Tadao Nagasaki

Increased periostin associates with greater airflow limitation in patients receiving inhaled corticosteroids.

BACKGROUND Periostin, an extracellular matrix protein, contributes to subepithelial thickening in asthmatic airways, and its serum levels reflect airway eosinophilic inflammation. However, the relationship between periostin and the development of airflow limitation, a functional consequence of airway remodeling, remains unknown. OBJECTIVE We aimed to determine the relationship between serum periostin levels and pulmonary function decline in asthmatic patients on inhaled corticosteroid (ICS) treatment. METHODS Two hundred twenty-four asthmatic patients (average age, 62.3 years) treated with ICS for at least 4 years were enrolled. Annual changes in FEV1, from at least 1 year after the initiation of ICS treatment to the time of enrollment or later (average, 16.2 measurements over 8 years per individual), were assessed. At enrollment, clinical indices, biomarkers that included serum periostin, and periostin gene polymorphisms were examined. Associations between clinical indices or biomarkers and a decline in FEV1 of 30 mL or greater per year were analyzed. RESULTS High serum periostin levels (≥ 95 ng/mL) at enrollment, the highest treatment step, higher ICS daily doses, a history of admission due to asthma exacerbation, comorbid or a history of sinusitis, and ex-smoking were associated with a decline in FEV1 of 30 mL or greater per year. Multivariate analysis showed that high serum periostin, the highest treatment step, and ex-smoking were independent risk factors for the decline. Polymorphisms of periostin gene were related to higher serum periostin levels (rs3829365) and a decline in FEV1 of 30 mL or greater per year (rs9603226). CONCLUSIONS Serum periostin appears to be a useful biomarker for the development of airflow limitation in asthmatic patients on ICS.

Generation of Alveolar Epithelial Spheroids via Isolated Progenitor Cells from Human Pluripotent Stem Cells

Summary No methods for isolating induced alveolar epithelial progenitor cells (AEPCs) from human embryonic stem cells (hESCs) and induced pluripotent stem cells (hiPSCs) have been reported. Based on a study of the stepwise induction of alveolar epithelial cells (AECs), we identified carboxypeptidase M (CPM) as a surface marker of NKX2-1+ “ventralized” anterior foregut endoderm cells (VAFECs) in vitro and in fetal human and murine lungs. Using SFTPC-GFP reporter hPSCs and a 3D coculture system with fetal human lung fibroblasts, we showed that CPM+ cells isolated from VAFECs differentiate into AECs, demonstrating that CPM is a marker of AEPCs. Moreover, 3D coculture differentiation of CPM+ cells formed spheroids with lamellar-body-like structures and an increased expression of surfactant proteins compared with 2D differentiation. Methods to induce and isolate AEPCs using CPM and consequently generate alveolar epithelial spheroids would aid human pulmonary disease modeling and regenerative medicine.

Using Exhaled Nitric Oxide and Serum Periostin as a Composite Marker to Identify Severe/Steroid-Insensitive Asthma

