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Background: Chronic rhinosinusitis with nasal polyps affects approximately 2–4% of the general population, and long-term use of systemic corticosteroids is associated with adverse effects. The aim of this study was to assess the efficacy and safety of mepolizumab in adults with recurrent, refractory severe bilateral chronic rhinosinusitis with nasal polyps. Methods: SYNAPSE was a randomised, double-blind, placebo-controlled, parallel-group, phase 3 trial done at 93 centres, mainly hospitals, in 11 countries. Eligible patients were aged 18 years or older with recurrent, refractory, severe, bilateral nasal polyp symptoms (nasal obstruction symptom visual analogue scale [VAS] score of >5), were eligible for repeat nasal surgery (overall symptoms VAS score >7 and endoscopic nasal polyps score of ≥5, with a minimum score of 2 in each nasal cavity) despite standard of care treatment, and had to have at least one nasal surgery in the past 10 years. Patients were randomly assigned (1:1), using permuted block design, to receive either 100 mg mepolizumab subcutaneously or placebo once every 4 weeks, in addition to standard of care (mometasone furoate intranasal spray for at least 8 weeks before screening and during the study, saline nasal irrigations, systemic corticosteroids or antibiotics, or both), as required, for 52 weeks. Site staff, the central study team, and patients were masked to study treatment and absolute blood eosinophil counts. The coprimary endpoints were change from baseline in total endoscopic nasal polyp score at week 52 and in mean nasal obstruction VAS score during weeks 49–52, assessed in the intention-to-treat population (ITT). This study is registered with ClinicalTrials.gov, NCT03085797. Findings: From May 25, 2017, to Dec 12, 2018, 854 patients were screened for eligibility. 414 patients were randomly assigned with 407 included in the ITT population; 206 received mepolizumab and 201 received placebo. Total endoscopic nasal polyp score significantly improved at week 52 from baseline with mepolizumab versus placebo (adjusted difference in medians −0·73, 95% CI −1·11 to −0·34; p

Background: Although estimates of suboptimal adherence to oral corticosteroids in asthma range from 30% to 50%, no ideal method for measurement exists; the impact of poor adherence in severe asthma is likely to be particularly high. Research Questions: What is the prevalence of suboptimal adherence detected by self-reporting and direct measures? Is suboptimal adherence associated with disease activity? Study Design and Methods: Data were included from individuals with severe asthma taking part in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes) study and prescribed daily oral corticosteroids. Participants completed the Medication Adherence Report Scale, a five-item questionnaire used to grade adherence on a scale from 1 to 5, and provided a urine sample for analysis of prednisolone and metabolites by liquid chromatography-mass spectrometry. Results: Data from 166 participants were included in this study: mean (SD) age, 54.2 (± 11.9) years; FEV 1, 65.1% (± 20.5%) predicted; female, 58%; 37% completing the Medication Adherence Report Scale reported suboptimal adherence; and 43% with urinary corticosteroid data did not have detectable prednisolone or metabolites in their urine. Good adherence by both methods was detected in 49 of the 142 (35%) of participants in whom both methods were performed; adherence detection did not match between methods in 53%. Self-reported high adherers had better asthma control and quality of life, whereas directly measured high adherers had lower blood eosinophil levels. Interpretation: Low adherence is a common problem in severe asthma, whether measured directly or self-reported. We report poor agreement between the two methods, suggesting some disassociation between self-assessment of medication adherence and regular oral corticosteroid use, which suggests that each approach may provide complementary information in clinical practice.

IntroductionAsthma is a heterogeneous disease with poorly defined phenotypes. Patients with severe asthma often receive multiple treatments including oral corticosteroids (OCS). Treatment may modify the observed metabotype, rendering it challenging to investigate underlying disease mechanisms. Here, we aimed to identify dysregulated metabolic processes in relation to asthma severity and medication.MethodsBaseline urine was collected prospectively from healthy participants (n=100), patients with mild-to-moderate asthma (n=87) and patients with severe asthma (n=418) in the cross-sectional U-BIOPRED cohort; 12–18-month longitudinal samples were collected from patients with severe asthma (n=305). Metabolomics data were acquired using high-resolution mass spectrometry and analysed using univariate and multivariate methods.ResultsA total of 90 metabolites were identified, with 40 significantly altered (p−20), OCS-treated asthmatic patients differed significantly from non-treated patients (p=9.5×10−4), and longitudinal metabotypes demonstrated temporal stability. Carnitine levels evidenced the strongest OCS-independent decrease in severe asthma. Reduced carnitine levels were associated with mitochondrial dysfunction via decreases in pathway enrichment scores of fatty acid metabolism and reduced expression of the carnitine transporter SLC22A5 in sputum and bronchial brushings.ConclusionsThis is the first large-scale study to delineate disease- and OCS-associated metabolic differences in asthma. The widespread associations with different therapies upon the observed metabotypes demonstrate the need to evaluate potential modulating effects on a treatment- and metabolite-specific basis. Altered carnitine metabolism is a potentially actionable therapeutic target that is independent of OCS treatment, highlighting the role of mitochondrial dysfunction in severe asthma.

Asthma is a heterogeneous disease with multiple clinical presentations (phenotypes). Neutrophilic asthma is characterised by increased sputum neutrophils and generally has a poor response to corticosteroids and limited other therapeutic options. Neutrophilia originates from different factors, including the defective resolution of inflammation or bacterial infections. An association between airway bacterial imbalance (disturbance) and the neutrophilic phenotype has been reported, suggesting that airway microbiota composition is involved in neutrophilic asthma. Rather than being a separate entity, neutrophilic asthma may be in part, an alliance between innate immunity and microbiota composition that prompts protective mechanisms against invading pathogens.

Background: Airway remodelling, which may include goblet cell hyperplasia / hypertrophy, changes in epithelial integrity, accumulation of extracellular matrix components, smooth muscle hypertrophy and thickening of the lamina reticularis, is a feature of severe asthma and contributes to the clinical phenotype. Objective: Within the U-BIOPRED severe asthma study, we have assessed histological elements of airway remodelling and their relationship to computed tomography (CT) measures of proximal airway dimensions. Methods: Bronchial biopsies were collected from two severe asthma groups, one non-smoker (SAns, n=28) and one current/ex-smoker (SAs/ex, n=13), and a mild-moderate asthma group (MMA, n=28) classified and treated according to GINA guidelines, plus a healthy control group (HC, n=33). A Movat’s pentachrome technique was used to identify mucin, elastin and total collagen in these biopsies. The number of goblet cells (mucin+) were counted as a percentage of the total number of epithelial cells and the percentage mucin epithelial area measured. The percentage area of elastic fibres and total collagen within the submucosa were also measured, and the morphology of the elastic fibres classified. Participants in the asthma groups also had a CT scan to assess large airway morphometry.Results: The submucosal tissue elastin percentage was higher in both severe asthma groups (16.1% SAns, 18.9% SAs/ex) compared to the HC (9.7%) but did not differ between asthma groups. There was a positive relationship between elastin and airway wall area measured by CT (n= 18-20, rho=0.544, p=0.024), which also related to an increase in elastic fibres with a thickened lamellar morphological appearance. Mucin epithelial area and total collagen were not different between the four groups. Due to small numbers of suitable CT scans it was not feasible to compare airway morphometry between the asthma groups. Conclusion: These findings identify a link between extent of elastin deposition and airway wall thickening in severe asthma.

Introduction: CT phenotypic patterns of chronic obstructive pulmonary (COPD) defining emphysema-dominant versus airway-dominant groups identify different clinical features of disease. The impact of these variables on the physiological response to exercise has been a great deal of research. Objective: To evaluate the relationship between CT phenotyping of COPD patients and the ventilatory response during cardiopulmonary exercise testing (CPET). Methods: Patients with COPD were classified into 4 phenotypes based on CT using two cut-offs: percentage of low attenuation area (%LAA) less than a threshold of -950 Hounsfield units of 15% and median value of the percentage of bronchial mean wall area (MWA%). Results: Eighty COPD patients (78.8% males, median age 65±1.3 years) were enrolled in the study. Based on CT phenotype, 25 (31,3%) patients were classified as normal, 27 (33,8%) air dominant, 17 (21,3%) emphysema dominant and 11 (13,8%) mixed type. The emphysema dominant phenotype showed the lowest peak aerobic capacity (VO2), the highest ventilatory equivalent for oxygen (VE/VO2) and for carbon dioxide (VE/VCO2) among the four groups (p Conclusion: CPET parameters such as aerobic capacity and ventilatory demands (VE/VO2, VE/VCO2) were associated with emphysematous change. These results suggested that phenotyping of CT may help predicting ventilatory response to exercise in COPD patients.

