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Mottais A, Riberi L, Falco A, Soccal S, Gohy S, De Rose V. Epithelial-Mesenchymal Transition Mechanisms in Chronic Airway Diseases: A Common Process to Target? Int J Mol Sci 2023; 24:12412. [PMID: 37569787 PMCID: PMC10418908 DOI: 10.3390/ijms241512412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Epithelial-to-mesenchymal transition (EMT) is a reversible process, in which epithelial cells lose their epithelial traits and acquire a mesenchymal phenotype. This transformation has been described in different lung diseases, such as lung cancer, interstitial lung diseases, asthma, chronic obstructive pulmonary disease and other muco-obstructive lung diseases, such as cystic fibrosis and non-cystic fibrosis bronchiectasis. The exaggerated chronic inflammation typical of these pulmonary diseases can induce molecular reprogramming with subsequent self-sustaining aberrant and excessive profibrotic tissue repair. Over time this process leads to structural changes with progressive organ dysfunction and lung function impairment. Although having common signalling pathways, specific triggers and regulation mechanisms might be present in each disease. This review aims to describe the various mechanisms associated with fibrotic changes and airway remodelling involved in chronic airway diseases. Having better knowledge of the mechanisms underlying the EMT process may help us to identify specific targets and thus lead to the development of novel therapeutic strategies to prevent or limit the onset of irreversible structural changes.
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Affiliation(s)
- Angélique Mottais
- Pole of Pneumology, ENT, and Dermatology, Institute of Experimental and Clinical Research, Université Catholique de Louvain, 1200 Brussels, Belgium; (A.M.); (S.G.)
| | - Luca Riberi
- Postgraduate School in Respiratory Medicine, University of Torino, 10124 Torino, Italy; (L.R.); (A.F.); (S.S.)
| | - Andrea Falco
- Postgraduate School in Respiratory Medicine, University of Torino, 10124 Torino, Italy; (L.R.); (A.F.); (S.S.)
| | - Simone Soccal
- Postgraduate School in Respiratory Medicine, University of Torino, 10124 Torino, Italy; (L.R.); (A.F.); (S.S.)
| | - Sophie Gohy
- Pole of Pneumology, ENT, and Dermatology, Institute of Experimental and Clinical Research, Université Catholique de Louvain, 1200 Brussels, Belgium; (A.M.); (S.G.)
- Department of Pneumology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Cystic Fibrosis Reference Centre, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Virginia De Rose
- Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
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House Dust Mite and Cat Dander Extract Induce Asthma-Like Histopathology with an Increase of Mucosal Mast Cells in a Guinea Pig Model. J Immunol Res 2023; 2023:9393497. [PMID: 36761882 PMCID: PMC9904926 DOI: 10.1155/2023/9393497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
Background Asthma is a chronic inflammatory disease with structural changes in the lungs defined as airway remodelling. Mast cell responses are important in asthma as they, upon activation, release mediators inducing bronchoconstriction, inflammatory cell recruitment, and often remodelling of the airways. As guinea pigs exhibit anatomical, physiological, and pharmacological features resembling human airways, including mast cell distribution and mediator release, we evaluated the effect of extracts from two common allergens, house dust mite (HDM) and cat dander (CDE), on histopathological changes and the composition of tryptase- and chymase-positive mast cells in the guinea pig lungs. Methods Guinea pigs were exposed intranasally to HDM or CDE for 4, 8, and 12 weeks, and airway histology was examined at each time point. Hematoxylin and eosin, Picro-Sirius Red, and Periodic Acid-Schiff staining were performed to evaluate airway inflammation, collagen deposition, and mucus-producing cells. In addition, Astra blue and immunostaining against tryptase and chymase were used to visualize mast cells. Results Repetitive administration of HDM or CDE led to the accumulation of inflammatory cells into the proximal and distal airways as well as increased airway smooth muscle mass. HDM exposure caused subepithelial collagen deposition and mucus cell hyperplasia at all three time points, whereas CDE exposure only caused these effects at 8 and 12 weeks. Both HDM and CDE induced a substantial increase in mast cells after 8 and 12 weeks of challenges. This increase was primarily due to mast cells expressing tryptase, but not chymase, thus indicating mucosal mast cells. Conclusions We here show that exposure to HDM and CDE elicits asthma-like histopathology in guinea pigs with infiltration of inflammatory cells, airway remodelling, and accumulation of primarily mucosal mast cells. The results together encourage the use of HDM and CDE allergens for the stimulation of a clinically relevant asthma model in guinea pigs.
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Hsieh A, Assadinia N, Hackett TL. Airway remodeling heterogeneity in asthma and its relationship to disease outcomes. Front Physiol 2023; 14:1113100. [PMID: 36744026 PMCID: PMC9892557 DOI: 10.3389/fphys.2023.1113100] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Asthma affects an estimated 262 million people worldwide and caused over 461,000 deaths in 2019. The disease is characterized by chronic airway inflammation, reversible bronchoconstriction, and airway remodeling. Longitudinal studies have shown that current treatments for asthma (inhaled bronchodilators and corticosteroids) can reduce the frequency of exacerbations, but do not modify disease outcomes over time. Further, longitudinal studies in children to adulthood have shown that these treatments do not improve asthma severity or fixed airflow obstruction over time. In asthma, fixed airflow obstruction is caused by remodeling of the airway wall, but such airway remodeling also significantly contributes to airway closure during bronchoconstriction in acute asthmatic episodes. The goal of the current review is to understand what is known about the heterogeneity of airway remodeling in asthma and how this contributes to the disease process. We provide an overview of the existing knowledge on airway remodeling features observed in asthma, including loss of epithelial integrity, mucous cell metaplasia, extracellular matrix remodeling in both the airways and vessels, angiogenesis, and increased smooth muscle mass. While such studies have provided extensive knowledge on different aspects of airway remodeling, they have relied on biopsy sampling or pathological assessment of lungs from fatal asthma patients, which have limitations for understanding airway heterogeneity and the entire asthma syndrome. To further understand the heterogeneity of airway remodeling in asthma, we highlight the potential of in vivo imaging tools such as computed tomography and magnetic resonance imaging. Such volumetric imaging tools provide the opportunity to assess the heterogeneity of airway remodeling within the whole lung and have led to the novel identification of heterogenous gas trapping and mucus plugging as important predictors of patient outcomes. Lastly, we summarize the current knowledge of modification of airway remodeling with available asthma therapeutics to highlight the need for future studies that use in vivo imaging tools to assess airway remodeling outcomes.
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Affiliation(s)
- Aileen Hsieh
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, BC, Canada,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Najmeh Assadinia
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, BC, Canada,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Tillie-Louise Hackett
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, BC, Canada,Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada,*Correspondence: Tillie-Louise Hackett,
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4
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Salter B, Zhao N, Son K, Tan NS, Dvorkin-Gheva A, Radford K, LaVigne N, Huang C, Kjarsgaard M, Li QZ, Tselios K, Lim HF, Khalidi N, Nair P, Mukherjee M. Airway autoantibodies are determinants of asthma severity. Eur Respir J 2022; 60:2200442. [PMID: 35777765 DOI: 10.1183/13993003.00442-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Local airway autoimmune responses may contribute to steroid dependence and persistent eosinophilia in severe asthma. Auto-IgG antibodies directed against granule proteins such as eosinophil peroxidase (EPX), macrophage scavenger receptor with collagenous structure (MARCO) and nuclear/extranuclear antigens (antinuclear antibodies (ANAs)) have been reported. Our objective was to describe the prevalence and clinical characteristics of asthmatic patients with airway autoreactivity, and to assess if this could be predicted from clinical history of autoreactivity. METHODS We analysed anti-EPX, anti-MARCO and ANAs in 218 sputum samples collected prospectively from 148 asthmatic patients, and evaluated their association with lung function parameters, blood/airway inflammation, severity indices and exacerbations. Additionally, 107 of these patients consented to fill out an autoimmune checklist to determine personal/family history of systemic autoimmune disease and symptoms. RESULTS Out of the 148 patients, 59 (40%) were anti-EPX IgG+, 53 (36%) were anti-MARCO IgG+ and 64 out of 129 (50%) had ≥2 nuclear/extranuclear autoreactivities. A composite airway autoreactivity score (CAAS) demonstrated that 82 patients (55%) had ≥2 airway autoreactivities (considered as CAAS+). Increased airway eosinophil degranulation (OR 15.1, 95% CI 1.1-199.4), increased blood leukocytes (OR 3.5, 95% CI 1.3-10.1) and reduced blood lymphocytes (OR 0.19, 95% CI 0.04-0.84) predicted CAAS+. A third of CAAS+ patients reported an exacerbation, associated with increased anti-EPX and/or anti-MARCO IgG (p<0.05). While no association was found between family history or personal diagnosis of autoimmune disease, 30% of CAAS+ asthmatic patients reported sicca symptoms (p=0.02). Current anti-inflammatory (inhaled/oral corticosteroids and/or adjunct anti-interleukin-5 biologics) treatment does not attenuate airway autoantibodies, irrespective of eosinophil suppression. CONCLUSION We report 55% of moderate-severe asthmatic patients to have airway autoreactivity that persists despite anti-inflammatory treatment and is associated with exacerbations.
