Clinical outcomes of KRAS-mutant non-small cell lung cancer under untargeted therapeutic regimes in the real world: a retrospective observational study.

Background: Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation seemingly suffered less effective therapeutic regimens in the absence of widely-accepted targeted drugs compared with other mutation types in non-small cell lung cancer (NSCLC). However, whether these non-selective therapy schedules for KRAS mutation matters is still under debate. Correspondingly, we aimed to compare the long term expectancy of indicated therapeutic regimes and further explore the optimal schemes of KRAS mutated NSCLC in the absence of targeted drugs in this retrospective study cohort. Methods: We conducted a single-center retrospective analysis among 66 patients diagnosed with KRAS-mutant advanced NSCLC from November 2018 to December 2020. These enrolled cases were divided into different subgroups in light of mutant isotypes, pathological characteristics, and therapeutic regimes to uncover indicated long-term survival benefits. Additionally, clinical outcomes of treatment schedules and interventional lines to KRAS-mutant NSCLC were described in detail. Results: This cohort enrolled 8 patients with stage IIIB (12.1%) and 58 patients with stage IV (87.9%) with the median age 62 years, ranging from 32 to 91 years old. Genetically, G12C conducted as the most common KRAS mutation type, accounting for 30.3%. Pemetrexed combined with platinum chemotherapy seemed to be a priority (72.7%), and chemotherapy combined with immunotherapy became an alternative (15.2%) in clinic. Performing further analysis of long-term survival of patients receiving different treatment methods indicated that the median overall survival (mOS) in first-line therapy with antiangiogenesis or untreated was 13 and 12 months, respectively (P=0.79). In the first-line regimen, median survival was 17 months for patients who received combined immune checkpoint inhibitors and 12 months for those who did not (P=0.34). The mOS was 20 months for those who had used immune checkpoint inhibitors and 12 months for those who had not (P=0.11). Survival analysis results of NSCLC patients with different KRAS mutation types showed the median survival time of patients with G12C mutation type and patients without with nonG12C mutation type was 19 and 12 months, respectively (P=0.37). Conclusions: In the absence of KRAS targeted drugs, available treatment plans failed to benefit KRAS mutant sufferers regardless of isotypes, making the KRAS-targeted drugs urgent.

Using inflammatory index to distinguish asthma, asthma-COPD overlap and COPD: A retrospective observational study.

Background: Although asthma and chronic obstructive pulmonary disease (COPD) are two well-defined and distinct diseases, some patients present combined clinical features of both asthma and COPD, particularly in smokers and the elderly, a condition termed as asthma-COPD overlap (ACO). However, the definition of ACO is yet to be established and clinical guidelines to identify and manage ACO remain controversial. Therefore, in this study, inflammatory biomarkers were established to distinguish asthma, ACO, and COPD, and their relationship with the severity of patients' symptoms and pulmonary function were explored. Materials and methods: A total of 178 patients, diagnosed with asthma (n = 38), ACO (n = 44), and COPD (n = 96) between January 2021 to June 2022, were enrolled in this study. The patients' pulmonary function was examined and routine blood samples were taken for the analysis of inflammatory indexes. Logistic regression analysis was used to establish inflammatory biomarkers for distinguishing asthma, ACO, and COPD; linear regression analysis was used to analyze the relationship between inflammatory indexes and symptom severity and pulmonary function. Result: The results showed that, compared with ACO, the higher the indexes of platelet, neutrophil-lymphocyte ratio (NLR) and eosinophil-basophil ratio (EBR), the more likely the possibility of asthma and COPD in patients, while the higher the eosinophils, the less likely the possibility of asthma and COPD. Hemoglobin and lymphocyte-monocyte ratio (LMR) were negatively correlated with the severity of patients' symptoms, while platelet-lymphocyte ratio (PLR) was negatively correlated with forced expiratory volume in the 1 s/forced vital capacity (FEV1/FVC) and FEV1 percent predicted (% pred), and EBR was positively correlated with FEV1% pred. Conclusion: Inflammatory indexes are biomarkers for distinguishing asthma, ACO, and COPD, which are of clinical significance in therapeutic strategies and prognosis evaluation.

