The right tools at the right time

STAT6 inhibitory peptide reduces dendritic cell migration to the lymph nodes to control Th2 adaptive immunity in the mouse lung

Type 2 immunity in the lung is promoted through the release of innate cytokines, including TSLP, from lung structural cells. These cytokines drive Type 2 immunity in part through upregulation of OX40L on dendritic cells (DCs). DCs expressing OX40L are potent inducers of Th2 differentiation. We have shown previously that STAT6 inhibitory peptide (STAT6-IP), a cell penetrating peptide designed to inhibit the STAT6 transcription factor, reduces the induction of Th2 adaptive immunity in murine models of respiratory syncytial virus infection. Here we show that intranasal administration of STAT6-IP at the time of antigen priming with ovalbumin (OVA), in conjunction with the Nod2 agonist, MDP, reduced frequencies of CD11b⁺ lung DCs expressing OX40L. Consistent with these reductions, fewer activated DCs were localized to the lung draining lymph nodes in STAT6-IP-treated mice. Upon OVA challenge four weeks later, mice treated with STAT6-IP at the time of OVA/MDP priming did not develop airway hyperresponsiveness (AHR) and had reduced influx of eosinophils into the airways, mucus production, and serum OVA-specific IgE levels. Our findings provide evidence that the long-lasting inhibitory effects of STAT6-IP are due in part to inhibition of DC responses that drive maladaptive Th2 adaptive immunity and allergic airways disease.

A systematic review of predictive models for asthma development in children

BACKGROUND

Asthma is the most common pediatric chronic disease affecting 9.6 % of American children. Delay in asthma diagnosis is prevalent, resulting in suboptimal asthma management. To help avoid delay in asthma diagnosis and advance asthma prevention research, researchers have proposed various models to predict asthma development in children. This paper reviews these models.

METHODS

A systematic review was conducted through searching in PubMed, EMBASE, CINAHL, Scopus, the Cochrane Library, the ACM Digital Library, IEEE Xplore, and OpenGrey up to June 3, 2015. The literature on predictive models for asthma development in children was retrieved, with search results limited to human subjects and children (birth to 18 years). Two independent reviewers screened the literature, performed data extraction, and assessed article quality.

RESULTS

The literature search returned 13,101 references in total. After manual review, 32 of these references were determined to be relevant and are discussed in the paper. We identify several limitations of existing predictive models for asthma development in children, and provide preliminary thoughts on how to address these limitations.

CONCLUSIONS

Existing predictive models for asthma development in children have inadequate accuracy. Efforts to improve these models' performance are needed, but are limited by a lack of a gold standard for asthma development in children.

MLBCD: a machine learning tool for big clinical data

Background

Predictive modeling is fundamental for extracting value from large clinical data sets, or “big clinical data,” advancing clinical research, and improving healthcare. Machine learning is a powerful approach to predictive modeling. Two factors make machine learning challenging for healthcare researchers. First, before training a machine learning model, the values of one or more model parameters called hyper-parameters must typically be specified. Due to their inexperience with machine learning, it is hard for healthcare researchers to choose an appropriate algorithm and hyper-parameter values. Second, many clinical data are stored in a special format. These data must be iteratively transformed into the relational table format before conducting predictive modeling. This transformation is time-consuming and requires computing expertise.

Methods

This paper presents our vision for and design of MLBCD (Machine Learning for Big Clinical Data), a new software system aiming to address these challenges and facilitate building machine learning predictive models using big clinical data.

Results

The paper describes MLBCD’s design in detail.

Conclusions

By making machine learning accessible to healthcare researchers, MLBCD will open the use of big clinical data and increase the ability to foster biomedical discovery and improve care.

[Montelukast in the treatment of mild to moderate persistent asthma]

INTRODUCTION

Anti-inflammatory preventive treatment is recommended in cases of persistent asthma. Besides inhaled corticosteroids (ICS), which represent the mainstay of treatment, other therapeutic options are available, of which only antileukotrienes are approved for all age groups.

BACKGROUND

Given as a substitute of low-dose ICS, montelukast prevents exacerbations as efficiently and for a longer period than long-acting β2-agonists. Montelukast is as efficient as doubling the dose of ICS on asthma symptoms in cases of inadequate control with low-dose ICS. Combined with ICS, it can lead to better control of asthma and potentially to ICS sparing.

CONCLUSIONS

Given the efficacy, tolerance and long-term treatment compliance of montelukast in mild persistent asthma in adults and children, montelukast, given as a substitute or combined with ICS, could contribute to enhanced control of asthma, especially in children.

Improving the differential diagnosis of chronic obstructive pulmonary disease in primary care

Chronic obstructive pulmonary disease (COPD) and asthma represent a substantial portion of primary care practice. In adults, differentiating asthma from COPD can be difficult but is important because of the marked differences in treatment, disease progression, and outcomes between the 2 conditions. Currently, clinical COPD is often misdiagnosed or undiagnosed until late in the disease. Earlier diagnosis could markedly reduce morbidity and improve quality of life. Establishing a diagnosis of COPD requires spirometry testing, interpreted in the context of the patient's symptoms, smoking status, age, and comorbidities. Additional tests and tools may be helpful in the differential diagnosis, including questionnaires specifically developed to discriminate between COPD and asthma and, in special cases, imaging studies. Follow-up and monitoring of asthma and COPD are always necessary and provide additional benefit in patients in whom only continued care and reassessment can confirm the final diagnosis, such as younger individuals with fixed airway obstruction, smokers with asthma, and patients with both disorders. Key areas for improvement include enhanced case identification, improved quality and interpretation of findings on spirometry, and increased use of tools such as differential diagnosis questionnaires and algorithms to guide the diagnostic and monitoring process. To achieve optimal outcomes, the primary care team should make every effort to establish a firm diagnosis. For this review, we conducted a PubMed search with no time limits using the Medical Subject Headings chronic obstructive pulmonary disease or COPD and asthma, in association with the following search terms: diagnosis, differential diagnosis, mixed or comorbid disease, diagnostic techniques, spirometry, questionnaires, and primary care.

