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Lung cancer outcomes
S1 CARBOPLATIN AND VINORELBINE AS FIRST LINE OUTPATIENT TREATMENT IN NSCLC
J. Maguire, N. Smith, V. Kelly, M. Ledson, M. Walshaw. Liverpool Lung Cancer Unit, Cardiothoracic Centre, Thomas Drive, Liverpool, UK
Outpatient chemotherapy offers advantages for the Health Service in terms of resource utilisation and expense compared to the patient treatment, and is preferred by the vast majority of patients and their families.
We have treated 130 patients (84 male, mean age 65.8 years, 46 female, mean age 62.2 years) with stage III or Stage IV NSCLC and performance status 0–2 with outpatient chemotherapy using Carboplatin and Vinorelbine using the following regimen:
Carboplatin AUC 5 day 1,
Vinorelbine 25 mg/m2 day 1, day 8
The intended duration of treatment was 3 or 4 courses of chemotherapy using a 21 day treatment cycle. The mean number of courses given was 3.2 (range 1–6).
With 102 patients so far having completed treatment, response rates are as follows: Complete Responses 2%, Partial Responses 34.8%, Stable Disease 32%, and Progressive Disease 17.1%. Overall median survival is 9.1 months.
Treatment was generally tolerated. Toxicity included neutropenic sepsis in 22% and anaemia requiring blood transfusion in 29%. There were 8 (7.8%) treatment related deaths. Patients with performance status 2 at commencement of treatment were at significantly greater risk of serious morbidity and treatment related death compared to patients with performance status 0–1. Patients aged >70 were more likely to require blood transfusions but were not at increased risk of neutropenic sepsis or treatment related death. We conclude that Carboplatin and Vinorelbine is a relatively safe and effective regimen for the outpatient treatment of patients with NSCLC.
S2 A COMPARISON OF ACE AND CE CHEMOTHERAPY IN SCLC
N. Diar Bakerley, N.P. Keaney, K. Sridharan, I.K. Taylor, H.W. Clague. Chest Diseases Unit, Sunderland Royal Hospital, Sunderland SR4 7TP, UK
Background: Chemotherapy plays an important role in the treatment of Small Cell Lung Cancer (SCLC). Several standard regimens are in existence but there have been few direct comparisons with regard to toxicity. In this retrospective audit we compare the toxicity of ACE (Adriamycin, Cyclophosphamide and Etoposide) with CE (Carboplatin and Etoposide).
Methods: Over a 12 month period from April 2000 28 patients with SCLC received chemotherapy with either ACE or CE chemotherapy. Toxicity was evaluated by a retrospective audit of case notes looking in particular at neutropenia, neutropenic sepsis, clinically significant anaemia, in hospital duration of stay and toxic death.
Results: Eleven patients (39.2%) received ACE, 12 patients (42.8%) received CE and five patients (17.8%) received both. In total 63 ACE and 80 CE chemotherapy cycles were given.
Severe neutropenia (neutrophils 0–0.5%) complicated 21 (33.3%) ACE compared with 11 (13.7%) CE chemotherapy sessions (p=0.005). Neutropenic sepsis occurred in 14 (22.2%) ACE sessions compared with 2 (2.5%) CE sessions (p=0.0002). Thirty (46.8%) ACE sessions were complicated with clinically significant anaemia compared to 18 (22.5%) in the CE group (p=0.002). The average in-hospital stay per patient was 19.3 days for patients receiving ACE and 3.6 days for patients receiving CE. Toxic death happened in 1 patient in the ACE group and 1 patient in the CE group (p=0.9).
Conclusion: This retrospective audit indicates that in our experience ACE chemotherapy for SCLC is associated with greater toxicity than the CE regimen. This led to a greater use of resources in terms of antibiotic therapy, blood transfusion, and hospital bed usage and has led us to adopt the CE regimen as first choice chemotherapy for this group of patients.
S3 PROLONGED SURVIVAL IN INOPERABLE NSCLC WITH CONCURRENT CHEMO-RADIOTHERAPY
J. Maguire, R. Page, V. Kelly, N. Smith, M. Ledson, M. Walshaw. Liverpool Lung Cancer Unit, Cardiothoracic Centre, Thomas Drive, Liverpool, UK
Synchronous chemotherapy and radiotherapy is a highly effective treatment modality for a number of solid tumours including inoperable Non-Small Cell Lung Cancer, and has been adopted as a standard therapy for lung cancer in the United States. However, experience with this form of treatment for lung cancer in the UK is limited.
We have treated 54 patients with locally advanced, inoperable NSCLC (8 Stage IIB, 46 Stage IIIB) with concurrent cisplatinum and radical radiotherapy using a tumour dose of 52.5 Gy given in 20 daily fractions over four weeks, together with cisplatinum 20 mg/m2 concurrent with fractions 1–5 and 16–20. Thirty four patients received 2–4 courses of chemotherapy after concurrent chemo-radiation. Toxicity was acceptable, with three cases of severe but self-limiting oesophagitis, a 70% incidence of mild to moderate oesophagitis and no treatment related deaths.
One, two, and three year survival rates for patients with Stage IIIB disease are 74%, 35%, and 32% respectively. Patients with Stage IIIB disease treated with concurrent chemo-radiotherapy followed by systemic chemotherapy have a median survival of 25 months, 3 year survival of 49%, and a local control rate of 89.5%.
Concurrent chemo-radiotherapy is a highly effective treatment modality for patients with locally advanced inoperable NSCLC, but this form of treatment is only suitable for patients who have good performance status (PS 0–1), minimal co-morbidity and disease which can be encompassed within a radical radiotherapy treatment volume.
S4 OUTCOME OF PATIENTS OVER SEVENTY YEARS OLD WITH SMALL CELL LUNG CANCER TREATED WITH CHEMOTHERAPY
P. Temblett1, J. Baker1, F. MacBeth2, A.P. Smith1. 1Section of Respiratory Medicine, University of Wales College of Medicine, Llandough Hospital, Cardiff, UK CF64 2XX, UK; 2Velindre Hospital, Whitchurch, Cardiff CF14 2JL, UK
Introduction: Small cell lung cancer (SCLC) accounts for 25% of all newly diagnosed cases of lung cancer over seventy years. No standard treatment is defined for elderly patients with SCLC, and prognosis remains poor.
Methods: We performed a retrospective review of all SCLC cases over 70 years treated with carboplatin and etoposide between 01/01/2000 and 31/12/2001. Prophylactic cranial irradiation (PCI), chest and palliative radiotherapy were used when indicated.
Results: 29 patients were treated, median age 73.7 years, four patients over 80 years. 52% had limited disease. 7% had performance status (PS)=0, 41% PS=1, 35% PS=2, 17% PS=3. The average number of cycles given was 3.27, 55% receiving a dose reduction. PCI and chest radiotherapy was used in 4 patients, 5 patients received palliative radiotherapy. The overall response rate was 65%. Actuarial median survival was 30 weeks (95% CI 22.1–37.9 ), 1 year survival = 23%, 18 month survival = 18%, 2 year survival =10%. Four patients are still alive (range 33 B 121.4 weeks) Febrile neutropenia occurred in 17% and neutropenic death in 10%. 21% of patients received blood transfusions. There were 5 (17%) early deaths (<21 days), 3 of which were neutropenic.
Conclusions: This review confirms that the treatment of unselected SCLC elderly patients with chemotherapy causes significant risks with lower response rates and survival than previously reported. Despite this palliation is achieved in a significant number with prolongation of survival. Co-morbidity and quality of life issues should be carefully considered when treating such patients.
S5 WHAT PERCENTAGE OF PATIENTS WITH LUNG CANCER PRESENT WITH POTENTIALLY CURABLE DISEASE?
