Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

Noninvasive ventilation in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials

The clinical benefits of noninvasive ventilation (NIV) for patients with acute hypoxemic respiratory failure (AHRF) is still inconclusive. We aimed to evaluate the effect of NIV compared with conventional oxygen therapy (COT)/high-flow nasal cannula (HFNC) in this patient population. We searched for relevant studies from PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CINHAL, Web of Science up to August 2019 for randomized controlled trials (RCTs) that compared NIV with COT/HFNC in AHRF. The primary outcome was the tracheal intubation rate. Secondary outcomes were intensive care unit (ICU) mortality, and hospital mortality. We applied the GRADE approach to grade the strength of the evidence. Seventeen RCTs that recruited 1738 patients were included in our meta-analysis. When comparing NIV versus COT/HFNC, the pooled risk ratio (RR) for the tracheal intubation rate was 0.68, 95% confidence interval (CI) 0.52-0.89, p = 0.005, I² = 72.4%, low certainty of evidence. There were no significant differences in ICU mortality (pooled RR = 0.87, 95% CI 0.60-1.26), p = 0.45, I² = 64.6%) and hospital mortality (pooled RR = 0.71, 95% CI 0.51-1.00, p = 0.05, I² = 27.4%). Subgroup analysis revealed that NIV application with helmet was significantly associated with a lower intubation rate than NIV with face mask. NIV did not show a significant reduction in intubation rate compared to HFNC. In conclusion, NIV application in patients with medical illness and AHRF was associated with a lower risk of tracheal intubation compared to COT. NIV with helmet and HFNC are promising strategies to avoid tracheal intubation in this patient population and warrant further studies. NIV application had no effect on mortality.The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018087342).

Involvement of Transforming Growth Factor-β-Associated Kinase 1 in Fixed Airway Obstruction in Asthmatic Patients with Longer Disease Duration Independent on Airway Eosinophilia

Objective

Transforming growth factor-β-associated kinase 1 (TAK1) mediates non-canonical TGF-β signalling by promoting adhesive, migratory, proliferative and contractile responses of fibroblasts to TGF-β₁. However, TAK1 expression status in asthmatic patients with or without fixed airway obstruction (FAO) is unknown.

Patients and Methods

A total of 60 adult asthmatics with FAO were recruited and compared to 43 those without FAO (nFAO). TGF-β₁ concentrations, and total TAK1 and phosphorylated TAK1 (p-TAK1) levels were determined in sputum supernatants, cytospin, and whole cell lysate by ELISA, immunocytochemistry, and Western blot analysis, respectively, in asthmatics with and without FAO.

Results

Asthmatic patients with FAO had much greater sputum TGF-β₁ concentrations than those without FAO. This was independent of airway eosinophilia as there was no significant difference in TGF-β₁ levels between high and low eosinophil counts within FAO and nFAO groups. In contrast, patients with FAO in the presence of sputum eosinophilia had greater expression of TAK1 and p-TAK1 than those without sputum eosinophilia (P=0.0032 and P=0.0061, respectively). The Western Blot data of total TAK1 and p-TAK1 were consistent with the immunocytochemistry, showing upregulation in all sputum cell types (neutrophils, eosinophils, macrophages, lymphocytes and airway epithelial cells). In addition, total TAK1 expression negatively correlated with pre- and post-bronchodilator FEV₁/FVC ratio.

Conclusion

TAK1 may play a key role in asthmatic patients with fixed airway obstruction, which was independent of eosinophilic airway inflammation. The interruption of TAK1 might have favourable clinical impact.

New Versus Old: The Impact of Changing Patterns of Inhaled Corticosteroid Prescribing and Dosing Regimens in Asthma Management

Inhaled corticosteroid (ICS)-containing therapies are the mainstay of pharmacological management of asthma. They can be administered alone or in combination with a long-acting bronchodilator, depending on asthma severity, and may also be supplemented with short-acting bronchodilators for as-needed rescue medication. Adherence to asthma therapies is generally poor and characterized by underuse of ICS therapies and over-reliance on short-acting bronchodilators, which leads to poor clinical outcomes. This article reviews efficacy versus systemic activity profiles for various dosing regimens of budesonide (BUD) and fluticasone propionate (FP). We performed a structured literature review of BUD and FP regular daily dosing, and BUD/formoterol (FOR) as-needed dosing, to explore the relationship between various dosing patterns of ICS regimens and the risk–benefit profile in terms of the extent of bronchoprotection and cortisol suppression. In addition, we explored how adherence could potentially affect the risk–benefit profile, in patients with mild, moderate, and moderate-to-severe asthma. With a specific focus on BUD or FP-containing treatments, we found that regular daily ICS and ICS/long-acting β₂-agonist (LABA) dosing had a greater degree of bronchoprotection than as-needed BUD/FOR dosing or BUD/FOR maintenance and reliever therapy (MART) dosing, and still maintained low systemic activity. We also found that the benefits of regular daily ICS dosing regimens were diminished when adherence was low (50%); the shorter duration of bronchoprotection observed was similar to that seen with typical as-needed BUD/FOR usage. These findings have implications for aiding clinicians with selecting the most suitable treatment option for asthma management, and subsequent implications for the advice clinicians give their patients.

Inhaled corticosteroid (ICS)-containing therapies can be administered in a variety of ways depending on a patient’s asthma severity. Patients with mild asthma tend to experience symptom relief with as-needed or regular daily use of an ICS alone, whereas patients with more severe asthma may require regular daily use of an ICS plus a long-acting β₂-agonist (LABA) to experience sufficient asthma control. However, failure to correctly adhere to ICS-containing therapies or an over-reliance on short-acting bronchodilators for symptom relief hinders optimal asthma management, thus negatively affecting overall patient health and wellbeing. Understanding how different dosing regimens affect the degree of bronchoprotection (efficacy) and cortisol suppression (systemic activity) of ICS treatments would benefit physicians by helping them to prescribe the most appropriate treatment for their patient’s asthma. We performed a structured literature review of two ICS molecules—budesonide (BUD) (alone and combined with formoterol [FOR]) and fluticasone propionate (FP)—to explore the relationship between various ICS dosing regimens, and then used these findings to construct models for ICS risk–benefit profiles. Our models factored in different ICS dosing regimens—as-needed, regular daily dosing, and maintenance and reliever therapy (MART)—and various degrees of treatment adherence. We found that regular daily ICS and ICS/LABA dosing provided better bronchoprotection than as-needed BUD/FOR dosing or BUD/FOR MART dosing, but this benefit was diminished with low adherence. Regular daily dosing maintained low cortisol suppression, which indicated a fairly low risk of negative side effects. Our findings have subsequent implications for optimizing treatment in patients with asthma.

