Effect of switching from salmeterol/fluticasone to formoterol/ budesonide combinations in patients with uncontrolled asthma.

BACKGROUND: Combination therapy with an inhaled corticosteroid (ICS) and a long-acting ß(2)-agonist (LABA) in a single inhaler is the mainstay of asthma management and salmeterol/fluticasone combination (SFC) and fixed-dose formoterol/budesonide combination (FBC) are currently available in Japan; however, there is nothing to choose between the two. The purpose of this study was to clarify the effect of switching from SFC to FBC in patients with asthma not adequately controlled under the former treatment regimen. METHODS: This was a prospective, multicenter, open-label, uncontrolled longitudinal study in 87 adult patients with an Asthma Control Questionnaire, 5-item version (ACQ5) score of greater than 0.75 under treatment with SFC 50/250µg one inhalation twice daily (bid). SFC was switched to FBC 4.5/160µg two inhalations bid. Study outcomes included ACQ5 score, peak expiratory flow (PEF), FEV(1), and fractional exhaled nitric oxide (FeNO) at the end of treatment period. RESULTS: Eighty-three patients completed the study. ACQ5 scores improved and exceeded the clinically meaningful difference after 12 weeks of treatment and well-controlled asthma (ACQ5 score ≤0.75) was attained in 37 (44.6%) patients. Minimum and maximum PEF and FEV(1) values improved significantly, but not FeNO values, after switching from SFC to FBC. CONCLUSIONS: Switching ICS/LABA combination therapy is a useful option in the management of asthma that is not optimally controlled.

Prognosis in adult patients with idiopathic pulmonary hemosiderosis.

BACKGROUND: Diffuse alveolar hemorrhage (DAH) of unknown cause has been characterized as idiopathic pulmonary hemosiderosis (IPH). IPH is a rare disease, which has a high prevalence in children and shows a poor prognosis. However, in adults, since there are few reports about collective cases, the details remain to be determined. METHODS: Between January 2003 and June 2008, consecutive adult patients strictly defined as unknown cause DAH by chest images, fiberoptic bronchoscopy, autoantibody testing, and exclusion of systemic disease were enrolled. We investigated the clinical characterization and course of the enrolled patients. RESULTS: Nine patients were included. All patients were middle-aged men (56.1 ± 4.2 year-old) with sudden onset. They did not present with anemia (the hemoglobin level was 13.9 ± 0.5 g/dL) despite the quantity of bleeding. In bronchoalveolar-lavage fluid analysis, the cell count was increased (7.6 ± 1.6×10(5) cells/mL) with neutorophilia (33.3 ± 13.3%). The illness resolved within 2 weeks with or without corticosteroid therapy. All of the patients were alive without recurrence during the follow-up period (45.2 ± 6.2 months) after diagnosis. CONCLUSION: Adult IPH patients showed good prognosis. However, the present patients are clinically slightly different from the previously characterized IPH.

Epithelial-mesenchymal transition induced by transforming growth factor-beta1 in mouse tracheal epithelial cells.

BACKGROUND AND OBJECTIVE: Epithelial-mesenchymal transition (EMT) is the process by which differentiated epithelial cells undergo a phenotypic transition to mesenchymal cells. This process may occur in certain fibrotic diseases that involve airway remodelling. However, few studies have directly proved the occurrence of EMT in primary cultures of airway epithelial cells. The aim of this study was to clarify whether airway epithelial cells can differentiate into mesenchymal cells through EMT. METHODS: Mouse tracheal epithelial cells (mTEC) were cultured in an air-liquid interface (ALI) culture system, in the presence or absence of transforming growth factor-beta1 (TGF-beta1). The expression of mesenchymal and epithelial cell markers was examined by immunofluorescence staining and western blotting. Secretion of matrix metalloproteinase (MMP)-9 into the culture medium was measured by ELISA. The phenotype of epithelial cells involved in EMT was also examined by immunofluorescence staining. RESULTS: Immunofluorescence staining and western blotting revealed that TGF-beta1 treatment for 14 days induced the expression of the mesenchymal markers, alpha-smooth muscle actin (alpha-SMA) and vimentin, and reduced the expression of the epithelial markers, zonula occludens-1 (Zo-1) and occludin. In addition, alpha-SMA and Zo-1 were colocalized within individual cells treated with TGF-beta1. Concentrations of MMP-9 in the culture medium were significantly higher in TGF-beta1-treated mTEC than in untreated cells. The basal cell markers, cytokeratin-5 and cytokeratin-17, were colocalized within the cells expressing alpha-SMA. CONCLUSIONS: EMT was induced by TGF-beta1 in primary cultures of mTEC, suggesting that airway epithelial cells, possibly the basal cells, may be involved in airway remodelling through EMT.

