Asthma: a disease remodeling the airways

Matrix metalloproteinase-9 gene polymorphisms in nasal polyposis

Background

Matrix metalloproteinase (MMP) is involved in the upper airway remodeling process. We hypothesized that genetic variants of the MMP-9 gene are associated with cases of chronic rhinosinusitis with nasal polyposis.

Methods

We conducted a case-control study where 203 cases of chronic rhinosinusitis with nasal polyposis and 730 controls were enrolled. Three tagging single nucleotide polymorphisms (SNPs) and one promoter functional SNP rs3918242 were selected. Hardy-Weinberg equilibrium (HWE) was tested for each SNP, and genetic effects were evaluated according to three inheritance modes. Haplotype analysis was also performed. Permutation was used to adjust for multiple testing.

Results

All four SNPs were in HWE. The T allele of promoter SNP rs3918242 was associated with chronic rhinosinusitis with nasal polyposis under the dominant (nominal p = 0.023, empirical p = 0.022, OR = 1.62) and additive models (nominal p= 0.012, empirical p = 0.011, OR = 1.60). The A allele of rs2274756 has a nominal p value of 0.034 under the dominant model and 0.020 under the additive model. Haplotype analysis including the four SNPs showed a global p value of 0.015 and the most significant haplotype had a p value of 0.0045. We did not see any SNP that was more significant in the recurrent cases.

Conclusions

We concluded that MMP-9 gene polymorphisms may influence susceptibility to the development of chronic rhinosinusitis with nasal polyposis in Chinese population.

Tryptase as an inflammatory marker in allergic disease and asthma

Asthma is a chronic inflammatory disease of the airways, varying from occasional episodes of wheezing and shortness of breath, to an irreversible, life-threatening obstructive disease. While many cases are managed with relative ease, others do not respond to the traditional inhaled therapy or even to oral glucocorticosteroids. Although it cannot be cured as yet, asthma can be controlled if properly diagnosed. Usually, functional clinical parameters form the basis for estimation of the disease severity. In addition, the growing database of cytokine and mediator profiles have allowed their exploitation as molecular markers for processes underlying airway inflammation in asthma. Tryptase is a potent and versatile mediator in allergic inflammation, orchestrating both acute and chronic events by acting on a vast array of cells and tissue components. For more than a decade, tryptase has been used as a marker for allergic inflammation in asthma as well as in a variety of other airway diseases. In this review, the current advantages and disadvantages of the use of tryptase as an inflammatory marker in asthma will be discussed.

Role of ADAM and ADAMTS metalloproteinases in airway diseases

Lungs are exposed to the outside environment and therefore to toxic and infectious agents or allergens. This may lead to permanent activation of innate immune response elements. A Disintegrin And Metalloproteinases (ADAMs) and ADAMs with Thrombospondin motifs (ADAMTS) are proteinases closely related to Matrix Metalloproteinases (MMPs). These multifaceted molecules bear metalloproteinase and disintegrin domains endowing them with features of both proteinases and adhesion molecules. Proteinases of the ADAM family are associated to various physiological and pathological processes and display a wide spectrum of biological effects encompassing cell fusion, cell adhesion, "shedding process", cleavage of various substrates from the extracellular matrix, growth factors or cytokines... This review will focus on the putative roles of ADAM/ADAMTS proteinases in airway diseases such as asthma and COPD.

Reduction of tumstatin in asthmatic airways contributes to angiogenesis, inflammation, and hyperresponsiveness

RATIONALE

Angiogenesis is a prominent feature of remodeling in asthma. Many proangiogenic factors are up-regulated in asthma, but little is known about levels of endogenous antiangiogenic agents. Collagen IV is decreased in the airway basement membrane in asthma. It has six alpha chains, of which the noncollagenous domain-1 domains have endogenous antiangiogenic properties.

OBJECTIVES

To study the expression of the noncollagenous domain-1 of the alpha3 chain of collagen IV, tumstatin, in the airways of subjects with and without asthma and to examine the potential for tumstatin to regulate angiogenesis and inflammation.

METHODS

We used immunohistochemistry and dot blots to examine the expression of tumstatin in bronchial biopsies, bronchoalveolar lavage fluid, and serum. We then used an in vitro angiogenesis assay and a murine model of allergic airways disease to explore tumstatin's biological function.

MEASUREMENTS AND MAIN RESULTS

The level of tumstatin is decreased 18-fold in the airways of patients with asthma but not in subjects without asthma, including those with chronic obstructive pulmonary disease, cystic fibrosis, and bronchiectasis. In vitro, recombinant tumstatin inhibited primary pulmonary endothelial cell tube formation. In a mouse model of chronic allergic airways disease, tumstatin suppressed angiogenesis, airway hyperresponsiveness, inflammatory cell infiltration, and mucus secretion and decreased levels of vascular endothelial growth factor and IL-13.

CONCLUSIONS

The observation that tumstatin is decreased in asthmatic airways and inhibits airway hyperresponsiveness and angiogenesis demonstrates the potential use of antiangiogenic agents such as tumstatin as a therapeutic intervention in diseases that are characterized by aberrant angiogenesis and tissue remodeling, such as asthma.

Oxygen-enhanced MRI vs. quantitatively assessed thin-section CT: pulmonary functional loss assessment and clinical stage classification of asthmatics

PURPOSE

The purpose of this study was to prospectively compare the efficacy of oxygen-enhanced MR imaging (O(2)-enhanced MRI) and CT for pulmonary functional loss assessment and clinical stage classification of asthmatics.

MATERIALS AND METHODS

O(2)-enhanced MRI, CT and %FEV(1) measurement were used 34 consecutive asthmatics classified into four stages ('Mild Intermittent [n=7]', 'Mild Persistent [n=8], 'Moderate Persistent [n=14]' and 'Severe Persistent [n=5]'). Relative enhancement ratio maps for every subject were generated, and determine mean relative enhancement ratios (MRERs). Mean lung density (MLD) and the airway wall area (WA) corrected by body surface area (WA/BSA) were also measured on CT. To compare the efficacy of the two methods for pulmonary functional loss assessment, all indexes were correlated with %FEV(1). To determine the efficacy of the two methods for clinical stage classification, all parameters for the four clinical stages were statistically compared.

RESULTS

%FEV(1) showed fair or moderate correlation with all parameters (0.15≤r(2)≤0.30, p<0.05). WA, WA/BSA and MRER of the 'Severe Persistent' group were significantly larger than those of 'Mild Intermittent' and 'Mild Persistent' groups (p<0.05), and MRER of the 'Moderate Persistent' group significantly lower than that of the 'Mild Intermittent' group (p<0.05).

CONCLUSION

O(2)-enhanced MRI is as effective as CT for pulmonary functional loss assessment and clinical stage classification of asthmatics.

Biomarker discovery in asthma-related inflammation and remodeling

Asthma is a complex inflammatory disease of airways. A network of reciprocal interactions between inflammatory cells, peptidic mediators, extracellular matrix components, and proteases is thought to be involved in the installation and maintenance of asthma-related airway inflammation and remodeling. To date, new proteic mediators displaying significant activity in the pathophysiology of asthma are still to be unveiled. The main objective of this study was to uncover potential target proteins by using surface-enhanced laser desorption/ionization-time of flight-mass spectrometry (SELDI-TOF-MS) on lung samples from mouse models of allergen-induced airway inflammation and remodeling. In this model, we pointed out several protein or peptide peaks that were preferentially expressed in diseased mice as compared to controls. We report the identification of different five proteins: found inflammatory zone 1 or RELM alpha (FIZZ-1), calcyclin (S100A6), clara cell secretory protein 10 (CC10), Ubiquitin, and Histone H4.

