Global strategy for asthma management and prevention: GINA executive summary

Efficacy of leukotriene receptor antagonists and synthesis inhibitors in asthma

Cysteinyl leukotrienes are important mediators of asthmatic responses. They are the most potent bronchoconstrictors known; their release is triggered by exposure to inhaled allergens after exercise and after aspirin ingestion by subjects with aspirin-sensitive asthma. The cysteinyl leukotrienes promote inflammatory cell migration into the airways, as well as bone marrow eosinophilopoiesis after allergen inhalation. Leukotriene inhibitors are effective at attenuating asthmatic responses to all of these stimuli and are also effective at treating persistent asthma. These drugs are a viable alternative to low-dose inhaled corticosteroid (ICS) treatment but should be reserved for patients who cannot or will not use ICSs, often because of concerns about potential side effects of ICS treatment, which limits their use, particularly in children. Leukotriene receptor antagonists are also alternatives to long-acting inhaled beta(2)-agonists as add-on therapy to ICSs, but their efficacy together with ICSs is less than that of ICS/long-acting inhaled beta(2)-agonist combinations. Leukotriene receptor antagonists have an excellent safety profile.

Targeted NF-kappaB inhibition of asthmatic serum-mediated human monocyte-derived dendritic cell differentiation in a transendothelial trafficking model

Transendothelial trafficking model mimics in vivo differentiation of monocytes into dendritic cells (DC). The serum from patients with systemic lupus erythematosus promotes the differentiation of monocytes into mature DC. We have shown that selective inhibition of NF-kappaB by adenoviral gene transfer of a novel mutated IkappaBalpha (AdIkappaBalphaM) in DC contributes to T cell tolerance. Here we demonstrated for the first time that asthmatic serum facilitated human monocyte-derived DC (MDDC) maturation associated with increased NF-kappaB activation in this model. Furthermore, selective blockade of NF-kappaB by AdIkappaBalphaM in MDDC led to increased apoptosis, and decreased levels of CD80, CD83, CD86, and IL-12 p70 but not IL-10 in asthmatic serum-stimulated MDDC, accompanied by reduced proliferation of T cells. These results suggest that AdIkappaBalphaM-transferred MDDC are at a more immature stage which is beneficial to augment the immune tolerance in asthma.

Demographic data in asthma clinical trials: a systematic review with implications for generalizing trial findings and tackling health disparities

The prevalence of asthma, and the morbidity, adverse events, mortality and healthcare utilisation of asthmatic patients vary widely among racial/ethnic and other socio-demographic groups. Debates over the meanings of race and ethnicity and the strategic need to resolve health inequalities have prompted extensive recommendations for reporting and analyzing racial/ethnic and demographic information in clinical trials. We conducted a systematic review to determine the extent to which race/ethnicity, socio-economic status and other demographic variables are analyzed and reported in publications from randomized controlled trials of asthma interventions. Randomized controlled trials of inhaled corticosteroids and long-acting beta-agonists in asthmatic patients were identified by systematically searching 12 electronic bibliographic databases. We identified peer-reviewed papers reporting 87 relevant trials published during 1985-2006, from which we extracted data on patients' race/ethnicity, ancestry, gender, socio-economic variables and geographical attributes. The proportion of the papers reporting the race/ethnicity of their participants was lower than would be expected by chance and has recently declined. None of the papers included race/ethnicity or gender in statistical analyses or reported socio-economic variables, ancestry, or genetic data for their participants, and few discussed the generalizability of their findings. The frequency of reporting race/ethnicity was statistically significantly lower in trials conducted in the UK than in the US, but 23 of the 87 papers did not identify countries. Despite extensive recommendations in the literature, guidance from health agencies on analyzing and reporting demographic data in clinical trials still appears inconsistent and vague. There remains a need to improve guidance on the representation and analysis of minority populations in asthma clinical trials, in order to encourage transparent reporting of population selection, analysis approaches, and trial generalizability. To assist this process, asthma clinical trials should be based on clear hypotheses that link both to existing demographic evidence and to demographic healthcare goals.

Rescue treatment in asthma. More than as-needed bronchodilation

International guidelines recommend the use of rapid-onset inhaled beta(2)-agonists alone for symptom relief in all asthmatic patients. However, recent clinical trials have shown that the "as-required," or PRN, use of inhaled combinations of a corticosteroid and a rapid-onset beta(2)-agonist provides clinical advantages over the traditional PRN inhaled rapid-onset beta(2)-agonists alone in patients with different degrees of asthma severity. Asthma symptoms are associated not only with bronchoconstriction but also with increased airway inflammation. Inhaled beta(2)-agonists have a rapid onset of bronchodilator action that is mainly mediated by a relaxing effect on airway smooth muscle. Inhaled corticosteroids also have rapid clinical effects that can suppress lower airway inflammation, and there is a rapid synergistic potentiation of the antiinflammatory effect of corticosteroids and of the bronchodilatory action of beta(2)-agonists when the two drugs are given simultaneously. On the basis of this emerging evidence, we propose that the current rescue use of rapid-onset inhaled beta(2)-agonists alone should now be replaced by an inhaled rapid-acting beta(2)-agonist combined with a corticosteroid as preferred PRN strategy. We conclude with a call for clinical trials aimed to test the superiority of this approach in all degrees of asthma severity in a real-world setting in addition to any of the regular treatments recommended by international guidelines. In the future it might even be possible to control asthma entirely with PRN combination inhalers without maintenance therapy, at least in patients with less severe disease.

Esophageal candidiasis--an adverse effect of inhaled corticosteroids therapy

Over the last few decades, inhaled corticosteroids (ICs) became the cornerstone in the treatment of persistent asthma. Their use improved asthma control, decreased mortality and also minimized adverse reactions associated with systemic steroid. Esophageal candidiasis is a rare complication resulting from the use of ICs. Although, in recent years, as their prescriptions has increased, more cases have been reported, especially in Japan. Listed are 4 case reports regarding esophageal candidiasis in asthmatic patients associated with inhaled budesonide administration. In the cases reported herein, the use of a different device of dry powder budesonide might have favored esophageal drug deposition and Candida infection. Patients denied using systemic corticosteroids in the previous 6 months. Furthermore, none of the patients presented Diabetes mellitus, malignant disease, HIV infection, or other immunosuppressive conditions. We conclude that patients treated with high doses of ICs are at higher risk of developing esophageal candidiasis. These patients should undergo upper gastrointestinal endoscopy whenever they present symptoms. Nevertheless, we must keep in mind that infection might also be asymptomatic and esophageal candidiasis prevalence may be higher than that reported thus far.

Deaths with asthma in France, 2000-2005: a multiple-cause analysis

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000-2005. In 2004-2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (-12% and -11%/year in the 1-44 and 45-64 age groups, respectively). The decline for all deaths with asthma was less pronounced (-9%/year in the 1-44 age group and -8%/year in the 45-64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (-12%/year for underlying cause, -9% for multiple-cause) than women (-5% and -3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1-44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%. Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.

Asthma-like symptoms are increased in the metabolic syndrome

BACKGROUND

The prevalence of obesity and asthma has been increasing during the last several decades. Obesity has been reported to be associated with asthma. Obesity, especially abdominal obesity, is the main component of the metabolic syndrome.

OBJECTIVES

We thus hypothesized that metabolic syndrome is an important contributing factor for the development of asthma-like symptoms.

METHODS

The Korean Health and Genome Study started in 2001 as an ongoing population-based study of Korean adults 40 to 69 years of age. The prevalence of asthma-like symptoms in the previous 12 months was obtained by a questionnaire, and spirometric testing was conducted.

