Alternate treatments in asthma

Potential impacts of Acu-TENS in the treatment of adolescents with moderate to severe bronchial asthma: A randomized clinical study

OBJECTIVE

The purpose of this study was to evaluate the efficacy of transcutaneous electrical nerve stimulation over the acupuncture points (Acu-TENS) on total serum immunoglobulin E (IgE_total), pulmonary function, and quality of life in adolescents with asthma.

METHODS

In a double-blind randomized clinical trial, 32 adolescents (age; 12-16 years) with asthma participated and were assigned randomly to receive either the breathing retraining program (control group) or the breathing retraining program plus Acu-TENS application (Acu-TENS group). Acu-TENS was applied for 40 min' day-after-day session for two successive months, with no side-effects reported. Serum IgE_total, pulmonary function [forced vital capacity (FVC), forced expiratory volume at one second (FEV₁), and FEV₁/FVC], and quality of life were evaluated pre- and post-treatment.

RESULTS

Serum IgE_total (P = 0.028, η_p² = 0.15), Pulmonary function [FVC (P = 0.043, η_p² = 0.13), FEV₁ (P = .046, η_p² = 0.12)], and quality of life (P < .001, η_p² = 0.17) increased significantly in the Acu-TENS group when compared to the control group.

CONCLUSION

This study demonstrates that the Acu-TENS is an impending asthma treatment that may be used to reinforce the immune system response, ameliorate lung function, and increase the quality of life in adolescents with asthma.

Cyclosporin A indirectly attenuates activation of group 2 innate lymphoid cells in papain-induced lung inflammation

Cyclosporin A (CsA) is a well-known immunosuppressant that is used against steroid-resistant asthma. Group 2 innate lymphoid cells (ILC2s) and type 2 helper T (Th2) cells produce Th2 cytokines including IL-5 and play important roles in asthma pathogenesis. Here, we studied the effects of CsA in allergen-induced lung inflammation in mice and found that CsA decreased the number of lung ILC2s and attenuated papain-induced activation of ILC2s accompanied with IL-5 expression. The ILC2 suppression mediated by CsA was not observed in culture or in lymphocyte-deficient Rag2^-/- mice. Thus, we propose a new suppressive effect of CsA, i.e., administration of CsA indirectly suppresses maintenance and activation of lung ILC2s in addition to direct suppression of T-cell activation and cytokine production.

Effect of Topical Furosemide on Intraoperative Bleeding During Functional Endoscopic Sinus Surgery

Intraoperative bleeding reduction during functional endoscopic sinus surgery is a key factor in preventing surgery complications. That is implemented through prescribing systemic corticostroid before surgery. This study aimed to explore an efficient nasal Furosemide versus systematic corticosteroids to reduce intraoperative bleeding.

Advances in anti-IgE therapy

Omalizumab depletes free IgE in the blood and interstitial space and inhibits IgE binding to FcεRI on basophils, mast cells, and dendritic cells. We stopped omalizumab treatment after four years. Recurrences of urticaria symptoms were found to be higher in patients with chronic urticaria than recurrences of asthmatic symptoms in severe persistent asthma patients. For the very first time, we used omalizumab in symptomatic therapy of recurrent laryngeal oedema and urticaria attacks in a patient with postoperative pulmonary carcinoid tumor for eight months. During the four years of follow-up, no recurrence was noted in pulmonary carcinoid tumor. Control PET CT results revealed normal findings. After omalizumab treatment, laryngeal oedema and urticaria symptoms were decreased. The most common adverse reaction from omalizumab is injection site induration, injection site itching, injection site pain, and bruising but the package insert contains warnings regarding parasitic infections. While there are no reports of fatal anaphylaxis as a result of omalizumab, some cases have been serious and potentially life-threatening. Therefore, the FDA requires that people receiving omalizumab be monitored in the physician's office for a period of time after their injections.

