Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy

Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.

Intranasal Fluticasone Once Daily Compared with Once-Daily Cetirizine in the Treatment of Seasonal Allergic Rhinitis : Results of a Multicentre, Double-Blind Study

The efficacy and tolerability of fluticasone aqueous nasal spray, 200µg once daily for 21 days, was compared with cetirizine, 10mg once daily for 21 days, in a multicentre, randomised, double-blind, double-dummy, parallel group study. 237 evaluable patients aged 12 years and above, with seasonal allergic rhinitis (defined as having a positive skin test and a total symptom score of ≥ 6/15), received either fluticasone aqueous nasal spray (n = 119) or cetirizine (n = 118). Improvement in total symptom score was observed in patients from both treatment groups, with the improvement in the fluticasone treatment group being significantly greater (decrease in total symptom score from 9.23 to 2.13) than in the cetirizine treatment group (decrease in total symptom score from 9.36 to 4.31; p < 0.001). There was also a significantly greater improvement in the number of symptom-free days for all symptoms in favour of fluticasone aqueous nasal spray compared with cetirizine (p < 0.001). Furthermore, the percentage of days when patients did not require terfenadine as rescue therapy was significantly greater in the fluticasone group (87%) than in the cetirizine group (80%; p < 0.05). Five adverse events were reported during intranasal fluticasone treatment and 10 adverse events were reported during cetirizine therapy. There were no treatment-related withdrawals from therapy in the fluticasone group, but 5 treatment-related withdrawals were reported in the cetirizine group.This study demonstrated that fluticasone aqueous nasal spray, 200µg once daily, was significantly more effective than cetirizine, 10mg once daily, and had comparable (if not better) tolerability, in the treatment of seasonal allergic rhinitis.

Variable content of Fel d 1 variants in house dust and cat extracts may have an impact on allergen measurement

BACKGROUND

The major cat allergen, Fel d 1, is a tetrameric glycoprotein composed of 2 heterodimers. Polymorphisms in this allergen are well documented. Recent work shows that Fel d 1 samples can contain core fragments of variable immunoreactivity.

OBJECTIVES

Our objective was to compare Fel d 1 polymorphism in cat extracts and house dust, which is used as an indicator of allergen exposure and to understand how the combination of individual Fel d 1 variants can affect cat allergen measurement.

METHODS

Natural Fel d 1 allergens were water-extracted from house dust and from the chest area and anal sacs of a cat. Recombinant Fel d 1 was provided commercially. The samples were analyzed by immunoblotting; variants were isolated using gel electrophoresis and tested using enzyme-linked immunosorbent assay.

RESULTS

Four Fel d 1 variants of 40, 30, 19-21, and 14-16 kDa were consistently identified in Fel d 1 samples. Fel d 1 patterns found in house dust and the chest area wash were similar. Dimers were shown to be the major variant, while intact or truncated tetramers and core fragments were found in variable amounts. Intact and truncated dimers of Fel d 1 displayed similar antibody binding. Conversely, the intact tetramer-but not the core tetramer-was found to bind twice the antibody amount as the dimers and core fragments.

CONCLUSIONS

Despite a common pattern of Fel d 1 variants in cat extracts and house dust, variations in the tetramer-to-dimer ratio among samples may introduce major discordances in cat allergen measurements using immunoassays. Our findings indicate the need for further harmonization of allergen immunoassays.

Histamine induces Th2 activation through the histamine receptor 1 in house dust mite rhinitic but not asthmatic patients

BACKGROUND

Effects of mast cell-released histamine on smooth muscle and endothelial cells are considered as responsible of immediate symptoms of anaphylaxis. However, little is known about histamine effects on Th2 lymphocytes, which orchestrate the allergic reaction upstream of mast cells.

OBJECTIVE

We addressed this question in house dust mite (HDM) allergics, according to the presence of rhinitis or asthma and allergen stimulation.

METHODS

Peripheral blood mononuclear cell from 15 rhinitic and 14 asthmatic HDM-allergic subjects and 16 controls were cultured with Der p 1 or histamine. The effect of Der p 1 on histamine receptor (H1R and H2R) expression was studied. T-cell cytokine production was studied upon Der p 1 or histamine stimulation. The role of H1R in histamine effects was assessed with levocetirizine.

RESULTS

H1R and H2R are overexpressed on T cells from asthmatic but not from rhinitic subjects. Der p 1 increases H1R expression on CD4(+) cells from both allergic groups, and decreases it in controls, on CD4(+) and CD8(+) subsets. Der p 1 decreases T-cell H2R expression in asthmatics. Allergen increases IL-4 and IL-13 in both allergic groups. Histamine increases Th2 cytokines in rhinitics only, and levocetirizine abolishes this effect. In asthmatics and controls, histamine decreases T-cell cytokines through a non-H1R dependent pathway.

CONCLUSION

In rhinitis but not in asthma, histamine is able to increase allergic inflammation by increasing Th2 cytokine production in a positive feedback dependent on H1R. This result could explain in part why H1R antagonists, are very efficient in rhinitis, but not in asthma.