Indoleamine 2,3 dioxygenase (IDO) level as a marker for significant coronary artery disease

Background

Indoleamine 2,3 dioxygenase (IDO), the rate-limiting enzyme in the kynurenine (Kyn) pathway of tryptophan (Trp) degradation, is modulated by inflammation, and is regarded as a key molecule driving immunotolerance and immunosuppressive mechanisms. Little is known about IDO activity in patients with active coronary artery disease (CAD).

Methods

We prospectively enrolled patients who were scheduled to undergo coronary angiography. Measurement of IDO, high-sensitivity troponin T (hs-TnT), and high-sensitivity C-reactive protein (hs-CRP) levels was performed at baseline, and IDO activity was monitored at the 6-month follow-up.

Results

Three hundred and five patients were enrolled. Ninety-eight patients (32.1%) presented with recent acute coronary syndrome (ACS). Significant difference in IDO, kynurenine, and hs-TnT between patients with and without significant CAD was observed. Baseline IDO activity, kynurenine level, and hs-TnT level were all significantly higher in significant CAD patients with 3-vessel, 2-vessel, and 1-vessel involvement than in those with insignificant CAD [(0.17, 0.13, and 0.16 vs. 0.03, respectively; p = 0.003), (5.89, 4.58, and 5.24 vs. 2.74 µM/g, respectively; p = 0.011), and (18.27, 12.22, and 12.86 vs. 10.89 mg/dL, respectively; p < 0.001)]. One-year mortality was 3.9%. When we compared between patients who survived and patients who died, we found a significantly lower prevalence of left main (LM) disease by coronary angiogram (6.1% vs. 33.3%, p = 0.007), and also a trend toward higher baseline kynurenine (5.07 vs. 0.79 µM/g, p = 0.082) and higher IDO (0.15 vs. 0.02, p = 0.081) in patients who survived.

Conclusion

Immunometabolic response mediated via IDO function was enhanced in patients with CAD, and correlated with the extent and severity of disease. Patients with LM disease had higher 1-year mortality. Lower level of IDO, as suggested by inadequate IDO response, demonstrated a trend toward predicting 1-year mortality.

Trial registration TCTR Trial registration number TCTR20200626001. Date of registration 26 June 2020. “Retrospectively registered”.

Microparticles from human the lower airway show inhibitory activity against respiratory syncytial virus

Airway microparticles (MPs) have been shown previously to inhibit influenza virus by trapping virions on their surface through their surface viral receptor. It was hypothesized that airway MPs may carry most of the epithelial cell surface molecules, including receptors for respiratory viruses, and may be able to inhibit various respiratory viruses. We show here that MPs from human bronchoalveolar lavage (BAL) can inhibit respiratory syncytial virus (RSV). Those MPs stained positive for the RSV receptor, CX3CR1. Furthermore, incubating the MPs with a monoclonal antibody against CX3CR1 reduced the anti-RSV activity. These data indicate that MPs can contribute to respiratory innate antiviral defense.

Role of autophagy in regulating interleukin-10 and the responses to corticosteroids and statins in asthma

BACKGROUND

Interleukin (IL)-10 is a key anti-inflammatory cytokine that may be reduced in asthma but is enhanced by corticosteroids, especially when combined with a statin, although the mechanisms of these effects are uncertain.

OBJECTIVE

To study the role of autophagy in macrophages in promoting inflammation in asthma through reducing IL-10 secretion and how corticosteroids and statins may reverse this process.

METHODS

We conducted a randomised double-blind placebo-controlled study in moderate to severe asthmatic patients (n = 44) to investigate the effect of an inhaled corticosteroid (budesonide 400 μg/day) and the combination of budesonide with an oral statin (simvastatin 10 mg/day) given for 8 weeks on autophagy protein expression in sputum cells by using immunocytochemistry and measurement of IL-10 release. In in vitro experiments, we studied cross-regulation between autophagy and IL-10 release by measuring the expression of autophagy proteins in M2-like macrophages and the effects of budesonide and simvastatin on these mechanisms.

RESULTS

In asthmatic patients, inhaled budesonide inhibited airway macrophage autophagy (beclin-1, LC3) as well as autophagic flux (p62), which was enhanced by simvastatin and was correlated with increased sputum IL-10 and reduced IL-4 concentrations. In macrophages in vitro, budesonide and simvastatin inhibited rapamycin-induced autophagy as well as autophagic flux, with reduced expression of beclin-1 and LC3, but enhanced the accumulation of p62 and increased expression of IL-10, which itself further inhibited autophagy in macrophages. With siRNA-mediated silencing, LC3-deficient macrophages also showed a maximal induction of IL-10 transcription. Neutralisation of IL-10 with recombinant specific blocking antibody and silencing IL-10 transcription reversed the inhibitory effects of budesonide and simvastatin on macrophage autophagy.

CONCLUSION AND CLINICAL RELEVANCE

Inhibition by corticosteroids and a statin of macrophage autophagy enhances IL-10 production, resulting in the control of asthmatic inflammation.

Indoleamine 2,3 dioxygenase (IDO) as a new predictor for advance coronary artery diseases

Background

Indoleamine 2,3 dioxygenase (IDO), the rate-limiting enzyme in in the kynurenine (Kyn) pathway of tryptophan (Trp) degradation, is modulated by inflammation and regarded as a key molecule driving immunotolerance and immunosuppressive mechanisms. This response accelerates the resolution of inflamed tissues to protect them against collateral damage and facilitate tissue healing. A growing body of evidence indicates that IDO-mediated Trp metabolism is involved directly or indirectly in atherogenesis. Little is known about IDO activity in patients with active coronary artery disease (CAD).

Purpose

We hypothesized that IDO activity as reflected by Kyn/Trp ratio and Kyn levels correlated with coronary artery disease (CAD) severity and predicted 1-year major adverse cardiac events (MACE).

Method

We prospectively enrolled the patients whom underwent coronary angiography in our institute. We excluded the patients whom might have other non-cardiac causes of elevated inflammatory biomarkers such as rheumatoid arthritis, allergic asthma, and so on. Measurements of IDO, hs-troponin and hs-CRP levels were performed at baseline and IDO activity was monitored every 6 month at interval. Baseline demographic, coronary angiogram/interventions data were recorded. Significant CAD defined as &gt;70% stenosis in major epicardial vessel. Patients were followed up for 1-year. MACE were pre-specified.

Results

Three-hundred and five patients were enrolled. Ninety-eight patients (32%) presented with acute coronary syndrome. There was a significant difference in IDO, kynurenine, and hs-troponin between patients with and without significant CAD (Table 1). In addition, baseline IDO activity, kynurenine and hs-troponin levels were significantly higher in significant CAD patients with 3-vessel, 2-vessel and 1-vessel involvements than those with insignificant CAD; (0.17 vs 0.14 vs 0.14 vs 0.04, p&lt;0.01), (5.8 vs 4.5 vs 5.1 vs 2.9 μM/g, p&lt;0.01) and (18.2 vs 12.4 vs 12.7 vs 11.1 mg/dL, p&lt;0.001), respectively. Preliminary data in 287 patients with completion of 1-year follow up showed that 1-year mortality was 2.9%. In comparison between patients who survived and death, it demonstrated markedly higher baseline kynurenine (5.12 vs 0.54 μM/g, p&lt;0.03) and IDO (0.15 vs 0.01, p&lt;0.02) in the patients without 1-year mortality.