Airway vascular reactivity and vascularisation in human chronic airway disease

Altered bronchial vascular reactivity and remodelling including angiogenesis are documented features of asthma and other chronic inflammatory airway diseases. Expansion of the bronchial vasculature under these conditions involves both functional (vasodilation, hyperperfusion, increased microvascular permeability, oedema formation, and inflammatory cell recruitment) and structural changes (tissue and vascular remodelling) in the airways. These changes in airway vascular reactivity and vascularisation have significant pathophysiological consequences, which are manifest in the clinical symptoms of airway disease. Airway vascular reactivity is regulated by a wide variety of neurotransmitters and inflammatory mediators. Similarly, multiple growth factors are implicated in airway angiogenesis, with vascular endothelial growth factor amongst the most important. Increasing attention is focused on the complex interplay between angiogenic growth factors, airway smooth muscle and the various collagen-derived fragments that exhibit anti-angiogenic properties. The balance of these dynamic influences in airway neovascularisation processes and their therapeutic implications is just beginning to be elucidated. In this review article, we provide an account of recent developments in the areas of vascular reactivity and airway angiogenesis in chronic airway diseases.

Opposite effect of fluticasone and salmeterol on fibronectin and tenascin-C expression in primary human lung fibroblasts

BACKGROUND

Airway remodelling is a key feature of asthma and chronic obstructive pulmonary disease (COPD). The remodelling process involves the deposition of extracellular matrix (ECM) proteins within the airways. Current therapies for asthma and COPD consist of inhaled corticosteroids and long-acting beta(2)-agonists (LABA). However, their effect on airway remodelling is not well understood so far.

OBJECTIVE

In this study we investigated the effect of fluticasone and salmeterol, either alone or in combination, on fibronectin and tenascin-C protein, isoform, and mRNA levels in primary human lung fibroblasts.

METHODS

In our model, fibroblasts cultured in serum-free medium represented a non-inflammatory condition and stimulation with 5% fetal calf serum and/or TGF-beta(1) mimicked a pro-fibrotic environment with activation of tissue repair. Using these two different conditions, the effects of fluticasone and salmeterol on fibronectin and tenascin-C protein and mRNA levels were analysed by immunoblotting and semi-quantitative RT-PCR.

RESULTS

In both conditions, fluticasone increased fibronectin transcript and protein levels, whereas it decreased those of tenascin-C. Salmeterol neither affected fibronectin and tenascin-C synthesis significantly nor did it influence the effect of fluticasone when applied in combination. Furthermore, we found that treatment with fluticasone had an opposite effect on extra domain A and B containing fibronectin isoforms generated by alternative splicing compared with total fibronectin transcript levels, whereas tenascin-C isoforms were not differently modulated by fluticasone.

CONCLUSIONS

Our results indicate that standard therapies for inflammatory lung disorders influence ECM protein composition and relative expression levels. In contrast to corticosteroids, LABA did not significantly alter the expression of tenascin-C and fibronectin in cultures of primary human lung fibroblasts.

Reconstruction is not renovation - the role of remodeling in asthma

The chronicity of asthma results not only in persistent lung inflammation but also in changes in structure and composition of this vital organ. These changes are most commonly referred to as remodeling, and include epithelial dysplasia, angiogenesis, changes in the extracellular matrix and increased smooth muscle mass. In this review we summarize recent findings on the contribution of remodeling to the pathological phenotype of asthma. We discuss how and why current treatment (such as corticosteroids) options fail to adequately treat remodeling.

The role of the extracellular matrix and specific growth factors in the regulation of inflammation and remodelling in asthma

Asthma is a disease characterised by persistent inflammation and structural changes in the airways, referred to as airway remodelling. The mechanisms underlying these processes may be interdependent or they may be separate processes that are driven by common factors. The levels of a variety of growth factors (including transforming growth factor beta, granulocyte macrophage colony stimulating factor, and vascular endothelial growth factor) are known to be changed in the asthmatic airway. These and other growth factors can contribute to the development and persistence of inflammation and remodelling. One of the prominent features of the structural changes of the airways is the increased deposition and alterations in the composition of the extracellular matrix proteins. These proteins include fibronectin, many different collagen types and hyaluronan. There is a dynamic relationship between the extracellular matrix proteins and the airway mesenchymal cells such that the changes in the extracellular matrix proteins can also contribute to the persistence of inflammation and the airway remodelling. This review aims to summarise the role growth factors and extracellular matrix proteins play in the regulation of inflammation and airway remodelling in the asthmatic airway.

Tissue and matrix influences on airway smooth muscle function

Asthma is characterized by structural changes in the airways - airway remodelling. These changes include an increase in the bulk of the airway smooth muscle (ASM) and alterations in the profile of extracellular matrix (ECM) proteins in the airway wall. The mechanisms leading to airway remodelling are not well understood. ASM cells have the potential to play a key role in these processes through the production and release of ECM proteins. The ASM cells and ECM proteins are each able to influence the behaviour and characteristics of the other. The modified ECM profile in the asthmatic airway may contribute to the altered behaviour of the ASM cells, such responses to ECM proteins are modulated through the cell surface expression of integrin receptors. ASM cells from asthmatic individuals express different levels of some integrin subunits compared to nonasthmatic ASM cells, which have the potential to further influence their responses to the ECM proteins in the airways. ECM homeostasis requires the presence and activation of matrix metalloproteinases and their tissue inhibitors, which in turn modulate the interaction of the ASM cells and the ECM proteins. Furthermore, the complex interactions of the ASM cells and the ECM in the asthmatic airways and the role played by external stimuli, such as viral infections, to modulate airway remodelling are currently unknown. This review summarises our current understanding of the influence of the ECM on ASM function.

Inducible nitric oxide synthase inhibition attenuates lung tissue responsiveness and remodeling in a model of chronic pulmonary inflammation in guinea pigs

We evaluated the influence of iNOS-derived NO on the mechanics, inflammatory, and remodeling process in peripheral lung parenchyma of guinea pigs with chronic pulmonary allergic inflammation. Animals treated or not with 1400 W were submitted to seven exposures of ovalbumin in increasing doses. Seventy-two hours after the 7th inhalation, lung strips were suspended in a Krebs organ bath, and tissue resistance and elastance measured at baseline and after ovalbumin challenge. The strips were submitted to histopathological measurements. The ovalbumin-exposed animals showed increased maximal responses of resistance and elastance (p<0.05), eosinophils counting (p<0.001), iNOS-positive cells (p<0.001), collagen and elastic fiber deposition (p<0.05), actin density (p<0.05) and 8-iso-PGF2alpha expression (p<0.001) in alveolar septa compared to saline-exposed ones. Ovalbumin-exposed animals treated with 1400 W had a significant reduction in lung functional and histopathological findings (p<0.05). We showed that iNOS-specific inhibition attenuates lung parenchyma constriction, inflammation, and remodeling, suggesting NO-participation in the modulation of the oxidative stress pathway.

Pharmacology of airway smooth muscle proliferation

Airway smooth muscle thickening is a pathological feature that contributes significantly to airflow limitation and airway hyperresponsiveness in asthma. Ongoing research efforts aimed at identifying the mechanisms responsible for the increased airway smooth muscle mass have indicated that hyperplasia of airway smooth muscle, due in part to airway myocyte proliferation, is likely a major factor. Airway smooth muscle proliferation has been studied extensively in culture and in animal models of asthma, and these studies have revealed that a variety of receptors and mediators contributes to this response. This review aims to provide an overview of the receptors and mediators that control airway smooth muscle cell proliferation, with emphasis on the intracellular signalling mechanisms involved.

