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Khadka P, Hejazi M, Hindle M, Schuman T, Longest W, Kaviratna A, Chopski S, Walenga R, Newman B, Golshahi L. Anatomically-detailed segmented representative adult and pediatric nasal models for assessing regional drug delivery and bioequivalence with suspension nasal sprays. Int J Pharm 2024:124743. [PMID: 39343330 DOI: 10.1016/j.ijpharm.2024.124743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 09/04/2024] [Accepted: 09/20/2024] [Indexed: 10/01/2024]
Abstract
In vitro nasal models can potentially facilitate development and approval of nasal drug products. This study aims to evaluate the potential for using regional deposition measurements from in vitro nasal models to evaluate nasal spray performance across several products. To accomplish this, the posterior regions of six anatomically realistic nasal airway models of adult and pediatric subjects, representing Low (L), Mean (M) and High (H) posterior drug deposition (PD) for each of the two age groups, were segmented with high anatomical precision into five regions of interest. These models were previously developed with the goal of quantifying the range of intersubject variability of PD following administration of inhaled corticosteroids. The in vitro regional drug deposition values were measured for the reference listed drug (RLD) product for triamcinolone acetonide and two corresponding generic (test) nasal spray products, as well as an RLD product for fluticasone furoate nasal spray. In general, the pediatric models mostly demonstrated higher PD compared to the adult models. The majority (>85 %) of PD was confined to the front and the inferior meatus regions. Subsequent population bioequivalence (PBE) analyses of the regional nasal deposition suggested that the anatomical differences among subjects may impact the nasal spray performance across different nasal products.
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Affiliation(s)
- Prakash Khadka
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - Mohammad Hejazi
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael Hindle
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA, USA
| | - Theodore Schuman
- Department of Otolaryngology - Head and Neck Surgery, VCU Health, Richmond, VA, USA
| | - Worth Longest
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA, USA; Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA, USA
| | - Anubhav Kaviratna
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Steven Chopski
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Ross Walenga
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Bryan Newman
- Division of Therapeutic Performance I, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Laleh Golshahi
- Department of Mechanical and Nuclear Engineering, Virginia Commonwealth University, Richmond, VA, USA.
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Al-Moamary MS, Alhaider SA, Allehebi R, Idrees MM, Zeitouni MO, Al Ghobain MO, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2024; 19:1-55. [PMID: 38444991 PMCID: PMC10911239 DOI: 10.4103/atm.atm_248_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/31/2023] [Indexed: 03/07/2024] Open
Abstract
The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed Saad Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyad Allehebi
- Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Respiratory Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah F. Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Paediatrics, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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3
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Stratakis N, Garcia E, Chandran A, Hsu T, Alshawabkeh A, Aris IM, Aschner JL, Breton C, Burbank A, Camargo CA, Carroll KN, Chen Z, Claud EC, Dabelea D, Dunlop AL, Elliott AJ, Ferrara A, Ganiban JM, Gern JE, Gold DR, Gower WA, Hertz-Picciotto I, Karagas MR, Karr CJ, Lester B, Leve LD, Litonjua AA, Ludena Y, McEvoy CT, Miller RL, Mueller NT, O’Connor TG, Oken E, O’Shea TM, Perera F, Stanford JB, Rivera-Spoljaric K, Rundle A, Trasande L, Wright RJ, Zhang Y, Zhu Y, Berhane K, Gilliland F, Chatzi L. The Role of Childhood Asthma in Obesity Development: A Nationwide US Multicohort Study. Epidemiology 2022; 33:131-140. [PMID: 34561347 PMCID: PMC8633057 DOI: 10.1097/ede.0000000000001421] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
RATIONALE Asthma and obesity often co-occur. It has been hypothesized that asthma may contribute to childhood obesity onset. OBJECTIVES To determine if childhood asthma is associated with incident obesity and examine the role of asthma medication in this association. METHODS We studied 8,716 children between ages 6 and 18.5 years who were nonobese at study entry participating in 18 US cohorts of the Environmental influences on Child Health Outcomes program (among 7,299 children with complete covariate data mean [SD] study entry age = 7.2 [1.6] years and follow up = 5.3 [3.1] years). MEASUREMENTS AND MAIN RESULTS We defined asthma based on caregiver report of provider diagnosis. Incident obesity was defined as the first documented body mass index ≥95th percentile for age and sex following asthma status ascertainment. Over the study period, 26% of children had an asthma diagnosis and 11% developed obesity. Cox proportional hazards models with sex-specific baseline hazards were fitted to assess the association of asthma diagnosis with obesity incidence. Children with asthma had a 23% (95% confidence intervals [CI] = 4, 44) higher risk for subsequently developing obesity compared with those without asthma. A novel mediation analysis was also conducted to decompose the total asthma effect on obesity into pathways mediated and not mediated by asthma medication use. Use of asthma medication attenuated the total estimated effect of asthma on obesity by 64% (excess hazard ratios = 0.64; 95% CI = -1.05, -0.23). CONCLUSIONS This nationwide study supports the hypothesis that childhood asthma is associated with later risk of obesity. Asthma medication may reduce this association and merits further investigation as a potential strategy for obesity prevention among children with asthma.