Rationale: New approaches are needed to guide personalized treatment of asthma. Objectives: To test if urinary eicosanoid metabolites can direct asthma phenotyping. Methods: Urinary metabolites of prostaglandins (PGs), cysteinyl leukotrienes (CysLTs), and isoprostanes were quantified in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Diseases Outcomes) study including 86 adults with mild-to-moderate asthma (MMA), 411 with severe asthma (SA), and 100 healthy control participants. Validation was performed internally in 302 participants with SA followed up after 12-18 months and externally in 95 adolescents with asthma. Measurement and Main Results: Metabolite concentrations in healthy control participants were unrelated to age, body mass index, and sex, except for the PGE 2 pathway. Eicosanoid concentrations were generally greater in participants with MMA relative to healthy control participants, with further elevations in participants with SA. However, PGE 2 metabolite concentrations were either the same or lower in male nonsmokers with asthma than in healthy control participants. Metabolite concentrations were unchanged in those with asthma who adhered to oral corticosteroid treatment as documented by urinary prednisolone detection, whereas those with SA treated with omalizumab had lower concentrations of LTE 4 and the PGD 2 metabolite 2,3-dinor-11β-PGF 2α. High concentrations of LTE 4 and PGD 2 metabolites were associated with lower lung function and increased amounts of exhaled nitric oxide and eosinophil markers in blood, sputum, and urine in U-BIOPRED participants and in adolescents with asthma. These type 2 (T2) asthma associations were reproduced in the follow-up visit of the U-BIOPRED study and were found to be as sensitive to detect T2 inflammation as the established biomarkers. Conclusions: Monitoring of urinary eicosanoids can identify T2 asthma and introduces a new noninvasive approach for molecular phenotyping of adult and adolescent asthma.Clinical trial registered with www.clinicaltrials.gov (NCT01976767).

Background: The aim of the study was to document cardiovascular clinical findings, cardiac imaging and laboratory markers in children presenting with the novel multisystemic inflammatory syndrome associated with COVID-19. Methods: A real-time internet based survey was sent via the member mailing database for Association for European Paediatric and Congenital Cardiologists (AEPC) working groups for Cardiac Imaging and Cardiovascular Intensive Care member. Inclusion criteria was children 0-18 years admitted to hospital between March 1 and June 6, 2020 with diagnosis of an inflammatory syndrome and acute cardiovascular complications. Findings: A total of 286 children from 55 centres from 17 European countries were included. The median age was 8·4 years (IQR 3·8-12·4 years) and 67% were males. Most common cardiovascular complications were shock (40%), cardiac arrhythmias (35%), pericardial effusion (28%) and coronary artery dilatation (24%). Reduced left ventricular ejection fraction was present in 52% of patients and 93% had raised cardiac troponin (cTnT). The biochemical markers of inflammation were raised in majority of patients on admission: elevated CRP (99%), ferritin (79%), procalcitonin (96%), NT-proBNP (93%), IL-6 level (88%) and D-dimers (90%). There was a statistically significant correlation between degree of elevation in cardiac and biochemical parameters and need of intensive care support (p

Aortic arch aneurysm or pseudoaneurysm is a rare complication early after coarctation repair in the neonatal period. We report the case of a newborn with a ventricular septal defect and aortic coarctation with a hypoplastic aortic arch that developed a large aortic arch pseudoaneurysm following a radically extended end-to-end coarctation repair. Successful surgical correction of the pseudoaneurysm was performed.

Background Asthma prevalence is 339 million globally. ‘Severe asthma’ (SA) comprises subjects with uncontrolled asthma despite proper management. Objectives To compare asthma from diverse ethnicities and environments. Methods A cross-sectional analysis of two adult cohorts, a Brazilian (ProAR) and a European (U-BIOPRED). U-BIOPRED comprised of 311 non-smoking with Severe Asthma (SAn), 110 smokers or ex-smokers with SA (SAs) and 88 mild to moderate asthmatics (MMA) while ProAR included 544 SA and 452 MMA. Although these projects were independent, there were similarities in objectives and methodology, with ProAR adopting operating procedures of U-BIOPRED. Results Among SA subjects, age, weight, proportion of former smokers and FEV1 pre-bronchodilator were similar. The proportion of SA with a positive skin prick tests (SPT) to aeroallergens, the scores of sino-nasal symptoms and quality of life were comparable. In addition, blood eosinophil counts (EOS) and the % of subjects with EOS > 300 cells/μl were not different. The Europeans with SA however, were more severe with a greater proportion of continuous oral corticosteroids (OCS), worse symptoms and more frequent exacerbations. FEV1/FVC pre- and post-bronchodilator were lower among the Europeans. The MMA cohorts were less comparable in control and treatment, but similar in the proportion of allergic rhinitis, gastroesophageal reflux disease and EOS >3%. Conclusions ProAR and U-BIOPRED cohorts, with varying severity, ethnicity and environment have similarities, which provide the basis for global external validation of asthma phenotypes. This should stimulate collaboration between asthma consortia with the aim of understanding SA, which will lead to better management.

Introduction Appropriate timing for dual bronchodilator therapy initiation in chronic obstructive pulmonary disease (COPD) management is uncertain. Combination therapy is recommended as step-up from monotherapy or first-line treatment in patients with persistent symptoms. In this setting, umeclidinium/vilanterol (UMEC/VI) demonstrated improved lung function and reduced rescue medication use over tiotropium/olodaterol (TIO/OLO). This subgroup analysis explored efficacy differences between these combinations in patients naïve to COPD maintenance therapy before study entry. Methods Post hoc analysis of an 8-week, randomized, open-label, assessor-blind, two-period crossover study (204990; NCT02799784) comparing UMEC/VI 62.5/25 mcg and TIO/OLO 5/5 mcg, focused on maintenance-naïve (MN) patients with moderate COPD and persistent symptoms (modified Medical Research Council dyspnea score ≥ 2). Change from baseline (CFB) in trough forced expiratory volume in 1 s (FEV1), percentage of FEV1 responders (CFB ≥ 100 ml), rescue medication use and safety were evaluated. Results The MN population comprised 63% of the intent-to-treat (ITT) population (148/236 patients) and had similar baseline demographics. At week 8, adjusted mean (standard error) improvements in trough FEV1 from baseline were clinically meaningful for both combinations (UMEC/VI: 167 [17] ml; TIO/OLO 110 [18] ml; adjusted mean difference [95% confidence interval (CI)]: 57 [23–92] ml; p = 0.001; %CFB: 11 vs. 8%). Proportion of FEV1 responders was greater with UMEC/VI versus TIO/OLO at week 8 (60 vs. 42%; odds ratio [95% CI] 1.90 [1.12–3.22]; p = 0.018). Reduction in rescue medication use was 0.20 (95% CI 0.07–0.34) puffs/day greater with UMEC/VI versus TIO/OLO over weeks 1–8 (p = 0.003). Adverse events incidence was similar (UMEC/VI: 24%; TIO/OLO: 29%). Conclusions These results highlight that the efficacy difference between UMEC/VI and TIO/OLO demonstrated in the ITT population is maintained in MN patients. Greater lung function improvements with UMEC/VI versus TIO/OLO were accompanied by symptom improvements, as reflected in a significantly lower need for supplemental rescue medication. Funding GSK. Trial registration NCT02799784

Introduction We report the results of the first direct comparison of the once-daily fixed-dose long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) combinations umeclidinium/vilanterol (UMEC/VI) and tiotropium/olodaterol (TIO/OLO) in patients with COPD. Methods This was a randomized, two-period crossover open-label study in symptomatic patients with COPD [age 40 years or older, postbronchodilator forced expiratory volume in 1 s (FEV1) of 70% or less and 50% or more of predicted normal values, and modified Medical Research Council Dyspnoea Scale score of 2 or greater] not receiving inhaled corticosteroid therapy. Patients were randomized to receive UMEC/VI (62.5/25 µg once daily) via a multidose dry powder inhaler (ELLIPTA) followed by TIO/OLO (5/5 µg once daily) via a soft mist inhaler (Respimat), each for 8 weeks with an interim 3-week washout or vice versa. The primary end point was the change from baseline in trough FEV1 at week 8 with a noninferiority margin of − 50 mL in the per-protocol (PP) population. The incidence of adverse events was also assessed. Results In total, 236 patients (mean age 64.4 years, 60% male) were included in the intent-to-treat population and 227 were included in the PP population. UMEC/VI treatment was noninferior in the PP population and superior in the intent-to-treat population to TIO/OLO treatment with regard to trough FEV1 at week 8 [FEV1 change from baseline 180 mL vs 128 mL; difference 52 mL (95% confidence interval 28–77 mL); p