P.M. Donnelly, W.J.A. Anderson on behalf of the Northern Board Lung Cancer Group. Regional Cancer Center for the Northern Board, Antrim Hospital, Bush Rd, Antrim BT41 2QB, UK
Background: Since 1995 there has been concern that the 5 year survival of patients suffering from lung cancer in the UK (6–7%) was significantly less than that quoted for America and other western countries (14–15%). This might represent differences in recording, differences in disease or differences in treatment. The aim of this audit was to define the number of patients with curable disease at presentation.
Method: We prospectively filled in audit sheets based on the diagnostic module of he RCP (London) lung cancer data sheets from 1/1/2001–1/5/2002. At the end of the audit period we checked the hospital databases in the catchment area for any additional patients recorded as having lung cancer and retrospectively collected data for these patients.
Results: 175 patients were identified. Patients had a mean age of 70 years (range 43–94). 133 had a pathological diagnosis—27 had small cell tumours and 106 had non small cell tumours. 59 patients were excluded from radical treatment by performance status, a further 62 by stage of disease, a further 15 by inadequate pulmonary function and 8 by other co-morbidity. Thirty-one (16%) remained and were potentially suitable for radical treatment
Conclusion: In this study only 16% of patients were potentially curable at presentation. On the basis of these figures targets for surgical resection rates around 20% seem unrealistic, although with current resection rates running around 10% in the UK there may be some subjects who are suitable for surgery to whom it is not offered. Offering surgery or radical radiotherapy to these patients might result in some improvement in survival.
COPD: Cellular activation and inflammation
S6 RELATIONSHIP BETWEEN BRONCHIAL BIOPSY INFLAMMATORY CELL POPULATIONS AND PHYSIOLOGICAL PARAMETERS IN COPD
I.S. Patel1, N.J. Roberts1, R.J. Sapsford1, M. Sheaff2, J.A. Wedzicha1. 1Academic Unit of Respiratory Medicine; 2Department of Morbid Anatomy, Barts and the London NHS Trust, UK
This study was designed to evaluate the relationships between patterns of bronchial biopsy inflammation and physiological parameters in COPD. Bronchoscopic biopsies were taken from 36 patients with COPD (mean (SD) age 69.5 (8.75) yrs, FEV1 1.36 (0.59) l, FVC 2.6 (0.88) l, FEV1% predicted 54.5 (16.2)%, Pao2 8.8 (1.2) kPa, Paco2 5.4 (0.65) kPa, 46.2 (31.8) pack years of smoking, MRC dyspnoea score 3.06 (1.24), daily inhaled steroid dosage 747 (810) μg, 16 current smokers). Samples were wax embedded and stained for CD3, CD4, CD8, CD68, and EG2 positive inflammatory cells by immunohistochemistry. Intraepithelial CD3 positive cells (per 100 epithelial cells) were related to daily inhaled steroid dosage (rho=0.675, p=0.046) and inversely related to the Pao2 (rho= −0.714, p=0.047). Patients with symptoms of daily dyspnoea had significantly higher numbers of intraepithelial CD3 cells than those without (median (IQR) CD3 cells/100=17 (8.5) versus 9.5 (6.75), p=0.016). Numbers of intraepithelial CD68 positive cells/100 were related to daily inhaled steroid dosage (rho=0.731, p=0.016) and the MRC dyspnoea score (rho=0.815, p=0.007). Patients with symptoms of daily dyspnoea also had significantly higher numbers of intraepithelial CD68 cells than those without (median (IQR) CD68 cells/100 = 9 (7) versus 4 (3), p=0.027). Intraepithelial CD4 positive cells/100 were related to inhaled steroid dosage (rho=0.850, p=0.032). An inverse relationship was seen between numbers of intraepithelial EG2 positive cells/100 and the FEV1% predicted (rho= −0.753, p=0.031). Numbers of EG2 cells per high-powered field also increased with increasing daily inhaled steroid dosage (rho=0.442, p=0.076). No effect on cell numbers was seen with current smoking.
Bronchial wall inflammation in COPD increases with increasing indices of disease severity, as measured by Pao2, FEV1% predicted, inhaled steroid dosage and the symptoms of daily dyspnoea.
Supported by the Joint Research Board, St. Bartholomew’s Hospital.
S7 NEUTROPHILS FROM PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE DEMONSTRATE ENHANCED ENDOTHELIAL CELL INTERACTIONS
I.S. Woolhouse, N. Carrabino, D. Bayley, P.F. Lalor1, D.H. Adams1, R.A. Stockley. Lung Investigation Unit; 1Liver Research Laboratories, Queen Elizabeth Hospital, Birmingham B15 2TH, UK
Chronic obstructive pulmonary disease (COPD) is usually caused by smoking, yet only 10–15% of smokers develop clinically significant disease. Given that neutrophil (PMN) recruitment, and subsequent inflammation, is central to the development of COPD, it is possible that PMN from smokers who develop the disease are primed to migrated from the bloodstream into the lung. The aim of this study was to compare endothelial cell interactions, under flow conditions, and adhesion molecule expression of PMN from non-smokers (NS), smokers without COPD (HS) and patients with COPD.
PMN were isolated from 8 NS, 8 HS and 10 COPD patients. The three groups were age and sex matched, and the mean (SD) FEV1 % predicted were 101.8 (10.9), 97.4 (12.9), and 45.9 (20.9), respectively. Pack year smoking history was similar in the HS and COPD groups (32.1 (10.0) v 47.0 (19.3), p=ns). To assess endothelial adhesion and migration, PMN were perfused at a physiological flow rate over interleukin-1β stimulated human umbilical vein endothelial cells cultured in microslides. Adherent and migrated PMN were counted by phase contrast microscopy. CD11b/CD18 (Mac-1) and CD62l (L-selectin) expression were assessed by flow cytometry. Mean (SE) PMN-endothelial cell interaction results are tabulated in the table.
There were no significant differences in PMN expression of Mac-1 and L-selectin between the three groups.
The data suggest that PMN from smokers who develop COPD are primed to adhere to, and migrate across, vascular endothelium. This appears to be independent of Mac-1 or L-selectin expression. Further work is needed to clarify the mechanism, but the PMN priming seen here in COPD provides a potential target for new therapy.
S8 DIFFERENCES IN AIRWAY NEUTROPHIL NUMBERS, ACTIVATION AND TLR-2 EXPRESSION IN SUBJECTS WITH COPD AND AGE-MATCHED CONTROLS
M.I. Allenby, B. Sempasa, M.W. Lethbridge, J.C. Ratoff, M.W. Jensen, B.J. O’Connor. Department of Respiratory Medicine and Allergy, King’s College London, UK
Rationale: Subjects with COPD have higher numbers of airway neutrophils and these numbers correlate with airflow limitation (Lacoste, et al 1993). The activation status of these neutrophils, and the effect of smoking on this, is unknown. The toll-like receptor family is responsible for innate immune responses against a wide variety of bacterial molecules. Their presence on airway neutrophils has not previously been investigated.
Methods: 15 subjects with COPD and 18 healthy age-matched controls underwent flexible bronchoscopy for collection of bronchoalveolar lavage fluid (BALF). Both groups contained a mix of smokers and ex/non-smokers. A BALF differential cell count was performed. The neutrophils were labelled with fluorochrome-conjugated antibodies against surface markers of activation (CD63, CD14) and the toll-like receptor 2 (TLR-2), and analysed using flow cytometry. The percentage of cells expressing the antibodies was calculated. Statistical analysis was performed using an unpaired t test.
Results: All data are expressed as means (SD). There was an increase in the percentage of neutrophils within the BALF of subjects with COPD when compared with controls (1.644 (1.717) v 0.343 (0.084); p=0.0037) irrespective of smoking status. However, the percentage of CD63+ve neutrophils was significantly lower in current smokers when compared to ex/non-smokers (14.78 (17.06) v 45.64 (22.86); p<0.0001) regardless of airflow limitation. The same was true for CD14+ve neutrophils (11.18 (15.65) v 40.98 (25.78); p=0.0002). Similarly, the percentage of TLR2 expression was reduced in current smokers (10.57 (11.20) v 38.41 (23.80); p=0.0004).