An overview of the effects of anti-IgE therapies

Omalizumab, a humanized mAb that binds to the CH3 domain near the binding site for the high-affinity type-I IgE Fc receptors of human IgE, can neutralize free IgE and inhibit the IgE allergic pathway without sensitizing mast cells and basophils. We found that omalizumab in patients with severe persistent asthma (SPA) was an effective therapy for asthma and the following co-morbid conditions: chronic urticaria (CU), bee venom allergy, latex allergy, atopic dermatitis, food allergy and Samter's syndrome. Information on the use of omalizumab in treatment of asthma and other allergic diseases has improved our understanding that treatment acts on many levels, including regulating levels of inflammatory proteins, including cytokines (copper-containing alpha- 2-glycoprotein, total antioxidant capacity, MDA, NO, H2O2, CXCL8, IL-10, TGF-β, GMCSF, IL-17, IL-1β), MPV, Hs-CRP, eosinophil cationic peptide, vitamin-D (25(OH)D), homocysteine (Hcy), OX-2, d- dimer, albumin, and sApo-2L. The decrease in Hcy concentrations and increase in 25(OH)D also support the existence of a vascular endothelial protection mechanism. Mediators and cells classically involved in pro-coagulant and anticoagulant pathways together play a role in SPA and CU pathophysiology and omalizumab effect. The mechanism of action of omalizumab in the treatment of asthma is believed to be multifactorial, and includes effects mediated through altered production of redox metabolites, extrinsic coagulation pathway, oxidative markers-related mi RNA, TRAIL-related mi RNA, and regulation of production of known inflammatory proteins.

Specific calcineurin targeting in macrophages confers resistance to inflammation via MKP-1 and p38

Macrophages contribute to tissue homeostasis and influence inflammatory responses by modulating their phenotype in response to the local environment. Understanding the molecular mechanisms governing this plasticity would open new avenues for the treatment for inflammatory disorders. We show that deletion of calcineurin (CN) or its inhibition with LxVP peptide in macrophages induces an anti-inflammatory population that confers resistance to arthritis and contact hypersensitivity. Transfer of CN-targeted macrophages or direct injection of LxVP-encoding lentivirus has anti-inflammatory effects in these models. Specific CN targeting in macrophages induces p38 MAPK activity by downregulating MKP-1 expression. However, pharmacological CN inhibition with cyclosporin A (CsA) or FK506 did not reproduce these effects and failed to induce p38 activity. The CN-inhibitory peptide VIVIT also failed to reproduce the effects of LxVP. p38 inhibition prevented the anti-inflammatory phenotype of CN-targeted macrophages, and mice with defective p38-activation were resistant to the anti-inflammatory effect of LxVP. Our results identify a key role for CN and p38 in the modulation of macrophage phenotype and suggest an alternative treatment for inflammation based on redirecting macrophages toward an anti-inflammatory status.

D-dimer levels decreased in severe allergic asthma and chronic urticaria patients with the omalizumab treatment

BACKGROUND

D-dimer (DD), a fibrin degradation product formed during the lysis of a thrombus, is also detected in high levels in patients with active chronic urticaria (CU). Severe persistent allergic asthma (SPA) is associated with a procoagulant state in the bronchoalveolar space, further aggravated by impaired local activities of the anticoagulant protein C/protein S, antithrombin III system and fibrinolysis. This was demonstrated as massive fibrin depositions found in the alveoli of a SPA patient who died from a SPA attack and who did not respond to treatment.

OBJECTIVES

For this reason, we investigated the effect of omalizumab both in bronchial and systemic vascular areas and evaluated SPA (group I) and CU (group II) patients before and after therapy period.

METHODS

Blood samples were taken before treatment (A), on 4th month (B), on 8th month (C) and on 12th month (D) post treatment in both groups.

RESULTS

We compared DD levels between groups: the significant DD difference was observed between group-IA and group-IC (p = 0.031); between group-IA and group-ID (p = 0.003); between group-IB and group-ID (p = 0.049) and between group IIA-1 and group-IID (p = 0.015). In the IIA-1 group, there was a significant positive correlation between DD and age (p = 0.008, r = 0.848).

CONCLUSION

In conclusion, mediators and cells classically involved in procoagulant and anticoagulant pathways together play a role in SPA and CU pathophysiology, where omalizumab has its effect.