17q21 variants modify the association between early respiratory infections and asthma

Single nucleotide polymorphisms (SNPs) at chromosome 17q21 confer an increased risk of early-onset asthma. The objective was to study whether 17q21 SNPs modify associations between early respiratory infections and asthma. Association analysis was conducted in 499 children (268 with asthma, median age 11 yrs) from the Epidemiological Study on the Genetics and Environment of Asthma (EGEA). The 12-yr follow-up data were used to assess persistent or remittent asthma in young adulthood. Respiratory infection before 2 yrs of age was assessed retrospectively. For the 12 17q21 SNPs studied, the odds ratios (OR) for association between infection and early-onset asthma (age at onset <or=4 yrs) were higher in carriers of risk genotypes (OR 3.42-6.36) than in noncarriers (OR 1.84-2.44; p-value for interaction 0.02-0.04 for five SNPs). Risk genotypes also increased the association between infection and childhood asthma that remits in adulthood (OR 4.84-7.16 in carriers and 1.74-2.25 in noncarriers; p-value for interaction 0.008-0.05 for 10 SNPs). In children with 17q21 risk genotypes and early-life environmental tobacco smoke (ETS) exposure, associations between infection and asthma were further enhanced. 17q21 genetic variants and early ETS exposure enhance the association between early respiratory infections and early-onset asthma and childhood asthma that remits in adulthood.

T-cell activation during exacerbations: a longitudinal study in refractory asthma

BACKGROUND

Asthma exacerbations represent the main source of costs and morbidity in asthma care, and drugs specifically designed to prevent exacerbations are needed. A prerequisite is to dispose of a precise knowledge of inflammatory events leading to exacerbations.

OBJECTIVE

To study T-cell activation during exacerbations from severe refractory asthmatics.

METHODS

Proportions of blood T-cell interleukin (IL)-13, interferon-gamma, IL-4, IL-5, IL-10 production and of CD4+CD25+(high)CD62L+CD45RO+ [T regulatory (Treg)] cells were determined by flow cytometry. Blood cytokine mRNA was studied by reverse transcription-polymerase chain reaction and the respective protein levels were determined by cytokine beads array. Depletion of Treg cells was performed to study their activation. T-cell cytokines were detected in parallel in induced sputum.

RESULTS

At baseline, T helper 2 (Th2) cells were increased in asthmatics, whereas T helper 1 (Th1) and Treg T cells were decreased. T helper 2 cells increased before exacerbations, followed by Th1 cells, in blood and induced sputum, albeit Treg cells decreased in parallel with IL-10-producing T cells. Concordant results were found at the mRNA level. The suppressive activity of Treg cells was impaired during exacerbations compared to baseline.

CONCLUSIONS

New insights are given into pathophysiology of asthma exacerbations: Although at baseline T-cell activation is Th2-biased, a mixed Th1/Th2 activation occurs during exacerbations. The Treg cell deficiency found at baseline in SRA increases during exacerbations.

[Environmental factors for asthma severity and allergy: results from the EGEA study]

INTRODUCTION

EGEA (Epidemiological study on the genetics and environment of asthma, bronchial hyperresponsiveness and atopy), a case control and family study including 2048 individuals, was initiated to look for environmental and genetic risk factors for asthma. A synthesis of the results obtained since 2002 on phenotypic and environmental aspects of asthma severity and allergy are presented in this article.

METHODS AND RESULTS

The results support a role for hormonal factors in asthma severity and in various allergic markers of asthma. A greater body mass index was related to a more severe asthma in women with early menarche. Associations between markers of allergy (eosinophils, IgE and atopy) and hormonal dependent events in women (premenstrual asthma, menopause and oral contraceptive use) have been found. In asthmatics, exposure to agents known to be associated with occupational asthma, active and passive smoking were associated with an increased clinical asthma severity score. The study underlines the protective role of country living and exposure to pets in early life on allergy markers in adulthood, supporting the hygiene hypothesis.

CONCLUSIONS

New hypothesis will be tested in the near future from the second stage of this survey.

T-cell activation in occupational asthma and rhinitis

BACKGROUND

Allergic asthma and rhinitis are described as associated with a Th2 activation. However, recent works indicate that a Th1 activation can also be associated with these diseases, concomitantly to a defect in regulatory T (Treg) cell activation. Occupational asthma (OA) and occupational rhinitis (OR) are peculiar cases of these diseases in which the T-cell activation profile is largely unknown.

OBJECTIVE

To characterize T-cell activation induced after a specific inhalation test (SIT) in OA and OR.

MATERIAL AND METHODS

A total of 21 subjects with OA, 10 subjects with OR, 10 exposed nonallergic (ENA) subjects, and 14 healthy volunteers were included. The SIT with the incriminated substance was performed in patients and ENA subjects. Blood and induced sputum were obtained before and after SIT. T cells were analysed for CD69, CD25, IL-13, and IFN-gamma expression by flow cytometry. IL-4 and IFN-gamma were assayed by enzyme-linked immunosorbent assay (ELISA) in cell culture supernatants. Treg cells were identified as CD4(+)CD25(+high)CD45RO(+)CD69(-) T cells in peripheral blood.

RESULTS

Baseline IFN-gamma production was decreased in OA and OR compared with controls. The SIT induced an increase in both Th1 and Th2 cells in blood and sputum from OA. In this group, the proportion of peripheral Treg cells decreased after SIT. Similar results were found in the CD8(+) population. ELISA assays were concordant with flow cytometry. In OR, an attenuated activation profile was found, with an increase in the proportion of IL-13-producing T cells after SIT. By contrast, in ENA subjects, SIT induced Th2 activation, with an increase in Treg cells and a decrease in Th1 cells.

