Amino acid substitutions in conserved domains of factor VIII and related proteins: study of patients with mild and moderately severe hemophilia A.

Mutations leading to hemophilia A by substitution of amino acids in coagulation factor VIII may provide important clues to the structure and function of this large and enigmatic protein. To efficiently find missense mutations, hemophiliacs with mild and moderately severe forms of the disease were surveyed. DNA samples from affected individuals were assayed for mutations by denaturing gradient gel electrophoresis following DNA amplification of target regions, which included all coding regions except for that of the dispensable B domain. Missense mutations were observed in 20 of the 34 patients examined, with identical mutations found in five pairs of patients. All mutations were found in the repetitive A and C domains. By aligning these domains in factor VIII with homologous domains in factor V, ceruloplasmin, and the mouse milk fat globule membrane protein, it was determined that most mutations change amino acids in areas of strong sequence conservation. Three additional mutations were detected, including a point mutation in an intron, a stop codon mutation, and a silent base change. Ten of the 18 different mutations discovered in this patient population are reported here for the first time.     

Slight steroid-sparing effect of intravenous immunoglobulin in children and adolescents with moderately severe bronchial asthma

Jakobsson T, Croner S, Kjellman N-IM, Pettersson A, Vassella C, Björkstén B. Slight steroid-sparing effect of intravenous immunoglobulin in children and adolescents with moderately severe bronchial asthma. Twenty subjects (aged 6-20 years) with moderately severe bronchial asthma participated in an open controlled trial with intravenous immunoglobulin (IVIG) given as five monthly infusions with a mean dose of 0.8 g/kg body weight. A follow-up was performed 4 and 14 months after the treatment period. Nine of 14 children in the treatment group completed the trial. Two children experienced severe headache after the first infusion, another two patients were taken off the study for reasons unrelated to the IVIG therapy, and one patient dropped out from lack of motivation. In six of the IVIG-treated children, there was a reduction in the daily intake of inhaled steroids at an unchanged or reduced histamine reactivity. Of the remaining three children, two showed a reduction in bronchial hyperreactivity, but their steroid dose was not reduced. Six patients participated in a reference group to determine seasonal variations of symptoms. One of them improved during the study period, and the condition of the other five deteriorated, as indicated by increased medication without reduced histamine reactivity. After 14 months, there were no significant differences in clinical symptoms, nor in sensitivity to histamine between the treated patients and the controls, as the condition had improved also in the latter. We have thus been able to confirm, in a group larger than those in previously published reports, some clinical improvement of asthma by IVIG therapy at a lower dose than previously used and in children with only moderately severe disease. The effect was still present 4 months after the termination of IVIG therapy but not after 14 months. As the effects were small and temporary and the treatment is complicated and expensive, IVIG therapy cannot at present be recommended for general use. A double-blind, placebo-controlled study of the effect of IVIG in asthma is needed.     

Greater involvement of neurokinins found in Guinea pig models of severe asthma compared with mild asthma

BACKGROUND: Involvement of neurokinins in asthma has been previously pointed out by several reports. However, the relationship between neurokinins and the severity of asthma has remained unclear. We developed a model of mild asthma (model I) and severe asthma (model II) in guinea pigs, and investigated the function of neurokinins in both models. METHODS: In models I and II, systemically sensitized guinea pigs were made to inhale ovalbumin once and three times, respectively. Substance P (SP) and neurokinin A (NKA) concentrations in the bronchoalveolar lavage fluid (BALF) were measured in models I and II. Then, the effects of a capsaicin pretreatment, which depletes neurokinins, in both animal models on airway narrowing induced by the last ovalbumin inhalation, airway hyperresponsiveness to inhaled methacholine, and eosinophil accumulation in BALF, were investigated. RESULTS: SP concentration tended to increase and the NKA concentration increased significantly in model II, but not in model I. Capsaicin pretreatment significantly inhibited the late bronchial response that was observed 2-6 h after the last ovalbumin inhalation, airway hyperresponsiveness and eosinophil accumulation in model II. On the other hand, it had no effects on the responses in model I. CONCLUSION: It is suggested that the more severe the disease, the greater the involvement of neurokinins.     

Clinical, physiologic, and psychologic comparison of treatment by cromolyn or theophylline in childhood asthma

Treatment of chronic perennial childhood asthma with cromolyn sodium (CS) or long-acting theophylline (LAT) was compared in 13 children by a double-blind, cross-over trial in which each drug was administered for 4 wk. LAT was administered twice daily in individual doses to elicit adequate blood levels (mean 14.0 +/- 1.6 SEM, micrograms per milliliters). Powdered CS was administered by inhalation in a dose of 20 mg four times daily. The patients were followed by means of a daily symptom and drug consumption diary and twice daily peak flow measurements. A series of psychologic studies were performed in the third week of each month. Exercise and histamine bronchial provocation tests were performed at the end of each month. There were no significant differences between the month in which CS was taken and the month in which LAT was taken in terms of diary scores, peak flow rates, additional drug consumption, or in bronchial reactivity to exercise or histamine at the end of each month. The results of psychologic tests reflecting visual-spatial planning were significantly better for the four children receiving CS with lower IQ scores (87 to 105) but not for the nine children with higher IQ scores (111 to 134). The possibility that the psychologic performance of children with lower intelligence may be adversely affected by theophylline requires further evaluation.     

