Zataria multiflora affects pulmonary function tests, respiratory symptoms, bronchodilator drugs use and hematological parameters in chronic obstructive pulmonary disease patients: A randomized doubled-blind clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Zataria multiflora is employed as an antitussive, anti-spasmodic, analgesic and etc. Agent in traditional medicine. The modern medical studies are also confirmed effects of this plant for treatment of respiratory problems via anti-inflammatory, anti-oxidant and immunomodulatory properties.

AIM OF STUDY

We evaluated efficacy of Z. multiflora on tests of pulmonary function, respiratory symptoms, inhaled bronchodilator drugs use, and hematological factors in COPD patients.

METHODS

Patients (n = 45) were randomly grouped in the following three groups: placebo group (P), groups received Z. multiflora extract 3 and 6 mg/kg/day (Z3 and Z6). FEV1 and MEF25-75, respiratory symptoms, inhaled bronchodilator drugs use and hematological factors were evaluated before and 1-2 months after treatment.

RESULTS

Z. multiflora led to significant enhancement of FEV1 (p < 0.05 to p < 0.01). Respiratory symptoms were also considerably ameliorated following treatment with extracts for 1 and 2 months compared to baseline values (p < 0.05 to p < 0.001). In groups received extract, inhaled bronchodilator drugs use was remarkably declined at the end of study (both, p < 0.05). Reduction of total WBC was observed 1-2 months after treatment in treated groups with extract compared to baseline values (p < 0.05 to p < 0.001). Neutrophils were remarkably declined in Z3 and Z6 groups after 2-monthes compared to 1-month treatment (p < 0.05 to p < 0.01).

CONCLUSION

The evidence show therapeutic effect of this herb on COPD patients which could be result from properties that help to decrease inflammation.

Efficacy of Herbal Medicines on Lung Function in Asthma: a systematic review and meta-analysis of randomized controlled trials

Objectives

The present study was designed to conduct a comprehensive systematic review and meta-analysis to assess the efficacy of herbal medicines as add-on therapy on lung function in asthmatic patients.

Methods

A comprehensive search of online databases was performed up to December 2021 to identify randomized controlled trials that used orally herbal preparations for asthma as add-on therapy. Studies were assessed for methodological quality using the Cochrane Collaboration's Risk of Bias tool. The main outcome was percent predicted value of forced expiratory volume (% predicted FEV1). Pooled weighted mean difference (WMD) estimate with corresponding 95% confidence interval (CI) was calculated using inverse-variance weights method while random effects meta-analysis was used, taking into account clinical and conceptual heterogeneity.

Results

As a result, 1,525 studies were identified. 169 studies were reviewed in-depth and 23 studies met our systematic review inclusion criteria. Finally, nine randomized controlled trials were included in the meta-analysis. Findings indicated that use of herbal medicines in patients with asthma significantly improved % predicted FEV1 (WMD 3.73, 95% CI 1.76-5.70), with no evidence for significant heterogeneity (p = 0.56 [Q statistic], I² = 0.0%). In subgroup analysis by age, improvement in % predicted FEV1 was higher and significant in adults (WMD 5.16; 95% CI 2.68-7.63) compared to children (WMD = 1.27; 95% CI -1.98-4.51). Sensitivity analysis showed the significant effect of herbal medicine consumption on improving FEV1 was consistently (range of summary WMDs 3.27-4.59), indicating that the meta-analysis model was robust. There was no evidence of publication bias both visually and statistically.

Conclusion

Findings support, the complementary use of herbal medicines resulted in significant improvement in the lung function compared to standard treatment in asthmatic patients with no considerable adverse events. This improvement is more likely to be observed amongst adults.

Comparison of the effects of itraconazole and prednisolone on fibroblast growth factor-2 gene expression and clinical manifestations in patients with persistent severe asthma

Background and Purpose

Considering the possible role of fungal sensitization in the treatment of resistant asthma, which may lead to the remodeling of bronchial structure, we theorized that itraconazole could result in better control of asthma. In this regard, this study aimed to compare the effects of itraconazole and prednisolone (routinely prescribed) on clinical, structural, and biomarker findings of the remodeling of asthma.

Materials and Methods

This double-blind controlled randomized clinical trial was performed on 70 adult patients suffering from severe persistent asthma. The intervention group received 200 mg of itraconazole per day, and the control group received 10 mg of prednisolone per day, for 32 weeks, in addition to the classic treatment of asthma. The subjects were randomly divided into two groups, and assigned by sealed envelope. Blinding was performed by repacking the drug in a similar container. Primary outcomes were asthma control test score, fibroblast growth factor 2, and wall area percentage on RB1 bronchus measured by computed tomography. The outcomes were compared in subjects classified as allergic, eosinophilic, T2 low asthma, and four types of inflammatory cell classification in sputum.

Results

Seventy subjects finished the 32-week trial (35 subjects in each group). Baseline data did not show significant differences between groups. A comparison of asthma variants showed significantly more severe cough and dyspnea in the allergic variant and higher spirometry results in T2-low asthma. Sputum cytology revealed a mixed pattern as the most frequent type (47%). After the trial, two groups improved in many parameters; however, FGF-2 improved more significantly by itraconazole (4.66±16.92 decreased to 1.14±2.98), and FEV1/FVC was significantly higher in the itraconazole group, compared to the control group. These results did not change in terms of asthma variants and sputum classification.

Conclusion

Itraconazole was superior to prednisolone in the treatment of many clinical and spirometry aspects in severe persistent asthma.

The association between MUC5AC and MUC5B genes expression and remodeling progression in severe neutrophilic asthma: A direct relationship

BACKGROUND

MUC5 dysregulation is a hallmark of severe neutrophilic asthmatic patients. This study investigates the expression of MUC5AC and MUC5B at mRNA levels on asthma severity and airway wall thickness in severe neutrophilic asthmatic patients.