Conclusions: Although airway neutrophils are increased in the lungs of COPD subjects, their activation is related to the smoking status of the subject. The fall in the level of neutrophil activation in smokers may represent an immune suppression or increased recruitment of neutrophils from the circulation.
Work supported by a grant from GKT School of Medicine.
S9 SPUTUM BACTERIAL COLONISATION IN STABLE COPD: ITS INFLUENCE ON AIRWAY INFLAMMATION, HEALTH STATUS, AND FIBRINOGEN
D. Banerjee1 2, D. Honeybourne2, O.A. Khair1. 1Department of Respiratory Medicine, City Hospital NHS Trust, Dudley Road, Birmingham, UK; 2Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
Introduction and aims: It is unclear if the presence of potential pathogenic micro-organisms (PPMs) in the sputum of patients with moderate to severe COPD influences health status and blood fibrinogen levels during the stable clinical state. This study aimed to determine if health status, fibrinogen and bronchial airway inflammation in those harbouring PPMs differ from those who do not (Non-PPMs).
Methods: moderate to severe patients with no recent exacerbations in the last 6 weeks were recruited. Saline sputum induction was performed and markers of airway inflammation (total cell count, neutrophil count, IL-8, LTB4, TNF-α, neutrophil elastase (NE), and neutrophil chemotaxis (NC)—Boyden chamber technique), sputum bacterial culture, health status (SGRQ and SF-36) and blood fibrinogen were measured.
Results: 67 patients were recruited, 69% male, mean age (SD) 66.7 (7.9) years and 27 (40%) were current smokers. 27 (40%) of patients grew PPMs, total number of bacterial isolates 38; H influenzae (14), M catarrhalis (10), S pneumoniae (9) and others (5). There was no significant difference in age, spirometry or smoking pack years between the PPMs and Non-PPMs groups. Those with PPMs had a worse health status score, mean (SD): Total SGRQ 58.7 (14.7) v 47.4 (15.7), p=0.004, SGRQ impact 46.1 (16.1) v 34.1 (17.3), p=0.005, SGRQ symptoms 70.3 (14.8) v 60.5 (21.4), p=0.03, SGRQ activity 76.8 (17) v 63.2 (20.4), p=0.004. SF-36 vitality and physical role limitation were also worse in this group. The PPMs group had an exaggerated airway inflammatory response, mean (SD): sputum supernatant log IL-8 (nM) 0.01 (0.35) v −0.29 (0.47) p = 0.001, Log LTB4 (nM) 0.32 (0.33) v 0.01 (0.40), p=0.008), Log TNF-α (pM) −0.15 (0.78) v −0.78 (0.56), p = 0.001, NE (μM) −1.27 (1.01) v −2.04 (0.52), p = 0.001 and NC (% fMLP) 70.4 (17.1) v 54.6 (19.0), p=0.001. There were increased numbers of sputum neutrophils (absolute count) but this was not statistically significant (p=0.058). Fibrinogen level (g/l) was greater in the PPMs group: 3.21 (0.87) v 2.85 (0.64), p=0.05.
Conclusion: clinically stable moderate to severe COPD patients with sputum PPMs have a worse health status, exaggerated bronchial airway inflammation and a higher blood fibrinogen level.
S10 RELATIONSHIP BETWEEN BRONCHIAL BIOPSY CELL POPULATIONS, EXACERBATION FREQUENCY, AND BACTERIAL COLONISATION IN COPD
I.S. Patel1, N.J. Roberts1, R.J. Sapsford1, M. Sheaff2, J.A. Wedzicha1. 1Academic Unit of Respiratory Medicine; 2Department of Morbid Anatomy, Barts and the London NHS Trust, UK
The effect of exacerbation frequency on bronchial wall inflammation in COPD, and the effect of bacterial colonisation in this context are unknown. Bronchoscopic biopsies were taken from 36 patients with COPD (mean (SD) age 69.5 (8.75) yrs, FEV1 1.36 (0.59) l, FVC 2.6 (0.88) l, FEV1% predicted 54.5 (16.2)%, Pao2 8.8 (1.2) kPa, Paco2 5.4 (0.65) kPa, 46.2 (31.8) pack years of smoking, MRC dyspnoea score 3.06 (1.24), daily inhaled steroid dosage 747 (810) μg, 16 current smokers, median (IQR) 2 (3) exacerbations per year). Samples were wax embedded and stained for CD3, CD4, CD8, CD68, and EG2 positive cells by immunohistochemistry. Lower airway bacterial colonisation was quantitatively assessed by means of protected specimen brushings in 30 patients, of whom 14 were colonised by a potential pathogen. Patients were defined as frequent (≥3 per year) or infrequent (≤ 2 per year) exacerbators. Total numbers of CD3 positive cells per section were related to exacerbation frequency (rho=0.512, p=0.013) and the number of exacerbations in the previous year (rho=0.459, p=0.011). Total CD8 positive cells per high-powered field were related to exacerbation frequency (rho=0.454, p=0.03) and number (rho=0.443, p=0.034). CD4 positive cells per high-powered field also increased with exacerbation number (rho=0.573, p=0.016). CD68 positive cells per high-powered field were related to exacerbation frequency (rho=0.655, p=0.002) and number (rho=0.584, p=0.007), as were numbers of activated eosinophils (rho=0.623, p=0.003 and rho=0.555, p=0.009 respectively). Exacerbation frequency was related to colonisation with a potential pathogen (rho=0.383, p=0.041). The total bacterial count was related to numbers of CD3 cells per high-powered field (rho=0.443, p=0.06) and worsening MRC dyspnoea score (rho=0.597, p=0.007).
Patients with frequent COPD exacerbations show increased numbers of lymphocytes, macrophages and eosinophils in their bronchial biopsies when stable. These cells may contribute to the increased airway inflammation seen in patients with frequent COPD exacerbations, which may also be modulated by the presence of lower airway bacterial colonisation.
Supported by the Joint Research Board, St. Bartholomew’s Hospital.
Smoking cessation, attitudes, and examples
S11 A SURVEY OF PUBLISHED CURRICULUM CONTENT ON SMOKING AND SMOKING CESSATION IN UK MEDICAL SCHOOLS
E.L. Jones, P.J. Rubin, J. Britton. University of Nottingham, UK
Rationale: Cigarette smoking is the single most important avoidable cause of respiratory disease in the UK, and smoking cessation interventions are amongst the most cost-effective interventions available in medicine. We have assessed the extent to which UK medical schools recognise and address smoking as a medical problem in their training programmes by a search of published data on curriculum content.
Methods: We searched printed and electronic information on course content published by UK medical schools for teaching on smoking and smoking cessation, using the keywords “smoking”, “smoking cessation”, “tobacco”, “tobacco control”, and “nicotine” in electronic searches. Content was assessed according to previously defined criteria.1
Results: Of 23 UK medical schools with current students, 9 (40%) make no references to smoking or smoking cessation in their published curriculum material. Most of the references made in the remaining 14 schools relate to the importance of taking a smoking history, and to the occurrence of tobacco-related diseases. Four medical schools (17%) offer optional modules in smoking related issues, four include management of nicotine addiction as part of psychology or public health modules, one included a module on smoking within respiratory medicine, and one included a role-playing smoking cessation session within a Primary Care module. No references were found to teaching on the pharmacology of nicotine addiction.
Conclusions: This study suggests that teaching on the pharmacology and determinants of nicotine addiction, and practical training in the delivery of effective smoking cessation interventions, receive little attention in UK undergraduate medical curricula.
