Impact of Hymenoptera venom allergy and the effects of specific venom immunotherapy on mast cell metabolites in sensitized children.

INTRODUCTION AND OBJECTIVE: Mast cells (MC) are effector cells during severe systemic reactions (SR) to Hymenoptera stings. Venom specific immunotherapy (VIT) is the treatment of choice for prevention of SR to stings. Tryptase and prostaglandin D2 metabolites (PGD2) are the markers of MC activation. The study design was to 1. compare baseline values of serum tryptase concentration (BST) and PGD2 metabolites in children with/without venom sensitization, 2. to evaluate an influence of rush VIT on MC markers in treated children. MATERIALS AND METHODS: Sensitized group: 25 children with SR to Hymenoptera sting. CONTROL GROUP: 19 healthy children. Active treatment: 5-day-rush-VIT. BST was evaluated by ImmunoCAP, PGD2 metabolites in blood and urine by GC-NICI-MS. RESULTS: The baseline blood levels of MC markers were significantly higher, while urinary concentration of 9α,11ß-PGF2 was significantly lower in the whole group of venom-sensitized children compared to controls. Severity of SR showed negative correlation with urinary PGD2 metabolites, while positive with plasma 9α,11ß-PGF2 and BST concentration The highest sensitivity was obtained for plasma 9α,11ß-PGF2 whereas the highest specificity for urinary PGD-M. CONCLUSIONS: In children with IgE-mediated SR to Hymenoptera stings, elevation of baseline values of PGD2 metabolites in blood is accompanied by decreased excretion of its urinary metabolites. Assessment of stable PGD2 metabolites might serve as an independent MC marker to identify allergic children. There is an association between urinary PGD2 metabolites and severity of the SR to Hymenoptera stings.

Aspirin desensitization in patients with aspirin-induced and aspirin-tolerant asthma: a double-blind study.

BACKGROUND: Numerous open trials have demonstrated the beneficial clinical effects of aspirin desensitization (AD) in patients with aspirin-induced asthma (AIA). These beneficial effects might be attributable to aspirin's potent anti-inflammatory properties, but that supposition requires further corroboration. OBJECTIVE: We sought to compare the clinical and biochemical responses to chronic oral AD in 20 patients with AIA and 14 patients with aspirin-tolerant asthma (ATA). All of the patients had chronic rhinosinusitis and nasal polyposis, and these responses were investigated in a pilot, double-blind, placebo-controlled study. METHODS: Twelve patients with AIA and 6 patients with ATA were randomly assigned to receive 624 mg of aspirin, and 8 patients with AIA and 8 patients with ATA received placebo. Both aspirin and placebo were administered once daily for 6 months. Nasal symptoms, Sino-Nasal Outcome Test (SNOT20) scores, peak nasal inspiratory flows, Asthma Control Questionnaire scores, spirometric parameters, peak expiratory flows, blood eosinophilia, and corticosteroid doses were assessed on a monthly basis. Levels of urinary leukotriene E4 and the stable plasma prostaglandin (PG) D2 metabolite 9α,11ß-PGF2 were evaluated at baseline and after 1, 3, 5, and 6 months. RESULTS: Only the patients with AIA subjected to AD reported improvements in smell and reductions in sneezing and nasal blockade. The SNOT20 and Asthma Control Questionnaire scores of these patients decreased, and their peak nasal inspiratory flows increased. The dosages of inhaled corticosteroids were reduced. There were no changes in leukotriene E(4) or 9α,11ß-PGF(2) levels after AD. CONCLUSION: The clinically beneficial effects of AD on nasal and bronchial symptoms occurred only in the patients with AIA.