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Affiliation(s)
- Brittany Salter
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
- Brittany Salter and Nan Zhao contributed equally
| | - Nan Zhao
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
- Lady David Institute, Jewish General Hospital, Montreal, QC, Canada
- Pulmonary Division, Jewish General Hospital, McGill University, Montreal, QC, Canada
- Brittany Salter and Nan Zhao contributed equally
| | - Kiho Son
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Nadia Suray Tan
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Anna Dvorkin-Gheva
- McMaster Immunology Research Centre, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Katherine Radford
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Nicola LaVigne
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Chynna Huang
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Melanie Kjarsgaard
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Quan-Zhen Li
- Dept of Immunology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Konstantinos Tselios
- Division of Rheumatology, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Hui Fang Lim
- Dept of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nader Khalidi
- Division of Rheumatology, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Parameswaran Nair
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Manali Mukherjee
- Dept of Medicine, Firestone Institute of Respiratory Health and St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, Dept of Medicine, McMaster University, Hamilton, ON, Canada
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5
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Giant Multinucleated Cells Are Associated with Mastocytic Inflammatory Signature Equine Asthma. Animals (Basel) 2022; 12:ani12091070. [PMID: 35565497 PMCID: PMC9103648 DOI: 10.3390/ani12091070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 01/22/2023] Open
Abstract
Equine asthma is currently diagnosed by the presence of increased neutrophil (>5%), mast cell (>2%), and/or eosinophil (>1%) differential cell count. Macrophages are normal resident cells within the alveoli. Their presence in BALF is considered normal, but the clinical implication of the presence of activated or fused macrophages (giant multinucleated cells, GMC) is currently overlooked. We aimed to assess the prevalence, cytological determinants, and clinical significance of increased GMC counts in BALF of 34 asthmatic horses compared to 10 controls. Counts were performed on 15 randomly selected high magnification fields per cytospin slide (40×), and expressed as GMC:single macrophage (GMC:M) ratio. Regression models were used for statistical analysis. GMC was frequently observed in both asthmatic and control horses, with an increased prevalence of equine asthma (p = 0.01). GMC:M ratio was significantly higher in severe vs. mild to moderate equine asthmatic and control horses. In asthmatic horses, an increased GMC:M ratio was significantly associated with BALF mastocytosis (p = 0.01), once adjusting for age and the presence and severity of clinical signs of the horses. Tachypnea was the only clinical sign that tended to be positively associated with GMC:M ratio after adjustment (p = 0.08). In conclusion, our data suggest that a relationship might exist between molecular mechanisms regulating GMC formation and mast cell recruitment in the equine lung. The same mechanisms could lead to tachypnea even in the absence of respiratory effort at rest. We suggest including GMC count in the basic cytological assessment of BALF samples to gain more insights into their role in equine asthma.
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Lee DH, Jang JH, Sim S, Choi Y, Park HS. Epithelial Autoantigen-Specific IgG Antibody Enhances Eosinophil Extracellular Trap Formation in Severe Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:479-493. [PMID: 36174991 PMCID: PMC9523418 DOI: 10.4168/aair.2022.14.5.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Dong-Hyun Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Hyuk Jang
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Soyoon Sim
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Youngwoo Choi
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
- Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
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7
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Kurukulaaratchy RJ, Rupani H, Fong WCG, Kyyaly A. A Role for Mucolytics and Expectorants in Aiding Inhaled Therapies in Asthma? [Response To Letter]. J Inflamm Res 2021; 14:5183-5185. [PMID: 34675596 PMCID: PMC8517631 DOI: 10.2147/jir.s341547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Ramesh J Kurukulaaratchy
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK.,NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Hitasha Rupani
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Wei Chern Gavin Fong
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
| | - Aref Kyyaly
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
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8
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Ho J, Alvarado R, Rimmer J, Sewell WA, Walter S, Earls P, Campbell RG, Sacks R, Kalish LH, Harvey RJ. Comparison of Sinonasal Histopathological Changes in Biological Treatment of Eosinophilic Chronic Rhinosinusitis. Am J Rhinol Allergy 2021; 36:72-80. [PMID: 34096329 DOI: 10.1177/19458924211021031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Biologic therapies such as mepolizumab and benralizumab are currently utilised in the treatment of eosinophilic asthma, and are emerging in the management of eosinophilic chronic rhinosinusitis (eCRS). These biologics inhibit the interaction of IL-5 with its receptor, thus impairing cytokine signalling and eosinophil inflammation. Mepolizumab does so by targeting IL-5, whereas benralizumab targets the α chain of the IL-5 receptor. This study compares the sinonasal tissue response to anti-IL-5 biologic therapies in patients with eCRS. METHODS A cross-sectional study of adult eCRS patients who had completed at least 2 cycles of biologic therapy and underwent endoscopic sinus surgery as part of their management were included. Sinonasal mucosal tissue biopsies were obtained intraoperatively and assessed with structured histopathological examination. Comparisons of tissue histopathology outcomes following treatment with mepolizumab or benralizumab were performed. RESULTS 18 patients (age 49.6 ± 14.2 years, 47% female, 100% co-morbid asthma) were included in this study, comprising 10 patients managed with mepolizumab and 8 patients managed with benralizumab. Even after mepolizumab, the tissue had predominantly eosinophilic inflammation compared to benralizumab (90% v 0%, p < 0.01), which demonstrated a greater lymphoplasmacytic inflammation (10% v 75%, χ2(2) = 14.53, p < 0.01). Compared with benralizumab, mepolizumab had increased tissue eosinophil count (100% v 37.5% >10 eosinophils/HPF, τb = -8.47, p < 0.001) and more severe subepithelial oedema (80% v 37.5% severe, τb = -2.37, p = 0.02). CONCLUSION Tissue histopathologic outcomes reflect the differing mechanism of action of mepolizumab and benralizumab in eCRS. Further analysis at the tissue level will provide further information to guide application of mAbs in type 2 inflammatory diseases.
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Affiliation(s)
- Jacqueline Ho
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Janet Rimmer
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Woolcock Institute, University of Sydney, Sydney, Australia.,Faculty of Medicine, Notre Dame University, Sydney, Australia
| | - William A Sewell
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Immunology Division, Garvan Institute of Medical Research, Sydney, Australia
| | - Sophie Walter
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Peter Earls
- Department of Anatomical Pathology, St Vincent's Hospital, Sydney, Australia
| | - Raewyn G Campbell
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
| | - Larry H Kalish
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Wenzel SE. Severe Adult Asthmas: Integrating Clinical Features, Biology, and Therapeutics to Improve Outcomes. Am J Respir Crit Care Med 2021; 203:809-821. [PMID: 33326352 PMCID: PMC8017568 DOI: 10.1164/rccm.202009-3631ci] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/15/2020] [Indexed: 12/18/2022] Open
Abstract
Evaluation and effective management of asthma, and in particular severe asthma, remains at the core of pulmonary practice. Over the last 20-30 years, there has been increasing appreciation that "severe asthma" encompasses multiple different subgroups or phenotypes, each with differing presentations. Using clinical phenotyping, in combination with rapidly advancing molecular tools and targeted monoclonal antibodies (human knockouts), the understanding of these phenotypes, and our ability to treat them, have greatly advanced. Type-2 (T2)-high and -low severe asthmas are now easily identified. Fractional exhaled nitric oxide and blood eosinophil counts can be routinely employed in clinical settings to identify these phenotypes and predict responses to specific therapies, meeting the initial goals of precision medicine. Integration of molecular signals, biomarkers, and clinical responses to targeted therapies has enabled identification of critical molecular pathways and, in certain phenotypes, advanced them to near-endotype status. Despite these advances, little guidance is available to determine which class of biologic is appropriate for a given patient, and current "breakthrough" therapies remain expensive and even inaccessible to many patients. Many of the most severe asthmas, with and without T2-biomarker elevations, remain poorly understood and treated. Nevertheless, conceptual understanding of "the severe asthmas" has evolved dramatically in a mere 25 years, leading to dramatic improvements in the lives of many.