Critical Asthma Syndrome in the ICU

Critical asthma syndrome represents the most severe subset of asthma exacerbations, and the critical asthma syndrome is an umbrella term for life-threatening asthma, status asthmaticus, and near-fatal asthma. According to the 2007 National Asthma Education and Prevention Program guidelines, a life-threatening asthma exacerbation is marked by an inability to speak, a reduced peak expiratory flow rate of <25 % of a patient's personal best, and a failed response to frequent bronchodilator administration and intravenous steroids. Almost all critical asthma syndrome cases require emergency care, and most cases require hospitalization, often in an intensive care unit. Among asthmatics, those with the critical asthma syndrome are difficult to manage and there is little room for error. Patients with the critical asthma syndrome are prone to complications, they utilize immense resources, and they incite anxiety in many care providers. Managing this syndrome is anything but routine, and it requires attention, alacrity, and accuracy. The specific management strategies of adults with the critical asthma syndrome in the hospital with a focus on intensive care are discussed. Topics include the initial assessment for critical illness, initial ventilation management, hemodynamic issues, novel diagnostic tools and interventions, and common pitfalls. We highlight the use of critical care ultrasound, and we provide practical guidelines on how to manage deteriorating patients such as those with pneumothoraces. When standard asthma management fails, we provide experience-driven recommendations coupled with available evidence to guide the care team through advanced treatment. Though we do not discuss medications in detail, we highlight recent advances.

The critically ill asthmatic--from ICU to discharge

Status asthmaticus (SA) is defined as an acute, severe asthma exacerbation that does not respond readily to initial intensive therapy, while near-fatal asthma (NFA) refers loosely to a status asthmaticus attack that progresses to respiratory failure. The in-hospital mortality rate for all asthmatics is between 1% to 5%, but for critically ill asthmatics that require intubation the mortality rate is between 10% to 25% primarily from anoxia and cardiopulmonary arrest. Timely evaluation and treatment in the clinic, emergency room, or ultimately the intensive care unit (ICU) can prevent the morbidity and mortality associated with respiratory failure. Fatal asthma occurs from cardiopulmonary arrest, cerebral anoxia, or a complication of treatments, e.g., barotraumas, and ventilator-associated pneumonia. Mortality is highest in African-Americans, Puerto Rican-Americans, Cuban-Americans, women, and persons aged ≥ 65 years. Critical care physicians or intensivists must be skilled in managing the critically ill asthmatics with respiratory failure and knowledgeable about the few but potentially serious complications associated with mechanical ventilation. Bronchodilator and anti-inflammatory medications remain the standard therapies for managing SA and NFA patients in the ICU. NFA patients on mechanical ventilation require modes that allow for prolonged expiratory time and reverse the dynamic hyperinflation associated with the attack. Several adjuncts to mechanical ventilation, including heliox, general anesthesia, and extra-corporeal carbon dioxide removal, can be used as life-saving measures in extreme cases. Coordination of discharge and follow-up care can safely reduce the length of hospital stay and prevent future attacks of status asthmaticus.

Current treatment of severe asthma

Severe asthma is considered a heterogeneous disease in which a variety of clinical, physiological and inflammatory markers determine disease severity. Pivotal studies in the last 5 years have led to substantial progress in many areas, ranging from a more accurate definition of truly severe, refractory asthma, to classification of the disease into distinct clinical phenotypes, and introduction of new therapies. This review focuses on three common clinical phenotypes of severe asthma in adults (early onset severe allergic asthma, late onset non-atopic eosinophilic asthma, late onset non-eosinophilic asthma with obesity), and provides an overview of recent developments regarding treatment options that are best suited for each of these phenotypes.

Asthma and coagulation

Asthma is a chronic airway disease characterized by paroxysmal airflow obstruction evoked by irritative stimuli on a background of allergic lung inflammation. Currently, there is no cure for asthma, only symptomatic treatment. In recent years, our understanding of the involvement of coagulation and anticoagulant pathways, the fibrinolytic system, and platelets in the pathophysiology of asthma has increased considerably. Asthma is associated with a procoagulant state in the bronchoalveolar space, further aggravated by impaired local activities of the anticoagulant protein C system and fibrinolysis. Protease-activated receptors have been implicated as the molecular link between coagulation and allergic inflammation in asthma. This review summarizes current knowledge of the impact of the disturbed hemostatic balance in the lungs on asthma severity and manifestations and identifies new possible targets for asthma treatment.