The in vitro and in vivo effect of corticosteroides on basophi releasabihty in patients with mild and severe bronchial asthma

Background While inhalation of corticosteroids (CST) is considered very effective in most asthmatic patients, some require a high dose of orul prcdnisonc to control the disease. Basophils, which participate in inflammation, are responsive to cortiseosteroids by suppressing histamine release. Objectives We investigated the in vivo (oral prednisone) and in vitro (dexamethasone, DEX) effect on basophil histamine release in mild and steroid-dependent asthmatics. Methods Histamine release from basophils to anti-IgE and anti-IgE + IL₃ was evaluated following live days of prednisone given 20 mg twice daily in eight subjects with mild disease and 2 h following their daily prednisone ingestion in eight subjects with severe disease, as well as after in vitro DEX was added to the cells. Results Histamine release from basophils was seen following anti- IgE as well as anti-IgE + IL-3. The same amount of release was seen in the mild and severe asthmatics. In vivo prednisone suppressed histamine release to both stimuli and DEX added to the suppression in the mild asthmatics. In the severe ones. DEX showed no inhibitory effect on histamine release. Conclusion Oral and in-vitro CST suppressed histamine release from basophils of mild but not severe CST-dependent asthmatics. Suppression of basophil releasability can be a reflection of asthma severity.     

A controlled study on the effect of treatment with cromolyn sodium pressurized aerosol on bronchial reactivity in patients with asthma

The effect of cromolyn sodium (CS) pressurized aerosol on bronchial hyperreactivity was assessed by comparison with placebo in a double-blind crossover study of 14 adult patients with clinically stable asthma. The trial was performed in a cold climate during the pollen-free winter months and the patient's risk of exposure to clinically relevant allergens was judged to be low. The dose was two puffs, each of 1 mg CS or placebo, four times daily over two successive 4-week periods, the order of treatment being decided by random allocation. No significant difference between treatments was observed in bronchial reactivity to histamine, determined as PC15. There was no difference between treatments with regard to symptoms, which were slight, or daily peak expiratory flow recordings, which showed minimal circadian variation. The results suggest that, although prolonged treatment with CS may decrease bronchial reactivity by reducing airway inflammation secondary to the assault of allergic stimuli, the drug probably has little or no effect on the basal bronchial reactivity in asthma.     

A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma

BACKGROUND: Inhaled corticosteroids are effective in the treatment of children with asthma. It is uncertain how inhaled corticosteroids compare with oral corticosteroids in the management of severe acute disease. METHODS: We performed a double-blind, randomized trial involving 100 children five years of age or older who had severe acute asthma (indicated by a forced expiratory volume in one second [FEV1] that was less than 60 percent of the predicted value) and in whom the results could be evaluated. All were treated with an aggressive bronchodilator regimen and received one dose of either 2 mg of inhaled fluticasone through a metered-dose inhaler with a spacer or 2 mg of oral prednisone per kilogram of body weight. They were assessed hourly for up to four hours. RESULTS: The mean (+/-SD) base-line FEV1 as a percentage of the predicted value was 46.3+/-12.5 in the fluticasone group (51 subjects) and 43.9+/-9.9 in the prednisone group (49 subjects). The FEV1 increased by a mean of 9.4+/-12.5 percentage points in the fluticasone group and by 18.9+/-9.8 percentage points in the prednisone group four hours after therapy (P< 0.001). None of the children in the prednisone group had a reduction in FEV1 as a percentage of the predicted value from base line to four hours, as compared with 25 percent of those in the fluticasone group (P<0.001). Sixteen (31 percent) of the children treated with fluticasone were hospitalized, as compared with five (10 percent) of those treated with prednisone (P=0.01). CONCLUSIONS: Children with severe acute asthma should be treated with oral prednisone and not with inhaled fluticasone or a similar inhaled corticosteroid.     