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Affiliation(s)
- Nikos Stratakis
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Erika Garcia
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Aruna Chandran
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tingju Hsu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Akram Alshawabkeh
- Department of Civil and Environmental Engineering, Northeastern University, Boston, MA
| | - Izzuddin M. Aris
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston MA
| | - Judy L. Aschner
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley NJ and the Albert Einstein College of Medicine, Bronx, NY
| | - Carrie Breton
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Allison Burbank
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kecia N. Carroll
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Zhanghua Chen
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Erika C. Claud
- Departments of Pediatrics and Medicine, The University of Chicago, Chicago, IL
| | - Dana Dabelea
- University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Anne L. Dunlop
- Nell Hodgson Woodruff School of Nursing and Department of Family & Preventive Medicine, Emory University, Atlanta, GA
| | | | | | - Jody M. Ganiban
- Department of Psychology The George Washington University, Washington, DC
| | - James E. Gern
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Diane R Gold
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States; Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - William A. Gower
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | | | - Catherine J. Karr
- Department of Pediatrics & Environmental and Occupational Health Sciences, University of Washington, WA
| | - Barry Lester
- Department of Psychiatry and Human Behavior and Department of Pediatrics, Brown Alpert Medical School and Women and Infants Hospital, Providence, RI
| | - Leslie D. Leve
- Department of Education, University of Oregon, Eugene, OR
| | - Augusto A. Litonjua
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Yunin Ludena
- University of California, Davis, School of Medicine, CA
| | - Cindy T. McEvoy
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Rachel L. Miller
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Noel T. Mueller
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Thomas G. O’Connor
- Departments of Psychiatry, Psychology, Neuroscience and Obstetrics and Gynecology, University of Rochester, NY
| | - Emily Oken
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston MA
| | - T. Michael O’Shea
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Frederica Perera
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Joseph B. Stanford
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT
| | - Katherine Rivera-Spoljaric
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of PediatricsSt. Louis Children’s Hospital, Washington University School of Medicine St. Louis, MO
| | - Andrew Rundle
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | - Leonardo Trasande
- Departments of Pediatrics, Environmental Medicine and Population Health, New York University School of Medicine, NY
| | - Rosalind J. Wright
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yue Zhang
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Yeyi Zhu
- Kaiser Permanente Northern California Division of Research
| | - Kiros Berhane
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Frank Gilliland
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Lida Chatzi
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
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Weare-Regales N, Hudey SN, Lockey RF. Practical Guidance for Prevention and Management of Glucocorticoid-Induced Osteoporosis for the Allergist/Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1841-1850. [PMID: 33444813 DOI: 10.1016/j.jaip.2020.12.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/27/2022]
Abstract
Osteoporosis is a silent disorder with dire consequences, and glucocorticoid use remains the most common iatrogenic cause illustrated by the fact that 30% to 50% of subjects on such long-term therapy experience fractures (Oimomi M, Nakamichi T, Ohara T, Sakai M, Igaki N, Hata F, et al. Fructose-related glycation. Diabetes Res Clin Pract 1989;7:137-9; Reid IR. Glucocorticoid osteoporosis--mechanisms and management. Eur J Endocrinol 1997;137:209-17). By directly affecting bone quality while actively used, glucocorticoids increase the risk of fracture that is independent of a subject's bone density status at the time (Weinstein RS. True strength. J Bone Miner Res 2000;15:621-5). A large number of subjects seen in an allergy and immunology clinic have asthma, chronic rhinosinusitis, or other chronic inflammatory diseases, necessitating the use of these medications and placing them at higher risk for this disease. Data on the effects of both oral and inhaled glucocorticoids on fracture risk are presented. This review concretizes the importance of osteoporosis, its pathophysiology, and provides practical guidelines to prevent and treat it. Management recommendations are tailored to 2 different age groups. The first group consists of children, adolescents, and adults 40 years or younger with a focus on attaining peak bone mass. The second group consists of adults 40 years or older where the use of imaging modalities and Fracture Risk Assessment Tool scores helps triage subjects into fracture risk categories. Those at moderate to high risk require bone-sparing medications. Universal preventive measures for both groups are reviewed. Complicated and severe cases may need additional expertise by an endocrinologist or rheumatologist.
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Affiliation(s)
- Natalia Weare-Regales
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, University of South Florida, Morsani College of Medicine and James A. Haley Veterans' Hospital, Tampa, Fla
| | - Stephanie N Hudey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla.
| | - Richard F Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla
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5
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Rayas MS, Kelly A, Hughan KS, Daley T, Zangen D. Adrenal function in cystic fibrosis. J Cyst Fibros 2020; 18 Suppl 2:S74-S81. [PMID: 31679732 DOI: 10.1016/j.jcf.2019.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Cystic fibrosis (CF) is not known to directly affect the adrenal gland, but commonly used CF therapies do impact the function of the hypothalamic-pituitary-adrenal (HPA) axis. By binding to the glucocorticoid receptor, medications such as inhaled and oral corticosteroids can enhance the systemic effects of cortisol and result in iatrogenic Cushing syndrome. Prolonged use suppresses the body's ability to make cortisol, resulting in iatrogenic adrenal insufficiency upon medication discontinuation. Chronic use of inhaled and oral corticosteroids can negatively affect bone health, growth, and glucose metabolism. This chapter provides practical guidelines regarding the screening, diagnosis, and treatment of iatrogenic adrenal insufficiency. As the guidelines are mainly derived from the asthma literature, this chapter also highlights the need for studies to evaluate the impact of CF therapies on adrenal function and other CF-endocrinopathies.
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Affiliation(s)
- Maria Socorro Rayas
- Division of Pediatric Endocrinology and Diabetes, University of Texas Health San Antonio, 7703 Floyd Curl, San Antonio, TX 78229, USA.
| | - Andrea Kelly
- Division of Pediatric Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine of University of Pennsylvania, 2716 South Street, Philadelphia, PA 19146, USA.
| | - Kara S Hughan
- Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tanicia Daley
- Division of Pediatric Endocrinology and Metabolism, Emory Children's Center/Emory Pediatric Institute, Emory University School of Medicine, 1400 Tullie Road, Atlanta, GA 30329, USA.
| | - David Zangen
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem 91240, Israel.