A potential nanomedicine consisting of heparin-loaded polysaccharide nanocarriers for the treatment of asthma

A new nanomedicine consisting of chitosan/carboxymethyl-β-cyclodextrin loaded with unfractioned or low-molecular-weight heparin is described and its potential in asthma treatment is evaluated. The nanoparticles are prepared by ionotropic gelation showing a size that between 221 and 729 nm with a positive zeta potential. The drug association efficiency is higher than 70%. Developed nanosystems are stable in Hank's balanced salt solution at pH = 6.4, releasing the drug slowly. Ex vivo assays show that nanocarriers lead to an improvement of heparin preventing mast cell degranulation. These results agree with the effective cellular internalization of the fluorescently labeled nanocarriers, and suggest these nanomedicines as promising formulations for asthma treatment.

Medication Repurposing: New Uses for Old Drugs

Background:

Medication repurposing, the practice of using old drugs in new ways, is becoming more common. Old drugs that had previously fallen out of favor due to safety concerns, lack of efficacy, or development of more desirable therapeutic alternatives have been resurfacing in the literature and on pharmacy shelves. Developing new uses for old drugs may provide patients with access to helpful therapies but may also present challenges and risks.

Objective:

To explore the rationale for, and historical context of, the developing trend of recycling existing drugs for new, innovative uses, and to provide pharmacy practitioners with information about how to find clinical evidence regarding these new uses.

Data Synthesis:

The process of obtaining marketing approval for new drugs can take an average of over 10 years and exceed $1 billion. Repurposing old drugs (both approved and unapproved) for new uses requires considerably fewer resources since information about production needs, pharmacology, and pharmacokinetics is already known. Other advantages of using old drugs include faster availability for patient use and known safety concerns for the original indication. Disadvantages of new uses for old drugs may include lack of clinical evidence, unknown safety for the new clinical context, limited availability of information about new uses, and liability or legal concerns. Several methods of identifying potential new uses exist, including the observance of previously unknown desirable pharmacologic effects during clinical use, new knowledge of a mechanism of action leading to exploration of innovative therapeutic areas, or screening compound libraries for targeted clinical activity.

Conclusions:

There are many examples of recycling existing medications for new purposes. Pharmacy practitioners should be aware of this developing trend and know how to find information about utilizing old drugs in new ways.

Dexamethasone and FK506 inhibit expression of distinct subsets of chemokines in human mast cells

Mast cells produce a large amount of several chemokines after cross-linking of FcepsilonRI and participate in the pathogenesis of allergic diseases. The objective of this study was to comprehensively investigate FcepsilonRI-mediated chemokine induction in human mast cells and the effect of a corticosteroid (dexamethasone) and a calcineurin inhibitor (FK506). Human peripheral blood-derived mast cells were stimulated with anti-IgE Ab in the presence of dexamethasone or FK506. Gene expression profiles were evaluated using GeneChip and confirmed by real-time PCR, and chemokine concentrations were measured by cytometric bead arrays and ELISA. Expression of eight chemokines was significantly induced in mast cells by anti-IgE stimulation. Induction of CCL2, CCL7, CXCL3, and CXCL8 by anti-IgE was significantly inhibited by dexamethasone but was enhanced by FK506. In contrast, induction of CCL1, CCL3, CCL4, and CCL18 was significantly inhibited by FK506 but, with the exception of CCL1, was enhanced by dexamethasone. Combination of dexamethasone and FK506 suppressed production of all chemokines by anti-IgE stimulation. Studies using protease inhibitors indicate that mast cell proteases may degrade several of the chemokines. These results suggest that corticosteroids and calcineurin inhibitors inhibit expression of distinct subsets of chemokines, and a combination of these drugs almost completely suppresses the induction of all chemokine genes in human mast cells in response to FcepsilonRI-dependent stimulation. This implies that a combination of a corticosteroid and a calcineurin inhibitor may be more effective than each single agent for the treatment of allergic diseases in which mast cell-derived chemokines play a major role.

