Persistent airflow obstruction in young adult asthma patients

BACKGROUND

Lung function determined by spirometry and the severity of dyspnea correlate weakly in asthma patients. We attempted to determine the risk factors in asthma patients having persistent airway obstruction despite of having only mild subjective symptoms, and to examine the possibility of improving FEV1 by treating asthma on the basis of the bronchodilator change in FEV1.

METHODS

We examined asthma patients in their 20s and who visited Sagamihara National Hospital for the first time over a period of four years, by reviewing their clinical records. They underwent tests on the bronchodilator change in FEV1 and a test of airway hyperresponsiveness to histamine dihydrochloride.

RESULTS

One hundred thirty-eight subjects (mean age, 25.6 years; 51 males, 87 females; current smoking, 30.4%; history of childhood asthma, 48.6%) were enrolled. Among them, 18.8% (26/138) showed persistent airway obstruction (postbronchodilator FEV1/FVC (%) <80%). Using the multiple logistic regression model, we found that history of childhood asthma and smoking history were the significant isolated risk factors for persistent airway obstruction. Moreover, we determined that the factors associated with the reversibility of airway obstruction in asthma patients without subjective symptoms were history of childhood asthma.

CONCLUSIONS

In this study, patients not undergoing treatment for asthma were examined. History of childhood asthma and smoking history may be the risk factors for persistent airway obstruction in the asthma patients with mild subjective symptoms. Tests on the bronchodilator change in FEV1 should be performed in patients with history of childhood asthma and smoking history, even if they have only mild subjective symptoms.

[Use of forced oscillation technique to detect airflow limitations in adult Japanese asthmatics]

BACKGROUND

The forced oscillation technique (FOT) is a noninvasive method that is used to measure respiratory mechanics, including respiratory resistance and reactance at multiple frequencies. The advantage of FOT over spirometry is that FOT does not require forced expiratory maneuvers. Moreover, a new FOT machine called MostGraph (Chest Co. Ltd., Tokyo, Japan), has been developed in Japan, and can be used clinically to diagnose and monitor asthma. The purpose of this study is to show the standard of FOT measured with MostGraph in adult Japanese asthmatics.

METHODS

From our outpatient clinic, we recruited 151 stable asthmatics who were being treated with inhaled corticosteroids at the time of the study. For each subject, we measured the fraction of exhaled nitric oxide (FeNO) by using a chemiluminescent nitric oxide analyzer (Sievers280, GE, Boulder, Co); we determined the levels of forced expiratory volume in 1s (%FEV1) and maximum mid-expiratory flow rate (%MMF) by using spirometory; and we measured resistance at 5 Hz(R5), resistance at 20 Hz(R20), R5-R20, reactance at 5 Hz(X5), frequency of resonance (Fres), and low-frequency reactance area (ALX), by using a MostGraph FOT machine.

RESULTS

Each of the FOT parameters measured by using the MostGraph machine was significantly correlated with %FEV1 and %MMF (p<0.001), with Fres showing the strongest association. Three of the FOT parameters, X5, Fres, and ALX, were significantly associated with the subject's age (p=0.01, p<0.001, p<0.001, respectively), and all FOT parameters were significantly associated with the subject's body mass index (BMI) (p<0.001 to p=0.018). The results of multiple regression analyses between FOT parameters and FEV1, age, BMI, and FeNO, showed that Fres was significantly associated with FEV1(p<0.001) and BMI (p<0.001). From the results of the simple linear regression between Fres and FEV1, we estimated that Fres values of 17.5 Hz corresponded to %FEV1 values of 60%; Fres values of 11.3 Hz corresponded to %FEV1 values of 80%; and Fres values of 4.94 Hz corresponded to %FEV1 values of 100%.

CONCLUSION

FOT parameters measured by using a MostGraph machine can be used successfully to assess the level of airflow limitation in adult stable asthmatics.

283 Relationship between Aeroallergen Sensitization and Asthma Severity in Patients with Aspirin-Exacerbated Respiratory Disease

Background

The pathogenesis of aspirin-exacerbated respiratory disease (AERD) is presumed to involve the aspirin/non steroidal anti-inflammatory drug (NSAID)-induced abnormal metabolism of arachidonic acid, resulting in the production of 5-lipoxygenase metabolites, particularly leukotriene C4. Aspirin intolerance occurs around the same time as asthma onset, and a few of the patients with AERD had suffered from pediatric asthma. Although atopy is not associated with the pathogenesis of AERD, some of the patients with AERD have aeroallergen sensitization. There are few studies in which the association between the pathogenesis of AERD and atopy has been clarified.