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6
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Mailhot G, White JH. Vitamin D and Immunity in Infants and Children. Nutrients 2020; 12:E1233. [PMID: 32349265 PMCID: PMC7282029 DOI: 10.3390/nu12051233] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023] Open
Abstract
The last couple of decades have seen an explosion in our interest and understanding of the role of vitamin D in the regulation of immunity. At the molecular level, the hormonal form of vitamin D signals through the nuclear vitamin D receptor (VDR), a ligand-regulated transcription factor. The VDR and vitamin D metabolic enzymes are expressed throughout the innate and adaptive arms of the immune system. The advent of genome-wide approaches to gene expression profiling have led to the identification of numerous VDR-regulated genes implicated in the regulation of innate and adaptive immunity. The molecular data infer that vitamin D signaling should boost innate immunity against pathogens of bacterial or viral origin. Vitamin D signaling also suppresses inflammatory immune responses that underlie autoimmunity and regulate allergic responses. These findings have been bolstered by clinical studies linking vitamin D deficiency to increased rates of infections, autoimmunity, and allergies. Our goals here are to provide an overview of the molecular basis for immune system regulation and to survey the clinical data from pediatric populations, using randomized placebo-controlled trials and meta-analyses where possible, linking vitamin D deficiency to increased rates of infections, autoimmune conditions, and allergies, and addressing the impact of supplementation on these conditions.
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Affiliation(s)
- Geneviève Mailhot
- Department of Nutrition, University of Montreal, Montreal, QC H3T 1A8, Canada
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC H3T 1C5, Canada
| | - John H. White
- Department of Physiology, McGill University, Montreal, QC H3G 1Y6, Canada
- Department of Medicine, McGill University, Montreal, QC H4A 3J1, Canada
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7
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Floris I, Chenuet P, Togbe D, Volteau C, Lejeune B. Potential Role of the Micro-Immunotherapy Medicine 2LALERG in the Treatment of Pollen-Induced Allergic Inflammation. Dose Response 2020; 18:1559325820914092. [PMID: 32269504 PMCID: PMC7093691 DOI: 10.1177/1559325820914092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 12/22/2022] Open
Abstract
In this study, we evaluated the efficacy of a micro-immunotherapy medicine (MIM),
2LALERG, in a preclinical model of allergic respiratory disease sensitized with
birch pollen extract (BPE). BALB/c mice were immunized with BPE, or saline
solution, and were then challenged. Micro-immunotherapy medicine pillules were
diluted in water, and 3 doses (0.75; 1.5; 3 mg/mouse) were tested and compared
to vehicle control (3 mg/mouse). Treatments and vehicle were orally administered
by gavage for 10 days. Micro-immunotherapy medicine (0.75 mg/mouse) reduced the
number of total cells as well as the levels of interleukin (IL)-13 in
bronchoalveolar lavage fluid (BALF) compared to vehicle control. Eosinophils in
BALF tended to be lower compared to vehicle group, and the difference is close
to significance. Histological analysis in the lungs confirms a moderate effect
of MIM (0.75 mg/mice) on inflammatory infiltration and mucus production. Serum
levels of IL-5 in MIM (0.75 mg/mouse)-treated mice were lower compared to
vehicle; IL-4 levels tended to be lower too. Total immunoglobulin E (IgE)
decreased in serum of MIM (1.5 and 0.75 mg/mouse) groups compared to vehicle
control. Micro-immunotherapy medicine exerted the highest effect at the lowest
dose tested. Micro-immunotherapy medicine resolved the local and systemic
inflammation, even if partially, in a model of pollen-induced, IgE-mediated
inflammation.
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Affiliation(s)
- Ilaria Floris
- Preclinical & Clinical Development and Regulatory Affairs, Labo'Life France, Nantes, France
| | | | | | - Christelle Volteau
- Preclinical & Clinical Development and Regulatory Affairs, Labo'Life France, Nantes, France
| | - Beatrice Lejeune
- Preclinical & Clinical Development and Regulatory Affairs, Labo'Life France, Nantes, France
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8
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Chung LP, Paton JY. Two Sides of the Same Coin?-Treatment of Chronic Asthma in Children and Adults. Front Pediatr 2019; 7:62. [PMID: 30915319 PMCID: PMC6421287 DOI: 10.3389/fped.2019.00062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/18/2019] [Indexed: 12/17/2022] Open
Abstract
Globally, asthma is one of the most common chronic conditions that affect individuals of all ages. When poorly controlled, it negatively impacts patient's ability to enjoy life and work. At the population level, effective use of recommended strategies in children and adults can reduce symptom burden, improve quality of life and significantly reduce the risk of exacerbation, decline of lung function and asthma-related death. Inhaled corticosteroid as the initial maintenance therapy, ideally started within 2 years of symptom onset, is highly effective in both children and adults and across various degrees of asthma severity. If asthma is not controlled, the choice of subsequent add-on therapies differs between children and adults. Evidence supporting pharmacological approach to asthma management, especially for those with more severe disease, is more robust in adults compared to children. This is, in part, due to various challenges in the diagnosis of asthma, in the recruitment into clinical trials and in the lack of objective outcomes in children, especially those in the preschool age group. Nevertheless, where evidence is emerging for younger children, it seems to mirror the observations in adults. Clinicians need to develop strategies to implement guideline-based recommendations while taking into consideration individual variations in asthma clinical phenotypes, pathophysiology and treatment responses at different ages.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - James Y. Paton
- School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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9
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Papadopoulos NG, Čustović A, Cabana MD, Dell SD, Deschildre A, Hedlin G, Hossny E, Le Souëf P, Matricardi PM, Nieto A, Phipatanakul W, Pitrez PM, Pohunek P, Gavornikova M, Jaumont X, Price DB. Pediatric asthma: An unmet need for more effective, focused treatments. Pediatr Allergy Immunol 2019; 30:7-16. [PMID: 30312503 PMCID: PMC7380053 DOI: 10.1111/pai.12990] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite remarkable advances in our understanding of asthma, there are still several unmet needs associated with the management of pediatric asthma. METHODS A two-day, face-to-face meeting was held in London, United Kingdom, on October 28 and 29, 2017, involving a group of international expert clinicians and scientists in asthma management to discuss the challenges and unmet needs that remain to be addressed in pediatric asthma. RESULTS These unmet needs include a lack of clinical efficacy and safety evidence, and limited availability of non-steroid-based alternative therapies in patients <6 years of age. An increased focus on children is needed in the context of clinical practice guidelines for asthma; current pediatric practice relies mostly on extrapolations from adult recommendations. Furthermore, no uniform definition of pediatric asthma exists, which hampers timely and robust diagnosis of the condition in affected patients. CONCLUSIONS There is a need for a uniform definition of pediatric asthma, clearly distinguishable from adult asthma. Furthermore, guidelines which provide specific treatment recommendations for the management of pediatric asthma are also needed. Clinical trials and real-world evidence studies assessing anti-immunoglobulin E (IgE) therapies and other monoclonal antibodies in children <6 years of age with asthma may provide further information regarding the most appropriate treatment options in these vulnerable patients. Early intervention with anti-IgE and non-steroid-based alternative therapies may delay disease progression, leading to improved clinical outcomes.