CONCLUSIONS

Our results demonstrate a gradient of T-cell activation from a tolerating profile in ENA subjects to an inflammatory profile in OA, with an intermediate stage in OR.

Safety and efficacy of Juniperus ashei sublingual-swallow ultra-rush pollen immunotherapy in cypress rhinoconjunctivitis. A double-blind, placebo-controlled study

BACKGROUND

The safety and efficacy of high-dose sublingual-swallow immunotherapy (SLIT) has been established in pollen rhinoconjunctivitis. This treatment has now been evaluated using an ultra-rush incremental dose regimen with a Juniperus ashei allergen extract in patients allergic to Cupressus sempervirens and Cupressus arizonica.

METHODS

Patients received either placebo or SLIT. Evaluation of safety was based on the frequency of adverse events during the incremental dose period (half a day) and during maintenance therapy (4 months). Evaluation of efficacy was based on symptom and medication scores at the pollen peak.

RESULTS

Seventy of the 76 patients included completed the study. There were no drop-outs during the rush procedure. One patient in the active group dropped out during the maintenance therapy due to adverse events: gastric pain and vomiting. There was also 1 drop-out in the placebo group due to pregnancy. Adverse events were infrequent, local and mild. Symptom scores for rhinitis and conjunctivitis were not statistically different between groups, but there was a marked and significant (p < 0.03) decrease of the medication score (about 50%) and nasal steroid consumption (about 75%) in the active treatment group. An increase from baseline of serum IgE and IgG4 J. ashei-specific antibodies was only observed in actively treated patients (p < 0.04 and p < 0.01, respectively).

CONCLUSIONS

The tolerability and safety of high-dose ultra-rush SLIT were comparable to those reported in previous SLIT studies. SLIT with J. ashei extract, due to its high Jun a 1 content, significantly reduced nasal steroid consumption in patients allergic to European cypress.

Ultra-rush venom immunotherapy induces differential T cell activation and regulatory patterns according to the severity of allergy

BACKGROUND

Venom immunotherapy (VIT) induces immune tolerance to hymenoptera venom antigens in allergic patients and is therefore a helpful model for studying modulation of allergic immune response. The objectives were to assess the early effects of ultra-rush VIT on T lymphocyte activation and regulatory profile induction, in all subjects combined and according to the four severity grades of the Mueller classification.

MATERIALS AND METHODS

Blood samples from 30 vespid-allergic patients were taken before and after the first day of treatment, and before day 15 and day 45 booster injections. IFN-gamma and IL-4 levels were assayed by ELISA, in whole-blood supernatants. IFN-gamma and IL-13-producing T cells, but also natural CD4+CD25+high regulatory T cells and acquired regulatory T cell proportions were assessed by flow cytometry. Results were analysed in the whole population and compared between patients with I-II or III-IV allergic reactions.

RESULTS

During VIT, IFN-gamma increased in whole blood when IL-4 decreased. Among T cells, the percentage of CD3+IFN-gamma+ cells increased while IL-13-producing T cells decreased. Proportions of CD4+CD25+high cells and IL-10-producing T cells increased with VIT. In I-II subjects, IFN-gamma increased gradually, whereas it remained at low levels in III-IV patients. By contrast, IL-4 decrease was more pronounced in III-IV patients. Increase in CD4+CD25+high T cells occurred early in I-II patients but was delayed in III-IV patients. IL-10-producing T cells increased gradually in both groups but were in a lower proportion in III-IV patients.

CONCLUSION

A T helper type 2 (Th2)-to-Th1 switch occurs during ultra-rush VIT, in parallel with natural and acquired regulatory T cell increase. These events occur earlier and at a higher level in less severe subjects, suggesting that VIT tolerance induction is easier to achieve in these patients.

Do patients with skin allergies have higher levels of anxiety than patients with allergic respiratory diseases? Results of a large-scale cross-sectional study in a French population

BACKGROUND

Psychological comorbidity is a known aspect of allergic disease. However, there is recent evidence that a large proportion of allergic patients remains undiagnosed and untreated for psychological disease. In addition, the complexities of the anxiety-allergy relationship, i.e. differences for current and past disease, or differences among allergic disease types, are not well understood.

OBJECTIVES

To measure the level of anxiety in a large allergic population in France using a standardized measure, the State/Trait Anxiety Inventory (STAI).

METHODS

Allergy patients in France (n = 3939) who visited their allergy specialists participated in the study. The patients completed a questionnaire which was then linked to the questionnaire completed by their physician. Only patients with both subject and physician questionnaire were kept in the analyses. Mean STAI scores for the State (S) and Trait (T) scales were obtained for each allergic disease. ANCOVA models testing group differences on the mean scores, using the categories "current disease", "past disease" and "allergic disease ever", were assessed along with relevant confounders.