Chitosan-hyaluronic acid nanoparticles loaded with heparin for the treatment of asthma

The purpose of this study was to produce mucoadhesive nanocarriers made from chitosan (CS) and hyaluronic acid (HA), and containing the macromolecular drug heparin, suitable for pulmonary delivery. For the first time, this drug was tested in ex vivo experiments performed in mast cells, in order to investigate the potential of the heparin-loaded nanocarriers in antiasthmatic therapy. CS and mixtures of HA with unfractionated or low-molecular-weight heparin (UFH and LMWH, respectively) were combined to form nanoparticles by the ionotropic gelation technique. The resulting nanoparticles loaded with UFH were between 162 and 217 nm in size, and those prepared with LMWH were 152 nm. The zeta potential of the nanoparticle formulations ranged from +28.1 to +34.6 mV, and in selected nanosystems both types of heparin were associated with a high degree of efficiency, which was approximately 70%. The nanosystems were stable in phosphate buffered saline (PBS), pH 7.4, for at least 24h, and released 10.8% of UFH and 79.7% of LMWH within 12h of incubation. Confocal microscopy experiments showed that fluorescent heparin-loaded CS-HA nanoparticles were effectively internalized by rat mast cells. Ex vivo experiments aimed at evaluating the capacity of heparin to prevent histamine release in rat mast cells indicated that the free or encapsulated drug exhibited the same dose-response behaviour.

[Treatment of an asthmatic patient on dialysis and awaiting transplantation with anti-IgE]

INTRODUCTION

Omalizumab, a monoclonal antibody to IgE, is a possible treatment for severe, uncontrolled allergic asthma.

CASE REPORT

A severe asthmatic patient with renal insufficiency and on dialysis was awaiting transplantation. The asthma was uncontrolled with poor respiratory function. He received anti IgE treatment with omazilumab with immediate clinical improvement and his renal transplant was performed satisfactorily.

CONCLUSION

Anti-IgE treatment can improve severe, uncontrolled allergic asthmatic patients allowing, in this case, transplantation without further respiratory problems.

Cyclosporin A inhibits CD11a/CD18 adhesion molecules due to inhibition of TNFalpha and IL-1 beta levels in the mouse model of pleurisy induced by carrageenan

The mouse model of pleurisy induced by carrageenan is characterized by a significant enhancement of cell migration due to neutrophils 4 h after pleurisy induction. Forty-eight hours after pleurisy induction, a significant increase in cell migration due to mononuclear cells occurs. Recently, studies in our laboratory have demonstrated that cyclosporine A (CsA) inhibits leukocyte migration in the pleural cavity and lungs in the mouse model of pleurisy induced by carrageenan. In the present work we evaluated whether CsA was able to downregulate CD11a/CD18 adhesion molecule in the lungs, as well as TNFalpha and IL-1 beta levels in the fluid leakage of the pleural cavity in this model. Our results showed that CsA significantly decreased CD11a/CD18 in the lungs, as well as TNFalpha and IL-1 beta levels in the fluid leakage of the pleural cavity 4 h and 48 h after pleurisy induction. It is our hypothesis that the inhibitory effect elicited by CsA upon these adhesion molecules may be also be attributed to the downregulation of TNFalpha and IL-1 beta cytokines.

Targeting airway inflammation in asthma: current and future therapies

Asthma is a chronic inflammatory disease of the airway that requires long-term antiinflammatory therapy. Inhaled corticosteroids (ICSs) are recommended for first-line treatment of persistent disease, but not all patients achieve asthma control even when these agents are used in high doses and in combination with other medications, including a long-acting beta(2)-agonist or a leukotriene modifier. Such patients may require additional therapy. As information about asthma pathophysiology and inflammatory phenotypes continues to increase, and additional antiinflammatory options become available, it may be possible to target antiinflammatory therapy to various aspects of the disease and consequently to improve the treatment of patients with inadequate responses to standard ICS-based therapy. Several novel antiinflammatory therapies are in different stages of clinical development. The most clinically advanced of these is omalizumab, a recombinant humanized monoclonal antibody that specifically targets IgE and is indicated for patients with moderate-to-severe asthma caused by allergies. Omalizumab has demonstrated efficacy in patients with moderate-to-severe asthma and documented evidence of allergen sensitivity. Other key therapy options in clinical development either target proinflammatory cytokines (eg, interleukin-4 and tumor necrosis factor-alpha) or inflammatory cells (eg, T-helper type 2 cells and eosinophils). This review provides an overview of the current and future approaches targeting airway inflammation in patients with asthma.