At present, exhaled nitric oxide (FENO) is a clinically useful biomarker of eosinophilic airway inflammation (1); its levels increase during exacerbation and decrease with inhaled corticosteroid (ICS) treatment (2). Evidence has demonstrated that high FENO levels (>35 ppb) indicate the presence of a highly reactive phenotype among patients with asthma (3), which is useful for the management of patients. Nonetheless, additional markers are required for better characterization of patients with asthma with elevated FENO (>25 ppb), particularly to identify patients who may have steroid resistance (2). Serum periostin is a biomarker of helper T type 2/eosinophilic airway inflammation in asthma (4, 5) distinct from FENO (6). Periostin is a matricellular protein actively involved in airway remodeling (4, 7, 8), with partial steroid resistance (9), although steroid-sensitive aspects were initially highlighted (10). Indeed, high serum periostin levels are associated with refractory eosinophilic inflammation (5) and accelerated decline in pulmonary function in patients with asthma under ICS treatment (11, 12). Importantly, serum periostin levels are relatively stable and less variable than FENO (5, 6), which is advantageous for long-term monitoring of patients with asthma. Therefore, we hypothesized that high serum periostin could be used as a biomarker to efficiently identify ICS-insensitive patients among patients with elevated FENO. In the present study, we demonstrated the reliability of comeasurement of FENO and serum periostin to identify ICS-insensitive patients; they were defined as those with an accelerated decline in FEV1 of at least 30 ml/year (11) or a risk of asthma exacerbations requiring systemic corticosteroid bursts despite adequate ICS treatments in this study. This is a substudy of the Kinki Hokuriku Airway Disease Conference (KiHAC) study that investigated genobiological factors associated with pulmonary function decline in adults with asthma receiving ICS treatment; the patients had undergone 16.26 13.9 FEV1 measurements over 8.06 4.5 years (11). The study protocol (UMIN000002414) was approved by the ethics committee of each participating institution. The present study included the patients who agreed to FENO measurements with a chemiluminescence analyzer (NOA 280; Sievers, Boulder, CO) at enrollment. All patients underwent baseline examination, including a selfcompleted questionnaire, the asthma control test, spirometry, and blood tests at enrollment, as described previously (11). FENO levels were determined at an expiratory flow rate of 50 ml/second, according to the present guidelines (13, 14). The frequency of asthma exacerbation, requiring systemic corticosteroid bursts, was documented for 2 years after enrollment, except for one patient who was lost to follow-up 1 year after enrollment. Serum periostin levels were determined using an enzyme-linked immunosorbent assay at Shino-Test (Kanagawa, Japan), and a cutoff point of 95 ng/ml was used to define high serum periostin (11). Follow-up FENO and serum periostin measurements were not obligatory, but they were measured in several patients on various occasions during the subsequent 2 years (see the online supplement). Statistical analysis was performed with JMP version 9.0 software (SAS Institute Inc., Tokyo, Japan). FENO and serum periostin levels were log-transformed to achieve normal distribution. Pearson correlation coefficients were used to identify relationships between the parameters. Two data sets were compared, using the unpaired t test or Wilcoxon rank-sum test for numerical data and the x test or Fisher exact test for nominal data, as deemed appropriate. The comparison between high and low serum periostin groups or FENO groups regarding an accelerated decline in FEV1 was performed after adjustment for sex, height, age at enrollment, and FEV1 at the first measurement. Logistic regression analysis was performed to estimate the risk of subsequent asthma exacerbations (see the online supplement). Data are presented as means6 SD or percentage. P< 0.05 was considered statistically significant. The FENO levels, determined in 121 patients, were weakly associated with serum periostin levels (Figure 1). This relationship between FENO and serum periostin was stronger when the analysis was confined to patients undergoing treatment step 4 or 5 as

Directed Induction of Functional Multi-ciliated Cells in Proximal Airway Epithelial Spheroids from Human Pluripotent Stem Cells

Summary Multi-ciliated airway cells (MCACs) play a role in mucociliary clearance of the lung. However, the efficient induction of functional MCACs from human pluripotent stem cells has not yet been reported. Using carboxypeptidase M (CPM) as a surface marker of NKX2-1+-ventralized anterior foregut endoderm cells (VAFECs), we report a three-dimensional differentiation protocol for generating proximal airway epithelial progenitor cell spheroids from CPM+ VAFECs. These spheroids could be induced to generate MCACs and other airway lineage cells without alveolar epithelial cells. Furthermore, the directed induction of MCACs and of pulmonary neuroendocrine lineage cells was promoted by adding DAPT, a Notch pathway inhibitor. The induced MCACs demonstrated motile cilia with a “9 + 2” microtubule arrangement and dynein arms capable of beating and generating flow for mucociliary transport. This method is expected to be useful for future studies on human airway disease modeling and regenerative medicine.