Conclusion

Immunometabolic response mediated through IDO function were enhanced in patients with CAD and correlated with the severity and extent of the disease. Patient with inadequate IDO response had a higher 1-year mortality.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Siriraj grant for research development and medical education of the Faculty of Medicine Siriraj Hospital

Long-term effectiveness of omalizumab treatment in Thai severe asthmatic patients: A real-life experience

BACKGROUND

To evaluate long-term effectiveness of omalizumab in 'real-life' setting of Thai asthmatic patients.

METHODS

We conducted multi-center, observational study in severe asthma patients who received omalizumab in Thailand. Outcomes were asthma exacerbation (hospitalization and ER visit), asthma control test (ACT), and daily ICS dose. Data were evaluated at baseline, 16 Week, and 52 Week.

RESULTS

A total of 78 patients received omalizumab treatment (average duration 16.9 months with range 16 weeks-2 years). The mean annualized rate of exacerbations was reduced from baseline (3.79) at Week 16 (3.54) and Week 52 (1.16), (p<0.05), respectively. The mean hospitalization rate was reduced from 0.49 in previous year to 0.15 at Week 16 and 0.19 at Week 52. A reduction in ER visit rates was observed at Week 16 (0.15) and Week 52 (0.97) respectively from baseline (1.44) (p<0.05). The ACT score increased from 15.4 at baseline to 20.6 at Week 16 (p<0.001) and increased to 21.5 at Week 52 (p<0.001). The number of patients with controlled asthma (ACT≥20) increased from 16 of 51 at baseline to 32 of 45 at Week 16 and 25 of 32 at week 52, respectively. The median daily dose of ICS equivalent to fluticasone was reduced from baseline 680 mcg to 500 mcg at Week 52. In all, 22 patients discontinued omalizumab after 1 year. Six patients who discontinued omalizumab were restarted due to relapse of symptoms.

CONCLUSIONS

These data confirms the effectiveness of one-year duration of omalizumab treatment in Thai severe asthmatic patients. Furthermore, 27% of patients who discontinued treatment required restarting due to relapse of symptoms.

Assessment of proximal and peripheral airway dysfunction by computed tomography and respiratory impedance in asthma and COPD patients with fixed airflow obstruction

OBJECTIVE:

To ascertain: (i) if elderly patients with fixed airflow obstruction (FAO) due to asthma and chronic obstructive pulmonary disease (COPD) have distinct airway morphologic and physiologic changes; (ii) the correlation between the morphology of proximal/peripheral airways and respiratory impedance.

METHODS:

Twenty-five asthma cases with FAO and 22 COPD patients were enrolled. High-resolution computed tomography was used to measure the wall area (WA) and lumen area (LA) of the proximal airway at the apical segmental bronchus of the right upper lobe (RB1) adjusted by body surface area (BSA) and bronchial wall thickening (BWT_r) of the peripheral airways and extent of expiratory air trapping (AT_exp). Respiratory impedance included resistance at 5 Hz (R₅) and 20 Hz (R₂₀) and resonant frequency (Fres). Total lung capacity (TLC) and residual volume (RV) were measured.

RESULTS:

Asthma patients had smaller RB1-LA/BSA than COPD patients (10.5 ± 3.4 vs. 13.3 ± 5.0 mm²/m², P = 0.037). R₅(5.5 ± 2.0 vs. 3.4 ± 1.0 cmH₂O/L/s, P = 0.02) and R₂₀(4.2 ± 1.7 vs. 2.6 ± 0.7 cmH₂O/L/s, P = 0.001) were higher in asthma cases. AT_exp and BWT_r were similar in both groups. Regression analysis in asthma showed that forced expiratory volume in one second (FEV₁) and Fres were associated with RB1-WA/BSA (R²= 0.34, P = 0.005) and BWT_r (0.5, 0.012), whereas RV/TLC was associated with AT_exp (0.38, 0.001).

CONCLUSIONS:

Asthma patients with FAO had a smaller LA and higher resistance of the proximal airways than COPD patients. FEV₁ and respiratory impedance correlated with airway morphology.

Microparticle and anti-influenza activity in human respiratory secretion

Respiratory secretions, such as saliva and bronchoalveolar fluid, contain anti-influenza activity. Multiple soluble factors have been described that exert anti-influenza activity and are believed to be responsible for the anti-influenza activity in respiratory secretions. It was previously shown that a bronchial epithelial cell culture could produce exosome-like particles with anti-influenza activity. Whether such extracellular vesicles in respiratory secretions have anti-influenza activity is unknown. Therefore, we characterized bronchoalveolar lavage fluid and found microparticles, which mostly stained positive for epithelial cell markers and both α2,3- and α2,6-linked sialic acid. Microparticles were purified from bronchoalveolar lavage fluid and shown to exhibit anti-influenza activity by a hemagglutination inhibition (HI) assay and a neutralization (NT) assay. In addition, physical binding between influenza virions and microparticles was demonstrated by electron microscopy. These findings indicate that respiratory microparticles containing viral receptors can exert anti-viral activity by probably trapping viral particles. This innate mechanism may play an important role in the defense against respiratory viruses.

Abstract A39: Cholangiocarcinoma-exposed cytokine-induced killer cells developed senescence and exhaustion

The existence of cellular exhaustion and senescence have been well-documented in T cells, but not yet in CIK cells. The exposure of CIK cells to HubCCA1 cholangiocarcinoma cells resulted in sustaining the proportion of CD3+CD56+ subset at the expense of that of the pure T cell (CD3+CD56-) subset. All major subsets (CD3+CD56+, T cell subsets, and NK cell (CD3-CD56+ subset) of the survived CIK cells were inflicted with increasing senescence markers (KLRG1, CTLA4, and CD57) upon the exposure length. However, CD28, a T cell activation marker, was up-regulated in CD3+CD56+ and NK cell subsets upon tumor exposure, but was suppressed in T cell subset. The co-culture of CIK cells with dendritic cells (DCs) could alleviate CD57, but not KLRG1 nor CTLA4. For exhaustion, the co-culture with DCs could lower the level of PD-1 in CD3+CD56+ and T cell subset, but was unable to withstand the massive up-regulation of PD-1 and Tim-3 in all 3 major subsets upon the tumor exposure. The co-culture with DCs raised the proportion of Treg (CD4+CD25+Foxp3+) subset in CIK cells, but surprisingly reversed by the eventual exposure to tumor cells. In summary, the exposure of CIK cells to tumor cells rendered the development of senescence and exhaustion to the CIK cells. The co-culture of CIK cells with DCs had limited role in preventing these opposing effects.