RESULTS

Allergic rhinitis (AR), asthma and atopic dermatitis (AD) were the most prevalent conditions of the 12 allergic diseases assessed in the study. Women had higher mean STAI S/T scores than men and age was also found to be associated with higher S scores; therefore, both age and gender were included as covariates where relevant. A single ANCOVA model for each STAI scale showed a statistical difference among the various allergic diseases. Using the category "current disease" each allergic disease was assessed separately regarding the presence or absence of that disease. Higher, statistically significant mean STAI scores were found for AD and allergic urticaria on the S scale and for AD on the T scale. Similarly, for the category "allergic disease ever", AD and allergic urticaria reached statistical significance on the S scale, while on the T scale only AD was statistically significant. When patients were assessed for anxiety based on their past disease, asthma, AR and sinusitis were significant on the S scale while asthma and nasal polyps were statistically significant on the T scale. When asthma and AD were tested simultaneously, only the latter was significant.

CONCLUSIONS

High mean scores for State and Trait anxiety were mostly associated with AD.

Diesel exhaust particles enhance T-cell activation in severe asthmatics

Prevalence of asthma is increasing in westernized countries. Epidemiological studies showed the impact of traffic pollution on the triggering of asthma symptoms and exacerbations, and this effect is mainly attributed to the polycyclic aromatic hydrocarbon core of diesel exhaust particles (DEP). However, although DEP induce IgE synthesis, little is known of their role on T-cell activation, the main cells orchestrating asthma inflammation. We assessed the effect of DEP on T-cell activation in severe uncontrolled asthmatics during (n = 13) and outside (n = 19) exacerbations. Results were compared with data obtained in healthy controls (n = 14). Peripheral blood mononuclear cells were cultured in the presence of low-dose DEP. T-cell activation markers, CD69 and CD25, interleukin-4 (IL-4) and interferon (IFN)-gamma production and T-cell proliferation were assessed by flow cytometry. DEP exposure increased the proportion of CD3+CD69+ T cells in all subjects. The proportion of CD25+ T cells increased under DEP stimulation in the exacerbation group only. IFN-gamma- and IL-4-producing T cells increased in both asthmatic groups, especially during exacerbations, but not in controls. This effect was more pronounced for IL-4. In response to DEP stimulation, T-cell proliferation increased in higher proportion in asthmatics compared with controls. These results show that DEP activate T cells in asthmatics only, with a higher effect during exacerbations. This is in keeping with epidemiological data which demonstrated that DEP trigger respiratory symptoms in asthmatics but not in controls. The higher effect of DEP in exacerbated asthmatics suggests that uncontrolled asthma is a risk factor for aggravation under exposure to traffic pollutants.

[T regulatory lymphocytes, atopy and asthma: a new concept in three dimensions]

BACKGROUND

Allergic inflammation is considered to be the result of a pattern of Th2 lymphocyte activation. However this inflammation, relevant for atopy and infiltration of affected tissues by eosinophils, is insufficient by itself to explain the clinical features of asthma. Several studies have demonstrated that Th2 type inflammation was also associated in asthma with a Th1 response, with production of gamma interferon. It has recently been shown that the regulatory T lymphocytes (Treg) which produce IL-10 and/or TGF-beta and induce tolerance are defective in allergic patients. In addition, these lymphocytes increase during specific immunotherapy. Their decrease could explain the Th2 activation found in atopic patients.

PERSPECTIVE

We review the potential importance of Treg cells in atopy and also asthma, and propose a concept whereby the allergic inflammatory response would not be due to a Th1/Th2 imbalance, but rather to a Treg deficiency progressively rising from normal to atopic, from atopy to asthma and from asthma to acute exacerbations.

CONCLUSION

Three dimensions of inflammation need therefore to be taken into account: Th1, Th2 and Treg.

Variation of T-cell activation in allergic subjects during natural pollen exposure

BACKGROUND

Allergic inflammation is characterized by a Th2 activation. However, little is known about dynamics of T-cell cytokine production during natural allergen exposure. The aim of this study was to assess the Th1/Th2 balance in cypress allergic patients compared with controls, and variations of this balance over the pollen season.

METHODS

Twenty cypress allergic patients and 10 controls were studied, distributed during two consecutive pollen seasons. Cytokine production was assessed by flow cytometry and ELISA. The variation of cytokine production during the pollen season was analyzed among patients in four occasions, and the preseason values were compared with controls. IL-13 and IFN-gamma-containing T cells were assessed among whole blood cells and PBMC. In addition the effect of specific stimulation by Juniperus ashei pollen extract was studied.

RESULTS

Compared with controls, IL-13-producing T cells were increased in allergics in any case. By contrast, compared with controls, allergic IFN-gamma-producing T cells were decreased in whole blood, but not in PBMC, and were increased after specific stimulation. During the season, an increase in IFN-gamma- and a decrease in IL-13-producing T cells occurred in patients, whatever the culture conditions.

CONCLUSION

These results show that the allergic T-cell activation is not limited to a Th2 profile: allergen-stimulated T cells are able to produce IFN-gamma at baseline, and the Th1/Th2 ratio increases during the pollen season.

Dog factor differences in Can f 1 allergen production

BACKGROUND

The clinical importance of dog allergy is well known, but it is unknown if all types of dogs represent the same risk for allergic patients. The purpose of this work was to evaluate among 288 healthy dogs if the levels of Can f 1 on fur vary between breeds (German Shepherd, Pyrenean Shepherd, Poodle, Cocker spaniel, Spaniel, Griffon, Labrador retriever and Yorkshire terrier), gender, hormonal status, hair length, and according to the presence of seborrhea.