RESULTS

Among the 10,038 participants, the data from 9,942 individuals (4,716 men and 5,226 women) was available. Asthma-like symptoms (wheeze [p = 0.0006], resting dyspnea [p = 0.0062], and post-exercise dyspnea [p < 0.0001]) were increased in the subjects of the metabolic syndrome group. Subjects with asthma-like symptoms had a decreased lung function compared to subjects without asthma-like symptoms. Among the components of the metabolic syndrome, abdominal obesity and hypertension were the risk factors for asthma-like symptoms.

CONCLUSIONS

Metabolic syndrome is associated with asthma-like symptoms. Among the components of metabolic syndrome, abdominal obesity and hypertension are the risk factors for asthma-like symptoms.

Control of asthma for reducing the risk of bronchospasm in asthmatics undergoing general anesthesia and/or intravascular administration of radiographic contrast media

BACKGROUND

It is well known that patients suffering from bronchial asthma undergoing surgical procedures requiring general anesthesia (GA) or the administration of water soluble radiographic contrast media (RCM) have an increased risk of potentially severe bronchospasm. Nevertheless, little attention has been devoted to the possible preventive measures to reduce the occurrence of this potentially life-threatening event. It has been shown that the most important risk factor for bronchospasm during GA induction and/or the use of RCM is represented by a high degree of bronchial hyperreactivity with airway instability not adequately controlled by long-term anti-inflammatory treatment.

AIMS

The aim of this commentary is to underline the need for an accurate clinical and functional evaluation of asthmatics undergoing surgical procedures requiring GA or radiological procedures requiring the administration of RCM, as well as to suggest a stepwise preventive pharmacological approach for reducing the risk of bronchospasm.

METHODS

The authors' suggestions represent clinical experience of the respiratory section of an internal hospital-based working group whose aim is the prevention of asthmatic/anaphylactic/anaphylactoid reactions during the administration of anesthetics and/or RCM. The MEDLINE database was searched with a combination of keywords: general anesthesia, radio contrast media [and] bronchial asthma. The main limitation of this commentary is the scarcity of available literature on this topic.

FINDINGS

The authors suggest a therapeutic approach before surgical procedures requiring GA and/or RCM administration based on the degree of asthma control as assessed by clinical/functional criteria. In this setting, in addition to the necessity of obtaining the best control of airway reactivity, the authors suggest that an optimal control of asthma symptoms in 'real life' conditions might likely constitute a safety issue in asthmatic patients in the case of emergency procedures.

Qualitative analysis of high-resolution CT scans in severe asthma

BACKGROUND

High-resolution CT (HRCT) scanning is part of the management of severe asthma, but its application varies between centers. We sought to describe the HRCT scan abnormalities of a large severe asthma cohort and to determine the utility of clinical features to direct the use of HRCT scanning in this group of patients.

METHODS

Subjects attending our Difficult Asthma Clinic (DAC) between February 2000 and November 2006 (n = 463) were extensively re-characterized and 185 underwent HRCT scan. The HRCT scans were analyzed qualitatively and the interobserver variability was assessed. Using logistic regression we defined clinical parameters that were associated with bronchiectasis (BE) and bronchial wall thickening (BWT) alone or in combination.

RESULTS

HRCT scan abnormalities were present in 80% of subjects and often coexisted with BWT (62%), BE (40%), and emphysema (8%). The interobserver agreement for BE (kappa = 0.76) and BWT (kappa = 0.63) was substantial. DAC patients who underwent HRCT scanning compared with those who did not were older, had longer disease duration, had poorer lung function, were receiving higher doses of corticosteroids, and had increased neutrophilic airway inflammation. The sensitivity and specificity of detecting BE clinically were 74% and 45%, respectively. FEV(1)/FVC ratio emerged as an important predictor for both BE and BWT but had poor discriminatory utility for subjects who did not have airway structural changes (FEV(1)/FVC ratio, >or= 75%; sensitivity, 67%; specificity, 65%).

CONCLUSION

HRCT scan abnormalities are common in patients with severe asthma. Nonradiologic assessments fail to reliably predict important bronchial wall changes; therefore, CT scan acquisition may be required in all patients with severe asthma.

Diminished sarco/endoplasmic reticulum Ca2+ ATPase (SERCA) expression contributes to airway remodelling in bronchial asthma

Phenotypic modulation of airway smooth muscle (ASM) is an important feature of airway remodeling in asthma that is characterized by enhanced proliferation and secretion of pro-inflammatory chemokines. These activities are regulated by the concentration of free Ca(2+) in the cytosol ([Ca(2+)](i)). A rise in [Ca(2+)](i) is normalized by rapid reuptake of Ca(2+) into sarcoplasmic reticulum (SR) stores by the sarco/endoplasmic reticulum Ca(2+) (SERCA) pump. We examined whether increased proliferative and secretory responses of ASM from asthmatics result from reduced SERCA expression. ASM cells were cultured from subjects with and without asthma. SERCA expression was evaluated by western blot, immunohistochemistry and real-time PCR. Changes in [Ca(2+)](i), cell spreading, cellular proliferation, and eotaxin-1 release were measured. Compared with control cells from healthy subjects, SERCA2 mRNA and protein expression was reduced in ASM cells from subjects with moderately severe asthma. SERCA2 expression was similarly reduced in ASM in vivo in subjects with moderate/severe asthma. Rises in [Ca(2+)](i) following cell surface receptor-induced SR activation, or inhibition of SERCA-mediated Ca(2+) re-uptake, were attenuated in ASM cells from asthmatics. Likewise, the return to baseline of [Ca](i) after stimulation by bradykinin was delayed by approximately 50% in ASM cells from asthmatics. siRNA-mediated knockdown of SERCA2 in ASM from healthy subjects increased cell spreading, eotaxin-1 release and proliferation. Our findings implicate a deficiency in SERCA2 in ASM in asthma that contributes to its secretory and hyperproliferative phenotype in asthma, and which may play a key role in mechanisms of airway remodeling.

Intrinsic asthma: not so different from allergic asthma but driven by superantigens?

The mechanisms of intrinsic or non-allergic asthma remain uncertain as allergens have no obvious role in driving the inflammatory process in the airways. However, IgE synthesis occurs in the airways, despite negative skin prick tests and serum-specific IgE. Furthermore, the inflammatory process in the airways is very similar between allergic and non-allergic asthma, with increased T-helper type 2 (Th2) cells, mast cell activation and infiltration of eosinophils. This pattern of inflammation is associated with a similar expression of inflammatory mediators, including Th2 cytokines and eosinophilotactic chemokines. There is increasing evidence that microbial superantigens, particularly Staphylococcal enterotoxins are important in amplifying inflammation in atopic dermatitis and chronic rhinosinusitis, in atopic and non-atopic patients. Superantigens may also be important in intrinsic asthma as airway epithelial cells may be colonized by Staphylococci and other superantigen-producing microbes. Superantigens produced locally in the airways may lead to class switching of local B cells, resulting in polyclonal IgE production in the airways and also specific IgE against the superantigen (which functions as a 'superallergen'). This leads to sensitization of mast cells, which can be activated by the usual asthma triggers, such as exercise. Superantigens also cause clonal expansion of T cells, resulting in increased Th2 cells and CD8(+) cells, while suppressing regulatory T cells. Superantigens may also reduce responsiveness to corticosteroids, resulting in more severe asthma. Finally, cytotoxic autoantibodies may also be implicated as IgG antibodies directed against epithelial proteins, such as cytokeratin-18, have been detected in intrinsic asthma, possibly as a result of epithelial damage and this may make epithelial cells more susceptible to microbial colonization. The therapeutic implications are that antibodies against local IgE and microbial superantigens or antibiotic therapy to eradicate the relevant superantigen-producing microorganisms may improve the efficacy of conventional therapy with corticosteroids.