Fibrocytes in lung disease

Fibrocytes were first described over a decade ago as a population of cells in circulation with fibroblast-like properties, which were involved in tissue repair. Since that time, we have learned a significant amount about these bone marrow-derived cells, which contribute to wound healing and fibrosis. Fibrocytes express leukocyte markers such as CD34, CD45, and CD13 and also express mesenchymal markers such as pro-collagens I and III, vimentin, and fibronectin. In addition, they have been shown to express the chemokine receptors CXCR4 and CCR7, which appear to be important in cellular trafficking from the vascular to the extravascular compartment. Fibrocytes have been shown to contribute to a number of fibrotic disorders, and here, we review their involvement in lung diseases including pulmonary fibrosis, asthma, and vascular remodeling.

Epithelial cell proliferation contributes to airway remodeling in severe asthma

RATIONALE

Despite long-term therapy with corticosteroids, patients with severe asthma develop irreversible airway obstruction.

OBJECTIVES

To evaluate if there are structural and functional differences in the airway epithelium in severe asthma associated with airway remodeling.

METHODS

In bronchial biopsies from 21 normal subjects, 11 subjects with chronic bronchitis, 9 subjects with mild asthma, and 31 subjects with severe asthma, we evaluated epithelial cell morphology: epithelial thickness, lamina reticularis (LR) thickness, and epithelial desquamation. Levels of retinoblastoma protein (Rb), Ki67, and Bcl-2 were measured, reflecting cellular proliferation and death. Terminal deoxynucleotidyl-mediated dUTP nick end labeling (TUNEL) was used to study cellular apoptosis.

MEASUREMENTS AND MAIN RESULTS

Airway epithelial and LR thickness was greater in subjects with severe asthma compared with those with mild asthma, normal subjects, and diseased control subjects (p=0.009 and 0.033, respectively). There was no significant difference in epithelial desquamation between groups. Active, hypophosphorylated Rb expression was decreased (p=0.002) and Ki67 was increased (p<0.01) in the epithelium of subjects with severe asthma as compared with normal subjects, indicating increased cellular proliferation. Bcl-2 expression was decreased (p<0.001), indicating decreased cell death suppression. There was a greater level of apoptotic activity in the airway biopsy in subjects with severe asthma as compared with the normal subjects using the TUNEL assay (p=0.002), suggesting increased cell death.

CONCLUSIONS

In subjects with severe asthma, as compared with subjects with mild asthma, normal subjects, and diseased control subjects, we found novel evidence of increased cellular proliferation in the airway contributing to a thickened epithelium and LR. These changes may contribute to the progressive decline in lung function and airway remodeling in patients with severe asthma.

Stem cells and chronic lung disease

Stem cells have been shown to contribute to the repair and regeneration of injured lungs. These stem cells are resident in specific protected niches in the lung, or they can be mobilized from the bone marrow and recruited from the circulation in the setting of severe injury. Normal repair of the airway involves regeneration of the airway epithelium by stem cells in both the proximal airway and distal airspace, whereas aberrant repair of the lung may result from stem cells that lead to fibrosis. The stem cell niche in the lung is probably critical in determining whether "good" or "bad" stem cells are involved in local repair, and therefore whether fibrosis predominates. There is much excitement about the possibility of harnessing stem cells for repair and regeneration of the lungs. This review highlights current knowledge of this area and identifies gaps in our understanding of this complicated process.

Time sequence of airway remodeling in a mouse model of chronic asthma: the relation with airway hyperresponsiveness

During the course of establishing an animal model of chronic asthma, we tried to elucidate the time sequence of airway hyperresponsiveness (AHR), airway inflammation, airway remodeling, and associated cytokines. Seven-week-old female BALB/c mice were studied as a chronic asthma model using ovalbumin (OVA). After sensitization, mice were exposed twice weekly to aerosolized OVA, and were divided into three groups depending on the duration of 4 weeks, 8 weeks, and 12 weeks. At each time point, airway responsiveness, inflammatory cells, cytokines in bronchoalveolar lavage fluids (BALF), serum OVA-specific IgE, IgG1, IgG2a, and histological examination were carried out. AHR to methacholine, increased levels of OVA-specific IgG1 and IgG2a, and goblet cell hyperplasia were continuously sustained at each time point of weeks. In contrast, we observed a time-dependent decrease in serum OVA-specific IgE, BALF eosinophils, BALF cytokines such as IL-13, transforming growth factor-beta1, and a time-dependent increase in BALF promatrix metalloproteinase-9 and peribronchial fibrosis. In this OVA-induced chronic asthma model, we observed airway remodelings as well as various cytokines and inflammatory cells being involved in different time-dependent manners. However, increased airway fibrosis did not directly correlate with a further increase in airway hyperresponsiveness.

Polymorphism of egfr Intron1 is associated with susceptibility and severity of asthma

To clarify the associations of the egfr CA repeat polymorphism with asthma and its severity, we examined 579 Japanese asthmatics and 232 control subjects. The number of CA repeat ranges from 9 to 24. Asthmatic patients had a significantly higher incidence of having shorter alleles (<==16 CA repeats) compared with control subjects (p < 0.05). The most severe asthmatic patients have the highest frequency of short alleles (p < 0.05). In addition, subjects treated with leukotriene modifiers had higher incidence of having shorter allele compared to those without it (p < 0.01). Thus, the egfr CA repeat polymorphism is associated with the susceptibility and the severity of asthma.

Expression of ADAMs and their inhibitors in sputum from patients with asthma

ADAMs (a disintegrin and metalloprotease) constitute a family of cell surface proteins containing disintegrin and metalloprotease domains which associate features of adhesion molecules and proteases. ADAMTSs (a disintegrin and metalloprotease with thrombospondin motifs) bear thrombospondin type I motifs in C-terminal extremity, and most of them are secreted proteins. Because genetic studies have shown that ADAM-33 gene polymorphisms are associated with asthma, we designed this study to assess mRNA expression profile of several ADAM and ADAMTS proteases in sputum from patients with asthma and to investigate the relationship between expression of these proteases and asthma-associated inflammation and airway obstruction. mRNA expression profile of selected ADAM and ADAMTS proteinases (ADAM-8, -9, -10, -12, -15, -17, and -33; ADAMTS-1, -2, -15, -16, -17, -18, and -19), their physiological inhibitors TIMP-1 and TIMP-3, and RECK, a membrane-anchored MMP activity regulator, was obtained by RT-PCR analysis performed on cells collected by sputum induction from 21 patients with mild to moderate asthma and 17 healthy individuals. mRNA levels of ADAM-8, ADAM-9, ADAM-12, TIMP-1, and TIMP-3 were significantly increased, whereas mRNA levels coding for ADAMTS-1, ADAMTS-15, and RECK were significantly decreased in patients with asthma compared with control patients. ADAM-8 expression was negatively correlated with the forced expiratory volume at the first second (FEV(1)) (r = -0.57, P < 0.01), whereas ADAMTS-1 and RECK expressions were positively correlated to FEV(1) (r = 0.45, P < 0.05, and r = 0.55, P = 0.01, respectively). We conclude that expression of ADAMs and ADAMTSs and their inhibitors is modulated in airways from patients with asthma and that these molecules may play a role in the pathogenesis of asthma.