The Department of Health funded this research.
1. Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education.
S12 ATTITUDES OF GENERAL PRACTITIONERS AND PATIENTS TOWARDS SMOKING CESSATION ADVICE IN PRIMARY CARE
J. Cleland, M. Thomas, H. Pinnock, T. Van der Molen. University of Aberdeen, UK
Despite compelling evidence for the effectiveness of smoking cessation advice from a GP, rates of provision of such advice remain persistently sub-optimal (Freeth S. Smoking-related behaviour and attitudes, 1997: a report on research using the ONS Omnibus Survey produced on behalf of the Department of Health. London: The Stationery Office, 1998). Why are GPs not providing routine opportunistic smoking cessation intervention? Previous research on provision of smoking cessation advice has focused mainly on the professional’s perspective. It may be that smokers have quite clear ideas about what approach and/or content they believe would be effective (
). Is there is an area of common ground between GP and patient attitudes where opportunistic interventions could be based, thus maximising the chance of such an intervention being received positively?
This qualitative study aimed to identify and explore barriers to the routine provision of smoking cessation advice by GPs, GP and patient attitudes towards such advice. Individual interviews and focus groups were carried out separately with GPs, smokers, and ex-smokers.
Our results indicate that both GPs and patients think that primary care smoking cessation interventions should be: (a) pertinent to the consultation rather than population-based advice, (b) personalised, linked to specific health benefits for that particular individual, and linked to the individual’s personal timetable of change, (c) positive, emphasising the positive benefits of quitting seems to be the preferred approach, and (d) practical, which includes GPs prescribing NRT and bupropion.
The importance and potential value of linking smoking to the presenting complaint needs to be further researched. Ways of linking information about the relationship of smoking to the patient’s own illness need to be explored. There needs to be rapid access at appropriate times for individuals who may be at a window of opportunity in the cycle of change. The recent development of problem-oriented guidelines for smoking cessation in primary care may encourage GPs to provide such advice and are likely to be more acceptable to patients.
S13 “IF SOMEONE COULD WAVE A MAGIC WAND I’D NEVER SMOKE AGAIN…”—BARRIERS AND MOTIVATORS TO ACCESSING SMOKING CESSATION SERVICES AMONGST SMOKERS IN DEPRIVED AREAS OF NOTTINGHAM
E.L. Jones, A.W.P. Molyneux, M. Anotoniak, J.R. Britton, S.A. Lewis. Division of Respiratory Medicine, City Hospital, University of Nottingham
Rationale: Smoking is the main factor responsible for inequalities in health between rich and poor.1 Although smoking cessation services have been developed in the UK as part of the Tobacco White Paper,2 these services have traditionally failed to reach many of the most deprived smokers.3 Qualitative research methods are an appropriate way to explore the views of smokers who live in deprived areas who have made an attempt to stop smoking but who have not accessed the local smoking cessation services.
Methods: We conducted a postal survey of the most deprived households in Nottingham, and invited respondents who had made an unsuccessful attempt to stop smoking in the last year without using the Nottingham NHS Smoking Cessation Service, to attend focus groups to explore attitudes, experiences, and knowledge of smoking and stopping smoking, attitudes to smoking cessation services and interventions, and barriers and motivators to the access of such services. Group discussions were recorded and transcribed and a line-by-line analysis was undertaken to allow themes and categories to emerge from the data.
Results: Most participants started smoking in their teens and felt highly addicted to nicotine. All were aware of the risks of smoking and had tried to quit smoking, many on multiple occasions, but knowledge of smoking cessation interventions and their effectiveness was poor. Barriers to the access of smoking cessation services—such as cost, timing, childcare, lack of appropriate information, perceived ineffectiveness, and negative publicity—were explored. Novel approaches to the management of nicotine addiction were discussed, including parallels with drug and alcohol addiction treatments, brain surgery, in-patient quit attempts, “staining” cigarettes and government subsidy for complementary therapies.
Conclusions: Deprived smokers are highly addicted, have a poor perception of the availability and efficacy of smoking cessation interventions and are unlikely to access services unless these barriers are broken down.
Funded by the New Leaf, Nottingham NHS Smoking Cessation Service.
1. Acheson D. Independent inquiry into inequalities in health. London: The Stationery Office, 1998.
2. Department of Health. Smoking kills: a white paper on tobacco. London, 1998.
3. Jarvis MJ. The tobacco epidemic. Basel: Karger, 1997:151–64.
S14 EXAMPLE OF AN EFFECTIVE SMOKING CESSATION SERVICE WITHIN A PRIMARY AND SECONDARY CARE TRUST
A. Burgoyne, A. Graham, M. Babores. East Cheshire NHS Trust, UK
Smoking is the nation’s single greatest cause of preventable illness and early death. More than 120 000 people a year in the UK die from smoking related diseases and it costs the NHS 1.7 billion each year. In April 2000, funding was allocated from South Cheshire Health Authority which supported the development of a locally based smoking cessation service in east Cheshire for the following two years—£suppl_ for year one and £18 500 for year two.
A multidisciplinary team was responsible for the co-ordination and development of the smoking cessation service in east Cheshire with representatives reporting to the Eastern Cheshire Primary Care Group (Trust) and the NSF CHD Local Implementation Team. These services were based in the Primary and Secondary health care settings delivering a standard rolling 6–8 weeks programme. This included one to one or group support, counselling from a trained smoking cessation adviser, provision of Nicotine Replacement Therapy and Bupropion where appropriate.
Targets set were 650 smokers setting quit dates over two years. Actual targets achieved doubled with 1190 smokers setting a quit date. Of those 612 (52%) were not smoking at 4 weeks with CO validation, 244 (20%) relapsed and 334 were lost to follow up (28%). Twelve months follow up rates are to be reported in August 2002.
Monitoring data supports the continuation of a smoking cessation service in east Cheshire. Planning for long term funding needs to be identified. Maintaining smoking cessation as a priority for health interventions is vital. Continued development and co-ordination of smoking cessation services will be required to meet increasing public and professional demand.
S15 12 MONTH QUIT RATES OF A “SPECIALISED” HOSPITAL BASED SMOKING CESSATION SERVICE
S. Brown, R.M. Angus, I. Davies. Aintree Chest Centre, University Hospital Aintree, Liverpool L9 7AL, UK
It is reported that intensive behavioural support plus Nicotine Replacement Therapy (NRT) or Bupropion enables about 20% of smokers to stop long term, compared to 5% from brief advice from a General Practitioner.1 Quit rates in those with established smoking related diseases are surprisingly lower than those in “healthy smokers”. We established a hospital-based smoking cessation service for smokers with respiratory disease. Patients are offered one-to-one counselling with frequent structured advice and regular support. NRT and/or Bupropion can be prescribed as required. All quit results were validated by expired air CO (carbon monoxide). From April 2001 to March 2002, 337 patients were referred into the service. Fifty nine (16%) did not attend their first appointment and 40 (12%) were not motivated to quit at the time of referral. Two hundred and thirty eight (71%) set quit dates and the following are the results of these 238 patients. Mean (SD) age 57 (9) years, 135 (57%) female. Two hundred and nine (88%) had previously tried to quit. Diagnoses were as follows: COPD 107 (45%), asthma 58 (24%), bronchiectasis 14 (6%), lung cancer 13 (5%) and “other” 46 (19%). Patients used the following pharmacological support: NRT patches 107 (45%), Bupropion 41 (17%), NRT inhalator 37 (16%), NRT gum 10 (4%), and NRT lozenge 7 (3%). Thirty six (15%) used willpower alone. Of 238 patients 147 (62%) reached a 4 week quit, 81 (55%) female. Thirty nine (16%) patients were lost to follow up. Quit results at 6 months were 49/102 (48%), with 19 (19%) lost to follow up and at 12 months were 18/24 (75%) with 3 (13%) lost to follow up. Of the 18 patients that were continuously abstinent at 12 months, 11 (61%) were female and products used were Bupropion 7 (39%), NRT patches 7 (39%), and willpower alone 4 (22%). These results compare favourably to recent Department of Health figures for smoking cessation services in the UK, where it was quoted that quit rates of around 20% at the 12 month follow up should be expected.2 This demonstrates the value of targeting thoracic patients in specialist smoking cessation services in the UK.