MicroRNA expression profiling in mild asthmatic human airways and effect of corticosteroid therapy

BACKGROUND

Asthma is a common disease characterised by reversible airflow obstruction, bronchial hyperresponsiveness and chronic inflammation, which is commonly treated using corticosteroids such as budesonide. MicroRNAs (miRNAs) are a recently identified family of non-protein encoding genes that regulate protein translation by a mechanism entitled RNA interference. Previous studies have shown lung-specific miRNA expression profiles, although their importance in regulating gene expression is unresolved. We determined whether miRNA expression was differentially expressed in mild asthma and the effect of corticosteroid treatment.

METHODOLOGY/PRINCIPAL FINDINGS

We have examined changes in miRNA using a highly sensitive RT-PCR based approach to measure the expression of 227 miRNAs in airway biopsies obtained from normal and mild asthmatic patients. We have also determined whether the anti-inflammatory action of corticosteroids are mediated through miRNAs by determining the profile of miRNA expression in mild asthmatics, before and following 1 month twice daily treatment with inhaled budesonide. Furthermore, we have analysed the expression of miRNAs from individual cell populations from the airway and lung. We found no significant difference in the expression of 227 miRNAs in the airway biopsies obtained from normal and mild asthmatic patients. In addition, despite improved lung function, we found no significant difference in the miRNA expression following one month treatment with the corticosteroid, budesonide. However, analysis of bronchial and alveolar epithelial cells, airway smooth muscle cells, alveolar macrophages and lung fibroblasts demonstrate a miRNA expression profile that is specific to individual cell types and demonstrates the complex cellular heterogeneity within whole tissue samples.

CONCLUSIONS

Changes in miRNA expression do not appear to be involved in the development of a mild asthmatic phenotype or in the anti-inflammatory action of the corticosteroid budesonide.

Association between renin-angiotensin system gene polymorphism and recurrent wheezing in Chinese children: a 4-year follow-up study

This study aimed to clarify the association between angiotensin-converting enzyme (ACE) gene polymorphisms and infant wheezing, and to determine whether an association may contribute to early prediction of persistent wheezing and asthma. The study cohort comprised 149 patients with asthma, 169 patients with wheezing but no clinical diagnosis of asthma and 165 healthy control subjects. The insertion/deletion (I/D) polymorphism of the ACE gene was determined by polymerase chain reaction. Total serum immunoglobulin E was determined for the wheezy group and a 4-year follow-up study was carried out to observe wheezing relapse. Significant differences were found between patients and controls in allele frequency and genotype distribution. The DD genotype was more frequent in patients in the wheezing and asthma groups than in the control subjects. Patients with the DD genotype had a higher frequency of relapse than patients expressing the ID or II genotypes. It is concluded that the DD genotype of ACE is a risk factor for recurrent wheezing in early childhood.

Montelukast in guidelines and beyond

In all asthma guidelines, preventive anti-inflammatory treatment is essential in all patients with persistent asthma. Inhaled corticosteroids are the mainstay of treatment in the control of asthma, but other treatments may be used as a monotherapy in patients with mild asthma or as an add-on treatment in those with moderate-to-severe asthma. Leukotriene modifiers are the only validated preventive treatment for all age groups. This review discusses the place of montelukast, a leukotriene receptor antagonist, using guidelines and consensus reports on asthma and rhinitis: the US National Asthma Education and Prevention Program (NAEPP); the British Guideline on the Management of Asthma; the Global Initiative on Asthma (GINA); and Allergic Rhinitis and its Impact on Asthma (ARIA). This review includes new studies that have not yet been considered in guidelines.

Glucocorticoid resistance in inflammatory diseases

Glucocorticoid resistance or insensitivity is a major barrier to the treatment of several common inflammatory diseases-including chronic obstructive pulmonary disease and acute respiratory distress syndrome; it is also an issue for some patients with asthma, rheumatoid arthritis, and inflammatory bowel disease. Several molecular mechanisms of glucocorticoid resistance have now been identified, including activation of mitogen-activated protein (MAP) kinase pathways by certain cytokines, excessive activation of the transcription factor activator protein 1, reduced histone deacetylase-2 (HDAC2) expression, raised macrophage migration inhibitory factor, and increased P-glycoprotein-mediated drug efflux. Patients with glucocorticoid resistance can be treated with alternative broad-spectrum anti-inflammatory treatments, such as calcineurin inhibitors and other immunomodulators, or novel anti-inflammatory treatments, such as inhibitors of phosphodiesterase 4 or nuclear factor kappaB, although these drugs are all likely to have major side-effects. An alternative treatment strategy is to reverse glucocorticoid resistance by blocking its underlying mechanisms. Some examples of this approach are inhibition of p38 MAP kinase, use of vitamin D to restore interleukin-10 response, activation of HDAC2 expression by use of theophylline, antioxidants, or phosphoinositide-3-kinase-delta inhibitors, and inhibition of macrophage migration inhibitory factor and P-glycoprotein.

Mometasone furoate: an effective anti-inflammatory with a well-defined safety and tolerability profile in the treatment of asthma

Inhaled corticosteroids (ICS) are recommended as a controller medication in the most recent Global Initiative for Asthma and the National Heart, Lung and Blood Institute guidelines. Mometasone furoate (MF) is an effective, well-tolerated inhaled steroid and is indicated for the maintenance treatment of adult and adolescent patients (> or = 12 years) with persistent asthma. MF is approved for once or bid maintenance treatment of asthma (in patients previously receiving ICS or bronchodilators). Low systemic bioavailability and high relative binding affinity for the glucocorticoid receptor are properties of MF that allow for a favourable efficacy and tolerability profile. Inhaled MF has been shown to be an effective and well-tolerated controller medication for those patients with mild, moderate or severe persistent asthma. MF has recently been approved by the US regulatory authorities for use in children (4-11 years). Future developments include the combination of MF with the long-acting bronchodilators, formoterol and indacaterol, to provide additional options in the treatment of asthma.

Montelukast as add-on therapy with inhaled corticosteroids alone or inhaled corticosteroids and long-acting beta-2-agonists in the management of patients diagnosed with asthma and concurrent allergic rhinitis (the RADAR trial)

OBJECTIVE

To evaluate the effectiveness of montelukast as add-on therapy for patients diagnosed with asthma and concurrent allergic rhinitis who remain uncontrolled while receiving inhaled corticosteroid (ICS) monotherapy or ICS/long-acting beta-2-agonist (LABA) therapy in a community practice setting.

DESIGN

An eight-week, multicentre, open-label, observational study. Patients were 15 years of age or older and, while treated with an ICS or ICS/LABA, had allergic rhinitis and uncontrolled asthma symptoms by at least two criteria as per the Canadian Asthma Consensus Guidelines. The primary outcome measure was the percentage of patients with controlled asthma symptoms after eight weeks of treatment with montelukast 10 mg once daily added to ICS or ICS/LABA therapy.

RESULTS

In total, 1004 patients participated in the survey phase of the study. Of these patients, 319 continued in the treatment phase and 301 (94.4%) completed the eight-week assessment. At baseline, all patients had uncontrolled asthma symptoms based on the Canadian Asthma Consensus Guidelines; at the eight-week assessment, 229 patients (76.1%) achieved asthma control. According to the Asthma Control Questionnaire (as determined by scores of 0.75 or less), 164 patients (54.7%) achieved well-controlled asthma at week 8. The mean (+/- SD) Asthma Control Questionnaire score decreased from 2.03+/-0.80 to 0.92+/-0.80 (P<0.001) for all patients, representing a clinically significant improvement. A statistically and clinically significant reduction in the overall Mini Rhinitis Quality of Life Questionnaire score was achieved with a decrease from 2.57+/-1.20 to 1.12+/-1.00 (-1.45+/-1.35; P<0.001). Patient and physician satisfaction rates with montelukast add-on therapy were also significantly increased when compared with baseline treatment.

