Masako To

Long-acting fluticasone furoate has a superior pharmacological profile to fluticasone propionate in human respiratory cells.

Currently available glucocorticoids are relatively short acting and may be less effective in patients with chronic obstructive pulmonary disease (COPD) where high levels of oxidative stress are seen. Here we show that a novel glucocorticoid, fluticasone furoate (FF), has a longer duration of action in several cell systems compared with fluticasone propionate (FP) and budesonide, and unlike FP, FF is resistant to oxidative stress. FF had similar or slightly higher potency to FP and was 2-9 fold more potent than budesonide, when assessed at 4h, in inhibiting inflammatory cytokine production in epithelial cell lines (BEAS2B, A549), primary bronchial epithelial cells and a monocytic cell line (U937). The potency of FF was sustained beyond 16 h with or without washout compared with FP or budesonide, such that it showed a greater duration of action in this range of cellular assays. The activated YFP-conjugated glucocorticoid receptor was detectable in nuclei of FF treated BEAS2B cells for at least for 30 h, and FF had a longer duration of action than FP in inhibiting activation of transcription factors such as NF-κB and AP-1. In addition, FF showed superior effects to FP in peripheral blood mononuclear cells from patients with COPD and also in U937 cells or primary bronchial epithelial cells under conditions of oxidative stress. The longer duration of action and oxidative stress insensitivity of FF compared with FP has potential clinical implications for the control of inflammation in respiratory diseases, such as COPD.

Hypoxia-inducible Factor 1α Induces Corticosteroid-insensitive Inflammation via Reduction of Histone Deacetylase-2 Transcription

Corticosteroids are potent anti-inflammatory agents, but corticosteroid insensitivity is a major barrier for the treatment of some chronic inflammatory diseases. Here, we show that hypoxia induces corticosteroid-insensitive inflammation via reduced transcription of histone deacetylase-2 (HDAC2) in lung epithelial and macrophage cells. HDAC2 mRNA and protein expression was reduced under hypoxic conditions (1% O2). Hypoxia enhanced interleukin-1β-induced interleukin-8 (CXCL8) production in A549 cells and decreased the ability of dexamethasone to suppress the CXCL8 production. Deletion or point mutation studies revealed that binding of the transcription factor hypoxia-inducible factor (HIF) 1α to a HIF response element at position −320, but not HIF-1β or HIF-2α, results in reduced polymerase II binding at the site, leading to reduced promoter activity of HDAC2. Our results suggest that activation of HIF-1α by hypoxia decreases HDAC2 levels, resulting in amplified inflammation and corticosteroid resistance.

The utility of galactomannan antigen in the bronchial washing and serum for diagnosing pulmonary aspergillosis

BACKGROUND The diagnosis of pulmonary aspergillosis is difficult because the sensitivity of the conventional methods for the detection of Aspergillus such as culture and cytology, is poor. To improve the sensitivity for Aspergillus detection, the detection of galactomannan antigen has been investigated. The serum galactomannan (GM) antigen has been recognized to be a useful tool for the diagnosis of invasive pulmonary aspergillosis. However, the utility of the galactomannan antigen for the diagnosis of pulmonary aspergillosis other than invasive pulmonary aspergillosis (IPA) has been unclear. METHODS The GM antigen using serum and bronchial washing (BW) using bronchofiberscopy for the diagnosis of pulmonary aspergillosis other than IPA were measured. RESULTS In 45 enrolled patients, 7 patients had pulmonary aspergillosis, 5 of these patients had chronic necrotizing pulmonary aspergillosis and 2 patients had allergic bronchopulmonary aspergillosis. The area under the receiver operating characteristic (ROC) curve was 0.89 for the BW GM antigen detection test, and 0.41 for the serum GM antigen detection test, suggesting that the BW GM antigen detection test exhibits a better diagnostic performance than the serum GM antigen detection test. The BW GM antigen detection test had a sensitivity of 85.7% and a specificity of 76.3% at a cut-off level of ≥0.5, which was the optimal cut-off level obtained by the ROC curve. CONCLUSION The BW GM antigen detection test is thought to be a promising test for the diagnosis of pulmonary aspergillosis other than IPA.