Background Patients with severe asthma appear relatively corticosteroid resistant. Corticosteroid responsiveness is closely related to the degree of eosinophilic airway inflammation. The extent to which eosinophilic airway inflammation in severe asthma responds to treatment with systemic corticosteroids is not clear. Objective To relate the physiological and inflammatory response to systemic corticosteroids in asthma to disease severity and the baseline extent of eosinophilic inflammation. Methods Patients with mild/moderate and severe asthma were investigated before and after two-weeks of oral prednisolone (Clintrials. gov NCT00331058 and NCT00327197). We pooled the results from 2 studies with common protocols. The US study contained 2 independent centres and the UK 1 independent centre. The effect of oral corticosteroids on FEV1, Pc20, airway inflammation and serum cytokines were investigated. Baseline measurements were compared with healthy subjects. Results 32 mild/moderate asthmatics, 50 severe asthmatics and 35 healthy subjects took part. At baseline both groups of asthmatics had a lower FEV1 and Pc20 and increased eosinophilic inflammation compared to healthy subjects. The severe group had a lower FEV1 and more eosinophilic inflammation compared to mild/moderate asthmatics. Oral prednisolone caused a similar degree of suppression of eosinophilic inflammation in all compartments in both groups of asthmatics. There were small improvements in FEV1 and Pc20 for both mild/ moderate and severe asthmatics with a correlation between the baseline eosinophilic inflammation and the change in FEV1. There was a ~50% reduction in the serum concentration of CXCL10 (IP-10), CCL22 (MDC), CCL17 (TARC), CCL-2 (MCP-1) and CCL-13 (MCP-4) in both asthma groups after oral corticosteroids. Conclusions and Clinical Relevance Disease severity does not influence the response to systemic corticosteroids. The study does not therefore support the concept that severe asthma is associated with corticosteroid resistance. Only baseline eosinophilic inflammation was associated with the physiological response to corticosteroids, confirming the importance of measuring eosinophilic inflammation to guide corticosteroid use. This article is protected by copyright. All rights reserved.

Background: Blood eosinophil counts ≥0.3x109/L are used to define Type-2, eosinophilic asthma. However, differential responses to T2 biologics of patients with eosinophilic asthma suggests that thi ...

Objectives To qualitatively explore patient experiences of severe, recurrent, bilateral nasal polyps (NP). Methods A targeted literature review of published qualitative studies and online blogs describing patient experiences of NP was conducted. Semistructured concept elicitation interviews were conducted in the United States and Germany with participants ≥18 years with severe, recurrent, bilateral NP to explore their symptom experience and impacts on health-related quality of life (HRQoL; NCT03221192 ). A subset of 10 participants reported symptoms and impacts using a smartphone or tablet application (app) over a 10-day period. Results A paucity of qualitative evidence regarding patient experience of NP was identified from the literature or blog review. Twenty-seven participant interviews were conducted. Thirty-six symptoms were identified, including 7 primary symptoms (nasal congestion [n = 27 of 27], breathing difficulties [n = 27 of 27], postnasal drip [n = 25 of 27], runny nose [n = 24 of 27], head/facial pressure [n = 23 of 27], loss of smell [n = 23 of 27], loss of taste [n = 22 of 27]) and 29 secondary symptoms (the most common were mucus/catarrh and nose bleeds [both n = 20 of 27]). Most symptoms were reported to vary both within and between days. Sixty impacts of severe NP were reported, including impacts on sleep (n = 22 of 27), physical functioning (n = 21 of 27), activities of daily living (n = 21 of 27), emotional well-being (n = 27 of 27), treatment (n = 23 of 27), social life (n = 26 of 27), and work (n = 19 of 27). Symptoms/impacts reported using the app were consistent with interview findings, although new symptoms were identified (ear pain, throat pain, nasal scabs, and nasal burning). These results supported the development of a conceptual model outlining concepts related to symptoms, impacts, and treatment of NP. Conclusions Severe, recurrent, bilateral NP are associated with a range of symptoms that have significant detrimental impact on HRQoL.

Background The role of IL-17 immunity is well established in patients with inflammatory diseases, such as psoriasis and inflammatory bowel disease, but not in asthmatic patients, in whom further study is required. Objective We sought to undertake a deep phenotyping study of asthmatic patients with upregulated IL-17 immunity. Methods Whole-genome transcriptomic analysis was performed by using epithelial brushings, bronchial biopsy specimens (91 asthmatic patients and 46 healthy control subjects), and whole blood samples (n = 498) from the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED) cohort. Gene signatures induced in vitro by IL-17 and IL-13 in bronchial epithelial cells were used to identify patients with IL-17–high and IL-13–high asthma phenotypes. Results Twenty-two of 91 patients were identified with IL-17, and 9 patients were identified with IL-13 gene signatures. The patients with IL-17–high asthma were characterized by risk of frequent exacerbations, airway (sputum and mucosal) neutrophilia, decreased lung microbiota diversity, and urinary biomarker evidence of activation of the thromboxane B2 pathway. In pathway analysis the differentially expressed genes in patients with IL-17-high asthma were shared with those reported as altered in psoriasis lesions and included genes regulating epithelial barrier function and defense mechanisms, such as IL1B, IL6, IL8, and β-defensin. Conclusion The IL-17–high asthma phenotype, characterized by bronchial epithelial dysfunction and upregulated antimicrobial and inflammatory response, resembles the immunophenotype of psoriasis, including activation of the thromboxane B2 pathway, which should be considered a biomarker for this phenotype in further studies, including clinical trials targeting IL-17.

The U-BIOPRED study is a multicentre European study aimed at a better understanding of severe asthma. It included three steroid-treated adult asthma groups (severe nonsmokers (SAn group), severe current/ex-smokers (SAs/ex group) and those with mild–moderate disease (MMA group)) and healthy controls (HC group). The aim of this cross-sectional, bronchoscopy substudy was to compare bronchial immunopathology between these groups.In 158 participants, bronchial biopsies and bronchial epithelial brushings were collected for immunopathologic and transcriptomic analysis. Immunohistochemical analysis of glycol methacrylate resin-embedded biopsies showed there were more mast cells in submucosa of the HC group (33.6 mm−2) compared with both severe asthma groups (SAn: 17.4 mm−2, p−2, p=0.01) and with the MMA group (21.2 mm−2, p=0.01). The number of CD4+lymphocytes was decreased in the SAs/ex group (4.7 mm−2) compared with the SAn (11.6 mm−2, p=0.002), MMA (10.1 mm−2, p=0.008) and HC (10.6 mm−2, pAffymetrix microarray analysis identified seven probe sets in the bronchial brushing samples that had a positive relationship with submucosal eosinophils. These mapped toCOX-2(cyclo-oxygenase-2),ADAM-7(disintegrin and metalloproteinase domain-containing protein 7),SLCO1A2(solute carrier organic anion transporter family member 1A2),TMEFF2(transmembrane protein with epidermal growth factor like and two follistatin like domains 2) andTRPM-1(transient receptor potential cation channel subfamily M member 1); the remaining two are unnamed.We conclude that in nonsmoking and smoking patients on currently recommended therapy, severe asthma exists despite suppressed tissue inflammation within the proximal airway wall.