Expression of ADAMs and their inhibitors in sputum from patients with asthma

ADAMs (a disintegrin and metalloprotease) constitute a family of cell surface proteins containing disintegrin and metalloprotease domains which associate features of adhesion molecules and proteases. ADAMTSs (a disintegrin and metalloprotease with thrombospondin motifs) bear thrombospondin type I motifs in C-terminal extremity, and most of them are secreted proteins. Because genetic studies have shown that ADAM-33 gene polymorphisms are associated with asthma, we designed this study to assess mRNA expression profile of several ADAM and ADAMTS proteases in sputum from patients with asthma and to investigate the relationship between expression of these proteases and asthma-associated inflammation and airway obstruction. mRNA expression profile of selected ADAM and ADAMTS proteinases (ADAM-8, -9, -10, -12, -15, -17, and -33; ADAMTS-1, -2, -15, -16, -17, -18, and -19), their physiological inhibitors TIMP-1 and TIMP-3, and RECK, a membrane-anchored MMP activity regulator, was obtained by RT-PCR analysis performed on cells collected by sputum induction from 21 patients with mild to moderate asthma and 17 healthy individuals. mRNA levels of ADAM-8, ADAM-9, ADAM-12, TIMP-1, and TIMP-3 were significantly increased, whereas mRNA levels coding for ADAMTS-1, ADAMTS-15, and RECK were significantly decreased in patients with asthma compared with control patients. ADAM-8 expression was negatively correlated with the forced expiratory volume at the first second (FEV(1)) (r = -0.57, P < 0.01), whereas ADAMTS-1 and RECK expressions were positively correlated to FEV(1) (r = 0.45, P < 0.05, and r = 0.55, P = 0.01, respectively). We conclude that expression of ADAMs and ADAMTSs and their inhibitors is modulated in airways from patients with asthma and that these molecules may play a role in the pathogenesis of asthma.

Eosinophils and CCR3 regulate interleukin-13 transgene-induced pulmonary remodeling

Interleukin (IL)-13 transgene overexpression in the lung induces features of chronic inflammatory lung disorders, including an eosinophil-rich inflammatory cell infiltration, airway hyper-reactivity, and remodeling of the airway (eg, subepithelial fibrosis, goblet cell metaplasia, and smooth muscle hypertrophy and hyperplasia). Here, we aimed to define the role of eosinophils and eosinophil signaling molecules [eg, eotaxins and CC chemokine receptor (CCR) 3] in IL-13-mediated airway disease. To accomplish this, we mated IL-13-inducible lung transgenic mice with mice deficient in eosinophil chemoattractant molecules (eotaxin-1, eotaxin-2, and their receptor CCR3) and with mice genetically deficient in eosinophils (Deltadbl-GATA). We report that in the absence of eotaxin-2 or CCR3, there was a profound reduction in IL-13-induced eosinophil recruitment into the lung lumen. In contrast, in the absence of eotaxin-1, there was a fourfold increase in IL-13-mediated eosinophil recruitment into the airway. IL-13 transgenic mice deficient in CCR3 had a 98% reduction in lung eosinophils. Furthermore, the reduction in pulmonary eosinophils correlated with attenuation in IL-13-induced mucus cell metaplasia and collagen deposition. Mechanistic analysis identified alterations in pulmonary protease and transforming growth factor-beta1 expression in eosinophil-deficient mice. Taken together, these data definitively identify a functional contribution by eosinophils on the effects of chronic IL-13 expression in the lung.

Expired breath condensate hydrogen peroxide concentration and pH for screening cough variant asthma among chronic cough

The reported studies suggest a role for eosinophils in the pathogenesis of cough variant asthma. In the present study, the expired breath condensate level of hydrogen peroxide and pH were determined in patients with cough variant asthma and compared to subjects with classical asthma, with chronic cough nonasthmatic and healthy control. Twenty-seven patients with cough variant asthma, 43 patients with classical asthma, 32 patients with chronic cough and 27 healthy subjects were studied in a cross-sectional study. Hydrogen peroxide concentration was significantly higher in cough variant asthma as compared to chronic cough nonasthmatic patients and healthy control subjects, while pH level was significantly lower in cough variant asthma as compared to chronic cough nonasthmatic patients and healthy control subjects. However, there was no significant difference in expired breath condensate hydrogen peroxide and pH between cough variant asthma and classical asthma. In conclusion, hydrogen peroxide concentration and pH of expired breath condensate may be used as noninvasive markers to differentiate cough variant asthma from chronic cough.

[Difficult asthma]

Difficult asthma is a major issue in pulmonary medicine today because of its cost for patients and society. Difficult asthma is asthma that remains uncontrolled despite optimal specialist management. The validity of the diagnosis must be reconsidered in these cases: associated or differential diagnoses may be involved in the lack of control, and it is always necessary to assess the patient's treatment adhesion. Sufficient time--at least a year--must be taken to get to know the patient and to meet the objectives set. The standard asthma therapies should be tested objectively. Severe asthma is the reality of difficult asthma that endures despite a reaffirmed diagnosis, optimal compliance and controlled comorbidities. Better knowledge is needed of the pathophysiology of these patients' asthma. Improved knowledge of these phenotypes will make it possible to develop innovative treatments. They will need to be validated in clinical research for subsequent use that is wider but more rational because targeted at phenotypes likely to benefit from them.

Tissue remodelling in upper airways: where is the link with lower airway remodelling?

Tissue remodelling reported in upper airways include epithelial hyperplasia, increased matrix deposition in the nasal or paranasal lining, matrix degradation and accumulation of plasma proteins. Genetic influences, foetal exposures and early life events may contribute to structural changes such as subepithelial fibrosis from an early age. Other structural alterations are related to duration of the disease and long-term uncontrolled inflammation. Structural changes may increase alteration of the protective functions of the upper airways namely by affecting mucociliary clearance and conditioning of inspired air. The sequences of tissue changes during wound repair of upper airway mucosa after surgery are illustrative of the complexicity of tissue modelling and remodelling and could be considered as an important source of information for a better understanding of the complex relationship between inflammatory reaction, of the subsequent tissue damages and fibroblast metabolism of upper airways.

A central regulatory role for eosinophils and the eotaxin/CCR3 axis in chronic experimental allergic airway inflammation

To clarify the role and regulation of eosinophils, we subjected several key eosinophil-related genetically engineered mice to a chronic model of allergic airway inflammation aiming to identify results that were independent of the genetic targeting strategy. In particular, mice with defects in eosinophil development (Deltadbl-GATA) and eosinophil recruitment [mice deficient in CCR3 (CCR3 knockout) and mice deficient in both eotaxin-1 and eotaxin-2 (eotaxin-1/2 double knockout)] were subjected to Aspergillus fumigatus-induced allergic airway inflammation. Allergen-induced eosinophil recruitment into the airway was abolished by 98%, 94%, and 99% in eotaxin-1/2 double knockout, CCR3 knockout, and Deltadbl-GATA mice, respectively. Importantly, allergen-induced type II T helper lymphocyte cytokine production was impaired in the lungs of eosinophil- and CCR3-deficient mice. The absence of eosinophils correlated with reduction in allergen-induced mucus production. Notably, by using global transcript expression profile analysis, a large subset (29%) of allergen-induced genes was eosinophil- and CCR3-dependent; pathways downstream from eosinophils were identified, including in situ activation of coagulation in the lung. In summary, we present multiple lines of independent evidence that eosinophils via CCR3 have a central role in chronic allergic airway disease.

Rinite, sinusite e asma: indissociáveis?

Este estudo tem como objetivo rever a literatura ressaltando aspectos epidemiológicos e fisiopatológicos relacionados à abordagem unificada de rinossinusite alérgica e da asma, com as respectivas implicações terapêuticas. O levantamento bibliográfico foi realizado a partir das informações disponibilizadas pelas bases de dados Medline, MD Consult, Highwire, Medscape, LILACS e por pesquisa direta, dos últimos trinta anos, utilizando-se os termos allergic rhinitis e asthma. Foram selecionados 55 artigos originais em revisão não sistemática abordando a questão da associação clínica entre rinossinusite alérgica e asma. Verifica-se que nos últimos anos, com o uso de medicamentos tópicos, para as vias aéreas superiores ou para as vias aéreas inferiores, a abordagem terapêutica tem sido distinta. Entretanto, inúmeros inquéritos epidemiológicos, estudos de imunopatologia e clínicos demonstram a inter-relação entre asma e rinossinusite alérgica evidenciados por: i) a rinite alérgica encontra-se associada à asma e constitui-se em fator de risco independente para o seu aparecimento; ii)as características imunopatológicas da rinite alérgica e da asma são semelhantes; iii)a rinite alérgica e a asma são manifestações de uma enfermidade sistêmica; iv)o controle da rinite favorece o controle da asma. A estreita associação entre a rinite alérgica e a asma requer a integração das abordagens diagnóstica, terapêutica e profilática dessas enfermidades. Opções terapêuticas que permitam o controle simultâneo de ambas oferecem vantagens relacionadas ao custo e à tolerabilidade.