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Affiliation(s)
- Nikolaos G. Papadopoulos
- Division of Infection, Inflammation & Respiratory MedicineThe University of ManchesterManchesterUK
- The Allergy Department, 2nd Pediatric Clinic, National & KapodistrianUniversity of AthensAthensGreece
| | - Adnan Čustović
- Department of PaediatricsImperial College LondonLondonUK
| | - Michael D. Cabana
- Departments of Pediatrics and Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy StudiesUniversity of CaliforniaSan FranciscoCalifornia
| | - Sharon D. Dell
- Division of Respiratory Medicine, Department of Pediatrics, Child Health Evaluative Sciences, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Antoine Deschildre
- CHU Lille, Pediatric Pulmonology and Allergy Unit, Hôpital Jeanne de FlandreCHRU de Lille and Université Nord de FranceLilleFrance
| | - Gunilla Hedlin
- Astrid Lindgren Children's Hospital, Lung and Allergy UnitKarolinska University HospitalStockholmSweden
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Elham Hossny
- Pediatric Allergy and Immunology UnitChildren's Hospital Ain Shams UniversityCairoEgypt
| | - Peter Le Souëf
- School of Paediatrics and Faculty of Child Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Paolo M. Matricardi
- Department of Pediatric Pneumology & ImmunologyCharité ‐ Universitätsmedizin BerlinBerlinGermany
| | - Antonio Nieto
- Pediatric Pulmonology & Allergy UnitChildren's Hospital La FeValenciaSpain
| | - Wanda Phipatanakul
- Pediatric Allergy and ImmunologyBoston Children’s HospitalBostonMassachusetts
| | - Paulo M. Pitrez
- School of MedicinePontifícia Universidade Católica do Rio Grande do Sul (PUCRS)Porto AlegreBrazil
| | - Petr Pohunek
- Pediatric Department, 2nd Faculty of MedicineCharles University Prague, and University Hospital MotolPragueCzech Republic
| | | | | | - David B. Price
- Observational and Pragmatic Research InstituteSingaporeSingapore
- University of AberdeenAberdeenUK
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Al-Moamary MS, Alhaider SA, Alangari AA, Al Ghobain MO, Zeitouni MO, Idrees MM, Alanazi AF, Al-Harbi AS, Yousef AA, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2019; 14:3-48. [PMID: 30745934 PMCID: PMC6341863 DOI: 10.4103/atm.atm_327_18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S Al-Moamary
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed O Al Ghobain
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Respiratory Division, Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah F Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Adel S Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hassan S Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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11
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Bernstein JA, Mansfield L. Step-up and step-down treatments for optimal asthma control in children and adolescents. J Asthma 2018; 56:758-770. [PMID: 29972079 DOI: 10.1080/02770903.2018.1490752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To review therapeutic options for stepwise management of pediatric asthma in the context of this population's unique needs such as potential effects of asthma, treatments, or both on growth and psychosocial development, and caregiver involvement. DATA SOURCES AND STUDY SELECTION We conducted PubMed searches to identify relevant articles then reviewed resultant articles, guidelines for asthma management in children, and articles from personal files. RESULTS Stepwise management of asthma, similar to adults, is recommended for children in current global and US guidelines. Treatment may be stepped up or stepped down temporarily or long-term based on response over time. Inhaled corticosteroids remain the recommended treatment for persistent childhood asthma and any potential small effects on growth are considered relatively minor compared with their benefit. Controller medication options for patients <18 years old are limited, especially for Global Initiative for Asthma Steps 2-5. The long-acting antimuscarinic antagonist tiotropium (Steps 4/5, patients aged ≥12 years) and in certain circumstances (Step 5), anti-immunoglobulin E (aged ≥6 years) and interleukin-5 antibodies (aged ≥12 years) are newer treatment options. Tiotropium is indicated in the United States and Europe for patients ≥6 years old. Stepping down treatment, which is recommended but infrequently practiced, can maintain symptom control and minimize adverse events while substantially reducing costs. Patient education and better monitoring remain important for self-management and optimum outcomes. CONCLUSION A need exists to target individual treatment goals for children with asthma by using step-up and step-down approaches to maximize treatment benefits and minimize potential adverse effects.