Pulmonary rehabilitation ameliorates regional lung function in chronic obstructive pulmonary disease: a prospective single-arm clinical trial.

Background: Pulmonary rehabilitation (PR) is a widely recognized nonpharmacologic therapy for chronic obstructive pulmonary disease (COPD), but most of the current studies on whether PR can benefit COPD patients are based on the evaluation of symptoms and pulmonary function, which is limited to a certain extent. Because COPD is characterized by potential regional lung changes in morphology and pathophysiology, this study was designed to evaluate the effects of individualized PR on regional lung function in patients with stable COPD. Methods: In this study, patients with stable COPD who met the criteria were included, and they were treated with PR for 2 weeks using the respiratory rehabilitation training instrument. The symptoms, and global and regional lung function before and after 2 weeks of PR treatment were evaluated using surveys, spirometry, and electrical impedance tomography (EIT), respectively. The spatial coefficient of variation (CV) of regional spirometry parameters were calculated to quantify spatial heterogeneity of lung function. Temporal inhomogeneity was determined by the regional expiration time. Results: A total of 34 participants were recruited in this study, of whom 24 completed the PR. After 2 weeks of intervention, the modified Medical Research Council (mMRC) dyspnea scale and the COPD assessment test (CAT) score was significantly lower compared to those measured before the treatment (2.3±1.17 vs. 2.1±0.93, P=0.034; and 15.0±7.18 vs. 10.9±6.06, P<0.001, respectively). Global spirometry forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1 predicted percentage (%pred), and peak expiratory flow (PEF) were significantly better than they were pre-rehabilitation (2.1±0.86 vs. 2.3±0.90 L, P=0.018; 1.2±0.65 vs. 1.4±0.66 L, P=0.001; 46.8%±23.16% vs. 51.4%±24.41%, P<0.001; and 3.1±1.80 vs. 3.8±2.23 L/s, P=0.005, respectively). In addition, the CV for regional FEV1/FVC was significantly decreased after the PR treatment (0.26±0.161 vs. 0.17±0.077, P=0.002). Regional lung ventilation was more homogeneous and regional expiration time was shorter after 2 weeks of the PR treatment. Conclusions: Two weeks of PR treatment can improve both spatial and temporal regional ventilation in COPD. In addition, EIT may be useful in developing individualized PR treatment program to improve regional lung function in COPD.

A Novel Electromagnetic Navigation Bronchoscopy System for the Diagnosis of Peripheral Pulmonary Nodules: A Randomized Clinical Trial.

Rationale: Endobronchial ultrasound (EBUS) combined with a guide sheath (GS) as an instrument for confirming the proximity of the bronchoscope and its relationship to the lesion can increase the diagnostic yield when conducting transbronchial lung biopsy of peripheral pulmonary nodules (PPNs). A novel electromagnetic navigational bronchoscopy (ENB) system comprising a thinner locatable sensor probe as a guidance instrument was developed to be suitable for a thin bronchoscope with a working channel 2 mm in diameter. The diagnostic efficacy of EBUS-GS with or without this ENB system has not been confirmed. Objectives: To compare the diagnostic value and safety of EBUS-GS with or without the ENB system for diagnosing PPNs. Methods: A prospective, multicenter, randomized controlled clinical trial was designed and conducted at three centers. Patients with PPNs suspected to be malignant were enrolled and randomly assigned to the ENB-EBUS-GS group or the EBUS-GS group. The primary endpoint was the diagnostic yield in each group. The secondary endpoint was the procedural time and other factors affecting diagnostic yield. The safety endpoint was procedural complications. Results: Four hundred participants were enrolled from July 2018 to October 2019, and 385 patients were analyzed, 193 in the ENB-EBUS-GS group and 192 in the EBUS-GS group. The mean nodule size was 21.7 ± 5.3 mm. The diagnostic yields were 82.9% (95% confidence interval [CI], 77.6-88.2%) in the ENB-EBUS-GS group and 73.4% (95% CI, 67.2-79.7%) in the EBUS-GS group. The difference between the two groups was 9.5% (95% CI, 2.6-16.3%), with an adjusted difference of 9.0% (95% CI, 2.3-15.8%) after adjusting for the stratification factors and center. The time to find lesions in the ENB-EBUS-GS group was shorter than in the EBUS-GS group (213.2 ± 145.6 vs. 264.8 ± 189.5 s; P = 0.003). Intraoperative hemorrhage occurred 3.6% of subjects in the ENB-EBUS-GS group and 3.1% in the EBUS-GS group, without significant differences between the two groups. Conclusions: The novel ENB system combined with EBUS-GS demonstrated improved ability to locate PPNs, achieving a high diagnostic yield for PPNs compared with EBUS-GS alone in a safe and efficient procedure. Clinical trial registered with www.clinicaltrials.gov (NCT03569306).