CONCLUSION

Montelukast add-on therapy is effective for managing asthma and allergic rhinitis symptoms in patients who were previously uncontrolled with ICS or ICS/LABA treatment.

The effect of inhaled corticosteroids on Chlamydophila pneumoniae and Mycoplasma pneumoniae infection in children with bronchial asthma

The purpose of this study was to clarify whether inhaled corticosteroids (ICSs) increased the infectious load of Chlamydophila pneumoniae and/or Mycoplasma pneumoniae in the respiratory tracts of asthmatic children. We studied a total of 310 outpatients with chronic stable asthma. Real-time polymerase chain reaction (PCR)-positive results for C. pneumoniae were obtained in 21 of 310 (6.8%) throat samples and 21 of 293 (7.2%) nasopharyngeal samples. There was no significant difference in the rate of detection or in the quantity of detection for C. pneumoniae between the ICS group and the non-ICS group, nor were there differences among groups classified by Japanese pediatric guidelines (JPGL) severity criteria. Real-time PCR-positive results for M. pneumoniae were obtained in 60 of 310 (19.4%) throat samples and 49 of 293 (16.7%) nasopharyngeal samples. There was no significant difference in the rate of detection or the quantity of detection between the ICS group and the non-ICS group, nor were there differences among age groups. The results of this research do not support the hypothesis that ICSs influence the infectious load of C. pneumoniae and M. pneumoniae. ICSs did not increase C. pneumoniae or M. pneumoniae infection in the upper respiratory tract, in contrast to the effect of ICSs in causing oral candidiasis. Our data exclude the concern that there is an increase in C. pneumoniae and M. pneumoniae infections due to ICS use, the use of ICSs being the gold standard in the long-term anti-inflammatory treatment of persistent asthma in children and adults.

Management of work-related asthma

The physician managing work-related asthma (WRA) assumes many roles. The first is to confirm an accurate diagnosis, recognizing that WRA has multiple phenotypes, including sensitizer-induced occupational asthma (OA) caused by high-molecular-weight (HMW) proteins or low-molecular-weight (LMW) chemicals; irritant-induced asthma; and work-exacerbated asthma. Pharmacotherapy for WRA is identical to nonwork-related asthma and should be guided by current asthma guidelines emphasizing control of both asthma impairment and risk domains. It is well established that the majority of workers diagnosed with OA caused by sensitizers experience persistent asthma after leaving the workplace. However, the long-term risk of persistent unremitting asthma can be prevented in a minority of cases, particularly with OA caused by LMW sensitizers, by establishing an early diagnosis of OA and reducing or eliminating exposure. The physician consultant may advise employers on workplace interventions needed to minimize effectively an affected employee's exposure to a causative agent or condition, and what measures are required to prevent new cases of WRA (ie, primary prevention). Although allergen immunotherapy has a putative role in treating and preventing WRA caused by HMW sensitizers, further study is needed.

[Improving the control of asthma]

Asthma control is the cornerstone of monitoring for patients with this disease. Monitoring limited to questions of the type "how is your asthma?" underestimates the real effects of the disease. Measuring control requires assessing several criteria, which differ by the kinetics of their course during treatment. Basing monitoring on only a single criterion risks overestimating control, stepping down treatment too early, and losing control of the disease. In the case of inadequate control, uncontrolled comorbid conditions and aggravating factors or poor treatment adhesion must be sought before determining that the treatment itself is insufficient. After stepping up treatment, the chances of obtaining adequate control increase progressively with time, for at least a year. When the physician and patient jointly determine that the current treatment is the maximum acceptable, waiting may be a solution. Similarly, in seeking the minimal efficacious treatment, treatment must not be stepped down too rapidly. Once control is obtained, continuation of the treatment maintains long-term control for most patients.

An imbalance in C/EBPs and increased mitochondrial activity in asthmatic airway smooth muscle cells: novel targets in asthma therapy?

The asthma prevalence was increasing over the past two decades worldwide. Allergic asthma, caused by inhaled allergens of different origin or by food, is mediated by inflammatory mechanisms. The action of non-allergic asthma, induced by cold air, humidity, temperature or exercise, is not well understood. Asthma affects up to 15% of the population and is treated with anti-inflammatory and muscle relaxing drugs which allow symptom control. Asthma was first defined as a malfunction of the airway smooth muscle, later as an imbalanced immune response of the lung. Recent studies placed the airway smooth muscle again into the focus. Here we summarize the molecular biological basis of the deregulated function of the human airway smooth muscle cell as a cause or important contributor to the pathology of asthma. In the asthmatic human airway smooth muscle cells, there is: (i) a deregulation of cell differentiation due to low levels of maturation-regulating transcription factors such as CCAAT/enhancer binding proteins and peroxisome proliferator-activated receptors, thereby reducing the cells threshold to proliferate and to secrete pro-inflammatory cytokines under certain conditions; (ii) a higher basal energy turnover that is due to increased number and activity of mitochondria; and (iii) a modified feedback mechanism between cells and the extracellular matrix they are embedded in. All these cellular pathologies are linked to each other and to the innate immune response of the lung, but the sequence of events is unclear and needs further investigation. However, these findings may present the basis for the development of novel curative asthma drugs.

Clinical and Immunological Correlates of Pre-Co-Seasonal Sublingual Immunotherapy with Birch Monomeric Allergoid in Patients with Allergic Rhinoconjunctivitis

Sublingual immunotherapy is safe and efficacious in the treatment of patients with allergic rhinitis. The clinical and biological efficacy of modified allergens (allergoids) has not been fully clarified. We investigated in birch allergic patients the effect of a pre-co-seasonal sublingual immunotherapy regimen with a modified allergen extract on clinical parameters and on T cell proliferation and regulatory cytokine production (IL-10, TGF-beta). We found that during the birch pollen season symptoms and drug usage scores were 30 and 40% improved, respectively, in treated versus control subjects (p<0.0001 for both comparisons) whereas well days were 23.5 (33%) versus 16.9 (23%) (p=0.0024), respectively. Bet v 1 allergen specific proliferation decreased (p = 0.0010), whereas IL-10 transcription increased (p = 0.0010) in treated, but not in control patients. Moreover, TGF-beta transcription was increased, although not significantly (p=0.066), following immunotherapy. Thus, sublingual immunotherapy with modified allergen in birch-allergic subjects was safe, clinically efficacious and associated with the reduction of allergen-specific proliferation and with the increased production of the IL-10 regulatory cytokine.

Inflammatory and oxidative stress biomarkers in allergic rhinitis: the effect of smoking

BACKGROUND

Accumulating evidence confirms the presence of pan-airway inflammation in allergic rhinitis patients. Smoking is known to affect the asthmatic airway inflammation. However, no study has evaluated the impact of smoking on airway inflammation of allergic rhinitis patients.

OBJECTIVE

The aim of the present study was to evaluate the impact of smoking on inflammatory and oxidative stress biomarkers in patients with seasonal allergic rhinitis, using non-invasive methods for sample collection.