METHOD

In this case-control clinical trial, twenty-five severe neutrophilic asthmatic patients and ten control subjects were enrolled. Subjects underwent ACT, pulmonary functions tests, and fractional exhaled nitric oxide (FENO). Also, induced sputum has been obtained to assess the expression of MUC5AC and MUC5B by the real-time PCR. In addition, the thickness of the airway wall was assessed by high-resolution computed tomography (HRCT), and bioinformatic analysis was implemented to approve the selection of the appropriate genes and for further investigations.

RESULT

A significant difference was observed between the asthmatic and control in MUC5AC and MUC5B mRNA expression. Meanwhile, the expression of MUC5AC increased remarkably by asthma severity; also, it is associated with airway wall thickness (WT) (both P-value <0.05). The expression of MUC5B in asthmatic patients was lower than in control. There is no significant correlation between MUC5B mRNA level and WT and asthma severity. Notably, MUC5AC transcription level was correlated to sputum neutrophil percentage, while MUC5B transcription level had a positive correlation with sputum macrophages and a negative one with sputum neutrophils.

CONCLUSION

In severe neutrophilic asthma, airway wall thickness increases with MUC5AC mRNA overexpression, which is probably related to asthma severity and the formation of mucus plugs. However, the expression of MUC5B was decreased, resulting in poor mucociliary clearance in the airways.

TRIAL REGISTRATION

IR.IAU.MSHD.REC.1400.124.

Parietal Pleural Lymphatic Blockage by Anthracotic Nodule Laden Macrophage, Leading Cause of Pleural Effusion in Anthracosis

Anthracosis of lung is assumed to be a disease that causes parenchymal accumulation of macrophage-laden anthracotic nodules, which leads to bronchial obstruction, lung mass, and lymphadenopathy. Pleural surface anthracosis involvement as extra-parenchymal involvement has been rarely reported. Still, due to presentation with a transudate pattern, pleural effusion is considered to be a side effect of lung collapse. I represent two subjects with patches of anthracosis in the presumptive place of anatomical fenestra of lymphatic vessels in the parietal pleural. It may cause inhibition of reabsorption of pleural fluid and finally accumulation of transudate pleural effusion. Involvement of the pleura by anthracosis, and black discoloration of the parietal pleura have already been discovered by physicians who perform pleuroscopy. The pleural involvement by anthracosis is usually diffuse. In these two subjects, pleural involvement was in the early stage of anthracosis, which helped me to introduce a new mechanism for transudative pleural effusion due to blockage of the pleural lymphatic channels entrance.

Itraconazole Improved Bronchial Wall thickness in Severe Persistent Asthma: A Double-blind Placebo-controlled Randomized Clinical Trial

The purpose of this study was to evaluate the effect of 8 months of treatment with itraconazole on airway wall thickness in patients with severe persistent asthma. It was a double-blind, randomized, placebo-controlled clinical trial (IRCT20091111002695N9). Seventy-five subjects with severe persistent asthma received itraconazole (100 mg), prednisolone (5 mg), or placebo twice a day for eight months in three treatment groups (n=25 in each group). The primary objective was to improve the right upper lobe apical segmental bronchus (RB1) wall thickness percentage measured by high-resolution computed tomography scan of the lungs. Other morphometric measurements of RB1, asthma control test (ACT) score, presence of wheezing, dyspnea severity, rate of asthma exacerbation, fractional exhaled nitric oxide (FeNO), and expiratory volume in 1 second (FEV1) were set as the secondary outcomes. Wall thickness percentage reduced significantly from 46% to 43.7% from pre- to post-treatment in the itraconazole-treated subjects. Similarly, lumen area and radius increased significantly in both the prednisolone and itraconazole groups. Itraconazole led to a significant improvement in wheezing, dyspnea severity, FEV1, ACT score, and FeNO. Although prednisolone was also effective in improving pulmonary function tests and ACT scores, it was associated with significantly more side effects than itraconazole. Long-term treatment with itraconazole resulted in a significant reduction in bronchial wall thickness and improvements in clinical findings and pulmonary function tests. Thus, itraconazole could be a helpful add-on treatment option for severe persistent asthma patients to achieve better disease control.

Comparison of Longevity in Patients with Idiopathic Pulmonary Fibrosis Using Pirfenidone Versus Triple Therapy with Prednisolone, Azathioprine, and Acetylcysteine

Background

The effect of the combination of prednisolone, azathioprine, and acetylcysteine for the treatment of Idiopathic pulmonary fibrosis (IPF) is minimal. We aimed to investigate the effect of these drugs in case of intolerance to new anti-fibrotic drugs.

Materials and Methods

This historical prospective study was performed on 91 patients with idiopathic pulmonary fibrosis who were referred to a pulmonologist in Mashhad during 2016-2020. Patients were divided into two groups, Pirfenidone which was prescribed for 46 subjects, and a combination of prednisolone, azathioprine, and acetylcysteine which was prescribed for 45 subjects. Patients were selected by convenience sampling and a life expectancy comparison between the two groups was performed by Cox regression.

Results

There were no statistically significant differences between age, gender, and drug type in the two groups at the beginning of treatment. The death rate per year in the triple-drug treatment group was 44.44% (n = 20) and in the Pirfenidone treatment group was 11.08% (n=2). Of the 65 recovered population, 49% (22 patients) were in the triple-drug treatment group, and 78% (36 patients) were in the Pirfenidone treatment group which indicated that Pirfenidone has a significant impact on reducing death rate compared to triple-drug treatment (pvalue=0.003 <0.05). Pirfenidone decreased the risk of death, compared to triple therapy (0.23 when death was set up as one in the triple-therapy group).

Conclusion

Pirfenidone has a favorable effect on increasing life expectancy and triple therapy should be considered as short-term only in subjects intolerant to anti-fibrotic.