Methods

Ninety AERD patients, whose aspirin sensitivity was determined by the aspirin challenge test, and 100 aspirin-tolerant asthma (ATA) patients, whose age and sex were adjusted, participated in this study. Atopy was defined as a positive reaction in an intradermal test to one or more of 19 common aeroallergens, or a positive reaction above class one in Immuno CAP RAST. We analyzed the relationships between aeroallergen sensitization and clinical settings of AERD patients.

Results

The atopic and non atopic AERD groups showed median serum total IgE concentrations of 464 and 130 IU/l (P value = 0.004), respectively. The asthma of atopic patients with AERD was milder than that of non atopic patients with AERD. (P value = 0.05) The Lund-Mackay score of atopic patients with AERD was lower than that of non atopic patients with AERD. (P value = 0.02)

Conclusions

Two-thirds of the patients with AERD showed aeroallergen sensitization. The asthma and sinusitis in atopic patients with AERD were significantly milder than those in non atopic patients with AERD. Aeroallergen sensitization might prevent the worsening of asthma in patients with AERD.

Characterization of mandibular fractures using 64-slice multidetector CT

OBJECTIVE

The aim of this study was to characterize mandibular fracture locations using 64-slice multidetector CT (MDCT).

METHODS

CT scans of 138 patients with mandibular fractures who underwent 64-slice MDCT were studied. Mandibular fractures were classified into five types: median, paramedian, angle, condylar and coronoid process. Statistical analysis for the relationship between multiple fractures and type of mandibular fractures was performed using χ(2) test with Fisher's exact test.

RESULTS

The percentage of multiple mandibular fractures was 80.9% median type, 74.3% paramedian type, 52.9% angle type and 60.9% condylar type. The resultant data showed a significant relationship between multiple fractures and the median type (p = 0.000), paramedian type (p = 0.002) and condylar type (p = 0.003).

CONCLUSION

The results suggest that multiple fractures are related to the type of mandibular fractures.

Obesity and aspirin intolerance are risk factors for difficult-to-treat asthma in Japanese non-atopic women

BACKGROUND

Asthma is a clinical syndrome characterized by variabilities in disease expression and severity. The pathophysiological mechanism underlying anti-asthma treatment resistance is also assumed to be different between disease phenotypes.

OBJECTIVE

To elucidate the effect of gender and atopic phenotype on the relationship between clinical factors and the risk of treatment resistance.

METHODS

We compared outpatients with difficult-to-treat asthma (DTA; n = 486) in a tertiary hospital for allergic diseases in central Japan with those with controlled severe asthma (n = 621) with respect to clinical factors including body mass index (BMI) and aspirin intolerance using multivariate logistic regression analysis stratified by gender and atopic phenotype.

RESULTS

When analysis was performed on the entire study populations, obesity (BMI ≥ 30 kg/m(2); adjusted odds ratio (OR) 1.92; 95% confidence interval (95% CI: 1.07-3.43) and aspirin intolerance (OR: 2.56, 95% CI: 1.44-4.57) were found to be the significant risk factors for DTA. However, after the stratification by gender and atopic phenotype, the association between obesity and DTA was significant only in women (OR: 2.76, 95% CI: 1.31-5.78), but not in men (OR: 1.03, 95% CI: 0.38-2.81), and only in non-atopics (OR: 4.03, 95% CI: 1.15-14.08), but not in atopics (OR: 1.54, 95% CI: 0.79-3.02). The similar gender and phenotypic differences were also observed in the association between aspirin intolerance and DTA: namely, the association was significant only in women (OR: 3.96, 95% CI: 1.84-8.50), but not in men (OR: 1.19, 95% CI: 0.46-3.05); and only in non-atopics (OR: 5.49, 95% CI: 1.98-15.19), but not in atopics (OR: 1.39, 95% CI: 0.65-2.98).