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Affiliation(s)
- Jonathan A Bernstein
- a University of Cincinnati, College of Medicine , Cincinnati , OH , USA.,b Clinical Research for the Division of Immunology , Cincinnati , Ohio , USA.,c The Bernstein Allergy Group/Clinical Research Center , Cincinnati , OH , USA
| | - Lyndon Mansfield
- d Pediatrics, Paul L. Foster School of Medicine , El Paso , Texas , USA.,e Department of Pediatrics, Paul Foster School of Medicine , El Paso , TX , USA
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12
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Abstract
BACKGROUND Asthma exacerbations in school-aged children peak in autumn, shortly after children return to school following the summer holiday. This might reflect a combination of risk factors, including poor treatment adherence, increased allergen and viral exposure, and altered immune tolerance. Since this peak is predictable, interventions targeting modifiable risk factors might reduce exacerbation-associated morbidity and strain upon health resources. The peak occurs in September in the Northern Hemisphere and in February in the Southern Hemisphere. OBJECTIVES To assess the effects of pharmacotherapy and behavioural interventions enacted in anticipation of school return during autumn that are designed to reduce asthma exacerbations in children during this period. SEARCH METHODS We searched the Cochrane Airways Group Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, reference lists of primary studies and existing reviews, and manufacturers' trial registries (Merck, Novartis and Ono Parmaceuticals). We searched databases from their inception to 1 December 2017, and imposed no restriction on language of publication. SELECTION CRITERIA We included all randomised controlled trials comparing interventions aimed specifically at reducing autumn exacerbations with usual care, (no systematic change in management in preparation for school return). We included studies providing data on children aged 18 years or younger. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently screened records identified by the search and then extracted data and assessed bias for trials meeting the inclusion criteria. A third review author checked for accuracy and mediated consensus on disagreements. The primary outcome was proportion of children experiencing one or more asthma exacerbations requiring hospitalisation or oral corticosteroids during the autumn period. MAIN RESULTS Our searches returned 546 trials, of which five met our inclusion criteria. These studies randomised 14,252 children to receive either an intervention or usual care. All studies were conducted in the Northern Hemisphere. Three interventions used a leukotriene receptor antagonist, one used omalizumab or a boost of inhaled corticosteroids, and the largest study, (12,179 children), used a medication reminder letter. Whilst the risk of bias within individual studies was generally low, we downgraded the evidence quality due to imprecision associated with low participant numbers, poor consistency between studies, and indirect outcome ascertainment.A US study of 513 children with mild/severe asthma and allergic sensitisation was the only study to provide data for our primary outcome. In this study, the proportion of participants experiencing an exacerbation requiring oral corticosteroids or hospital admission in the 90 days after school return was significantly reduced to 11.3% in those receiving omalizumab compared to 21.0% in those receiving placebo (odds ratio 0.48, 95% confidence interval 0.25 to 0.92, moderate-quality evidence). The remaining studies used alternative exacerbation definitions. When data from two leukotriene receptor antagonist studies with comparable outcomes were combined in a random-effects model, there was no evidence of an effect upon exacerbations. There was no evidence that a seasonal medication reminder letter decreased unscheduled contacts for a respiratory diagnosis between September and December.Four studies recorded adverse events. There was no evidence that the proportion of participants experiencing at least one adverse event differed between intervention and usual care groups. Lack of data prevented planned subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS Seasonal omalizumab treatment from four to six weeks before school return might reduce autumn asthma exacerbations. We found no evidence that this strategy is associated with increased adverse effects other than injection site pain, but it is costly. There were no data upon which to judge the effect of this or other seasonal interventions on asthma control, quality of life, or asthma-related death. In future studies definitions of exacerbations should be provided, and standardised where possible. To investigate possible differential effects according to subgroup, participants in future trials should be well characterised with respect to baseline asthma severity and exacerbation history in addition to age and gender.
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Affiliation(s)
- Katharine C Pike
- UCL Great Ormond Street Institute of Child HealthRespiratory, Critical Care & AnaesthesiaLondonUK
| | - Melika Akhbari
- King's College LondonGKT School of Medical EducationLondonUK
| | - Dylan Kneale
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education20 Bedford WayLondonUKWC1H 0AL
| | - Katherine M Harris
- Queen Mary University of LondonCentre for Child Health, Blizard InstituteLondonUKE1 2AT
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13
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Richardson E, Seibert T, Uli NK. Growth perturbations from stimulant medications and inhaled corticosteroids. Transl Pediatr 2017; 6:237-247. [PMID: 29184805 PMCID: PMC5682374 DOI: 10.21037/tp.2017.09.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Stimulant medications for the treatment of attention deficit hyperactivity disorder (ADHD) and inhaled corticosteroids (ICS) for the treatment of asthma are two classes of medications that are commonly prescribed in pediatrics. Among other adverse effects of these medications, growth attenuation has long been a focus of investigation. With stimulants, growth deficits of 1-1.4 cm/year have been observed in the short term, mainly in the first 2 years of treatment, in a dose-dependent manner. Long-term studies on stimulants have reported divergent effects on growth, with many studies showing no clinically significant height deficits by adulthood. The study that followed the largest cohort of children on stimulants, however, reported an overall adult height deficit of 1.29 cm in subjects who had received stimulant medications, with mean adult height deficit of 4.7 cm among those taking the medication consistently. With ICS use, mild growth suppression is seen in the short term (particularly in the first year of therapy) with growth rates reduced by 0.4-1.5 cm/year. Available current evidence indicates that the impact of ICS use on adult height is not clinically significant, with effects limited to 1.2 cm or less. There is significant individual variability in growth suppression with ICS use, with the specific pharmacologic agent, formulation, dose exposure, age, puberty, medication adherence, and timing of administration being important modifying factors. Based on currently available evidence, the therapeutic benefits of ICS for management of asthma and stimulant medications for management of ADHD outweigh the potential risk for growth suppression. Strategies to minimize growth attenuation and other potential adverse effects of these medications include using the lowest efficacious dose, frequent assessments and dose titration. Particular vigilance is essential with concomitant use of multiple medications that can attenuate growth and to evaluate for potential adrenal insufficiency from ICS use.
