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1.  Classification of chronic cough by systematic treatment cascade trial starting with beta agonist 
Background
Chronic cough is one of the most challenging symptoms to diagnose and treat, not only because of the variety of underlying disorders but also its varying susceptibility to treatments. Etiological studies of chronic cough vary depending on the clinical settings and the particular interests of investigators.
Objectives
The purposes of this study were first to categorize the etiology of chronic cough by its response to systematic diagnostic treatments starting from the β2 agonist and second to sub-categorize β2 agonist responsive cough (BRC) by the airway hyperresponsiveness.
Methods
One hundred and eighty-four never-smokers received the maximal dose of procaterol to diagnose BRC. BRC was sub-categorized into two groups with or without airway hyperresponsiveness measured by the methacholine challenge test. Sinobronchial syndrome (SBS) was diagnosed by postnasal drip symptoms and by the response to clarythromycin and carbocysteine. Atopic cough (AC) was diagnosed by the evidence of atopy and the response to cetirizine hydrochloride. Gastroesophageal reflux disease (GERD) was diagnosed by the response to rabeprazole sodium. Since we did not investigate eosinophil counts in the tissue or in the induced sputum, no diagnosis of eosinophilic bronchitis was made.
Results
One hundred and nine patients had BRC. Twenty-three of them had bronchial asthma (BA), 53 had cough variant asthma (CVA) and 33 had non-hyperresponsive BRC (NHBRC). Thirty-one patients had GERD, 27 had AC and 14 had SBS. Twenty-five patients had more than one diagnosis in combination, while 6 had other miscellaneous diseases. Twelve patients were undiagnosed and 11 dropped out of the study.
Conclusions
The majority of chronic cough was BRC. NHBRC was a new chronic cough entity. GERD is a common cause of chronic cough in Japan, as in Western countries. AC and SBS are also causes of chronic cough in Japan.
Trial registration
University hospital medical information network (UMIN 000007483)
doi:10.1186/1745-9974-9-4
PMCID: PMC3602065  PMID: 23391257
Airway hyperresponsiveness; β2 agonist; Bronchial asthma; Cough variant asthma; Non-hyperresponsive and β2 agonist responsive cough; Gastroesophageal reflex disease; Sinobronchial syndrome; Atopic cough; Postnasal drip; Chronic cough
2.  Bronchial hyperreactivity and spirometric impairment in polysensitized patients with allergic rhinitis 
Background
We previously demonstrated in a group of patients with perennial allergic rhinitis alone impairment of spirometric parameters and high percentage of subjects with bronchial hyperreactivity (BHR). The present study aimed at evaluating a group of polysensitized subjects suffering from allergic rhinitis alone to investigate the presence of spirometric impairment and BHR during the pollen season.
Methods
One hundred rhinitics sensitized both to pollen and perennial allergens were evaluated during the pollen season. Spirometry and methacholine bronchial challenge were performed.
Results
Six rhinitics showed impaired values of FEV1 without referred symptoms of asthma. FEF 25–75 values were impaired in 28 rhinitics. Sixty-six patients showed positive methacholine bronchial challenge. FEF 25–75 values were impaired only in BHR positive patients (p < 0.001). A significant difference was observed both for FEV1 (p < 0.05) and FEF 25–75 (p < 0.001) considering BHR severity.
Conclusions
This study evidences that an impairment of spirometric parameters may be observed in polysensitized patients with allergic rhinitis alone during the pollen season. A high percentage of these patients had BHR. A close relationship between upper and lower airways is confirmed.
doi:10.1186/1476-7961-2-3
PMCID: PMC385251  PMID: 15018619
allergic rhinitis; polysensitization; bronchial hyperreactivity; methacholine challenge; FEF 25–75
3.  Bronchial Hyperresponsiveness to Methacholine and AMP in Children With Atopic Asthma 
Purpose
Bronchial hyperresponsiveness (BHR) is typically measured by bronchial challenge tests that employ direct stimulation by methacholine or indirect stimulation by adenosine 5'-monophosphate (AMP). Some studies have shown that the AMP challenge test provides a better reflection of airway inflammation, but few studies have examined the relationship between the AMP and methacholine challenge tests in children with asthma. We investigated the relationship between AMP and methacholine testing in children and adolescents with atopic asthma.
Methods
The medical records of 130 children with atopic asthma (mean age, 10.63 years) were reviewed retrospectively. Methacholine and AMP test results, spirometry, skin prick test results, and blood tests for inflammatory markers (total IgE, eosinophils [total count, percent of white blood cells]) were analyzed.
Results
The concentration of AMP that induces a 20% decline in forced expiratory volume in 1 second [FEV1] (PC20) of methacholine correlated with the PC20 of AMP (r2=0.189, P<0.001). No significant differences were observed in the levels of inflammatory markers (total eosinophil count, eosinophil percentage, and total IgE) between groups that were positive and negative for BHR to methacholine. However, significant differences in inflammatory markers were observed in groups that were positive and negative for BHR to AMP (log total eosinophil count, P=0.023; log total IgE, P=0.020, eosinophil percentage, P<0.001). In contrast, body mass index (BMI) was significantly different in the methacholine positive and negative groups (P=0.027), but not in the AMP positive and negative groups (P=0.62). The PC20 of methacholine correlated with FEV1, FEV1/forced vital capacity (FVC), and maximum mid-expiratory flow (MMEF) (P=0.001, 0.011, 0.001, respectively), and the PC20 of AMP correlated with FEV1, FEV1/FVC, and MMEF (P=0.008, 0.046, 0.001, respectively).
