Interactions via α2ß1 Cell Integrin May Protect against the Progression of Airway Structural Changes in Asthma.

Increased airway wall thickness and remodeling of bronchial mucosa are characteristic of asthma and may arise from altered integrin signaling on airway cells. Here, we analyzed the expression of ß1-subfamily integrins on blood and airway cells (flow cytometry), inflammatory biomarkers in serum and bronchoalveolar lavage, reticular basement membrane (RBM) thickness and collagen deposits in the mucosa (histology), and airway geometry (CT-imaging) in 92 asthma patients (persistent airflow limitation subtype: n = 47) and 36 controls. Persistent airflow limitation was associated with type-2 inflammation, elevated soluble α2 integrin chain, and changes in the bronchial wall geometry. Both subtypes of asthma showed thicker RBM than control, but collagen deposition and epithelial α1 and α2 integrins staining were similar. Type-I collagen accumulation and RBM thickness were inversely related to the epithelial expression of the α2 integrin chain. Expression of α2ß1 integrin on T-cells and eosinophils was not altered in asthma. Collagen I deposits were, however, more abundant in patients with lower α2ß1 integrin on blood and airway CD8+ T-cells. Thicker airway walls in CT were associated with lower α2 integrin chain on blood CD4+ T-cells and airway eosinophils. Our data suggest that α2ß1 integrin on inflammatory and epithelial cells may protect against airway remodeling advancement in asthma.

Direct oral anticoagulants in patients with severe inherited thrombophilia: a single-center cohort study.

We investigated the safety and efficacy of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) associated with severe inherited thrombophilia. In this single-center cohort study, we enrolled 56 consecutive VTE patients with severe inherited thrombophilia, defined as the presence of antithrombin (n = 18), protein C (n = 12) and protein S (n = 12) deficiencies, homozygous Factor V Leiden (n = 3) and prothrombin G20210AA (n = 4) mutations, or combined defects (n = 7). During a median follow-up of 44.5 (IQR 30-52.5) months, rivaroxaban was used in 30 (53.6%), apixabanin 14 (25%), and dabigatran in 12 (21.4%) subjects. Recurrent nonfatal VTE was observed in 5 (8.9%) patients (2.4 per 100 patient-years), treated with rivaroxaban (n = 4) and apixaban (n = 1). Major bleeding and clinically relevant non-major bleeding (CRNMB) occurred in 2 (3.5%) and 4 (7%) subjects, respectively (0.96 per 100 patient-years and 1.92 per 100 patient-years, respectively), including 4 patients on rivaroxaban. The event-free survival analysis showed that the use of rivaroxaban was associated with increased risk of recurrent VTE or bleeding, compared with apixaban or dabigatran (HR 2.76, 95% CI 1.26-3.92, p = 0.039). In conclusion, the results of our cohort study indicate that full-dose dabigatran or apixaban are effective and safe in patients with severe inherited thrombophilia.

Citrullinated histone H3, a marker of extracellular trap formation, is increased in blood of stable asthma patients.

BACKGROUND: Emerging data indicates that extracellular traps (ETs), structures formed by various immune cell types, may contribute to the pathology of noninfectious inflammatory diseases. Histone hypercitrullination is an important step in ETs formation and citrullinated histone H3 (H3cit) is considered a novel and specific biomarker of that process. In the present study we have evaluated circulating H3cit in stable asthmatics and investigated its relationship with asthma severity, pulmonary function and selected blood and bronchoalveolar lavage (BAL) biomarkers. METHODS: In 60 white adult stable asthmatics and 50 well-matched controls we measured serum levels of H3cit. In asthmatics we also performed bronchoscopy with BAL. We analyzed blood and BAL biomarkers, including interleukin (IL)-4, IL-5, IL-6, IL-10, IL-12p70, IL-17A and interferon γ. For statistical analysis, Mann-Whitney U-test, χ2 test, one-way ANCOVA, ROC curve analysis and univariate linear regression were applied. Independent determinants of H3cit were established in a multiple linear regression model. RESULTS: Asthma was characterized by elevated circulating H3cit (17.49 [11.25-22.58] vs. 13.66 [8.66-18.87] ng/ml, p = 0.03). In asthmatics positive associations were demonstrated between serum H3cit and lung function variables, including total lung capacity (TLC) (ß = 0.37 [95% CI 0.24-0.50]) and residual volume (ß = 0.38 [95% CI 0.25-0.51]). H3cit was increased in asthma patients receiving systemic steroids (p = 0.02), as well as in subjects with BAL eosinophilia above 144 cells/ml (p = 0.02). In asthmatics, but not in controls, circulating H3cit correlated well with number of neutrophils (ß = 0.31 [95% CI 0.19-0.44]) and monocytes (ß = 0.42 [95% CI 0.29-0.55]) in peripheral blood. Furthermore, BAL macrophages, BAL neutrophils, TLC, high-sensitivity C-reactive protein, Il-12p70 and bronchial obstruction degree were independent determinants of H3cit in a multivariate linear regression model. CONCLUSIONS: Asthma is characterized by increased circulating H3cit likely related to the enhanced lung ETs formation. Inhibition of ETs might be a therapeutic option in selected asthma phenotypes, such as neutrophilic asthma.