Sputum Plasminogen Activator Inhibitor-1 Elevation by Oxidative Stress-Dependent Nuclear Factor-κB Activation in COPD

BACKGROUND Plasminogen activator inhibitor-1 (PAI-1) is an important regulator of fibrinolysis at sites of vascular injury and thrombus formation. Recently, sputum PAI-1 was reported to be elevated in COPD. However, the mechanism of PAI-1 elevation in COPD has yet to be clarified. Here, we show that PAI-1 elevation in COPD is closely associated with oxidative stress-induced nuclear factor κB (NF-κB) activation. METHODS Patients and control subjects were recruited from the outpatient department of Royal Brompton Hospital, local general practice, and the National Heart and Lung Institute. Sputum samples were obtained, and sputum sample processing was performed to obtain sputum supernatants and sputum macrophages. RESULTS The mean PAI-1 level in COPD sputum (1.92 ± 3.11 ng/mL, n = 32) was higher than that of both age-matched smokers without COPD (0.48 ± 0.63 ng/mL, n = 11) and healthy nonsmokers (0.55 ± 1.11 ng/mL, n = 9). Sputum PAI-1 significantly correlated with sputum malondialdehyde (MDA) in COPD (r = 0.59, P < .001). In addition, NF-κB activity in sputum macrophages (three control and seven COPD subjects) significantly correlated with both sputum PAI-1 (r = 0.72, P < .05) and sputum MDA (r = 0.78, P < .01). An in vitro study showed that both hydrogen peroxide and cigarette smoke-conditioned medium induced PAI-1 production in A549 cells, and the production was inhibited by an inhibitor of I κB kinase-β in a concentration-dependent manner. Furthermore, histone deacetylase 2 (HDAC2) knockdown by RNA interference, a mimic of oxidative-stress-dependent HDAC2 reduction, enhanced tumor necrosis factor-α-induced PAI-1 induction (half maximal effective concentration [EC50], 0.64 ± 0.19 ng/mL in HDAC2-KD, 7.64 ± 3.70 ng/mL in control) concomitant with enhancement of NF-κB p65 acetylation and NF-κB DNA-binding activity. CONCLUSIONS Oxidative stress, directly or indirectly via HDAC reduction, plays a role in PAI-1 expression in COPD via activation of NF- κ B.

Defect of Adaptation to Hypoxia in Patients With COPD Due to Reduction of Histone Deacetylase 7

Background: Hypoxia inducible factor (HIF)-1 plays an important role in cellular adaptation to hypoxia by activating oxygen-regulated genes such as vascular endothelial growth factor (VEGF) and erythropoietin. Sputum VEGF levels are reported to be decreased in COPD, despite hypoxia. Here we show that patients with COPD fail to induce HIF-1α and VEGF under hypoxic condition because of a reduction in histone deacetylase (HDAC) 7. Methods: Peripheral blood mononuclear cells (PBMCs) were obtained from patients with moderate to severe COPD (n = 21), smokers without COPD (n = 12), and nonsmokers (n = 15). PBMCs were exposed to hypoxia (1% oxygen, 5% CO2, and 94% N2) for 24 h, and HIF-1α and HDAC7 protein expression in nuclear extracts were determined by sodium dodecyl sulfate poly acrylamide gel electrophoresis (SDS-PAGE)/Western blotting. Results: HIF-1α was significantly induced by hypoxia in each group when compared with the normoxic condition (12-fold induction in nonsmokers, 24-fold induction in smokers without COPD, fourfold induction in COPD), but induction of HIF-1α under hypoxia was significantly lower in patients with COPD than in nonsmokers and smokers without COPD (P < .05 and P < .01, respectively). VEGF messenger RNA detected by quantitative real-time polymerase chain reaction was correlated with HIF-1α protein in nuclei (r = 0.79, P < .05), and HDAC7 protein expression was correlated with HIF-1α protein in nuclei (r = 0.46, P < .05). HDAC7 knockdown inhibited hypoxia-induced HIF-1α activity in U937 cells, and HIF-1α nuclear translocation and HIF-1α binding to the VEGF promoter in A549 cells. Conclusions: HDAC7 reduction in COPD causes a defect of HIF-1α induction response to hypoxia with impaired VEGF gene expression. This poor cellular adaptation might play a role in the pathogenesis of COPD.