The Effect of Glasthma Syrup in Asthma: a study protocol for a triple-blind randomized controlled trial

Objectives

Asthma is a chronic disease, and the demand for herbal medicines in this field has increased in recent years. The new findings highlight the role of the gut-lung axis in the pathophysiology of asthma. Hence, this study will evaluate the safety and efficacy of Glasthma syrup, an herbal formula based on Persian medicine, in improving asthma and regulating intestinal permeability. The formula consists of five herbal ingredients that have anti-inflammatory effects on the respiratory tract, also known as gut tonics.

Methods

The study will be conducted as a placebo-controlled, triple-blind, randomized trial. It will consist of a 4-week intervention followed by a 4-week follow-up period. The target sample size is 20 patients with moderate asthma aged 18 to 60 years. Eligible participants will be randomly assigned to either the experimental group or the control group in equal numbers. Patients in the experimental group will take Glasthma syrup (7.5 mL, twice a day), while patients in the control group will take a matching placebo. Both groups will receive a 4-week combination of a long-acting beta2 agonist and a leukotriene modulator as standard of care. Inhaled corticosteroids can be used as rescue medication as needed.

Results

The primary outcomes are asthma symptom scale, lung function, and intestinal permeability. Secondary outcomes include quality of life, symptom recurrence rates, and blood tests. A safety assessment will also be conducted during the trial.

Conclusion

In this trial, the effects of Glasthma syrup in patients with moderate asthma will be examined. The study will also assess the effects of the formulation on the gut-lung axis by simultaneously monitoring the gut permeability index, asthma symptoms, and lung function.

The effect of two-month treatment with Zataria multiflora on inflammatory cytokines, pulmonary function testes and respiratory symptoms in patients with chronic obstructive pulmonary disease (COPD)

ETHNOPHARMACOLOGICAL RELEVANCE

Zataria multiflora Boiss. (Z. multiflora) is a valuable medicinal plant that has been used in Iranian traditional and folk medicine as an antiseptic, carminative, diaphoretic, diuretic, anti-spasmodic and analgesic herbal medicine. This plant has been also used to relieve cough in common cold and respiratory tract disorders. The previous studies reported the pharmacological effects of Z. multiflora such as anti-inflammatory and anti-oxidant properties in respiratory disorders in animal models and clinical studies.

AIM OF THE STUDY

The effects of Z. multiflora extract on inflammatory cytokines, pulmonary function tests (PFT), and respiratory symptoms in chronic obstructive pulmonary diseases (COPD) patients were investigated.

MATERIALS AND METHODS

COPD patients (41 cases) were divided to three groups including placebo group (P) and groups received 3 and 6 mg/kg/day Z. multiflora extract (Z3 and Z6) for two months. Inflammatory cytokines, PFT values, and respiratory symptoms were assessed before treatment (stage 0), one (stage I) and two (stage II) months after treatment.

RESULTS

Serum levels of TNF-α and IL-8 were significantly decreased after two months treatment compared to baseline values in Z3 and Z6 groups. The PFT values including forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) were significantly increased during two months treatment with Z3 and Z6. The peak expiratory flow (PEF) was also significantly increased after one-month treatment with Z6. The respiratory symptoms including cough, chest tightness, modified medical research council (mMRC) dyspnea scale were significantly improved after one and two treatments with both doses of Z. multiflora compared to baseline values.

CONCLUSION

The results suggest the potential therapeutic effect of Z. multiflora in COPD patients through reduction of inflammatory cytokines, increasing PFT values and improvement of respiratory symptoms.

Effect of azithromycin on bronchial wall thickness in severe persistent asthma: A double-blind placebo-controlled randomized clinical trial

BACKGROUND

Azithromycin reduced airway remodeling in animal models of asthma. However, its effect on human subjects has not been studied yet. This study aimed to investigate the effect of long-term treatment with azithromycin on airways wall thickness in patients with severe persistent asthma.

METHODS

In this randomized, double-blind, placebo-controlled clinical trial, patients with severe persistent asthma received azithromycin (250 mg, BID, three days a week), prednisolone (5 mg, BID), or placebo for eight months in three separate groups in addition to the standard therapy. The improvement in right upper lobe apical segmental bronchus (RB1) wall thickness obtained by high resolution computed tomography was set as the primary outcome. Secondary outcomes included: cough severity, dyspnea severity, asthma control test (ACT) score, asthma exacerbation rate, pulmonary function tests, and fractional exhaled nitric oxide (FENO).

RESULTS

Seventy-eight out of ninety randomized subjects completed eight months of treatment with azithromycin (n = 25), prednisolone (n = 27), or placebo (n = 26). Bronchial wall thickness percentage did not change significantly in any of the groups. However, the inner radius and lumen area of azithromycin and prednisolone-treated subjects increased significantly (p < 0.05 for both). Azithromycin also significantly improved the dyspnea severity, ACT score, FENO, and FEV1, FEF_25-75, and FEV1/FVC (p < 0.05 for all). Cough severity or asthma exacerbation rate did not change significantly after eight months of treatment with azithromycin.

CONCLUSION

Long-term treatment with azithromycin increased lumen radius and lumen area in patients with severe persistent asthma. However, there was no significant change in wall thickness in any of the treatment groups.

TRIAL REGISTRATION

IRCT.com (IRCT20091111002695N8).

Long-term effect of antifungal therapy for the treatment of severe resistant asthma: an active comparator clinical trial

Background and Purpose:

Itraconazole therapy has been reported to control asthma in severe therapy-resistant asthma with fungal sensitization. The aim of this study was to investigate the impact of anti-fungal therapy on the treatment of severe asthma, irrespective of sensitization.