Involvement of the p38 MAPK pathway in IL-13-induced mucous cell metaplasia in mouse tracheal epithelial cells.

BACKGROUND AND OBJECTIVE: IL-13 has been shown to play a pivotal role in mucous cell metaplasia, which is an important feature of the pathogenesis of asthma. However, the signalling pathways evoked by IL-13 in airway epithelial cells remain unclear. This study investigated the signalling mechanism of IL-13-induced mucous cell metaplasia in primary cultures of mouse tracheal epithelial cells (mTEC). METHODS: mTEC were cultured in an air-liquid interface system in the presence or absence of IL-13. Goblet cell hyperplasia was evaluated quantitatively by immunofluorescent staining for MUC5AC, which is a major component of airway mucins. Western blotting was used to assess activation of the signalling molecules, signal transducer and activator of transcription 6 (STAT6), p38 mitogen-activated protein kinase (MAPK) and extracellular signal-regulated kinase (ERK) 1/2. MUC5AC gene expression was measured by RT-PCR. RESULTS: IL-13 induced mucous cell metaplasia for 7-14 days in mTEC. IL-13 phosphorylated STAT6 within 20 min, whereas it induced delayed phosphorylation of p38 MAPK 36-48 h after stimulation. In contrast, ERK1/2 was constantly activated and was not enhanced by IL-13. An inhibitor of p38 MAPK (SB202190) suppressed mucous cell differentiation in a concentration-dependent manner. In STAT6 knockout mice, IL-13 failed to induce mucous cell metaplasia and activate p38 MAPK. Cycloheximide also diminished activation of p38 MAPK and induction of MUC5AC mRNA expression by IL-13. CONCLUSIONS: The p38 MAPK pathway is involved in IL-13-induced mucous cell metaplasia and MUC5AC mRNA regulation in mTEC. In addition, p38 MAPK phosphorylation may require STAT6-dependent de novo protein synthesis induced by IL-13.

Blocking airway mucous cell metaplasia by inhibiting EGFR antiapoptosis and IL-13 transdifferentiation signals.

Epithelial hyperplasia and metaplasia are common features of inflammatory and neoplastic disease, but the basis for the altered epithelial phenotype is often uncertain. Here we show that long-term ciliated cell hyperplasia coincides with mucous (goblet) cell metaplasia after respiratory viral clearance in mouse airways. This chronic switch in epithelial behavior exhibits genetic susceptibility and depends on persistent activation of EGFR signaling to PI3K that prevents apoptosis of ciliated cells and on IL-13 signaling that promotes transdifferentiation of ciliated to goblet cells. Thus, EGFR blockade (using an irreversible EGFR kinase inhibitor designated EKB-569) prevents virus-induced increases in ciliated and goblet cells whereas IL-13 blockade (using s-IL-13Ralpha2-Fc) exacerbates ciliated cell hyperplasia but still inhibits goblet cell metaplasia. The distinct effects of EGFR and IL-13 inhibitors after viral reprogramming suggest that these combined therapeutic strategies may also correct epithelial architecture in the setting of airway inflammatory disorders characterized by a similar pattern of chronic EGFR activation, IL-13 expression, and ciliated-to-goblet cell metaplasia.

[Analysis of CD1 molecules in the process of granuloma formation with sarcoidosis].