Mycophenolate mofetil and triptolide alleviating airway inflammation in asthmatic model mice partly by inhibiting bone marrow eosinophilopoiesis

The bone marrow eosinophilopoiesis makes a major contribution to the chronic airway inflammation in asthmatic animals and patients. Some anti-asthmatic medicines alleviated the asthmatic airway inflammation by inhibiting the bone marrow eosinophilopoiesis. Immunosuppressive agents have been commonly used in patients with glucocorticoid refractory asthma and have been proved to be effective. However, the research on the effect of the immunosuppressive agents on the bone marrow eosinophilopoiesis has seldom been reported. The purpose of the study was to explore the effect of mycophenolate mofetil (MMF) and triptolide (TP) on the bone marrow eosinophilopoiesis and to further investigate the mechanisms of the immunosuppressive agents involved in the anti-asthmatic effect. Balb/c mice were sensitized and challenged by OVA to establish the asthmatic model, and respectively administered orally with sterile saline, MMF, and TP once daily for 2 weeks. Airway inflammation, and inflammatory mediators IL-5 and eotaxin in the peripheral blood and bone marrow were measured by histology and ELISA. Immunocytochemistry combined with in situ hybridization technique and Western blot analysis was performed to estimate the amount of CD34+ IL-5R mRNA+ cells and IL-5R expression in the bone marrow. The count of new produced eosinophils in the bone marrow was detected by anti-BrdU immunocytochemistry. We found that MMF and TP attenuated OVA-induced eosinophil (EOS) recruitment in bronchoalveolar lavage fluid (BALF), inflammatory mediator expression of IL-5 and eotaxin in the peripheral blood, inflammatory cells expressing eotaxin in the lung tissues and the number of new produced EOS in the bone marrow. Also, MMF abated the migration of CD34+ cells from the bone marrow to the peripheral blood, which was associated with a decreased eotaxin expression in the bone marrow and a decreased CCR3 expression on bone marrow cells. While, MMF or TP failed to decrease the amount of CD34+ IL-5R mRNA+ cells (EOS progenitors), and IL-5R expression in the bone marrow of asthmatic model mice. These results demonstrated that MMF and TP reduce the eosinophilopoiesis of the bone marrow; this is associated with a decrease of IL-5 produced by T cells, which contribute to alleviate the allergic airway inflammation in asthma. In addition, MMF decreased the CD34+ cells migration from the bone marrow to the peripheral blood by the reduction of the level of eotaxin in the bone marrow and the expression of CCR3 on the bone marrow cells.

Omalizumab (Xolair) in patients with steroid-resistant asthma: lessons to be learnt

Very severe asthma and local pulmonary steroid resistance causes major problems for patients, physicians and the health system at large. It usually results in multiple admissions to hospital and high morbidity. Omalizumab was used to treat such patients with success. However, in doing so, it raised a number of issues relating to the best methods of using this treatment in such patients.

Role of macrolide therapy in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability worldwide. The Global Burden of Disease study has concluded that COPD will become the third leading cause of death worldwide by 2020, and will increase its ranking of disability-adjusted life years lost from 12th to 5th. Acute exacerbations of COPD (AECOPD) are associated with impaired quality of life and pulmonary function. More frequent or severe AECOPDs have been associated with especially markedly impaired quality of life and a greater longitudinal loss of pulmonary function. COPD and AECOPDs are characterized by an augmented inflammatory response. Macrolide antibiotics are macrocyclical lactones that provide adequate coverage for the most frequently identified pathogens in AECOPD and have been generally included in published guidelines for AECOPD management. In addition, they exert broad-ranging, immunomodulatory effects both in vitro and in vivo, as well as diverse actions that suppress microbial virulence factors. Macrolide antibiotics have been used to successfully treat a number of chronic, inflammatory lung disorders including diffuse panbronchiolitis, asthma, noncystic fibrosis associated bronchiectasis, and cystic fibrosis. Data in COPD patients have been limited and contradictory but the majority hint to a potential clinical and biological effect. Additional, prospective, controlled data are required to define any potential treatment effect, the nature of this effect, and the role of bronchiectasis, baseline colonization, and other cormorbidities.