Osteoprotegerin in Sputum Is a Potential Biomarker in COPD

BACKGROUND COPD is characterized by chronic airflow limitation and inflammation of the respiratory tract. Several inflammatory biomarkers have been evaluated in COPD but are poorly related to disease severity and progression. Osteoprotegerin (OPG) is a glycoprotein mediator that is expressed in the lung and macrophages, so we have studied its concentration in induced sputum and macrophages of patients with COPD. METHODS OPG was measured by enzyme-linked immunosorbent assay in induced sputum of patients with COPD and control subjects. RESULTS OPG concentrations in induced sputum of patients with COPD (18.7 ± 18.6 ng/mL, n = 39) were significantly higher than those of healthy smokers (8.1 ± 5.6 ng/mL, n = 15), healthy nonsmokers (3.5 ± 3.8 ng/mL, n = 14), or patients with asthma (8.0 ± 5.4 ng/mL, n = 18). Sputum OPG levels in COPD negatively correlated with FEV(1) and positively correlated with residual volume to total lung capacity ratio (RV/TLC) (r = 0.55, P < .05), transfer factor of the lung for carbon monoxide (r = -0.53, P < .05), and carbon monoxide transfer coefficient (r = -0.61, P < .01). By contrast, sputum IL-8 concentrations were related to disease severity but not to RV/TLC or gas diffusion. Airway macrophages and neutrophils were positive for OPG by immunocytochemistry in sputum and peripheral lung tissue. OPG induced matrix metalloproteinase-9 release from sputum macrophages in vitro. CONCLUSIONS Sputum OPG may be a useful biomarker to monitor parenchymal destruction in COPD.

Obesity-related systemic oxidative stress: An important factor of poor asthma control

Spirometry FVC (L) 2.53 ± 0.80 2.58 ± 0.93 0.907 %FVC (%) 83.2 ± 18.1 83.8 ± 13.8 0.881 FEV1 (L) 2.12 ± 0.71 2.13 ± 0.82 0.991 %FEV1 (%) 82.6 ± 22.5 85.1 ± 15.7 0.773 FEV1/FVC (%) 82.4 ± 9.9 81.8 ± 7.0 0.579 %PEF (%) 78.6 ± 21.6 81.9 ± 20.6 0.741 %FEF50 (%) 76.8 ± 42.4 83.4 ± 36.6 0.515 %FEF75 (%) 71.1 ± 43.7 64.7 ± 30.5 1.000 Serum markers Serum Leptin (ng/mL) 16.9 ± 11.3 27.3 ± 12.1 0.007 Serum MDA (mM) 2.8 ± 0.7 3.3 ± 0.8 0.034

Risk Factors of Local Oropharyngeal and Laryngeal Adverse Effects from Use of Single Inhaled Corticosteroids and Long-Acting Beta-Agonists

BACKGROUND Single inhaled corticosteroids and long-acting beta-agonists (ICS/LABA) are clinically effective and safe. However, if local oropharyngeal and laryngeal adverse effects (LOLAE) appear, adherence to the use of ICS is impaired. To minimize the development of adverse effects, it is essential to identify the underlying risk factors. METHODS The study included 481 asthmatic patients who were prescribed ICS/LABA for the first time in their life between January and September of 2010. Patients ranged in age from 14 to 86 years old and consisted of 281 never smokers and 200 smokers. All data were collected retrospectively by respirologists. RESULTS Seventy-three out of 481 patients suffered from one or more adverse effects, with 54 of these exhibiting LOLAE. Patients with LOLAE (51.4 ± 16.2 yrs) were significantly older than those without LOLAE (43.7 ± 15.9 yrs) (p = 0.0011) and were also prescribed a significantly higher dose of ICS. The pack-years of patients with LOLAE (2.1 ± 4.9) were significantly lower than those without LOLAE (6.0 ± 13.0) (p = 0.0087). The type of administered ICS was also significantly associated with a risk of developing LOLAE. CONCLUSIONS Our survey indicated that a greater age, a higher dose of ICS, and the type of ICS were potential risk factors of LOLAE. The identified factors should be considered in a clinical setting in order to prevent the development of LOLAE and provide optimal treatment to patients.

