Weekly self-monitoring and treatment adjustment benefit patients with partly controlled and uncontrolled asthma: an analysis of the SMASHING study

Background

Internet-based self-management has shown to improve asthma control and asthma related quality of life, but the improvements were only marginally clinically relevant for the group as a whole. We hypothesized that self-management guided by weekly monitoring of asthma control tailors pharmacological therapy to individual needs and improves asthma control for patients with partly controlled or uncontrolled asthma.

Methods

In a 1-year randomised controlled trial involving 200 adults (18-50 years) with mild to moderate persistent asthma we evaluated the adherence with weekly monitoring and effect on asthma control and pharmacological treatment of a self-management algorithm based on the Asthma Control Questionnaire (ACQ). Participants were assigned either to the Internet group (n = 101) that monitored asthma control weekly with the ACQ on the Internet and adjusted treatment using a self-management algorithm supervised by an asthma nurse specialist or to the usual care group (UC) (n = 99). We analysed 3 subgroups: patients with well controlled (ACQ ≤ 0.75), partly controlled (0.75>ACQ ≤ 1.5) or uncontrolled (ACQ>1.5) asthma at baseline.

Results

Overall monitoring adherence was 67% (95% CI, 60% to 74%). Improvements in ACQ score after 12 months were -0.14 (p = 0.23), -0.52 (p < 0.001) and -0.82 (p < 0.001) in the Internet group compared to usual care for patients with well, partly and uncontrolled asthma at baseline, respectively. Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma (+278 μg, p = 0.001), but not in patients with well or partly controlled asthma. After one year there were no differences in daily inhaled corticosteroid use or long-acting β₂-agonists between the Internet group and usual care.

Conclusions

Weekly self-monitoring and subsequent treatment adjustment leads to improved asthma control in patients with partly and uncontrolled asthma at baseline and tailors asthma medication to individual patients'' needs.

Trial registration

Current Controlled Trials ISRCTN79864465     

Rhizobium leguminosarum bv. viciae 3841 Adapts to 2,4-Dichlorophenoxyacetic Acid with “Auxin-Like” Morphological Changes,Cell Envelope Remodeling and Upregulation of Central Metabolic Pathways

There is a growing need to characterize the effects of environmental stressors at the molecular level on model organisms with the ever increasing number and variety of anthropogenic chemical pollutants. The herbicide 2,4-dichlorophenoxyacetic acid (2,4-D), as one of the most widely applied pesticides in the world, is one such example. This herbicide is known to have non-targeted undesirable effects on humans, animals and soil microbes, but specific molecular targets at sublethal levels are unknown. In this study, we have used Rhizobium leguminosarum bv. viciae 3841 (Rlv) as a nitrogen fixing, beneficial model soil organism to characterize the effects of 2,4-D. Using metabolomics and advanced microscopy we determined specific target pathways in the Rlv metabolic network and consequent changes to its phenotype, surface ultrastructure, and physical properties during sublethal 2,4-D exposure. Auxin and 2,4-D, its structural analogue, showed common morphological changes in vitro which were similar to bacteroids isolated from plant nodules, implying that these changes are related to bacteroid differentiation required for nitrogen fixation. Rlv showed remarkable adaptation capabilities in response to the herbicide, with changes to integral pathways of cellular metabolism and the potential to assimilate 2,4-D with consequent changes to its physical and structural properties. This study identifies biomarkers of 2,4-D in Rlv and offers valuable insights into the mode-of-action of 2,4-D in soil bacteria.     