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Affiliation(s)
- Erin Richardson
- Division of Pediatric Endocrinology & Diabetes, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Tasa Seibert
- Division of Pediatric Endocrinology & Diabetes, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Naveen K Uli
- Division of Pediatric Endocrinology & Diabetes, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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Abstract
PURPOSE OF REVIEW The aim of this study is to characterize, diagnose, evaluate, and treat severe childhood asthma. RECENT FINDINGS Understanding the occurrence of the physiologic and clinical presentations of childhood severe asthma, the treatment and response may be predicted by biomarkers, but the patient's response is highly variable. The onset of severe asthma occurs early and is primarily predicted by severity of viral infection and coexistence of the atopic state.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, 5609 J Street, Suite C, Sacramento, CA, 95819, USA.
| | - Neil G Parikh
- Capital Allergy and Respiratory Disease Center, 5609 J Street, Suite C, Sacramento, CA, 95819, USA
| | - Sheena K Maharaj
- Capital Allergy and Respiratory Disease Center, 5609 J Street, Suite C, Sacramento, CA, 95819, USA
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15
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Vitale C, Maglio A, Pelaia C, Vatrella A. Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy. Expert Opin Pharmacother 2017; 18:667-676. [PMID: 28387160 DOI: 10.1080/14656566.2017.1317747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.
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Affiliation(s)
- Carolina Vitale
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Angelantonio Maglio
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
| | - Corrado Pelaia
- b Department of Medical and Surgical Sciences, Section of Respiratory Diseases , University "Magna Graecia" of Catanzaro , Catanzaro , Italy
| | - Alessandro Vatrella
- a Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases , University of Salerno , Salerno , Italy
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16
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Gordon CM, Zemel BS, Wren TAL, Leonard MB, Bachrach LK, Rauch F, Gilsanz V, Rosen CJ, Winer KK. The Determinants of Peak Bone Mass. J Pediatr 2017; 180:261-269. [PMID: 27816219 DOI: 10.1016/j.jpeds.2016.09.056] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 09/26/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Catherine M Gordon
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Babette S Zemel
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Tishya A L Wren
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | | | | | - Frank Rauch
- Shriners Hospital for Children, McGill University, Montreal, Canada
| | - Vicente Gilsanz
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | | | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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17
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Adequate Vitamin D Intake but Low Serum Levels in Pediatric Asthma Patients: A Pilot Study, Alberta Children's Hospital. Can Respir J 2016; 2016:6982010. [PMID: 27867307 PMCID: PMC5102727 DOI: 10.1155/2016/6982010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/23/2016] [Accepted: 10/09/2016] [Indexed: 12/23/2022] Open
Abstract
Background. We assessed vitamin D intakes and serum 25(OH) vitamin D levels in pediatric asthma patients on moderate-to-high dose inhaled steroids and compared them to published findings of healthy children in our city. Methods. Parents and/or patients were interviewed to estimate the children's vitamin D intakes from foods and supplements (using an adapted validated food frequency questionnaire) and asthma duration and management. Vitamin D status: serum 25-hyroxy vitamin D (25(OH)D) was obtained from the medical records. Results. Vitamin D intakes from food and supplements of the asthma patients (n = 20, 742 ± 185 IU/day) were significantly higher compared to healthy Canadian children (n = 1442, 229 ± 121 IU/day). Despite higher vitamin D intakes, the children had nonsignificantly lower serum 25(OH) vitamin D levels compared to the comparison group. Serum 25(OH)D levels increased by 3.6 nmol/L with each 100 IU of vitamin D intake (95% Confidence interval = 2.0-4.0, R2 = 0.931, and p = 0.001). Conclusion. Since adequate vitamin D status in asthma patients is necessary to support bone mineral accretion, it is important to achieve adequate vitamin D status by checking serum 25(OH)D status and supplement accordingly.
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18
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Hossny E, Rosario N, Lee BW, Singh M, El-Ghoneimy D, SOH JY, Le Souef P. The use of inhaled corticosteroids in pediatric asthma: update. World Allergy Organ J 2016; 9:26. [PMID: 27551328 PMCID: PMC4982274 DOI: 10.1186/s40413-016-0117-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/21/2016] [Indexed: 02/07/2023] Open
Abstract
Despite the availability of several formulations of inhaled corticosteroids (ICS) and delivery devices for treatment of childhood asthma and despite the development of evidence-based guidelines, childhood asthma control remains suboptimal. Improving uptake of asthma management plans, both by families and practitioners, is needed. Adherence to daily ICS therapy is a key determinant of asthma control and this mandates that asthma education follow a repetitive pattern and involve literal explanation and physical demonstration of the optimal use of inhaler devices. The potential adverse effects of ICS need to be weighed against the benefit of these drugs to control persistent asthma especially that its safety profile is markedly better than oral glucocorticoids. This article reviews the key mechanisms of inhaled corticosteroid action; recommendations on dosage and therapeutic regimens; potential optimization of effectiveness by addressing inhaler technique and adherence to therapy; and updated knowledge on the real magnitude of adverse events.