Inflammatory biomarkers in airways of patients with severe asthma compared with non-severe asthma

Background About 5–10% of patients with asthma suffer from poorly-controlled disease despite corticosteroid (CS) therapy.
Objective We determined whether there were any differences in inflammatory biomarkers between severe and non-severe asthma patients.
Methods Nineteen severe and 20 non-severe asthma patients were recruited and underwent collection of induced sputum, bronchoalveolar lavage (BAL) fluid and bronchial biopsies.
Results Biopsy results showed no differences in eosinophils (major basic protein positive), neutrophils, macrophages, T cells and mast cells in the bronchial submucosa. However, subbasement membrane (SBM) thickness and smooth muscle area were increased in the biopsies. No significant differences were observed in the induced sputum inflammatory cells. In BAL fluid, there was a significant increase in neutrophils but a significant decrease in macrophages. Eosinophil counts were non-significantly increased threefold in both sputum and BAL in severe asthma. Levels of IL-8 and IL-13 in sputum supernatants were similar in both groups of asthma patients. There was a significant inverse correlation between post-bronchodilator forced expiratory volume in 1 s and provocative concentration of methacholine causing a 20% fall in FEV₁ with SBM thickness.
Conclusion Differences in inflammatory cells were observed mainly in terms of increased neutrophils and reduction in macrophage numbers in BAL fluid with a trend towards increased eosinophils in severe asthma compared with non-severe asthma. However, the most notable features are the increase in features of airway wall remodelling of SBM thickness and smooth muscle area.     

A breath for health: an exploratory study in severe asthma patients in Turkey

Background:  Severe asthma puts enormous burden on patients. To evaluate asthma-related restrictions on patients' daily lives along with their expectations about future asthma care.
Methods:  A structured questionnaire was administered to severe asthma patients at 25 centers across Turkey. The patients were divided into; uncontrolled ( n : 274) and controlled asthma ( n : 177) according to the existence of symptoms despite the GINA step 4 or 5 treatment.
Results:  A total of 451 patients (F/M: 337/114, mean age: 47.6 ± 13.2 years) were included; 93% were nonsmokers and 51.2% were atopic. Chronic rhino-sinusitis, ASA/NSAID sensitivity, and osteoporosis were significantly higher in uncontrolled patients. Nearly 70% of the uncontrolled asthmatics defined asthma as disturbing with significant restrictions in daily life. The most important role for medication was symptom relief. One inhaler or one tablet a month was the most preferred form of drug usage. In addition, 30.6% of the patients had tried alternative treatment with herbal remedies. Although patients were willing to become members of an asthma association, they expected the Turkish government to provide special asthma clinics and fund research into new treatments. Controlled patients achieved or were close to achieving asthma control goals. Uncontrolled patients seemed to be more pessimistic in this respect, but they reserved significant levels of hope for the future. Two-thirds of all the patients thought that they would receive better treatment in the next 5 years.
Conclusions:  In this study group, severe asthma patients face significant limitations in their daily lives, but they are optimistic about better asthma control and treatment options in the future.     

Mometasone furoate antagonizes AMP-induced bronchoconstriction in patients with mild asthma

BACKGROUND: Mometasone furoate (MF) is a new potent corticosteroid for use in treating asthma. OBJECTIVE: To test the lower range of the dose-response curve, effects of MF delivered by dry powder inhaler (DPI) on AMP-induced bronchoconstriction were compared with those of placebo. METHODS: In a placebo-controlled, 3-phase cross-over, single-center, double-blind study, 15 patients with mild asthma were randomized to three 2-week treatment phases (separated by 4-week washout phases) with MF DPI 50 microg twice daily, MF DPI 100 microg twice daily, or placebo. AMP challenge was performed before and at the end of each treatment phase. RESULTS: Thirteen patients completed all 3 phases and were included in the primary efficacy analysis. Treatment with MF DPI 50 microg twice daily or with MF DPI 100 microg twice daily significantly reduced the bronchoconstrictor response to AMP, displacing the dose-response curve to the right by 2.81 and 3.11 doubling dilutions, respectively, compared with placebo (P <.001). The improvement in FEV(1) over the 2-week treatment phase was significantly (P < or =.033) greater during treatment with MF DPI 50 microg or 100 microg twice daily than with placebo. Peak expiratory flow rate, wheezing scores, difficulty breathing scores, nocturnal awakenings requiring salbutamol, and puffs of salbutamol per day also indicated a greater improvement in respiratory function and symptoms of asthma with MF DPI 50 or 100 microg twice daily than with placebo. Both doses of MF DPI were well tolerated. CONCLUSIONS: Treatment with low doses of MF DPI decreased airway responsiveness to AMP challenge and improved secondary measures of pulmonary function and asthma symptoms.     

A clinical evaluation of rush immunotherapy in adult patients with severe bronchial asthma

Rush immunotherapy (RIT) using house dust (HD) antigen were performed in ten adult patients with chronic severe bronchial asthma who had mite allergy. All cases have reached to the maintenance dose of 10(-1) X 0.50 ml within 10 days and been able to introduce maintenance therapy smoothly. After the RIT, remarkable improvement of asthmatic symptom was seen in 4 cases and one of them was considered to be completely cured of the asthma. Although side effects such as local skin reaction, rhinorrhea and asthmatic attack were seen, severe side effect was not observed at all. IgE-RAST scores for both HD and mite were unchanged before and after RIT. On the other hand, the values of specific IgG4 for both HD and mite antibody were significantly increased 2 or 4 weeks after RIT. These results indicated that RIT can be performed safely and securely, and rapid immunological response as well as clinical effectiveness are able to be expected for adult severe asthmatics.