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Affiliation(s)
- Sally E Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh Asthma and Environmental Lung Health Institute at UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
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10
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van den Bosch WB, James AL, Tiddens HA. Structure and function of small airways in asthma patients revisited. Eur Respir Rev 2021; 30:200186. [PMID: 33472958 PMCID: PMC9488985 DOI: 10.1183/16000617.0186-2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
Small airways (<2 mm in diameter) are probably involved across almost all asthma severities and they show proportionally more structural and functional abnormalities with increasing asthma severity. The structural and functional alterations of the epithelium, extracellular matrix and airway smooth muscle in small airways of people with asthma have been described over many years using in vitro studies, animal models or imaging and modelling methods. The purpose of this review was to provide an overview of these observations and to outline several potential pathophysiological mechanisms regarding the role of small airways in asthma.
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Affiliation(s)
- Wytse B. van den Bosch
- Dept of Paediatric Pulmonology and Allergology, Erasmus MC – Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Dept of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alan L. James
- Dept of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Harm A.W.M. Tiddens
- Dept of Paediatric Pulmonology and Allergology, Erasmus MC – Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Dept of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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11
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Debray MP, Ghanem M, Khalil A, Taillé C. [Lung imaging in severe asthma]. Rev Mal Respir 2021; 38:41-57. [PMID: 33423858 DOI: 10.1016/j.rmr.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/02/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Asthma is a common disease whose diagnosis does not typically rely on the results of imaging. However, chest CT has gained a key place over the last decade to support the management of patients with difficult to treat and severe asthma. STATE OF THE ART Bronchial wall thickening and mild dilatation or narrowing of bronchial lumen are frequently observed on chest CT in people with asthma. Bronchial wall thickening is correlated to the degree of obstruction and to bronchial wall remodeling and inflammation. Diverse conditions which can mimic asthma should be recognized on CT, including endobronchial tumours, interstitial pneumonias, bronchiectasis and bronchiolitis. Ground-glass opacities and consolidation may be related to transient eosinophilic infiltrates, infection or an associated disease (vasculitis, chronic eosinophilic pneumonia). Hyperdense mucous plugging is highly specific for allergic bronchopulmonary aspergillosis. PERSPECTIVES Airway morphometry, air trapping and quantitative analysis of ventilatory defects, with CT or MRI, can help to identify different morphological subgroups of patients with different functional or inflammatory characteristics. These imaging tools could emerge as new biomarkers for the evaluation of treatment response. CONCLUSION Chest CT is indicated in people with severe asthma to search for additional or alternative diagnoses. Quantitative imaging may contribute to phenotyping this patient group.
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Affiliation(s)
- M-P Debray
- Service de Radiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 46, rue Henri Huchard, 75018 Paris; Inserm UMR1152, France.
| | - M Ghanem
- Service de Pneumologie et Centre de Référence constitutif des Maladies Pulmonaires Rares, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France
| | - A Khalil
- Service de Radiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 46, rue Henri Huchard, 75018 Paris; Université de Paris, Inserm UMR1152, France
| | - C Taillé
- Service de Pneumologie et Centre de Référence constitutif des Maladies Pulmonaires Rares, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France; Département Hospitalo-Universitaire FIRE ; Université de Paris ; Inserm UMR 1152 ; LabEx Inflamex, 75018 Paris, France
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12
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Ray A, Camiolo M, Fitzpatrick A, Gauthier M, Wenzel SE. Are We Meeting the Promise of Endotypes and Precision Medicine in Asthma? Physiol Rev 2020; 100:983-1017. [PMID: 31917651 PMCID: PMC7474260 DOI: 10.1152/physrev.00023.2019] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 02/07/2023] Open
Abstract
While the term asthma has long been known to describe heterogeneous groupings of patients, only recently have data evolved which enable a molecular understanding of the clinical differences. The evolution of transcriptomics (and other 'omics platforms) and improved statistical analyses in combination with large clinical cohorts opened the door for molecular characterization of pathobiologic processes associated with a range of asthma patients. When linked with data from animal models and clinical trials of targeted biologic therapies, emerging distinctions arose between patients with and without elevations in type 2 immune and inflammatory pathways, leading to the confirmation of a broad categorization of type 2-Hi asthma. Differences in the ratios, sources, and location of type 2 cytokines and their relation to additional immune pathway activation appear to distinguish several different (sub)molecular phenotypes, and perhaps endotypes of type 2-Hi asthma, which respond differently to broad and targeted anti-inflammatory therapies. Asthma in the absence of type 2 inflammation is much less well defined, without clear biomarkers, but is generally linked with poor responses to corticosteroids. Integration of "big data" from large cohorts, over time, using machine learning approaches, combined with validation and iterative learning in animal (and human) model systems is needed to identify the biomarkers and tightly defined molecular phenotypes/endotypes required to fulfill the promise of precision medicine.
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Affiliation(s)
- Anuradha Ray
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Pulmonary Allergy Critical Care Medicine, Departments of Medicine and of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Matthew Camiolo
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Pulmonary Allergy Critical Care Medicine, Departments of Medicine and of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Anne Fitzpatrick
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Pulmonary Allergy Critical Care Medicine, Departments of Medicine and of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Marc Gauthier
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Pulmonary Allergy Critical Care Medicine, Departments of Medicine and of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Sally E Wenzel
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Pulmonary Allergy Critical Care Medicine, Departments of Medicine and of Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Pediatrics, Emory University, Atlanta, Georgia
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13
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Januska MN, Goldman DL, Webley W, Teague WG, Cohen RT, Bunyavanich S, Vicencio AG. Bronchoscopy in severe childhood asthma: Irresponsible or irreplaceable? Pediatr Pulmonol 2020; 55:795-802. [PMID: 31730298 PMCID: PMC7385726 DOI: 10.1002/ppul.24569] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
For children with severe asthma, guideline-based management focuses on the escalation of anti-inflammatory and bronchodilatory medications while addressing comorbid conditions. Bronchoscopy, in this context, has been relegated to ruling out asthma mimickers. More recently, however, there have been questions surrounding the clinical utility of bronchoscopy in severe childhood asthma. In this solicited lecture summary, we discuss the past, present, and potential future applications of bronchoscopy in severe childhood asthma.
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Affiliation(s)
- Megan N. Januska
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
| | | | | | | | | | - Supinda Bunyavanich
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
- Ichan School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences, New York, NY
| | - Alfin G. Vicencio
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
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14
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Colella S, Ravaglia C, Massaccesi C, D'Emilio V, Panella G, Fioretti F, Conte EG, Collina G, Pela R, Poletti V. Does transbronchial lung cryobiopsy give useful information in asthmatic patients? Multidiscip Respir Med 2019; 14:12. [PMID: 30997044 PMCID: PMC6452509 DOI: 10.1186/s40248-019-0176-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/13/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction Lung biopsy in asthmatic patients is justified in case of atypical presentations of asthma, when other differential diagnoses, such as hypersensitivity pneumonitis or eosinophilic granulomatosis with polyangiitis, could be possible or for research purposes. Aim We aim to describe the utility and the safety of TBLC (transbronchial lung cryobiopsy) in asthmatic patients, providing data on the pathological changes occurring in the airways and in the lung parenchyma. Methods We reviewed asthmatic patients that underwent TBLC, that eventually had only a final diagnosis of asthma. Results Three patients were detected. TBLC described pathological abnormalities in peribronchiolar and alveolar spaces already well identified with SLB (surgical lung biopsy); the pathological information provided could be useful to better understand the pathobiology of the disease. Finally, we had no complications, confirming a satisfactory safety profile of TBLC. Conclusion We suggest the potential role of TBLC in asthmatic patients: its safety and its acceptable diagnostic accuracy lead to consider this procedure instead of SLB when histological changes in lung parenchyma are needed for the differential diagnosis. Furthermore, TLBC could be useful for research in the pathobiology of asthma and severe asthma.
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Affiliation(s)
- Sara Colella
- Pulmonology Unit, "C. & G. Mazzoni" Hospital, Ascoli Piceno, Italy
| | - Claudia Ravaglia
- Department of Thoracic Diseases, "GB. Morgagni" Hospital, Forlì, Italy
| | | | | | - Gianluca Panella
- Pulmonology Unit, "C. & G. Mazzoni" Hospital, Ascoli Piceno, Italy
| | | | | | - Guido Collina
- Pathology Department, "C. & G. Mazzoni" Hospital, Ascoli Piceno, Italy
| | - Riccardo Pela
- Pulmonology Unit, "C. & G. Mazzoni" Hospital, Ascoli Piceno, Italy
| | - Venerino Poletti
- Department of Thoracic Diseases, "GB. Morgagni" Hospital, Forlì, Italy.,4Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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15
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Ledford DK, Wenzel S. Severe Asthma with Joint Pain, Thrombophilia, and Irritable Bowel Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 4:1011-2. [PMID: 27587324 DOI: 10.1016/j.jaip.2016.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Dennis K Ledford
- Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla.