1. World Health Organisation. The case for commissioning smoking cessation services. London, 2001.
2. Department of Health. New NHS Smoking Cessation Services. London: Stationery Office, 1999.
Sleep: New outlooks
S16 THE UPPER AIRWAY IN PREGNANCY AND PRE-ECLAMPSIA
B. Izci1, R.L. Riha1, S.E. Martin1, M. Vennelle1, W.A. Liston2, K. Dundas2, A. Calder2, N.J. Douglas1. 1Edinburgh Sleep Centre, University of Edinburgh, UK; 2Department of Reproductive and Developmental Sciences, University of Edinburgh, UK
Background: Snoring is common in pregnancy and snoring pregnant women have increased rates of pre-eclampsia. Patients with pre-eclampsia have an increased rate of upper airways (UA) narrowing during sleep which may contribute to their blood pressure elevation.
Aims: To compare upper airway dimensions in pregnant and non-pregnant women and in patients with pre-eclampsia.
Method: 50 women in the 3rd trimester of pregnancy and 37 women with pre-eclampsia were recruited consecutively from the antenatal service and matched with 50 non-pregnant women. UA dimensions were measured using acoustic reflection. Comparisons were by analysis of variance and Student-Newman-Keuls tests.
Results: The pregnant, pre-eclamptic, and non-pregnant women did not differ in terms of age or height, or in pre-pregnant weight or body mass index. 14% of non-pregnant, 28% of pregnant, and 75% of pre-eclamptic women reported they snored (p<0.001). Oropharyngeal junction area (OPJ) in the supine position was narrower in pregnant than non-pregnant women (1.0 SD 0.1, 1.1 SD 0.1cm2; p=0.05) and smaller yet in pre-eclamptics (0.8 SD 0.1 cm2; p<0.05). Seated OPJ was narrower (p<0.05) in the pre-eclamptics (1 SD 0.1cm2) than either controls(1.2 SD 0.1cm2) or pregnant women (1.3 SD 0.1cm2).
Conclusions: Upper airways are narrower during the third trimester of pregnancy, and women with pre-eclampsia have further airway narrowing. This could result from a combination of FRC reduction due to the pregnancy and generalised oedema. These changes could contribute to the increased snoring in pregnancy, and to the upper airways resistance episodes during sleep in pre-eclampsia which may further increase blood pressure.
Study supported by the Cunningham Trust.
S17 BRAIN fMRI ACTIVATION AND EVOKED POTENTIALS DURING VISUAL STIMULATION AND VISUO-MOTOR TRACKING IN NORMAL SUBJECTS BEFORE AND AFTER SLEEP DEPRIVATION
G.V. Robinson1, R.C. Miall2, P.M. Matthews3, E.M. Jones1, J. Winter2, J. Stein2, J.R. Stradling1, R.J.O. Davies1. 1Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK; 2University Laboratory of Physiology, Oxford, UK; 3FMRIB Centre, John Radcliffe Hospital, Oxford, UK
Patients sleep deprived by obstructive sleep apnoea (OSA) have a 4–7 fold increased motor accident rate. This is associated with impairment on tasks that test vision and tracking, including simulated steering tests (
). The neural explanation for this is unknown.
Methods: Using a previously developed paradigm (
), we have assessed the brain functional magnetic resonance imaging (fMRI) activation patterns in normal subjects during pure visual stimulation and during performance of coordinated hand/eye tracking manoeuvres, before and after 28–32 hours total sleep deprivation (TSD). Evoked potentials to a potent visual stimulus were also recorded from the occipital cortex.
After pre-training, 10 normal subjects (7M, 3F, mean age 27) underwent fMRI imaging, while looking at an alternating chequerboard (pure visual stimulus) and while performing the visual tracking paradigm (visuo-motor stimulus). Subjects were assessed at baseline after normal sleep. Further assessments were performed, in random order, after normal sleep and 28–32 hours of actigraphy monitored TSD and stimulant abstinence. 4 subjects also had occipital visual evoked potentials (VEPs) recorded.
Results: Following normal sleep, the expected brain areas were activated on fMRI by both tasks. Tracking performance was significantly impaired by TSD (mean tracking error 114.3 SD 49.1 after normal sleep, 219.7 SD 47.6 after TSD, p<0.0001, paired t test). During the chequerboard (pure visual stimulus), TSD increased brain activation in the primary visual cortex, precuneus and left prefrontal areas, but decreased activation in the extra striate visual cortex. The VEP studies confirmed a neural basis for this reduced brain activation. During the tracking (visuo-motor) task, TSD lead to reduced cerebellar and premotor activation, with unchanged primary motor cortex activation.
Conclusion: TSD in normal subjects impairs tracking. This is associated with activation of neural centres that may be associated with vigilance maintenance (prefrontal cortex and precuneus) and depression of visual association areas and secondary motor centres.
S18 PLATELET ACTIVATION IS INCREASED IN OBSTRUCTIVE SLEEP APNOEA AND DOES NOT FALL WITH CPAP TREATMENT
G.V. Robinson1, J.C.T. Pepperell1, H. Segal2, B. Langford1, R.J.O. Davies1, J.R. Stradling1. 1Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK; 2Oxford Haemophilia and Thrombosis Unit, Churchill Hospital, Oxford, UK
Obstructive sleep apnoea (OSA) is an independent risk factor for hypertension and arterial thrombotic disease (
). The increased cardiovascular risk is probably multifactorial, and related to insulin resistance and endothelial dysfunction, in addition to hypertension (the increased incidence of which in OSA is now well established). Platelets have a central role in the pathogenesis of acute cardiovascular syndromes, and platelet activation is associated with increased cardiovascular risk in normals (
). The influence of OSA on platelet function is not clear.
Methods: 94 male subjects mean (SD) age 48 (11) with OSA defined as ≥10 oxygen saturation dips ≥4% per hour (actual dip rate 42.5 (23.0)) and an Epworth sleepiness score (ESS) ≥10 (actual ESS 15.7 (3.0)) were randomised to one month’s treatment with therapeutic or sub-therapeutic (∼1cm water pressure) continuous positive airways pressure (CPAP) treatment. Plasma levels of soluble P-selectin (sP-sel), a marker of chronic platelet activation, were measured by ELISA before and after treatment. 22 unmatched normal subjects were used to establish a normal range.
Results: sP-sel was higher in the untreated OSA patients than in the normal subjects (OSA patients 55.4 ng/ml (37.3), normal subjects 29.5 ng/ml (10.5), p<0.0001, unpaired t test). No significant fall in sP-sel was seen following one month’s treatment with either therapeutic or sub-therapeutic CPAP: therapeutic CPAP, pre treatment 58.3 ng/ml (41.9), post treatment 54.0 ng/ml (35.5), p>0.4, paired t test; sub-therapeutic CPAP, pre treatment 52.5 ng/ml (32.1), post treatment 45.4 ng/ml (22.7), p>0.1, paired t test.
Conclusion: OSA may cause increased platelet activation, which does not fall with one month’s CPAP treatment. This is likely to be a further contributor to the increased vascular morbidity of OSA, which is not improved with one months standard OSA treatment.