CONCLUSIONS AND CLINICAL RELEVANCE

Significant associations of obesity and aspirin intolerance with DTA were observed only in women and in non-atopics. These findings suggest that a phenotype-specific approach is needed to treat patients with DTA.

Selective cyclooxygenase-2 inhibitor cross-reactivity in aspirin-exacerbated respiratory disease

Aspirin-induced asthma (AIA) is a severe and difficult-to-treat allergic disease in which acute asthma attacks are induced by nonsteroidal anti-inflammatory drugs. Patients with AIA rarely experience asthma attacks when taking celecoxib, a specific inhibitor of cyclooxygenase (COX) 2. A 33-year-old woman had a severe asthma attack with hypoxia and lost consciousness after oral provocation testing with 15 mg of aspirin and also with 50 mg of celecoxib. After 2 months of treatment with 10 mg/day of oral prednisolone, 1600 μg/day of inhaled fluticasone propionate, montelukast as a leukotriene receptor antagonist (LTRA), and long-term beta-agonist, we again challenged her with a provocation test with up to 200 mg of celecoxib; this time there were neither allergic symptoms nor decrease in forced expiratory volume in 1 second. Patients with severe or poorly controlled asthma may experience asthma attacks even if using selective COX-2 inhibitors. However, treatment with steroids and an LTRAs may inhibit asthma attacks induced by celecoxib.

Increase in salivary cysteinyl-leukotriene concentration in patients with aspirin-intolerant asthma

BACKGROUND

Cysteinyl-leukotrienes (CysLTs; LTC4, LTD4, and LTE4) play a considerable role in the pathophysiology of aspirin-intolerant asthma (AIA). Saliva has recently been validated as novel, simple, and noninvasive method for investigating inflammation in patients with asthma. The aim of this study is to clarify the molecular species of CysLT in saliva and to evaluate the CysLT and LTB4 concentrations in saliva in AIA patients. We also examined how the CysLT concentration in saliva reflects that of their corresponding urinary metabolite.

METHODS

We preformed an analytical cross-sectional study. CysLT and LTB4 concentrations in saliva were quantified by enzyme immunoassay (EIA) following purification by high-performance liquid chromatography (HPLC).

RESULTS

1. When analyzed by EIA in combination with HPLC, saliva was found to consist of LTC4, LTD4 and LTE4 in similar amounts. 2. In saliva analysis among the three groups (AIA patients, aspirin-tolerant asthma [ATA] patients, and healthy subjects), both the concentrations of CysLTs and LTB4 were significantly higher in AIA patients than in ATA patients and healthy subjects. 3. We found significant correlations between CysLT concentration and LTB4 concentration in saliva in each group. 4. No significant correlation was found between the concentration of LTE4 in urine and that of CysLTs in saliva.

CONCLUSIONS

In this study, we found higher concentrations of CysLTs and LTB4 in saliva from AIA patients than in saliva from ATA patients, suggesting that the quantification of CysLT and LTB4 concentrations in saliva may be another diagnostic strategy for AIA.

Actual control state of intermittent asthma classified on the basis of subjective symptoms

BACKGROUND

Many primary care physicians begin treatment of asthma patients on the basis of their subjective symptoms. We hypothesized that patients diagnosed as having intermittent asthma on the basis of subjective symptoms by a primary care physician may have their asthma severity underestimated.

METHODS

We investigated 293 patients who were in their 20s and diagnosed as having asthma. Two hundred and fifteen patients with intermittent asthma diagnosed on the basis of subjective symptoms were chosen. We evaluated their asthma severity using FEV(1) (% predicted), airway hyperresponsiveness to histamine dihydrochloride, and exhaled nitric oxide level as factors that determine asthma severity.

RESULTS

Among these patients, 27.8% were determined to have moderate or severe asthma by the pulmonary function test. History of childhood asthma was the only significant risk factor for a low pulmonary function. Among the patients, 60.9% showed moderate or severe airway hyperresponsiveness. History of childhood asthma was the only significant risk factor for the increase in airway hyperresponsiveness. Moreover, 53.8% showed a high exhaled nitric oxide level. History of childhood asthma was associated with an increased risk of a high eNO level as determined by univariate analysis, but no significant difference was observed in the comparison by multiple logistic regression analysis. The percentage of subjects classified into the mild group by all of the results of the three tests was only 20.6%.