There have been many reports studying the presentation for lipid antigen by CD1 molecules on dendritic cells (DC), mainly in the infection of acid-fast bacilli. But little is known about the expression of CD1 molecules in sarcoidosis. In this study, we analyzed the expression of CD1 molecules by immunohistochemical stain with monoclonal anti-CD1a, CD1b and CD1c antibody for the specimens of nine sarcoidosis patients (sarcoidosis group) and seven control cases (control group). Aggregation of CD1 positive cells was present adjacent to granulomas in five cases of the sarcoidosis group, but was absent in all cases of the control group. There were no differences in the results of laboratory findings or disease activity between CD1-positive and negative cases in the sarcoidosis group. These data suggest that the presentation of lipid antigens mediated by CD1 molecules on DC is involved in granuloma formation in sarcoidosis.

Impaired toll-like receptor 9 expression in alveolar macrophages with no sensitivity to CpG DNA.

Unmethylated CpG motifs in bacterial DNA or synthetic oligodeoxynucleotides (ODN) potently stimulate the innate immune system, and they are recognized by Toll-like receptor 9 (TLR9), which is expressed by monocytes/macrophages, dendritic cells, and B cells. However, it is unknown whether alveolar macrophages (AMs) express functional TLR9. To clarify this, we analyzed mRNA expressions of TLRs in murine AMs by real-time polymerase chain reaction, and compared with those in other tissue macrophages and lung antigen-presenting cells. In addition, we determined the sensitivity of these cell populations to CpG-ODN. Interestingly, TLR9 mRNA was almost absent in AMs, but highly expressed in bone marrow-derived macrophages and peritoneal macrophages, whereas TLR2 and TLR4 were present in all macrophage populations. Consistent with the receptor expression, AMs showed no sensitivity to CpG-ODN, whereas other macrophage populations secreted tumor necrosis factor alpha, interleukin 12 p40, and interleukin 6, and enhanced expression of CD40, CD80, and CD86, in response to CpG-ODN. Lung dendritic cells and B cells highly expressed TLR9 mRNA and responded to CpG-ODN. These results indicate selective loss of TLR9 expression in AMs with no sensitivity to CpG-ODN, suggesting that dendritic cells and B cells play a role in the immune response against bacterial DNA in the lung.

Differences in clinical features and prognosis of interstitial lung diseases between polymyositis and dermatomyositis.

OBJECTIVE: To assess the difference in clinical features and prognosis of patients with interstitial lung disease (ILD) comparing polymyositis (PM) and dermatomyositis (DM). METHODS: Medical records of 28 ILD patients with PM/DM (16 PM-ILD, 12 DM-ILD) were reviewed retrospectively. RESULTS: Serum CPK concentrations were significantly higher in PM-ILD than in DM-ILD. Bronchoalveolar lavage analysis showed that the percentages of lymphocytes and eosinophils were significantly higher in DM-ILD than in PM-ILD. Ten patients (5 PM-ILD, 5 DM-ILD) underwent surgical lung biopsy, and 3 (3 DM-ILD) had an autopsy. Nonspecific interstitial pneumonia (NSIP) was found in 7 (4 PM-ILD, 3 DM-ILD) and usual interstitial pneumonia (UIP) in 3 (1 PM-ILD, 2 DM-ILD). Interestingly, diffuse alveolar damage (DAD) was found in 3 patients with DM-ILD, who all died of deterioration of ILD; but no one with PM-ILD had DAD. Corticosteroid treatment alone achieved a favorable response in 6 patients (37.5%) with PM-ILD, but in only one (8.3%) with DM-ILD. Administration of cyclosporine in the early phase of onset benefited 4 corticosteroid-resistant patients with DM-ILD. Conclusively, survival in DM-ILD was significantly worse than that in PM-ILD. CONCLUSION: DM-ILD is more refractory to corticosteroid therapy, resulting in poorer prognosis compared with PM-ILD. These data indicate that intensive therapy, including cyclosporine, should be considered for DM-ILD.

[A case of adenocarcinoma of the lung presenting symptoms of choroidal metastasis as the initial clinical manifestation].

A 51-year-old woman was referred to our hospital with a complaint of disturbance in vision. Ophthalmologic examination revealed multiple choroidal tumors. High-resolution CT showed a nodular shadow in the left lower lobe. Transbronchial biopsy and right supraclavicular lymph node biopsy specimens showed a poorly-differentiated adenocarcinoma. We concluded that the choroidal tumors had metastasized from the lung. Combined chemotherapy (CDDP + CPT-11) followed by irradiation of both eyes and brain were performed. Nevertheless, she died 6 months after the initial presentation. It is important to notice ophthalmologic symptoms because lung cancer may metastasize to the choroids.