Persistent effects induced by IL-13 in the lung

IL-13 overexpression in the lung induces inflammatory and remodeling responses that are prominent features of asthma. Whereas most studies have concentrated on the development of IL-13-induced disease, far fewer studies have focused on the reversibility of IL-13-induced pathologies. This is particularly important because current asthma therapy appears to be poor at reversing lung remodeling. In this manuscript, we used an externally regulatable transgenic system that targets expression of IL-13 to the lung with the aim of characterizing the reversibility process. After 4 wk of doxycycline (dox) exposure, IL-13 expression resulted in mixed inflammatory cell infiltration, mucus cell metaplasia, lung fibrosis, and airspace enlargement (emphysema). After withdrawal of dox, IL-13 protein levels were profoundly reduced by 7 d and below baseline by 14 d. During this time frame, the level of lung eosinophils returned to near normal, whereas macrophages, lymphocytes, and neutrophils remained markedly elevated. IL-13-induced mucus cell metaplasia significantly decreased (91%) 3 wk after withdrawal of dox, showing strong correlation with reduced eosinophil levels. In contrast, IL-13-induced lung fibrosis did not significantly decline 4 wk after dox withdrawal. Importantly, IL-13-induced emphysema persisted, but modestly declined 4 wk after dox. Examination of transcript expression profiles identified a subset of genes that remained increased weeks after transgene expression was no longer detected. Notably, numerous IL-13-induced cytokines and enzymes were reversible (IL-6 and cathepsins), whereas others were sustained (CCL6 and chitinases) after IL-13 withdrawal, respectively. Thus, several hallmark features of IL-13-induced lung pathology persist and are dissociated from eosinophilia after IL-13 overexpression ceases.

Matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs in the respiratory tract: potential implications in asthma and other lung diseases

In healthy lung, Matrix Metalloproteinases (MMPs) and their physiological inhibitors, tissue inhibitors of matrix metalloproteinases (TIMPs), are produced in the respiratory tract by a panel of different structural cells. These activities are mandatory for many physiological processes including development, wound healing and cell trafficking. Deregulation of proteolytic-antiproteolytic network and inappropriate secretion of various MMPs by stimulated structural or inflammatory cells is thought to take part to pathophysiology of numerous lung diseases including asthma, chronic obstructive pulmonary disease (COPD), lung fibrosis and lung cancer. Cytokines and growth factors are involved in these inflammatory processes and some of those mediators interact directly with MMPs and TIMPs leading either to a regulation of their expression or changes in their biological activities by proteolytic cleavage. In turn, cytokines and growth factors modulate secretion of MMPs establishing a complex network of reciprocal interactions. Every MMP seem to play a rather specific role and some variations of their expression are observed in different lung diseases. The precise role of these enzymes and their inhibitors is now studied in depth as they could represent relevant therapeutic targets for many diseases. Indeed, MMP inhibition can lead either to a decrease of the intensity of a pathological process or, in the contrary for some of them, to an increase of disease severity. In this review, we focus on the role played by MMPs and TIMPs in asthma and we provide an overview of their potential roles in COPD, lung fibrosis and lung cancer, with a special emphasis on loops including MMPs and cytokines and growth factors relevant in these diseases.

Effects of low doses of inhaled fluticasone propionate on inflammation and remodelling in persistent-mild asthma

In asthma a dysregulation of eosinophil apoptosis and an imbalance of metalloproteinase-9 (MMP-9) and tissue inhibitor metalloproteinase-1 (TIMP-1) play an important role in airway inflammation and remodelling. We evaluated the effects of a low dose of inhaled fluticasone proprionate (FP) (100 microg bid by Diskus) for 4 weeks in 24 steroid naive patients with mild persistent asthma, symptomatic and with a sputum eosinophilia >or=3% on clinical outcomes and inflammatory markers such as the induced sputum eosinophils, the induced sputum apoptotic eosinophils, the levels of MMP-9 and TIMP-1 and their molar ratio in the induced sputum supernatants. After FP treatment forced expiratory volume (FEV1) and FEV1/forced vital capacity values, PEF (L/min), sputum apoptotic eosinophils, and MMP-9/TIMP-1 molar ratio in sputum supernatants of asthmatic subjects were significantly increased in comparison with baseline, while sputum eosinophils significantly decreased. Change (Delta) in FEV1 after treatment with FP negatively correlated with the Delta in sputum eosinophils, while the Delta in MMP-9 values positively correlated with Delta in TIMP-1 values. This study shows that the clinical improvement achieved by the use of low doses of FP in asthmatics is related, at least in part, to the resolution of eosinophilic inflammation and the downregulation of remodelling markers.

Asthma: a disuse contracture?

The incidence of asthma is increasing. There is no obvious explanation for this increase and current theory has no explanation for the occurrence of the disease in the non-allergic, the sudden onset of the asthma attack, the hyper-reactivity of the muscular wall, the association of the disease with obesity, or its precipitation by exercise. Biopsy studies have shown that the narrowing of air passages which characterises the disease is associated with thickening of their fibrous and muscular layers. As narrowing of air passages necessarily involves shortening of annular and helical components, this narrowing is in effect an annular contracture, analogous to those seen in underextended longitudinal structures such as muscles and tendons. The only common cause for such contractures is habitual underextension. As the only extending force in annular air passages is inspiration, this leads to the hypothesis that the basic cause of the disease is an insufficiency of aerobic exercise in childhood. Should the airways fail to develop their normal calibre, the narrowing will precipitate a sequence of events which can be predicted from the laws of physics. La Place's Law explains the instability of the muscle wall, the sudden onset of the attacks, reflecting episodes of critical collapse and the occurrence of the disease in the non-allergic. Bernoulli's Law explains the provocative effect of exercise and the postulated lack of exercise explains the increasing prevalence and the association with obesity. The hypothesis can be tested by comparative epidemiology. If it is correct, the disease should be preventable.

Connective tissue growth factor induces extracellular matrix in asthmatic airway smooth muscle

Transforming growth factor (TGF)-beta and connective tissue growth factor may be implicated in extracellular matrix protein deposition in asthma. We have recently reported that TGF-beta increased connective tissue growth factor expression in airway smooth muscle cells isolated from patients with asthma. In this study, we examined fibronectin and collagen production and signal transduction pathways after stimulation with TGF-beta and connective tissue growth factor. In both asthmatic and nonasthmatic airway smooth muscle cells, TGF-beta and connective tissue growth factor led to the production of fibronectin and collagen I. Fibronectin and collagen expression was extracellular regulated kinase-dependent in both cell types but phosphoinositide-3 kinase-dependent only in asthmatic airway smooth muscle cells. p38 was implicated in fibronectin but not collagen expression in both cell types. TGF-beta induction of fibronectin and collagen was in part mediated by an autocrine action of connective tissue growth factor. Phosphorylation of SMAD-2 may represent an additional pathway because this was increased in asthmatic cells. Our results suggest that these two cytokines may be important in the deposition of extracellular matrix proteins and that the signal transduction pathways may be different in asthmatic and nonasthmatic cells.

A Comparison of Airway and Serum Matrix Metalloproteinase-9 Activity Among Normal Subjects, Asthmatic Patients, and Patients With Asthmatic Mucus Hypersecretion

BACKGROUND

The rate of decline in lung function is increased in asthmatic patients, particularly in those with coexisting asthmatic mucus hypersecretion (AMH), in whom inflammation and the activity of matrix metalloproteinase (MMP)-9 and tissue inhibitor of metalloproteinase (TIMP)-1 in serum and BAL fluid (BALF) may be increased.