Development of Diagnosis Model for Early Lung Nodules Based on a Seven Autoantibodies Panel and Imaging Features.

Background: There is increasing incidence of pulmonary nodules due to the promotion and popularization of low-dose computed tomography (LDCT) screening for potential populations with suspected lung cancer. However, a high rate of false-positive and concern of radiation-related cancer risk of repeated CT scanning remains a major obstacle to its wide application. Here, we aimed to investigate the clinical value of a non-invasive and simple test, named the seven autoantibodies (7-AABs) assay (P53, PGP9.5, SOX2, GAGE7, GUB4-5, MAGEA1, and CAGE), in distinguishing malignant pulmonary diseases from benign ones in routine clinical practice, and construct a neural network diagnostic model with the development of machine learning methods. Method: A total of 933 patients with lung diseases and 744 with lung nodules were identified. The serum levels of the 7-AABs were tested by an enzyme-linked Immunosorbent assay (ELISA). The primary goal was to assess the sensitivity and specificity of the 7-AABs panel in the detection of lung cancer. ROC curves were used to estimate the diagnosis potential of the 7-AABs in different groups. Next, we constructed a machine learning model based on the 7-AABs and imaging features to evaluate the diagnostic efficacy in lung nodules. Results: The serum levels of all 7-AABs in the malignant lung diseases group were significantly higher than that in the benign group. The sensitivity and specificity of the 7-AABs panel test were 60.7% and 81.5% in the whole group, and 59.7% and 81.1% in cases with early lung nodules. Comparing to the 7-AABs panel test alone, the neural network model improved the AUC from 0.748 to 0.96 in patients with pulmonary nodules. Conclusion: The 7-AABs panel may be a promising method for early detection of lung cancer, and we constructed a new diagnostic model with better efficiency to distinguish malignant lung nodules from benign nodules which could be used in clinical practice.

Removing Clinical Motion Artifacts During Ventilation Monitoring With Electrical Impedance Tomography: Introduction of Methodology and Validation With Simulation and Patient Data.

OBJECTIVE: Electrical impedance tomography (EIT) is a bedside tool for lung ventilation and perfusion assessment. However, the ability for long-term monitoring diminished due to interferences from clinical interventions and motion artifacts. The purpose of this study is to investigate the feasibility of the discrete wavelet transform (DWT) to detect and remove the common types of motion artifacts in thoracic EIT. METHODS: Baseline drifting, step-like and spike-like interferences were simulated to mimic three common types of motion artifacts. The discrete wavelet decomposition was employed to characterize those motion artifacts in different frequency levels with different wavelet coefficients, and those motion artifacts were then attenuated by suppressing the relevant wavelet coefficients. Further validation was conducted in two patients when motion artifacts were introduced through pulsating mattress and deliberate body movements. The db8 wavelet was used to decompose the contaminated signals into several sublevels. RESULTS: In the simulation study, it was shown that, after being processed by DWT, the signal consistency improved by 92.98% for baseline drifting, 97.83% for the step-like artifact, and 62.83% for the spike-like artifact; the signal similarity improved by 77.49% for baseline drifting, 73.47% for the step-like artifact, and 2.35% for the spike-like artifact. Results from patient data demonstrated the EIT image errors decreased by 89.24% (baseline drifting), 88.45% (step-like artifact), and 97.80% (spike-like artifact), respectively; the data correlations between EIT images without artifacts and the processed were all > 0.95. CONCLUSION: This study found that DWT is a universal and effective tool to detect and remove these motion artifacts.