S19 THE MULTIDIMENSIONAL FATIGUE INVENTORY (MFI-20) IN OBSTRUCTIVE SLEEP APNOEA (OSA): EFFECTS OF NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
N. Wiltshire, F. Buchanan, A. Harper, J.R. Catterall, A.H. Kendrick. Sleep Unit, Department of Respiratory Medicine, Bristol Royal Infirmary, Bristol, UK
We have shown that the MFI-20 provides useful additional information to the Epworth Score (ESS) and SF-36 in patients with OSA, and separates sleepiness and fatigue (
Aim: To assess the response of the MFI-20 in a CPAP naïve patients and to compare this with data from the ESS and the dimensions of the SF-36.
Methods: Patients were given the ESS, SF-36 and MFI-20 questionnaires before and at the end of a 4 week trial of CPAP as part of our clinical management of patients with OSA. Data are given as median (range).
Results: 50 patients (6F), age 54.5 yr (27–80) and Body Mass Index 31.8 kg.m-2 (22.8 to 52.6) were studied. The results are summarised in table 1.
At the end of the trial and using a cut-off of 10 for each MFI-20 dimension and for ESS, 16/50 had a MFI-20 GH >10, 17/50 had an MFI-20 PH >10 and 20/50 had an MFI-20 RA >10 indicating significant fatigue problems remain in the absence of daytime hypersomnolence. The relation between changes in ESS and MFI-20 are shown in table 2.
Conclusion: The MFI-20 is a simple self-completion questionnaire that provides useful additional information to that obtained from the ESS and the SF-36 and separates out sleepiness and fatigue pre and post CPAP.
S20 MODAFINIL IMPROVES WAKEFULNESS AND OVERALL CLINICAL CONDITION AS ADJUNCTIVE THERAPY FOR RESIDUAL EXCESSIVE SLEEPINESS IN OBSTRUCTIVE SLEEP APNEA: A 12 WEEK RANDOMISED TRIAL
A. Williams and the Modafinil OSA study group. Sleep Disorders Centre, St. Thomas’s Hospital NHS Trust, UK
Objective/Methods: A 12 week, randomised, double-blind, placebo-controlled study was conducted to assess the efficacy and safety of modafinil as adjunctive therapy for residual excessive sleepiness in patients with obstructive sleep apnea (OSA) treated with nasal continuous positive airway pressure (nCPAP). Patients were randomized to receive placebo, modafinil 200 mg once daily, or modafinil 400 mg once daily. Modafinil was initiated at 100 mg/d and titrated to 200 or 400 mg/d within 1 week. Key outcomes included changes from baseline in objective (Maintenance of Wakefulness Test [MWT]) and subjective (Epworth Sleepiness Scale [ESS]) measures of wakefulness and patients’ overall clinical condition (Clinical Global Impression of Change [CGI-C]) at Week 12. Secondary efficacy measures included changes from baseline in MWT, ESS, and CGI-C at Weeks 4 and 8. nCPAP use and adverse events were monitored.
Results: A total of 3 23 randomised patients received treatment (placebo: n=108; modafinil 200 mg/d: n=109; modafinil 400 mg/d: n=106). Modafinil significantly improved patients’ ability to sustain wakefulness on the MWT at Week 12 (increases of 1.6 min for modafinil 200 mg/d and 1.5 min for modafinil 400 mg/d) compared with placebo (decrease of 1.1 min; p<0.0001). Modafinil treatment also significantly improved wakefulness as measured by the ESS scores: a 4.5-point decrease in ESS score was observed with modafinil compared with a 1.9-point decrease with placebo at Week 12 (p<0.0001). Modafinil significantly improved patients’ overall clinical condition at Week 12, as measured by the CGI-C (p<0.0001). Modafinil had no effect on nCPAP use or nighttime sleep. Modafinil was associated with significant improvements in wakefulness and clinical condition at Weeks 4, 8, and 12. Headache (12%; 26%), nausea (2%; 11%), and anxiety (2%; 8%) were the most common adverse events occurring in the placebo and modafinil treatment groups, respectively.
Conclusions: Adjunct modafinil therapy significantly improves wakefulness and overall clinical condition and is well tolerated in patients with OSA who have residual sleepiness despite treatment with nCPAP.
Pulmonary hypertension: Clinical issues
S21 PULSE PRESSURE PREDICTS MORTALITY IN PULMONARY ARTERIAL HYPERTENSION
J.D. Chalmers1, R. Syyed2 , V. Impey1, A. Peacock2. 1University of Glasgow; 2Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow, UK
Introduction: It is known that mean pulmonary artery pressure predicts survival in pulmonary hypertension. Following the Framingham heart study, it was shown that pulse pressure (PP) outperformed mean arterial, systolic and diastolic pressures as predictors of mortality in systemic hypertension. We wished to discover if this held true for the pulmonary circulation.
Methods: We retrospectively reviewed all the patients with Pulmonary hypertension who had been studied between 1996 and January 2002. 80 patients had Pulmonary hypertension (PHT). Of the 80 patients 19 (11 female, 8 male) had PPH, 18 (10 female, 8 male) had thromboembolic disease, 17 (13 female, 4 male) had connective tissue disease, 10 (8 female, 2 male) had COPD, 10 (8 female, 2 male) had Eisenmengers, 3 (2 female, 1 male) had porto-pulmonary hypertension, 2 (2 female) had valvular heart disease and 1 (1 female) had Sarcoidosis. Haemodynamic variables as well as performance status and medical history were examined. Kaplain Meier Survival curves and regression analysis were used to determine correlation between variables and survival.
Results: PP against survival produced a correlation coefficient (r) of −0.76 (p<0.001) and Kaplain Meier survival curves revealed a 100% probability of survival at 2 years for PP<30 mmHg compared to 85% probability of survival for PP 30–40 and 46% for PP greater than 40.
No other variable predicted survival with this accuracy.
Conclusion: Pulse pressure is a powerful predictor of mortality in all causes of pulmonary hypertension. No other variables proved superior to pulse pressure, regardless of underlying diagnosis.
S22 LONG DURATION OF BREATHLESSNESS AT DIAGNOSIS IS ASSOCIATED WITH LONGER SURVIVAL IN PPH: A CLINICAL PARADOX
V. Impey, A. Peacock1. University of Glasgow, Glasgow G12 8QQ, UK; 1Scottish Pulmonary Vascular Unit, Western Infirmary, Glasgow G11 6NT, UK
Introduction: Previous studies have shown that breathlessness predicts survival. It is widely believed that a longer duration of breathlessness is related to a worse prognosis, probably due to slower time to diagnosis. We expected to confirm this supposition in our data series but found the reality to be the opposite. We have previously found cardiac index (CI) to be an important predictor of survival so we correlated duration of breathlessness and CI.
Methods: We examined admission data in all our patients with PPH. We included demographic variables (sex, age) medical history (duration of breathlessness, NYHA class), haemodynamic data (mean pulmonary artery pressure, cardiac index). Kaplan-Meier (KM) survival curves and regression analysis were used to examine the correlation between these variables and survival.
Results: For our 25 patients with PPH, the probability of survival at 12 months after diagnosis was 100% for those 8 patients with a history of breathlessness >3 years and 51% for those with breathlessness <3 years (13 patients). There was also a positive correlation coefficient of 0.6 between cardiac index and duration of breathlessness (we excluded 2 patients with breathlessness longer than 6 years as outliers).
Conclusion: A longer duration of symptoms at diagnosis may represent a slower progression of disease and better survival prospects, reflected by the improved cardiac index.
S23 SCREENING FOR EARLY PULMONARY ARTERIAL HYPERTENSION IN PATIENTS WITH SYSTEMIC SCLEROSIS (SScPAH): RATIONALE FOR AN INVASIVE APPROACH
D. Mukerjee, D. St George, J. Davar, C.M. Black, J.G. Coghlan. Departments of Rheumatology and Cardiology, Royal Free Hospital, Pond Street, London NW3 2QG, UK
Aims: To document the accuracy of echocardiography to identify early pulmonary hypertension (PHT) in a high-risk Systemic Sclerosis (SSc) cohort, we identified 140 patients who have had echo and cardiac catheter within ±3 months of either investigation. Previous studies have documented under-estimation of echo-estimated tricuspid gradient (TG) compared to catheter results, with only a few studies reporting echo over-estimation of this parameter.