Materials and Methods:

This active comparator clinical trial was performed on 110 therapy-resistant asthmatic patients who were randomly assigned into two groups of case and control. The patients in the case group were administered 200 mg itraconazole twice a day and the control group received 10 mg prednisolone after breakfast for 4 months. The asthma control test (ACT) which was used as a marker for the global evaluation of treatment effectiveness (GETE) was applied as the primary endpoint parameter. Cough, dyspnea, and sleep disturbance were measured on a scale of 1-4, with 1 representing no symptom and 4 indicating severe exhausting disturbance.

Results:

Based on the obtained results, 71% of the itraconazole group demonstrated a marked improvement in the GETE score after a four-month treatment. Itraconazole was able to suppress clinical symptoms, including cough, dyspnea, and night symptoms, and their physical exam was indicative of normalization in 60% of the patients. On the other hand, the patients in the parallel group "prednisolone" were only able to control dyspnea. The ACT score represented a notable improvement with itraconazole (mean: 14 before the trial and >20 after the trial) and spirometry parameters underwent a considerable change from obstructive pattern to normal. Furthermore, adverse effects were only detected in 6% of itraconazole users.

Conclusion:

The results of this clinical trial indicted the effectiveness of antifungal therapy for the control of the clinical condition of a subgroup of patients with severe steroid-refractory asthma.

Cromolyn, a New Hope for Limited Treatment of Neutrophilic Asthma: a Phase II Randomized Clinical Trial

BACKGROUND

In this study, we aimed to determine the effects of cromolyn on the clinical outcomes and neutrophilic inflammation in patients with resistant cough-variant asthma.

MATERIALS AND METHODS

Patients with cough-variant asthma, with normal physical examination and spirometry results, were treated by inhaled corticosteroids, antileukotrienes, antibiotics, and proton-pump inhibitors according to the Global Initiative for Asthma (GINA) guidelines. Seventy patients, who were resistant to these treatments, were enrolled in this double-blind randomized clinical trial. After randomization, eligible subjects received a cromolyn metered dose inhaler (MDI) or a placebo MDI, which was completely similar in appearance to the cromolyn inhaler. The primary outcomes included cough and Asthma Control Test (ACT) score.

RESULTS

Based on the findings, cough significantly decreased with cromolyn therapy, compared to the placebo group. Other clinical findings, including dyspnea, sputum production, and nocturnal symptoms, also improved. The ACT score significantly improved to a nearly normal level (23.53±2.25) in the cromolyn group. Moreover, fractional exhaled nitric oxide (FeNO) significantly decreased with cromolyn treatment (14±9.31 ppm after treatment vs. 28.88±27.39 before treatment). The neutrophil count significantly decreased in the cromolyn group (from 44±24.2% before the trial to 34.08±16.7% after the trial), while it increased in the placebo group (from 39.67±26.47% to 56.71±27.22%).

CONCLUSION

Cromolyn improved the clinical findings of resistant cough-variant asthma and could suppress neutrophilic inflammation.

Effect of Salmeterol-Fluticasone Combination and Tiotropium on Clinical and Physiological Improvement of Bronchial Anthracofibrosis: a Double Blind Randomized, Cross Over, Placebo Controlled, Clinical Trial

BACKGROUND

Bronchial anthracosis is the black discoloration of bronchial mucosa that exhibits similar manifestations to Chronic Obstructive Pulmonary Disease ( COPD). The etiology of this obstructive lung disease has not been elucidated and standard therapy for this disease has not been introduced in the literature. The objective of this study is to determine the efficacy of the salmeterol-fluticasone inhaler and tiotropium as two safe treatments of obstructive lung disease for the treatment of symptomatic subjects of anthracofibrosis of the lung.

MATERIALS AND METHODS

Twenty anthracofibrosis subjects who suffered from dyspnea were enrolled in this three-phase, cross over, placebo-controlled clinical trial. The primary outcome variable was quality of life (evaluated with the CAT questionnaire). Clinical findings and spirometry were the secondary outcome variables. Both of these drugs were delivered by an inhaler and were made identically by the reference manufacturer. Salmeterol-fluticasone was prescribed with a spacer and tiotropium by its special device, and the method of utilization was taught to the patients.

RESULTS

Twenty anthracofibrosis subjects were enrolled in this three-phase, five-month course of treatment with either salmeterol-fluticasone or tiotropium inhalers. The response to therapy was not good; neither for salmeterol-fluticasone nor for tiotropium in the short course of the treatment. However, the overall results of 5 months of therapy with both of the drugs have shown improvement in 57% of the subjects. The most prominent results were found in the CAT score [25.1±5.54 before the trial, which decreased to 19.2±5.14 (Z score=2.7, P=0.007)] and clinical findings especially sputum, chest pain, and wheezing (81, 94 and 92% before the trial and 50, 56, 54% after the trial, respectively). Neither clinical findings nor spirometry was able to predict a good response to salmeterol-fluticasone or tiotropium.

CONCLUSION

The combination of salmeterol-fluticasone and tiotropium inhaler was able to improve the clinical findings of symptomatic anthracofibrosis patients.

Effects of Rosmarinus officinalis and Platanus orientalis extracts on asthmatic subjects resistant to routine treatments

OBJECTIVE

The present study aimed to determine the effects of Rosmarinus officinalis (R. officinalis) and Platanus orientalis (P. orientalis) extracts on asthma.

MATERIALS AND METHODS

We conducted a randomized, double-blind, active-comparator study to evaluate the effect of P. orientalis and R. officinalis extracts on asthmatic patients resistant to routine treatment. The subjects were randomly divided into three groups receiving P. orientalis and R. officinalis extracts alone or in combination. The primary endpoints were clinical findings, spirometry, exhaled nitric oxide (FENO) and Asthma Control Test (ACT) assessed over the one-month treatment period.