Immunomodulatory effects of macrolide antibiotics in respiratory disease: therapeutic implications for asthma and cystic fibrosis

The macrolide antibiotics are a family of related 14- or 15-membered lactone ring antibiotics. There has been recent interest in the beneficial effects of these drugs as immune modulators in respiratory conditions in children. Cystic fibrosis (CF) and asthma, both of which occur in childhood, have an underlying inflammatory component and are associated with significant morbidity. The pathogenesis of both conditions is poorly understood but several molecular mechanisms have been suggested. In CF, these mechanisms broadly involve altered chloride transport and alteration of the airway surface liquid with disordered neutrophilic inflammation. There is much evidence for a proinflammatory propensity in CF immune effector and epithelial cells and many studies indicate that macrolides modulate these inflammatory processes. Recent studies have confirmed a clinical improvement in CF following treatment with macrolides, but the exact mechanisms by which they work are unknown. Asthma is likely to represent several different phenotypes but in all of these, airway obstruction, bronchial hyperresponsiveness, and inflammation are central processes. Results from trials using macrolides have suggested an improvement in clinical outcome. The putative mechanisms of macrolide immunomodulatory action include improvement of the primary defense mechanisms, inhibition of the bacteria-epithelial cell interaction, modulation of the signaling pathway and chemokine release, and direct neutrophil effects. Putative mechanisms of phenotypic modulation have also been proposed involving interactions with nitric oxide, endothelin-1, and bronchoconstriction, endothelial growth factors and airway remodeling, and bioactive phospholipids in both CF and asthma. Further characterization of these effects and development of targeted designer drugs will further expand our therapeutic repertoire and lead to improved quality and quantity of life for patients with CF and asthma.

Sideline management of asthma

The timely, efficient, and effective sideline management of asthma must be grounded on an understanding of the disease processes, awareness of evidence-based therapeutic intervention, and thorough knowledge of the individual athlete's medical history and current physical condition. There is accumulating evidence that exercise-induced airway narrowing, if unrecognized or inadequately treated, can progress to a severe life-threatening status and should always be viewed as a potential medical emergency. A widening range of therapeutic measures is currently available to prevent and to treat exercise asthma, and treatment must be tailored to the individual circumstances to optimize response.

The Difficult-to-Control Asthmatic: A Systematic Approach

With the judicious use of inhaled corticosteroids, beta2 agonists, and leukotriene modifiers, most patients with asthma are easily controlled and managed. However, approximately 5% of asthmatics do not respond to standard therapy and are classified as "difficult to control." 1 Typically, these are patients who complain of symptoms interfering with daily living despite long-term treatment with inhaled corticosteroids in doses up to 2,000 mug daily. Many factors can contribute to poor response to conventional therapy, and especially for these patients, a systematic approach is needed to identify the underlying causes. First, the diagnosis of asthma and adherence to the medication regimen should be confirmed. Next, potential persisting exacerbating triggers need to be identified and addressed. Concomitant disorders should be discovered and treated. Lastly, the impact and implications of socioeconomic and psychological factors on disease control can be significant and should be acknowledged and discussed with the individual patient. Less conventional and novel strategies for treating corticosteroid-resistant asthma do exist. However, their use is based on small studies that do not meet evidence-based criteria; therefore, it is essential to sort through and address the above issues before reverting to other therapy.

Sideline management of asthma

The timely, efficient, and effective sideline management of asthma must be based on an understanding of the disease processes, awareness of evidence-based therapeutic intervention, and thorough knowledge of the individual athlete's past and present medical history. There is accumulating evidence that exercise-induced airway narrowing, if unrecognized or inadequately treated, can progress to a severe life-threatening status and should always be viewed as a potential medical emergency. A widening range of therapeutic measures is currently available to prevent and treat exercise asthma, and treatment must be tailored to the individual circumstances in order to optimize response.

Revisiting asthma control: how should it best be defined?

Management guidelines for asthma emphasize a stepwise approach in treating this disease based on daytime symptoms, nighttime symptoms, and lung function assessed by peak expiratory flow or forced expiratory volume at 1s (FEV(1)). Although improvement of lung function is a key goal in managing asthma, clinicians often see patients who may have achieved a normal FEV(1) with guideline-recommended treatment but continue to experience limitations in their daily activities. In such situations, focusing the assessment solely on pulmonary function (e.g. FEV(1)) is often inadequate and may lead to undertreatment. Alternate assessment measures are therefore often needed to assess asthma control and achieve a successful treatment outcome. This review will provide practical guidance relevant to the clinical assessment of asthma control.