Method: Echo-estimated TGs and the catheter-measured TGs were correlated and a linear regression was derived to predict catheter-measured mean Pulmonary Artery Pressures (mPAPs) from echo estimated TGs.
Results: N=140, (F:M=119:21), mean age=56 (7) years. Haemodynamic parameters: mPA Systolic Pressure=47 mmHg, mPA diastolic Pressure=18 mmHg, mPAP=34 mmHg, mRAP=4 mmHg, mean echo estimated TG=42 mmHg. Echo-estimated TG showed a positive correlation with catheter-measured TGs in 140 patients (r2=0.44, p<0.005). By linear regression, echocardiography was sufficiently accurate at moderate/ high pressures (echo TG >45 mmHg) identifying >80 % of patients correctly. In contrast, at lower pressures where early diagnosis is critical, echo was less accurate—it both under-estimated the catheter-measured mPAPs in 30% and over-estimated the catheter-measured mPAPs in 32% of cases. The latter inaccuracy may lead to a potential for over-diagnosis in unaffected patients.
Conclusions: Though echo accurately identified a poor prognostic group of PHT patients (mPAP >35 mmHg on cardiac catheter), reliance on the present technique to accurately identify early PHT in an “at risk” SSc cohort is inadequate. In its current form, echo-estimated TGs demonstrate a tendency to both under and over-estimation at the lower end of the spectrum of pulmonary artery pressures—with the subsequent risk of exposing a patient with either no or mildly elevated pulmonary pressures to over-investigation. This latter finding is particularly relevant when applied to low prevalence PHT populations where the false positive rates are proportionately higher and in such scenarios the accuracy of echo is further diminished.
S24 THE UTILITY OF D-DIMERS AND OTHER PREDICTORS OF PULMONARY EMBOLI IN A LARGE SERIES FROM A DISTRICT GENERAL HOSPITAL
S.A. Evans, S.C. Ward, M. Jarral, R.J. Clark, J. Langham-Brown, T. Fail, P. Featherstone, P. Schmidt. Portsmouth Hospitals Trust, UK
Previous studies suggest that a negative D-dimer can have a negative predictive value (NPV) for objectively diagnosed pulmonary emboli (PE) of 99 % (
). A pilot study in our hospital comparing bed side and laboratory SimpliRED and a ELISA D-dimer assays for DVT gave NPV=s of between 69% and 76 %.
We have used 4 parameters to assess the pre-test probability of PE: (a) D-dimers (SimpliRED, performed on the ward), (b) Respiratory rate (RR) > 20/minute (c) Pao2 on air of <10.7kPa, (d) Important risk factors from the history i.e. surgery/trauma, malignancy, cardiovascular disease, previous PE/DVT, post-partum, immobilisation, and hereditary thrombotic disorders.
These were prospectively evaluated in 521 patients who were investigated for suspected PE. Assessment was incomplete in 101 cases, leaving 420 cases for analysis. Those with a normal CXR and no chronic lung disease initially had a perfusion (Q) scan (n=297). Leg dopplers (n=95) were performed on those with an abnormal CXR, chronic lung disease or an indeterminate Q scan. CT pulmonary angiograms were requested on those with negative or indeterminate leg dopplers (n=51). 27 patients had features of a massive PE and were investigated with urgent CT angiogram or an echocardiogram.
PE was confirmed in 131 patients, excluded in 289. The NPV of a D-dimer was 83%, a RR <20 90%, a Pao2>10.7kPa 83%, and absent clinical risk factor(s) 81%. Logistic regression gave RR high odds ratios and suggested that Pao2 added little to the other 3 parameters. A combination of no risk factor and a RR<20 gave a risk of objectively confirmed PE of <5% irrespective of the D-dimer result and the Pao2.
We conclude that negative D-dimer results are best used in conjunction with other predictors to exclude PE.
S25 OUTCOME AFTER PULMONARY THROMBOENDARTERECTOMY FOR CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION
F. Reichenberger, J. Pepke Zaba, D. Hodgkins, A. Vuylsteke, K. McNeill, J. Dunning. Papworth Hospital, Cambridge, UK
Pulmonary thromboendarterecomy (PTE) is the treatment of choice in chronic thromboembolic pulmonary hypertension (CTEPH) with proximal vascular obstructions. However PTE is associated with a significant perioperative risk. Over the last 5 years, 100 patients (50 male, 50 female, mean age 53 (18–81) years) underwent PTE at Papworth Hospital. 71 patients survived the procedure, whereas 29 died postoperatively: 10 due to reperfusion oedema, ARDS, or bronchopulmonary infections despite significant improved haemodynamics, 12 had incomplete clearance of vascular obstruction with additional peripheral vascular obstructions, 3 were misdiagnosed preoperatively (PPH, peripheral CTEPH, advanced pulmonary artery sarcoma). Four patients developed surgical complications. The quartile distribution of the outcome is shown below. Evaluating preoperative factors that influenced perioperative outcome, the surviving patients had a significantly higher 6 minute walking distance (268 v 194 metres, p<0.01), and higher cardiac index (1.8 v 1.5 l/min/qm, p<0.01) compared to the non-survivors, whereas right atrial and pulmonary artery pressures were similar in both groups. At our institution, experience within the recently established PTE programme shows a learning curve associated with a significant improvement in the postoperative outcome in this high risk patient population.
S26 THE USE OF NEBULISED ISOTONIC MAGNESIUM SULPHATE AS AN ADJUVANT TO SALBUTAMOL IN THE TREATMENT OF SEVERE ASTHMA IN ADULTS
R.J. Hughes1 3, A.L. Goldkorn2, M. Masoli3, M. Weatherall2, C. Burgess2, C.R.W. Beasley3. 1Greenlane Hospital; 2Wellington School of Medicine; 3Medical Research Institute of New Zealand, New Zealand
Background: Intravenous magnesium has been shown to cause significant bronchodilation in the treatment of severe asthma, however its effect by the nebulised route is uncertain. In this study we assessed the efficacy of isotonic magnesium sulphate as an adjuvant to nebulised salbutamol in severe asthma.
Methods: We enrolled 52 subjects with severe exacerbations of asthma (FEV1 <50% predicted) presenting to the Emergency Departments at two hospitals in New Zealand. In this randomised double-blind placebo-controlled trial subjects received nebulised salbutamol (2.5 mg) mixed with either 2.5 mL of isotonic magnesium sulphate or isotonic saline on three occasions at 30 minute intervals. The primary outcome measures were FEV1 at 90 minutes and requirement for admission.
Results: The mean FEV1 in both groups at randomisation was similar (1.24 litres, 31.9% predicted v 1.20 litres, 31.8% predicted, p=0.73). Subjects who received nebulised salbutamol with the magnesium adjuvant achieved a greater improvement in FEV1 (0.72 v 0.35 litres, difference 0.37 litres, p=0.004) when compared with nebulised salbutamol with the saline adjuvant. A corresponding reduction in requirement for admission (relative risk 0.61, confidence interval 0.37 to 0.99) was demonstrated. The greatest difference between the two regimens occurred in those individuals presenting with life-threatening exacerbations, defined by an FEV1 of less than 30% predicted (increase in FEV1 0.83 v 0.18 litres, difference 0.75 litres, p<0.0001).
Conclusions: The use of isotonic magnesium as an adjuvant to nebulised salbutamol results in an enhanced bronchodilator response in the treatment of severe asthma.