| | - Sally Wenzel
- University of Pittsburgh Asthma Institute, Pittsburgh, Pa
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16
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Hvidtfeldt M, Pulga A, Hostrup M, Sanden C, Mori M, Bornesund D, Larsen KR, Erjefält JS, Porsbjerg C. Bronchoscopic mucosal cryobiopsies as a method for studying airway disease. Clin Exp Allergy 2018; 49:27-34. [PMID: 30244522 DOI: 10.1111/cea.13281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/13/2018] [Accepted: 09/17/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Investigating disease mechanisms and treatment responses in obstructive airway diseases with invasive sampling are hampered by the small size and mechanical artefacts that conventional forceps biopsies suffer from. Endoscopic cryobiopsies are larger and more intact and are being increasingly used. However, the technique has not yet been explored for obtaining mucosa biopsies. OBJECTIVE To investigate differences in size and quality of endobronchial mucosal biopsies obtained with cryotechnique and forceps. Further, to check for eligibility of cryobiopsies to be evaluated with immunohistochemistry and in situ hybridization and to investigate tolerability and safety of the technique. METHODS Endobronchial mucosal biopsies were obtained with cryotechnique and forceps from patients with haemoptysis undergoing bronchoscopy and evaluated by quantitative morphometry, automated immunohistochemistry and in situ hybridization. RESULTS A total of 40 biopsies were obtained from 10 patients. Cross-sectional areas were threefold larger in cryobiopsies (median: 3.08 mm2 (IQR: 1.79) vs 1.03 mm2 (IQR: 1.10), P < 0.001). Stretches of intact epithelium were 8-fold longer (median: 4.61 mm (IQR: 4.50) vs 0.55 mm (IQR: 1.23), P = 0.001). Content of glands (median: 0.095 mm2 (IQR: 0.30) vs 0.00 mm2 (IQR: 0.01), P = 0.002) and airway smooth muscle (median: 0.25 mm2 (IQR: 0.30) vs 0.060 mm2 (IQR: 0.11), P = 0.02) was higher in the cryobiopsies compared with forceps biopsies. Further, the cryobiopsies had well-preserved protein antigens and mRNA. Mild to moderate bleeding was the only complication observed. CONCLUSION AND CLINICAL RELEVANCE By yielding significantly larger and more intact biopsies, the cryotechnique represents a valuable new research tool to explore the bronchi in airway disease. Ultimately with the potential to create better understanding of underlying disease mechanisms and improvement of treatments.
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Affiliation(s)
| | - Alexis Pulga
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Morten Hostrup
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Nutrition, Exercise and Sport, University of Copenhagen, Copenhagen Ø, Denmark
| | | | - Michiko Mori
- Unit of Airway Inflammation, Lund University, Lund, Sweden
| | | | - Klaus R Larsen
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
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17
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Airway Eosinophilopoietic and Autoimmune Mechanisms of Eosinophilia in Severe Asthma. Immunol Allergy Clin North Am 2018; 38:639-654. [PMID: 30342585 DOI: 10.1016/j.iac.2018.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophils are critical in asthma biology, contributing to symptoms, airflow obstruction, airway hyperresponsiveness, and remodeling. In severe asthma, in addition to local maturation in bone marrow, in situ eosinophilopoiesis plays a key role in the persistence of airway eosinophilia. Local milieu of structural, epithelial and inflammatory cells contribute by generating eosinophilopoietic cytokines in response to epithelial-derived alarmins. Another mechanism of persistent airway eosinophilia is glucocorticosteroid insensitivity, which is linked to recurrent airway infections and presence of local autoantibodies. Novel molecules are being developed to target specific immune pathways as potential steroid-sparing strategies.
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18
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Choudhury RH, Hashemi H, Tran T, Zhang H, Millard MW. Asthmatic granulomatosis as a rare variant of uncontrolled severe asthma. Proc (Bayl Univ Med Cent) 2018; 31:473-475. [PMID: 30948984 DOI: 10.1080/08998280.2018.1484221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 12/16/2022] Open
Abstract
Asthmatic granulomatosis (AG) is a variant of severe asthma, first described in 2012, that consists of small airway changes compatible with asthma as well as interstitial nonnecrotizing granulomas. Treatment of AG requires immunosuppression as opposed to the traditional asthma therapy of inhaled steroids. We describe a 5-year course of a patient with AG that has shown no improvement with immunosuppression or other standards of therapy.
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Affiliation(s)
- Rakin H Choudhury
- Department of Internal Medicine, Baylor University Medical CenterDallasTexas
| | - Helen Hashemi
- Department of Internal Medicine, Baylor University Medical CenterDallasTexas
| | - Tuan Tran
- Department of Pathology, Baylor University Medical CenterDallasTexas
| | - Haiying Zhang
- Department of Pathology, Baylor University Medical CenterDallasTexas
| | - Mark W Millard
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical CenterDallasTexas
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19
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Abstract
PURPOSE OF REVIEW Glucocorticosteroids (GCSs) remain the cornerstone of therapy for treating the inflammatory component of asthma. Clinical response to GCS is heterogeneous, varying both within asthma 'endotypes', as well as the same individual. Different factors and micro-environment can alter the canonical GCS-induced signalling pathways leading to reduced efficacy, collectively termed as GCS subsensitivity, which includes the entire spectrum of steroid insensitivity and steroid resistance. RECENT FINDINGS In the past, steroid subsensitivity has been associated with dysregulated expression of glucocorticoid-receptor isoforms, neutrophilic inflammation and Th17 cytokines, oxidative stress-inducing factors and their downstream effect on histone deacetylase activities and gene expression. The review highlights recent observations, such as GCS-induced dysregulation of key transcription factors involved in host defence, role of airway infections altering expression of critical regulatory elements like the noncoding microRNAs, and the importance of interleukin (IL)-10 in reinstating steroid response in key immune cells. Further, emerging concepts of autoimmunity triggered because of delayed resolution of eosinophilic inflammation (due to GCS subsensitivity) and observed lymphopenia (plausibly a side-effect of continued GCS use) are discussed. SUMMARY This review bridges concepts that have been known, and those under current investigation, providing both molecular and clinical insights to aid therapeutic strategies for optimal management of asthmatics with varying degree of steroid subsensitivity and disease severity, with particular emphasis on the PI3 kinase pathways.
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20
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Spencer CY, Millman J, Veiga K, Vicencio AG. Airway Autoimmune Inflammatory Response (AAIR) Syndrome: An Asthma-Autoimmune Overlap Disorder? Pediatrics 2018; 141:peds.2017-0138. [PMID: 29449341 DOI: 10.1542/peds.2017-0138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 11/24/2022] Open
Abstract
Asthma encompasses numerous phenotypes that may require alternate approaches to diagnosis and therapy, particularly for patients whose symptoms remain poorly controlled despite escalating treatment. We describe 3 patients with apparent asthma who demonstrated unusual findings on cryobiopsy by flexible bronchoscopy and responded to therapy directed against autoimmune disease.
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Affiliation(s)
- Chantal Y Spencer
- Department of Pediatrics (Kravis Children's Hospital), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Millman
- Department of Pediatrics (Kravis Children's Hospital), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Keila Veiga
- Department of Pediatrics (Kravis Children's Hospital), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alfin G Vicencio
- Department of Pediatrics (Kravis Children's Hospital), Icahn School of Medicine at Mount Sinai, New York, New York
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21
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Mukherjee M, Nair P. Autoimmune Responses in Severe Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:428-447. [PMID: 30088364 PMCID: PMC6082822 DOI: 10.4168/aair.2018.10.5.428] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/29/2018] [Accepted: 02/13/2018] [Indexed: 12/11/2022]
Abstract
Asthma and autoimmune diseases both result from a dysregulated immune system, and have been conventionally considered to have mutually exclusive pathogenesis. Autoimmunity is believed to be an exaggerated Th1 response, while asthma with a Th2 underpinning is congruent with the well-accepted Th1/Th2 paradigm. The hypothesis of autoimmune involvement in asthma has received much recent interest, particularly in the adult late-onset non-atopic patients (the “intrinsic asthma”). Over the past decades, circulating autoantibodies against diverse self-targets (beta-2-adrenergic receptors, epithelial antigens, nuclear antigens, etc.) have been reported and subsequently dismissed to be epiphenomena resulting from a chronic inflammatory condition, primarily due to lack of evidence of causality/pathomechanism. Recent evidence of ‘granulomas’ in the lung biopsies of severe asthmatics, detection of pathogenic sputum autoantibodies against autologous eosinophil proteins (e.g., eosinophil peroxidase) and inadequate response to monoclonal antibody therapies (e.g., subcutaneous mepolizumab) in patients with evidence of airway autoantibodies suggest that the role of autoimmune mechanisms be revisited. In this review, we have gathered available reports of autoimmune responses in the lungs, reviewed the evidence in the context of immunogenic tissue-response and danger-associated molecular patterns, and constructed the possibility of an autoimmune-associated pathomechanism that may contribute to the severity of asthma.
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Affiliation(s)
- Manali Mukherjee
- Division of Respirology, Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
| | - Parameswaran Nair
- Division of Respirology, Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada.