The relationship of airway structural changes to blood and bronchoalveolar lavage biomarkers, and lung function abnormalities in asthma.

BACKGROUND: Airway structural changes are important in asthma pathology and require further investigations. OBJECTIVE: We sought to evaluate which computed tomography (CT) indices, bronchial histological traits, or blood and bronchoalveolar lavage (BAL) biomarkers correlate best with lung function abnormalities in asthma. METHODS: In 105 white adult asthmatics (53 with a component of fixed airflow obstruction), we determined airway cross-sectional geometry of two proximal (the right upper lobe apical segmental and the left apicoposterior) and two distal (the right and the left basal posterior) bronchi, quantified the low-attenuation lung area (LAA%), and analysed clusters based on airway CT-metrics. We also performed bronchofiberoscopy with BAL and endobronchial biopsy, assessed blood and BAL biomarkers, including interleukin (IL)-4, IL-5, IL-6, IL-10, IL-12p70, IL-17A, IL-23, interferon (INF)γ and periostin, together with circulating a disintegrin and metalloproteinase domain-containing protein (ADAM)33, and investigated interplays between analysed variables. RESULTS: Patients with fixed airflow limitation were characterized by lower lumen area and increased wall area and wall thickness ratios in distal airways, accompanied by raised LAA%. They had also higher blood neutrophilia, blood and BAL eosinophilia, increased circulating fibrinogen, periostin, and ADAM33. Blood neutrophilia, serum high density lipoproteins, thyroid-stimulating hormone, and shortened activated partial thromboplastin time were determinants of thicker reticular basement membrane (RBM). BAL eosinophilia was the only positive predictor of collagen I accumulation. Surprisingly, we observed a negative correlation between RBM thickening and collagen I deposit. Cluster analysis based on CT-metrics of the right lower lobe basal posterior bronchus revealed three well-separated clusters similar in age, asthma duration, and BMI, but different in RBM thickness, collagen I accumulation, and inflammatory markers. CONCLUSIONS AND CLINICAL RELEVANCE: Airway remodelling traits are mainly related to the Th2 profile, higher circulating ADAM33, and blood neutrophilia. Lung function abnormalities and RBM thickening correlate better with CT-metrics of distal than proximal airways.

Direct oral anticoagulants in the treatment of cerebral venous sinus thrombosis: a single institution's experience.

AIM OF THE STUDY: Oral anticoagulants, preferentially vitamin K antagonists (VKA), are recommended for 3-12 months in patients with cerebral venous sinus thrombosis (CVST). We present a series of patients with CVST treated with direct oral anticoagulants (DOAC). MATERIALS AND METHODS: We prospectively recruited 36 patients with CVST (aged 40.3 ± 9.2 years, 58.3% female) treated with DOAC based on the physician's or patient's preferences. Functional outcome was assessed with modified Rankin Scale. Recanalisation was assessed on imaging at 3-6 months post the event. Patients were followed for a median of 30 [interquartile range (IQR) 25-37] months. RESULTS: After use of heparin (median: 6 days; IQR 5-8.75), patients received dabigatran (150 mg bid, n = 16 or 110 mg bid, n = 2), rivaroxaban (20 mg qd, n = 10) or apixaban (5 mg bid, n = 8) for a median of 8.5 months (IQR 6.25-12). Complete or partial recanalisation was observed in 34 cases (94.4%). Three patients (8.3%) experienced major bleeding: menorrhagia on rivaroxaban (n = 2) and gastrointestinal bleeding on dabigatran (n = 1). A favourable functional outcome was observed in 24 (66.7%) patients, without any fatality. CSVT recurred in two patients (5.6%) and two venous thromboses developed in two other patients with inherited thrombophilia after anticoagulation withdrawal. CONCLUSIONS AND CLINICAL IMPLICATIONS: DOACs could be an alternative to VKA in CVST patients.