[Cyclosporin treatment of interstitial pneumonia and monitoring of serum concentration].

Recently, cyclosporin has been reported to be a promising drug for the treatment of interstitial pneumonia. Monitoring of the serum cyclosporin concentration is important for the safety and efficacy of treatment. We measured the concentrations of this drug just before (C0) and 2 hours after (C2) administration, and the area under the concentration-time curve from the start of administration for 5 hours (AUC 0-5) in 58 patients. We found that C2 has the strongest correlation with AUC 0-5, which indicates the efficacy of cyclosporin. In 11 cases of interstitial pneumonia, 5 showed deterioration despite cyclosporin treatment. Three of those 5 cases had low C2 and AUC 0-5 levels, indicating that they were low absorbers and slow absorbers, which may be associated with a poor response. Therefore, the monitoring of the cyclosporin concentration is important especially in progressive cases of interstitial pneumonia that deteriorate despite cyclosporin treatment.

Effects of suplatast tosilate on cytokine profile of bronchoalveolar cells in allergic inflammation of the lung.

OBJECTIVE: Suplatast tosilate is an anti-allergic agent that inhibits IgE antibody production. It appears to have an inhibitory effect on the production of Th2 cytokines (interleukin (IL)-4, IL-5) in vitro. In the present study, we investigated the effects of suplatast on eosinophil infiltration and cytokine mRNA expression in bronchoalveolar lavage (BAL) fluid in a Brown Norway (BN) rat model of bronchial asthma. METHODOLOGY: Suplatast (50 mg/kg per day) was administered intraperitoneally for 15 consecutive days to 8-week-old male BN rats that had been actively sensitized to ovalbumin (OA) and alum and rats were challenged with OA aerosol to induce allergic bronchial inflammation. The control group was examined 48 h after antigen inhalation to measure the cell count and cell fraction in BAL fluid. Reverse transcription-polymerase chain reaction using primers for IL-4, IL-5, interferon (IFN)-gamma and beta-actin was used to semiquantitatively measure mRNA expression in BAL cells 24 h after antigen inhalation. RESULTS: Suplatast was found to decrease the total cell count and the eosinophil count. The mean total cell count in BAL in the suplatast-treated group was 18.8 x 10(5) and the mean eosinophil count was 7.8 x 10(5) compared with 73.0 x 10(5) and 48.9 x 10(5), respectively, in the control group. Suplatast also suppressed expression of IL-4 and IL-5 mRNA in BAL cells. However, there were no significant changes in IFN-gamma expression. CONCLUSIONS: Suplatast was found to have an inhibitory effect on eosinophil infiltration in a rat model of bronchial asthma. It also appeared to inhibit allergic inflammation by altering the cytokine profile.

Oncostatin M production by human dendritic cells in response to bacterial products.

Oncostatin M (OSM) is a pleiomorphic cytokine that belongs to the IL-6 cytokine family. It is produced by activated T cells and monocytes/macrophages and plays an important role in the process of inflammatory responses. Although dendritic cells (DCs) have been shown to secrete a variety of cytokines, it is not elucidated whether DCs are able to produce OSM. To clarify this, using human DCs derived from peripheral blood cells, we measured the protein levels of OSM in the supernatants of DC cultures by ELISA and examined the expression of OSM mRNA by RT-PCR after stimulation with lipopolysaccharide (LPS) or fixed Staphylococcus aureus (SACS). Upon stimulation with bacterial products, DCs secreted a large amount of OSM protein in a dose- and time-dependent manner. Concomitantly, the expression of OSM mRNA by DCs was markedly up-regulated. Compared the ability of DCs to produce OSM with that of monocytes, which are major producers of OSM, DCs released significantly higher amounts of OSM protein in the culture supernatants than monocytes. These findings indicate for the first time that human monocyte-derived DCs can synthesize and secrete large amounts of OSM in response to bacterial products, suggesting that OSM produced by DCs at infectious sites may play a role in modulating inflammatory responses.