Type-2 (T2) immune responses in airway epithelial cells (AECs) classifies mild–moderate asthma into a T2-high phenotype. We examined whether currently available clinical biomarkers can predict AEC-defined T2-high phenotype within the U-BIOPRED cohort.The transcriptomic profile of AECs obtained from brushings of 103 patients with asthma and 44 healthy controls was obtained and gene set variation analysis used to determine the relative expression score of T2 asthma using a signature from interleukin (IL)-13-exposed AECs.37% of asthmatics (45% nonsmoking severe asthma, n=49; 33% of smoking or ex-smoking severe asthma, n=18; and 28% mild–moderate asthma, n=36) were T2-high using AEC gene expression. They were more symptomatic with higher exhaled nitric oxide fraction (FeNO) and blood and sputum eosinophils, but not serum IgE or periostin. Sputum eosinophilia correlated best with the T2-high signature. FeNO (≥30 ppb) and blood eosinophils (≥300 cells·µL−1) gave a moderate prediction of T2-high asthma. Sputum IL-4, IL-5 and IL-13 protein levels did not correlate with gene expression.T2-high severe asthma can be predicted to some extent from raised levels of FeNO, blood and sputum eosinophil counts, but serum IgE or serum periostin were poor predictors. Better bedside biomarkers are needed to detect T2-high.

Oxidative stress is believed to be a major driver of inflammation in smoking asthmatics. The U-BIOPRED project recruited a cohort of Severe Asthma smokers/ex-smokers (SAs/ex) and non-smokers (SAn) with extensive clinical and biomarker information enabling characterization of these subjects. We investigated oxidative stress in severe asthma subjects by analysing urinary 8-iso-PGF2α and the mRNA-expression of the main pro-oxidant (NOX2; NOSs) and anti-oxidant (SODs; CAT; GPX1) enzymes in the airways of SAs/ex and SAn. All the severe asthma U-BIOPRED subjects were further divided into current smokers with severe asthma (CSA), ex-smokers with severe asthma (ESA) and non-smokers with severe asthma (NSA) to deepen the effect of active smoking. Clinical data, urine and sputum were obtained from severe asthma subjects. A bronchoscopy to obtain bronchial biopsy and brushing was performed in a subset of subjects. The main clinical data were analysed for each subset of subjects (urine-8-iso-PGF2α; IS-transcriptomics; BB-transcriptomics; BBr-transcriptomics). Urinary 8-iso-PGF2α was quantified using mass spectrometry. Sputum, bronchial biopsy and bronchial brushing were processed for mRNA expression microarray analysis. Urinary 8-iso-PGF2α was increased in SAs/ex, median (IQR) = 31.7 (24.5-44.7) ng/mmol creatinine, compared to SAn, median (IQR) = 26.6 (19.6-36.6) ng/mmol creatinine (p< 0.001), and in CSA, median (IQR) = 34.25 (24.4-47.7), vs. ESA, median (IQR) = 29.4 (22.3-40.5), and NSA, median (IQR) = 26.5 (19.6-16.6) ng/mmol creatinine (p = 0.004). Sputum mRNA expression of NOX2 was increased in SAs/ex compared to SAn (probe sets 203922_PM_s_at fold-change = 1.05 p = 0.006; 203923_PM_s_at fold-change = 1.06, p = 0.003; 233538_PM_s_at fold-change = 1.06, p = 0.014). The mRNA expression of antioxidant enzymes were similar between the two severe asthma cohorts in all airway samples. NOS2 mRNA expression was decreased in bronchial brushing of SAs/ex compared to SAn (fold-change = -1.10; p = 0.029). NOS2 mRNA expression in bronchial brushing correlated with FeNO (Kendal's Tau = 0.535; p< 0.001). From clinical and inflammatory analysis, FeNO was lower in CSA than in ESA in all the analysed subject subsets (p< 0.01) indicating an effect of active smoking. Results about FeNO suggest its clinical limitation, as inflammation biomarker, in severe asthma active smokers. These data provide evidence of greater systemic oxidative stress in severe asthma smokers as reflected by a significant changes of NOX2 mRNA expression in the airways, together with elevated urinary 8-iso-PGF2α in the smokers/ex-smokers group. Trial registration ClinicalTrials.gov-Identifier: NCT01976767.

Background: Precision medicine of asthma requires understanding of its heterogeneity and molecular pathophysiology. Aim: Three sputum-derived transcriptomic clusters (TACs) were previously identified [Kuo at al. Eur Respir J.2017, 49] in the U-BIOPRED cohort: TAC1 consisting of T2 high patients with eosinophilia, TAC2 with neutrophilia and inflammasome activation and TAC3, a more heterogeneous cluster with mostly paucigranulocytic patients. We further refine TAC3. Methods: Gaussian mixture modelling for model-based clustering was applied to sputum gene expression of 104 asthmatic participants from the adult cohort to substructure TAC3. Gene set variation analysis (GSVA) was used to explore the enrichment of gene signatures across the TACs. Results: We again produce the three TACs (TAC1 N=23, TAC2 N=24) but TAC3 was further split into two groups (TAC3a N=28, TAC3b N=29), distinguished by distinct neutrophils and macrophages density and enrichment of IL13 stimulation, inflammasome activation and OXPHOS gene signatures (Figure), as well as IL-4 and LPS-stimulated macrophage gene signatures. However, there were no distinguishing clinical features. Conclusion: Identification of sub-structure of sputum TACs, particularly of TAC3, will help towards improved targeted therapies.

Background: Many children with asthma exhibit uncontrolled symptoms despite inhaled corticosteroid therapy. The molecular pathways linked to this phenotype are unknown. Aim: To investigate gene expression in paediatric severe and moderate/mild asthma blood samples. Methods: Gene expression analysis was applied on severe and mild asthma samples from pre- and school-age children (SApre,N=62; MApre,N=42; SAsc,N=75 and MAsc,N=37). Gene network analysis (WGCNA) was applied separately on the pre- and school-age data. Obtained gene modules were compared with the Jaccard Index. Results: No genes weresignificantly differentially-expressed in SA versus MA asthma in the two age groups (FDR Conclusion: WGCNA implicates mitochondrial oxidative stress in early onset severe asthma that needs further investigation.

Introduction: Rates of sub-optimal adherence to medications in asthma range up to 70%; the impact in severe asthma is likely to be particularly high. We measured self-reported adherence in participants in the U-BIOPRED cohort prescribed daily prednisolone using the Medication Adherence Response Scale (MARS), and compared to measured urinary prednisolone and metabolites in order to determine: 1. the prevalence of suboptimal adherence by each method; 2. the ability of MARS to predict urinary steroid detection. Methods: Participants completed the MARS, and/or provided urine samples (analysed for prednisolone and metabolites by LCMS). The performance characteristics of the MARS predicting undetected urinary steroid were calculated in the subgroup having both tests. Results: 181 participants currently taking regular oral corticosteroids were included, 59% female, mean (SD) age 54(12)yrs, FEV1 64.7(20.4)% predicted. Sub-optimal adherence (MARS score < 4.5) was reported in 62 participants, and 76 did not have detectable urinary prednisolone or metabolites. Good adherence by both methods was detected in only 52 participants (34%, see table). There was no difference in daily prednisolone dose between detectable and undetectable metabolites groups (p=0.848). Conclusion: Low levels of adherence to treatment in severe asthma is a common problem, when measured either directly or self-reported. There was very poor agreement (48% concordance) between these two methods, and we suggest that, for now both approaches should be used.

Item does not contain fulltext BACKGROUND: Several prediction models assessing future risk of exacerbations in adult patients with asthma have been published. Applicability of these models is uncertain because their predictive performance has often not been assessed beyond the population in which they were derived. OBJECTIVE: This study aimed to identify and critically appraise prediction models for asthma exacerbations and validate them in 2 clinically distinct populations. METHODS: PubMed and EMBASE were searched to April 2017 for reports describing adult asthma populations in which multivariable models were constructed to predict exacerbations during any time frame. After critical appraisal, the models' predictive performances were assessed in a primary and a secondary care population for author-defined exacerbations and for American Thoracic Society/European Respiratory Society-defined severe exacerbations. RESULTS: We found 12 reports from which 24 prediction models were evaluated. Three predictors (previous health care utilization, symptoms, and spirometry values) were retained in most models. Assessment was hampered by suboptimal methodology and reporting, and by differences in exacerbation outcomes. Discrimination (area under the receiver-operating characteristic curve [c-statistic]) of models for author-defined exacerbations was better in the primary care population (mean, 0.71) than in the secondary care population (mean, 0.60) and similar (0.65 and 0.62, respectively) for American Thoracic Society/European Respiratory Society-defined severe exacerbations. Model calibration was generally poor, but consistent between the 2 populations. CONCLUSIONS: The preservation of 3 predictors in models derived from variable populations and the fairly consistent predictive properties of most models in 2 distinct validation populations suggest the feasibility of a generalizable model predicting severe exacerbations. Nevertheless, improvement of the models is warranted because predictive performances are below the desired level.