METHODS

Forty patients with seasonal allergic rhinitis (20 smokers and 20 non-smokers) and 30 healthy subjects (15 smokers and 15 non-smokers) were recruited for the study during pollen season. All subjects were submitted to measurement of the fraction of exhaled NO (FeNO), exhaled breath condensate (EBC) collection, nasal lavage collection, pre- and post- bronchodilation spirometry and metacholine bronchial challenge testing. pH, leukotriene B(4) (LTB(4)) and 8-isoprostane were determined in EBC and nasal lavage samples.

RESULTS

Patients with allergic rhinitis presented higher LTB(4) and 8-isoprostane levels in nasal lavage (P<0.0001 for both comparisons), with no significant differences between smokers and non-smokers. Patients with allergic rhinitis also presented higher LTB(4) levels and lower pH in EBC (P<0.001 and P=0.004, respectively), with prominent differences between smokers and non-smokers (P<0.0001 and P=0.003, for LTB(4) and pH, respectively). A significant correlation between nasal lavage and EBC LTB(4) values was observed (r(s)=0.313, P=0.048).

CONCLUSIONS

Patients with allergic rhinitis present increased LTB(4) and 8-isoprostane in their nasal cavity, however, with no significant differences between smokers and non-smokers. In contrast, smokers with allergic rhinitis present higher LTB(4) levels and lower pH in EBC, suggesting that these patients may be more susceptible to the deleterious effects of smoking, compared with non-smokers.

Quality of life in asthmatic adolescents: an overall evaluation of disease control

OBJECTIVE

to evaluate the relative impact of reported symptoms, school absenteeism, hospital admission, medical visits, and the presence of emotional and behavioral disorders on the health-related quality of life (HRQL) of low income asthmatic adolescents.

METHODS

Asthmatic adolescents were randomly selected among public schools in Belo Horizonte/MG, Brazil. Asthma severity was rated according to the Global Initiative for Asthma (GINA) classification. Emotional and behavior disorders (EBDs) were evaluated through the Strengths and Difficulties Questionnaire. HRQL was assessed through the Pediatric Asthma Quality of Life Questionnaire (PAQLQ). PAQLQ score was analyzed for each intervening variable. Multivariate regression analysis was conducted.

RESULTS

One hundred and forty-six adolescents participated in the present study, 45% being male and age ranging from 14 to 16 years old. Mean PAQLQ score was 5.7 +/- 1.3 SD, with no significant difference regarding sociodemographic characteristics, except for gender (p = 0.001). The regression equation of the final model for the multivariate analysis was as follows: Mean PAQLQ score = 1.88 (Constant) - 0.42 gender + 1.14 nighttime symptoms + 0.69 medical visits in the past 12 months + 0.95 EBDs. Therefore, if the other variables remained constant, PAQLQ score: reduced in 0.42 points for females (p = 0.01); increased in 1.14 when there were no nighttime symptoms (p < 0.01); increased in 0.69 when there was no medical visit for respiratory problems within the past 12 months (p < 0.01); and increased in 0.95 when no EBDs were present (p < 0.01). This model was able to explain approximately half of the variation found in PAQLQ score (R-Sq = 49.4%).

CONCLUSIONS

HRQL of asthmatic adolescents is influenced by the complex interaction among several factors: the severity of clinical symptoms, morbidity, gender, and the psychological resources available so as to deal with such difficulties. A careful evaluation of HRQL is essential in order to capture feelings and subjective perceptions, which are not investigated by the conventional evaluation of asthma control.

Provoked models of asthma: what have we learnt?

Asthma is a chronic inflammatory disease of the airways characterized by physiological abnormalities of variable airflow obstruction and airway hyperresponsiveness (AHR) to a wide variety of physical and inhaled chemical stimuli and the presence of symptoms. AHR is measured by challenging the airways with a variety of agonists and naturally occurring stimuli, which results in constriction of the airway smooth muscle, leading to airway narrowing and airflow limitation. There are two distinct mechanisms by which the airways can narrow to a constrictor stimulus and these are defined by the pathways they take to induce AHR. Direct stimuli are pharmacological agents administered exogenously (such as histamine or methacholine) that act 'directly' on specific receptors on the bronchial smooth muscle to cause constriction. The other mechanism by which the airway can narrow is via the inhalation of indirect stimuli, which include natural stimuli, such as allergen or exercise, and pharmacological agents such as adenosine monophosphate and hyper-osmotic agents (e.g. hypertonic saline or dry powder mannitol). These stimuli induce airway narrowing 'indirectly' by causing the endogenous release of mediators of bronchoconstriction from airway inflammatory cells. Provoked models of asthma have been extremely valuable in understanding the pathobiology of asthma, in aiding diagnosis, in helping to clarify the mechanisms of actions of effective drugs and in the development of new entities to treat asthma. Some provoked models are valuable clinically, particularly those that measure direct AHR, while others, particularly allergen challenge, have been used in animal models and in humans to study the mechanisms of allergen-induced airway inflammation and the associated physiological changes, as well in the development of new drugs for asthma. An emerging role for measurements of AHR is in the evaluation of the optimal treatment for patients with asthma.

Complexities of diagnosis and treatment of allergic respiratory disease in the elderly

Atopic diseases such as rhinitis and asthma are relatively common in children and young adults. However, many patients aged >65 years are also affected by these disorders. Indeed, the literature suggests that between 3-12% and 4-13% of individuals in this age range have allergic rhinitis and asthma, respectively. However, these numbers are most likely underestimates because atopic diseases are frequently not considered in older patients. The diagnosis of both allergic rhinitis and asthma in older patients is more difficult than in younger patients because of a wide differential diagnosis of other diseases that can produce similar symptoms and must be excluded. Furthermore, treatment of these disorders is complicated by the potential for drug interactions, concern about the adverse effects of medications, in particular corticosteroids, and the lack of drug trials specifically targeting treatment of older patients with allergic rhinitis and asthma.

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.

Indacaterol, A Novel Once Daily Inhaled beta2-Adrenoreceptor Agonist

In this article we will review the role of long acting β2-adrenoreceptor agonists and long-acting muscarinic agents in the management of airflow obstruction. We will then focus our attention on indacaterol, one of the new once daily inhaled β2-adrenoreceptor agonists. Pharmacologically this drug is a nearly full β2-agonist without loss of efficacy after prolonged administration. We will also discuss its dosing, safety and tolerability.

Comparability of the Asthma Control Test telephone interview administration format with self-administered mail-out mail-back format

OBJECTIVE

The aim of this study was to evaluate the comparability of ACT * scores from a telephone interview format ('Telephone') against the original paper-and-pencil format ('Paper'). * Asthma Control Test (ACT) is a registered trademark of QualityMetric Incorporated, Lincoln, RI, USA METHODS: This was a randomized, crossover design with subjects completing both paper and telephone interview questionnaires. Subjects were >or=18 years old, with an asthma diagnosis, and receiving treatment within the last year. Eligible subjects were randomized to one of four administration form (AF) groups--(1) Telephone-Telephone, (2) Paper-Paper, (3) Paper-Telephone, (4) Telephone-Paper. Internal consistency and test-retest reliability were compared across groups. Differential item functioning (DIF) tests were conducted at baseline to evaluate AF effects on individual ACT items. Unadjusted and adjusted mean ACT scores were compared between AFs at baseline and unadjusted and adjusted means changes in ACT scores from baseline to follow-up were compared across the four groups. Lastly, the ability of ACT scores to discriminate between self-reported asthma severity was compared between the AFs using ANOVA.

RESULTS

A total of 1090 asthma respondents completed paper (n = 579) and telephone interview (n = 511) questionnaires. Internal consistency reliability of ACT scores at baseline was 0.81 and 0.83 for the paper and telephone AFs, respectively. Test-retest reliabilities ranged from 0.87 to 0.91 across the four groups. Responses to ACT items showed no significant DIF between AFs (chi(2) = 6.6, p = 0.25). ACT scores differed significantly across asthma severity levels in the hypothesized way for both paper (F = 230.1, p < 0.001) and telephone (F = 173.4, p < 0.001) AFs.