Conclusions
Our results suggest that the AMP and methacholine challenge test results correlated well with respect to determining BHR. The BHR to AMP more likely implicated airway inflammation in children with atopic asthma. In contrast, the BHR to methacholine was related to BMI.
doi:10.4168/aair.2012.4.6.341
PMCID: PMC3479227  PMID: 23115730
AMP; atopic asthma; bronchial hyper-responsiveness; methacholine
4.  Cough sensitivity and extrathoracic airway responsiveness to inhaled capsaicin in chronic cough patients. 
Journal of Korean Medical Science  2002;17(5):616-620.
Enhanced cough response has been frequently observed in chronic cough. Recently, extrathoracic airway constriction to inhaled histamine was demonstrated in some chronic cough patients. However, relation between extrathoracic airway hyperresponsiveness (EAHR) and cough sensitivity determined by capsaicin inhalation is unclear in each etiological entity of chronic cough. Seventy-seven patients, with dry cough persisting for 3 or more weeks, normal spirometry and chest radiography, and 15 controls, underwent methacholine bronchial provocation test and capsaicin cough provocation test. Elicited cough number and flow-volume curve was examined after inhalation of capsaicin to evaluate cough sensitivity and EAHR. Thirty-three patients, with postnasal drip, showed normal extrathoracic airway responsiveness, and 27 of them showed normal cough sensitivity to capsaicin. Cough sensitivity was enhanced in 14 patients with cough variant asthma (CVA) who showed bronchial hyperresponsiveness; EAHR to inhaled capsaicin was present in 12 of them. The remaining 30 patients were tentatively diagnosed as idiopathic chronic cough (ICC). Eleven ICC patients showed enhanced cough sensitivity and EAHR to inhaled capsaicin while 19 patients showed normal values. These results indicate that cough sensitivity is closely related with extrathoracic airway responsiveness during capsaicin provocation in some chronic cough patients. EAHR and enhanced cough sensitivity to inhaled capsaicin may be a part of mechanism developing chronic cough.
PMCID: PMC3054948  PMID: 12378011
5.  Effect of loratadine, an H1 antihistamine, on induced cough in non-asthmatic patients with chronic cough. 
Thorax  1996;51(8):810-814.
BACKGROUND: H1 antihistamines have been shown to have an antitussive effect in patients with asthma, postnasal drip, and allergic rhinitis. No study has been performed to determine whether orally administered H1 antihistamines can reduce the number of coughs induced by stimulation of cough receptors in non-asthmatic patients with chronic dry cough. METHODS: The effect of loratadine (10 mg) on the number of coughs induced by ultrasonically nebulised distilled water (UNDW) was examined in 10 patients with nasal disease and in seven patients with unexplained chronic cough using a randomised, double blind crossover method. Eleven normal volunteers were also studied. Each subject inhaled UNDW for one minute, and the numbers of coughs during the one minute inhalation and the 30 seconds following it were counted. RESULTS: There was no difference in the results of pulmonary function tests performed before and one minute after UNDW inhalation for either patients or normal subjects. There was also no significant difference between the results of pulmonary function tests before or after oral administration of loratadine. Loratadine significantly reduced the number of coughs in patients with nasal disease and in those with unexplained chronic cough, but not in normal subjects. CONCLUSIONS: The H1 antihistamine loratadine reduces cough induced by UNDW. The release of histamine may contribute to the chronic cough in patients with unexplained chronic cough or nasal disease.
Images
PMCID: PMC472550  PMID: 8795669
6.  Associations of airway inflammation and responsiveness markers in non asthmatic subjects at start of apprenticeship 
Background
Bronchial Hyperresponsiveness (BHR) is considered a hallmark of asthma. Other methods are helpful in epidemiological respiratory health studies including Fractional Exhaled Nitric Oxide (FENO) and Eosinophils Percentage (EP) in nasal lavage fluid measuring markers for airway inflammation along with the Forced Oscillatory Technique measuring Airway resistance (AR). Can their outcomes discriminate profiles of respiratory health in healthy subjects starting apprenticeship in occupations with a risk of asthma?
Methods
Rhinoconjunctivitis, asthma-like symptoms, FEV1 and AR post-Methacholine Bronchial Challenge (MBC) test results, FENO measurements and EP were all investigated in apprentice bakers, pastry-makers and hairdressers not suffering from asthma. Multiple Correspondence Analysis (MCA) was simultaneously conducted in relation to these groups and this generated a synthetic partition (EI). Associations between groups of subjects based on BHR and EI respectively, as well as risk factors, symptoms and investigations were also assessed.
Results
Among the 441 apprentice subjects, 45 (10%) declared rhinoconjunctivitis-like symptoms, 18 (4%) declared asthma-like symptoms and 26 (6%) suffered from BHR. The mean increase in AR post-MBC test was 21% (sd = 20.8%). The median of FENO values was 12.6 ppb (2.6-132 range). Twenty-six subjects (6.7%) had EP exceeding 14%. BHR was associated with atopy (p < 0.01) and highest FENO values (p = 0.09). EI identified 39 subjects with eosinophilic inflammation (highest values of FENO and eosinophils), which was associated with BHR and atopy.
Conclusions
Are any of the identified markers predictive of increased inflammatory responsiveness or of development of symptoms caused by occupational exposures? Analysis of population follow-up will attempt to answer this question.
doi:10.1186/1471-2466-10-37
PMCID: PMC2913998  PMID: 20604945
7.  320 Development of a Questionnaire for the Assessment of Bronchial Hyperresponsiveness in Korea 
Background
Bronchial hyperresponsiveness (BHR) is an important pathophysiological feature of asthma. In addition to the diagnostic significance, BHR is associated with the severity of airway inflammation and BHR- based treatment approaches has been shown to be effective. Nevertheless, challenge tests are time consuming, inconvenient to patients, and are not accessible in every primary care physicians. We aimed to develop a questionnaire for the assessment of BHR in Korean subjects.