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Affiliation(s)
- Elham Hossny
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Cairo, 11566 Egypt
| | | | - Bee Wah Lee
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Meenu Singh
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dalia El-Ghoneimy
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Cairo, 11566 Egypt
| | - Jian Yi SOH
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Peter Le Souef
- Winthrop Professor of Paediatrics & Child Health, School of Paediatrics & Child Health, University of Western Australia, Crawley, Australia
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De Leonibus C, Attanasi M, Roze Z, Martin B, Marcovecchio ML, Di Pillo S, Chiarelli F, Mohn A. Influence of inhaled corticosteroids on pubertal growth and final height in asthmatic children. Pediatr Allergy Immunol 2016; 27:499-506. [PMID: 26919136 DOI: 10.1111/pai.12558] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Controversial data exist on the possibility that inhaled corticosteroids (ICs) affect growth in children with mild-to-moderate asthma. We assessed whether ICs affect growth and final height (FH) in asthmatic children compared to controls. METHODS A retrospective study was conducted on 113 asthmatic children compared with 66 control children. Asthmatic children presented with mild-to-moderate asthma and had exclusive ICs. Anthropometric data of four specific time-points were collected for both groups (pre-puberty, onset and late puberty, and FH) and converted to standard deviation scores (SDS). Growth trajectories were assessed as follows: (i) in puberty, using peak height velocity (PHV) and pubertal height gain SDS (PHG-SDS); (ii) until FH achievement, using FH-SDS and FH gain SDS (FHG-SDS). Repeated measurement analysis was performed across longitudinal study visits. A general linear model (GLM) was performed in asthmatic group evaluating the effect of corticosteroid type, treatment duration, and cumulative dose on FH corrected for multiple variables. RESULTS At pre-puberty, height and weight SDS were similar between the groups (p > 0.05). Height SDS progressively declined over the study period in asthmatic patients from pre-puberty to FH (p-trend < 0.05), whereas it did not change over time in controls (p-trend > 0.05), in both boys and girls. Asthmatic children had exclusive ICs [budesonide (n = 36) vs. fluticasone (n = 43) vs. mometasone (n = 34)] for a mean period of 6.25 ± 1.20 years and a mean cumulative dose of 560.07 ± 76.02 mg. They showed decreased PHG-SDS and lower PHV compared to controls (all p < 0.05). FH-SDS and FHG-SDS were significantly reduced in asthmatic group compared to controls. FH in asthmatic patients was 2.5 ± 2.89 cm lower in boys and 2.0 ± 2.03 cm lower in girls than controls. The GLM showed that FH achievement was dependent on the type of ICs, duration of the treatment, and cumulative dose (p < 0.05). CONCLUSIONS ICs affect pubertal growth determining reduced final height in asthmatic children compared to controls, in a dose- and duration-dependent manner.
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Affiliation(s)
| | - Marina Attanasi
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Zane Roze
- Riga Stradins University Faculty of Continuing Education, Children's Clinical University Hospital, Riga, Latvia
| | | | - Maria Loredana Marcovecchio
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center of Excellence on Aging, "G. D'Annunzio" University Foundation, University of Chieti, Chieti, Italy
| | | | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center of Excellence on Aging, "G. D'Annunzio" University Foundation, University of Chieti, Chieti, Italy
| | - Angelika Mohn
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center of Excellence on Aging, "G. D'Annunzio" University Foundation, University of Chieti, Chieti, Italy
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Early treatment in preschool children: an evidence-based approach. Curr Opin Allergy Clin Immunol 2016; 15:175-83. [PMID: 25961392 DOI: 10.1097/aci.0000000000000151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Wheezing is a common symptom in early childhood but only some of these children will experience continued wheezing symptoms in later childhood making the diagnosis and treatment of these children challenging. This review covers recent findings regarding the epidemiology, diagnosis, evaluation, and treatment of preschool-aged children with asthma. RECENT FINDINGS Key characteristics that distinguish the childhood asthma-predictive phenotype include male sex, history of wheezing with lower respiratory tract infections, history of parental asthma, history of atopic dermatitis, eosinophilia, early sensitization to food or aeroallergens, or lower lung function in early life. The preschool-aged asthma population tends to be characterized as exacerbation prone with relatively limited impairment. The diagnosis of asthma in preschool-aged children is often based on symptom patterns, presence of risk factors, and therapeutic responses. Asthma management includes intermittent and daily inhaled corticosteroids, daily leukotriene-receptor antagonists, and, in rare cases, combination therapies. SUMMARY The diagnosis of asthma in preschool-aged children is based on symptom patterns and the presence of risk factors, and the goals of asthma management are achieved through a partnership between the family and the healthcare team using regular assessment of symptom control and response to daily controller therapy.
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Schwingshackl A, Meduri GU. Rationale for Prolonged Glucocorticoid Use in Pediatric ARDS: What the Adults Can Teach Us. Front Pediatr 2016; 4:58. [PMID: 27379217 PMCID: PMC4906037 DOI: 10.3389/fped.2016.00058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/23/2016] [Indexed: 12/21/2022] Open
Abstract
Based on molecular mechanisms and physiologic data, a strong association has been established between dysregulated systemic inflammation and progression of acute respiratory distress syndrome (ARDS). In ARDS patients, glucocorticoid receptor-mediated downregulation of systemic inflammation is essential to restore homeostasis, decrease morbidity and improve survival and can be significantly enhanced with prolonged low-to-moderate dose glucocorticoid treatment. A large body of evidence supports a strong association between prolonged glucocorticoid treatment-induced downregulation of the inflammatory response and improvement in pulmonary and extrapulmonary physiology. The balance of the available data from eight controlled trials (n = 622) provides consistent strong level of evidence for improving patient-centered outcomes and hospital survival. The sizable increase in mechanical ventilation-free days (weighted mean difference, 6.48 days; CI 95% 2.57-10.38, p < 0.0001) and intensive care unit-free days (weighted mean difference, 7.7 days; 95% CI, 3.13-12.20, p < 0.0001) by day 28 is superior to any investigated intervention in ARDS. For treatment initiated before day 14 of ARDS, the increased in hospital survival (70 vs. 52%, OR 2.41, CI 95% 1.50-3.87, p = 0.0003) translates into a number needed to treat to save one life of 5.5. Importantly, prolonged glucocorticoid treatment is not associated with increased risk for nosocomial infections (22 vs. 27%, OR 0.61, CI 95% 0.35-1.04, p = 0.07). Treatment decisions involve a tradeoff between benefits and risks, as well as costs. This low-cost, highly effective therapy is familiar to every physician and has a low risk profile when secondary prevention measures are implemented.
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Affiliation(s)
- Andreas Schwingshackl
- Department of Pediatrics, Division of Critical Care Medicine, Mattel Children's Hospital at UCLA , Los Angeles, CA , USA
| | - Gianfranco Umberto Meduri
- Departments of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Memphis Veterans Affairs Medical Center , Memphis, TN , USA
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22
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Al-Moamary MS, Alhaider SA, Idrees MM, Al Ghobain MO, Zeitouni MO, Al-Harbi AS, Yousef AA, Al-Matar H, Alorainy HS, Al-Hajjaj MS. The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med 2016; 11:3-42. [PMID: 26933455 PMCID: PMC4748613 DOI: 10.4103/1817-1737.173196] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022] Open
Abstract
This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.