Citation Format: Adisak Wongkajornsilp, Nathawadee Sawatpiboon, Sunisa Duangsa-ard, Kanda Kasetsinsombat, Kittipong Maneechotesuwan, Suradej Hongeng. Cholangiocarcinoma-exposed cytokine-induced killer cells developed senescence and exhaustion. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2016 Oct 20-23; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2017;5(3 Suppl):Abstract nr A39.

Effects of the Ayurved Siriraj Wattana recipe on functional and phenotypic characterization of cytokine-induced killer cells and dendritic cells in vitro

Background

Ayurved Siriraj Wattana recipe (AVS073), has been prescribed as tonic, to increase appetite, and for pain relief. It also exhibits antioxidant, anti-inflammatory, immunomodulating and anti-cancer activities. However, the immunomodulatory effects on antigen-presenting cells and effector T cells remained elusive. We thus aimed to study the effects of AVS073 on differentiation, maturation, functions and proportions of CIK cells and monocyte-derived DCs.

Methods

CIK cells and monocyte-derived DCs were treated with AVS073, followed by the assessment of T-helper (Th) phenotypes using real-time RT-PCR and flow cytometry.

Results

AVS073 promoted Th1 phenotype in CD3⁺CD56⁺ subset of CIK cells through increasing STAT4, T-bet, and interferon-γ. AVS073 inhibited Th2 phenotype through decreasing STAT6. AVS073 inhibited Treg phenotype through decreasing STAT5A, STAT5B and IDO. AVS073 promoted Th17 phenotype through increasing STAT3, RORC and IL-17. AVS073 treatment of mDCs resulted in increasing Th1-prone cytokine (IL-12) and Th17-prone cytokines (IL-6 and IL-23).

Conclusions

AVS073 upregulated Th1 and Th17, but downregulated Th2 and Treg phenotypes within CD3⁺CD56⁺ cells. The treatment of mDCs drove Th1 and Th17-polarizations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-016-1480-7) contains supplementary material, which is available to authorized users.

Simvastatin up-regulates adenosine deaminase and suppresses osteopontin expression in COPD patients through an IL-13-dependent mechanism

Background

Adenosine deaminase (ADA) and osteopontin (OPN) may play opposing roles in the pathogenesis of COPD. Deficiency of ADA results in enhanced adenosine signaling which up-regulates OPN expression. Although statins suppress OPN in cancer cells, little is known about their effects on ADA and OPN in COPD patients.

Methods

We extended a previous randomized double-blind placebo crossover study to investigate the effects of simvastatin (20 mg/day) on sputum ADA and OPN expression and explored the underlying signaling pathways involved by conducting in vitro experiments with cigarette smoke extract (CSE)-treated monocyte-derived macrophages (MDM) from COPD patients and healthy subjects.

Results

Simvastatin decreased sputum IL-13, OPN and CD73, while increasing ADA expression, irrespective of inhaled corticosteroid treatment and smoking status in parallel to increased inosine levels. The degree of simvastatin-restored ADA activity was significantly correlated with the magnitude of changes in pre-bronchodilator FEV₁. Mechanistic exploration showed that CSE enhanced the expression of IL-13, which induced an increase in OPN and inhibited ADA mRNA accumulation in MDM from COPD patients but not healthy subjects through a STAT6-dependent mechanism. Simvastatin treatment inhibited IL-13 transcription in a dose-dependent manner, and therefore diminished the IL-13-induced increase in OPN and restored IL-13-suppressed ADA. There was no effect of simvastatin on adenosine receptors in CSE-stimulated MDM, indicating that its effects were on the adenosine pathway.

Conclusion

Simvastatin reversed IL-13-suppressed ADA activity that leads to the down-regulation of adenosine signaling and therefore inhibits OPN expression through the direct inhibition of IL-13-activated STAT6 pathway. Inhibition of IL-13 may reverse the imbalance between ADA and OPN in COPD and therefore may prevent COPD progression.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-016-0424-6) contains supplementary material, which is available to authorized users.

Association between levels of fractional exhaled nitric oxide and asthma exacerbations in Thai children

BACKGROUND AND OBJECTIVE

Fractional exhaled nitric oxide (FeNO) has been used as a marker for airway inflammation. We evaluated the association between FeNO levels and asthma exacerbations (AEs) in Thai children and young adults.

METHODS

This was a prospective cohort study in patients with atopic asthma aged 7-20 years. Asthma control level and management were evaluated every 3 months for 1 year. Spirometry and FeNO measurements were performed at baseline, and 6 and 12 months.

RESULTS

In all, 70 patients (median age: 12.6 (7.2-19.8) years) were enrolled, of whom 18% had an AE during the study period. Median FeNO levels were significantly higher in patients with an AE than in those without an AE (35.6 ppb vs 16.5 ppb; P = 0.012). FeNO of 31 ppb provided optimal sensitivity (92.3%) and specificity (75.4%) for AE prediction. Sensitivity and specificity of FeNO levels were higher than those of forced expiratory volume in 1 s and forced expiratory flow at 25-75% of forced vital capacity bronchodilator reversibility for the prediction of an AE, but the difference was not significant (P = 0.121). None of the patients with FeNO level of 0-20 ppb had an AE within 12 months. Percentage of patients with FeNO of 21-40 ppb who suffered an AE was 20% and 30% at 6 and 12 months, respectively.

CONCLUSION

The optimal cut-off point of FeNO level for the prediction of AE is 31 ppb. AE within the next 12 months was significantly more common in patients with higher FeNO levels and in patients with a higher rate of previous 12-month exacerbations.

Simvastatin Suppresses Airway IL-17 and Upregulates IL-10 in Patients With Stable COPD

BACKGROUND:

Statins have immunomodulatory properties that may provide beneficial effects in the treatment of COPD. We investigated whether a statin improves the IL-17/IL-10 imbalance in patients with COPD, as has previously been demonstrated in patients with asthma.

METHODS:

Thirty patients with stable COPD were recruited to a double-blind, randomized, controlled, crossover trial comparing the effect of simvastatin, 20 mg po daily, with that of a matched placebo on sputum inflammatory markers and airway inflammation. Each treatment was administered for 4 weeks separated by a 4-week washout period. The primary outcome was the presence of T-helper 17 cytokines and indoleamine 2,3-dioxygenase (IDO) in induced sputum. Secondary outcomes included sputum inflammatory cells, FEV₁, and symptoms using the COPD Assessment Test (CAT).