Methods
From the 24 University-affiliated hospitals, we recruited 149 adults between age 20 and 40 years with more than one asthmatic symptom (cough, sputum or dyspnea) and who had bronchial provocation test. A list of 33 symptoms, past history of allergy or smoking and 10 provoking stimuli were selected for the BHR questionnaire. After a methacholine challenge test patients were asked to complete each questionnaire. For each item of questionnaire, diagnostic odds ratios for the presence of BHR were calculated and multiple logistic regression analysis was performed to select final questionnaire items. Receiver operating characteristic (ROC) curve analysis was used to evaluate the sensitivity and specificity of the selected questionnaire items.
Results
Methacholine challenge test was positive in 36 patients (24.2%). Eleven symptoms and 2 provoking stimuli items were statistically significant by the results of diagnostic odds ratio. According to the result of multiple logistic regression analysis, 4 items were finally selected for the significant BHR questionnaire: the presence of wheezing episode, past history of physician-diagnosed asthma, family history of asthma. The psychiatric stress was negatively associated provoking stimuli item for the presence of BHR. The area under the ROC curve was 0.80 (95% CI, 0.72-0.86). Sensitivity was 84.9% (95% CI, 68.1-94.9) and specificity was 65.5% (95% CI, 55.8-74.3).
Conclusions
Four BHR questionnaire items including wheezing episode, past history of physician-diagnosed asthma, family history of asthma and psyachiatric stress stimuli were able to assess the presence of BHR in Korean adults.
doi:10.1097/01.WOX.0000412083.06151.cc
PMCID: PMC3512762
8.  CYTOLOGY OF THE POSTNASAL DRIP 
California Medicine  1950;73(1):39-41.
About half of a series of 100 consecutive patients with disturbances of the eyes, ears, nose or throat complained of postnasal drip. When smears of the mucous discharge were examined it was found that in about a third of the cases in which there was complaint of drip, neither eosinophils nor neutrophils could be demonstrated. This indicates that causes of the drip other than allergic disease and infection must be considered.
Cytologic examination of the postnasal drip showed that about one-third of the patients with nasal disease or histories positive for allergic reaction had nasal eosinophilia. Nasal eosinophilia was noted occasionally in patients with normal-appearing nasal structures and in patients with no history of allergic disease.
Images
PMCID: PMC1520561  PMID: 15426981
9.  241 Nasal Cytology is Important in the Classification of Patients with Allergic and Non-Allergic Rhinitis 
Background
The purpose of the study is the classification and clinical characterization of patients with allergic rhinitis and non-allergic and differentiate the presence of eosinophils and neutrophils in nasal cytology.
Methods
Prospective study of 405 patients with chronic symptoms of sneezes, pruritus, nasal congestion and rhinorrhea were evaluated by clinical examination, skin prick test and nasal cytology. Patients with diseases and/or treatments that could alter the outcome of these tests were excluded.
Results
405 patients from 3 to 80 years were evaluated; 248 female patients (61%) and 157 males (39%). The sample was divided into 2 groups according to skin prick tests: allergic 270 (67%), 135 non-allergic (33%). The mean age of onset of symptoms was 14.27 and 23.47 years in allergic and nonallergic respectively. Nasal symptoms (nasal congestion, sneezes/pruritus, rhinorrhea, postnasal secretion) and signs (turbinates color and edema, secretion and oropharynx redness) were accessed using scores from 0 to 3, ranging from 0 to 24. In the allergic group the mean total nasal symptoms and signs scores were 6.64 and 4.66, while in non-allergic were 5.67 and 3.52. Allergic patients had an average 27.82% of eosinophils and 64.09% of neutrophils in nasal smears, whereas non-allergic patients 8.38% and 85.30%. Using skin prick test and nasal cytology we were able to diagnose allergic rhinitis in 69.6% (208) of the patients. 20.7% (62) had neutrophilic non-allergic rhinitis (NARNA) and 9.7% (29) non-allergic rhinitis with eosinophilia syndrome (NARES). No idiopathic rhinitis patients were found.
Conclusions
The frequencies of the types of rhinitis were: allergic rhinitis 69.6%, RENA 9.7%, NARNA 20.7% and idiopathic rhinitis 0%. Despite the fact that each sub group of nonallergic rhinitis has particularities, in allergic rhinitis we found early onset of complaints, signs and symptoms more intense and a greater number of eosinophils, compared with the nonallergic patients.
doi:10.1097/01.WOX.0000411998.00373.31
PMCID: PMC3512858
10.  Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials 
BMJ : British Medical Journal  1998;317(7173):1624-1629.
Objective
To determine whether intranasal corticosteroids are superior to oral H1 receptor antagonists (antihistamines) in the treatment of allergic rhinitis.
Design
Meta-analysis of randomised controlled trials comparing intranasal corticosteroids with oral antihistamines.
Setting
Randomised controlled trials conducted worldwide and published between 1966 and 1997.
Subjects
2267 subjects with allergic rhinitis in 16 randomised controlled trials.
Main outcome measures
Nasal blockage, nasal discharge, sneezing, nasal itch, postnasal drip, nasal discomfort, total nasal symptoms, nasal resistance, and eye symptoms and global ratings. Outcomes measured on different scales were combined to determine pooled odds ratios (categorical outcomes) or standardised mean differences (continuous outcomes). Assessment of heterogeneity between studies, and subgroup analyses of eye symptoms, were undertaken.