Can the Cyanobacterial Carbon-Concentrating Mechanism Increase Photosynthesis in Crop Species? A Theoretical Analysis

Experimental elevation of [CO₂] around C₃ crops in the field has been shown to increase yields by suppressing the Rubisco oxygenase reaction and, in turn, photorespiration. Bioengineering a cyanobacterial carbon-concentrating mechanism (CCM) into C₃ crop species provides a potential means of elevating [CO₂] at Rubisco, thereby decreasing photorespiration and increasing photosynthetic efficiency and yield. The cyanobacterial CCM is an attractive alternative relative to other CCMs, because its features do not require anatomical changes to leaf tissue. However, the potential benefits of engineering the entire CCM into a C₃ leaf are unexamined. Here, a CO₂ and HCO₃⁻ diffusion-reaction model is developed to examine how components of the cyanobacterial CCM affect leaf light-saturated CO₂ uptake (A_sat) and to determine whether a different Rubisco isoform would perform better in a leaf with a cyanobacterial CCM. The results show that the addition of carboxysomes without other CCM components substantially decreases A_sat and that the best first step is the addition of HCO₃⁻ transporters, as a single HCO₃⁻ transporter increased modeled A_sat by 9%. Addition of all major CCM components increased A_sat from 24 to 38 µmol m⁻² s⁻¹. Several Rubisco isoforms were compared in the model, and increasing ribulose bisphosphate regeneration rate will allow for further improvements by using a Rubisco isoform adapted to high [CO₂]. Results from field studies that artificially raise [CO₂] suggest that this 60% increase in A_sat could result in a 36% to 60% increase in yield.C₃ species include the major grain crops rice (Oryza sativa) and wheat (Triticum aestivum) and overall accounted for approximately 75% of all primary foodstuff production in 2012 (FAOSTAT, 2013). The yield of many crop species has been substantially improved through breeding and agronomy, but advancement in yield has substantially slowed in many of the major C₃ crops in the last decade, suggesting that limits on yield improvement using these techniques are being reached and that other approaches are needed (Long and Ort, 2010; Ray et al., 2012).One largely unexploited approach would be to improve the efficiency of photosynthesis in these species (Zhu et al., 2010). The photosynthetic enzyme Rubisco catalyzes the reaction of CO₂ with ribulose bisphosphate (RuBP), which eventually forms carbohydrates. However, Rubisco will also react with oxygen as the first step in photorespiration. This reaction is considered wasteful, since energy is consumed to recover RuBP and CO₂ is lost in the process. In C₃ plants at 25°C and current atmospheric [CO₂], photorespiration results in an approximately 30% decrease in net carbon assimilation (Zhu et al., 2010). Thus, it is a large inefficiency in carbon uptake and a target for improvement.Since CO₂ and oxygen act competitively at Rubisco, photorespiration can be decreased by increasing [CO₂] around Rubisco. That this will increase yield is demonstrated by the many studies that have artificially increased atmospheric [CO₂] around C₃ crops growing in the field (Kimball et al., 2002; Long et al., 2006b). Other photosynthetic organisms have evolved mechanisms to internally elevate [CO₂] at Rubisco to decrease or eliminate photorespiration. Such carbon-concentrating mechanisms (CCMs) include C₄ photosynthesis, as in maize (Zea mays), and the carboxysome and pyrenoid CCMs of single-celled cyanobacteria and algae. The C₄ pathway requires the addition of the photosynthetic C₄ dicarboxylate cycle and inner photosynthetic cells (i.e. bundle sheath), where Rubisco is localized. Converting a C₃ crop to a C₄ crop will require a coordination of changes in photosynthetic tissue differentiation and enzyme and transporter localization. In contrast, cyanobacteria achieve the same effect in a single cell by localizing Rubisco to specialized subcellular compartments called carboxysomes, so in theory they would require fewer changes. Carboxysomes are polyhedral bodies with a protein shell that encloses carbonic anhydrase (CA) and Rubisco packed in an ordered or semiordered array (Long et al., 2007; Yeates et al., 2011). Bicarbonate is actively transported from the environment into the cytosol of the cyanobacteria, and CO₂ in the cytosol is actively hydrated to HCO₃⁻ using NADH. CO₂ is also hydrated to HCO₃⁻, which serves to increase the [CO₂] gradient between the medium and cytosol, increasing CO₂ flux, and also serves to refix CO₂ that leaks from the carboxysome. Since the cytosol lacks CA and the plasma membrane has low permeability to HCO₃⁻, a high cytosolic [HCO₃⁻] far from equilibrium with [CO₂] is achieved. Bicarbonate diffuses through the protein shell of the carboxysome, and since CA is localized to the inner side of the shell, it is rapidly converted to CO₂, given the disequilibrium. The resulting high [CO₂] around Rubisco inside the carboxysome accelerates carboxylation and competitively inhibits the oxygenation reaction (for review, see Price et al., 2008, 2011, 2013; Espie and Kimber, 2011).The C₄ pathway has been well characterized, and several projects are attempting to engineer it into C₃ plants with some success (Slewinski, 