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22
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Mukherjee M, Bulir DC, Radford K, Kjarsgaard M, Huang CM, Jacobsen EA, Ochkur SI, Catuneanu A, Lamothe-Kipnes H, Mahony J, Lee JJ, Lacy P, Nair PK. Sputum autoantibodies in patients with severe eosinophilic asthma. J Allergy Clin Immunol 2017; 141:1269-1279. [PMID: 28751233 DOI: 10.1016/j.jaci.2017.06.033] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The persistence of eosinophils in sputum despite high doses of corticosteroids indicates disease severity in asthmatic patients. Chronic inflamed airways can lose tolerance over time to immunogenic entities released on frequent eosinophil degranulation, which further contributes to disease severity and necessitates an increase in maintenance corticosteroids. OBJECTIVES We sought to investigate the possibility of a polyclonal autoimmune event in the airways of asthmatic patients and to identify associated clinical and molecular characteristics. METHODS The presence of autoantibodies against eosinophil peroxidase (EPX) and anti-nuclear antibodies was investigated in patients with eosinophilic asthma maintained on high-dose corticosteroids, prednisone, or both. The ability of sputum immunoglobulins to induce eosinophil degranulation in vitro was assessed. In addition, the associated inflammatory microenvironment in patients with detectable autoantibodies was examined. RESULTS We report a "polyclonal" autoimmune event occurring in the airways of prednisone-dependent asthmatic patients with increased eosinophil activity, recurrent pulmonary infections, or both, as evident by the concomitant presence of sputum anti-EPX and anti-nuclear antibodies of the IgG subtype. Extensive cytokine profiling of sputum revealed a TH2-dominated microenvironment (eotaxin-2, IL-5, IL-18, and IL-13) and increased signalling molecules that support the formation of ectopic lymphoid structures (B-cell activating factor and B cell-attracting chemokine 1). Immunoprecipitated sputum immunoglobulins from patients with increased autoantibody levels triggered eosinophil degranulation in vitro, with release of extensive histone-rich extracellular traps, an event unsuppressed by dexamethasone and possibly contributing to the steroid-unresponsive nature of these eosinophilic patients. CONCLUSION This study identifies an autoimmune endotype of severe asthma that can be identified by the presence of sputum autoantibodies against EPX and autologous cellular components.
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Affiliation(s)
- Manali Mukherjee
- Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - David C Bulir
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Katherine Radford
- Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Sergei I Ochkur
- Division of Pulmonary Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Ana Catuneanu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - James Mahony
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James J Lee
- Division of Pulmonary Medicine, Mayo Clinic, Scottsdale, Ariz
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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23
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Trejo Bittar HE, Doberer D, Mehrad M, Strollo DC, Leader JK, Wenzel S, Yousem SA. Histologic Findings of Severe/Therapy-Resistant Asthma From Video-assisted Thoracoscopic Surgery Biopsies. Am J Surg Pathol 2017; 41:182-188. [PMID: 28079597 PMCID: PMC5234856 DOI: 10.1097/pas.0000000000000777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The histologic changes occurring in severe/therapy-resistant asthma (SA) as defined by the European Respiratory Society/American Thoracic Society guidelines, particularly at the level of the distal airways are unknown. This study describes the clinical, radiologic, and histologic characteristics of 29 SA patients who underwent video-assisted thoracoscopic surgery lung biopsy. Pathologic observations were correlated with clinical features, especially the presence of autoimmune disease (AID) (15/29, 51.7%). Ten biopsies (10/29, 34.5%) showed only small airway manifestations of asthma, whereas in 19 (65.5%) asthmatic granulomatosis, manifested by asthmatic bronchiolitis supplemented by an alveolar septal mononuclear infiltrates with non-necrotizing granulomas, was present. SA patients without asthmatic granulomatosis showed more striking small airway injury, subbasement membrane thickening, and neutrophilic infiltrates. Cases with concurrent AID had a tendency to more parenchymal eosinophilic inflammation, more bronchiolocentric granulomas, and a suggestion of increased responsivity to nonsteroidal immunosuppressive therapy. Histologic examination of video-assisted thoracoscopic surgery lung biopsies in SA demonstrates diverse pathologies including cases associated with granulomatous inflammation in addition to eosinophilic infiltrates. This spectrum of histologies may link to a high incidence of AID.
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Affiliation(s)
| | - Daniel Doberer
- University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center, Pulmonary Allergy and Critical Care Medicine Division, Department of Medicine, Pittsburgh, PA, USA
| | - Mitra Mehrad
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, PA, USA
| | - Diane C. Strollo
- University of Pittsburgh Medical Center, Department of Cardiothoracic Surgery, Pittsburgh, PA, USA
| | - Joseph K. Leader
- University of Pittsburgh Medical Center, Department of Cardiothoracic Surgery, Pittsburgh, PA, USA
| | - Sally Wenzel
- University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center, Pulmonary Allergy and Critical Care Medicine Division, Department of Medicine, Pittsburgh, PA, USA
| | - Samuel A. Yousem
- University of Pittsburgh Medical Center, Department of Pathology, Pittsburgh, PA, USA
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24
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Fajt ML, Wenzel SE. Development of New Therapies for Severe Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:3-14. [PMID: 27826957 PMCID: PMC5102833 DOI: 10.4168/aair.2017.9.1.3] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 12/11/2022]
Abstract
Persistent asthma has long been treated with inhaled corticosteroids (CSs), as the mainstay of therapy. However, their efficacy in patients with more severe disease is limited, which led to the incorporation of poor response to ICSs (and thereby use of high doses of ICS) into recent definitions of severe asthma. Several studies have suggested that severe asthma might consist of several different phenotypes, each with ongoing symptoms and health care utilization, despite the use of high doses of ICS, usually in combination with a second or third controller. Several new therapies have been approved for severe asthma. Long-acting muscarinic agents have recently been approved as an additional controller agent and appear to improve lung function, although their effect on symptoms and exacerbations is less. Although bronchial thermoplasty (BT) has emerged as a therapy for severe asthma, little is understood regarding the appropriate selection of these patients. Considerable data have emerged to support the presence of a group of patients with severe asthma who have ongoing Type 2 inflammation. These patients appear to respond to targeted biologic approaches which are at the current time mostly investigational. In contrast, few effective therapies for patients with less or no evidence for Type 2 inflammation have emerged. Many new and exciting therapies are at the forefront for severe asthma therapy and, in conjunction with precision medicine approaches to identify the group of patients likely to respond to these approaches, will change the way we think about treating severe asthma.
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Affiliation(s)
- Merritt L Fajt
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Asthma Institute at UPMC/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sally E Wenzel
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Asthma Institute at UPMC/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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25
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Abstract
The term asthma encompasses a disease spectrum with mild to very severe disease phenotypes whose traditional common characteristic is reversible airflow limitation. Unlike milder disease, severe asthma is poorly controlled by the current standard of care. Ongoing studies using advanced molecular and immunological tools along with improved clinical classification show that severe asthma does not identify a specific patient phenotype, but rather includes patients with constant medical needs, whose pathobiologic and clinical characteristics vary widely. Accordingly, in recent clinical trials, therapies guided by specific patient characteristics have had better outcomes than previous therapies directed to any subject with a diagnosis of severe asthma. However, there are still significant gaps in our understanding of the full scope of this disease that hinder the development of effective treatments for all severe asthmatics. In this Review, we discuss our current state of knowledge regarding severe asthma, highlighting different molecular and immunological pathways that can be targeted for future therapeutic development.
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Affiliation(s)
- Anuradha Ray
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Department of Immunology, and
- University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahesh Raundhal
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Timothy B. Oriss
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Prabir Ray
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Department of Immunology, and
- University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sally E. Wenzel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Department of Immunology, and
- University of Pittsburgh Asthma Institute at University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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26
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Roth S, Fell AKM. Multiple subcutaneous granulomas and severe rhinitis after intradermal deposition of epoxy: a case report. J Occup Med Toxicol 2016; 11:30. [PMID: 27340424 PMCID: PMC4917976 DOI: 10.1186/s12995-016-0120-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/13/2016] [Indexed: 12/14/2022] Open
Abstract
Background We present an unusual case of subcutaneous granulomas that also highlights the importance of assessing possible associations between exposure and symptoms early in the diagnostic approach to prevent further adverse health effects. Granulomas of the skin are seen in association with several diseases and after foreign body penetration of soft tissue, but have not been described after contact with epoxy. Epoxy resins are commonly used in paints and other protective coatings, including flooring materials. Case presentation We report a case of granulomatous inflammation in a 58-year-old man after accidental intradermal deposition of unhardened epoxy. Multiple subcutaneous nodules were present on his right forearm, from hand to elbow, for a period of 6 months after the incident. Biopsies and histological analysis showed a granulomatous inflammation without necrosis. Microscopic analysis of the biopsies did not show mycobacterium tuberculosis, other bacteria, or fungal elements. Standard patch testing was negative. The nodules disappeared gradually, but intense pruritus remained. The patient returned to exposure and developed severe work related rhinitis. Conclusions This case report describes an unusual case of multiple subcutaneous granulomas after a small injury with an epoxy-contaminated tool. Initially no association between the granulomas and exposure was established and the patient returned to work and epoxy exposure. He subsequently developed severe work related rhinitis. The case highlights the challenges of establishing an association between exposure and dermal reactions and that exposure should be reduced or avoided when sensitisation to allergens may have occurred.