Results
Intranasal corticosteroids produced significantly greater relief than oral antihistamines of nasal blockage (standardised mean difference −0.63, 95% confidence interval −0.73 to −0.53), nasal discharge (−0.5, −0.6 to −0.4), sneezing (−0.49, −0.59 to −0.39), nasal itch (−0.38, −0.49 to −0.21), postnasal drip (−0.24, −0.42 to −0.06), and total nasal symptoms (−0.42, −0.53 to −0.32), and global ratings gave an odds ratio for deterioration of symptoms of 0.26 (0.08 to 0.8). There were no significant differences between treatments for nasal discomfort, nasal resistance, or eye symptoms. The effects on sneezing, total nasal symptoms, and eye symptoms were significantly heterogeneous between studies. Other combined outcomes were homogeneous between studies. Subgroup analysis of the outcome of eye symptoms suggested that the duration of assessment (averaged mean score over the study period versus mean score at end of study period) might have accounted for the heterogeneity.
Conclusion
The results of this systematic review, together with data on safety and cost effectiveness, support the use of intranasal corticosteroids over oral antihistamines as first line treatment for allergic rhinitis.
Key messagesAllergic rhinitis is increasing in prevalence and is a common cause of morbidityIntranasal corticosteroids produce greater relief from most nasal symptoms than do oral H1 receptor antagonists (antihistamines)Intranasal corticosteroids and oral antihistamines show no difference in the relief of the eye symptoms of allergic rhinitisIntranasal corticosteroids are more cost effective than oral antihistaminesIntranasal corticosteroids are recommended for first line treatment of allergic rhinitis
PMCID: PMC28740  PMID: 9848901
11.  Bronchial hyperresponsiveness in lung transplant recipients: lack of correlation with airway inflammation 
Thorax  1997;52(6):551-556.
BACKGROUND: Bronchial hyperresponsiveness (BHR) to methacholine has been reported to occur in most lung transplant recipients. BHR to physical stimuli such as exercise and non-isotonic aerosols has not been as extensively studied in this subject population. This report aims to assess the presence and degree of BHR to methacholine and hypertonic saline in stable lung transplant recipients and to relate it to the presence of airway inflammation. METHODS: Ten patients undergoing bilateral sequential lung transplantation and six heart-lung transplant recipients, all with stable lung function, were recruited 66- 1167 days following transplantation. Subjects underwent a methacholine challenge and bronchoscopy for sampling of bronchoalveolar lavage fluid, transbronchial and endobronchial biopsy tissues. Hypertonic saline challenge was performed six days later. RESULTS: Nine of the 16 transplant recipients had positive methacholine challenges (geometric mean PD20 0.18 mg, interquartile range 0.058-0.509) and three of these subjects also had positive hypertonic saline challenges (PD15 = 2.3, 33.0, and 51.5 ml). No clear relationship was found between BHR to either methacholine or hypertonic saline and levels of mast cells, eosinophils or lymphocytes in samples of biopsy tissue or lavage fluid. CONCLUSIONS: Most of the lung transplant recipients studied were responsive to methacholine and unresponsive to hypertonic saline. BHR was not clearly related to airway inflammation, suggesting an alternative mechanism for BHR following lung transplantation from that usually assumed in asthma. 



PMCID: PMC1758572  PMID: 9227723
12.  Clinical Efficacy and Safety of a Combined Loratadine-Betamethasone Oral Solution in the Treatment of Severe Pediatric Perennial Allergic Rhinitis 
Background
Allergic rhinitis is a highly prevalent condition, particularly among children, whose schoolwork and quality of life may be impaired by its symptoms.
Methods
In this prospective, multicenter study, children between 6 and 12 years old with a diagnosis of severe perennial allergic rhinitis received a combination of the nonsedating antihistamine loratadine and the corticosteroid betamethasone in an oral solution for 5 days.
Results
The total nasal and ocular symptom score was significantly reduced from 11.4 (± 2.1) before treatment to 2.9 (± 2.4) after treatment (P < 0.01). Significant reductions (P < 0.01) were also observed for sneezing, nasal pruritus, nasal congestion, rhinorrhea, postnasal drip, and ocular erythema and pruritus. No adverse events were reported, and no subject discontinued treatment.
Conclusions
The combination of loratadine and betamethasone in an oral solution was safe and effective as initial short-term treatment for symptoms of severe perennial allergic rhinitis in school-aged children.
doi:10.1097/WOX.0b013e31819f2105
PMCID: PMC3651010  PMID: 23282980
etamethasone; loratadine; pediatric; perennial allergic rhinitis; quality of life
13.  Bronchial hyperresponsiveness in women with chronic obstructive pulmonary disease related to wood smoke 
Purpose
Chronic obstructive pulmonary disease (COPD) related to wood smoke exposure is characterized by important inflammation of the central and peripheral airways without significant emphysema. The objective of this study is to describe the bronchial hyperresponsiveness (BHR) level in women with COPD related to wood smoke exposure and to compare it with the BHR in women with COPD related to tobacco smoking.
Materials and methods
Two groups of women with stable COPD were studied: (1) wood smoke exposed (WS-COPD); and (2) tobacco smoke exposed (TS-COPD). A methacholine challenge test (MCT) was performed in all patients according to American Thoracic Society criteria. BHR levels were compared using the methacholine concentration, which caused a 20% fall in the FEV1 (PC20).
Results
Thirty-one patients, 19 with WS-COPD and 12 with TS-COPD, were included. There were no significant differences between the groups in baseline FVC, FEV1, IC, FEF25–75, and FEF25–75/FVC. All 31 patients had a positive MCT (PC20 < 16 mg/mL) and the fall in the FEV1 and IC was similar in both groups. The severity of BHR was significantly higher in the WS-COPD patients (PC20: 0.39 mg/mL) than in the TS-COPD patients (PC20: 1.24 mg/mL) (P = 0.028). The presence of cough, phlegm, and dyspnea during the test were similar in both groups.