Periostin (POSTN) is secreted basolaterally by bronchial epithelial cells in asthma and is expressed in the extracellular matrix where it is thought to play a role in fibrosis and is associated with airway eosinophilia.In this study we have assessed the protein expression of POSTN in bronchial biopsies by immunohistochemistry, in serum by the Elecsys Periostin Immunoassay and measured gene expression by Affymetrix arrays in bronchial biopsies, bronchial brushings and in sputum in the U-BIOPRED severe asthma study in the bronchoscopy sub-cohort, which included 4 groups; severe non-smoker asthmatics (SAns), current / ex-smoker severe asthmatics (SAs), mild-moderate asthmatics (MMA) and non-asthmatic healthy controls (HC).Subepithelial protein expression in the bronchial biopsies was higher (p=0.02) in SAns, 9.2% (IQR 5.8-12.6)(n=44) compared to SAs 6.2% (3-9.2)(n=16), and in MMA 11% (7.5-12.6)(n=32) compared to SAs (p=0.002) or HC 7.1% (5.5-10.3)(p=0.01)(n=39). There was no difference between SAns and MMA. Gene expression was higher in biopsies from SAns (n=30), -0.044 (IQR -0.425-0.508), compared to both the SAs (n=9), -0.274 (-0.590-0.200), (p=0.02) and HC (n=21), -0.377 (-0.583-0.125), (p=0.008), but similar in MMA. There was no difference between the groups in POSTN serum levels or in gene expression in bronchial brushings or sputum. In asthmatics, the biopsy protein expression correlated with the biopsy gene expression, and both correlated with eosinophils numbers in the biopsies and blood, exhaled NO, and thickness of the lamina reticularis. These results highlight the potential relevance of tissue POSTN to asthma pathophysiology however, this does not appear to be reflected by serum POSTN measures.

Background: Adult-onset severe asthma is characterized by highly symptomatic disease despite high-intensity asthma treatments. Understanding of the underlying pathways of this heterogeneous disease is needed for the development of targeted treatments. Gene set variation analysis is a statistical technique used to identify gene profiles in heterogeneous samples. Objective: We sought to identify gene profiles associated with adult-onset severe asthma. Methods: This was a cross-sectional, observational study in which adult patients with adult-onset of asthma (defined as starting at age ≥18 years) as compared with childhood-onset severe asthma (

Introduction and Objectives Here we report the Results of the first direct comparison of the once-daily fixed-dose long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) combinations umeclidinium/vilanterol (UMEC/VI) 62.5/25 mcg and tiotropium/olodaterol (TIO/OLO) 5/5 mcg in patients with chronic obstructive pulmonary disease (COPD). Methods This randomised, 2-period crossover study (204990, NCT02799784) included inhaled corticosteroid-free patients with COPD, a modified Medical Research Council dyspnoea score ≥2, forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio of Results 236 patients (mean age 64.4 years, 60% male) were included in the intent-to-treat (ITT) population and 227 in the PP population. The primary endpoint of CFB in trough FEV1 at Week 8 confirmed NI of UMEC/VI vs TIO/OLO (175 mL vs 122 mL; least squares mean difference 53 mL [95% confidence interval: 26, 80]; p Conclusions In this first, direct, once-daily LAMA/LABA comparison, a greater likelihood of improvements in lung function was demonstrated with UMEC/VI vs TIO/OLO. The ELLIPTA inhaler was preferred to RESPIMAT. Both LAMA/LABAs were well tolerated. Funding GSK (204990 [NCT02799784]) Please refer to page A261 for declarations of interest in relation to abstract P275.

ObjectiveThe aim of these studies (NCT01957163; NCT02119286) was to evaluate the efficacy and safety of umeclidinium (UMEC 62.5 μg and 125 μg) added to fluticasone furoate/vilanterol (FF/VI, 100/25 μg) in chronic obstructive pulmonary disease (COPD).MethodsThese were 12-week, double-blind, placebo-controlled, parallel-group, multicenter studies. Eligible patients were randomized 1:1:1 to treatment with once-daily blinded UMEC 62.5 μg (delivering 55 μg), UMEC 125 μg (delivering 113 μg) or placebo (PBO) added to open-label FF/VI (delivering 92/22 μg; N = 1238 [intent-to-treat population]). The primary endpoint was trough forced expiratory volume in one second (FEV1) on Day 85; the secondary endpoint was 0–6 h post-dose weighted mean (WM) FEV1 at Day 84. Health-related quality of life was reported using St George's respiratory questionnaire (SGRQ). Adverse events (AEs) were also assessed.ResultsIn both studies, trough FEV1 was significantly improved with UMEC + FF/VI (62.5 μg and 125 μg) versus PBO + FF/VI (range: 0.111–0.128 L, all p

To the Editor: Heterogeneity in asthma is evident in every aspect of the disease process (1–3). Quantitative computed tomography (QCT) has emerged as a reliable, noninvasive tool for assessment of proximal airway remodeling and air trapping in asthma (4). We have identified three asthma clusters based on QCT indices, using factor and cluster analysis (3). Subjects in clusters 1 and 3, with more severe asthma, had distinct patterns of proximal airway remodeling: cluster 1 showing a dilated right upper lobe apical segmental bronchus (RB1) lumen with wall thickening and cluster 3 had no wall thickening and markedly narrowed lumen. Subjects in cluster 2 had milder asthma, and there was a lack of proximal airway remodeling. It remains elusive whether airway structural changes reflect cause or effect; namely, are they a consequence of asthma and represent different stages of disease progression or the distinct remodeling changes that are fundamental to the pathogenesis of asthma, representing distinct asthma endotypes (5)? Our aim was to assess the temporal pattern of proximal airway remodeling in QCT-derived asthma clusters. Some of the results of this study have been previously reported in the form of an abstract (6). Twenty-two patients with severe asthma of mean (SEM) disease duration 28.6 (4) years, who were in the placebo arm of a previous study (7), were included in the analysis. All 22 patients had undergone two inspiratory thoracic CT scans to image RB1 and further inspiratory and expiratory full thoracic CT scans as part of research studies at our institute (3, 7). All CT scans were performed after administration of long-acting β2-agonist. The mean (range) duration between the first (baseline) and second CT scan was 1.6 (0.9–2.7) years and between the second and third was 2.6 (1.9–3.7) years. QCT-derived asthma clusters were determined on the basis of full thoracic paired inspiratory and expiratory CT scans obtained at time point 3 (3). Only inspiratory scans were used for the current analysis. Informed consent was obtained from all subjects and the studies were approved by the Leicestershire, Northamptonshire, and Rutland Research Ethics Committees. Fully automated software (VIDA Pulmonary Workstation, version 2.0; VIDA Diagnostics, Coralville, IA) was used for quantitative airway morphometry as described previously (3). RB1 wall area (WA)/body surface area (BSA) demonstrated a significant increase over time (mean [SEM]: first CT, 14.3 [0.9]; second CT, 14.7 [0.9]; third CT, 16.5 [1.3] mm2/m2; repeated measure analysis of variance [ANOVA], P = 0.008). No significant change was seen in RB1 lumen area (LA)/BSA (mean [SEM]: first CT, 9.1 [1.0]; second CT, 9.6 [1.0]; third CT, 9.9 [0.9]; repeated measure ANOVA, P = 0.4). There was an increase in RB1 length at the time of the third CT (mean [SEM]: first CT, 11.3 [0.8]; second CT, 11.0 [0.7]; third CT, 13.1 [0.6] mm; repeated measure ANOVA, P

Monitoring sputum eosinophils in asthma predicts exacerbations and improves management of asthma. Thus far, blood eosinophils and FE(NO) show contradictory results in predicting eosinophilic airway inflammation. More recently, serum periostin was proposed as a novel biomarker for eosinophilic inflammation. Quantifying the mutual relationships of blood eosinophils, FE(NO), and serum periostin with sputum eosinophils by external validation in two independent cohorts across various severities of asthma. The first cohort consisted of 110 patients with mild to moderate asthma (external validation cohort). The replication cohort consisted of 37 patients with moderate to severe asthma. Both cohorts were evaluated cross-sectionally. Sputum was induced for the assessment of eosinophils. In parallel, blood eosinophil counts, serum periostin concentrations and FENO were assessed. The diagnostic accuracy of these markers to identify eosinophilic asthma (sputum eosinophils ≥3%) was calculated using receiver operating characteristics area under the curve (ROC AUC). In the external validation cohort, ROC AUC for blood eosinophils was 89% (p

Introduction: Asthma is heterogeneous disease consisting of multiple sub-phenotypes that are poorly defined Aim: To investigate the utility of the urinary metabolome to identify sub-phenotypes of severe asthma via molecular phenotyping Methods: Spot urine was collected from healthy controls (HC, n=108), mild-to-moderate asthmatics (MMA, n=87), severe asthmatics (SA); including both non-smokers (SAns, n=310) and smokers (SAs, n=108) from the U-BIOPRED cohort (Shaw et al, Eur Respir J. 2015; 46:1308). Metabolomics data were acquired using liquid chromatography coupled to mass spectrometry. Data were analysed using Principal Components–Canonical Variate Analysis (PC-CVA), topological data analysis (TDA), and hierarchical clustering. Results: 90 metabolites were conclusively identified, of which 44 were significantly altered with asthma (FDR Conclusions: SA evidence an altered urinary metabolic profile relative to HC. These shifts are associated with tryptophan metabolism, which may represent a useful strategy for sub-phenotyping asthma.