System introduction and evaluation of the first Chinese chest EIT device for ICU applications.

Chest electrical impedance tomography (EIT) is a promising application which is used to monitor the ventilation and perfusion of the lung at the bedside dynamically. The aim of the study was to introduce the first Chinese made chest EIT device for ICU application (Pulmo EIT-100). The system design of the hardware and software was briefly introduced. The performance of the system was compared to PulmoVista 500 (Dräger Medical) in healthy volunteers. The EIT system Pulmo EIT-100 consists of impedance measurement module, power supply module, PC all-in-one machine, medical cart and accessories. The performance of the system current source and voltage measurement unit was tested. A total of 50 healthy lung volunteers were prospectively examined. Subjects were asked to perform repetitive slow vital capacity (SVC) maneuvers with a spirometer. EIT measurements were performed in the following sequence during each SVC with: (1) Pulmo EIT-100, (2) PulmonVista500, (3) Pulmo EIT-100 and (4) PulmonVista500. Linearity and regional ventilation distribution of the reconstructed images from two devices were compared. The output frequency stability of the current source was 2 ppm. The amplitude error within one hour was less than 0.32‰. The output impedance of the current source was about 50kΩ. The signal-to-noise ratio of each measurement channel was ≥ 60 dB. For fixed resistance measurements, the measured values drifted about 0.08% within one hour. For human subjects, the correlations between the spirometry volume and EIT impedance from two devices were both 0.99 ± 0.01. No statistical significances were found in the parameters investigated. The repeatability (variability) of measures from the same device was comparable. Our EIT device delivers reliable data and might be used for patient measurement in a clinical setting.

Combined analysis of C-reactive protein in pleural fluid and serum is effective in the differential diagnosis of exudative pleural effusions.

BACKGROUND: Exudative pleural effusion (EPE) is one of the common pleural manifestations of various diseases. Differential diagnosis of EPE is imperative clinically as it identifies different causes of EPE, thereby, enabling effective treatments. Thoracoscopy is a useful tool for differential diagnosis of EPE; however, some patients refuse thoracoscopic examination due to its invasive nature. In addition, the specificity and sensitivity of existing routine tests of EPE are unsatisfactory. Therefore, there is a great need to establish an effective method for the differential diagnosis of EPE. METHODS: This study was a single-institution retrospective analysis of diagnostic efficiency of C-reactive protein (CRP) and procalcitonin (PCT) between March 2018 and September 2018. A total of 87 patients diagnosed with EPE were enrolled. All participants underwent diagnostic thoracentesis. The EPE was examined using biochemical, routine, microbiological, and cytological methods. Pathological cytology detection was necessary for those suspected of malignant PE. Benign PE originates in patients with pneumonia, empyema, and tuberculosis. The levels of CRP and PCT in EPE and serum were measured before treatment. Correlation analysis and receiver-operating characteristic (ROC) curve analysis were conducted to determine the underlying relationship between levels of CRP and PCT, and for differential diagnosis. RESULTS: The ROC analysis showed that the sensitivity and specificity for the analysis of pleural fluid CRP (p-CRP) were higher (cut-off: 17.55 pg/mL; sensitivity: 75.00%, specificity: 83.90%) than that of serum CRP (s-CRP, cut-off: 23.90 pg/mL; sensitivity: 71.00%, specificity: 80.4%) in the differential diagnosis for EPE. However, the analysis of pleural fluid PCT (p-PCT) and serum PCT (s-PCT) did not demonstrate correlations with EPE. Combined analysis of p-CRP (cut-off: 17.55 mg/dL) with s-CRP (cut-off: 23.9 pg/mL) showed the highest diagnostic accuracy (88.4%) in diagnosing infectious EPE. CONCLUSIONS: The data support the close relationship between combined analysis of p-CRP with s-CRP and effective and accurate differential diagnosis of EPE, due to its higher sensitivity and specificity. However, as a highly sensitive marker for diagnosing bacterial infections, neither s-PCT nor p-PCT, showed correlations with the differential diagnosis of EPE.

Assessment of Financial Toxicity Among Patients With Advanced Lung Cancer in Western China.