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Affiliation(s)
- Mohamed S. Al-Moamary
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sami A. Alhaider
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Majdy M. Idrees
- Department of Medicine, Pulmonary Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed O. Al Ghobain
- Department of Medicine, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed O. Zeitouni
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Adel S. Al-Harbi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah A. Yousef
- Department of Pediatrics, College of Medicine, University of Dammam, Dammam, Saudi Arabia
| | - Hussain Al-Matar
- Department of Medicine, Imam Abdulrahman Al Faisal Hospital, Dammam, Saudi Arabia
| | - Hassan S. Alorainy
- Department of Respiratory Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Medicine, Respiratory Division, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abstract
Glucocorticoids are the most effective treatment for asthma. However, their clinical applications are limited by low efficacy in severe asthma and by undesired side effects associated with high dose or prolonged use. The most successful approach to overcome these limitations has been the development of highly potent glucocorticoids that can be delivered to the lungs by inhalation to achieve local efficacy with minimal systemic effects. On the basis of our previous structural studies, we designed and developed a highly potent glucocorticoid, VSGC12, which showed an improved anti-inflammation activity in both cell-based reporter assays and cytokine inhibition experiments, as well as in a gene expression profiling of mouse macrophage RAW264.7 cells. In a mouse asthma model, VSGC12 delivered a higher efficacy than fluticasone furoate, a leading clinical compound, in many categories including histology and the number of differentiated immune cells. VSGC12 also showed a higher potency than fluticasone furoate in repressing most asthma symptoms. Finally, VSGC12 showed a better side effect profile than fluticasone furoate at their respective effective doses, including better insulin response and less bone loss in an animal model. The excellent therapeutic and side effect properties of VSGC12 provide a promising perspective for developing this potent glucocorticoid as a new effective drug for asthma.
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Remick AK, Catlin NR, Quist EM, Steinbach TJ, Dixon D. Juvenile Toxicology: Relevance and Challenges for Toxicologists and Pathologists. Toxicol Pathol 2015; 43:1166-71. [PMID: 26220944 PMCID: PMC4670269 DOI: 10.1177/0192623315595883] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Society of Toxicologic Pathology (STP) Education Committee and the STP Reproductive Special Interest Group held a North Carolina regional meeting entitled, "Juvenile Toxicology: Relevance and Challenges for Toxicologists and Pathologists" on March 13, 2015, at the National Institute of Environmental Health Sciences/National Toxicology Program in Research Triangle Park, North Carolina. The purpose of this regional meeting was to familiarize attendees with the topic of juvenile toxicity testing and discuss its relevance to clinical pediatric medicine, regulatory perspectives, challenges of appropriate study design confronted by toxicologists, and challenges of histopathologic examination and interpretation of juvenile tissues faced by pathologists. The 1-day meeting was a success with over 60 attendees representing industry, government, research organizations, and academia.
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Affiliation(s)
| | - Natasha R Catlin
- Developmental and Reproductive Toxicology Group, Toxicology Branch, National Toxicology Program (NTP) Division, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Erin M Quist
- Reproductive Endocrinology Group, National Toxicology Program Laboratory (NTPL), and NTP Pathology Group, Cellular & Molecular Pathology Branch, NTP Division, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | | | - Darlene Dixon
- Molecular Pathogenesis Group, National Toxicology Program Laboratory (NTPL), Division of the NTP, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
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25
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Fahmy MA, Farghaly AA, Hassan NHA, Diab KAE. Molecular and cytogenetic evaluation for potential genotoxicity of hydrocortisone. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2015. [DOI: 10.1016/s2222-1808(15)60921-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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26
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miR-195 plays a role in steroid resistance of ulcerative colitis by targeting Smad7. Biochem J 2015; 471:357-67. [PMID: 26303523 DOI: 10.1042/bj20150095] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 08/24/2015] [Indexed: 12/18/2022]
Abstract
An imbalance in pro- and anti-inflammation is an important mechanism of steroid resistance in UC (ulcerative colitis), and miRNAs may participate in this process. The present study aimed to explore whether miRNAs play a role in the steroid resistance of UC by regulating gene expression of the inflammation signal pathway. SS (steroid-sensitive) patients, SR (steroid-resistant) patients and healthy individuals were recruited. In vivo miRNA profiles of serum samples showed that miR-195 was decreased significantly in the SR group compared with the SS group (P<0.05). This result was confirmed by qPCR (quantitative real-time PCR) and miRNA ISH (in situ hybridization) in serum and colon tissue samples. Online software was used to identify Smad7 mRNA as a potential target of miR-195. The direct interaction of miR-195 and Smad7 mRNA was investigated using a biotinylated miR-195 pull-down assay. Overexpression of a miR-195 precursor lowered cellular levels of Smad7 protein; conversely, antagonism of miR-195 enhanced Smad7 translation without disturbing Smad7 mRNA levels. A luciferase reporter assay revealed a repressive effect of miR-195 via a single Smad7 3'-UTR target site, and point mutation of this site prevented miR-195-induced repression of Smad7 translation. Furthermore, increased levels of miR-195 led to a decrease in c-Jun and p65 expression. In contrast, transfection with anti-miR-195 led to increased levels of c-Jun and p65 protein. The decrease in miR-195 led to an increase in Smad7 expression and corresponding up-regulation of p65 and the AP-1 (activator protein 1) pathway, which might explain the mechanism of steroid resistance in UC patients.
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27
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Smith MBH. Pros and cons …. ACTA ACUST UNITED AC 2015; 9:749-50. [PMID: 25504968 DOI: 10.1002/ebch.1986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael B H Smith
- Department of Paediatrics, Craigavon Hospital, Craigavon, Northern Ireland.
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