METHODS

Seven nonasthmatic subjects and 22 asthmatic subjects completed a questionnaire, and underwent lung function testing and bronchoscopy, during which AMH was diagnosed by the presence of mucus plugging. Subjects were classified as follows: mild/moderate asthma; severe asthma; and AMH. In BALF, we measured the differential WBC counts and MMP-9 activity by zymography. We measured total MMP-9 and TIMP-1 activity by enzyme-linked immunosorbent assay in BALF and serum.

RESULTS

The mean (+/- confidence interval) FEV1 was lower in AMH patients (73 +/- 13% predicted) compared with nonasthmatic subjects (95 +/- 7%) and patients with mild/moderate asthma (73 +/- 9%; p < 0.05), and was similar to that of patients with severe asthma (80 +/- 20%). MMP-9 activity was greater in AMH patients and in patients with severe asthma compared with nonasthmatic subjects (p = 0.05 and p = 0.01, respectively), as were TIMP-1 activities (p = 0.001 and p = 0.04, respectively), but MMP-9/TIMP-1 ratios were not. MMP-9 activity increased across the four groups from nonasthmatic subjects to AMH patients (r = 0.58; p = 0.0009), but the differential and total WBC counts were similar. There were no relationships between FEV1 percent predicted and either MMP-9 activity or MMP-9/TIMP-1 ratio. There were no differences in serum MMP-9 activity, which did not correlate with MMP-9 activity in BALF.

CONCLUSIONS

AMH and severe asthma were associated with greater proteolytic enzyme activities despite similar airway inflammation, which might play a role in remodeling and accelerated the decline in lung function in these patients.

Occupational asthma

Substantial epidemiologic and clinical evidence indicates that agents inhaled at work can induce asthma. In industrialized countries, occupational factors have been implicated in 9 to 15% of all cases of adult asthma. Work-related asthma includes (1) immunologic occupational asthma (OA), characterized by a latency period before the onset of symptoms; (2) nonimmunologic OA, which occurs after single or multiple exposures to high concentrations of irritant materials; (3) work-aggravated asthma, which is preexisting or concurrent asthma exacerbated by workplace exposures; and (4) variant syndromes. Assessment of the work environment has improved, making it possible to measure concentrations of several high- and low-molecular-weight agents in the workplace. The identification of host factors, polymorphisms, and candidate genes associated with OA is in progress and may improve our understanding of mechanisms involved in OA. A reliable diagnosis of OA should be confirmed by objective testing early after its onset. Removal of the worker from exposure to the causal agent and treatment with inhaled glucocorticoids lead to a better outcome. Finally, strategies for preventing OA should be implemented and their cost-effectiveness examined.

Steroid naive eosinophilic asthma: anti-inflammatory effects of fluticasone and montelukast

BACKGROUND

Inhaled corticosteroids and leukotriene receptor antagonists reduce airway eosinophilia and have been used as first line anti-inflammatory therapy for mild persistent asthma.

METHODS

A multicentre, randomised, placebo controlled, parallel group study was performed to compare the anti-inflammatory effects of fluticasone propionate and montelukast as measured by sputum eosinophils in 50 adults with symptomatic steroid naive asthma and sputum eosinophilia of > or =3.5%.

RESULTS

Eighteen patients received low dose fluticasone (250 mug/day), 19 received montelukast (10 mg/day), and 13 were given placebo for 8 weeks. Fluticasone treatment resulted in a greater reduction in sputum eosinophils (geometric mean (SD) 11.9 (2.3)% to 1.7 (5.1)%) than montelukast (10.7 (2.3)% to 6.9 (3.8)%; p = 0.04) or placebo (15.4 (2.4)% to 7.8 (4.2)%; p = 0.002), and improvement in FEV(1) (mean (SD) 2.6 (0.9) l to 3.0 (0.9) l) than montelukast (2.8 (0.7) l to 2.8 (0.9) l; p = 0.02) or placebo (2.4 (0.8) l to 2.4 (0.9) l; p = 0.01). Treatment with fluticasone suppressed sputum eosinophilia within a week while montelukast only attenuated it. The effect of montelukast was maximal at 1 week and was maintained over 4 weeks. The effect of fluticasone was maintained over 8 weeks while that of montelukast was not.

CONCLUSIONS

Montelukast is not as effective as low dose fluticasone in reducing or maintaining an anti-inflammatory effect in steroid naive eosinophilic asthma.

Airway smooth muscle and fibroblasts in the pathogenesis of asthma

Asthma is a disease characterized by marked structural changes within the airway wall. These changes include deposition of extracellular matrix proteins and an increase in the numbers of airway smooth muscle cells and subepithelial fibroblasts. Both these cell types possess properties that would enable them to be involved in remodeling and inflammation. These properties include the production of a variety of cytokines; growth factors and fibrogenic mediators; proliferation, migration and release of extracellular matrix proteins; matrix metalloproteinases; and their tissue inhibitors. Airway smooth muscle and subepithelial fibroblasts are likely to be key players in the asthmatic airway pathophysiology through their interaction with each other, inflammatory cells, and other mesenchymal cells, such as the epithelium. Current asthma therapies lack the ability to completely prevent or reverse the remodeling of the airways, therefore indicating the need for new therapeutic strategies to counter this important aspect of asthma.

[Efficacy of immunotherapy in the treatment of asthma]

Specific immunotherapy consists of the administration of allergen extracts to patients with allergic disease to achieve clinical tolerance to the causative allergens. Currently, it is the only etiologic treatment for respiratory allergy. A World Health Organization opinion paper published in 1997 defines immunotherapy as "the only form of treatment able to modify the natural course of allergic diseases". In patients with allergic rhinitis, several studies suggest that immunotherapy can modify the natural history of respiratory allergy by preventing the development of asthma in children with this disease. Numerous studies demonstrate its efficacy in IgE-mediated asthma and particularly in mild-to-moderate asthma. When complete avoidance of the allergen cannot be achieved with measures that allow the patient to lead a normal life, pharmacological treatment can help to control symptoms, but symptoms immediately return when treatment is interrupted. However, asthma care can be improved by allergen-specific treatment; immunotherapy may shift the immune response from an allergic pattern toward a more protective response, producing persistent improvement with reduction of symptoms and the need for pharmacological treatment. Numerous comparative studies with specific immunotherapy vs. placebo or pharmacological treatment have demonstrated the efficacy of this treatment and its advantages in control of the disease. Specific immunotherapy induces favorable clinical, biological and functional modifications in the course of allergic asthma. Significant improvement in clinical manifestations has been demonstrated, even with levels of allergen exposure higher than those at the beginning of treatment. This improvement is associated with a reduced need for antiinflammatory and bronchodilator treatment. Moreover, specific bronchial reactivity shows a clear improvement with disappearance of delayed response and a clear increase in the threshold for immediate response to the allergen. Reduction in nonspecific bronchial hyperreactivity and improvement in exercise-induced asthma are also observed. Several studies recommend an optimal duration of specific immunotherapy for allergic asthma of between 3 and 5 years to achieve maximal therapeutic efficacy. A direct relationship between treatment duration and the persistence of its effects has been observed. Moreover, the treatment is more effective when started early. The possible adverse effects related to systemic reactions should be borne in mind. Although these effects are infrequent, maximal precautions should be taken when administering this treatment. Immunotherapy is contraindicated in cases of severe asthma, heart disease, autoimmune disease and associated severe neoplastic processes. However, all the beneficial effects of immunotherapy are conditioned by an accurate and early etiological diagnosis confirming the causative allergen. The availability of high-quality allergen extracts is essential to obtain the desired effect. Inappropriate patient selection for this treatment is the main cause of its failure. The integral treatment of allergic asthma includes environmental measures, patient education, pharmacological treatment and, whenever possible, immunotherapy.