Unfavourably altered plasma clot properties in patients with primary Raynaud's phenomenon: association with venous thromboembolism.

Associations of Raynaud's phenomenon (RP) with venous thromboembolism (VTE) are unclear. We investigated the occurrence of RP together with prothrombotic state markers and fibrin clot properties in VTE patients. In this prospective cohort study we enrolled 360 patients free of known autoimmune disease. D-dimer, von Willebrand factor (vWF), plasma clot permeability (Ks), clot lysis time (CLT) along with fibrinolysis activators and inhibitors were determined at least 3 months since the VTE event. The presence/absence of RP was diagnosed at least 6 months before VTE. Primary RP occurred in 57 subjects (17%) with a 3.6-fold higher prevalence among women. Patients with RP had 11% higher fibrinogen, 16% higher vWF, 5% lower Ks, and 10% longer CLT (all p < 0.05). Females with RP (21%) had 6.6% lower Ks, 11.2% longer CLT, and 18.5% higher vWF (all p < 0.05) compared with men. CLT was predicted by PAI-1 and vWF levels. Regression analysis showed that RP was a predictor of prolonged CLT in the whole patient group (OR 3.46, 95% CI 1.92-6.24) and in women following VTE (OR 2.75, 95% CI 1.31-5.78). Primary RP patients tend to form denser plasma fibrin clots displaying impaired lysability and increased endothelial damage. RP might be a novel risk factor for VTE, especially in women.

Blocking of α1ß1 and α2ß1 adhesion molecules inhibits eosinophil migration through human lung microvascular endothelial cell monolayer.

INTRODUCTION: In cell trafficking to the airways in asthma, among integrins the most important are those containing α4 and ß2 subunits. We have previously shown that also blocking of collagen receptors, α1ß1 and α2ß1 integrins, inhibits transmigration of eosinophils of asthmatic subjects through a monolayer of skin microvascular endothelial cells seeded on collagen IV coated inserts. However, it was not clear whether this observation was limited to asthma or depended on the type of microvascular cell and collagen IV used as a base. MATERIALS & METHODS: In the current study we performed a transmigration assay using human lung microvascular endothelial cells seeded directly on a plastic surface as a base and blood cells isolated from 12 representatives of each of two groups, asthmatics and healthy donors, by gradient centrifugation, followed by immunomagnetic negative separation of eosinophils. Isolated eosinophils and peripheral blood mononuclear cells (PBMC) were inhibited by snake venom-derived integrin antagonists including viperistatin and VP12, as inhibitors of α1ß1 and α2ß1 integrin, respectively, and VLO5 and VLO4, as inhibitors of α4ß1 and α5ß1 integrin, respectively. RESULTS: All snake venom-derived anti-adhesive proteins were effective in inhibiting eosinophil transmigration, whilst only VLO5 and VLO4 reduced PBMC mobility in this assay. This observation was similar in both groups of subjects studied. DISCUSSION: α1ß1 and α2ß1 integrins could be involved in transmigration of eosinophil to the inflammatory site. Migratory inhibition was observed in asthma subjects as well as in healthy donors, and did not depend on origin of endothelial cells or the extracellular matrix component used as a base.

Granulomatosis with polyangiitis (Wegener's granulomatosis) with hard palate and bronchial perforations treated with rituximab - a case report.

We present a case of a 57-year-old woman suffering from granulomatosis with polyangiitis (GPA), who in the seventh months of immunosuppressive treatment (cyclophosphamide) progressed with new pulmonary changes and perforations of the hard palate and bronchi. Rituximab was introduced resulting in B-cell depletion and disappearance of anti-PR3 antibody. Palatal holes have substantially diminished and all bronchial perforations disappeared, covered by fibrous tissue. In the fourth month after rituximab administration, large scarring obstruction of the right main bronchus with upper and middle lobes atelectasis emerged. Because of increasing dyspnoea, stenotic bronchus was re-opened by bronchoscopy. Intervention was complicated by bilateral pneumothorax and later, on the seventh day, by fatal pulmonary bleeding. To our knowledge, this is the first report of GPA refractory to cyclophosphamide complicated by palatal and bronchial perforations.