Topical furosemide versus oral steroid in preoperative management of nasal polyposis

The efficacy of topical nasal furosemide treatment has been shown in the protection of nasal polyp recurrence. The aim of the study was to compare the effect of oral steroid, as standard preoperative treatment, and inhaled furosemide, as alternative treatment, for 7 days preoperatively in terms of subjective improvement of nasal symptoms, polyp size reduction, inflammation in the polyp tissue, and intraoperative blood loss. A group of 40 patients with nasal polyposis entered the study and they were randomly allocated to 7-day preoperative treatment with either oral methylprednisolon (1 mg/kg/day) or topical furosemide by inhalation (6.6 mmol/l solution). Subjective scores of rhinosinusitis symptoms, polyp scores at endoscopy, and biopsy of the most superficial polyp were taken at inclusion. All procedures were repeated on day 7. Intraoperative blood loss was estimated (scores 0-10) by the surgeon at the operation. Eosinophils, mastocytes, and oedema were quantified by histomorphometry. Subjective symptoms and endoscopy scores did not differ significantly between the groups after the treatment although improvement of olfaction was insignificantly better in the steroid group. Steroid treatment significantly reduced eosinophil count, with no effect on mastocytes and oedema. Furosemide treatment did not affect inflammatory cells count significantly, but it has significantly reduced oedema in previously unoperated patients. No difference in intraoperative bleeding was observed between the groups.

Return to play following exercise-induced bronchoconstriction

OBJECTIVE

To review evidence-based support for return to play criteria following acute exercise-induced bronchoconstriction.

DATA SOURCES

Electronic databases Ovid Medline and PubMed were searched for papers relating to exercise related asthma and bronchoconstriction and return to play criteria. Additional references from the bibliographies of retrieved articles were also reviewed.

DATA SYNTHESIS

There is clear evidence that exercise-induced airways narrowing is increasing in prevalence among athletes from school children to Olympians to professionals, yet there have been no studies specifically addressing return to play criteria. Although deaths from exercise associated bronchoconstriction were previously thought to be rare, recent reports of such deaths call for increased awareness by physicians, athletic trainers, and coaches of the potential fatal consequences of unrecognized episodes or of inadequate treatment.

CONCLUSIONS

No agreed-upon protocol for safe return to play following an acute episode of exercise induced bronchoconstriction has been published. A specific detailed protocol for return to play would assist physicians and other heath professionals to determine with greater confidence that an athlete is fully recovered and can safely return to play.

Suppression of Ca2+ influx by unfractionated heparin in non-excitable intact cells via multiple mechanisms

Effect of unfractionated heparin (UFH), described as a cell-impermeant IP3 receptor antagonist, was studied on the capacitive Ca(2+) entry in non-permeabilized, intact cells, measuring the intracellular Ca(2+) levels using fluorescence microplate technique. Ca(2+) influx induced via Ca(2+) mobilization by histamine in Hela cells or evoked by store depletion with thapsigargin in RBL-2H3 cells was dose-dependently suppressed by UFH added either before or after the stimuli. UFH also prevented the spontaneous Ba(2+) entry indicating that the non-capacitive Ca(2+) channels may also be affected. In addition, UFH caused a significant and dose-dependent delay in Ca(2+), and other bivalent cation inflow after treatment of the cells with Triton X-100, but it did not diminish the amount of these cations indicating that UFH did not act simply as a cation chelator, but modulated the capacitive Ca(2+) entry possibly via store operated Ca(2+) channels (SOCCs). Inhibitory activities of UFH and 2-aminoethyl diphenyl borate on the capacitive Ca(2+) influx was found reversible, but the time courses of their actions were dissimilar suggesting distinct modes of action. It was also demonstrated using a fluorescence potentiometric dye that UFH had a considerable hyperpolarizing effect and could alter the changes of membrane potential during Ca(2+) influx after store depletion by thapsigargin. We presume that the hyperpolarizing property of this agent might contribute to the suppression of Ca(2+) influx. We concluded that UFH can negatively modulate SOCCs and also other non-capacitive Ca(2+) channels and these activities might also account for its multiple biological effects.