A probative approach for noninvasive evaluation of airway hyperresponsiveness and remodeling in adult asthmatics

We propose a probative approach for noninvasive evaluation of airway hyperresponsiveness (AHR) and remodeling to investigate their outcome in adult asthmatics treated according to the Global Initiative for Asthma (GINA) guideline. Pulmonary function and AHR to methacholine were measured twice with an interval of 24.3 +/- 3.4 months in 18 adult asthmatics during the ongoing treatments. Mathematical formulas previously used in an animal model were applied in human asthmatics to eliminate the effect of airway wall thickening on respiratory resistance (Rrs), calculating indices for the proportional changes with time in airway wall thickness (PW(1)/PW(0)) and airway smooth muscle shortening (PMS(1)/PMS(0)), respectively. The minimum cumulative dose of methacholine (Dmin), an ordinary index of AHR measured with the oscillometry Asthograph, correlated with the asthma severity. The disease periods significantly correlated with the indices of airflow limitation. While there was no change in PW(1)/PW(0) (1.00 +/- 0.07) during the assessment periods, methacholine-induced airway smooth muscle shortening was attenuated by 46% (PMS(1)/PMS(0)=0.54 +/- 0.16). Less improvement in PMS(1)/PMS(0) was seen with a correlation to the disease periods, but PMS(1)/PMS(0) improved correlating to the relative length of the assessment period with ongoing treatments in the disease period. In conclusion, this probative approach may be useful to investigate the outcome of AHR and remodeling in human asthmatics, and shows that remodeling may get worse with time or may halt and AHR may improve with a stepwise, early intervention and prolonged treatment given according to the GINA guideline.

Extracellular matrix proteins modulate asthmatic airway smooth muscle cell proliferation via an autocrine mechanism

BACKGROUND

Airway remodeling is a key feature of persistent asthma and includes alterations in the extracellular matrix protein profile around the airway smooth muscle (ASM) and hyperplasia of the ASM. We have previously shown that nonasthmatic ASM cells in culture produce a range of extracellular matrix protein proteins and that asthmatic ASM cells proliferate faster than cells from nonasthmatic patients.

OBJECTIVE

In this study, we compared the profile of extracellular matrix proteins produced by nonasthmatic and asthmatic ASM cells. We also examined the influence of these extracellular matrix protein proteins and conditioned medium derived from nonasthmatic or asthmatic ASM cells on the proliferation of nonasthmatic and asthmatic ASM cells.

METHODS

Extracellular matrix proteins were measured by ELISA; proliferation of ASM cells was measured by tritiated thymidine incorporation.

RESULTS

Production of perlecan and collagen I by the cells from asthmatic patients were significantly increased. In contrast, laminin alpha1 and collagen IV were decreased. Chondroitin sulfate was detectable only in the cells from nonasthmatic patients. Compared with nonasthmatic extracellular matrix proteins, proteins from asthmatic cells enhanced ASM cell proliferation. Conditioned medium from asthmatic ASM cells did not induce greater proliferation compared with conditioned medium from nonasthmatic cells.

CONCLUSIONS

The data show that the profile of extracellular matrix protein components is altered in asthmatic cells and that this altered profile and not soluble mediators secreted from the ASM cells has the potential to influence the proliferation of these cells. These changes are likely to contribute to the airway wall remodeling that occurs in asthma.

Matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases mRNA transcripts in the bronchial secretions of asthmatics

Asthma is a chronic inflammatory disease characterized by profound extracellular matrix changes referred to as bronchial remodelling. In this study, we evaluated matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) mRNA expression in bronchial secretions of asthmatics and correlated MMPs modulations with the lung function as a reflection of the bronchial extracellular matrix remodelling. Quantitative RT-PCR was performed on cell pellets obtained from induced sputum in order to detect the mRNAs for MMP-1, -2, -3, -8, -9, -12, -13 TIMP-1, -2, while semiquantitative RT-PCR was performed to assess the expression of MMP-7, monocyte chemoattractant protein-1 (MCP-1) and transforming growth factor-beta(1) (TGF-beta(1)). The mRNA transcripts for MMP-1, TIMP-1 and monocyte chemoattractant protein-1 (MCP-1) were increased in cell pellets of induced sputum from asthmatics when compared to controls (P<0.05), and the intensity of MMP-1 mRNA expression inversely correlated with the FEV(1) in asthmatics (r=-0.49, P<0.05). The MMP-1 mRNA/TIMP-1 mRNA ratio correlated with the levels of MCP-1 mRNA in asthmatics (r=0.47, P<0.05). There were no differences between the groups with respect to mRNA coding for MMP-2, -3, -7, -8, -9, -12, -13, -14, TIMP-2 and TGF-beta(1). We conclude that cells contained in the bronchial secretions from asthmatics express higher amounts of mRNA for MMP-1 and TIMP-1, perhaps related to an increased expression of MCP-1, which might contribute to the extracellular matrix changes observed during airway remodelling.

Imbalance between matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in toluene diisocyanate-induced asthma

BACKGROUND

Toluene diisocyanate (TDI)-induced asthma is an inflammatory disease of the airways characterized by airway remodelling due, at least in part, to an excess of extracellular matrix deposition in the airway wall. The ratio of matrix metalloproteinase-9 (MMP-9) and its inhibitor, tissue inhibitor of metalloproteinase-1 (TIMP-1) may be a marker of the balance between airway tissue destruction and repair.

OBJECTIVE

We determined whether an imbalance of the MMP-9 : TIMP-1 molar ratio is present before and/or after challenge with TDI.

METHODS

We used a murine model of TDI-induced asthma to evaluate the MMP-9 and TIMP-1 balance in the lung.

RESULTS

The expression of MMP-9 and TIMP-1 mRNAs and proteins in the lungs increased at 7 h after TDI inhalation and continued for up to 72 h. Immunohistochemical and immunocytological analyses in the lungs of TDI-exposed mice revealed increases of immunoreactive MMP-9 and TIMP-1. There were significant correlations between the levels of MMP-9 or TIMP-1 and the number of neutrophils, lymphocytes, or eosinophils. The molar ratio of MMP-9/TIMP-1 significantly decreased at 7 h after TDI inhalation and continued up to 72 h.

CONCLUSION

These data suggest that TDI-induced asthma may be associated with an imbalance between MMP-9 and TIMP-1, which could be useful as a marker of airway inflammation and airway remodelling in this disease.

Interleukin-13-dependent expression of matrix metalloproteinase-12 is required for the development of airway eosinophilia in mice

We investigated the expression and function of matrix metalloproteinase-12 (MMP-12) in a model of allergic airway inflammation. Mice were sensitized mucosally by exposure to aerosolized ovalbumin (OVA) daily over a period of 10 d in the context of adenovirus-mediated granulocyte macrophage colony-stimulating factor (GM-CSF) expression. The ensuing inflammatory response is characterized by a Th2 cytokine profile, OVA-specific IgE, and airway eosinophilia. Using real-time, quantitative reverse transcriptase-polymerase chain reaction we assessed MMP-12 mRNA expression in whole lung tissue. We observed a 12- and 70-fold increase in expression at Days 7 and 11, respectively, in OVA-exposed mice when compared with naive controls. Immunoblot analysis revealed an increase in MMP-12 protein in the bronchoalveolar lavage fluid of mice exposed to OVA in the context of GM-CSF. No such elevation was observed in mice exposed to saline only in the context of GM-CSF. To assess functional role of MMP-12, MMP-12 knockout (KO) mice were subjected to the aforementioned protocol. We observed an 80% reduction in eosinophils in the bronchoalveolar lavage fluid of KO mice compared with their wild-type littermates. Using interleukin-13 KO mice, we demonstrated that expression of MMP-12 is interleukin-13-dependent. Collectively, our data indicate a novel function for MMP-12 in the process of airway eosinophil accumulation.

