophilic inflammation. On the other hand, treatment with Rof in asthmatic mice without CS exposure reduced airway resistance and airway eosinophilia, although the inhibitory effect of Rof on AHR was unremarkable. In asthmatic mice with CS exposure, Rof treatment did not exacerbate lung tissue resistance but modestly restored AHR, without any significant effects on airway inflammation. These results suggest that CS exposure mitigates sensitivity to both Dex and Rof. In asthmatic mice with CS exposure, Dex is still effective in reducing eosinophilic inflammation but increases lung tissue resistance, AHR and neutrophilic inflammation. Rof is ineffective in improving lung function and inflammation in asthmatic mice with CS exposure. This study did not support our initial hypothesis that Rof might be more effective than glucocorticoids for improving asthma in smokers. However, glucocorticoids may have a detrimental effect on smoking asthmatics.

Tobacco use disorder and the lungs

This narrative review provides a summary of the impact of tobacco smoking on the respiratory system and the benefits of smoking cessation. Tobacco smoking is one of the leading preventable causes of death world-wide and a major risk factor for lung cancer and chronic obstructive pulmonary disease. Smoking is also associated with an increased risk of respiratory infections and appears to be related to poorer outcomes among those with COVID-19. Non-smokers with second-hand smoke exposure also experience significant adverse respiratory effects. Smoking imposes enormous health- and non-health-related costs to societies. The benefits of smoking cessation, in both prevention and management of respiratory disease, have been known for decades and, to this day, cessation support remains one of the most important cost-effective interventions that health professionals can provide to people who smoke. Cessation at any age confers substantial health benefits, even in smokers with established morbidities. As other treatments for chronic respiratory disease advance and survival rates increase, smoking cessation treatment will become even more relevant. While smoking cessation interventions are available, the offer of these by clinicians and uptake by patients remain limited.

Possible Crosstalk of the Immune Cells within the Lung and Mediastinal Fat-Associated Lymphoid Clusters in the Acute Inflammatory Lung Asthma-Like Mouse Model

Recently, we clarified the function of mediastinal fat-associated lymphoid clusters (MFALCs) in the progression of several respiratory diseases. However, their role has not yet been identified in the lung asthmatic condition. Hence, we compared the immune cells in lung and MFALCs of C57BL/6N mice on days 3 and 7 following intranasal instillation of either papain (papain group "PG") or phosphate buffer saline (PBS) (vehicle group "VG"). The PG showed significantly prominent MFALCs, numerous goblet cells (GCs), and higher index ratios of different immune cells (macrophages, natural helper cells (NHC), B- and T-lymphocytes) within the MFALCs and lung than in the VG on both days 3 and 7. Interestingly, a tendency of decreased size of MFALCs and a significant reduction in the number of GCs and immune cells were observed within the MFALCs and lung in the PG on day 7 than on day 3. Furthermore, the quantitative parameters of these immune cells in MFALCs were significantly and positively correlated with the size of MFALCs and immune cells in the lung. This suggested that the possible crosstalk between immune cells within MFALCs and the lung could play a critical role in the progression and recovery of the acute inflammatory lung asthma.

Smoking and COVID-19 Infection and Related Mortality: A Prospective Cohort Analysis of UK Biobank Data

Background

Several papers have shown contradictory evidence about the relationship between smoking and COVID-19-related deaths. There is little evidence about smoking and risk of infection. We aim to examine association between smoking and COVID-19 infection and subsequent mortality.

Methods

This was a prospective study with participants from the UK Biobank cohort. Participants who lived in England were followed up from 01/02/2020 to 28/06/2020 with data linked to hospital episode statistics, Office for National Statistics and Public Health England PCR tests. We compared current-smokers, previous-smokers with never-smokers and estimated risk ratio (RR) of COVID-19 infection and subsequent mortality using Poisson regression adjusting for age, sex, ethnicity, body mass index and socio-economic status. Interactions between smoking status and age and sex were tested for using multiplicative interactions, and analyses were stratified by median age (49–68 years, 69–86 years) and sex.

Results

In total, 402,978 participants were included in the analyses. The majority were never smokers, 226,294 (56.2%), 140,090 (34.8%) were previous smokers, and 39,974 (9.9%) current smokers. COVID-19 infection was identified in 1591 (0.39%) people, and 372/1591 (23.4%) died. Amongst the younger participants, smokers were nearly twice as likely to become infected with COVID-19 than never smokers (RR 1.88 [1.49–2.38]) whereas there was no difference for those aged 69+ (RR 1.05 [0.82–1.34]). In contrast, amongst the older participants, smokers were twice as likely to die from COVID-19 compared to non-smokers (RR 2.15 [1.11–4.16]) whereas there was no difference for those under the age of 69 (RR 1.22[0.83–1.79]). Similar patterns were observed for previous smokers. The impact of smoking was similar in men and women.

Conclusion

The association between smoking and COVID-19 infection and subsequent death is modified by age. Smokers and previous smokers aged under 69 were at higher risk of COVID-19 infection, suggesting the risk is associated with increased exposure to SARS-COV-2 virus. Once infected, older smokers were twice as likely to die from COVID-19 than never smokers, possibly mediated by increased risk of chronic conditions/illnesses.