Certain subphenotypes of aspirin-exacerbated respiratory disease distinguished by latent class analysis.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is recognized as a distinct asthma phenotype. It usually has a severe course accompanied by chronic hyperplastic eosinophilic sinusitis with nasal polyps, blood eosinophilia, and increased concentrations of urinary leukotriene E4 (LTE4). More insightful analysis of individual patients shows this group to be nonhomogeneous. OBJECTIVE: We sought to identify any likely subphenotypes in a cohort of patients with AERD through the application of latent class analysis (LCA). METHODS: Clinical data from 201 patients with AERD (134 women) were collected from questionnaires. Standard spirometry, atopy traits, blood eosinophilia, and urinary LTE4 concentrations were evaluated. LCA was applied to identify possible AERD subphenotypes. RESULTS: Four classes (subphenotypes) within the AERD phenotype were identified as follows: class 1, asthma with a moderate course, intensive upper airway symptoms, and blood eosinophilia (18.9% of patients); class 2, asthma with a mild course, relatively well controlled, and with low health care use (34.8% of patients); class 3, asthma with a severe course, poorly controlled, and with severe exacerbations and airway obstruction (41.3% of patients); and class 4, poorly controlled asthma with frequent and severe exacerbations in female subjects (5.0% of patients). Atopic status did not affect class membership. Patients with particularly intensive upper airway symptoms had the highest levels of blood eosinophilia and the highest concentrations of urinary LTE4. CONCLUSIONS: LCA revealed unique AERD subphenotypes, thus corroborating the heterogeneity of this population. Such discrimination might facilitate more individualized treatment in difficult-to-treat patients.

Risk of venous thromboembolism associated with single and combined effects of Factor V Leiden, Prothrombin 20210A and Methylenetethraydrofolate reductase C677T: a meta-analysis involving over 11,000 cases and 21,000 controls.

Genetic and environmental factors interact in determining the risk of venous thromboembolism (VTE). The risk associated with the polymorphic variants G1691A of factor V (Factor V Leiden, FVL), G20210A of prothrombin (PT20210A) and C677T of methylentetrahydrofolate reductase (C677T MTHFR) genes has been investigated in many studies. We performed a pooled analysis of case-control and cohort studies investigating in adults the association between each variant and VTE, published on Pubmed, Embase or Google through January 2010. Authors of eligible papers, were invited to provide all available individual data for the pooling. The Odds Ratio (OR) for first VTE associated with each variant, individually and combined with the others, were calculated with a random effect model, in heterozygotes and homozygotes (dominant model for FVL and PT20210A; recessive for C677T MTHFR). We analysed 31 databases, including 11,239 cases and 21,521 controls. No significant association with VTE was found for homozygous C677T MTHFR (OR: 1.38; 95 % confidence intervals [CI]: 0.98-1.93), whereas the risk was increased in carriers of either heterozygous FVL or PT20210 (OR = 4.22; 95 % CI: 3.35-5.32; and OR = 2.79;95 % CI: 2.25-3.46, respectively), in double heterozygotes (OR = 3.42; 95 %CI 1.64-7.13), and in homozygous FVL or PT20210A (OR = 11.45; 95 %CI: 6.79-19.29; and OR: 6.74 (CI 95 % 2.19-20.72), respectively). The stratified analyses showed a stronger effect of FVL on individuals ≤ 45 years (p value for interaction = 0.036) and of PT20210A in women using oral contraceptives (p-value for interaction = 0.045). In this large pooled analysis, inclusive of large studies like MEGA, no effect was found for C677T MTHFR on VTE; FVL and PT20210A were confirmed to be moderate risk factors. Notably, double carriers of the two genetic variants produced an impact on VTE risk significantly increased but weaker than previously thought.

Comparison of two treadmill training programs on walking ability and endothelial function in intermittent claudication.

BACKGROUND: In this randomized trial we compared two treadmill trainings, based on exercises performed to moderate claudication pain vs pain-free training, with respect to their effects on walking ability and endothelial function. METHODS: A total of sixty patients with stable intermittent claudication were randomized to the pain-free treadmill training (repetitive intervals to onset of claudication pain) or moderate treadmill training (repetitive intervals to moderate claudication pain). In both groups exercises were performed 3 times a week for 3 months. Changes in flow mediated dilatation (FMD) and treadmill walking performance as well as plasma levels of C-reactive protein (hs-CRP) and fibrinogen were assessed before and after the program. RESULTS: Fifty-two patients completed the training program. Post-training maximal walking time was prolonged by 100% (p<0.001) vs 98% (p<0.001), and pain-free walking time by 120% (p<0.001) vs 93% (p<0.001) in the moderate training group as compared to the pain-free training group, respectively. FMD increased by 56% (p<0.001) in the moderate training group and by 36% (p<0.01) in the pain-free training group. No significant changes in the levels of hs-CRP and fibrinogen were seen after treadmill program in either group. CONCLUSIONS: Both pain-free treadmill training and the moderate treadmill training have similar efficacy on walking ability in patients with claudication. The improvement of post-training FMD indicates systemic effect of both treadmill programs on endothelial function. Both programs appear to be safe therapeutic modes, since none of them escalates the inflammation. Pain-free treadmill training seems useful and effective therapeutic option for patients with claudication.