METHODS

Each dog was shaved in a limited area and Can f 1 concentrations were measured in mug/g fur by ELISA. The results (geometric mean values and 95% confidence intervals) were analyzed using analysis of variance and with nonparametric tests.

RESULTS

A wide variability in Can f 1 levels was found between dog breeds, from Labradors [1.99 (0.03-129.91)] to Yorkshires [16.72 (3.67-76.16)] and Poodles [17.04 (2.79-103.94)] but only the Labrador levels were significantly different from each other breed. Males produced more Can f 1 than females, 11.75 (1.27-108.40) vs 8.89 (0.91-86.39). No difference was found according to hair length or hormonal status. The seborrheic status highly (P = 0.0019) influenced the presence of Can f 1 on hair: 16.66 (1.59-173.96) vs 9.40 (1.03-85.70).

CONCLUSION

Breeds (Labrador retriever), sex and seborrhea seem to influence the levels of Can f 1 on fur.

Twenty five year mortality and air pollution: results from the French PAARC survey

AIMS AND METHODS

Long term effects of air pollution on mortality were studied in 14,284 adults who resided in 24 areas from seven French cities when enrolled in the PAARC survey (air pollution and chronic respiratory diseases) in 1974. Daily measurements of sulphur dioxide, total suspended particles, black smoke, nitrogen dioxide, and nitric oxide were made in 24 areas for three years (1974-76). Cox proportional hazards models controlling for individual confounders (smoking, educational level, body mass index, occupational exposure) were applied, and frailty models used to take into account spatial correlation. Indicators of air pollution were the mean concentration.

RESULTS

Models were run before and after exclusion of six area monitors influenced by local traffic (NO/NO2 >3 in ppb). After exclusion of these areas, analyses showed that adjusted risk ratios (95% CI) for TSP, BS, NO2, and NO for non-accidental mortality were 1.05 (1.02 to 1.08), 1.07 (1.03 to 1.10), 1.14 (1.03 to 1.25), and 1.11 (1.05 to 1.17) for 10 microg/m3 respectively. Consistent patterns for lung cancer and cardiopulmonary causes were observed.

CONCLUSIONS

Urban air pollution assessed in the 1970s was associated with increased mortality over 25 years in France.

Genome screen in the French EGEA study: detection of linked regions shared or not shared by allergic rhinitis and asthma

In the sample of 295 French EGEA families with at least one asthmatic subject, a genome screen was conducted to identify potential linkage regions specific either to allergic rhinitis (AR) or to asthma as well as those shared by the two diseases. Two binary rhinitis phenotypes based on (1) diagnosis (ARbin1) and (2) symptoms (ARbin2) and a categorical ordered trait (ARcat) were considered. Asthma phenotype was based on answers to a standardized questionnaire plus the presence of bronchial hyper-responsiveness. Linkage analyses were conducted using the maximum likelihood binomial (MLB) method. These analyses provided potential evidence for linkage to three regions in the whole sample: 1p31 for the phenotype defined by ARbin2 plus asthma (P=0.00016), 2q32 for ARbin2 (P=0.00016) and 3p24-p14 for ARcat (P=0.001). Two other regions were detected in the subset of 185 families with at most one asthmatic sib: 9p22 and 9q22-q34 for ARbin1 (P=0.001 and 0.0007, respectively). No region showed evidence for linkage to asthma without being also linked to AR. While 1p31 may contain a genetic determinant common to asthma and AR, 2q32, 3p24-p14, 9p22 and 9q22-q34 are more likely to harbor genetic factors specific to AR.

Impact économique de la BPCO en France : étude SCOPE

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a major health problem. Few data about COPD economic burden are available.

METHODS

SCOPE was an observational economical retrospective and prospective study conducted in France in 2001, by 114 general practitioners (GPs) and 57 lung specialists. The aim was to describe the burden of COPD patients and to estimate the annual cost according to severity stages. Health resource utilization was collected by questionnaires over a 12-month period for 285 patients.

RESULTS

It was a cost-of-illness analysis. COPD patients followed by a lung specialist were more severe than patients followed by a GP and had a higher level of medical resource consumption. The COPD disease and its complications explained 66% of the total cost. The main cost drivers were inpatient care (35%, or 1509,9 euros/year/patient) and prescription medications (31%, or 1340,6 euros/year/patient). The direct total cost varied according to COPD severity on account of inpatient care and respiratory assistance.

DISCUSSION

This study confirmed the economic burden of COPD in France. Actions allowed to slow down the disease's evolution and to anticipate the exacerbation could reduce the cost.

« Classification 2002 des pneumopathies interstitielles idiopathiques »

OBJECTIVES

Diagnosis of interstitial lung diseases was recently improved by the use of diagnostic tools, such as high-resolution Computed Tomography, and by new insights in their pathogenesis and histology. This led the American Thoracic Society and the European Respiratory Society to propose a new classification of these diseases, in the aim to facilitate early diagnosis and specific care.