Background: Lung cancer is the leading source of cancer-caused disability-adjusted life years. Medical cost burden impacts the well-being of patients through reducing income, cutting daily expenses, curtailing leisure activities, and depleting exhausting savings. The COmprehensive Score for Financial Toxicity (COST) was created and validated by De Souza and colleagues. Our study intends to measure the financial burdens of cancer therapy and investigate the link between financial toxicity and health-related quality of life (HRQoL) in an advanced lung cancer population. Methods: Patients aged ≥ 18 years with confirmed stage III to IV lung cancer were eligible. The COST questionnaire verified by de Souza et al. was used to identify financial toxicity. Multivariable linear regression analysis with log transformation univariate analysis and Pearson correlations were used to perform the analysis. Results: The majority of the patients (90.8%, n = 138/152) had an annual income of $50,000 ($7,775). The cohort's insurance situation was as follows: 64.5% of the cohort had social insurance, 20.4% had commercial insurance, and 22.0% had both. Patients who were younger age (50-59, P < 0.001), employed but on sick leave, and had lower income reported increased levels of financial toxicity (P < 0.05). The risk factors for high financial toxicity: (i) younger age (50-59), (ii) <1 month of savings, and (iii) being employed but on sick leave. Increased financial toxicity is moderately correlated with a decrease in QoL. Conclusion: Poorer psychological status and specific demographics are linked to increased financial toxicity (lower COST). Financial toxicity has a modest relationship with HRQoL and may have a clear link with HRQoL measurements.

Disruption of the Notch pathway aggravates airway inflammation by inhibiting regulatory T cell differentiation via regulation of plasmacytoid dendritic cells.

Plasmacytoid dendritic cells (pDCs) regulate immunity and promote tolerance in asthma. Notch signalling is a highly conserved pathway that regulates the immune response; however, its role in pDC-mediated asthmatic airway inflammation is unclear. This study clarified the effects of Notch signalling on pDC-mediated airway inflammation using murine models of ovalbumin-sensitized allergic asthma. RBP-J-deficient pDCs (RBP-J-/- pDCs) were co-cultured with naïve CD4+ T cells and supernatants and T cell subtypes were analysed. RBP-J-/- pDCs were intranasally transferred to the airways of ovalbumin-sensitized recipient mice. Lung samples of all mice were subjected to tests for histopathology, cytokine profile of bronchoalveolar lavage fluid, airway hyperactivity and expression of T helper type 1 (Th1)/Th2 cells, regulatory T cells and type 2 innate lymphoid cells (ILC2s). The results showed that pDCs with and without RBP-J deficiency significantly differed in expression levels of cluster of differentiation 83 (CD83), but not CD80, CD86 and major histocompatibility complex class II. Co-culturing pDCs with naïve T cells revealed a poorer immunosuppressive effect of RBP-J-/- pDCs. This may be attributed to the lower expression levels of inducible co-stimulator ligand and lower production of interleukin 10 in RBP-J-/- pDCs than in control pDCs, which impeded T cell activation and Treg suppression. RBP-J-/- pDCs were associated with high ILC2 expression and severe Th2 immune responses and airway inflammation. Therefore, Notch signalling is critical for pDC-dependent immunoregulation, and RBP-J deficiency reduces pDC-based immunosuppression via T cell activation and Th cell differentiation. Thus, this pathway may be a therapeutic target for pDC-based anti-asthma immunotherapy.

Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients with diagnosis of pulmonary embolism for the first time in real world.