RESULTS

ACT score showed significant improvement after treatment with R. officinalis (p<0.05) but not with P. orientalis. Clinical evaluations showed that cough, sputum production and wheezing were significantly improved in R. officinalis group (p<0.05 to p<0.001) while in P. orientalis group only improvement of cough and chest tightness were shown. Spirometry results showed significant improving in FEV1/VC values for subjects treated with P. orientalis and those who received the combination of extracts as well as significant decrease in FEF25-75 value only for P. orientalis group (p<0.05 for all cases). FENO was decreased in both groups but the results were statistically significant only for R. officinalis group (p<0.05). Abdominal pain and skin rash were the most frequent side effects of the treatments which led to discontinuation of the intervention.

CONCLUSION

R. officinalis extract showed promising results in treatment of resistant asthma. Further studies to find the most effective components of these herbal medicines are recommended.

A Viewpoint on the Leaky Gut Syndrome to Treat Allergic Asthma: A Novel Opinion

Asthma is a common respiratory disease characterized by airway inflammation, airway hyperreactivity, and reversible airflow obstruction. Despite current treatments, the prevalence of asthma has increased markedly over decades. According to the theories proposed to explain the pathophysiology of autoimmune diseases in integrative medicine, leaky gut syndrome is a phenomenon of increased intestinal permeability due to the disruption of tight junctions and is thought to be related to many chronic diseases, such as food intolerance, inflammatory bowel disease, rheumatoid arthritis, asthma, and other autoimmune disease. One of the classical approaches used by integrative physicians to treat leaky gut syndrome is to repair intestinal permeability to prevent allergic cascade. Due to several mechanisms that have been mentioned in the protective effects of plant gums and plantain family seeds on the intestinal epithelium, we can propose an effective management for leaky gut syndrome to treat asthma.

Effect of Borago Officinalis Extract on Moderate Persistent Asthma: A Phase two Randomized, Double Blind, Placebo-Controlled Clinical Trial

BACKGROUND

Borago officinalis and its derivatives are used in folk medicine to treat asthma because of its special effect on allergic disorders. It suppresses the tumor necrosis factor-alpha (TNF-alpha) and delivers gamma-linolenic acid. The objective of this clinical trial was to determine the effect of Borago officinalis on clinical and physiological findings in moderate persistent asthma.

MATERIALS AND METHODS

This prospective, randomized, double blind, placebo-controlled, clinical trial was conducted on patients aged 15-90 years with moderate asthma and forced expiratory volume in one second (FEV1) of 60-79% of predicted who presented to a sub-specialty clinic of pulmonary medicine. We randomly allocated subjects to receive either Borago extract (5 mL three times a day) or a matched placebo for one month. The primary outcome was the asthma control test (ACT) score and fractional exhaled nitric oxide (FENO) test. Secondary outcomes included clinical findings, spirometry, and sputum cytology including inflammatory cells.

RESULTS

Thirty-eight subjects with a mean age of 46.8±15.3 years and mean duration of asthma of 71±103 months were enrolled in our study. Cough, dyspnea, wheezing, nocturnal symptoms, and airway hyper-responsiveness reduced significantly in the Borago group after the treatment and ACT scores improved significantly (10.8±5.26 before and 15.4±5.12 after the trial). Flare up of asthma and emergency department visits in the Borago group also decreased significantly (3.6±2.33 to 2±1.86 flare ups per month and 0.62±0.9 to 0.05±0.23 for emergency department visits per month). Physiological parameters including spirometry, FENO, and sputum cytology including eosinophil and neutrophil did not change significantly.

CONCLUSION

Borago improved the clinical findings of asthma, but it was not able to suppress the inflammation involved in asthma.

Frequency of tuberculosis in anthracosis of the lung: a systematic review

INTRODUCTION

Anthracosis of the lung is the blackening of bronchial tissues which can lead to chronic bronchial obstruction. Many studies have shown association of bronchial anthracosis and tuberculosis. The aim of this study was accumulation of scattered studies and getting the definite conclusion about the association between anthracosis and tuberculosis.

MATHERIALS AND METHODS

We conducted a systematic search that included studies with sufficient information about the frequency of tuberculosis in anthracosis (anthracofibrosis) patients and non-anthracotic control group. Moreover, tuberculosis should be confirmed by microbiologic (smear or culture) or histopathological methods.

RESULTS

Twelve studies (eight studies on anthracofibrosis and four studies on anthracosis as a general term) comprising of 6280 patients was entered into our meta-analysis. The frequency of tuberculosis in all anthracosis patients was 22.5 % (32.3 % for anthracofibrosis and 16.6 % for anthracosis), which was significantly higher than the control group. Determination of risk showed that the cumulated odds ratio of tuberculosis in all studies of anthracosis was 3.16 (95 % CI = 2.49 - 6.85), which revealed significantly higher risk than the control group. The analysis of the subgroups showed that the cumulated odds ratio of tuberculosis in subgroups of anthracofibrosis (3.28; 95 % CI = 2.16 - 9.12) was significantly higher than anthracosis as a general term (2.85; 95 % CI = 1.73 - 6.61).

DISCUSSION

The association of tuberculosis with all types of anthracosis of the lung was confirmed and a proper mechanism should be defined.

Anthracosis of the lungs: etiology, clinical manifestations and diagnosis: a review

Anthracosis of the lungs is black discoloration of bronchial mucosa that can occlude bronchial lumen and is associated with bronchial anthracofibrosis (BAF). This disease usually presents with a chronic course of dyspnea and or cough in an elderly non-smoker woman or man. In addition, concomitant exposure to dust and wood smoke is the most postulated etiology for anthracosis. Pulmonary function tests usually show an obstructive pattern with no response to bronchodilators and normal DLCO, but some cases with restrictive pattern have also been seen. Computed tomography (CT) may show more specific findings such as lymph node or bronchial calcification and mass lesions. Final diagnosis can be made by bronchoscopy when obtaining samples for tuberculosis (TB), which is the most common disease associated with BAF. Endobronchial ultrasound shows a hypoechoic scattered nodular pattern in adjacent lymph nodes, which is unique to anthracosis. Treatment is very similar to that of chronic obstructive pulmonary disease (COPD) with a chronic course and low mortality. This review discusses this disease as a separate entity; hence, anthracosis should be added to the list of obstructive lung diseases and benign mass lesions and differentiated from biomass induced COPD.