Comprehensive efficacy of omalizumab for severe refractory asthma: a time-series observational study

BACKGROUND Omalizumab, a humanized anti-IgE monoclonal antibody, is reportedly an effective treatment for severe allergic asthma. However, there have been few comprehensive analyses of its efficacy, including assessments of small airways or airway remodeling. OBJECTIVE To comprehensively evaluate the efficacy of omalizumab, including its effects on small airways and airway remodeling, in adult patients with severe refractory asthma. METHODS In this prospective, time-series, single-arm observational study, 31 adult patients with severe refractory asthma despite the use of multiple controller medications, including high-dose inhaled corticosteroids (1,432 ± 581 μg/d of fluticasone propionate equivalent), were enrolled. Clinical variables, including Asthma Quality of Life Questionnaire, asthma exacerbations, exhaled nitric oxide, pulmonary function, methacholine airway responsiveness, induced sputum, and chest computed tomogram, were assessed at baseline and after 16 and 48 weeks of treatment with omalizumab. RESULTS Twenty-six of the 31 patients completed 48 weeks of treatment. For these patients, Asthma Quality of Life Questionnaire scores and peak expiratory flow values significantly and continuously improved throughout the 48 weeks (P < .001 for all comparisons). Unscheduled physician visits, asthma exacerbations requiring systemic corticosteroids, fractional exhaled nitric oxide at 50 mL/s and alveolar nitric oxide levels, sputum eosinophil proportions, and airway-wall thickness as assessed by computed tomography significantly decreased at 48 weeks (P < .05 for all comparisons). CONCLUSION Omalizumab was effective for adult patients with severe refractory asthma. Omalizumab may have anti-inflammatory effects on small airways and reverse airway remodeling. TRIAL REGISTRATION UMIN000002389.

Smoking attenuates the age-related decrease in IgE levels and maintains eosinophilic inflammation

Epidemiological studies have shown that smoking increases the propensity for atopy and asthma. However, the effects of smoking on atopy and eosinophilic inflammation in asthmatics, including the elderly, remain unknown.

Integrating longitudinal information on pulmonary function and inflammation using asthma phenotypes.

From the Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md; the Clinical Research Directorate/CMRP, Leidos Biomedical Research (formerly SAIC-Frederick), Frederick National Laboratory for Cancer Research, Frederick, Md; the Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; the Clinical Center and the Department of Laboratory Medicine, National Institutes of Health, Bethesda, Md; and the Department of Internal Medicine, Virginia Commonwealth University, Richmond, Va. E-mail: jdmilner@ niaid.nih.gov. Or: twilson@mail.nih.gov. Supported by National Institutes of Health (NIH) U19AI77435, and in part by grants from Food Allergy Research and Education (formerly the Food Allergy and Anaphylaxis Network [FAAN], the Food Allergy Project [FAP], and the Food Allergy Initiative [FAI]), the Buckeye Foundation, and the Campaign Urging Research for Eosinophilic Diseases (CURED) Foundation. This project has been funded in part with federal funds from the National Cancer Institute, NIH, under contract no. HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. This research was supported in part by the NIAID. Disclosure of potential conflict of interest: N. Jones has received a grant from LEIDOS. J. P. Abonia has received grants from the National Institutes of Health (NIH), Food Allergy Research and Education (FARE), the Food Allergy & Anaphylaxis Network, the Buckeye Foundation, and the Campaign Urging Research for Eosinophilic Diseases Foundation. M. E. Rothenberg has received research support from the NIH, the CURED Foundation, FARE, and the Buckeye Foundation; is a board member of the International Eosinophil Society Steering Committee and the APFED Medical Panel; has consultant arrangements with Immune Pharmaceuticals, Pluristem Pharmaceuticals, Receptos, and Novartis; is an inventor on patents submitted and owned by Cincinnati Children’s Hospital Medical Center; receives royalties from Teva Pharmaceuticals; and has stock/stock options in Immune Pharmaceuticals and Receptos. L. B. Schwartz is on the board of directors for the Clinical Immunology Society and the Asthma and Allergy Foundation of America; has consultant arrangements with Sanofi Aventis, Dyax, and Viropharma; has received grants from CSL Behring and Dyax; receives royalties for licensing arrangements through VCU Tech Transfer; and receives honorarium as Associate Editor of the Journal of Clinical Immunology. The rest of the authors declare that they have no relevant conflicts of interest.