Exercise training in intermittent claudication: effects on antioxidant genes, inflammatory mediators and proangiogenic progenitor cells.

Exercise training remains a therapy of choice in intermittent claudication (IC). However, too exhaustive exercise may cause ischaemic injury and inflammatory response. We tested the impact of three-month treadmill training and single treadmill exercise on antioxidant gene expressions, cytokine concentrations and number of marrow-derived proangiogenic progenitor cells (PPC) in the blood of IC patients. Blood samples of 12 patients were collected before and after training, before and 1, 3 and 6 hours after the single exercise. PPCs were analysed with flow cytometry, cytokine concentrations were checked with Milliplex MAP, while expression of mRNAs and miRNAs was evaluated with qRT-PCR. Treadmill training improved pain-free walking time (from 144 ± 44 seconds [s] to 311 ± 134 s, p=0.02) and maximum walking time (from 578 ± 293 s to 859 ± 423 s, p=0.01) in IC patients. Before, but not after training, the single treadmill exercise increased the number of circulating CD45dimCD34+CD133-KDR+ PPCs (p=0.048), decreased expression of HMOX1 (p=0.04) in circulating leukocytes, reduced tumour necrosis factor-α (p=0.03) and tended to elevate myeloperoxidase (p=0.06) concentrations in plasma. In contrast, total plasminogen activator inhibitor-1 was decreased by single exercise only after, but not before training (p=0.02). Both before and after training the single exercise decreased monocyte chemoattractant protein (MCP)-1 (p=0.006 and p=0.03) concentration and increased SOD1 (p=0.001 and p=0.01) expression. Patients after training had also less interleukin-6 (p=0.03), but more MCP-1 (p=0.04) in the blood. In conclusion, treadmill training improves walking performance of IC patients, attenuates the single exercise-induced changes in gene expressions or PPC mobilisation, but may also lead to higher production of some proinflammatory cytokines.

Increased production of IL-5 and dominant Th2-type response in airways of Churg-Strauss syndrome patients.

OBJECTIVE: Churg-Strauss syndrome (CSS) is a rare systemic vasculitis associated with eosinophilia and asthma. We assessed the local immune response in airways of CSS patients with different activity of the disease. METHODS: Concentration of IL-5, CCL17, CCL22 and CCL26 (ELISA) together with cell expression of T-helper-related genes (real-time PCR array) were measured in bronchoalveolar lavage fluid (BALF) sampled from 11 patients with active CSS, 11 patients with CSS in remission and 9 control subjects with bronchial asthma. RESULTS: In active CSS, both BALF and blood eosinophil counts were increased (P<0.01). BALF cells in active disease were characterized by an increased expression of Th2 and regulatory-type transcripts: STAT6, STAT3, GATA3, IL4, IL5 and IL10 as compared with asthmatics, and STAT5A, CCR4, FOXP3, IL4, IL5 and IL10 when compared with inactive CSS. There was significant increase in BALF concentration of IL-5 and CCL26 in exacerbation of CSS. CCR4-active chemokines were detected more frequently in active disease. We found a strong positive correlation between clinical parameters of disease activity (BVAS, eosinophilia) and expression of IL4, IL5, IL10 and STAT5A. CONCLUSION: These results indicate that as compared with asthma, active-CSS patients have much stronger local Th2 response in the airways. Airway cells may contribute to lung eosinophilia in CSS by producing IL-5 and eosinophil active chemokines.

Mild asthmatics benefit from music therapy.