BACKGROUND: The incidence and risk factors of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with acute pulmonary embolism (PE) have been well reported. However, in real world, patients diagnosed with PE for the first time were usually composed of acute PE, sub-acute PE, and chronic PE, and the cumulative incidence and risk factors of CTEPH in this cohort were still unknown. METHODS: A prospective, long-term, follow-up study was conducted to assess the incidence of symptomatic CTEPH in consecutive patients with PE diagnosed for the first time. Patients with unexplained persistent dyspnea during follow-up underwent transthoracic echocardiography and, if the findings indicated pulmonary hypertension, ventilation-perfusion lung scanning and right heart catheterization. CTEPH was confirmed if perfusion defects were present, mean pulmonary artery pressure (mPAP) ≥25 mmHg and pulmonary artery wedge pressure (PAWP) ≤15 mmHg. RESULTS: The cumulative incidence of CTEPH in patients with PE diagnosed for the first time was 11.2% at 3 months, 12.7% at 1 year, 13.4% at 2 years, and 14.5% at 3 years. The following factors increased the risk of CTEPH: time from symptoms to treatment of PE ≥1 month (odds ratio (OR), 14.77), intermediate (OR, 37.63) to high risk PE (OR, 39.81), segmental and sub-segmental branch location of embolism (OR, 8.30) and PE-related primary risk factors (OR, 5.01). 9.4% of CTEPH patients developed from acute PE, and 90.6% from sub-acute and chronic PE. CONCLUSIONS: In real world, CTEPH is a relatively common and serious complication in PE patients diagnosed for the first time. Early diagnosis and treatment of PE will decrease the incidence of CTEPH in these unspecified patients.

Notch signaling pathway regulates the growth and the expression of inflammatory cytokines in mouse basophils.

Basophils (BAs) are the least common granulocytes of all leukocytes, but they play an important role in orchestrating of chronic allergic inflammation. The Notch signaling pathway is a highly conserved pathway that influences cell lineage decisions and differentiation during various stages of development. However, the relationship between Notch signaling and BA remains to be elucidate. Here, we report that several Notch signaling molecules were found to be expressed in BAs. γ-secretase inhibitor (GSI) treatment increase BAs apoptosis, and suppress BAs proliferation. Furthermore, GSI reduced BAs in the S phase, with a concomitant accumulation in G1 and G2 phases. In addition, GSI also significantly down-regulated mRNA levels of cytokines IL-4, IL-6 and IL-13 induced by A23187, and this effect was dependent on MAPK pathway. Finally, IL-6 inhibition was specifically associated with ERK and IL-13 with JNK. Therefore, Notch signaling regulates BA biological function, at least partially via the modulation of MAPK.

Transcription factor RBP-J-mediated signalling regulates basophil immunoregulatory function in mouse asthma model.

Basophils (BA) play an important role in the promotion of aberrant T helper type 2 (Th2) immune responses in asthma. It is not only the effective cell, but also modulates the initiation of Th2 immune responses. We earlier demonstrated that Notch signalling regulates the biological function of BAin vitro. However, whether this pathway plays the same role in vivo is not clear. The purpose of the present study was to investigate the effect of Notch signalling on BA function in the regulation of allergic airway inflammation in a murine model of asthma. Bone marrow BA were prepared by bone marrow cell culture in the presence of recombinant interleukin-3 (rIL-3; 300 pg/ml) for 7 days, followed by isolation of the CD49b+ microbeads. The recombination signal binding protein J (RBP-J-/- ) BA were co-cultured with T cells, and the supernatant and the T-cell subtypes were examined. The results indicated disruption of the capacity of BA for antigen presentation alongside an up-regulation of the immunoregulatory function. This was possibly due to the low expression of OX40L in the RBP-J-/- BA. Basophils were adoptively transferred to ovalbumin-sensitized recipient mice, to establish an asthma model. Lung pathology, cytokine profiles of brobchoalveolar fluid, airway hyperactivity and the absolute number of Th1/Th2 cells in lungs were determined. Overall, our results indicate that the RBP-J-mediated Notch signalling is critical for BA-dependent immunoregulation. Deficiency of RBP-J influences the immunoregulatory functions of BA, which include activation of T cells and their differentiation into T helper cell subtypes. The Notch signalling pathway is a potential therapeutic target for BA-based immunotherapy against asthma.

Treatment of Pulmonary Arterial Hypertension Using Initial Combination Therapy of Bosentan and Iloprost.