2013). However, a primary obstacle has been achieving the necessary two tissue types with the correct localization of the key enzymes (Covshoff and Hibberd, 2012). In this regard, cyanobacterial CCM may provide an attractive parallel approach to eliminating photorespiration in C₃ plants for two reasons. First, the biochemical, structural, and genetic components of the CCM are well understood, in that all of the necessary proteins and their genes have been identified. Second, chloroplasts of higher plants evolved from a common ancestor with modern cyanobacteria (Raven and Allen, 2003) and, therefore, are structurally similar. Thus, engineering carboxysomes into the chloroplast could involve introducing an operon containing the genes associated with the cyanobacterial CCM into the chloroplast genome.There are, however, multiple proteins in the cyanobacterial CCM, and simultaneously transforming all of the required genes into an organism may be particularly challenging. Furthermore, some of the proteins appear to have a similar function, and others may be deleterious if introduced without the full apparatus. A random sequence of gene stacking would likely be inefficient, while the addition of some genes may simply be unnecessary. However, the biophysical reactions involved are well understood, and there are some measurements of the kinetics of the enzymatic reactions and transporters. With this information, a mathematical model can be created to simulate the CCM. Such a model will allow deduction of the minimal component set necessary for an improvement of leaf photosynthetic efficiency and identify a logical sequence of gene additions to deliver progressive improvements and avoid any lethal effects. This model will also be used to determine which aspects of the CCM exert the most control over the overall process of photosynthetic CO₂ assimilation, information that can then be used to optimize the CCM, help identify the ideal set of components, or identify parameters that need to be more accurately measured in order to improve the effectiveness of the CCM model. Similar kinetic models have been applied to propose systems optimization of the Calvin cycle when plants are grown in elevated [CO₂] (Zhu et al., 2007), of the whole C₃ photosynthetic system (Zhu et al., 2013), C₄ photosynthesis (Yu et al., 2014), and to determine the mechanistic basis of mesophyll conductance (Tholen and Zhu, 2011).This paper develops a kinetic model to determine the potential of the cyanobacterial CCM engineered into C₃ crops for improving photosynthesis by determining the necessary components and estimating the potential improvement of CO₂ assimilation rate and efficiency. There are four distinct features to the cyanobacterial CCM: (1) a carboxysome with internally localized Rubisco and CA; (2) active transport of HCO₃⁻ from the medium into the cyanobacterial cytosol (the equivalent compartment in higher plants is the stroma of the chloroplast); (3) active hydration of CO₂ to HCO₃⁻ within the cytosol; and (4) the absence of CA in the cyanobacterial cytosol, in contrast to the higher plant stroma, which contains high activities of CA. Cyanobacteria have three HCO₃⁻ transporters and two CO₂ hydration enzymes that have different kinetics and are induced under different conditions (Price et al., 2011). All of these enzymes were examined, giving a total of seven individual components (listed in Fig. 1A) to the full cyanobacterial CCM model. Because of the common ancestry between cyanobacteria and higher plant chloroplasts, the two have homologous membranes and compartments. Proteins were modeled within a C₃ leaf using locations equivalent to those in cyanobacteria. That is, bicarbonate transporters were localized to the inner chloroplast membrane, and carboxysomes were localized to the stroma. The CO₂ hydration enzymes are bound to the thylakoid and plasma membranes in cyanobacteria, but the reaction for both occurs within the cyanobacterial cytosol; therefore, in this model, hydration of CO₂ by these enzymes was localized to the stroma. This model was used to determine the necessity of each of the features noted above, potential improvements in light-saturated CO₂ uptake (A_sat; irradiance of 1,800 µmol photons m⁻² s⁻¹) that would be achieved on incorporation of each feature in turn, a possible sequence of gene additions that would give an incremental improvement, and the key components of the CCM. The model was also used to test the value of using higher plant isoforms of Rubisco versus prokaryotic isoforms adapted to incorporation within the carboxysome. Sources of uncertainty in the model are also defined.Open in a separate windowFigure 1.A_sat of leaf models with sequential addition of components of the cyanobacterial CCM. Each point represents a leaf that contains the component listed for that column and all of the components in the columns to the left of it. The columns represent the sequence of transformations that produce the fastest increase in A_sat assuming that it is not possible to simultaneously add carboxysomes and remove stromal CA and that it is not desirable to add CO₂ hydration enzymes before removal of stromal CA (A) and assuming that it is possible to simultaneously add carboxysomes and remove stromal CA (B).     