CONCLUSION

We showed that asthma severity classified on the basis of only subjective symptoms may be underestimated in young adults. We showed that the diagnosis of mild intermittent asthma needs to be determined carefully.

Latex anaphylaxis caused by a Swan-Ganz catheter

A 78-year-old woman visited the division of cardiovascular disease in our hospital. She underwent a cardiac catheter examination, and a Swan-Ganz catheter was inserted. Several minutes later, she developed anaphylactic shock. She had no past history of latex allergy, but did have a banana allergy. Skin prick tests showed a positive reaction to an extract of latex gloves and an extract of the balloon of a Swan-Ganz catheter. Anaphylactic shock caused by the latex balloon of a Swan-Ganz catheter was diagnosed. It is necessary to pay attention to not only latex allergy but also fruit allergies with a cross-reactivity to latex.

[Differences in fraction of exhaled nitric oxide values measured by two offline methods or NIOXmino in adult Japanese asthmatics]

BACKGROUND

The fraction of exhaled nitric oxide (FeNO) is a useful marker of asthma control. The FeNO measurement with two offline methods and NIOXmino may be more affordable, no studies have examined the differences in FeNO values measured with various methods in adult asthmatics.

METHODS

The study population comprised 39 stable asthmatics treated with inhaled steroids at our outpatient clinic. FeNO values were measured by two offline methods (Sievers and CEIS), NIOXmino.

RESULTS

FeNO(NIOXmino) values were significantly correlated with those of FeNO(Sievers) (r=0.935, P< 0.001) and FeNOCEIS (r=0.908, P< 0.001). However, FeNO(NIOXmino) values were low compared with FeNO(Sievers) (FeNO(NIOXmino)=0.848 x FeNO(Sievers)) and FeNO(CEIS) (FeNO(NIOXmino)=0.672 x FeNO(CEIS)).

CONCLUSION

Differences exist in the values of FeNO measured by various methods: conversion equations are needed to compare the FeNO values among these three methods.

Bronchial hyperresponsiveness to histamine correlates with airway remodelling in adults with asthma

BACKGROUND

Chronic eosinophilic inflammation may promote bronchial hyperresponsiveness (BHR), which involves reversible reduction of airflow and airway remodelling such as a thickening of the reticular basement membrane (RBM) and hypertrophy and hyperplasia of airway smooth muscle (ASM). BHR to histamine (Hist) and acetylcholine (ACh) cannot differentiate airway inflammation and remodelling.

OBJECTIVE

To examine the correlations between eosinophilic inflammation or airway remodelling and BHR to Hist or ACh in adults with severe asthma.

METHODS

We examined eosinophils in the sputum of 50 adult patients with severe asthma before inhaled corticosteroid (ICS) treatment. Airway responses to ACh and Hist were measured on separate days after the first hospital visit and before bronchofiberscopy. Bronchial specimens were obtained by bronchofibrescopy for evaluation of RBM and ASM thickening after systemic corticosteroid treatment.

RESULTS

Eosinophil scores in the sputum before ICS treatment were correlated with BHR to ACh but not to Hist. Asthma duration was inversely correlated with % forced expiratory volume in 1 s, %V(50), %V(25), BHR to Hist, and ASM thickness, but not BHR to ACh or RBM. A multivariate logistic regression model showed that Long duration of asthma affected ASM thickness more than it affected %V(50). ASM thickness was inversely correlated with BHR to Hist but not to ACh.

CONCLUSION

In adult patients with severe asthma, BHR to ACh is related to the degree of eosinophilic airway inflammation, whereas BHR to Hist indicates airway remodeling, particularly ASM hypertrophy.

CD203c expression on human basophils is associated with asthma exacerbation

BACKGROUND

CD203c is a basophil cell surface marker used to diagnose and monitor various allergic diseases, but its relationship to asthma is not clear.

OBJECTIVE

We determined whether CD203c expression levels are associated with stable and exacerbated asthma.

METHODS

We used flow cytometry to compare spontaneous expression levels of surface markers on basophils from patients with stable or exacerbated asthma and from healthy subjects. Longitudinal changes in these expression levels were measured after basophil stimulation by IgE-dependent or IgE-independent mechanisms and compared with patients' asthma status.