Conclusion
We found moderate to severe BHR in women with WS-COPD, which was more severe than in the TS-COPD women with similar age and airflow obstruction. This paper suggests that the structural and inflammatory changes induced by the chronic exposure to wood smoke, described in other studies, can explain the differences with TS-COPD patients. Future studies may clarify our understanding of the impact of BHR on COPD physiopathology, phenotypes, and treatment strategies.
doi:10.2147/COPD.S30410
PMCID: PMC3393338  PMID: 22791990
biomass fuels; indoor air pollution; wood smoke; COPD; methacholine challenge test
14.  Bronchial hyperresponsiveness and the development of asthma and COPD in asymptomatic individuals: SAPALDIA Cohort Study 
Thorax  2006;61(8):671-677.
Background
Bronchial hyperresponsiveness (BHR) is a common feature of asthma. However, BHR is also present in asymptomatic individuals and its clinical and prognostic significance is unclear. We hypothesised that BHR might play a role in the development of chronic obstructive pulmonary disease (COPD) as well as asthma.
Methods
In 1991 respiratory symptoms and BHR to methacholine were evaluated in 7126 of the 9651 participants in the SAPALDIA cohort study. Eleven years later 5825 of these participants were re‐evaluated, of whom 4852 performed spirometric tests. COPD was defined as an FEV1/FVC ratio of <0.70.
Results
In 1991 17% of participants had BHR, of whom 51% were asymptomatic. Eleven years later the prevalence of asthma, wheeze, and shortness of breath in formerly asymptomatic subjects with or without BHR was, respectively, 5.7% v 2.0%, 8.3% v 3.4%, and 19.1% v 11.9% (all p<0.001). Similar differences were observed for chronic cough (5.9% v 2.3%; p = 0.002) and COPD (37.9% v 14.3%; p<0.001). BHR conferred an adjusted odds ratio (OR) of 2.9 (95% CI 1.8 to 4.5) for wheezing at follow up among asymptomatic participants. The adjusted OR for COPD was 4.5 (95% CI 3.3 to 6.0). Silent BHR was associated with a significantly accelerated decline in FEV1 by 12 (5–18), 11 (5–16), and 4 (2–8) ml/year in current smokers, former smokers and never smokers, respectively, at SAPALDIA 2.
Conclusions
BHR is a risk factor for an accelerated decline in FEV1 and the development of asthma and COPD, irrespective of atopic status. Current smokers with BHR have a particularly high loss of FEV1.
doi:10.1136/thx.2005.052241
PMCID: PMC2104688  PMID: 16670173
bronchial hyperresponsiveness; asthma; chronic obstructive pulmonary disease; smoking; epidemiological study
15.  Bronchial hyperresponsiveness to methacholine in patients with primary Sjögren's syndrome. 
The prevalence of bronchial hyperresponsiveness (BHR) to methacholine inhalation in a consecutive series of 21 patients with primary Sjögren's syndrome was studied prospectively. Slight to severe BHR was seen in 12/20 (60%) of the patients. Ten of 12 patients with BHR (83%) had a non-productive cough, wheezing, or intermittent breathlessness. Bronchial hyperresponsiveness was more common in patients with extraglandular symptoms (10/14, 71%) than in those with only glandular symptoms (29%). Spirometrically 29% (6/21) of the patients had 'small airways' disease', and all those had BHR. Of 6/21 (29%) who had diffuse interstitial lung disease, two had BHR. Three of the four patients with obstructive lung function were challenged with methacholine and two of them had BHR. Only two patients with BHR had normal spirometry findings. The data showed that respiratory disease--mostly mild or moderate but even severe bronchial hyperresponsiveness--is commonly seen in patients with primary Sjögren's syndrome.
PMCID: PMC1004322  PMID: 1994866
16.  Patients with allergic rhinitis and allergic asthma share the same pattern of eosinophil and neutrophil degranulation after allergen challenge 
Background
Patients with allergic rhinitis and allergic asthma demonstrate comparable local and systemic eosinophil inflammation, and yet they present with different clinical pictures. Less is even known about the contribution of neutrophil inflammation in allergic diseases. The aim of the study was to examine the propensity and selectivity of granule release from primed systemic eosinophils and neutrophils in allergic rhinitis and allergic asthma after seasonal and experimental allergen exposure. We hypothesize that the dissimilar clinical manifestations are due to diverse eosinophil and neutrophil degranulation.
Methods
Nine birch pollen allergic patients with rhinitis, eight with asthma and four controls were studied during pollen season and after nasal and bronchial allergen challenge. Eosinophils and neutrophils were incubated in vitro with assay buffer and opsonized Sephadex particles for spontaneous and C3b-induced granule protein release. The released amount of eosinophil cationic protein (ECP), eosinophil peroxidase (EPO) and myeloperoxidase (MPO) was measured by specific radioimmunoassay.
Results
C3b-induced degranulation resulted in increased release of ECP and MPO from primed blood eosinophils and neutrophils in both allergic rhinitis and allergic asthma during pollen season and after both nasal and bronchial challenge (p-values 0.008 to 0.043). After bronchial challenge, the ECP release was significantly higher in the rhinitic group compared to the asthmatic group [19.8 vs. 13.2%, (p = 0.010)]. The propensity for EPO release was weak in all challenge models but followed the same pattern in both allergic groups.
Conclusions
Systemically activated eosinophils and neutrophils have similar patterns of degranulation after allergen exposure in allergic rhinitis and allergic asthma. The released amount of ECP, EPO and MPO was similar in all allergen challenge models in both allergic groups. Our results indicate that other mechanisms than the magnitude of eosinophil and neutrophil inflammation or the degranulation pattern of the inflammatory cells determines whether or not an allergic patient develops asthma.
doi:10.1186/1476-7961-9-3
PMCID: PMC3031270  PMID: 21255397
17.  AB 22. Study of IL-1, IL-4 and TNFα polymorphisms in extrinsic and intrinsic asthma in a Greek population 
Journal of Thoracic Disease  2012;4(Suppl 1):AB22.