CURRENT KNOWLEDGE AND KEY POINTS

Standard radiography gives the first suspicion of chronic diffuse infiltrative lung disease, and anamnesis and physical examination are essential steps of etiological diagnosis. High-Resolution computed tomography confirms the diagnosis of diffuse infiltrative lung disease. Longitudinal lung function tests are essential to assess the consequences of the lung disease. Lung biopsies are often, but not systematically, a useful tool. The 2000 classification consists of seven entities of idiopathic interstitial diseases which are defined on clinical, radiological and pathological criteria: idiopathic pulmonary fibrosis, non-specific interstitial pneumonia, cryptogenic organizing pneumonia, acute interstitial pneumonia, respiratory bronchiolitis associated interstitial lung disease, desquamative interstitial pneumonia and lymphoid interstitial pneumonia. The most frequent is Idiopathic Pulmonary Fibrosis, which has a poor prognosis.

FUTURE PROSPECT AND PROJECTS

This new classification results from a multidisciplinary confrontation with chest physicians, radiologists and pathologists. A better characterization of anatomoclinical entities should lead to a better pronostic evaluation, more informative comparisons of published studies, and therefore to rational therapeutic approach.

Increased prevalence of asthma and allied diseases among active adolescent tobacco smokers after controlling for passive smoking exposure. A cause for concern?

BACKGROUND

Whereas effects on allergic and respiratory health have been established for passive tobacco smoking, contradictory results still exist for active tobacco smoking.

OBJECTIVE

Whether adolescents with asthma and allied diseases have higher rates of active smoking compared with adolescents without asthma was assessed after controlling for environmental tobacco smoking exposure.

METHODS

A population-based sample of 14,578 adolescents was enrolled in an epidemiological survey on allergies in France.

RESULTS

After controlling for age, sex, geographic region, familial allergy and passive smoking, current (in the past year) wheezing (12.4%), current asthma (5.6%), lifetime asthma (12.3%), current rhinoconjunctivitis (13.9%), lifetime hayfever (14.4%) and current eczema (9.3%) but not lifetime eczema (22.5%) were all significantly related to active smoking (>1 cigarette/day) (9.3%). A higher risk of current wheezing, current and lifetime asthma or current eczema was seen in smokers exposed to passive smoking compared with smokers not exposed to it using a polychotomous logistic regression model, in which the different modalities of exposure to active and passive smoking constituted the response variable. Passive smoking was significantly associated only with current diseases. Active smoking was also highly related to both severe asthma (OR=4.02; 95% confidence interval: 1.37, 11.79) and severe rhinoconjunctivitis (OR=2.95; 1.58, 5.49). The highest rate of adolescents suffering from the co-morbidity of lifetime asthma and hayfever (3.6%) was also seen in active smokers compared with passive and non-smokers (5.5% vs. 3.6% and 3.1%, respectively; P=0.001).

CONCLUSIONS

Being asthmatic or allergic does not seem to act as a deterrent towards starting active smoking or continuing to smoke in adolescence. Results suggest the need for considering individual allergic status in programming health educational activities aimed at reducing smoking among adolescents.

[Bronchial obstruction by an aberrant left pulmonary artery misdiagnosed as asthma in a 7 year old child]

INTRODUCTION

Wheezing is common symptom in infants and is usually due to asthma. However an alternative diagnosis should be sought if there is no reversibility to B2-agonist.

CASE REPORT

This case report describes a 7 years old child who had been treated for poorly controlled asthma for several years. The absence of B2-agonist reversibility, indirect signs of thoracic straining on spirometry and evidence of right heart decompensation raised doubts about the diagnosis. CT angiography demonstrated a pulmonary artery malformation. Formal pulmonary angiography confirmed the diagnosis of pulmonary artery sling. This malformation had been causing intermittent bronchial compression and the symptoms resolved after surgical intervention.

CONCLUSION

Wheezing symptoms over two Years in a child, misdiagnosed as asthma, is an unusual presentation of this pulmonary vascular anomaly.

T cell activation, from atopy to asthma: more a paradox than a paradigm

During the last 15 years, it was largely shown that allergic inflammation was orchestrated by activated Th2 lymphocytes, leading to IgE production and eosinophil activation. Indeed, Th2 activation was shown to be necessary to induce allergic sensitization in animal models. In humans, a Th2 skewing was shown in atopic children soon after birth. In asthma, descriptive studies showed that Th2 cells were more numerous in patients than in controls. In addition, during specific allergen stimulation, an increase of Th2 cells was described in most cases. According to this Th2 paradigm, it was proposed that early avoidance of microbial exposure could explain the increase of atopic diseases seen in the last 20 years in developed countries, as the "hygiene hypothesis". Recently, it was proposed that early exposure to lipopolysaccharide (LPS) could be protective against atopic diseases. However, it is well established that exposure to LPS can induce asthma symptoms, both in animals and humans, although it induces a Th1 inflammatory response. In addition, most infections induce asthma exacerbations and Th1 responses. Recently, some studies have showed that some Th1 cells were present in asthmatic patients, which could be related to bronchial hyperreactivity. There is therefore an "infectious paradox" in asthma, which contributes to show that the Th2 paradigm is insufficient to explain the whole inflammatory reaction of this disease. We propose that the Th2paradigm is relevant to atopy and inception of asthma albeit a Th1 activation would account at least in part for bronchial hyperreactivity and asthma symptoms.