CONCLUSION

ACT scores from a telephone interview are reliable and comparable to ACT scores from a self-administered paper-and-pencil format. A potential limitation concerns the representativeness of study participants of asthmatics in the population.

Recommendations for treatment of intermittent mild persistent asthma in children and adolescents

Many parents and caretakers of children and adolescents with mild persistent asthma (MPA) do not follow proposed guidelines, namely the daily and continuous administration of inhaled corticosteroids (ICS). Instead, parents and caretakers tend to use ICS and bronchodilators intermittently for short periods and restart such therapy only when symptoms reappear. It is our opinion that intermittent treatment of MPA in children and adolescents might achieve the same level of asthma control as has been achieved in adults. We propose, therefore, that after an initial period of stabilization with age-appropriate doses of oral glucocorticoids or high-dose ICS and short-acting beta-2 agonists (SABA), caretakers can stop treatment once there are no longer signs or symptoms of asthma. When asthmatic symptoms recur, treatment should be restarted with ICS and SABA, or oral corticosteroids if the exacerbation is severe. The perception of developing asthma symptoms remains an unsolved problem. Based on our clinical experience in children and adolescents with asthma, we list a number of signs and symptoms that precede an exacerbation of asthma, allowing for an early re-introduction of treatment to prevent an exacerbation.

Treatment strategies in mild asthma

PURPOSE OF THE REVIEW

More than 10 years ago the category of mild asthma was split into mild intermittent and mild persistent asthma and maintenance therapy with low dose inhaled corticosteroids (ICS) was recommended for mild persistent asthma. The threshold for instituting regular ICS therapy was arbitrarily chosen, in the absence of clinical studies specifically addressing this issue.

RECENT FINDINGS

The results of recent trials have questioned the assumption that all patients at the mild end of the asthma severity spectrum should be committed to regular anti-inflammatory treatment with inhaled corticosteroids. As a consequence, the identification of the relevant outcomes for the treatment of mild persistent asthma has become a matter of discussion, which has provided the rationale to test the efficacy and well tolerance of new strategies, other than guidelines-recommended regular low-dose ICS, for the treatment of mild persistent asthma.

SUMMARY

Several approaches have been evaluated with some promising results, to include the combination of ICS and long-acting b2-agonists, oral leukotriene antagonists, and the intermittent or as-needed use of ICS in the absence of regular treatment. Conversely, little effort has been made to evaluate therapeutic options other than as-needed bronchodilation in mild intermittent asthma.

Using fractional exhaled nitric oxide to guide asthma therapy: design and methodological issues for ASthma TReatment ALgorithm studies

BACKGROUND

Current asthma guidelines recommend treatment based on the assessment of asthma control using symptoms and lung function. Noninvasive markers are an attractive way to modify therapy since they offer improved selection of active treatment(s) based on individual response, and improved titration of treatment using markers that are better related to treatment outcomes.

AIMS

To review the methodological and design features of noninvasive marker studies in asthma.

METHODS

Systematic assessment of published randomized trials of asthma therapy guided by fraction of exhaled nitric oxide(FENO).

RESULTS

FENO has appeal as a marker to adjust asthma therapy since it is readily measured, gives reproducible results, and is responsive to changes in inhaled corticosteroid doses. However, the five randomised trials of FENO guided therapy have had mixed results. This may be because there are specific design and methodological issues that need to be addressed in the conduct of ASthma TReatment ALgorithm(ASTRAL) studies. There needs to be a clear dose response relationship for the active drugs used and the outcomes measured. The algorithm decision points should be based on outcomes in the population of interest rather than the range of values in healthy people, and the algorithm used needs to provide a sufficiently different result to clinical decision making in order for there to be any discernible benefit. A new metric is required to assess the algorithm performance, and the discordance:concordance(DC) ratio can assist with this.

CONCLUSION

Incorporating these design features into future FENO studies should improve the study performance and aid in obtaining a better estimate of the value of FENO guided asthma therapy.

Adverse effects of salmeterol in asthma: a neuronal perspective

BACKGROUND

Regular use of inhaled beta(2)-agonists has been associated with a paradoxical loss of asthma control and a deterioration of airway hyper-responsiveness, but the underlying mechanism is unknown. The neurotrophin brain-derived neurotrophic factor (BDNF) has recently been identified as a mediator of airway hyper-responsiveness in asthma.

METHODS

Eighteen patients with mild allergic asthma who did not use any regular antiasthmatic therapy inhaled the long-acting beta(2)-agonist salmeterol for 2 weeks followed by 2 weeks of combination therapy with salmeterol and the corticosteroid fluticasone. Airway responsiveness to histamine and BDNF concentrations in blood were assessed prior to entry, after 14 days of salmeterol therapy and after 14 days of combination therapy. In a separate experiment, salmeterol effects on BDNF release by human peripheral blood mononuclear cells were assessed.

RESULTS

Monotherapy with salmeterol significantly increased BDNF concentrations in serum and platelets. This increase was abolished by the addition of fluticasone to the treatment. The findings were confirmed in vitro: salmeterol increased the release of BDNF by mononuclear cells, and this was inhibited by co-incubation with fluticasone. Increased BDNF concentrations in serum and platelets correlated with the deterioration of airway hyper-responsiveness following salmeterol monotherapy. In contrast, there was no association between beta(2)-receptor polymorphisms and changes in airway responsiveness.

CONCLUSION

Increased BDNF concentrations may underly the adverse effects of salmeterol monotherapy on airway responsiveness in asthma.

TRIAL REGISTRATION NUMBER

NCT00736801.

Personality, adherence, asthma control and health-related quality of life in young adult asthmatics

BACKGROUND

Striving for improved adherence and asthma control is of vital concern in today's asthma management. Several influential factors have been identified, but the importance of personality traits has been insufficiently explored. The aim was first to determine whether personality traits in young adult asthmatics are related to asthma control and health-related quality of life (HRQL), and second to examine the influences of personality traits on adherence to regular asthma medication treatment.

METHODS

Young adult asthmatics, 22 years of age (n=268) completed questionnaires. Statistical analyses were performed.

RESULTS

The personality traits Negative Affectivity and Impulsivity correlated negatively with asthma control, whereas in women Hedonic Capacity correlated positively with asthma control. Negative Affectivity, Impulsivity, Hedonic Capacity, Alexithymia and asthma control predicted the mental dimension of HRQL. Asthma control and physical activity predicted the physical dimension of HRQL. Among respondents with regular asthma medication (n=109), Impulsivity correlated negatively with adherence. In men, Antagonism and Alexithymia were associated with low adherence. Additionally, Alexithymia, Hedonic Capacity and Negative Affectivity showed non-linear relationships with adherence, meaning that initially increased scores on these personality traits scales were associated with increased adherence but higher scores did not increase adherence. Respondents who were prescribed a single inhaler combining ICS and LABA reported higher adherence than those with monotherapies.

CONCLUSION

These data suggest that personality can influence how asthma patients adhere to asthma medication treatment, and report their control and HRQL. Tools determining personality traits may be useful in the future in individualizing management of asthma patients.