RESULTS:

At 4 weeks, there was a significant reduction in sputum IL-17A, IL-22, IL-6, and CXCL8 concentrations (mean difference, −16.4 pg/mL, P = .01; −48.6 pg/mL, P < .001; −45.3 pg/mL, P = .002; and −190.9 pg/mL, P = .007, respectively), whereas IL-10 concentrations, IDO messenger RNA expression (fold change), and IDO activity (kynurenine to tryptophan ratio) were markedly increased during simvastatin treatment compared with placebo treatment periods (mean difference, 24.7 pg/mL, P < .001; 1.02, P < .001; and 0.47, P < .001, respectively). The absolute sputum macrophage count, proportion of macrophages, and CAT score were reduced after simvastatin compared with placebo (mean difference, −0.16 × 10⁶, P = .004; −14.1%, P < .001; and −3.2, P = .02, respectively). Values for other clinical outcomes were similar between the simvastatin and placebo treatments.

CONCLUSIONS:

Simvastatin reversed the IL-17A/IL-10 imbalance in the airways and reduced sputum macrophage but not neutrophil counts in patients with COPD.

TRIAL REGISTRY:

ClinicalTrials.gov; No.: NCT01944176; www.clinicaltrials.gov

Is fractional exhaled nitric oxide (FeNO) associated with asthma control in children?

INTRODUCTION

The most important way to achieve and maintain asthma control is to reduce airway inflammation. Fractional exhaled nitric oxide (FeNO) levels have been used as a marker of airway inflammation.

OBJECTIVES

To evaluate the association between FeNO levels and the asthma control status in children.

METHODS

This was a cross-sectional clinical trial in children with atopic asthma aged ≥ 7 years. The levels of asthma control were assessed by using the criteria from the GINA Guideline. FeNO levels and spirometry were measured. Asthma medications were recorded. The association between FeNO levels and asthma control status and the usage of asthma medications were analyzed.

RESULTS

One hundred and fourteen asthmatic children aged 12.1 ± 3.5 years were recruited into the study. Most of the patients had mild persistent asthma (79.8%). The administration of inhaled corticosteroid (ICS) was reported in 82.4% of cases. According to the GINA Guideline, 34.2% of cases were controlled, 44.7% were partly controlled and 21.1% were uncontrolled. We found that there was no significant difference in the median FeNO levels in the controlled, partly controlled and uncontrolled groups [19.2 (95% CI 5.1-108.9), 24.9 (2.2-85.7), and 39.2 (2.4-192.3) ppb, respectively (p = 0.24)]. However, in 20 cases who did not receive ICS treatment, the median FeNO levels showed a significant difference among controlled, partly controlled and uncontrolled groups [31.8 (95% CI 11.1-108.9), 34.1 (5.3-81.8), 92.0 (46.3-192.3) ppb, respectively; p <0.05].

CONCLUSIONS

FeNO levels were increased in ICS-treated asthmatic patients with less asthma control, albeit with no statistically significance. However, FeNO levels correlated with poor asthma control status in ICS untreated cases.

Comparison between the effects of generic and original salmeterol/fluticasone combination (SFC) treatment on airway inflammation in stable asthmatic patients

BACKGROUND

Little is known about the effect of inhaled corticosteroids (ICS)/long-acting beta2 agonists (LABA) in combination on inflammatory markers in asthma. In addition, therapeutic equivalence of generic salmeterol/fluticasone combination (SFC) and original SFC is as yet unknown.

OBJECTIVE

To determine the effects of SFC and the effects of generic and original SFC on airway inflammation in patients with mild-to moderate stable asthma.

MATERIAL AND METHOD

A randomized double-blinded, crossover non-inferiority study was conducted to compare the antiinflammatory effects of generic SFC and original SFC on sputum eosinophils as a primary outcome and fractional exhaled nitric oxide (FENO) as a secondary outcome.

PATIENTS

The authors studied 51 mild-to-moderate asthmatic patients who ranged from 18 to 80 years of age and were treated with ICS or ICS/LABA of any dose, and whose asthma was stable without an exacerbation episode for at least 3 months prior to study entry.

RESULTS

Both sputum eosinophils percentage and absolute eosinophil counts well correlated with FENO levels at baseline prior to the initiation of study medications. Significant reduction in sputum eosinophil percentage was observed following generic SFC and original SFC treatment. The degree of sputum eosinophil suppression by generic SFC was not inferior to original SFC, and this was not affected by treatments with the sequence of generic SFC first vs. original SFC second or original SFC first vs. generic SFC. In addition, there was no significant difference between treatments in terms of normalized gain in asthma control scores, including the number of patients found to have improved asthma control, irrespective of sequence, as change from baseline. However, this was not the case for the magnitude of FENO reduction that occurred after generic SFC treatment to a significantly larger extent than original SFC treatment.

CONCLUSION

This short-term study demonstrated that there was no significant difference between generic SFC and original SFC in terms of anti-inflammatory activity and the control of asthma symptoms. However, it is completely unknown whether generic SFC could effectively prevent the development of asthma exacerbations on a long-term basis. Therefore, longer-term studies are indicated to evaluate generic SFC's relative efficacy on asthma exacerbations.

Sunitinib indirectly enhanced anti-tumor cytotoxicity of cytokine-induced killer cells and CD3⁺CD56⁺ subset through the co-culturing dendritic cells

Cytokine-induced killer (CIK) cells have reached clinical trials for leukemia and solid tumors. Their anti-tumor cytotoxicity had earlier been shown to be intensified after the co-culture with dendritic cells (DCs). We observed markedly enhanced anti-tumor cytotoxicity activity of CIK cells after the co-culture with sunitinib-pretreated DCs over that of untreated DCs. This cytotoxicity was reliant upon DC modulation by sunitinib because the direct exposure of CIK cells to sunitinib had no significant effect. Sunitinib promoted Th1-inducing and pro-inflammatory phenotypes (IL-12, IFN-γ and IL-6) in DCs at the expense of Th2 inducing phenotype (IL-13) and regulatory phenotype (PD-L1, IDO). Sunitinib-treated DCs subsequently induced the upregulation of Th1 phenotypic markers (IFN-γ and T-bet) and the downregulation of the Th2 signature (GATA-3) and the Th17 marker (RORC) on the CD3⁺CD56⁺ subset of CIK cells. It concluded that sunitinib-pretreated DCs drove the CD3⁺CD56⁺ subset toward Th1 phenotype with increased anti-tumor cytotoxicity.

Statins enhance the effects of corticosteroids on the balance between regulatory T cells and Th17 cells

BACKGROUND

Plasticity of CD4(+) lymphocyte Th17/regulatory T cell (Treg) subsets is involved in the pathogenesis of chronic airway inflammatory diseases, such as asthma. Reversal of Th17/Treg cell balance towards Treg cells may be beneficial for the suppression of chronic Th2 cell-mediated inflammatory diseases, such as asthma. However, the effect of the combination of corticosteroids and a statin on the ratio of Treg/Th17 cells is unknown.