Human eosinophil transmigration.

In this chapter we describe an optimized eosinophil transmigration assay. Transmigration of purified human peripheral blood eosinophils can be studied using special insert with membrane coated with extracellular matrix components or membrane covered with cells growing as a confluent monolayer, such as vascular endothelial cells of any origin or airway epithelial cells. In our opinion, eosinophil transmigration assay performed through monolayer of human microvascular endothelial cells of lung origin is a suitable tool to estimate the full migratory potential of eosinophils in studies on the pathology of asthma or other respiratory diseases, where eosinophils play important effector functions. This experimental system is easy to perform, simple for optimization, and comparable to in vivo processes occurring during eosinophil migration to the inflammatory sites in lungs.

Increased expression of α2 (CD49b), α4 (CD49d) and ß1 (CD29) integrin subunits on peripheral blood T lymphocytes in clinically stable mild-to-moderate persistent asthma.

INTRODUCTION: Adhesive molecules, particularly selectins and integrins, are critical for the inflammatory cell trafficking from blood to the lungs. Among integrins, the most important for cell infiltration are those containing α4 and ß2 subunits. OBJECTIVES: The aim of this study was to evaluate the expression of α1 and α2 integrin subunits on peripheral blood T cells in asthmatic subjects, because previously we showed evidence that α1ß1 and α2ß1 integrins may be found on peripheral blood eosinophils in these subjects. In this study, we also analyzed the expression of α4 and ß1 subunits as a positive reference. PATIENTS AND METHODS: Expression of α1, α2, α4, and ß1 subunits was analyzed by flow cytometry on CD4+ and CD8+ T lymphocytes obtained from the peripheral blood of 54 clinically stable, asymptomatic, mild-to-moderate persistent asthmatics and 40 healthy controls. RESULTS: The α1 subunit was not present on peripheral blood T cells in the majority of subjects in both study groups. Expression of α2 was detectable on CD8+ cells in both groups and was increased on CD4+ in asthmatics. Both types of T cells showed higher expression of α4 and ß1 in patients with asthma. Expression of α4 was higher on CD8+ T cells both in asthmatics and controls. CONCLUSIONS: Expression of α4 and ß1 integrin subunits is increased on peripheral blood T cells in patients with asthma, which confirms the preactivation of blood lymphocytes even in stable and asymptomatic disease. The biological role of α2 subunit on T cells remains to be elucidated.

The course of asthma in Churg-Strauss syndrome.

OBJECTIVES: Asthma is one of the key features of Churg-Strauss syndrome (CSS); however its course in the disease is unclear. The aim of this study was to analyze the asthma course in CSS patients. PATIENTS AND METHODS: We conducted a retrospective study of 22 CSS patients. Medical documentation was studied and patients were questioned about asthma symptoms during follow-up visits, which took place at four points of the disease. These points, at which lung function tests were performed, were CSS diagnosis; introduction of treatment at hospital discharge; and assessment of the first and last clinical and laboratory CSS remissions. Asthma control and severity were assessed in compliance with current guidelines. RESULTS: In the asthmatic group examined, 21 patients had an adult-onset asthma, with a mean age of onset 35.5 ± 11.8 years, preceded by sinusitis (100%) and nasal polyposis (36%). Asthma at its onset was severe in 68.5%, moderate in 27%, and very poorly controlled in 21 patients. Atopy was present in 64% of patients. Onset of vasculitic symptoms and CSS diagnosis was accompanied by high blood eosinophilia (maximal 7.2 x 10(3)/l [1.2 - 32], asthma exacerbation with airway obstruction in 16 patients (mean values of FEV1 68.8 ± 17.5% and FVC 84.8 ± 19.6%), and lung involvement. After introducing the treatment and achieving stable remission, asthma severity/control and lung function tests (forced expiratory volume in 1 s 92.7 ± 13.3%, and forced vital capacity 101 ± 15.5%; p < .001) improved. CONCLUSIONS: Asthma in CSS, although severe as its onset improves after achieving CSS remission.