Background
The aim of present study was the definition of the IL-1, IL-4 and TNFα polymorphisms in asthmatic patients and their association with allergy and bronchial hyperresponsiveness (BHR).
Materials and methods
Thirty patients with allergic asthma, mean age 35.2±14.51 years (Group A) and 22 patients with non-allergic asthma, mean age 47.1±16.3 years (Group B) were included in the study. All patients were recruited from the Asthma Clinic of Pulmonary Department, University of Thessaloniki. 21 healthy control subjects of mean age 36.6±10.5 years were also included (Group C). All patients were subjected to skin prick tests and methacholine challenge. DNA was extracted from the patients’ peripheral blood samples. Determination of IL1α -889(T/C), IL1β-511(T/C), IL1β+3962(C/T), IL1R1970(C/T), IL1RA mspa111100(C/T), IL4-1098(T/G), IL4-590(C/T), IL4-33(C/T), TNFα-308(G/A) and TNFα-238(G/A) polymorphisms were performed by PCR using the INVITROGEN kit (C: cytokine, T: thymine, G: Guanine και A: Adenine).
Results
Analysis of IL-1 polymorphisms and in particular IL-1β (+3962) showed statistically significant differences between Group A-B (P=0.029) and Group B-C (P=0.024) respectively. Furthermore, analysis for IL-1 receptor (IL1R) showed statistically significant differences between Group B and C, where C/T showed an increased frequency in Group B and C/C in Group C (P=0.003). Besides, analysis of IL-1 receptor antagonist (IL-1RA) in C/T and Τ/Τ genotypes showed increased frequencies in Group A and C respectively (P=0.03). Analysis of IL4 -1098 polymorphisms showed an increased frequency of guanine in Group A (P=0.036) when compared to Group C whereas for IL4-590, C/C genotype showed an increased frequency in Group C and C/T in Group A (P=0.003), suggesting possible association between thymine and risk of asthma development. Analysis of TNFα-238 in G/G and A/G genotypes showed statistically significant differences between the Group A-C, (P=0.008) and Group B-C (P=0.001). G/G showed an increased frequency in Group C and A/G in Groups A and B. Moreover C/T genotype for IL-4 showed positive association with high concentrations of methacholine (P=0.022) and subsequently low BHR. On the contrary, G/G genotype in TNFα gene were positively associated with lower concentrations of methacholine (P: 0.033) and high BHR.
Conclusions
IL-1, IL-4 and TNFα polymorphisms showed significant differences between patients with allergic and non-allergic asthma and healthy control subjects, which are possibly associated with risk of asthma development. BHR was associated with IL-1, IL-4 and TNFα polymorphisms.
doi:10.3978/j.issn.2072-1439.2012.s022
PMCID: PMC3537442
18.  Exhaled nitric oxide is related to atopy, but not asthma in adolescents with bronchiolitis in infancy 
Background
The fraction of exhaled nitric oxide (FeNO) has been suggested as a non-invasive marker of eosinophilic inflammation in asthma, but lately rather as a biomarker of atopy than of asthma itself. Asthma after bronchiolitis is common up to early adolescence, but the inflammation and pathophysiology may differ from other phenotypes of childhood asthma. We aimed to assess if FeNO was different in children with former hospitalization for bronchiolitis and a control group, and to explore whether the role of FeNO as a marker of asthma, atopy or bronchial hyperresponsiveness (BHR) differed between these two groups of children.
Methods
The study included 108 of 131 children (82%) hospitalized for bronchiolitis in 1997–98, of whom 82 (76%) had tested positive for Respiratory syncytial virus, and 90 age matched controls. The follow-up took place in 2008–2009 at 11 years of age. The children answered an ISAAC questionnaire regarding respiratory symptoms and skin prick tests, spirometry, methacholine provocation test and measurement of FeNO were performed.
Results
Analysed by ANOVA, FeNO levels did not differ between the post-bronchiolitis and control groups (p = 0.214). By multivariate regression analyses, atopy, height (p < 0.001 for both) and BHR (p = 0.034), but not asthma (p = 0.805) or hospitalization for bronchiolitis (p = 0.359), were associated with FeNO in the post-bronchiolitis and control groups. The associations for atopy and BHR were similar in the post-bronchiolitis and in the control group.
Conclusion
FeNO did not differ between 11 year old children hospitalized for bronchiolitis and a control group. FeNO was associated with atopy, but not with asthma in both groups.
doi:10.1186/1471-2466-13-66
PMCID: PMC3840648  PMID: 24237793
Children; Eosinophilic inflammation; Respiratory syncytial virus; Wheezing
19.  81 Dose Response Relationship Between Ascaris Sensitisation and Atopy and Bronchial Hyper-Responsiveness but not Allergic Diseases in Black South Africans 
The World Allergy Organization Journal  2012;5(Suppl 2):S43-S44.
Background
The relationship between sensitisation to helminths and atopy, bronchial-hyperresponsiveness and allergic diseases may differ depending on many factors, including the genes of the population studied. We sought to examine this relationship in an African cohort.
Methods
Urban Xhosa children were tested for ascaris IgE levels, bronchial hyper-responsiveness (BHR) by methacholine challenge, atopic sensitisation (skin tests to aeroallergens) and allergic disease (asthma, eczema and rhinitis) assessed by questionnaire.