Prediction of R5, X4, and R5X4 HIV-1 coreceptor usage with evolved neural networks

The HIV-1 genome is highly heterogeneous. This variation affords the virus a wide range of molecular properties, including the ability to infect cell types, such as macrophages and lymphocytes, expressing different chemokine receptors on the cell surface. In particular, R5 HIV-1 viruses use CCR5 as co-receptor for viral entry, X4 viruses use CXCR4, whereas some viral strains, known as R5X4 or D-tropic, have the ability to utilize both co-receptors. X4 and R5X4 viruses are associated with rapid disease progression to AIDS. R5X4 viruses differ in that they have yet to be characterized by the examination of the genetic sequence of HIV-1 alone. In this study, a series of experiments was performed to evaluate different strategies of feature selection and neural network optimization. We demonstrate the use of artificial neural networks trained via evolutionary computation to predict viral co-receptor usage. The results indicate identification of R5X4 viruses with predictive accuracy of 75.5%.     

Gut Microbiome Developmental Patterns in Early Life of Preterm Infants: Impacts of Feeding and Gender

Gut microbiota plays a key role in multiple aspects of human health and disease, particularly in early life. Distortions of the gut microbiota have been found to correlate with fatal diseases in preterm infants, however, developmental patterns of gut microbiome and factors affecting the colonization progress in preterm infants remain unclear. The purpose of this prospective longitudinal study was to explore day-to-day gut microbiome patterns in preterm infants during their first 30 days of life in the neonatal intensive care unit (NICU) and investigate potential factors related to the development of the infant gut microbiome. A total of 378 stool samples were collected daily from 29 stable/healthy preterm infants. DNA extracted from stool was used to sequence the V4 region of the 16S rRNA gene region for community analysis. Operational taxonomic units (OTUs) and α-diversity of the community were determined using QIIME software. Proteobacteria was the most abundant phylum, accounting for 54.3% of the total reads. Result showed shift patterns of increasing Clostridium and Bacteroides, and decreasing Staphylococcus and Haemophilus over time during early life. Alpha-diversity significantly increased daily in preterm infants after birth and linear mixed-effects models showed that postnatal days, feeding types and gender were associated with the α-diversity, p< 0.05–0.01. Male infants were found to begin with a low α-diversity, whereas females tended to have a higher diversity shortly after birth. Female infants were more likely to have higher abundance of Clostridiates, and lower abundance of Enterobacteriales than males during early life. Infants fed mother’s own breastmilk (MBM) had a higher diversity of gut microbiome and significantly higher abundance in Clostridiales and Lactobacillales than infants fed non-MBM. Permanova also showed that bacterial compositions were different between males and females and between MBM and non-MBM feeding types. In conclusion, infant postnatal age, gender and feeding type significantly contribute to the dynamic development of the gut microbiome in preterm infants.