Assessment of T lymphocyte cytokine production in induced sputum from asthmatics: a flow cytometry study

BACKGROUND

Asthma results from a bronchial inflammation in which Th2 lymphocytes play a pivotal role, as shown in invasive bronchial biopsies and broncho-alveolar lavages. Induced sputum (IS) is a non-invasive method of recovery of bronchial cells, which can be repeated in the same patients. However, lymphocyte activation has not been studied in IS to date, because of the low number of T cells recovered. Herein we took advantage of flow cytometry, a method suitable for the study of small cell populations, to assess T cell cytokine production in IS.

OBJECTIVES

(1) To assess induced sputum T cell cytokine production by flow cytometry in asthmatic subjects and controls. (2) To compare the T cell cytokine production between symptomatic and non-symptomatic asthmatics.

METHODS

Thirteen asthmatics and 19 controls were included. Sputum was induced by a hypertonic saline. Sputum cells were stimulated and intracellular IL-13 and IFN-gamma were detected in T cells by flow cytometry.

RESULTS

Stimulation induced an increase of IL-13 and IFN-gamma production by T cells. This increase was higher in asthmatics. IL-13-producing T cells were increased in asthmatics after stimulation. In symptomatic asthma, IFN-gamma-producing T cells were in higher proportion than in controlled asthma.

CONCLUSION

IS T cell cytokine production indicates a basic Th2 bias in asthma, accompanied during symptoms by a Th1-like activation. These results open the field for longitudinal studies of the variation of T cell activation in asthma.

Study of cytokine gene expression in small cell samples: use in induced sputum

Sputum examination is being increasingly used as a non-invasive method for the study of airway inflammation. However, the technical applications of sputum are still limited because of the small number of cells recovered. In attempt to extend applications of sputum examinations, we developed and standardised, the reverse transcriptase-polymerase chain reaction (RT-PCR), a sensitive and specific technique of detection of mRNA, in induced sputum samples. Total RNA were extracted from samples containing as few as 50 to 80,000 cells, using a phenol-chloroform extraction method. RT-PCR was successfully tested on beta-actin, interferon-gamma (IFN-gamma), interleukin-4 (IL-4) and tumour necrosis factor-beta (TGF-beta) genes. This protocol provides a simple technique to extract total RNA from a few number of induced sputum cells. It permits the semi-quantitatively study of cytokine gene expression in airways with simple means.

Relationships of allergic sensitization, total immunoglobulin E and blood eosinophils to asthma severity in children of the EGEA Study

BACKGROUND

Although allergy is highly associated with childhood asthma, it is not well known if there is a relationship between the intensity of allergic sensitization and asthma severity.

OBJECTIVE

The objectives of the study were to examine the relationships between several markers of allergy and asthma severity in asthmatic children included in the Epidemiological study on the Genetics and Environment of Asthma, bronchial hyper-responsiveness and atopy (EGEA).

METHODS

The population comprised 216 asthmatic children below 16 years of age. Total IgE and blood eosinophil counts were measured and skin prick tests to 11 aeroallergens were performed. The intensity of the allergic sensitization was assessed by the number of positive skin prick tests and by skin weal sizes. Asthma severity was measured with four criteria: a clinical severity score, history of hospitalization for asthma, FEV1% predicted and inhaled steroid use in the last 12 months.

RESULTS

Most of the children were sensitized to at least one aeroallergen (88.2%). Atopy was not related to the severity of asthma, except for a tendency for a more severe clinical score in non-atopic children. The type and intensity of the allergic sensitization were not associated with any criteria of asthma severity. Total IgE was significantly increased in children treated with inhaled corticosteroids and in children ever hospitalized for asthma (P-values 0.009 and 0.04, respectively). Eosinophil counts were not related to asthma severity.

CONCLUSION

Our results suggest that severe childhood asthma may be related to a high level of total IgE but not to blood eosinophil counts. The lack of positive relationships between both atopy and the intensity of allergic sensitization with asthma severity supports the hypothesis of different risk factors being associated with asthma and with the severity of asthma.

Triggers in intrinsic asthma in the EGEA study

The objective of the study was to compare triggers for asthma attacks in a group of intrinsic (IA) and extrinsic asthmatic (EA) subjects. We included 205 asthmatic patients divided, according to skin-prick tests, in a group (n = 63) of IA and a group (n = 142) of EA. The questionnaire provided information on associated conditions (nasal polyps and intolerance to aspirin) as well as on allergenic and nonallergenic triggers. Data analysis demonstrated that in IA, some airborne nonallergenic factors were significantly more often involved. In addition, this association did hold true when comparing subgroups of patients with normal baseline FEV1 values. For those subjects, PC20 and the slopes of the dose-response curves to metacholine were comparable. In conclusion, the higher sensitivity of a group IA subjects to some nonallergenic factors is not related to a lower baseline spirometric value in this subgroup. It may be hypothesized that, in these patients, sensitivity of airways irritant receptors might be increased.

Medical Indoor Environment Counselor (MIEC): role in compliance with advice on mite allergen avoidance and on mite allergen exposure

BACKGROUND

In order to improve patient compliance in allergen avoidance, a new occupational activity was created: Medical Indoor Environment Counselor (MIEC). The aim of this study was to assess the impact of an MIEC on compliance with advice for mite allergen reduction in patients sensitized and exposed to mite allergens, and on mite allergen levels.