Ciclesonide and the treatment of asthma

IMPORTANCE OF THE FIELD

Asthma is a chronic disease characterized by airway inflammation and hyper-responsiveness. Inhaled corticosteroids (ICSs) constitute the guideline-recommended first-line therapy for persistent asthma. However, concerns regarding ICS-related adverse events may contribute to their underutilization by physicians and patients.

AREAS COVERED IN THIS REVIEW

The currently available published data on the pharmacokinetic and pharmacodynamic properties, safety and efficacy of the ICS, ciclesonide, is described. Peer-reviewed publications (1996 - 2009) on the pharmacodynamic and pharmacokinetic profile, safety and efficacy of ciclesonide were reviewed.

WHAT THE READER WILL GAIN

Ciclesonide is delivered as an inactive prodrug, which is cleaved to the active molecule by intracellular esterases located in the lungs. This and other pharmacodynamic and pharmacokinetic properties may limit the amount of active molecule outside the lung and may reduce the incidence of side effects. Randomized placebo-controlled studies found that ciclesonide can initiate and maintain disease control in subjects with persistent asthma of all disease severities. Moreover, studies have found that ciclesonide is as effective as other ICSs in establishing and controlling disease symptoms. Controlled clinical trials also showed that ciclesonide is associated with minimal systemic and local treatment-related adverse events.

TAKE HOME MESSAGE

Published findings indicate that ciclesonide is effective at initiating and maintaining asthma control and is well tolerated, with a positive safety profile.

Efficacy, safety, and tolerability of mometasone furoate in adult Japanese patients with mild asthma: open-label clinical trial findings

OBJECTIVE

To evaluate the clinical efficacy and safety of mometasone furoate administered via a dry powder inhaler (MF-DPI) in Japanese patients with intermittent or mild persistent asthma who were not previously receiving inhaled corticosteroids.

RESEARCH DESIGN AND METHODS

This was an 8-week open-label study conducted in Japanese patients > or =16 years of age with intermittent or mild persistent asthma. All patients provided informed written consent before baseline and were treated with MF-DPI 200 microg/day, taken as 100 microg twice daily (BID). Inhaled steroids other than the study drug are not used, the drugs used previously are continued, dose of concomitant drug may be reduced if symptoms are improved and no new drugs were allowed during the trial. The primary efficacy variable was the change from baseline in morning peak expiratory flow (AM PEF). Secondary efficacy variables were evening (PM) PEF, spirometric measurements of lung function, and subjective symptoms. Descriptive statistics and standard errors were calculated for each efficacy evaluation. The safety of MF-DPI treatment was evaluated by measuring adverse events (AEs) and laboratory tests.

RESULTS

Twenty patients received MF-DPI, and 19 patients (nine with intermittent asthma and 10 with mild persistent asthma) were included in the full analysis set (FAS). The mean AM PEF and PM PEF values increased by 9.1% (P < 0.0001) and 7.3% (P < 0.0001), respectively, in the FAS. Improvements in AM and PM PEF occurred as early as week 1 and were sustained throughout treatment. Improvements at week 8 in forced expiratory volume in 1 second and forced vital capacity were 11.0% and 8.2%, respectively. Notable decreases occurred for subjective symptom scores. The reported AEs were mild to moderate in severity. Study limitations include the small sample size and open-label treatment. This study was planned as the first study of MF-DPI in Japanese mild asthma patients without receiving other inhaled steroids. In addition, the cost:benefit ratio of MF-DPI in patients with intermittent asthma was not addressed.

CONCLUSION

MF-DPI 100 microg BID is an effective treatment for Japanese patients with intermittent or mild persistent asthma.

History of guidelines for the diagnosis and management of asthma: from opinion to control

The Global Initiative on Asthma (GINA) was launched in 1993 in collaboration with the National Heart, Lung, and Blood Institute, the National Institutes of Health (USA) and the WHO. Its first effort was the production of a consensus report on asthma treatment, which aimed to bridge the gap between the various treatment options and the incorporation and implementation of innovative treatment forms into daily clinical practice. The first report published in 1995, A Global Strategy for Asthma Management and Prevention, has been translated into several languages, widely adopted and provided the foundation for several asthma guidelines worldwide. The GINA and other guidelines were primarily based on consensus of expert opinion in order to employ a severity-based classification system as a guide to treatment. However, in the late 1990s, guidelines underwent a major paradigm shift from opinion- to evidence-based classification as the foundation for asthma management. A second major shift involved the classification of asthma according to the level of disease control as a guide to treatment, which was realized for the first time in the revised 2006 GINA guidelines. Since their first appearance, asthma guidelines have played a leading role in disseminating information about asthma. In addition, they have had a substantial impact on standardizing asthma care around the world, which is likely to continue in the future. This article addresses the history of guideline development and issues related to asthma guidelines, with particular emphasis on the GINA guidelines.