Background: We have previously reported altered gene expression in adults with asthma compared to healthy controls from the U-BIOPRED study (Bigler, 2016). Altered transcripts may define dysregulated biological pathways and identify novel therapeutic targets. We hypothesised that similar dysregulation would be seen in children with asthma. Aim: To compare blood transcriptomic profiles of children and adults with asthma. Methods: Affymetrix blood transcriptomic profiles of severe asthmatic adult non-smokers, n=152, were compared to mild moderate asthmatics, n=50 (Shaw, 2015; Fleming, 2015). Profiles of school-aged children with severe asthma, n=75, were compared to mild moderate asthmatics, n=37, and in the preschool age group severe wheeze, n=62, was compared to mild moderate wheeze, n=42. Differentially expressed genes (DEG) were identified as probe sets with maximum median group intensity >log2 5, with a significant (raw P≤0.01) change ≥ 20%. Overlapping genes were determined and pathway analysis performed. Results: We found 1887 DEG comparing severe and mild moderate asthmatic adults. Only 28 DEG were found between the severe wheeze and mild pre-school age children, with a larger signature (569 DEG) in the school aged children. 480 genes were specific to school-aged children and 1801 specific to adults, with 89 DEG in common between the adults and school-aged children. Conclusions: Preschool age children were poorly defined in terms of blood transcriptomics by the clinical definitions used. While the school-aged children showed some DEG overlap with the adults, they were distinct in many DEG and pathways indicating that childhood and adult asthma may be mechanistically different.

Background: The Group 1 innate lymphoid cell (Gp 1 ILC), which includes ILC1 and natural killer (NK) cells, express T-bet and IFNγ, and are cytotoxic. Their role in asthma is unclear. Aim: Explore the enrichment of ILC1, ILC2, ILC3 and NK activation signatures in asthmatic transcriptomic samples. Methods: U-BIOPRED participants were classified as moderate to severe asthma eosinophilic, neutrophilic, mixed and paucigranulocytic, based on sputum cell counts, and healthy. We applied Gene Set Variation Analysis to sputum, nasal, bronchial brush and bronchial biopsies using published signatures [Bjorklund et al. Nat Immunol 2016,17:451-60]. Results: ILC1 but not ILC2 or ILC3 ES were higher in non-smoking severe sputum, particularly in neutrophilic and mixed patients. This phenotype has been associated with inflammasome, IFNγ and TNF activation [Kuo at al. Eur Respir J.2017, 49, in press]. In eosinophilic asthma, ILC1 ES was lower, ILC2 higher and ILC3 similar across groups (Fig1A). ILC1 and NK ES correlated with M1 macrophage signature in all compartments (Fig1B). ILC2 ES correlated with M2 macrophage signature, except in nasal brush. Conclusion: A neutrophilic severe asthma phenotype has been characterized by Group 1 ILC activation, associated with inflammasome, IFNγ, and TNF, which may reflect an antimicrobial response and contribute to chronic inflammation and remodelling in severe asthma.

Introduction: Severe asthma is a heterogeneous disease and tobacco smoke is an important risk factor. Asthmatics who smoke show adverse effects on clinical, prognostic and therapeutic outcomes. Metabolomic analysis of volatile organic compounds (VOCs)in exhaled breath can be useful to identify a“severe asthma smoking phenotype” Aims: To investigate VOCs associated with a significant smoking history (>5 pack-years)in severe asthma by examining the breathomics data among severe asthma non-smokers(SAn)and severe asthma smokers/ex-smokers(SAs/ex)U-BIOPRED cohorts Methods: Breathomics and clinical data were obtained from 34 SAn and 14 SAs/ex(13 ex-smokers and one current smoker, as assessed by urinary cotinine).Exhaled breath was collected in Tedlar bags and VOCs trapped on Tenax tubes. VOCs were desorbed and analysed by GC-MS at Philips Research. ANOVA adjusted for age and sex was applied and p Results: VOCs comparison between SAn and SAs/ex showed a significant difference in 29 VOCs:23 were increased in SAs/ex, while six VOCs were decreased in SAs/ex.Identified VOCs include hydrocarbons, ketones, nitriles, and furans.Acetonitrile, 2-hexenal and 1,4-cyclohexadiene were increased in SAs/ex with p Conclusions: Acetonitrile, 1,4-cyclohexadiene and furans were elevated in SAs/ex group, as several authors have reported in active smokers.However, patients in SAs/ex group were almost all ex-smokers. This implies that the observed differences are not due to active smoke per se, but potentially reflect differences in the airways nflammation/metabolism/microbiome associated with smoking history

BACKGROUND: Asthma is a heterogeneous disease in which there is a differential response to asthma treatments. This heterogeneity needs to be evaluated so that a personalised management approach can be provided.OBJECTIVES: We stratified patients with moderate-to-severe asthma based on clinico-physiological parameters and performed an -omics analysis of sputum.METHODS: Partition-around-medoid clustering was applied to a training set of 266 asthma participants from the European U-BIOPRED adult cohort using 8 pre-specified clinic-physiological variables. This was repeated in a separate validation set of 152 asthmatics. The clusters were compared based on sputum proteomic and transcriptomic data.RESULTS: Four reproducible and stable clusters of asthmatics were identified. The training set cluster T1 consists of well-controlled moderate-to-severe asthmatics, while cluster T2 is a group of late-onset severe asthmatics with history of smoking and chronic airflow obstruction. Cluster T3 is similar to cluster T2 in terms of chronic airflow obstruction but is composed of non-smokers. Cluster T4 is predominantly composed of obese female uncontrolled severe asthmatics with increased exacerbations, but with normal lung function. The validation set exhibited similar clusters, demonstrating reproducibility of the classification. There were significant differences in sputum proteomics and transcriptomics between the clusters. The severe asthma clusters, T2, T3 and T4, had higher sputum eosinophilia than T1 with no differences in sputum neutrophil counts, exhaled nitric oxide and serum IgE levels.CONCLUSION: Clustering based on clinico-physiological parameters yielded 4 stable and reproducible clusters that associate with different pathobiological pathways.CLINICAL IMPLICATIONS: The definition of four distinct clusters of asthma linked to different pathobiological pathways provides a better template for the phenotyping and personalised treatment of severe asthma, where high unmet needs remain.CAPSULE SUMMARY: Unsupervised clustering of asthma on clinical features alone has led to the definition of four phenotypes. Sputum 'omics' analysis has revealed different biological pathways pointing towards potential new treatments.