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Affiliation(s)
- Steffen Roth
- Department of Occupational and Environmental Medicine, Telemark Hospital, Ulefossveien 55, Skien, 3710 Norway ; Department of Occupational and Environmental Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Anne Kristin Møller Fell
- Department of Occupational and Environmental Medicine, Telemark Hospital, Ulefossveien 55, Skien, 3710 Norway
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Díaz Campos RM, Bobolea I, Banderas Montalvo ME, Melero Moreno C. Asthmatic granulomatosis: A new presentation or a new asthma phenotype? Ann Allergy Asthma Immunol 2016; 116:581-2. [PMID: 27079831 DOI: 10.1016/j.anai.2016.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/09/2016] [Accepted: 03/14/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Rocío M Díaz Campos
- Department of Pulmonology, Hospital Universitario 12 de Octubre, Institute for Health Research, Madrid, Spain
| | - Irina Bobolea
- Department of Allergy, Hospital Universitario 12 de Octubre, Institute for Health Research, Madrid, Spain.
| | | | - Carlos Melero Moreno
- Department of Pulmonology, Hospital Universitario 12 de Octubre, Institute for Health Research, Madrid, Spain
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Abstract
PURPOSE OF REVIEW Bronchial asthma is a common disorder that affects about 300 million people worldwide. Its signs and symptoms however, can be present in other pulmonary and/or airway diseases and therefore a careful workup of patients with respiratory symptoms that might be due to asthma is required to a) keep a broad differential diagnosis, especially in cases that do not respond well to standard antiasthmatic therapy and b) attempt to subphenotype patients within the syndrome of asthma to diagnose e.g. precipitating factors, inflammatory subtypes and comorbidities. RECENT FINDINGS The syndrome of asthma contains a number of different phenotypes that offer the possibility of personalized medicine based on the respective asthma phenotype. There are attempts to combine asthma and COPD in newly postulated overlap syndromes which this review discourages to do but instead, based on new and old information concerning asthma phenotyping, suggests to rule in comorbidities and rule out a number of other diseases that can mimick asthma clinically. SUMMARY Bronchial asthma, although one of the most common respiratory diseases, can be mimicked by a number of other pulmonary and airway diseases, and especially patients with so called severe or treatment refractory asthma should receive a detailed diagnostic workup with a rather broad differential diagnosis.
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Hosseini A, Hirota JA, Hackett TL, McNagny KM, Wilson SJ, Carlsten C. Morphometric analysis of inflammation in bronchial biopsies following exposure to inhaled diesel exhaust and allergen challenge in atopic subjects. Part Fibre Toxicol 2016; 13:2. [PMID: 26758251 PMCID: PMC4711081 DOI: 10.1186/s12989-016-0114-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 01/06/2016] [Indexed: 02/08/2023] Open
Abstract
Background Allergen exposure and air pollution are two risk factors for asthma development and airway inflammation that have been examined extensively in isolation. The impact of combined allergen and diesel exhaust exposure has received considerably less attention. Diesel exhaust (DE) is a major contributor to ambient particulate matter (PM) air pollution, which can act as an adjuvant to immune responses and augment allergic inflammation. We aimed to clarify whether DE increases allergen-induced inflammation and cellular immune response in the airways of atopic human subjects. Methods Twelve atopic subjects were exposed to DE 300 μg.m−3 or filtered air for 2 h in a blinded crossover study design with a four-week washout period between arms. One hour following either filtered air or DE exposure, subjects were exposed to allergen or saline (vehicle control) via segmental challenge. Forty-eight hours post-allergen or control exposure, bronchial biopsies were collected. The study design generated 4 different conditions: filtered air + saline (FAS), DE + saline (DES), filtered air + allergen (FAA) and DE + allergen (DEA). Biopsies sections were immunostained for tryptase, eosinophil cationic protein (ECP), neutrophil elastase (NE), CD138, CD4 and interleukin (IL)-4. The percent positivity of positive cells were quantified in the bronchial submucosa. Results The percent positivity for tryptase expression and ECP expression remained unchanged in the bronchial submucosa in all conditions. CD4 % positive staining in DEA (0.311 ± 0.060) was elevated relative to FAS (0.087 ± 0.018; p = 0.035). IL-4 % positive staining in DEA (0.548 ± 0.143) was elevated relative to FAS (0.127 ± 0.062; p = 0.034). CD138 % positive staining in DEA (0.120 ± 0.031) was elevated relative to FAS (0.017 ± 0.006; p = 0.015), DES (0.044 ± 0.024; p = 0.040), and FAA (0.044 ± 0.008; p = 0.037). CD138 % positive staining in FAA (0.044 ± 0.008) was elevated relative to FAS (0.017 ± 0.006; p = 0.049). NE percent positive staining in DEA (0.224 ± 0.047) was elevated relative to FAS (0.045 ± 0.014; p = 0.031). Conclusions In vivo allergen and DE co-exposure results in elevated CD4, IL-4, CD138 and NE in the respiratory submucosa of atopic subjects, while eosinophils and mast cells are not changed. Trial registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01792232. Electronic supplementary material The online version of this article (doi:10.1186/s12989-016-0114-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ali Hosseini
- Department of Medicine, Division of Respiratory Medicine, Chan-Yeung Centre for Occupational and Environmental Respiratory Disease, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada. .,Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, V6Z 1Y6, Canada. .,The Lung Center, Vancouver General Hospital (VGH) - Gordon and Leslie Diamond Health Care Centre, 2775 Laurel Street, 7th floor, Vancouver, BC, V5Z 1M9, Canada.
| | - Jeremy A Hirota
- Department of Medicine, Division of Respiratory Medicine, Chan-Yeung Centre for Occupational and Environmental Respiratory Disease, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada. .,Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, V6Z 1Y6, Canada. .,The Lung Center, Vancouver General Hospital (VGH) - Gordon and Leslie Diamond Health Care Centre, 2775 Laurel Street, 7th floor, Vancouver, BC, V5Z 1M9, Canada.
| | - Tillie L Hackett
- Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, V6Z 1Y6, Canada.
| | - Kelly M McNagny
- Biomedical Research Centre, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada.
| | - Susan J Wilson
- Histochemistry Research Unit, Faculty of Medicine, University of Southampton, Southampton, S016 6YD, UK.
| | - Chris Carlsten
- Department of Medicine, Division of Respiratory Medicine, Chan-Yeung Centre for Occupational and Environmental Respiratory Disease, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada. .,Institute for Heart and Lung Health, University of British Columbia, Vancouver, BC, V6Z 1Y6, Canada. .,The Lung Center, Vancouver General Hospital (VGH) - Gordon and Leslie Diamond Health Care Centre, 2775 Laurel Street, 7th floor, Vancouver, BC, V5Z 1M9, Canada.
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Pradere P, Gauvain C, Danel C, Debray MP, Borie R, Plantier L, Mal H, Aubier M, Crestani B, Taillé C. Airway-Centered Fibroelastosis: A Distinct Entity. Chest 2016; 149:767-74. [PMID: 26836939 DOI: 10.1016/j.chest.2015.10.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/11/2015] [Accepted: 10/15/2015] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To describe a new entity characterized by airway-centered fibroelastosis. METHODS We identified cases with prominent airway-centered elastosis in lung samples, and little or no pleural involvement identified through a pathologic database at a single institution over an 8-year period. RESULTS Airway-centered fibroelastosis was characterized by (1) extensive airway-centered fibroelastosis of the upper lobes on histopathology and (2) marked bronchial abnormalities with bronchial wall thickening, bronchial wall deformation, and bronchiectasis, along with progressive parenchymal retraction and predominantly subpleural upper-lobe consolidations on high-resolution CT. Pateints were five nonsmoking women aged between 38 and 56 years old. They experienced chronic dyspnea with acute attacks of wheezing and dyspnea. Moderate to severe physiological abnormalities were observed, with an obstructive pattern in three cases and a restriction in two. Despite inhaled and oral corticosteroids, the disease was progressive in all patients and evolved to chronic respiratory failure, requiring lung transplantation in two patients. Four patients had chronic asthma. CONCLUSIONS We consider airway-centered fibroelastosis to be a unique and distinct pathological entity in women that needs to be individualized, with a specific clinical, imaging, and pathological presentation. We hypothesize that airway-centered fibroelastosis may be idiopathic or asthma-associated.