RESULTS

Spontaneous expression levels of CD203c were significantly higher on basophils from patients with asthma exacerbation than patients with stable asthma or healthy subjects. In contrast, no differences in spontaneous expression levels of CD63 or CD69 were observed among the 3 groups. Anti-IgE-induced expression of CD203c significantly increased in basophils during asthma exacerbation (P = .005). Low concentrations of Dermatophagoides pteronyssinus or IL-3 induced higher expression levels of CD203c during asthma exacerbation than during clinical improvement; induction of CD203c expression by these antigens therefore correlates with asthma control. In the patients with clinical improvement, there was a correlation between spontaneous CD203c expression levels and the percent predicted values of FEV(1) (r = -0.761; P = .022).

CONCLUSION

Asthma exacerbation was accompanied by increased expression of CD203c on basophils that decreased significantly during remission. Basophil expression levels of CD203c might therefore be used to monitor asthma in patients.

Profile of eicosanoid generation in aspirin-intolerant asthma and anaphylaxis assessed by new biomarkers

BACKGROUND

It has recently demonstrated that a free radical-mediated pathway generates prostaglandins (PGs) and the corresponding prostaglandin enantiomers (ent-PGs). Aspirin-intolerant asthma and anaphylaxis accompany PGD(2) overproduction, possibly associated with mast cell activation via the COX pathway. However, free radical-mediated PG generation in the pathophysiology of these diseases, which can be demonstrated by measuring urinary ent-PGF(2)alpha, has not been reported.

OBJECTIVES

To evaluate the characteristic profile of eicosanoid generation via the COX and/or free radical-mediated pathway underlying aspirin-intolerant asthma and anaphylaxis.

METHODS

A comparative group analysis consisted of asthma (n = 17) and anaphylaxis (n = 8, none with aspirin-induced anaphylaxis) cases. Urinary eicosanoid concentrations were quantified as follows: 2,3-dinor-9alpha,11beta-PGF(2) by gas chromatography-mass spectrometry; leukotriene E(4), 9alpha,11beta-PGF(2), and PGs by enzyme immunoassay.

RESULTS

2,3-Dinor-9alpha,11beta-PGF(2) is a more predominant PGD(2) metabolite in urine than 9alpha,11beta-PGF(2). At baseline, the aspirin-intolerant asthma group (n = 10) had significantly higher leukotriene E(4) and lower PGE(2) concentrations in urine than the aspirin-tolerant asthma group. During the reaction, the urinary concentrations of leukotriene E(4) and PGD(2) metabolites correlatively increased, but with markedly different patterns of the mediator release, in the aspirin-intolerant asthma group and the anaphylaxis group, respectively. The urinary PGD(2) metabolites and primary PGs were significantly decreased in the aspirin-tolerant asthma group. Urinary ent-PGF(2)alpha concentrations were significantly increased in the anaphylaxis group but not the aspirin-intolerant asthma group.

CONCLUSIONS

When assessed by urinary 2,3-dinor-9alpha,11beta-PGF(2), PGD(2) overproduction during aspirin-intolerant bronchoconstriction was clearly identified, regardless of COX inhibition. It is evident that free radical-mediated PG generation is involved in the pathophysiology of anaphylaxis.

Changes in exhaled nitric oxide measured by two offline methods predict improvements in bronchial hyperresponsiveness after inhaled steroid therapy in Japanese adults with asthma

BACKGROUND

The fraction of exhaled nitric oxide (FeNO) is a useful marker of eosinophilic airway inflammation in asthmatics. No studies have examined the relationship between the change in FeNO levels measured offline and changes in bronchial hyperresponsiveness (BHR) in asthmatic patients treated with inhaled corticosteroids (ICS). The objective of this study was to investigate the relationship between the change in FeNO levels measured offline and the change in BHR to acetylcholine in asthmatic patients taking ICS.

METHODS

The study population comprised 41 ICS-treated asthmatics from our outpatient clinic. We measured FeNO levels by two methods -with a Sievers kit ("FeNOs") and with a kit from the Center for Environmental Information Science, Japan ("FeNOc") at baseline and after 1 year of regular treatment. We also used spirometry to test BHR to acetylcholine (PC(20Ach)).