METHODS

The study included 378 patients from four centers (Marseilles, Montpellier, Paris, Strasbourg) in a randomized prospective study. Patients in group A received advice from doctors only, and those in group B from doctors and MIEC. Mite allergen levels were measured on mattresses, mattress bases, and floors. Compliance and mite allergen levels were assessed 5 months later.

RESULTS

Compliance for changing the mattress bases, removing or treating the carpets, washing duvets, pillows and stuffed animals were significantly higher in group B than in group A. A significant decrease in mite allergen was obtained for group B in mattress bases (83.8-22.9 micro g/g) and in carpets (15.8-6.3 micro g/g), but not in group A.

CONCLUSION

Our results suggest that the home visit by the MIEC 1) increased the compliance to mite reduction methods advised; 2) induced a significant difference in mite reduction levels on mattress bases and on carpets; 3) avoided nonestablished avoidance advice.

Hymenoptera ultra-rush venom immunotherapy (210 min): a safety study and risk factors

BACKGROUND

In this study, which summarizes our last 5 years of experience, we evaluated the side-effects of ultra-rush venom immunotherapy and the possibility to define some risk factors for side-effects as age, Hymenoptera venom used for treatment, treatment phase, severity of prior insect sting reaction, concentration of skin test positivity, and level of specific IgE.

METHODS

In our protocol on day 1, an initial venom dose of 0.1 microg was followed by 1, 10, 20 microg at 30-min intervals and then 30 and 40 microg at 60-min intervals. Patients who completed this protocol received two booster injections of 50 microg on day 15 and one of 100 microg on day 45. Subsequently, monthly 100 microg boosters were given.

RESULTS

Fifty-one children (9.20 +/- 3.41 years) and 207 adults (40.62 +/- 14.00 years) underwent an ultra-rapid venom immunotherapy (ultra-RVIT). Single ultra-RVIT was administered to 195 patients: 69 with honeybee, 123 with yellow jacket and three with wasp venoms. Two venoms were injected into 59 patients: 42 with yellow jacket and wasp, 17 with yellow jacket and honeybee. Four patients received the three venoms. The frequency of immediate systemic reactions (SR) was not significantly different between adults and children: 11.2% vs. 10.8%. SR were experienced more frequently on day 1 (n= 33). They were uncommon on day 15 (n= 2) and on day 45 (n= 1). No late reactions have been observed. Honeybee venom induced significantly more SR (30%) vs. yellow jacket (3.2%) and wasp venom (6.1%). Among the 33 patients who experienced a SR on day 1, 24 had a reaction grade 1 or 2 and nine had a reaction grade 3 or 4. There is a significant risk for patients with a prior reaction grade 3 or 4 to experience a SR during venom immunotherapy (VIT). The strength of positive skin tests and the level of specific IgE were not related to an increased risk of SR (P= NS).

CONCLUSION

Treatment with honeybee extract induced more SR than the treatment with yellow jacket and wasp venom. Doses increase phase on day 1 is risk factors for SR of ultra-RVIT, as well as the severity of the prior reaction. Age, degree of positive skin tests, and specific IgE are not risk factors.

[Induced sputum as a new approach of the assessment of inflammation in asthma]

Asthma is an inflammatory condition. Traditionally bronchoalveolar lavage and bronchial biopsies obtained by bronchoscopy have been used to demonstrate inflammation. Induced-sputum is a non-invasive, reliable, reproducible and safer technique for monitoring inflammatory activity in patients with asthma. Studies have shown that induced-sputum measures aspects of inflammation distinct to that measured by bronchoalveolar lavage or bronchial biopsies. Numerous studies have suggested that induced-sputum is a potentially useful tool for early diagnosis of exacerbation, monitoring of therapy, identification of the lowest effective dose and assessing compliance in asthmatics. In this respect, we suggest that this test can be routinely used in the management of difficult asthmatics.

[Factors associated with smoking in sixth grade (11-13 years old)]

Because smoking begins most often in adolescence it is important to define clearly, with a view to prevention, the motivation of an adolescent to smoke. The role of the social group is well known. The aim of this study was to evaluate the potentially preventative role of knowledge in the field of respiration and the effects of cigarette smoke on one hand and of involvement in activities involving breathing on the other. The group studied was made up of 1,802 pupils at state schools, randomly selected, in the city of Marseilles. These pupils filled in an anonymous questionnaire in the classroom. The overall percentage of non-responders was very small. Overall 10.5% if the children declared that they had already smoked, more often boys (13.1%) than girls (8.1%). In contrast to smoking by the father, smoking by the mother and siblings significantly influenced smoking in the child. The child was not influenced by smoking by a sibling of the same sex. The proportion of children having already smoked increased progressively in proportion to the number of smokers in the household. Using a logistical regression analysis the following were predictive of smoking: being a boy, having a best friend who smoked, and the number of smokers in the family. On the other hand a history of allergy, an understanding of the effects of the environment on the respiratory system, knowledge of the effects of cigarettes, and finally involvement in sport, playing a wind instrument or singing in a choir were not associated with a lower incidence of smoking. These results call into question the effectiveness of the standard preventative methods and of anti-smoking programmes that are based on such strategies.