OBJECTIVE: The aim of the study was to evaluate the effectiveness of pulmonary rehabilitation with music therapy in patients with asthma. METHODS: Seventy-six selected inpatients (54 women and 22 men; mean age = 56.4 years; SD = 11.8) with stable asthma underwent pulmonary rehabilitation in two groups: standard versus music therapy. RESULTS: After the intervention, an increase in analyzed spirometric values (forced expiratory volume at the first second (FEV(1)), FEV(1) as a percentage of vital capacity (FEV(1) % FVC), forced expiratory flow at 25%, 50%, and 75% of vital capacity (FEF(25), FEF(50), and FEF(75), respectively), and peak expiratory flow) was observed in both the groups (p < .05) but without any intergroup differences (p > .05). A greater increase of mean FEV(1) % FVC, FEF(50), and FEF(75) values was observed only in the patients with mild asthma from the music therapy group (p < .05). In both the groups, a dyspnea reduction was noted (p < .001). However, it was influenced neither by the type of rehabilitation nor by the gender (p > .05), but the interaction of these variables was significant (p = .044). A dyspnea reduction was observed in women in both the groups (p < .001) and in men in the music therapy group only (p = .001). A change in the value of anxiety (6.43, SD = 7.73) on the 10th day compared with the first day of the study was noticed (p < .001). However, this change was not influenced by the type of rehabilitation, gender, or a combination of these two variables (p > .05). CONCLUSION: Music therapy improves the respiratory function in patients with mild asthma and reduces dyspnea mainly in men with asthma.

Use of sensitive, broad-spectrum molecular assays and human airway epithelium cultures for detection of respiratory pathogens.

Rapid and accurate detection and identification of viruses causing respiratory tract infections is important for patient care and disease control. Despite the fact that several assays are available, identification of an etiological agent is not possible in ~30% of patients suffering from respiratory tract diseases. Therefore, the aim of the current study was to develop a diagnostic set for the detection of respiratory viruses with sensitivity as low as 1-10 copies per reaction. Evaluation of the assay using a training clinical sample set showed that viral nucleic acids were identified in ~76% of cases. To improve assay performance and facilitate the identification of novel species or emerging strains, cultures of fully differentiated human airway epithelium were used to pre-amplify infectious viruses. This additional step resulted in the detection of pathogens in all samples tested. Based on these results it can be hypothesized that the lack of an etiological agent in some clinical samples, both reported previously and observed in the present study, may result not only from the presence of unknown viral species, but also from imperfections in the detection methods used.

Nitric oxide production and endothelium-dependent vasorelaxation ameliorated by N1-methylnicotinamide in human blood vessels.

N(1)-methylnicotinamide (MNA(+)) has until recently been thought to be a biologically inactive product of nicotinamide metabolism in the pyridine nucleotides pathway. However, the latest observations imply that MNA(+) may exert antithrombotic and anti-inflammatory effects through direct action on the endothelium. We examined both in vivo and in vitro whether the compound might induce vasorelaxation in human blood vessels through the improvement of nitric oxide (NO) bioavailability and a reduction of oxidative stress mediated by endothelial NO synthase (eNOS) function. MNA(+) treatment (100 mg/m(2) orally) in healthy normocholesterolemic and hypercholesterolemic subjects increased the l-arginine (l-NMMA)-inhibitable flow-mediated dilation (FMD) of brachial artery responses that also positively correlated with MNA(+) plasma concentrations (r=0.73 for normocholesterolemics and r=0.78 for hypercholesterolemics; P<0.0001). MNA(+) increased FMD at the same concentration range at which it enhanced NO release from cultured human endothelial cells after stimulation with either the receptor-dependent (acetylcholine) or the receptor-independent endothelial NO synthase agonists (calcium ionophore A23187). MNA(+) restored the endothelial NO synthase agonist-stimulated NO release after the exposure of the cells to oxidized low-density lipoprotein. This effect was also associated with the normalization of the [NO]/[superoxide] balance in the endothelial cells. Taken together, the increased NO bioavailability in the endothelium contributes to the vasorelaxating properties of MNA(+). Targeting eNOS with MNA(+) might be therapeutically relevant for functional disorders of the endothelium, such as hypercholesterolemia and atherosclerosis.

Locus of control and selected mental health variables in asthmatics: what are the associations with dyspnea?