Control of asthma

Control is the aim of asthma management and clinical trials show that control can be achieved in the majority of patients. However, population surveys show that poorly controlled asthma still imposes a considerable burden. This fact has led to a re-evaluation of the international asthma guidelines and the updated 2006 and 2007 GINA and NAEPP guidelines suggest that the level of control should be used as the key feature for the classification and management of asthma. Furthermore, in the latest guidelines, a clearer definition of control is given and new tools for the assessment and monitoring of control are instituted. In order to achieve asthma control, not only relevant pharmacological treatment but, the establishment of a good patient-doctor relationship, proper education of the asthmatic patient, reduction of exposure to triggers and treatment of co-morbidities are pivotal issues and must be ensured.

Validation of the Spanish version of the Asthma Control Questionnaire

BACKGROUND

The Asthma Control Questionnaire (ACQ) has not been validated in the Spanish population, and the fact that it requires spirometry poses an important limitation on its widespread use in the primary care setting in Spain.

OBJECTIVE

The aim of this study was to evaluate the psychometric properties of the Spanish version of the ACQ.

METHODS

In this multicenter, prospective study, consecutive adult patients with persistent asthma were recruited at 62 respiratory and allergy units across Spain. Patients were assessed at baseline and at weeks 2 and 6. The following clinical variables were recorded: lung function (forced expiratory volume in 1 second [FEV(1)]), symptoms, exacerbations, concomitant diseases, asthma severity according to the Global Initiative for Asthma international guideline, and asthma control as perceived by patients and physicians through direct ad hoc questions. The latter measures were derived specifically for this study. Patients self-completed the ACQ at all visits before the rest of the study variables were recorded. The ACQ's feasibility, validity, reliability, and sensitivity to change were assessed. Cross-sectional and longitudinal validity was assessed using the relationship between ACQ score and clinical parameters. Sensitivity to change was assessed by estimating the global effect size and the minimal important difference (MID). Reliability was assessed using estimation of the Cronbach alpha coefficient (CCalpha) and intraclass correlation coefficient (ICC).

RESULTS

A total of 607 patients were included. The mean (SD) age was 45.6 (17.1) years and 61.4% of the patients were women. Of these 607, 235 (39%) had mild asthma; 246 (41%), moderate; and 126 (21%), severe. Mean (SD) time to complete the ACQ was 3.9 (4.4) minutes. The Pearson correlation coefficient in the relationship between ACQ and FEV(1) (% predicted value) was -0.23. ACQ was found to be significantly related to asthma severity and intensity and frequency of symptoms (coughing, wheezing, and dyspnea) (both, P < 0.001). Change in ACQ was significantly related to changes in FEV(1), intensity and frequency of symptoms, and number of exacerbations (all, P < 0.001). The global effect size of ACQ was 0.46 and the MID was 0.47 point of a maximum of 6. CCalpha was 0.90 and ICC was 0.86.

CONCLUSION

In these adults with asthma in Spain, the Spanish version of the ACQ was found to be a reliable and valid questionnaire, suggesting that it can be used in this population as a discriminative and evaluative instrument.

Acute bronchiolitis and croup

Croup and acute bronchiolitis are common forms of virally induced respiratory disease in infancy and early childhood. There is good evidence that corticosteroids can ameliorate disease severity and alter the natural history of symptoms in patients who have croup and that temporary symptomatic benefit can be obtained from the use of nebulized adrenaline. The principle weakness when reviewing therapeutic interventions for acute bronchiolitis is the lack of a clear diagnostic test or definition. Current evidence suggests that oxygen is the only useful pharmacologic agent for correcting hypoxia.

Cancer risk in hospitalised asthma patients

Asthma is an increasingly common disorder, affecting 5–10% of the population. It involves a dysregulated immune function, which may predispose to subsequent cancer. We examined cancer risk among Swedish subjects who had hospital admission once or multiple times for asthma. An asthma research database was created by identifying asthma patients from the Swedish Hospital Discharge Register and by linking them with the Cancer Registry. A total of 140 425 patients were hospitalised for asthma during 1965–2004, of whom 7421 patients developed cancer, giving an overall standardised incidence ratio (SIR) of 1.36. A significant increase was noted for most sites, with the exception of breast and ovarian cancers and non-Hodgkin's lymphoma and myeloma. Patients with multiple hospital admissions showed a high risk, particularly for stomach (SIR 1.70) and colon (SIR 1.99) cancers. A significant decrease was noted for endometrial cancer and skin melanoma. Oesophageal and lung cancers showed high risks throughout the study period, whereas stomach cancer increased towards the end of the period. The relatively stable temporal trends suggest that the asthmatic condition rather than its medication is responsible for the observed associations.

[Infections and asthma]

Asthma is a chronic inflammatory disorder of the airways. Allergen-induced airway inflammation plays a central role in the pathogenesis of the disease whereas infections are known to be important triggers of acute exacerbations. Chronic or latent infections may also influence and enhance the local inflammation. The aim of this review is to give an overview of the different pathogens and to present the current understanding of the role of respiratory viruses and atypical bacteria in the pathogenesis of the disease.

[Guideline-adherent treatment for asthma]

Asthma is a complex syndrome with numerous clinical phenotypes. An increase in prevalence is detectable worldwide. Efforts to optimize diagnosis and care of patients with asthma have led to the development of international and national guidelines. Besides preventive and non-pharmacological measures such as patient education and physical training, the guidelines particularly recommend standardized drug therapy. In the present article we summarize the recommended pharmacotherapy for patients with bronchial asthma.

Eosinophils in bronchial mucosa of asthmatics after allergen challenge: effect of anti-IgE treatment

BACKGROUND

Anti-IgE, omalizumab, inhibits the allergen response in patients with asthma. This has not been directly related to changes in inflammatory conditions. We hypothesized that anti-IgE exerts its effects by reducing airway inflammation. To that end, the effect of anti-IgE on allergen-induced inflammation in bronchial biopsies in 25 patients with asthma was investigated in a randomized, double-blind, placebo-controlled study.

METHODS

Allergen challenge followed by a bronchoscopy at 24 h was performed at baseline and after 12 weeks of treatment with anti-IgE or placebo. Provocative concentration that causes a 20% fall in forced expiratory volume in 1 s (PC(20)) methacholine and induced sputum was performed at baseline, 8 and 12 weeks of treatment. Changes in the early and late responses to allergen, PC(20), inflammatory cells in biopsies and sputum were assessed.

RESULTS

Both the early and late asthmatic responses were suppressed to 15.3% and 4.7% following anti-IgE treatment as compared with placebo (P < 0.002). This was paralleled by a decrease in eosinophil counts in sputum (4-0.5%) and postallergen biopsies (15-2 cells/0.1 mm(2)) (P < 0.03). Furthermore, biopsy IgE+ cells were significantly reduced between both the groups, whereas high-affinity IgE receptor and CD4+ cells were decreased within the anti-IgE group. There were no significant differences for PC(20) methacholine.

CONCLUSION

The response to inhaled allergen in asthma is diminished by anti-IgE, which in bronchial mucosa is paralleled by a reduction in eosinophils and a decline in IgE-bearing cells postallergen without changing PC(20) methacholine. This suggests that the benefits of anti-IgE in asthma may be explained by a decrease in eosinophilic inflammation and IgE-bearing cells.