RESULTS

The mean of duration of observation was 406 days. There were significant relationships between DeltalogPC(20Ach) and logPC(20Ach) (r = -0.877, P < 0.001), FeNOs (r = 0.465, P = 0.002), and FeNOc (r = 0.524, P = 0.004) at baseline, but not with age, the dose of ICS, FEV(1), or %FEV(1). Moreover, there was a significant relationship between DeltalogPC(20Ach) and DeltaFeNOs (r = -0.386, P = 0.013) and DeltaFeNOc (r = -0.473, P = 0.004), but not with DeltaFEV(1).

CONCLUSIONS

Changes in FeNOs and FeNOc correlated with improvements in BHR to acetylcholine in adult asthmatics after ICS therapy. Our findings suggest that offline monitoring of FeNO will facilitate the management of bronchial asthma in patients treated with ICS.

Clinical evaluation of severe asthma attacks requiring tracheal intubation and mechanical ventilation

BACKGROUND

Although the number of patients requiring hospitalization due to asthma attacks has decreased over the years, there are many who still require hospitalization for tracheal intubation and mechanical ventilation following a severe asthma attack. Therefore, we evaluated the characteristics of patients with asthma who required tracheal intubation and mechanical ventilation in our hospital.

METHODS

We evaluated 20 patients who had severely exacerbated asthma, requiring tracheal intubation and mechanical ventilation. An evaluation was made based on their smoking history, the number of days from the onset of the asthma attack to admission, the level of asthma control, treatments before presenting to our hospital, the frequency of hospital visits, the reason for tracheal intubation and mechanical ventilation, and outcome.

RESULTS

Of the 20 patients with asthma 13 were men and 7 women, with a mean age of 48.7 years. The characteristics of patients who required tracheal intubation and mechanical ventilation were as follows: (1) smokers, (2) not taking or irregularly taking medication, (3) using inhaled short-acting beta(2)agonist (SABA) alone as needed, and (4) not using inhaled corticosteroids (ICS).

CONCLUSIONS

Our findings suggest that treatment mainly using ICS, in addition to increased awareness of the dangers of asthma among the patients themselves, are important in preventing severe asthma attacks requiring tracheal intubation and mechanical ventilation.

[The effect of inhaled corticosteroid on the fraction of exhaled nitric oxide (FeNO) with off-line method in adult Japanese asthmatics]

BACKGROUND

The fraction of exhaled nitric oxide (FeNO) is a useful marker of asthma control. The FeNO measurement with our offline method using SIEVERS bag collection kit may be more affordable, but there have been no studies to show the effect of anti-asthmatic therapy on FeNO with our offline method.

METHODS

The study population comprised 36 steroid-naïve asthmatics at our outpatient clinic. We treated them according to asthma prevention and management guideline 2006, Japan. We also measured eNO levels by our offline method and spirometory on baseline, 4weeks, and 12 weeks of treatment.

RESULTS

All asthmatics were symptom-free on 12 weeks of treatment. The levels of FeNO FEV1/FVC were significantly decreased on 4 weeks and 12 weeks of treatment, compared with that on first visit. We classified the subjects into two groups; (A) FEV1/FVC <70% (n=11) or (B) FEV1/FVC > or =70% (n=25) on baseline. In (A) group, the level of FeNO and FEV1/FVC were significantly improved on 4 and 12 weeks of treatment. In (B) group, on 4 weeks of treatment, the level of FEV1/FVC was significantly increased but the level of FeNO was not significantly changed. On 12 weeks of treatment, the levels of FeNO was significantly decreased, but the level of FEV1/FVC was not significantly changed.

CONCLUSION

The levels of FeNO were decreased by antiasthmatic therapy, so that offline monitoring of eNO will facilitate the management of bronchial asthma in patients treated with these drugs.

Relationship between exhaled nitric oxide measured by two offline methods and bronchial hyperresponsiveness in Japanese adults with asthma

BACKGROUND

Exhaled nitric oxide (eNO) is a useful marker of eosinophilic airway inflammation in asthmatics. There have been no studies to show the relationship between eNO measured by offline methods and the degree of bronchial hyperresponsiveness in asthmatic patients treated with inhaled corticosteroids.