Pathophysiological characteristics of asthma in the elderly: a comprehensive study

BACKGROUND Comprehensive studies of the pathophysiologic characteristics of elderly asthma, including predominant site of disease, airway inflammation profiles, and airway hyperresponsiveness, are scarce despite their clinical importance. OBJECTIVE To clarify the pathophysiologic characteristics of elderly patients with asthma. METHODS Patients older than 65 years (elderly; n = 45) vs those no older than 65 years (nonelderly; n = 67) were retrospectively analyzed by spirometry, computed tomographic indices of large airway wall thickness and small airway involvement (air trapping), impulse oscillation measurements, exhaled nitric oxide levels, blood and induced sputum cell differentials, methacholine airway responsiveness, and total and specific serum IgE levels. RESULTS Elderly patients with asthma had significantly lower values for forced expiration volume in 1 second, mid-forced expiratory flow (percentage predicted), and ratio of forced expiration volume in 1 second to forced vital capacity than nonelderly patients with asthma (median 81.2% vs 88.8%, P = .02; 50.9% vs 78.6%, P = .03; 0.72 vs 0.78, P = .001, respectively). In computed tomographic measurements, elderly patients with asthma had significantly greater airway wall thickening and air trapping than nonelderly patients. Impulse oscillation measurements indicated that elderly patients with asthma showed significantly greater resistance at 5 Hz (used as an index of total airway resistance), greater decrease in resistance from 5 to 20 Hz, a higher ratio of decrease in resistance from 5 to 20 Hz to resistance at 5 Hz, higher integrated area between 5 Hz and frequency of resonance, greater frequency of resonance, and lower reactance at a frequency of 5 Hz (potential markers of small airway disease) than nonelderly patients. There were no significant differences in blood or sputum cell differentials, exhaled nitric oxide, or methacholine airway responsiveness between the 2 groups. Total serum IgE levels and positive rates of specific IgE antibodies against several allergens were significantly lower in elderly than in nonelderly patients with asthma. CONCLUSION Based on spirometric, computed tomographic, and impulse oscillation analyses, elderly patients with asthma have greater involvement of small and large airways than nonelderly patients with asthma.

Efficacy of omalizumab in eosinophilic chronic rhinosinusitis patients with asthma

Disclosures: Authors have nothing to disclose. [3] Yesudian PD, Penny M, Azurdia RM, King CM. Ibuprofen-induced acute generalized exanthematous pustulosis. Int J Dermatol. 2004;43:208e210. [4] Rastogi S, Modi M, Dhawan V. Acute localized exanthematous pustulosis (ALEP) caused by Ibuprofen: a case report. Br J Oral Maxillofac Surg. 2009;47: 132e134. [5] Romano A, Torres MJ, Castells M, Sanz ML, Blanca M. Diagnosis and management of drug hypersensitivity reactions. J Allergy Clin Immunol. 2011;127 (3 Suppl):S67eS73. [6] Drew AC, Eusebius NP, Kenins L, de Silva HD, Suphioglu C, Rolland JM, et al. Hypoallergenic variants of the mayor latex allergen Hev b 6.01 retaining human T lymphocyte reactivity. J Immunol. 2004;173:5872e5879. [7] Speeckaert MM, Speeckaert R, Lambert J, Brochez L. Acute generalized exanthematous pustulosis: an overview of the clinical, immunological and diagnostic concepts. Eur J Dermatol. 2010;20:425e433. [8] Torres MJ, Mayorga C, Blanca M. Nonimmediate allergic reactions induced by drugs: pathogenesis and diagnostic tests. J Invest Allergol Clin Immunol. 2009; 19:80e90.

Utility of serum periostin and free IgE levels in evaluating responsiveness to omalizumab in patients with severe asthma

Omalizumab, a humanized anti‐IgE monoclonal antibody, has demonstrated efficacy in patients with severe allergic asthma. However, treatment responses vary widely among individuals. Despite a lack of data, free serum IgE levels following omalizumab treatment have been proposed as a marker of treatment responsiveness.