Airway smooth muscle--its relationship to the extracellular matrix

The airway smooth muscle cell has a variety of properties, which confer on it the ability to participate actively in the inflammatory process and the remodeling events, which accompany severe, persistent asthma. Among these properties is its relationship to the extracellular matrix (ECM) with which it interacts by releasing matrix proteins, matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs). Muscle cells derived from asthmatic subjects proliferate faster, release a different profile of matrix proteins, produce more connective tissue growth factor (CTGF) in response to TGFbeta stimulation and these changes may impact on airway smooth muscle contraction and proliferation. Integrins on the surface of the airway smooth muscle transduce signals between the muscle cell and the ECM, but whether the expression and/or function of these is altered in asthma is not known. It is unlikely that current therapy is effective in preventing or reversing remodeling, and therefore, understanding the pathophysiological events, which underlie its mechanism is critical.

Exhaled nitric oxide corresponds with office evaluation of asthma control

Exhaled NO (ENO) has been studied as a noninvasive marker of airway inflammation, and has been shown to be elevated in asthma patients. The aim of this study was to investigate whether ENO measurements differ significantly between groups of asthmatic children with different disease control and to compare ENO measurements with the clinical assessment of asthma control. Seventy-three children between 5-18 years old with a diagnosis of asthma were recruited. ENO was measured online during a slow vital capacity maneuver. The mean of three plateau NO levels was used for analysis. Baseline and postbronchodilator spirometry were performed. The assessment of disease control was based on the frequency of use of beta2-agonists, occurrence of day- and nighttime asthma symptoms, and spirometry results. Twenty-one children (group 1) had good asthma control. In 31 patients (group 2), asthma control was acceptable. In 21 patients (group 3), asthma was insufficiently controlled. ENO levels were (median (quartiles)): group 1, 11 ppb (9-21); group 2, 15 ppb (11-26); and group 3, 28 ppb (19-33). Measurements were significantly different between all three groups (P = 0.009, Kruskal-Wallis), between groups 1 and 3 (P = 0.01, Mann-Whitney U test), and between groups 2 and 3 (P = 0.01, Mann-Whitney-U test). The same was true for reversibility testing. We found significantly different ENO levels between a group of pediatric asthma patients with insufficient and good/sufficient control, as defined by clinical assessment. These results suggest that ENO measurements may be useful for monitoring asthma patients.

The histamine-cytokine network in allergic inflammation

Histamine is synthesized and released by human basophils, mast cells, and neurons. Its pleiotropic effects are mediated by the activation of 4 receptors: H(1), H(2), H(3), and H(4). With the advent of selective antagonists (the antihistamines widely used to treat allergic disorders), the H(1)-receptor was the first member of the receptor family to be pharmacologically defined. Increasing evidence indicates that, in addition to exerting immediate vascular and bronchial responses, histamine might modulate the immune reaction by interacting with T cells, macrophages, basophils, eosinophils, and monocytes. We have shown that, in vitro, histamine induces a concentration-dependent release of IL-6 and beta-glucuronidase from macrophages isolated from the human lung parenchyma. These effects are inhibited by fexofenadine, an H(1)-receptor antagonist, but not by ranitidine, an H(2)-receptor antagonist. This observation raises the possibility that long-term treatment with fexofenadine might have beneficial effects on immune dysregulation and tissue damage/remodeling associated with histamine-mediated macrophage activation.

Tidal off-line exhaled nitric oxide measurements in a pre-school population

Exhaled nitric oxide (ENO) is used as a non-invasive marker of airway inflammation. The aim of this study was to measure ENO in a pre-school population using a relatively novel method, the off-line tidal breathing method, and to investigate differences in ENO between subjects with different presentations of wheezing. ENO was measured in 129 children (median age 4.4 years, quartiles 4.0-4.8 years) through a mouth mask attached to a two-way valve with an expiratory resistance of 5 cm H(2)0. Mean tidal ENO concentration (tENO) was calculated from triplicate measurements. Mean +/- SEM tENO for 89 control subjects was 13+/-0.4 ppb (95%CI 11.8-13.7 ppb); this level was significantly different from tENO in 15 children with a history of recurrent wheezing (18.6+/-1.9 ppb; 95%CI 14.5-22.7 ppb; t-test P<0.0001). Mean tENO in 16 children with a single wheezing episode was 11.4+/-1.0 ppb (95%CI 9.2-13.6 ppb) and thus significantly different from the recurrent wheezing group (t-test P=0.0024).

CONCLUSION

The off-line tidal breathing method is a feasible and appealing method for measuring exhaled nitric oxide in pre-school children. With this method, higher tidal exhaled nitric oxide levels were found in children with recurrent wheezing.

Enhancement of gelatinase activity during development of subepithelial fibrosis in a murine model of asthma

BACKGROUND

Chronic asthma is characterized by inflammatory cell infiltration and tissue remodelling leading to subepithelial fibrosis. Metalloproteinases (MMPs) are involved in degradation of extracellular matrix in most chronic inflammatory diseases.

OBJECTIVE

The aim of this study was to investigate the expression of MMPs in the development of inflammatory processes associated or not with the concomitant development of subepithelial fibrosis in an experimental model of asthma.

METHODS

Sensitized BP2 mice were challenged with ovalbumin (OA) every 2 weeks during 8 months. Several mice were removed once a month and bronchoalveolar lavages (BAL) or lung biopsies were performed.

RESULTS

Lung sections stained with picrosirius and hydroxyproline measurements showed a significant collagen deposition after 16 weeks of OA challenge, demonstrating the development of subepithelial fibrosis. Pulmonary inflammation was present from the first OA challenge and was consistent throughout the 8 months of the study. Moreover, an up-regulation and activation of MMP-9 and, to a less extent, MMP-2 were observed in BAL fluid from challenged mice. The level of tissue inhibitor of metalloproteinases (TIMP)-1 increased after 12 weeks of OA challenge vs. control mice.

CONCLUSION

This study reveals that a decrease in the activation of the MMP-9 due to the increase in TIMP-1, could contribute to excessive collagen deposition following repeated antigen challenge in sensitized mice.

Inflammation and remodeling of the sinus mucosa in children and adults with chronic sinusitis

OBJECTIVES/HYPOTHESIS

The sinus mucosal inflammatory response in adult patients with chronic sinusitis is well documented in the literature. In contrast, little is known about the pathogenesis of this condition in children. The objective of the study was to compare the inflammatory cell profile and the extent of tissue remodeling in the sinus mucosa of children and adults with chronic sinusitis.

STUDY DESIGN

Prospective design.

METHODS

Children (n = 7) and adult patients (n = 7) with chronic sinusitis undergoing functional endoscopic sinus surgery were recruited for the study. Patients with no evidence of sinus disease (n = 6) were used as control subjects. Using immunohistochemical analysis, sinus mucosal specimens were assessed for the presence of T lymphocytes, eosinophils, basophils, mast cells, and neutrophils. The extent of submucosal collagen deposition was evaluated in histological sections using van Gieson stain.

RESULTS

The number of T lymphocytes, eosinophils, and basophils and the amount of subepithelial collagen deposition are significantly higher in the mucosa of both adults and children with chronic sinusitis compared with normal control subjects (P <.01). The number of mast cells is significantly higher in the mucosa of children with chronic sinusitis compared with normal control subjects (P <.01). The number of eosinophils and neutrophils and the amount of subepithelial collagen deposition are significantly greater in adults compared with children with chronic sinusitis (P <.01).

CONCLUSIONS

The sinus mucosal inflammatory profile is similar in adults and children with chronic sinusitis. However, the degree of tissue eosinophilia and remodeling is significantly greater in adult sinus specimens when compared with those of children with chronic sinusitis.