OBJECTIVE

We investigated the in vitro effects of the combination of simvastatin and fluticasone propionate (FP) on the numbers of Treg and Th17 cells in asthmatic patients after co-incubation with monocyte-derived DCs (mDCs), and explored the underlying signalling pathways involved.

METHODS

Using flow cytometry, we determined the effects of FP and simvastatin on Treg/Th17 balance after co-incubation of asthmatic CD4(+) T cells with mDCs. We also measured the relevant Treg and Th17-polarizing cytokines released from mDCs and also investigated the role of indoleamine 2, 3-dioxygenase (IDO) in this response.

RESULTS

The combination of simvastatin and FP significantly increased Treg and concomitantly reduced Th17 cell numbers to a greater extent than FP or statin treatment alone. The enhancing effects of simvastatin on FP effects were mediated through the up-regulation of indoleamine 2, 3-dioxygenase and interleukin (IL)-10, together with down-regulation of IL-6 and IL-23 expression in mDCs.

CONCLUSION

On the basis of this in vitro model of asthma, we suggest that the combination of a statin and a corticosteroid could augment the Treg/Th17 cell ratio and thus more effectively suppress airway inflammation in asthma patients. This may be particularly relevant in the treatment of severe asthma where Th17 cells are activated and linked to neutrophilic inflammation.

Bronchodilator effect of Ipraterol on methacholine-induced bronchoconstriction in asthmatic patients

BACKGROUND

The addition of ipratropium, a synthetic cholinergic antagonist, to beta2-agonist therapy provides an additive improvement in adult with acute severe asthma and COPD because of increased vagal tone in the airways. We asked whether ipratropium in combination with fenoterol (Ipraterol) improved pulmonary function in comparison with original Berodual.

MATERIAL AND METHOD

In order to determine the effects of nebulized a single dose of Ipraterol, the study was conducted in a double-blind, randomized and crossover manner by comparing the effect of nebulized a single dose of Berodual on methacholine-induced bronchoconstriction. The study consisted of an 1-week run-in phase and two study visits separated by a washout period of 7 days.

PATIENTS

We studied 20 patients who ranged from 18 to 80 years of age and had mild to moderate persistent asthma.

RESULTS

Nebulized Ipraterol provided a rapid onset of bronchodilation effect similar to nebulized Berodual within 5 minutes by significantly increasing FEV, from 1.19 L to 1.73 L (p < 0.001) and from 1.19 to 1.69 L (p = 0.0001), respectively. This effect of Ipraterol lasted as long (up to 6 hours) and was similar to that of Berodual. The absolute FEV1 values at 360 min after Ipraterol treatment was still higher than the baseline values. We also found that there were no significant differences in the degree of improvement in FEV1 and hypokalemia following treatment with Ipraterol and Berodual.

CONCLUSION

Our data suggest that nebulized Ipraterol offers a statistically significant improvement in pulmonary function without significant systemic absorption causing hypokalemia, with the improvement being comparable to that achieved with nebulized Berodual.

Differential expression of Th2 chemokine receptors on T cells from atopic and nonatopic asthmatics in response to Der p 1-pulsed dendritic cells

BACKGROUND

In vitro polarized human Th2 cells preferentially express the chemokine receptors CCR3 and CCR4 and migrate to their ligands: eotaxin, monocyte-derived chemokine (MDC) or CCL22, thymus- and activation-regulated chemokine (TARC) or CCL17. However little is known about the regulation of these chemokine receptor axes by Der p 1-pulsed dendritic cells in house dust mite (HDM)-sensitive and non-atopic asthmatics.

OBJECTIVE

The aim was to investigate the modulatory effects of Der p 1-pulsed DCs on the expression of CCR3 and CCR4 on CD4+ T cells of HDM-sensitive and non-atopic asthmatics.

MATERIAL AND METHOD

Using real-time RT-PCR and flow cytometry analysis, the expression of CCR3 and CCR4 were assessed in autologous CD4+ T cells after co-incubation with Der p 1-pulsed DCs from these two asthmatic groups. We also determined the mRNA expression of CCR4 ligands TARC/CCL17 and MDC/CCL22 in monocyte-derived DCs after Der p 1 pulsation.

RESULTS

We performed flow cytometry analysis of CD4+ T cells from HDM-sensitive and non-atopic asthmatics, taken 24 and 48 h after co-incubation with Der p 1-pulsed DCs. We demonstrated that after co-incubation, there was a significant increase in CCR3+ and CCR4+ CD4+ T cells from HDM-sensitive asthmatics, which began to occur at 24 h and 48 h respectively, and corresponded to their expression at mRNA levels. In contrast, only CCR4 mRNA but not protein expression was increased in non-atopic CD4+ T cells. After Der p 1 pulsation, mRNA expression of CCR4-specific ligands (CCL17 and CCL22) was also markedly upregulated in HDM-sensitive DCs whereas only CCL17 gene expression was increased in non-atopic DCs.

CONCLUSION

These data support the role of DCs in differential regulation of CCR3 and CCR4 on CD4+ T cells from HDM-sensitive and non-atopic asthmatics after Der p 1 exposure.

IgE production in allergic asthmatic patients with different asthma control status

BACKGROUND

Although much is known about the fact that IgE-mediated allergic inflammatory response contributes to airway inflammation, bronchial hyperresponsiveness, and asthma severity, little is known about the degree of IgE response in allergic asthmatics during treatment.

OBJECTIVE

To determine the amount of total serum IgE among allergic asthmatic patients with various asthma controls.

MATERIAL AND METHOD

A total of 190 non-smoking patients with allergic asthma were divided into three groups by using the asthma control definition according to the GINA 2006 criteria. There were 64 well-controlled, 88 partly-controlled, and 38 uncontrolled. After study entry, patients underwent lung function test, methacholine challenge and skin prick test to establish allergic status. Peripheral venous blood specimens were collected to measure total IgE and absolute eosinophil numbers. The data are expressed as mean +/- SD.

RESULTS

The logarithm of total serum IgE was significantly higher in subjects with uncontrolled allergic asthma than in those with well-controlled disease (p < .0001). IgE response in uncontrolled asthmatics was still high despite having been treated with ICS at a dose which was significantly high when compared with well-controlled subjects (1075.4 +/- 420 vs. 703.5 +/- 355, p < .0001). The logarithm of total serum IgE was associated with increased blood eosinophil counts (r = 0.25, p .0007) among three asthmatic groups and with decreased prebronchodilator FEV1 (r = -0.42, p = .0075) and PC20 (r = -0.36, p = .04) only in uncontrolled group.

CONCLUSION

In allergic asthmatic patients with various disease control stages, there are differences in IgE immune response. Both high and non-suppressible total serum IgE response may be involved in the development of uncontrolled asthma.