Results
Ascaris sensitisation was strongly associated with BHR but not with asthma, eczema or rhinitis. There was a dose-response relationship between increasing class of ascaris IgE and increased BHR (Prevalence ratio (PR) 1.75; CI 1.09-2.82). Higher levels of ascaris IgE were seen in those with BHR. Ascaris IgE was associated with atopic sensitisation to aeroallergens. There was a dose-response relationship between increasing class of ascaris IgE and sensitisation to one or more allergen (PR 1.65; CI, 1.27-2.13), sensitisation to house dust mites (HDM) (PR 1.79; CI, 1.29-2.46) and grass (PR 2.66; CI, 1.24-5.71) and number of positive skin prick tests (PR 1.78; CI, 1.27-2.49). Presence of any sensitisation to ascaris was associated with more than doubling the prevalence of HDM sensitisation (41.5 vs 18.5%) and almost quadrupling the prevalence of grass sensitisation (10.8 vs 2.8%).
Conclusions
Ascaris sensitisation was strongly associated with BHR and with atopy, but not with allergic diseases. Possible explanations might be that the type of ascaris infection that causes high levels of ascaris IgE in this genetic population may also favour the development of atopy or that atopics in Africa have upregulation of their defence system against parasitic infection. These hypotheses are not mutually exclusive.
doi:10.1097/01.WOX.0000411826.46882.45
PMCID: PMC3512651
20.  Reduced pH and chloride levels in exhaled breath condensate of patients with chronic cough 
Thorax  2004;59(7):608-612.
Background: Increased hydrogen and reduced chloride ionic environments of the airways are conducive to the stimulation of cough. However, the constituents of the local milieu of the airways of patients with chronic cough are unknown.
Methods: The pH and chloride levels in exhaled breath condensate and capsaicin cough threshold (C5) were measured in 50 patients with chronic cough and in 16 healthy controls. pH and chloride measurements were repeated after capsaicin challenge in those with cough. The cause of cough was asthma (n = 13), postnasal drip/rhinitis (n = 7), gastro-oesophageal reflux (n = 5), bronchiectasis (n = 5), but remained unidentified in 20.
Results: Compared with controls, patients with chronic cough had lower pH (mean 7.9 v 8.3, 95% CI of difference –0.5 to –0.2, p<0.0001), chloride levels (median 4 v 6 mmol/l, 95% CI –3.1 to –0.2, p = 0.007), and C5 (median 3.9 v 125 µM, 95% CI –270.0 to –17.6, p = 0.002). The pH levels were different in the six subgroups including controls, and were reduced in all diagnostic subgroups of patients with cough compared with controls but did not differ between them. Chloride levels were significantly different in the six subgroups but were lower than controls in only the gastro-oesophageal reflux subgroup. There was a weak but significant correlation between chloride levels and C5 when all participants were analysed together, but not between pH and C5 or chloride levels. pH and chloride levels did not change after capsaicin challenge.
Conclusions: The epithelial lining fluid of patients with chronic cough has a reduced pH and reduced chloride levels which could contribute to the enhanced cough reflex.
doi:10.1136/thx.2003.012906
PMCID: PMC1747079  PMID: 15223872
21.  Fractional Exhaled Nitric Oxide and Impulse Oscillometry in Children With Allergic Rhinitis 
Purpose
Airway inflammation, bronchial hyper-responsiveness (BHR), and bronchodilator response (BDR) are representative characteristics of asthma. Because allergic rhinitis (AR) is a risk factor for asthma development, we evaluated these 3 characteristics in AR using measurement of fractional exhaled nitric oxide (FeNO), a methacholine challenge test (MCT), and impulse oscillometry (IOS).
Methods
This study included 112 children with asthma (asthma group), 196 children with AR (AR group), and 32 control subjects (control group). We compared pulmonary function parameters and FeNO levels among the 3 groups. The AR group was subdivided into 2 categories: the AR group with BHR and the AR group without, and again pulmonary function and FeNO levels were compared between the 2 subgroups.
Results
FeNO levels were more increased in the AR and asthma groups than in the control group; within the AR group, FeNO was higher in the AR group with BHR than in the AR group without. The BDR was more increased in the AR group than in the control group when percent changes in reactance at 5 Hz (Δ X5) and reactance area (Δ AX) were compared. In the AR group, however, there was no difference in Δ X5 and Δ AX between the AR group with BHR and the AR group without.
Conclusions
Reversible airway obstruction on IOS and elevated FeNO levels were observed in children with AR. Because elevated FeNO levels can indicate airway inflammation and because chronic inflammation may lead to BHR, FeNO levels may be associated with BHR in AR. IOS can be a useful tool for detecting lower airway involvement of AR independent of BHR assessed in the MCT.
doi:10.4168/aair.2014.6.1.27
PMCID: PMC3881396  PMID: 24404390
Asthma; allergic rhinitis; bronchial hyper-responsiveness; bronchodilator effect; child; nitric oxide
22.  Relationship Between Atopy and Bronchial Hyperresponsiveness 
Both atopy and bronchial hyperresponsiveness (BHR) are characteristic features of asthma. They are also found among non-asthmatic subjects, including allergic rhinitis patients and the general population. Atopy and BHR in asthma are closely related. Atopy induces airway inflammation as an IgE response to a specific allergen, which causes or amplifies BHR. Moreover, significant evidence of the close relationship between atopy and BHR has been found in non-asthmatic subjects. In this article, we discuss the relationship between atopy and BHR in the general population, asthmatic subjects, and those with allergic rhinitis. This should widen our understanding of the pathophysiology of atopy and BHR.
doi:10.4168/aair.2013.5.4.181
PMCID: PMC3695231  PMID: 23814670
Allergic rhinitis; asthma; atopy; bronchial hyperresponsiveness; patients; population
23.  33 Exhaled Nitric Oxide and Airway Function in Seasonal Allergic Rhinitis 
Background
Seasonal allergic rhinitis could predispose to the development of chronic bronchial inflammation. However, association between seasonal allergic rhinitis and airway function, especially exhaled nitric oxide [FENO], are not fully understood.
Objectives
The aim of this study was to evaluate the relationship among FENO and airway function and nasal symptoms in patients with seasonal allergic rhinitis without asthma.