Diagnosis of chronic obstructive pulmonary disease earlier than current Global Initiative for Obstructive Lung Disease guidelines using a feasible spirometry parameter (maximal-mid expiratory flow/forced vital capacity)

Some patients suffer from clinical symptoms of chronic obstructive pulmonary disease (COPD) but their pulmonary function tests are in the normal range (at risk group). The objective of this study was to discover a practical test to distinguish these patients from non-COPD subjects. A total of 77 subjects including 40 COPD patients, 37 subjects at risk for developing COPD, and 32 control subjects were entered in this study. The accuracy of maximal-mid expiratory flow (MMEF)/forced vital capacity (FVC) for the diagnosis of COPD in at risk patients and its capability to differentiate from early COPD and normal patients were evaluated. Body plethysmography was used for measurement of lung volume as the Global Initiative for Obstructive Lung Disease standard. MMEF/FVC in the at risk group of COPD (0.73 ± 0.19) was significantly lower than the normal control group (0.9 ± 0.24, respectively), and also, it was significantly higher than the COPD group (0.31 ± 0.17). There was significant correlation between the MMEF/FVC and amount of smoking measured by pack year ( r2 = 0.112, p = 0.005) and stages of COPD (Spearman’s ρ = 0.82, p = 0.0001). Early stage COPD (smoker subjects without spirometry derangement) can be diagnosed by MMEF/FVC. Using this tool we may be able to detect this highly preventable disease at an earlier stage.

Simple screening of pulmonary artery hypertension using standard chest x ray: an old technique, new landmark

BACKGROUND

Pulmonary artery hypertension (PAH) is difficult to diagnose because of its nonspecific symptoms. Although echocardiography can reliably and rapidly recognize the presence of pulmonary hypertension, chest X ray (CXR) is more widely used because of its availability. The objective of this study was to find a parameter, which, by changing the scale of CXR, is still useful for detection of PAH.

MATERIALS AND METHODS

This case control prospective study included 100 subjects with a clinical finding of dyspnea. Additionally, thirty healthy volunteers (control group) were included in this study. Systolic pulmonary artery pressure (SPAP) was determined by echocardiography. Widening of pulmonary hilum, projection of the right side of the heart border (PRHB) and the ratio of these parameters to the chest diameter were compared to SPAP using the regression method. A cut-off point was determined for parameters that showed significant correlation.

RESULTS

The most prevalent disease in the dyspnea group was COPD (28%). Average SPAP was 41.8±17.3 (ranging from 10 to 87 mmHg). Multivariate analysis of the covariance revealed significant correlation between SPAP, age, sex and hilar widening (r = 0.44, P = 0.0001) that was higher than PRHB and hilar widening + PRHB (r= 0.374. and r= 0.438, respectively). The ROC curve showed that the area under the curve was not significantly different for all parameters and the best cut-off point with sensitivity of more than 80% was as follows: hilar size more than 112 mm, PRHB more than 44 and hilum/chest ratio more than 0.44.

CONCLUSION

Hilum/chest ratio is the proper substitution for the hilar size in case of changing the scale of the chest X ray. Evaluation of hilar widening and PRHB could lead to identifying more subjects suffering from undiagnosed PAH.

Bronchial anthracosis: a new diagnosis for benign mass lesions of the lung

BACKGROUND

This study aimed to identify the most important new radiological presentations of anthracosis and anthracofibrosis and evaluate the risk ratio for accurate diagnosis of these conditions using computed tomography instead of bronchoscopy.

MATERIALS AND METHODS

This prospective, case-control study evaluated three groups of 70 patients with a bronchoscopic diagnosis of simple anthracosis and anthracofibrosis and 40 patients with a non-anthracotic diagnosis (control group). Bronchoscopy, chest radiographs and computed tomography (CT) (parenchymal and mediastinal windows) were reviewed. Special attention was given to mass lesions, calcified lymph nodes, bronchi and bronchial stenosis.

RESULTS

Abnormal chest x-rays were observed in 93% of patients with bronchial anthracofibrosis; patchy consolidation was the most prevalent finding. The most significant CT finding was lymph node calcification (80%, odds ratio = 22.9), followed by bronchial calcification and bronchial stenosis (odds ratio = 6 and 2.91, respectively). Other significant findings were mass-like lesions (14%) and collapse (20%). CT findings were unremarkable in less than 1/6 of subjects.

CONCLUSION

Lymph node and bronchial calcification can serve as accurate signs in diagnosing anthracosis of the lung. In addition, mass lesions, collapse and infiltration may be associated with a benign course.

Decreased levels of soluble Toll-like Receptor 2 in patients with asthma

BACKGROUND

Recently, reports have indicated a role for the membrane form of Toll-like Receptor 2 (TLR2) in asthma pathogenesis. In this study we examined soluble TLR2 levels in serum and sputum of asthmatic and healthy subjects.

METHODS

Serum and sputum samples were obtained from 33 asthmatic and 19 healthy subjects. The asthmatics were classified into four groups according to the Global Initiative for Asthma. A sandwich ELISA was developed to measure soluble TLR2 (sTLR2) in serum and sputum. TLR2 mRNA expression was determined by semi-quantitative RT-PCR of all sputum samples.