Suppression of GATA-3 nuclear import and phosphorylation: a novel mechanism of corticosteroid action in allergic disease

BACKGROUND

GATA-3 plays a critical role in regulating the expression of the cytokines interleukin (IL)-4, IL-5, and IL-13 from T helper-2 (Th2) cells and therefore is a key mediator of allergic diseases. Corticosteroids are highly effective in suppressing allergic inflammation, but their effects on GATA-3 are unknown. We investigated the effect of the corticosteroid fluticasone propionate on GATA-3 regulation in human T-lymphocytes in vitro and in vivo.

METHODS AND FINDINGS

In a T lymphocyte cell line (HuT-78) and peripheral blood mononuclear cells stimulated by anti-CD3 and anti-CD28 in vitro we demonstrated that fluticasone inhibits nuclear translocation of GATA-3 and expression of Th2 cytokines via a mechanism independent of nuclear factor-kappaB and is due, in part, to competition between GATA-3 and the ligand-activated glucocorticoid receptor for nuclear transport through the nuclear importer importin-alpha. In addition, fluticasone induces the expression of mitogen-activated protein kinase (MAPK) phosphatase-1 (MKP-1), the endogenous inhibitor of p38 MAPK, which is necessary for GATA-3 nuclear translocation. These inhibitory effects of fluticasone are rapid, potent, and prolonged. We also demonstrated that inhaled fluticasone inhibits GATA-3 nuclear translocation in peripheral blood lymphocytes of patients with asthma in vivo.

CONCLUSIONS

Corticosteroids have a potent inhibitory effect on GATA-3 via two interacting mechanisms that potently suppress Th2 cytokine expression. This novel mechanism of action of corticosteroids may account for the striking clinical efficacy of corticosteroids in the treatment of allergic diseases.

Sputum indoleamine-2, 3-dioxygenase activity is increased in asthmatic airways by using inhaled corticosteroids

BACKGROUND

Indoleamine-2, 3-dioxygenase (IDO), a tryptophan-degrading enzyme, plays a key role in the regulation of T-lymphocyte function. IDO inhibits eosinophilic inflammation in a murine asthma model, but little is known about its role in asthmatic patients or the effects of corticosteroids on this key regulatory enzyme.

OBJECTIVE

We studied IDO activity and the effect of inhaled corticosteroids (ICSs) in patients with asthma and how this correlated with eosinophilic inflammation.

METHODS

After a 1-week run-in period on no therapy, 34 asthmatic patients were treated with only short-acting beta(2)-agonists as required or an ICS or an ICS in combination with a long-acting beta(2)-agonist, which were required for asthma control, and the treatment was continued for a further 4 weeks. Each patient underwent sputum induction at the end of the run-in and treatment periods. Sputum supernatant specimens were analyzed for IDO activity and kynurenine concentrations by using HPLC.

RESULTS

All patients with mild intermittent and mild-to-moderate persistent asthma had low baseline IDO activity in induced sputum compared with that seen in age-matched nonasthmatic subjects. The IDO activity was markedly enhanced by either ICS (P = .03) or ICS/long-acting beta(2)-agonist (P < .0001) treatment, and this increase negatively correlated with sputum eosinophils but was positively associated with an increase in IL-10-positive macrophages.

CONCLUSION

ICSs might exert their anti-inflammatory activity in asthmatic airways, at least in part, through the upregulation of IDO activity associated with increased IL-10 secretion from macrophages.

Loss of Control of Asthma Following Inhaled Corticosteroid Withdrawal Is Associated With Increased Sputum Interleukin-8 and Neutrophils

BACKGROUND

The role of neutrophils in exacerbations of asthma is poorly understood. We examined the effect of withdrawal of inhaled corticosteroids on sputum inflammatory indexes in a double-blind study in patients with moderate, stable asthma.

METHODS

Following a 2-week run in period, 24 subjects were randomized to receive either budesonide (400 microg bid) or placebo, and the study was continued for another 10 weeks.

RESULTS

Loss of asthma control developed in 8 of 12 patients over the 10-week period of steroid withdrawal, whereas only 1 of 10 patients with budesonide treatment had exacerbations. Those with an exacerbation had increased sputum interleukin (IL)-8 (p < 0.0001) and increased sputum neutrophil numbers (p < 0.0001) compared to those without an exacerbation. The significant elevation in sputum IL-8 and neutrophil counts initially occurred 2 weeks prior to an exacerbation. Sputum neutrophilia correlated positively with changes in IL-8 levels (r(2) = 0.76, p = 0.01).

CONCLUSIONS

Rapid withdrawal of inhaled corticosteroids results in an exacerbation of asthma that is preceded by an increase in sputum neutrophils and IL-8 concentrations, in contrast to an increase in eosinophils reported in previous studies in which inhaled steroids are slowly tapered.

Regulation of Th2 Cytokine Genes by p38 MAPK-Mediated Phosphorylation of GATA-3

GATA-3 plays a critical role in allergic diseases by regulating the release of cytokines from Th2 lymphocytes. However, the molecular mechanisms involved in the regulation of GATA-3 in human T lymphocytes are not yet understood. Using small interfering RNA to knock down GATA-3, we have demonstrated its critical role in regulating IL-4, IL-5, and IL-13 release from a human T cell line. Specific stimulation of T lymphocytes by costimulation of CD3 and CD28 to mimic activation by APCs induces translocation of GATA-3 from the cytoplasm to the nucleus, with binding to the promoter region of Th2 cytokine genes, as determined by chromatin immunoprecipitation. GATA-3 nuclear translocation is dependent on its phosphorylation on serine residues by p38 MAPK, which facilitates interaction with the nuclear transporter protein importin-alpha. This provides a means whereby allergen exposure leads to the expression of Th2 cytokines, and this novel mechanism may provide new approaches to treating allergic diseases.

Comparison of telomerase activity between malignant and tuberculous pleural effusions

OBJECTIVE

To determine if telomerase activity can differentiate malignant from tuberculous pleural effusions.

DESIGN

Telomerase activity in malignant and tuberculous pleural effusions was measured in a blinded manner using a PCR-based telomeric repeat amplification protocol (TRAP) assay.

MATERIAL AND METHOD

Fifty-two patients with lymphocytic exudative pleural effusions were identified on thoracocentasis over a period of 18 months.

RESULTS

Telomerase activity was detected in 34% of malignant pleural fluid samples and 50% of tuberculous pleural effusions. The positive rate of telomerase activity was 30.7% for primary lung cancer and 37.5% for metastatic pleural effusion. The sensitivity and specificity of telomerase activity assay were extremely low (35.7% and 52.9%, respectively), compared with that of cytological examination (52.6% and 65.4%, respectively). Moreover the diagnostic accuracy of telomerase activity in combination with cytology was even lower than cytological examination alone (46.7% vs. 60%, respectively). This finding was in contrast to previous reports and demonstrated that the detection rate of telomerase activity in tuberculous pleural effusions was greater than that observed in malignant pleural exudates.