METHODS

The study population comprised asthmatics at our outpatient clinic. We measured eNO levels by two methods ("eNOs" was measured with a Sievers kit; and "eNOc" was measured with a kit from the Center for Environmental Information Science, Japan). We also used spirometry to test bronchial hyperresponsiveness to acetylcholine (PC(20Ach)).

RESULTS

We recruited 192 stable asthmatics. There was a significant relationship between eNOs and eNOc (r = 0.919, p < 0.001). LogPC(20Ach) levels were negatively correlated with eNOs or eNOc levels (eNOs, r = -0.31, p < 0.001; eNOc, r = -0.23, p = 0.0013). We classified the subjects into two groups based on eNOs levels ((A) the subjects with high eNOs levels (n = 92) and (B) the subjects with normal eNOs levels (n = 100)) ; logPC(20Ach) was significantly correlated with eNOs (r = -0.34, p = 0.001) or eNOc (r = -0.28, p = 0.0075) but not correlated with %FEV(1) in (A), whereas logPC(20Ach) was not significantly correlated with eNO but significantly correlated with %FEV(1) (r = 0.33, p = 0.002) in (B).

CONCLUSIONS

Levels of eNOs and eNOc were correlated with the degree of bronchial hyperresponsiveness to acetylcholine in adult asthmatics treated with inhaled corticosteroids. Our findings suggest that offline monitoring of eNO will facilitate the management of bronchial asthma in patients treated with these drugs.

[The methodological aspects of nasal and exhaled nitric oxide levels in adult Japanese asthmatics]

BACKGROUND

Because both allergic rhinitis and asthma are caused by eosinophilic airway inflammation, using the same method to measure the eosinophilic inflammation of both the upper and lower airway would be advantageous. The levels of nitric oxide in exhaled air (FeNO) and nasal air (nNO) are useful as noninvasive markers of eosinophilic airway inflammation. Although the off-line method of measuring these parameters is easier and more useful than the on-line method, studies using the off-line method are rare in Japan.

METHODS

In Study 1, we measured the levels of nNO and FeNO in 9 healthy controls and 9 subjects with allergic rhinitis, to validate the methodology for using the off-line method to measure nNO. In Study 2, we measured the nNO and FeNO levels of and performed spirometry on 69 stable asthmatics treated with inhaled corticosteroid.

RESULTS

In Study 1, nNO levels were significantly increased in patients with allergic rhinitis compared with healthy subjects (31.0 [20.8 to 41.2] versus 7.4 [0.0 to 14.8] ppb {median [95% confidence interval]}, p=0.018). The 69 patients with asthma that comprised the study population in Study 2 were classified as asthmatics with rhinitis (treatment-naïve, n=14; treated with antiallergic drugs, n=11; treated with intranasal corticosteroid, n=19) and asthmatics without rhinitis (n=15). Although FeNO did not differ among groups, nNO was significantly increased in treatment-naïve asthmatics with rhinitis compared with patients with asthma only (26.5 [17.1 to 35.9] versus 8.0 [-1.1 to 17.1] ppb, p=0.033).

CONCLUSION

nNO levels measured by the off-line method are useful markers of allergic rhinitis.

[Cutoff point of the fraction of exhaled nitric oxide (FeNO) with the off-line method for diagnosing asthma and the effect of smoking on FeNO]

Evidences have shown that the fraction of exhaled nitric oxide (FeNO) is a useful marker of eosinophilic airway inflammation in asthmatics. There is no study to show the FeNO cutoff point for detecting asthma and the influence of smoking, measured by the Sievers Bag collection kit. The study population comprised 60 steroid-naive asthmatic patients (BA) (32 non-smokers, 28 smokers) and 59 patients with chronic cough (CC) without asthma (42 non-smokers, 17 smokers) in our outpatient clinic. We measured FeNO levels, spirometory, bronchial hyperresponsiveness against acetylcholine, and other parameters. The levels of FeNO were significantly increased in asthmatics compared with subjects with chronic cough. According to the ROC curve, the cutoff point of FeNO was 30 ppb (AUC = 0.83, sensitivity 78.1%, specificity 73.5%, p < 0.001) in non-smokers. The levels of FeNO in smokers were not significantly different from those in non-smokers, both bronchial asthma and chronic cough subjects. But the cutoff point of FeNO was 40 ppb (AUC = 0.65, sensitivity 67.8%, specificity 70.6%, p = 0.012). In conclusion, the cutoff point of FeNO was 30 ppb in non-smokers and 40 ppb in smokers. In smokers, FeNO measurement was less useful.