RESULTS

The mean sTLR2 levels from serum and sputum of asthmatics were significantly lower than those from healthy subjects. Moreover, sTLR2 concentration decreased concomitantly with asthma severity. The differences observed, however, were not statistically significant. TLR2/GAPDH mRNA of sputum leukocytes was also significantly lower in asthmatics than in healthy subjects.

CONCLUSION

This study demonstrated for the first time thatsTLR2 levels are lower in serum and sputum samples from asthmatic than from healthy subjects, and this could be an indicator of TLR2 expression. We also found that sTLR2 concentration in serum decreased concomitantly with an increase of asthma severity clinical score .

Preventive Effect of Novel Bacterial Polysaccharide and Animal Splenic Protein as Natural Adjuvants on Animal Model of Asthma

OBJECTIVES

Two new adjuvants from natural animal lipids (G2) and bacterial polysaccharide extracts (PC) were previously prepared by our group and showed a reduction in tracheal responsiveness. The aim of this study was to evaluate the preventive effect of recently introduced natural products (G2 and PC) on the development of asthma.

MATERIALS AND METHODS

Asthma was induced using a standard method in four groups of BALB/c mice. A non-sensitized control group was also included in order to be compared with treated groups. Three groups were premedicated with novel agents named G2, PC, and a combination of these two for 20 days before starting the induction of asthma. Bronchoalveolar lavage fluid (BALF) was collected and analyzed for inflammatory cells. Interferon-γ, and IL-4 and the histopathological of both lungs were also evaluated.

RESULTS

In all pretreated groups, the inflammatory cells infiltration especially eosinophils and smooth muscle hyperplasia decreased significantly. BALF cytology also showed significant decrease in eosinophil count in all pretreated groups. There was a significant increase in the BALF and serum INF-γ in all pretreated groups but the combination of G2/PC was more effective. BALF IL-4 decreased significantly in the group pretreated with a combination of G2 and G2/PC (4.11±0.86 and 4.02±0.52 pg/ml in G2 and G2/PC, respectively). Serum IL-4 in the PC group was significantly higher than the sensitized control.

CONCLUSION

G2 and PC may effectively prevent asthma development by activation of the type 1 T helper system.

Pattern of pulmonary function test abnormalities in anthracofibrosis of the lungs

BACKGROUND

The objective of this study was to discuss the spirometric characteristics of anthracofibrosis which is a from of bronchial anthracosis associated with deformity.

MATERIALS AND METHODS

Forty anthracofibrosis subjects who were diagnosed with bronchoscopy were enrolled in this prospective study. Static and dynamic spirometry plus lung volumes and diffusion capacity were measured in this group and compared to a healthy control group.

RESULTS

Dyspnea (95%), cough (86%) and wheezing (68%) were the most frequent clinical findings. Spirometry showed significant decrease in all parameters including VC (FVC), FEV1, FEV1/FVC, FEF25-75 and FEF25-75 /FVC. The low value of FEV1/FVC and FEF25-75 and the increment of RV were in favor of obstructive patterns in 95% of subjects. Improving the obstruction with bronchodilator was not significant and diffusion capacity was mostly normal.

CONCLUSION

Anthracofibrosis should be added to the list of chronic obstructive pulmonary diseases.

Effect of verapamil on bronchial goblet cells of asthma: an experimental study on sensitized animals

INTRODUCTION

Goblet cell hyperplasia (GCH) and mucus hypersecretion in the airway is recognized as an important contributor to morbidity and mortality in asthma and COPD. Verapamil is a calcium channel blocker that binds to the alpha-subunit of L-type calcium channels and inhibits the mucin gene via the calmodulin and CaM kinase pathway. The objective of this study was to determine the in vivo effect of verapamil on GCH and eosinophilic inflammation in sensitized mice.

METHODS

Male BALB/c mice were sensitized to ovalbumin using the standard method. Two groups of animals were received verapamil via an intramuscular injection: 1-low dose (0.5 mg/kg/day for two weeks), 2-high dose (1.5 mg/kg/day for two weeks). Serum and bronchoalveolar lavage fluid (BALF) was collected and analyzed for inflammatory cells, interferon-γ and IL-4. The left lung was sent for histopathological evaluation, especially for periodic acid-Schiff (PAS), to identify goblet cells in the epithelium. The degree of inflammatory cell infiltration, including eosinophils, mucus plugging, and smooth muscle thickness of the airways were classified on a semi quantitative scale.

RESULTS

Inflammatory cell infiltration in peribronchial and perivascular areas was observed in all sensitized groups. Eosinophils percentage in the BALF significantly decreased in verapamil-treated mice compared with sensitized mice (from 19.8% in asthmatic to 5.4% for low dose and 4.4% for high dose). The ratio of airway goblet cells per epithelial cells were significantly lower in verapamil-treated mice versus sensitized mice (1.57±1.30% for low dose; 1.50±0.93% for high dose versus 12.93±7.55%, P<0.05, respectively). Mucus production of goblet cells decreased significantly in verapamil-treated mice versus sensitized mice (mean score was 1.45±0.30 for low dose; 0.81±1.00 for high dose versus 2.85±0.86 in the sensitized control group, P<0.05, respectively). The concentration of serum and BALF-IFN-γ in verapamil-treated mice markedly increased by the verapamil treatment when compared to sensitized mice (15.1±0.43 versus 4.7±0.96, P<0.05 and 91.8±47.7 versus 14.8±4.6, P<0.01, respectively).

CONCLUSION

Verapamil is a useful drug with therapeutic targeting on GCH and a potential way to limit mucous production and improve bronchial inflammation.

Prevalence of asthma in children of chemical warfare victims

OBJECTIVE

Exposure of DNA to sulfur mustard gas may increase the inheritance of asthma in chemical warfare victims' (CWV) offspring. The objective of this study was to determine the prevalence of asthma in children of CWV and compare it to asthmatic children in the general population.