Obesity-associated severe asthma in an adult Japanese population

BACKGROUND Severe asthma is increasingly being recognized as an important public health issue. Obesity has been identified as a risk factor for poor asthma control and for worsening of asthma severity. However, most studies investigating obese patients with asthma have been performed in Western countries. Reports on the characteristics of obese Japanese individuals with severe asthma are lacking. Herein, we investigated the clinical characteristics of patients with obesity-associated severe asthma in a Japanese population and the association between obesity and poor asthma control. METHODS We conducted a retrospective observational study of adult patients with severe asthma. Patients were classified into two groups based on the definition of obesity recommended by the Japan Society for the Study of Obesity: obese (OB) group (body mass index [BMI] ≥25 kg/m2) and non-obese (NOB) group (BMI <25 kg/m2). The two groups were compared. The characteristics of obesity and the metabolic functions are known to differ between males and females; therefore, we analyzed male-only and female-only cohorts separately. RESULTS A total of 492 patients were enrolled. Age, smoking history in terms of number of pack-years, daily controller medications use, and spirometric data were not significantly different between the OB and NOB groups in either cohort. In the female cohort, the annual exacerbation ratio and the percentage of frequent exacerbators were significantly higher in the OB group compared to the NOB group. A multivariate logistic regression analysis showed that obesity was independently associated with frequent asthma exacerbations in the female cohort. CONCLUSIONS Our study revealed that obesity, defined as a BMI ≥25 kg/m2, was independently associated with poor asthma control (including acute exacerbations) in adult Japanese females with severe asthma.

Menthol-Flavored Cigarettes: Potentially a Strong Trigger of Acute Eosinophilic Pneumonia

Menthol-flavored cigarettes recently have received significant attention. Lower quit rates and higher relapse rates of smoking in people who smoke menthol-flavored cigarettes have been demonstrated. Additional disadvantages of menthol cigarettes also might exist. We present a lesson learned from a case we experienced: Menthol cigarette smoking might be a stronger trigger of acute eosinophilic pneumonia compared with nonflavored cigarette smoking. A 19-year-old man visited our hospital with a 3-day history of dry cough, dyspnea, and high fever. He had been completely healthy until the appearance of these symptoms. He had started smoking menthol cigarettes approximately 1 month before his visit to our hospital. He had no history of lung disease. He had no obvious history of occupational dust inhalation or illegal drug use. When he visited our outpatient department, his oxygen saturation was 88% while breathing room air. His temperature was 38.8 C. His complete blood count and blood chemistry findings were unremarkable, except for elevations in white blood cell count (14,900/mL), C-reactive protein (11.45 mg/dL), serum surfactant protein-D (259 ng/mL), and immunoglobulin-E (437 IU/mL). Chest x-ray and computed tomography scan showed patchy shadows and infiltration in both lungs and thickening of interlobular septa (Figure, A, B). Bronchoalveolar lavage findings showed marked elevation of eosinophils (total cell count 12.7 10/mL, eosinophils 67.6%) (Figure, C). The bronchoalveolar lavage eosinophil elevation, typical radiologic findings, and clinical history of symptom onset after initiation of cigarette smoking suggested a diagnosis of acute eosinophilic pneumonia. Systemic corticosteroid therapy resulted in resolution of his symptoms and radiologic findings (Figure, D). The patient was advised to stop smoking, but continued to smoke nonflavored cigarettes against the advice.