BACKGROUND: Monotherapy and sequential combination therapy have been widely used in the treatment of pulmonary arterial hypertension (PAH). There is limited evidence for initial combination therapy in patients with PAH, particularly those with World Health Organization (WHO) functional class III or IV. METHODS: Twenty-seven consecutive treatment-naive PAH subjects with WHO functional class III or IV PAH were randomized into 3 groups with a 1:1:1 ratio: a combination therapy group with 125 mg of bosentan twice daily plus 10 µg of iloprost 4-6 times/d; a bosentan monotherapy group with 125 mg of bosentan twice daily; and a iloprost monotherapy group with 10 µg of iloprost 4-6 times/d. Clinical and hemodynamic data were collected at baseline, 6 weeks, and 3 months. The primary end point was the change in the 6-min walk distance (6MWD) from baseline values. RESULTS: At baseline, there were no differences in demographics, WHO classification, hemodynamics, classification of PAH, or 6MWD among the 3 groups. The 6MWD significantly improved in the combination therapy group compared with the bosentan monotherapy and iloprost monotherapy groups at week 6 (P = .001) and after 3 months (P < .001), respectively. Secondary end points significantly improved in the combination therapy group for mean pulmonary artery pressure, cardiac index, and WHO functional classification after 3 months of treatment and for N-terminal pro-brain natriuretic peptide, Minnesota Living with Heart Failure questionnaire scores, and PaO2 after 6 weeks and 3 months of treatment, compared with the monotherapy groups. CONCLUSIONS: Initial combination therapy in treatment-naive PAH subjects with WHO functional class III or IV can significantly improve 6MWD, hemodynamics, and quality of life compared with monotherapy. Further studies with large samples and placebo controls are required to assess the tolerability and efficacy of initial combination therapy in patients with PAH. (ClinicalTrials.gov registration NCT01712997).

The Chronic and Short-Term Effects of Gefinitib on Airway Remodeling and Inflammation in a Mouse Model of Asthma.

BACKGROUND: Asthma is a complex and heterogeneous chronic inflammatory disorder which is characterized by airway remodeling and airway inflammation, including goblet cell and airway smooth muscle cell hyperplasia, mucus hypersecretion and eosinophils infiltration. Epidermal growth factor receptor (EGFR) plays an important role in goblet cell hyperplasia and mucus hypersecretion. We aimed to investigate the effects of gefitinib, an EGFR inhibitor, on ovalbumin (OVA)-induced airway remodeling and inflammation of a mouse model of asthma. METHODS: Pathological changes of OVA sensitization of BALB/c mice were measured by H&E and PAS staining; pEGFR, Bcl-2 and Bax expression was measured by western blot; ELISA was used to measure the level of muc5ac, IL-13 and IFN-x03B3;; TUNEL staining was used to detect goblet cell apoptosis. RESULTS: At the present study, H&E and PAS staining showed that mice pretreated with gefinitib developed fewer pathological changes compared with asthmatic mice and gefinitib treatment asthmatic mice, such as a remarkable reduction in airway inflammation, goblet cell and airway smooth muscle cell hyperplasia. Chronic gefitinib treatment or short-term gefitinib treatment significant down-regulate the expression of pEGFR compared with asthma group. Also, chronic gefitinib treatment markedly decreased the levels of muc5ac and IL-13 in BALF, whereas the level of IFN-x03B3; did not change obviously. TUNEL staining showed that the goblet cell apoptosis rate was much higher in the short-term gefinitib treatment group compared with the asthma and chronic gefitinib treatment group which was accompanied by a decrease in Bcl-2 levels and an increase in Bax expression in goblet cells. CONCLUSION: In summary, our results suggested that gefinitib may have a potential role in airway remodeling and inflammation, and may be an effective pharmacotherapy for asthma.

Notch signaling regulates col1α1 and col1α2 expression in airway fibroblasts.