METHODS

Four hundred and nine children from 130 CWV fathers and 440 children from 145 asthmatic parents from two cities in Iran participated in this study. The prevalence of asthma was determined by standard questionnaire released for epidemiological survey of asthma in children and compared between two groups.

FINDINGS

The prevalence of asthma in the CWV group was 15%; this was not significantly different from the control group (12.5%). The children of the CWV group reported a significantly greater incidence of wheezing (1.2±3.1 attacks) per year, but the control group reported more severe attacks leading to speech difficulties (3%) and coughing (7%). Regression analysis showed that with increasing family size in the control group, the number of subjects suffering from asthmatic symptoms decreases significantly (r=0.86, P=0.001).

CONCLUSION

Chemical agents may increase the prevalence of asthma in the offspring of CWV.

Is serum or sputum eosinophil cationic protein level adequate for diagnosis of mild asthma?

Spirometry has been used as a common diagnostic test in asthma. Most of the patients with a mild asthma have a FEV1 within normal range. Hence, other diagnostic methods are usually used. The aim of this study was to evaluate whether eosinophil Cationic Protein (ECP) could be an accurate diagnostic marker of mild asthma. In this study diagnosis of asthma was made according to internationally accepted criteria. Asthma severity was evaluated according to frequency of symptoms and FEV1.Adequate sputum samples were obtained in 50 untreated subjects. A control group of 12 normal subjects that showed PC20 more than 8 mg/dl was also examined. Sputum was induced by inhalation of hypertonic saline. Inflammatory cells in sputum smears were assessed semi-quantitatively. ECP and IgE concentrations, eosinophil (EO) percentage and ECP/EO ratio in serum and sputum were also determined. The results revealed that Cough and dyspnea were the most frequent clinical findings. Dyspnea and wheezing were the symptoms that correlated with staging of asthma. FEV1 was within normal range (more than 80% of predicted) in 22 (44%) subjects.Asthmatic patients showed significantly higher numbers of blood eosinophils (4.5+/- 3.1% vs. 1.2+/-0.2%, P=0.009), and higher levels of serum ECP than control group (3.1+/- 2.6 % and 22.6+/- 15.8 ng/ml, respectively). Sputum ECP level in asthmatics was significantly higher than non- asthmatics (55.3+/-29.8ng/mL vs. 25.0+/-24.7ng/mL, P=0.045). Regression analysis showed no significant correlation between spirometric parameters and biomarkers, the only exception was significant correlation between FEF(25-75) and serum ECP (r= 0.28, P 0.041). Regarding clinical symptoms, wheezing was significantly correlated with elevation of most of biomarkers. Since, serum and sputum ECP levels are elevated in untreated asthmatics, the ECP level could be used for accurate diagnosis of mild form of asthma in which spirometry is unremarkable.

Prevalence of work-related respiratory symptoms in Iranian farmers

BACKGROUND

Animal exposure may be an important trigger for work-related symptoms among farmers.

OBJECTIVE

To estimate the prevalence of work-related respiratory symptoms (WRS) in sheep breeders and agricultural farmers and to determine work-related risk factors.

METHODS

A family doctor used a questionnaire to interview a cohort of 173 farmers comprised of 127 sheep breeders and 46 agricultural farmers in the rural area of Rokh (northeast Iran). The questionnaire pertained to recurrent wheezing, cough, breathlessness or chronic phlegm while at work (these symptoms define WRS), flu-like illness and physician-diagnosed asthma.

RESULTS

There were 71 subjects (41%) with WRS: 10 of 46 agricultural farmers (21.7%) and 61 of 127 sheep breeders (48.0%). The proportions of sheep breeders with wheezing (16.5%), asthma (14%), cough (29%), breathlessness (31.5%) and flu-like illness (38%) were higher than in agricultural farmers. A significant dose-response relationship among the daily hours worked with animals, the number of animals and the prevalence of symptoms was established for sheep farmers. Sheep shearing and the use of pesticide were associated with an increased risk of wheezing and phlegm.

CONCLUSIONS

The results suggest that sheep farmers in general have higher rates of work-related symptoms than agricultural farmers. The severity of work-related symptoms will increase with an increase in frequency of animal contact; therefore, these results may underestimate the impact of this exposure.

Airway hyperresponsiveness to methacholine in chemical warfare victims

BACKGROUND

The lung is one of the most exposable organs to chemical warfare agents such as sulfur mustard gas. Pulmonary complications as a result of this gas range from severe bronchial stenosis to mild or no symptoms. Airway hyperresponsiveness (AHR) which is usually assessed as response to inhaled methacholine is the most characteristic feature of asthma. AHR is reported in chronic obstructive pulmonary disease patients and smokers, and may also show in chemical warfare victims. However, there are little reports regarding AHR in chemical warfare victims.

OBJECTIVE

Therefore, in this study, airway responsiveness to methacholine in victims of chemical warfare was examined.

METHODS

The threshold concentrations of inhaled methacholine required for a 20% change in forced expiratory flow in 1 s (FEV1; PC20) or a 35% change in specific airway conductance (PC35) were measured in 15 chemical war victims and 15 normal control subjects.

RESULTS

In 10 out of 15 chemical warfare victims (two thirds), PC20 and PC35 methacholine could be measured and subjects were called responders. AHR to methacholine in responder chemical war victims (PC20 = 0.41 and PC35 = 0.82 g/l) was significantly lower than in normal subjects (PC20 = 5.69 and PC35 = 4.60 g/l, p < 0.001 for both cases). There was a significant correlation between FEV1 and PC20 methacholine (r = 0.688, p < 0.001). The correlations between PC20 and PC35 were statistically significant as well (r = 0.856, p < 0.001).

CONCLUSION

Results showed increased airway responsiveness of most chemical warfare victims to methacholine which correlated with the FEV1 value and which may be related to chronic airway inflammation or irreversible airway changes.