SummaryBackground Several chemokines, notably eotaxin, mediate the recruitment of eosinophils into tissues via the CCR3 receptor. Objective In this study, we investigated the role of CCR3 agonists in asthma by observing the effect of a small molecule antagonist of the CCR3 receptor (GW766994) on sputum eosinophil counts in patients with eosinophilic asthma. Methods Clinical and physiological outcomes, the chemotactic activity of sputum supernatant for eosinophils and the presence of eosinophil progenitors in sputum and blood samples were also studied. Results In a double-blind parallel group study, 60 patients with asthma were randomized to 300 mg of GW766994 twice daily or matching placebo for 10 days followed by prednisone 30 mg for 5 days. Of these patients, 53 had a sputum eosinophil count > 4.9% at baseline. Despite plasma concentrations of drug consistent with > 90% receptor occupancy during the dosing period, the CCR3 antagonist did not significantly reduce eosinophils or eosinophil progenitor cells (CD34+ 45+ IL-5Rα+) in sputum or in blood. The ex vivo chemotactic effect of sputum supernatants on eosinophils was attenuated by GW766944 compared to placebo. There was no improvement in FEV1; however, there was a modest but statistically significant improvement in PC20 methacholine (0.66 doubling dose) and ACQ scores, (0.43). Whilst the improvement in PC20 is statistically significant, it is not of clinical significance. Conclusions and Clinical Relevance In conclusion, this study calls into question the role of CCR3 in airway eosinophilia in asthma and suggests that other cellular mechanisms mediated by the CCR3 receptor may contribute to airway hyperresponsiveness.

Stratification of asthma at the molecular level, especially using accessible biospecimens, could greatly enable patient selection for targeted therapy. To determine the value of blood analysis to identify transcriptional differences between clinically defined asthma and nonasthma groups, identify potential patient subgroups based on gene expression, and explore biological pathways associated with identified differences. Transcriptomic profiles were generated by microarray analysis of blood from 610 patients with asthma and control participants in the U-BIOPRED (Unbiased Biomarkers in Prediction of Respiratory Disease Outcomes) study. Differentially expressed genes (DEGs) were identified by analysis of variance, including covariates for RNA quality, sex, and clinical site, and Ingenuity Pathway Analysis was applied. Patient subgroups based on DEGs were created by hierarchical clustering and topological data analysis. A total of 1,693 genes were differentially expressed between patients with severe asthma and participants without asthma. The differences from participants without asthma in the nonsmoking severe asthma and mild/moderate asthma subgroups were significantly related (r = 0.76), with a larger effect size in the severe asthma group. The majority of, but not all, differences were explained by differences in circulating immune cell populations. Pathway analysis showed an increase in chemotaxis, migration, and myeloid cell trafficking in patients with severe asthma, decreased B-lymphocyte development and hematopoietic progenitor cells, and lymphoid organ hypoplasia. Cluster analysis of DEGs led to the creation of subgroups among the patients with severe asthma who differed in molecular responses to oral corticosteroids. Blood gene expression differences between clinically defined subgroups of patients with asthma and individuals without asthma, as well as subgroups of patients with severe asthma defined by transcript profiles, show the value of blood analysis in stratifying patients with asthma and identifying molecular pathways for further study. Clinical trial registered with www.clinicaltrials.gov (NCT01982162)

Aim: Asthma has an increased prevalence of GORD. Our aim was to identify lipid biomarkers by unbiased lipidomics in sputum that predict clinically active GORD in asthmatic participants. Methods: This was a study of 157 asthmatics classified clinically into 3 groups: 82 severe non-smoking, 37 severe smoking and 38 mild/moderate, as defined by U-BIOPRED criteria: 57 with active GORD and 100 without GORD. Lipid profiles of sputum supernatants were obtained by high resolution shotgun mass spectrometry. Lipids with ≥20% abundance across the sample set were selected for analysis. Clinical and lipid data were analysed by non-parametric tests, univariate (ULR) and multiple logistic regression (MLR) analyses with stepwise backward selection for best predictors of active GORD. Results: Of all tested species, 123 differentially present lipids were selected by ULR (p≤0.10) and screened for contaminants. Further MLR was performed on 33 species (p≤0.05): 11 were found to be independent predictors by backward MLR, adjusted for cohort and gender (p m/z= 778.5802 and negative ESI m/z= 568.3601. The best clinical predictors were smoking severe asthma (p Conclusions: This study confirms disease severity as an independent predictor of active GORD and shows, for the first time, a set of lipid biomarkers that differentially predict active GORD, implying an effect of GORD on the airways. The role of these lipids remain to be elucidated.

Background This study tested the clinical non-inferiority of the fluticasone propionate/salmeterol combination 50/250 μg (FSC) Rotacaps ® /Rotahaler ® system, a single unit dose inhaler, with the multi-dose FSC Diskus ® inhaler in adults with chronic obstructive pulmonary disease (COPD). Methods This multi-centre, randomised, double-blind, double-dummy, two-way cross-over study compared 12 weeks' treatment of FSC administered twice daily using Rotacaps/Rotahaler or Diskus. The primary endpoint was change from baseline in trough morning forced expiratory volume in 1 s (FEV 1 ) at Day 85, and the pre-defined non-inferiority criteria was: the lower limit of the confidence interval (CI) for the treatment difference (Rotacaps/Rotahaler-Diskus) in least squares (LS) mean change from baseline, being greater than −45 mL. Secondary endpoints included change in breathlessness (as measured by transition dyspnoea index (TDI)) and COPD-specific health status measures. Results The LS mean increase from baseline in trough FEV 1 at Day 85 was 116 mL in the Rotacaps/Rotahaler group and 91 mL in the Diskus group (difference in model-adjusted LS mean change: 25 mL (95% CI 2 mL, 47 mL)), the lower limit of the CI for the treatment difference being greater than the protocol-defined criterion for non-inferiority i.e. −45 mL. Data for breathlessness, COPD-specific health status and safety parameters were similar following FSC treatment via either inhaler. Conclusions This study demonstrated the clinical non-inferiority of FSC 50/250 μg when administered using Rotacaps/Rotahaler compared with Diskus in patients with COPD. The risk:benefit profile for the two inhalers was comparable.

Airway remodelling in asthma remains poorly understood. This study aimed to determine the association of airway remodelling measured on bronchial biopsies with 1) lung function impairment and 2) thoracic quantitative computed tomography (QCT)-derived morphometry and densitometry measures of proximal airway remodelling and air trapping.Subjects were recruited from a single centre. Bronchial biopsy remodelling features that were the strongest predictors of lung function impairment and QCT-derived proximal airway morphometry and air trapping markers were determined by stepwise multiple regression. The best predictor of air trapping was validated in an independent replication group.Airway smooth muscle % was the only predictor of post-bronchodilator forced expiratory volume in 1 s (FEV1) % pred, while both airway smooth muscle % and vascularity were predictors of FEV1/forced vital capacity. Epithelial thickness and airway smooth muscle % were predictors of mean segmental bronchial luminal area (R2=0.12; p=0.02 and R2=0.12; p=0.015), whereas epithelial thickness was the only predictor of wall area % (R2=0.13; p=0.018). Vascularity was the only significant predictor of air trapping (R2=0.24; p=0.001), which was validated in the replication group (R2=0.19; p=0.031).In asthma, airway smooth muscle content and vascularity were both associated with airflow obstruction. QCT-derived proximal airway morphometry was most strongly associated with epithelial thickness and airway smooth muscle content, whereas air trapping was related to vascularity.

Item does not contain fulltext BACKGROUND: Preventing exacerbations of asthma is a major goal in current guidelines. We aimed to develop a prediction model enabling practitioners to identify patients at risk of severe exacerbations who could potentially benefit from a change in management. METHODS: We used data from a 12-month primary care pragmatic trial; candidate predictors were identified from GINA 2014 and selected with a multivariable bootstrapping procedure. Three models were constructed, based on: (1) history, (2) history+spirometry and (3) history+spirometry+FeNO. Final models were corrected for overoptimism by shrinking the regression coefficients; predictive performance was assessed by the area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow test. Models were externally validated in a data set including patients with severe asthma (Unbiased BIOmarkers in PREDiction of respiratory disease outcomes). RESULTS: 80/611 (13.1%) participants experienced >/=1 severe exacerbation. Five predictors (Asthma Control Questionnaire score, current smoking, chronic sinusitis, previous hospital admission for asthma and >/=1 severe exacerbation in the previous year) were retained in the history model (AUROC 0.77 (95% CI 0.75 to 0.80); Hosmer-Lemeshow p value 0.35). Adding spirometry and FeNO subsequently improved discrimination slightly (AUROC 0.79 (95% CI 0.77 to 0.81) and 0.80 (95% CI 0.78 to 0.81), respectively). External validation yielded AUROCs of 0.72 (95% CI 0.70 to 0.73; 71 to 0.74 and 0.71 to 0.73) for the three models, respectively; calibration was best for the spirometry model. CONCLUSIONS: A simple history-based model extended with spirometry identifies patients who are prone to asthma exacerbations. The additional value of FeNO is modest. These models merit an implementation study in clinical practice to assess their utility. TRIAL REGISTRATION NUMBER: NTR 1756.