INTRODUCTION: The literature provides ambiguous information concerning the associations between asthma and psychopathology. The concept of the locus of control (LOC) can shed some light on the psychosomatic aspects of asthma. OBJECTIVES: The aim of the study was to analyze the relationship between dyspnea perception and psychopathological symptoms in asthma. We also tested how a tendency to attribute the LOC affects the relations between psychopathology and dyspnea. PATIENTS AND METHODS: We examined 111 consecutive, unselected asthma patients, including 74 women and 37 men. The mean age was 49.79 ± 14.19 years, with no significant differences between sexes. There were mainly patients with level 2 (38.7%) and level 4 (35.1%) of asthma severity according to the Global Initiative for Asthma classification. Sociodemographic data were collected and the General Health Questionnaire (GHQ) by Goldberg and the Locus of Control questionnaire by Rotter were applied. The level of dyspnea was assessed by patients on the 10-point Borg scale. Spirometry tests were performed. RESULTS: Gender, education, and LOC differentiated patients according to psychopathological symptoms. There were no differences in psychopathology between the groups with different levels of asthma severity. In women, there was a significant correlation between intensity of dyspnea and higher scores on all GHQ scales; in men, the correlation was observed only for the depression subscale and the general scale. CONCLUSIONS: Psychopathological disorders are more significantly associated with subjective asthma symptoms than with asthma severity. Gender, education, and a tendency to attribute the LOC internally may be significant for this association.

Increase in plasma sCD23 levels precedes immunoglobulin E elevation after coronary artery bypass graft surgery.

INTRODUCTION: Recent reports have confirmed an increase in plasma immunoglobulin E (IgE), which had been previously observed in clinical situations associated with tissue injury. Studies on the regulation of IgE levels have pointed to the role of low-affinity IgE receptor, i.e., sFcεRII (soluble CD23 [sCD23]). OBJECTIVES: The aim of the study was to assess the changes in the levels of this receptor in response to surgical injury during coronary artery bypass grafting. PATIENTS AND METHODS: The study group consisted of 33 patients (28 men and 5 women, aged 45-75 years). Blood samples were obtained from all patients before surgery and 24, 48, 72, and 120 hours after the surgery. The expression of FcεRII on B cells was measured using flow cytometry and plasma levels of sCD23 were determined by an enzyme-linked immunosorbent assay. RESULTS: We observed a significant increase in the total number of leukocytes and a significant decrease in the total number of lymphocytes with a simultaneous increase in the proportion of B cells (P <0.001). At the same time, the percentage of CD23-positive B cells (CD19/23+) decreased significantly (P <0.001) at 24 hours after surgery and remained low over the period of 72 hours. The plasma levels of sCD23 increased significantly (P <0.05) at 24 hours after surgery and remained elevated until the end of follow-up. All the above changes in the immune status preceded an increase in plasma IgE levels (P <0.001), which reached peak values on the fifth day after surgery (120 h). CONCLUSIONS: Surgical procedures are associated with a transient increase in plasma IgE levels, which is preceded by an increase in the level of sCD23 and a simultaneous decrease in the expression of CD23 on B cells. FcεRII (CD23) and sFcεRII (sCD23) may be involved in the regulation of IgE levels after trauma.

Both Th2 and Th17 responses are involved in the pathogenesis of Churg-Strauss syndrome.

OBJECTIVES: Churg-Strauss syndrome (CSS) is a rare systemic vasculitis associated with eosinophilia and granuloma formation. The contribution of individual T-helper cell lineages in pathogenesis of CSS is unknown. We hypothesised that in CSS an imbalance of major effector T-cell subpopulations takes place, and is further influenced by the mode of treatment. METHODS: We investigated the immunophenotype, cytokine production and transcriptome profile in peripheral blood lymphocytes (PBL) from 19 patients with stable CSS (10 were treated with glucocorticoids alone (CSS/GC), 9 with steroids and other immunosuppressive drugs (CSS/IS)), and 13 healthy controls. Furthermore, serum IL-5 and CCR4-active chemokines (CCL17, CCL22) were measured in six patients with active disease and upon remission. RESULTS: All CSS patients had decreased percentage of FoxP3+ regulatory T cells. In the CSS/GC group we found an increase in the Th17/Treg ratio and up-regulation of both Th2 and Th17 markers as evidenced by (1) over expression of Th2-related genes (GATA3, STAT6) in PBL, (2) elevated concentrations of serum IL-5 and CCL17, and (3) a concomitant increase in the number of Th17 cells, and secretion of IL-17A by stimulated PBL. The level of CCR4-active chemokines was increased in active-CSS, and correlated with blood eosinophilia. The combined treatment with steroids and other immunosuppressive drugs was associated with a significant decrease in both Th2-related chemokines and the number of Th17 cells. CONCLUSIONS: Our results indicate that both Th2 and Th17 lineages are involved in the pathogenesis of CSS, while CCR4-active chemokines contribute to eosinophilia in the active disease. These phenomena are down regulated by immunosuppressive therapy.