Exercise-induced bronchoconstriction: The effects of montelukast, a leukotriene receptor antagonist

Exercise-induced bronchoconstriction (EIB) is very common in both patients with asthma and those who are otherwise thought to be normal. The intensity of exercise as well as the type of exercise is important in producing symptoms. This may make some types of exercise such as swimming more suitable and extended running more difficult for patients with this condition. A better understanding of EIB will allow the physician to direct the patient towards a type of exercise and medications that can result in a more active lifestyle without the same concern for resulting symptoms. This is especially important for schoolchildren who are usually enrolled in physical education classes and elite athletes who may desire to participate in competitive sports. Fortunately several medications (short- and long-acting beta(2)-agonists, cromolyn, nedocromil, inhaled corticosteroids, and more recently leukotriene modifiers) have been shown to be effective in preventing or attenuating the effects of exercise in many patients. In addition, inhaled beta(2)-agonists have been shown to quickly reverse the airway obstruction that develops in patients and continue to be the reliever medications of choice. Inhaled corticosteroids are increasingly being recommended as regular therapy now that the role of inflammation and airway injury has been identified in EIB. With the discovery that there is a release of mediators such as histamine and leukotrienes from cells in the airway following exercise with resulting airway obstruction in susceptible individuals, interest has turned to attenuating their effects with mediator antagonists especially those that block the effects of leukotrienes. Studies with an oral leukotriene antagonist, montelukast, have shown beneficial effects in adults and children aged as young as 6 years with EIB. These effects can be demonstrated as soon as two hours and as long as 24 hours after administration without a demonstrated loss of a protective effect after months of treatment. The studies leading up to and resulting in an approval of montelukast for EIB for patients aged 15 years and older are reviewed in this paper.

Comorbidities in severe asthma: frequency of rhinitis, nasal polyposis, gastroesophageal reflux disease, vocal cord dysfunction and bronchiectasis

OBJECTIVES

Severe asthma is found in approximately 10% of patients with asthma. Some factors associated with worse asthma control include rhinitis, gastroesophageal reflux disease, vocal cord dysfunction (VCD), nasal polyposis and bronchiectasis. Therefore, we evaluated the prevalence of these illnesses in patients with severe asthma.

METHODS

We conducted a retrospective analysis of data obtained from electronic medical records of patients with severe asthma between January 2006 and June 2008. Symptoms of rhinitis and gastroesophageal reflux disease were evaluated as well as intolerance to nonsteroidal anti-inflammatory drugs. We evaluated the results of esophagogastroduodenoscopy, videolaryngoscopy and CT scans of the chest in order to confirm gastroesophageal reflux disease, nasal polyposis, vocal cord dysfunction and bronchiectasis.

RESULTS

We evaluated 245 patients. Rhinitis symptoms were present in 224 patients (91.4%); 18 (7.3%) had intolerance to nonsteroidal anti-inflammatory drugs, and 8 (3.3%) had nasal polyposis. Symptoms of gastroesophageal reflux disease were reported for 173 (70.6%) patients, although the diagnosis of gastroesophageal reflux disease was confirmed based on esophagogastroduodenoscopy or laryngoscopy findings in just 58 (33.6%) patients. Vocal cord dysfunction was suspected in 16 (6.5%) and confirmed through laryngoscopy in 4 (1.6%). The patient records provided CT scans of the chest for 105 patients, and 26 (24.8%) showed bronchiectasis.

DISCUSSION

Rhinitis and gastroesophageal reflux disease were the most common comorbidities observed, in addition to bronchiectasis. Therefore, in patients with severe asthma, associated diseases should be investigated as the cause of respiratory symptoms and uncontrolled asthma.

Validation of a questionnaire for assessment of asthma patient knowledge and behaviour

BACKGROUND

For several years, educational programmes have been highlighted because care success depends on patient's knowledge and patient's asthma management. However, no tool is available to assess change in patient knowledge and behaviour before and after completing an educational programme.

OBJECTIVE

To validate a questionnaire measuring the knowledge and behaviour of asthmatics participating in an educational programme and to gauge the benefit of such a programme.

METHODS

The Asthma Behaviour Change (ABC) questionnaire was generated from literature, patient surveys and clinical situations. It was organized in eight dimensions assessing patient behaviour in seven different clinical situations and two assessing patient (pathophysiology and therapeutic) knowledge. A total of 139 asthmatics filled out the questionnaire before, during and after the educational programme.

RESULTS

The principal component analysis confirmed the structure empirically made by clinical situations. Internal consistency analysis yielded high Cronbach's alpha values. Different dimensions and the two global scores were able to discriminate patients according to asthma severity. Finally, the effect size of difference before and after educational programme was at least 0.47, and was larger than 0.74 for both global behaviour and knowledge scores. The difference between visit 1 and 3 for global behaviour and knowledge scores reached 18.84 +/- 20.83 (P < 0.001, 95% CI: 13.18-24.43) and 11.06 +/- 14.98 (P < 0.001, 95% CI: 7.10-15.03), respectively.

CONCLUSION

ABC questionnaire is a valid tool to assess asthmatics' knowledge and behaviour. Furthermore, this study confirmed that educational programmes lead to better awareness of asthma by patients.

Changes in skin test reactivity among adults with atopic disease: a 3-year prospective study

BACKGROUND

Our knowledge about longitudinal predictors of atopy is limited.

OBJECTIVES

To describe changes in skin test reactivity during a 3-year period in a sample of adolescents and adults with atopic disease and to identify factors of importance for these changes.

METHODS

From a sample of 1,186 candidates, ranging in age from 14 to 44 years, who in a screening questionnaire reported symptoms suggestive of respiratory allergic disease, 344 individuals with a positive skin prick test (SPT) result concomitantly with asthma and/or rhinitis were clinically studied on 2 occasions, 3 years apart.

RESULTS

In total, 134 (39% of the study population) had a different SPT result at follow-up compared with baseline, based on a diagnostic criterion of 3 mm for a positive test result; 77 (22%) developed de novo sensitizations to 1 or more allergens, 45 (13%) had remission of 1 or more sensitizations, and 12 (4%) both gained and lost sensitizations. Female sex (odds ratio = 1.90 [1.02-3.57], P = .04) significantly predicted incidence of 1 or more sensitizations.

CONCLUSIONS

Four of 10 adults with atopic disease will have changes in SPT status during a 3-year period, and most will gain new sensitizations. Women with atopic disease are at increased risk of developing new sensitizations compared with men.

Efficacy and safety of ciclesonide once daily and fluticasone propionate twice daily in children with asthma

BACKGROUND

Ciclesonide is a new inhaled corticosteroid (ICS). Information about its clinical efficacy and safety in relation to other ICS in children is needed for clinical positioning.

OBJECTIVE

This 12-week, randomized, double-blind, double-dummy, three-arm, parallel-group study compared the efficacy and safety of ciclesonide with fluticasone propionate in children with mainly moderate and severe persistent asthma.

METHODS

Seven hundred and forty-four patients (aged 6-11 years) were randomized to ciclesonide (80 or 160 microg once daily) or fluticasone propionate (88 microg twice daily), following a 2-4-week run-in. Efficacy measurements included forced expiratory flow in 1s (FEV(1)), morning peak expiratory flow (PEF), asthma symptom scores, rescue medication use and quality of life. Systemic effect was assessed by 24-hour urine free cortisol adjusted for creatinine.

RESULTS

FEV(1) and morning PEF increased from baseline in all groups (p<0.0001). Ciclesonide 160 microg was not inferior to fluticasone propionate 176 microg for FEV(1) (p=0.0030, one-sided). In all groups, asthma symptom score sums and rescue medication use significantly improved (p<0.0001). The percentages of asthma symptom-, rescue medication- and nocturnal awakening-free days were high, with no significant differences between treatments. Quality of life scores improved with all treatments (p<0.0001). A significant dose-response occurred between low and higher doses of ciclesonide for exacerbations and asthma control definitions. The incidences of adverse events were comparable across treatments. Urine free cortisol levels decreased significantly with fluticasone propionate (p=0.0103), but not with ciclesonide.

CONCLUSION

Once-daily ciclesonide has a clinical effect similar to that of fluticasone propionate, but does not suppress cortisol excretion, in children with moderate and severe asthma.