Increased urinary leukotriene E4 concentration in patients with eosinophilic pneumonia

Although eosinophils produce cysteinyl leukotrienes (CysLTs) in large quantities, information on the relationship between CysLTs and eosinophilic pneumonia (EP) is lacking. Inflammatory mediator concentrations in urine were quantified to clarify the relationship between CysLT concentrations and EP severity. Leukotriene (LT)E(4), eosinophil-derived neurotoxin (EDN), 9alpha,11beta-prostaglandin F2 and LTB(4) glucuronide concentrations were quantified in the urine of: EP patients during acute exacerbation and clinical remission; asthmatic patients during acute exacerbation and under stable conditions; and healthy control subjects. The urinary LTE(4) and EDN concentrations of EP patients during acute exacerbation were significantly higher than those of asthmatic patients and healthy subjects, and decreased immediately during clinical remission. The urinary LTE(4) concentration was associated with the urinary EDN concentration of EP patients during acute exacerbation. The urinary LTE(4) concentration significantly correlated with the diffusing capacity of the lung for carbon monoxide in EP patients during acute exacerbation. The increased urinary concentrations of leukotriene and eosinophil-derived neurotoxin were associated with acute exacerbation in eosinophilic pneumonia patients. The increased leukotriene concentration significantly correlated with diffusing capacity of the lung for carbon monoxide, suggesting that the monitoring of leukotriene concentration may aid in the management of eosinophilic pneumonia patients.

[Relationship between cysteinyl leukotriene in exhaled breath condensate and the severity of asthma in adult asthmatics in Japan]

BACKGROUND

The measurement of several mediators in exhaled breath condensate (EBC) can be useful as the biomarker for asthma. But there are a few reports about EBC of asthmatics in Japan.

AIM

We examined the safety of the collection of EBC and the utility of cysteinyl leukotriene (cysLTs) in EBC as the biomarker of asthma.

METHODS

Fifty-three asthmatics and eleven subjects without asthma were recruited. After the measuring of exhaled nitric oxide (eNO) and spirometory, EBC were collected. The levels of cysLTs in EBC were measurement by ELISA within 2 months.

RESULTS

The collection of EBC did not induce any other symptoms in all subjects. In 48 subjects, the collection significantly increased their FEV1 and MMF level (DeltaFEV1: 2.27+/-0.77%, DeltaMMF 14.6+/-3.92% (mean+/-SEM). The level of cysLTs in EBC on asthmatics treated with high-dose ICS was significantly high compared with control group (p=0.0034), steroid-naïve asthmatics or asthmatics treated with low-dose ICS (steroid naive vs. high dose ICS, p=0.041, low dose ICS vs. high dose ICS, p=0.021). The relationship between cysLTs in EBC and the levels of LTE4 in urine was significantly correlated (n=34, r=0.32, p=0.0435). The relationship between cysLTs in EBC and the levels of eNO was significantly correlated only in steroid-naïve asthmatics (r=-0.57, p=0.0369). There was no relationship between cysLTs in EBC and FEV1, or log PC20Ach.

CONCLUSION

The collection of EBC was perfectly non-invasive. The level of cysLTs can be useful as a biomarker of asthma.

Pneumoperitoneum recurring concomitantly with asthmatic exacerbation

We report a patient with pneumoperitoneum that recurred concomitantly with asthmatic exacerbation. The patient was a 71-year-old man with a medical history of bronchial asthma. Chest X-rays obtained during asthmatic exacerbation showed intra-abdominal air beneath his diaphragm. Subsequently, a computed tomography scan of his chest confirmed mediastinal emphysema and intra-abdominal air beneath his diaphragm. The intra-abdominal air disappeared after his asthmatic exacerbation was relieved by treatment. The patient showed recurrent pneumoperitoneum concomitant with asthmatic exacerbation. The cause of his pneumoperitoneum was conjectured to be the movement of air from the mediastinum to the peritoneal cavity through the sternocostal triangle.