Efficacy of physical therapy methods in airway clearance in patients with chronic obstructive pulmonary disease: a critical review.

Multiplicity and variety of chest physical therapy (CPT) methods for increasing bronchial clearance in patients with chronic obstructive pulmonary disease (COPD) require an assessment of validity and reliability of the available clinical evidence. The aim of the review was to evaluate publications on CPT in COPD patients and to establish the basis (objective criteria) on which given methods and techniques are recommended or refuted. Systematic reviews, narrative reviews, and clinical practice guidelines, published in English between January 1, 2000 and July 1, 2010, were identified from the PubMed/MEDLINE and Cochrane (DARE, CRD, The Cochrane Airways Review Group Register) databases. The PEDro and SIGN scales were used to assess the quality and grade of recommendations for selected papers. Generally, the papers that we identified were based on small studies, limited to short-term outcomes, mostly using crossover designs, and rarely including sham therapy. Recommendations from clinical guidelines were mainly grade C or D. Health-related quality-of-life analyses, including working and exercise capacity, are lacking. The evidence from the studies in patients with cystic fibrosis cannot be directly extrapolated to COPD subjects. Despite the lack of convincing evidence, clinical practice supports the value of CPT in COPD. However, when making a clinical decision, potential side effects should be considered.

Eoxins: a new inflammatory pathway in childhood asthma.

BACKGROUND: Increased levels of leukotrienes (LTs) in exhaled breath condensate (EBC) are associated with asthma and bronchial hyperresponsiveness (BHR), whereas eicosanoids generated through the 15-lipoxygenase (LO) pathway (15-hydroxyeicosatetraenoic acid [HETE] and eoxins) have been less studied. OBJECTIVE: We investigated whether metabolites of the 5- and 15-LO pathways in EBC are associated with childhood asthma, asthma severity, and clinical parameters. METHODS: The present study included 131 school-aged children (27 children with problematic severe asthma, 80 children with mild-to-moderate asthma, and 24 healthy children) from the Severe Asthma Recognized in Childhood study and 19 children with other nonasthmatic chronic lung diseases. Clinical work-up included spirometry, fractional exhaled nitric oxide measurements, skin prick testing, and methacholine challenge. Eicosanoids were analyzed in EBC by using mass spectrometry and are reported as concentrations (in picograms per milliliter) and eicosanoid/palmitic acid (PA) ratios. RESULTS: Eoxin C4/PA, eoxin D4/PA, eoxin E4/PA, 15-HETE/PA, and LTC4/PA ratios were significantly increased in asthmatic versus healthy children. Eoxin D4/PA and LTE4/PA ratios were also significantly higher in children with BHR. A nonsignificant trend was observed toward higher eoxin/PA ratios with increasing asthma severity. In contrast to asthma, children with chronic lung disease had the highest 15-HETE/PA, LTC4/PA, LTE4/PA, and LTB4/PA ratios. CONCLUSION: The results point to increased activity of the 15-LO inflammatory pathway in childhood asthma. Mass spectrometric analyses of EBC demonstrate that increased eoxin levels not only accompany the increased 5-LO product LTC4 but are also associated with BHR. These markers might represent a new therapeutic target for asthma treatment.

Aspirin-induced asthma: a tribute to John Vane as a source of inspiration.

Aspirin-induced asthma is a distinct clinical syndrome consisting of inflammation, characterized by chronic eosinophilic rhinosinusitis with asthma and often nasal polyposis. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) exacerbate asthma, resulting in violent attacks. This is the hallmark of the clinical syndrome as explained by the cyclooxygenase theory. This theory, which is now generally accepted, states that asthma attacks precipitated by aspirin and other NSAIDs have no allergic background; instead, they occur due to the inhibition of cyclooxygenase-1 in sensitive patients. This paper describes how the discoveries of John Vane inspired the authors of the cyclooxygenase theory and led to further insight into the biology of eicosanoid metabolism in this relatively common type of asthma.