CONCLUSION

Telomerase activity does not appear to be a useful marker for differentiating malignant from tuberculous effusions.

Formoterol attenuates neutrophilic airway inflammation in asthma

STUDY OBJECTIVES

Airway neutrophil levels are increased in patients with severe asthma and during asthma exacerbations. Long-acting beta2-agonists (LABAs), such as formoterol, reduce the number of asthma exacerbations. While beta2-agonists may affect neutrophil function in vitro, it is uncertain whether they have effects on neutrophilic inflammation in asthmatic patients in vivo.

DESIGN

In a double-blind randomized crossover study, we evaluated the effects of 4 weeks of treatment with formoterol (Turbuhaler), 24 microg bid, compared to placebo on sputum neutrophil numbers and interleukin (IL)-8 levels in asthmatic patients. Therapy with budesonide (administered via Turbuhaler), 400 microg bid for 4 weeks, was added at the end as a "gold standard" antiinflammatory effect comparison.

PATIENTS

We studied 15 steroid-naïve nonsmoking patients who ranged from 19 to 51 years of age and had mild persistent asthma.

RESULTS

Formoterol therapy significantly reduced sputum IL-8 levels and neutrophil numbers compared to placebo. There was a significant correlation between the reduction in sputum IL-8 levels and the number of neutrophils, indicating that formoterol may attenuate neutrophilic airway inflammation by inhibiting IL-8 production.

CONCLUSIONS

Our data suggest that the LABA formoterol reduces neutrophilic airway inflammation in patients with mild asthma and that this might be beneficial in preventing asthma exacerbations.

Glucocorticoid receptor nuclear translocation in airway cells after inhaled combination therapy

Clinical evidence is accumulating for the efficacy of adding inhaled long-acting beta(2)-agonists (LABAs) to corticosteroids in asthma. Corticosteroids bind to cytoplasmic glucocorticoid receptors (GRs), which then translocate to the nucleus where they regulate gene expression. This article reports the first evidence in vivo of an interaction between inhaled LABA and corticosteroid on GR nuclear translocation in human airway cells using immunocytochemistry. We initially demonstrated significant GR activation 60 minutes after inhalation of 800 microg beclomethasone dipropionate in six healthy subjects. Subsequently, we determined the effects of salmeterol and fluticasone propionate (FP) in seven steroid-naive patients with asthma. We observed dose-dependent GR activation with 100- and 500-microg doses of FP, and to a lesser extent with 50 microg salmeterol alone. However, combination therapy with 100 microg FP and salmeterol augmented the action of FP on GR nuclear localization. In vitro, salmeterol enhanced FP effects on GR nuclear translocation in epithelial and macrophage-like airway cell lines. In addition, salmeterol in combination with FP enhanced glucocorticoid response element (GRE)-luciferase reporter gene activity and mitogen-activated protein kinase phosphatase 1 (MKP-1) and secretory leuko-proteinase inhibitor (SLPI) gene induction. Together, our data confirm that GR nuclear translocation may underlie the complementary interactions between LABAs and corticosteroids, although the precise signal transduction mechanisms remain to be determined.

Molecular interactions between glucocorticoids and long-acting beta2-agonists

beta(2)-Adrenergic receptor agonists and glucocorticoids are the two most effective treatments for asthma, and used in combination they are more effective than either alone. Glucocorticoids mediate their anti-inflammatory effects through the action of activated glucocorticoid receptors (GRs), with the level of activity being related to the number of nuclear receptors. Glucocorticoids can upregulate the synthesis of several genes in human lung cells through interaction with specific DNA binding regions (glucocorticoid response elements) within the promoter region of glucocorticoid-responsive genes. Many of the down-regulating effects of GRs on the synthesis of cytokines and other inflammatory mediators are due to repression of other transcription factors, such as activator protein-1 and nuclear factor kappaB. GR functions such as nuclear localization and gene activation can be regulated by phosphorylation status. Long-acting beta(2)-agonists may affect GR nuclear localization through modulation of GR phosphorylation and furthermore through priming of GR functions within the nucleus by modifying GR or GR-associated protein phosphorylation. Glucocorticoids in turn may regulate beta(2)-adrenergic receptor function by increasing its expression, acting through glucocorticoid response elements, and, importantly, by restoring G-protein-beta(2)-receptor coupling and inhibiting beta(2)-receptor downregulation, thereby preventing desensitization.

Reference spirometric values for healthy lifetime nonsmokers in Thailand

The normal spirometric reference values for Thai people are still not yet available. The aim of this study was to establish standard spirometric equations for Thai people. Subjects 10 years of age and over were selected and their demographic distributions represented that of the population of the whole country. Inclusion criteria were strictly lifetime nonsmokers, no history of chronic cardiopulmonary disease (using a modified ATS--DLD 78 respiratory adult questionnaire), normal standard chest radiograph and unremarkable physical examination. They had to be without respiratory symptoms at the time of the study. Spirometric values were obtained by 5 turbine system 'Pony graphic' (Cosmed, Italy) spirometers which met ATS recommendations. A normal group of 2299 women and 1655 men were selected. Regression analyses using sex, height and age as independent variables were used to provide equations for predicted values. The results were: [table: see text] FVC and FEV1 from this study are close to the Chinese but are 8-20 per cent lower than the Caucasians. These predicted equations are recommended to be used for future reference values in the Thai population.

An exotic pulmonary infection in Thailand: melioidosis

Melioidosis is an infectious disease from Burkholderia pseudomallei and is confined in specific geographic areas such as Southeast Asia. Its highest prevalence in Thailand is in the north-eastern part. Most infected patients had worked paddy fields or had underlying diseases such as diabetes mellitus. Melioidosis can manifest clinically, with either disseminated or localized features. In the disseminated form patients developed an acute and progressive course with septicaemia. In contrast, patients with the localized form usually presented with prolonged fever, and symptoms of one or more organ involvement, in particular the lung and the liver. Definite diagnosis of melioidosis is made by an isolation of Burkholderia pseudomallei from a variety of clinical specimens. Treatment of choice for the septicaemic patients is an initial combination of ceftrazidime and trimethoprime-sulfamethoxazole, followed by trimethoprime-sulfamethoxazole for up to 6-12 months depending on the result of clinical specimen culture. Treatment for the localized form requires simultaneous antibiotic therapy and surgical drainage. However, optimum duration of antibiotic therapy remains unknown so further research is required. Melioidosis is an important disease in terms of mortality rate and it requires rapid diagnosis and treatment. To prevent recurrence, it is necessary to continue oral doxycycline or trimethoprime-sulfamethoxazole for 6-12 months.