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Affiliation(s)
- Pauline Pradere
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie A, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Département hospitalo-universitaire FIRE, Competence Center for Rare Pulmonary Diseases, Paris, France
| | - Clément Gauvain
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie A, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Département hospitalo-universitaire FIRE, Competence Center for Rare Pulmonary Diseases, Paris, France
| | - Claire Danel
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Département d'Anatomie Pathologique, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Marie Pierre Debray
- Service de Radiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Raphael Borie
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie A, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Département hospitalo-universitaire FIRE, Competence Center for Rare Pulmonary Diseases, Paris, France
| | - Laurent Plantier
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service d'explorations fonctionnelles, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Hervé Mal
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie et Transplantation, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Michel Aubier
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie A, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Département hospitalo-universitaire FIRE, Competence Center for Rare Pulmonary Diseases, Paris, France
| | - Bruno Crestani
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie A, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Département hospitalo-universitaire FIRE, Competence Center for Rare Pulmonary Diseases, Paris, France.
| | - Camille Taillé
- INSERM U1152, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Pneumologie A, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Département hospitalo-universitaire FIRE, Competence Center for Rare Pulmonary Diseases, Paris, France
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Agache I, Sugita K, Morita H, Akdis M, Akdis CA. The Complex Type 2 Endotype in Allergy and Asthma: From Laboratory to Bedside. Curr Allergy Asthma Rep 2015; 15:29. [PMID: 26141574 DOI: 10.1007/s11882-015-0529-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Better management of allergic diseases needs a sharpened understanding of disease heterogeneity and mechanisms in relation to clinically significant outcomes. Phenotypes describing observable clinical and morphologic characteristics and unique responses to treatment have been developed; however, they do not relate to disease mechanisms. Recently, extended heterogeneous and disease-related metabolic, inflammatory, immunological, and remodeling pathways have been described, and reproducible patterns are defined as disease endotypes. An endotype might consist of several intricated mechanisms that cannot be clearly separated into "pure single molecular mechanism" thus being a "complex endotype." The description of an endotype may rely on biomarkers, which can be the signature of a complex underlying pathway or a key molecule associated with or directly playing a role in a particular disease endotype. The Th2 type inflammation can be defined as a complex endotype in asthma and linked to mechanisms of disease development and response to treatment and to disease outcomes such as exacerbations and remodeling. The type 2 complex endotype in allergies and asthma includes innate lymphoid cells, T helper 2 cells, tissue eosinophilia, and IgE production. Currently, emerging endotype-driven strategies in asthma, particularly the development of biologicals that target a single molecular pathway, are being focused for solving individualized clinical problems on disease outcomes. Progress is also being made for endotyping rhinitis, chronic rhinosinusitis, and atopic dermatitis.
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Affiliation(s)
- Ioana Agache
- Department of Allergy and Clinical Immunology, Faculty of Medicine, Transylvania University of Brasov, Brasov, Romania,
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Doberer D, Trejo Bittar HE, Wenzel SE. Should lung biopsies be performed in patients with severe asthma? Eur Respir Rev 2015; 24:525-39. [PMID: 26324815 PMCID: PMC9487699 DOI: 10.1183/16000617.0045-2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Asthma, and severe asthma, in particular, is increasingly recognised as a heterogeneous disease. Identifying these different phenotypes of asthma and assigning patients to phenotype-specific treatments is one of the current conundrums in respiratory medicine. Any diagnostic procedure in severe asthma (or any disease) should have two aims: 1) better understanding or identifying the diagnosis, and 2) providing information on the heterogeneity of asthma phenotypes to guide therapy with the objective of improving outcomes. Lung biopsies can target the large and small airways as well as the lung parenchyma. All compartments are affected in severe asthma; however, knowledge on the distal lung is limited. At this point, it remains uncertain whether lung specimens routinely add diagnostic information that is unable to be obtained otherwise. Indeed, whether a lung biopsy is indicated in the workup of a patient with severe asthma remains an individual decision. It is hoped this review will support rational decision-making and provide a detailed synopsis of the varied histopathological features seen in biopsies of patients with a diagnosis of severe asthma. Due to limited data on this topic this review is primarily based on opinion with recommendations arising primarily from the personal experience of the authors.
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Affiliation(s)
- Daniel Doberer
- University of Pittsburgh Asthma Institute at UPMC, Pittsburgh, PA, USA,Dept of Internal and Pulmonary Medicine, Wilhelminenspital Wien, Medical University of Vienna, Vienna, Austria,Daniel Doberer, Dept of Internal and Pulmonary Medicine, Wilhelminenspital, Montleartstrasse 37, 1160 Vienna, Austria. E-mail:
| | | | - Sally E. Wenzel
- University of Pittsburgh Asthma Institute at UPMC, Pittsburgh, PA, USA
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Trejo Bittar HE, Yousem SA, Wenzel SE. Pathobiology of severe asthma. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2014; 10:511-45. [PMID: 25423350 DOI: 10.1146/annurev-pathol-012414-040343] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Severe asthma (SA) afflicts a heterogeneous group of asthma patients who exhibit poor responses to traditional asthma medications. SA patients likely represent 5-10% of all asthma patients; however, they have a higher economic burden when compared with milder asthmatics. Considerable research has been performed on pathological pathways and structural changes associated with SA. Although limitations of the pathological approaches, ranging from sampling, to quantitative assessments, to heterogeneity of disease, have prevented a more definitive understanding of the underlying pathobiology, studies linking pathology to molecular markers to targeted therapies are beginning to solidify the identification of select molecular phenotypes. This review addresses the pathobiology of SA and discusses the current limitations of studies, the inflammatory cells and pathways linked to emerging phenotypes, and the structural and remodeling changes associated with severe disease. In all cases, an effort is made to link pathological findings to specific clinical/molecular phenotypes.
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Lockey RF. Asthma phenotypes: an approach to the diagnosis and treatment of asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:682-5. [PMID: 25439357 DOI: 10.1016/j.jaip.2014.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
Abstract
I teach that "Asthma is the most treatable of all chronic diseases known to mankind." Yet, outcome data from throughout the world (emergency department visits, hospitalizations, and quality of life) indicate that the diagnosis and treatment of asthma are not optimal and need improvement. Why? First, asthma is not thought of as a complex, heterogeneous disease or syndrome that consists of different phenotypes and endotypes. Second, asthma is variable, particularly in its severity, and is influenced by known, unknown, avoidable, and unavoidable environmental factors. Third, treatment usually requires complex inhalational devices that are difficult to understand and use, and with which adherence is suboptimal. Continued education on how to appropriately use medications, particularly inhaled medications, is absolutely essential, and knowledge and access to a backup treatment plan to be initiated by the patient for an asthma flare is necessary. Fourth, assessment of asthma is primarily based on symptoms, and, at times, all symptoms are due to asthma, but many times some or all symptoms are due to unrecognized and untreated comorbid or coexisting conditions. Too often, asthma is viewed as a disease that occurs in isolation, and comorbid and coexisting conditions are not appropriately identified and treated. Allergists/immunologists are well suited to provide the type of comprehensive care required to optimize asthma outcomes for the benefit of individual patients and society.
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Affiliation(s)
- Richard F Lockey
- Division of Allergy and Immunology, University of South Florida Morsani College of Medicine, Tampa, Fla.
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Ray A, Oriss TB, Wenzel SE. Emerging molecular phenotypes of asthma. Am J Physiol Lung Cell Mol Physiol 2014; 308:L130-40. [PMID: 25326577 DOI: 10.1152/ajplung.00070.2014] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Although asthma has long been considered a heterogeneous disease, attempts to define subgroups of asthma have been limited. In recent years, both clinical and statistical approaches have been utilized to better merge clinical characteristics, biology, and genetics. These combined characteristics have been used to define phenotypes of asthma, the observable characteristics of a patient determined by the interaction of genes and environment. Identification of consistent clinical phenotypes has now been reported across studies. Now the addition of various 'omics and identification of specific molecular pathways have moved the concept of clinical phenotypes toward the concept of molecular phenotypes. The importance of these molecular phenotypes is being confirmed through the integration of molecularly targeted biological therapies. Thus the global term asthma is poised to become obsolete, being replaced by terms that more specifically identify the pathology associated with the disease.