Benefits of triple therapy with a long-acting muscarinic antagonist (LAMA), added to inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA), have been demonstrated. Limited data assessing the efficacy of the LAMA umeclidinium (UMEC) added to ICS/LABA are available. The aim of this study is to evaluate the efficacy and safety of UMEC added to ICS/LABAs in patients with moderate-to-very-severe COPD. This is a multicentre, randomised, double-blind, parallel-group study. Patients were symptomatic (modified Medical Research Council Dyspnoea Scale score ⩾2), despite receiving ICS/LABA (fluticasone propionate/salmeterol (FP/SAL, branded) 500/50 mcg, budesonide/formoterol (BD/FOR, branded) 200/6 mcg or 400/12 mcg, or other ICS/LABAs) ⩾30 days before the run-in (7±2 days). Patients were randomised 1:1 to once-daily UMEC 62.5 mcg or placebo (PBO), added to twice-daily open-label ICS/LABA for 12 weeks. Primary end point was trough forced expiratory volume in 1 s (FEV1) at Day 85; secondary end point was weighted mean (WM) 0–6 h FEV1 at Day 84; other end points included COPD Assessment Test (CAT) score and Transition Dyspnoea Index (TDI) score. Adverse events (AEs) were investigated. In the UMEC+ICS/LABA and PBO+ICS/LABA groups, 119 and 117 patients were randomised, respectively. Patients received FP/SAL (40%), BD/FOR (43%) and other ICS/LABAs (17%). UMEC+ICS/LABA resulted in significant improvements in trough FEV1 (Day 85) and in WM 0–6 h FEV1 (Day 84) versus PBO+ICS/LABA (difference: 123 and 148 ml, respectively, both P

Fetuses exposed to warfarin during pregnancy are at an increased risk of developing an embryopathy known as fetal warfarin syndrome or warfarin embryopathy. The most consistent anomalies are nasal hypoplasia and stippling of vertebrae or bony epiphyses. Management of pregnant patients on anticoagulation is challenging. Current guidelines suggest the use of warfarin if the therapeutic dose is ≤5 mg/day. We report the case of a newborn with signs of warfarin embryopathy born from a mother anticoagulated with warfarin due to mechanical mitral and aortic heart valves. Warfarin was required at the dose of 5 mg/day and was withheld without medical advice between weeks 8 and 10 with no other anticoagulation. The newborn presented with skeletal abnormalities and a ventricular septal defect that have not required specific treatment during the first year of life. Low-dose warfarin is associated with a lower risk of warfarin-related fetopathy but the risk of embryopathy seems unchanged.

BACKGROUND: Exacerbations of asthma are associated with substantial morbidity and mortality and with considerable use of health care resources. Preventing exacerbations remains an important goal of therapy. There is evidence that eosinophilic inflammation of the airway is associated with the risk of exacerbations. METHODS: We conducted a randomized, double-blind, placebo-controlled, parallel-group study of 61 subjects who had refractory eosinophilic asthma and a history of recurrent severe exacerbations. Subjects received infusions of either mepolizumab, an anti-interleukin-5 monoclonal antibody (29 subjects), or placebo (32) at monthly intervals for 1 year. The primary outcome measure was the number of severe exacerbations per subject during the 50-week treatment phase. Secondary outcomes included a change in asthma symptoms, scores on the Asthma Quality of Life Questionnaire (AQLQ, in which scores range from 1 to 7, with lower values indicating more severe impairment and a change of 0.5 unit considered to be clinically important), forced expiratory volume in 1 second (FEV(1)) after use of a bronchodilator, airway hyperresponsiveness, and eosinophil counts in the blood and sputum. RESULTS: Mepolizumab was associated with significantly fewer severe exacerbations than placebo over the course of 50 weeks (2.0 vs. 3.4 mean exacerbations per subject; relative risk, 0.57; 95% confidence interval [CI], 0.32 to 0.92; P=0.02) and with a significant improvement in the score on the AQLQ (mean increase from baseline, 0.55 vs. 0.19; mean difference between groups, 0.35; 95% CI, 0.08 to 0.62; P=0.02). Mepolizumab significantly lowered eosinophil counts in the blood (P

Background: FEV1 correlates with symptoms and exacerbation risk in asthma. Although considered an index of airway resistance (R), FEV1 also varies with vital capacity (VC) as a function of airway recruitment. Aims: Quantify the contributions of airway narrowing vs. closure by analyzing airflow limitation and bronchodilator reversibility in U-BIOPRED patients with severe (S) vs. mild-moderate (MM) disease. Methods: Patients with S (n=305) and MM (n=95) underwent spirometry and plethysmography (PFTs) in a cross-sectional design. Employing a single compartment lung model, FEV1 = (TLC-RV){1-exp[-1/(RC)]}1. PFT values were entered into the model to assess airway narrowing and closure in each cohort. Results: Baseline % predicted FEV1 (67.4 vs. 88.4%; p Conclusion: Modeling of PFT data from U-BIOPRED reveals distinct patterns of baseline physiology and bronchodilator responsiveness in S and MM cohorts. S display lower FEV1 with airway collapse and gas trapping, partly reversible with bronchodilators. MM display minimal gas trapping, less bronchodilator %ΔFEV1, but larger changes in R suggesting greater b-agonist effect on airway tone in milder disease.

We hypothesized that Gene Set Variation Analysis (GSVA) of gene expression in bronchial brushings can effectively classify airway Th2-high status in U-BIOPRED asthmatics. Airway Th2-status was defined as IL-13-induced transcriptional activity, evaluated as enrichment of IL-13 in-vitro stimulation (IVS) or expression of POSTN and SERPINB2 in human bronchial epithelial cell transcriptomic profiles from U-BIOPRED asthma patients. Based on IL-13 IVS GSVA enrichment scores above the 95 th percentile for healthy subjects, 53% of severe asthma (SA) non-smokers (n=49), 67% of SA smokers (n=18) and 36% of non-severe asthmatics (n=36) were classified as Th2-high. Eosinophilic inflammation marker values are shown in Figure 1. Using the mean normalised expression of POSTN and SERPINB2 as an alternative Th2 stratification factor, 35% of SA non-smokers, 22% of SA smokers, and 14% of non-severe asthmatics were Th2-high, mostly subsets of the IL-13 IVS-defined Th2-high asthma groups and consistent with the modest correlation (r=0.39) between the IL-13 IVS enrichment scores and POSTN/SERPINB2 scores. IL-13 IVS and POSTN/SERPINB2 based definitions of Th2 activity showed associations with eosinophilic and atopy markers, with good agreement for Th2-high vs. -low calls, although the latter approach may be too conservative. IL-13 IVS enrichment identified a broader set of subjects with airway Th2 activity when compared to POSTN and SERPINB2. Funded by IMI.

Objective: To assess once-daily (OD) long-acting muscarinic antagonist umeclidinium (UMEC) +inhaled corticosteroid/long-acting β 2 -agonist (ICS/LABA) or placebo (PBO) +ICS/LABA in GOLD D patients with COPD (symptomatic patients with high future exacerbation risk). Methods: Pooled data from 4 randomised, double-blind trials were analysed post hoc . Patients with COPD used open-label fluticasone furoate/vilanterol 100/25mcg or fluticasone propionate/salmeterol 250/50mcg for 4 wks before randomisation to OD add-on UMEC 62.5mcg, UMEC 125mcg or PBO for 12 wks. Primary endpoint was change from baseline (CFB) in trough forced expiratory volume in 1 s (FEV 1 ) on Day (D) 85; others were St George9s Respiratory Questionnaire (SGRQ), rescue use and moderate/severe exacerbations. Results: GOLD D group comprised 58% of 2458 intent-to-treat patients (n: UMEC 62.5+ICS/LABA=499; UMEC 125+ICS/LABA=463; PBO+ICS/LABA=474). UMEC 62.5+ICS/LABA vs PBO+ICS/LABA led to improved trough FEV 1 (CFB difference D2: 96mL [95%CI 81,111]; D85: 119mL [95%CI 98,141]; both p Conclusion: In GOLD D patients, adding UMEC 62.5 to ICS/LABA improved lung function and reduced exacerbation risk. Funded by GSK NCT01957163, 200109; NCT02119286, 200110; NCT01772134, AC4116135; NCT01772147, AC4116136.