Subepithelial fibrosis is one of the common pathological features of asthmatic airway remodeling. During subepithelial fibrosis, type I collagen becomes the most abundant extracellular protein component. Studies have shown that Notch signaling participates in the progression of fibrosis; however, whether Notch signaling is involved in regulating type I collagen expression in airway fibroblasts remains unclear. The aim of the present study was to examine whether Notch signaling can regulate type I collagen expression in airway fibroblasts and to explore the underlying molecular mechanisms. Here, the expression of Notch signaling components was examined in mouse L929 cells and human MRC-5 cells. After upregulating or downregulating Notch signaling in these cell lines, col1α1 and col1α2 expression was examined. Using gene reporter assays, site-directed mutagenesis, and ChIP assays, the role of Hes1 binding sites in both the mouse and human COL1A1 and COL1A2 promoters was investigated. This study revealed that Notch signaling-related molecules (including Notch1, Hes1, and others) are expressed in L929 and MRC-5 cells and that Notch signaling regulates the expression of col1α1 and col1α2 in both cell lines. Additionally, over-expression of the Notch intracellular domain resulted in activation of the COL1A1 and COL1A2 promoters, and site-directed mutagenesis reporter assays revealed that Hes1 proteins might augment both mouse and human COL1A1 and COL1A2 promoter activity. Furthermore, ChIP assays confirmed that Hes1 binds to the COL1A1 and COL1A2 promoters in both L929 and MRC-5 cells. Therefore, it is reasonable to assume that Notch signaling can directly upregulate COL1A1 and COL1A2 promoter activity through a Hes1-dependent mechanism, which could serve as a possible target for pharmacotherapy of airway subepithelial fibrosis.

Der p2 recombinant bacille Calmette-Guerin priming of bone marrow-derived dendritic cells suppresses Der p2-induced T helper17 function in a mouse model of asthma.

BACKGROUND AND OBJECTIVE: Previous studies have demonstrated that our recombinant bacille Calmette-Guerin (rBCG), which expresses Der p2 in house dust mite (Der p2 rBCG) suppresses asthmatic airway inflammation by regulating the phenotype and function of dendritic cells (DC) and reprogramming T helper (Th) 0 cell differentiation into different T cell (Th1/Th2/Treg) subtypes. However, the exact role of Der p2 rBCG in reprogramming Th17 differentiation and the relevant mechanisms are not known. The aim of this study was to examine whether Der p2 rBCG-mediated inhibition of allergic airway inflammation is mediated by regulating Th17 differentiation in a murine asthma model. METHODS: Primary mouse bone marrow-derived dendritic cells (BMDC) were infected with Der p2 rBCG and adoptively transferred to Der p2-intranasally sensitized mice. The role of Der p2 rBCG-BMDC on the regulation of airway inflammation and Th17 cell differentiation was assessed. RESULTS: Adoptive transfer of Der p2 rBCG-BMDC suppressed airway inflammation and mucin secretion. Der p2 rBCG-BMDC inhibited excessive Th17 immune responses but not BCG-BMDC. Furthermore, Der p2 rBCG decreased jagged-2 and increased delta-like-4 expressions on BMDC to a greater extent than BCG. CONCLUSIONS: These findings suggest that DC plays a key role in Der p2 rBCG-induced immunoregulation. Der p2 rBCG also displayed a potent inhibitory effect on Th17 differentiation, and these findings increase our understanding of the cellular basis of Der p2 BCG-mediated inhibition of asthma.

Notch signaling downregulates MUC5AC expression in airway epithelial cells through Hes1-dependent mechanisms.

BACKGROUND: Mucus overproduction is one of the major pathological features of asthma, and MUC5AC is the major mucin component of airway mucus. However, whether Notch signaling is implicated in the regulation of MUC5AC expression in airway secretary cells is still undetermined. OBJECTIVE: The aim of this study is to examine whether Notch signaling can regulate MUC5AC expression and explore the molecular mechanisms. METHODS: Mouse mtCC1-2 cells and human NCI-H292 cells were transfected with NIC, and MUC5AC expression was examined. Using gene reporter assays, site-directed mutagenesis, and ChIP assays, the activity of both mouse and human MUC5AC promoter was analyzed. RESULTS: Notch signaling regulated MUC5AC expression both in mouse mtCC1-2 cells and in human NCI-H292 cells. Several Hes-binding site N-boxes were identified in the 5' region of both mouse and human MUC5AC promoters. Overexpression of NIC resulted in activation of the MUC5AC promoter. Site-directed mutagenesis report assays revealed that Hes proteins might repress both mouse and human MUC5AC promoter activity. Furthermore, ChIP assays confirmed that Hes1 binds to the MUC5AC promoter both in mouse mtCC1-2 cells and in human NCI-H292 cells. CONCLUSIONS: Notch signaling can directly downregulate MUC5AC promoter activity through Hes1-dependent mechanisms, which may be identified as possible targets for pharmacotherapy of airway mucus hypersecretion in asthma.