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Affiliation(s)
- Anuradha Ray
- University of Pittsburgh Asthma Institute at UPMC, Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy B Oriss
- University of Pittsburgh Asthma Institute at UPMC, Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute at UPMC, Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Mycoplasma pneumoniae CARDS toxin exacerbates ovalbumin-induced asthma-like inflammation in BALB/c mice. PLoS One 2014; 9:e102613. [PMID: 25058417 PMCID: PMC4109942 DOI: 10.1371/journal.pone.0102613] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/20/2014] [Indexed: 01/21/2023] Open
Abstract
Mycoplasma pneumoniae causes a range of airway and extrapulmonary pathologies in humans. Clinically, M. pneumoniae is associated with acute exacerbations of human asthma and a worsening of experimentally induced asthma in mice. Recently, we demonstrated that Community Acquired Respiratory Distress Syndrome (CARDS) toxin, an ADP-ribosylating and vacuolating toxin synthesized by M. pneumoniae, is sufficient to induce an asthma-like disease in BALB/cJ mice. To test the potential of CARDS toxin to exacerbate preexisting asthma, we examined inflammatory responses to recombinant CARDS toxin in an ovalbumin (OVA) murine model of asthma. Differences in pulmonary inflammatory responses between treatment groups were analyzed by histology, cell differentials and changes in cytokine and chemokine concentrations. Additionally, assessments of airway hyperreactivity were evaluated through direct pulmonary function measurements. Analysis of histology revealed exaggerated cellular inflammation with a strong eosinophilic component in the CARDS toxin-treated group. Heightened T-helper type-2 inflammatory responses were evidenced by increased expression of IL-4, IL-13, CCL17 and CCL22 corresponding with increased airway hyperreactivity in the CARDS toxin-treated mice. These data demonstrate that CARDS toxin can be a causal factor in the worsening of experimental allergic asthma, highlighting the potential importance of CARDS toxin in the etiology and exacerbation of human asthma.
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Abstract
PURPOSE OF REVIEW The current guidelines for asthma diagnosis and management do not recognize that different phenotypes of asthma exist, with significant variations in the manifestation of airway inflammation, symptoms, severity, and response to treatment. This article will critically review new approaches to classify asthma together with the emerging endotype-driven therapeutic strategies. RECENT FINDINGS Several new approaches for classifying asthma are available, from precision and deep phenotyping to identification of novel causal pathways and translation of biomarkers into pathway-specific diagnostic tests. New phenotypes, such as epigenetic phenotypes, asthmatic granulomatosis, or neurophenotypes are described. Large clinical trials testing the endotype-driven approach are increasingly successful, but the dissociated effect and the drug efficacy at the target site remain unsolved issues. Profiling the Th2 low and the resident cell compartment of asthma are major unmet needs in asthma endotyping. SUMMARY Each of the hallmark characteristics of asthma (inflammation, remodeling, airway hyperreactivity) is the expression of a complex network of molecules, very diverse both within any given patient in time and between any two patients. Some of these networks are repetitive across individuals with asthma and specific for clinical expression, gene-environment interaction and inflammatory cell profiles represent novel endotype-specific diagnostic and therapeutic strategies.
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Abstract
Asthma is a common disease in the population and fatal asthma cases are not rare. Patients with fatal asthma not infrequently die outside of hospitals and become forensic cases. The pathologic features of asthma are very variable, but fatal asthma is always characterized by extensive mucous plugs in the airways and lungs that tend to remain inflated when the chest is opened. Other microscopic features that may be seen in asthma include increased amounts of airway smooth muscle, marked thickening of airway basement membranes, goblet cell hyperplasia, and various patterns of airway inflammation including eosinophils, neutrophils, and lymphocytes. Absent a history, a presumptive diagnosis of fatal asthma can be made in a patient whose lungs are hyperinflated and demonstrate numerous mucous plugs in the large airways, and this is usually accompanied by a markedly thickened basement membrane in the large airways on microscopic examination, but the possibility that the fatal asthma attack was precipitated by exogeneous factors such as drugs, fumes, or irritants should be borne in mind.
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Affiliation(s)
- Joanne L. Wright
- University of British Columbia, St. Paul's Hospital in Vancouver, BC
- Department of Pathology, University of British Columbia, Vancouver, BC (AC)
| | - Andrew M. Churg
- Department of Pathology, University of British Columbia, Vancouver, BC (AC)
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Affiliation(s)
- Erika von Mutius
- Dr. von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany
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Wenzel SE. Complex phenotypes in asthma: current definitions. Pulm Pharmacol Ther 2013; 26:710-5. [PMID: 23880027 DOI: 10.1016/j.pupt.2013.07.003] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 06/15/2013] [Accepted: 07/10/2013] [Indexed: 01/13/2023]
Abstract
Asthma is increasingly recognized as a heterogeneous disease. However, identification of different subgroups or phenotypes has been complex and controversial. The convergence of both clinical and statistical approaches to grouping patients and their characteristics, in association with increasing recognition of molecular patterns is now beginning to move the field forward. Integration of efficacy data with targeted molecular therapies will eventually lead to more complete understanding of these "molecular phenotypes" and eventually lead to the identification of fully defined endotypes. This process should improve our ability to treat more complex and severe forms of asthma.
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Affiliation(s)
- Sally E Wenzel
- University of Pittsburgh Asthma Institute@UPMC, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, NW 931 Montefiore, 3459 Fifth Ave, Pittsburgh, PA 15213, USA.
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Abstract
Asthma has a high prevalence worldwide, and contributes significantly to the socioeconomic burden. According to a classical paradigm, asthma symptoms are attributable to an allergic, Th2-driven airway inflammation that causes airway hyperresponsiveness and results in reversible airway obstruction. Diagnosis and therapy are based mainly on these pathophysiologic concepts. However, these have increasingly been challenged by findings of recent studies, and the frequently observed failure in controlling asthma symptoms. Important recent findings are the protective "farm effect" in children, the possible prenatal mechanisms of this protection, the recognition of many different asthma phenotypes in children and adults, and the partly disappointing clinical effects of new targeted therapeutic approaches. Systems biology approaches may lead to a more comprehensive view of asthma pathophysiology and a higher success rate of new therapies. Systems biology integrates clinical and experimental data by means of bioinformatics and mathematical modeling. In general, the "-omics" approach, and the "mathematical modeling" approach can be described. Recently, several consortia have been attempting to bring together clinical and molecular data from large asthma cohorts, using novel experimental setups, biostatistics, bioinformatics, and mathematical modeling. This "systems medicine" approach to asthma will help address the different asthma phenotypes with adequate therapy and possibly preventive strategies.
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Louie S, Zeki AA, Schivo M, Chan AL, Yoneda KY, Avdalovic M, Morrissey BM, Albertson TE. The asthma-chronic obstructive pulmonary disease overlap syndrome: pharmacotherapeutic considerations. Expert Rev Clin Pharmacol 2013; 6:197-219. [PMID: 23473596 PMCID: PMC7046086 DOI: 10.1586/ecp.13.2] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is a commonly encountered yet loosely defined clinical entity. ACOS accounts for approximately 15-25% of the obstructive airway diseases and patients experience worse outcomes compared with asthma or COPD alone. Patients with ACOS have the combined risk factors of smoking and atopy, are generally younger than patients with COPD and experience acute exacerbations with higher frequency and greater severity than lone COPD. Pharmacotherapeutic considerations require an integrated approach, first to identify the relevant clinical phenotype(s), then to determine the best available therapy. The authors discuss the array of existing and emerging classes of drugs that could benefit those with ACOS and share their therapeutic approach. A consensus international definition of ACOS is needed to design prospective, randomized clinical trials to evaluate specific drug interventions on important outcomes such as lung function, acute exacerbations, quality of life and mortality.
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Affiliation(s)
- Samuel Louie
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
| | - Amir A Zeki
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
| | - Michael Schivo
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
| | - Andrew L Chan
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Ken Y Yoneda
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Mark Avdalovic
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Brian M Morrissey
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of California, Davis, CA 95616, USA
- Veterans Administration Northern California Health Care System, Martinez, CA 94553, USA
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Carolan BJ, Sutherland ER. Clinical phenotypes of chronic obstructive pulmonary disease and asthma: recent advances. J Allergy Clin Immunol 2013; 131:627-34; quiz 635. [PMID: 23360757 DOI: 10.1016/j.jaci.2013.01.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/07/2013] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are prevalent obstructive lung diseases, both of which are characterized by airflow limitation. Although both represent distinct pathogenic entities, there can be significant clinical and physiologic overlap between the 2 disorders, creating potential management difficulties for clinicians. Although practice guidelines for both conditions outline diagnostic and management strategies, asthma and COPD are highly heterogeneous, and the symptoms of many patients remain poorly controlled despite adherence to current guidelines. Recent advances in phenotyping studies have elucidated heterogeneity in these airway diseases and might represent the best opportunity to enhance diagnosis, predict outcomes, and personalize treatments in patients with asthma and those with COPD. This review will focus on recent advances in describing phenotypic heterogeneity in asthma and COPD, including the evaluation of multiple clinical variables, molecular biomarkers, physiologic and radiologic data, and factors associated with disease progression and frequent exacerbations.
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