Methods
We included 37 subjects [9 males and 28 females] in this study. Total serum IgE were investigated and specific IgE for 4 pollen allergens and 5 perennial antigens were determined by RAST. Sensitization to a specific allergen was defined as over RAST score 2. We compared 4 groups. Group A: 7 nonatopic subjects [no nasal symptoms and RIST, RAST negative, 1 males and 6 females, mean age: 33.2 24–52 years]. Group B: 10 atopic subjects with a sensitization to Japanese ceder without medication [6 males and 4 females, mean age: 44 20–58 years]. Group C: 10 atopic subjects with a sensitization to Japanese ceder who took oral anti-histamine medicine during pollen season [2 males and 8 females, mean age: 34.9 24–52 years]. Group D: 10 atopic subjects with a sensitization to Japanese ceder who receive intranasal corticosteroid treatment during pollen season [2 males and 8 females, mean age: 40.2 26–56 years]. Score of nasal symptoms, FENO, spirometry, total eosinophils, nasal eosinophils, were investigated before, during, and after pollen season.
Results
Regardless of having treatment or not, in comparison with the subjects without the allergy, FENO showed a statistically significant increase in all patients with a sensitization to Japanese after pollen season. In group D, v 50/v 25 was the tendency to adversely affect after the pollen season, and correlation between FeNO rate of the change and v 50/v25 rate of the change admitted. As for the other indexes, a statistically change were not showed in the comparison of each group.
Conclusions
These results suggest that FENO is a primarily marker of bronchial inflammation in patients with seasonal allergic rhinitis during pollen season and intranasal corticosteroid treatment may be effective for improvements in lower airway outcome.
doi:10.1097/01.WOX.0000411778.82590.a0
PMCID: PMC3512698
24.  Rhinitis Patients With Sputum Eosinophilia Show Decreased Lung Function in the Absence of Airway Hyperresponsiveness 
Purpose
Sputum eosinophilia is observed frequently in patients with rhinitis. Sputum eosinophilia in patients with non-asthmatic allergic rhinitis has been suggested to be related to nonspecific airway hyperresponsiveness (AHR). However, the clinical significance of sputum eosinophilia in patients with non-asthmatic rhinitis without AHR has not been determined. We conducted a retrospective study examining the influence of sputum eosinophilia in patients with non-asthmatic rhinitis without AHR on pulmonary function and expression of fibrosis-related mediators.
Methods
Eighty-nine patients with moderate-to-severe perennial rhinitis without AHR were included. All underwent lung function tests (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]), skin tests to inhalant allergens, methacholine bronchial challenge tests, and hypertonic saline-induced sputum to determine eosinophil counts. Sputum mRNA levels for transforming growth factor-β (TGF-β), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) were also examined. Patients were divided into two groups according to the presence of sputum eosinophilia (≥3%, eosinophilia-positive [EP] and <3%, eosinophilia-negative [EN] groups).
Results
FEV1 was significantly lower (P=0.04) and FEV1/FVC tended to be lower (P=0.1) in the EP group than in the EN group. In sputum analyses, the MMP-9 mRNA level (P=0.005) and the ratio of MMP-9 to TIMP-1 expression (P=0.01) were significantly higher in the EP group than in the EN group. There was no significant difference in TGF-β mRNA expression between the two groups.
Conclusions
Sputum eosinophilia in patients with moderate-to-severe perennial rhinitis without AHR influenced FEV1 and the expression pattern of fibrosis-related mediators.
doi:10.4168/aair.2013.5.4.232
PMCID: PMC3695238  PMID: 23814677
Sputum; eosinophil; rhinitis; forced expiratory volume; matrix metalloproteinase-9
25.  Ca2+-Activated K+ Channel–3.1 Blocker TRAM-34 Attenuates Airway Remodeling and Eosinophilia in a Murine Asthma Model 
Key features of asthma include bronchial hyperresponsiveness (BHR), eosinophilic airway inflammation, and bronchial remodeling, characterized by subepithelial collagen deposition, airway fibrosis, and increased bronchial smooth muscle (BSM) mass. The calcium-activated K+ channel KCa3.1 is expressed by many cells implicated in the pathogenesis of asthma, and is involved in both inflammatory and remodeling responses in a number of tissues. The specific KCa3.1 blocker 5-[(2-chlorophenyl)(diphenyl)methyl]-1H-pyrazole (TRAM-34) attenuates BSM cell proliferation, and both mast cell and fibrocyte recruitment in vitro. We aimed to examine the effects of KCa3.1 blockade on BSM remodeling, airway inflammation, and BHR in a murine model of chronic asthma. BALB/c mice were sensitized with intraperitoneal ovalbumin (OVA) on Days 0 and 14, and then challenged with intranasal OVA during Days 14–75. OVA-sensitized/challenged mice received TRAM-34 (120 mg/kg/day, subcutaneous) from Days −7 to 75 (combined treatment), Days −7 to 20 (preventive treatment), or Days 21 to 75 (curative treatment). Untreated mice received daily injections of vehicle (n = 8 per group). Bronchial remodeling was assessed by histological and immunohistochemical analyses. Inflammation was evaluated using bronchoalveolar lavage and flow cytometry. We also determined BHR in both conscious and anesthetized mice via plethysmography. We demonstrated that curative treatment with TRAM-34 abolishes BSM remodeling and subbasement collagen deposition, and attenuates airway eosinophilia. Although curative treatment alone did not significantly reduce BHR, the combined treatment attenuated nonspecific BHR to methacholine. This study indicates that KCa3.1 blockade could provide a new therapeutic strategy in asthma.
doi:10.1165/rcmb.2012-0103OC
PMCID: PMC4035224  PMID: 23204391
asthma; KCa3.1; ion channel; remodeling; smooth muscle

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