S27 GLUCOCORTICOID RECEPTOR ACTIVATION IN INDUCED SPUTUM FOLLOWING INHALED LONG-ACTING β2-AGONIST AND GLUCOCORTICOID TREATMENT
O.S. Usmani, K. Maneechotesuwan, I.M. Adcock, P.J. Barnes. Department of Thoracic Medicine, National Heart and Lung Institute, Imperial College School of Medicine, London, UK
The clinical evidence is well established for the complementary effects of inhaled long-acting β2-agonists (LABA) and glucocorticoids (GC) on asthma control. Recent in vitro data suggest the molecular mechanisms may involve enhanced glucocorticoid receptor (GR) nuclear translocation, as LABA have been shown to induce ligand-independent GR translocation. GC activate GR which translocate to the nucleus and bind to DNA to regulate the expression of GC-sensitive target genes, or to coactivators to switch off inflammatory genes. The aim of our research was to develop a model using cells relevant to airway disease, to test the hypothesis that inhaled LABA were able to modulate the intracellular partitioning of GR in vivo.
We previously described a semi-quantitative method to identify GR subcellular expression in induced sputum cells using immunocytochemistry, and showed ligand-induced GR activation in this model. Six healthy subjects inhaled beclomethasone dipropionate (800μg) once, and sputum was induced at 0, 30, 60,120mins post-inhalation. We observed significant GR translocation (71%) at 60mins post GC inhalation compared to baseline (30%) (p<0.05). Using this information on the optimal time point for GR activation, we describe here the effects of LABA and GC in asthmatics.
Seven steroid-naïve asthmatics inhaled single doses of fluticasone propionate (FP)-100μg, FP-500μg, salmeterol (SALM)-50μg & combination FP/SALM 100/50μg on separate visits. Dose dependent GR activation was observed following FP; FP-100 (47%), FP-500 (61%) where the higher dose was significant v placebo (31%) (p<0.05). SALM alone achieved 43% GR translocation, but as combination therapy, SALM was able to augment the action of FP on GR translocation (54%) (p<0.05).
We have shown it is possible to use induced sputum to investigate the molecular effects of inhaled drug therapy. Our data support the proposition that GR nuclear translocation may underlie the complementary effects of LABA and GC. The precise signal transduction mechanisms remain unknown, but LABA may prime inactive GR through phosphorylation, and subsequently GR may require less GC for nuclear translocation. We now aim to research this hypothesis, as it may identify biochemical targets for future therapeutic modulation.
S28 DOSE-RESPONSE RELATION OF INHALED BUDESONIDE IN ADOLESCENTS AND ADULTS WITH ASTHMA
M. Masoli, S. Holt, M. Weatherall, R. Hughes, R. Beasley. Medical Research Institute of New Zealand.
Objective: To examine the dose-response relation of inhaled budesonide in adolescents and adults with asthma.
Design: Meta-analysis of placebo controlled, randomised clinical trials that presented data on at least one outcome measure of asthma and that used at least two doses of budesonide, delivered by turbuhaler twice daily.
Setting: Medline, Embase, and Astra-Zeneca’s internal clinical study registers.
Main outcome measures: FEV1, morning and evening peak expiratory flow, β-agonist use, withdrawals and exacerbations of asthma leading to withdrawal.
Results: Three studies of 1013 adolescents and adults with moderately severe asthma, met the inclusion criteria for the meta-analysis. Only one study examined doses >800 μg/day and no studies examined doses >1600 μg/day. A negative exponential model for the data, without meta-analysis, indicated that 80% of the benefit at 1600 μg/day was achieved at doses of 250–350 μg/day and 90% by 350–500 μg/day. A quadratic meta-regression showed that the maximum effect was obtained with doses of around 1000 μg/day. Comparison of the standardised difference in FEV1 for an inhaled dose of 400 μg/day against higher doses showed a difference in FEV1 of 0.03 of a standard deviation (−0.153 to 0.213). It was not possible to undertake a meaningful statistical analysis of withdrawals, however examination of individual study data indicated that most of the benefit with respect to reduction in asthma exacerbations leading to withdrawal was achieved with a dose of 400 μg/day.
Conclusions: Determination of the dose-response relation of budesonide was limited by the lack of individual patient data, the paucity of studies reporting the effect of doses of >800 μg/day and insufficient withdrawal data. However, utilising the available published data, most of the therapeutic benefit of budesonide delivered by the turbuhaler device was achieved with a total daily dose of 250–500 μg/day, and the maximum effect at around 1000 μg/day, in adolescents and adults with asthma. These findings are consistent with the recently determined dose-response relation of fluticasone propionate, assuming a potency ratio of 1:2. We recommend that national and international consensus guidelines and formularies are modified to ensure that they are consistent with the published data from which the therapeutic dose-response range of inhaled corticosteroids has been derived.
S29 DOSE-RESPONSE RELATION OF INHALED FLUTICASONE PROPIONATE IN CHILDREN WITH ASTHMA—A SYSTEMATIC REVIEW OF ITS EFFICACY AND ADRENAL EFFECTS
M. Masoli, M. Weatherall, S. Hold, R. Beasley. Medical Research Institute of New Zealand
Objective: To examine the dose-response relation of inhaled fluticasone propionate for both efficacy and adrenal function in children with asthma.
Design: Analysis of placebo-controlled randomised clinical trials of fluticasone in children of at least 4 weeks duration, that used at least one dose of fluticasone, and that presented data on at least one clinical outcome measure of asthma or at least one sensitive measure of adrenal function.
Setting: EMBASE and Medline.
Main outcome measures: FEV1, morning and evening peak expiratory flow, night awakenings, β-agonist use, major exacerbations leading to withdrawal, 12 or 24 hour urinary cortisol, peak plasma cortisol post-stimulation.
Results: Five studies of 1150 children with asthma met the inclusion criteria for efficacy, with no studies examining doses >200 μg per day. The dose-response curve for each outcome measure suggested that the response began to plateau between a dose of 100 and 200 μg per day. The odds ratio for patients remaining in a study at a dose of 100 μg, compared with 200 μg was 0.8 (95% CI 0.46 to 1.37).
Three studies of 523 children with asthma met the inclusion criteria for assessment of adrenal function with no studies examining doses >200 μg per day. A meta-analysis could not be undertaken as the data was not presented in an appropriate format. The largest study of 437 children reported no difference in 24 hour urinary cortisol between placebo and fluticasone at doses of 100 and 200 μg per day. However, the two smaller studies demonstrated evidence of a reduction in urinary cortisol at these doses.
Conclusions: There is insufficient data to determine the dose-response relation of fluticasone in children at doses >200 μg per day. The dose-response curve for fluticasone appears to plateau between 100 and 200 μg per day for efficacy; there was weak evidence of adrenal suppression at these doses. Pending formal studies which determine the dose-response relation of fluticasone in greater detail, we recommend that fluticasone should be routinely prescribed in children with asthma in doses of up to 200 μg per day.
S30 STEPPING DOWN INHALED CORTICOSTEROIDS IN ASTHMA: A RANDOMISED CONTROLLED TRIAL
G. Hawkins1, A.D. McMahon2, S. Twaddle3, S.F. Wood1, I. Ford2, N.C. Thomson4. 1Department of General Practice, University of Glasgow, UK; 2Robertson Centre for Biostatistics, University of Glasgow, UK; 3Stobhill Hospital, Glasgow, UK; 4Department of Respiratory Medicine, University of Glasgow, UK
Background: In an attempt to optimise the therapeutic action of inhaled corticosteroids whilst minimising their side effects, asthma management guidelines recommend that a reduction in the dose of inhaled corticosteroid is undertaken when asthma is stable.1 We aimed to determine whether a 50% reduction in the dose of inhaled corticosteroid could be undertaken in patients with chronic stable asthma, whilst maintaining control.
Methods: We recruited 259 adult asthmatics receiving regular treatment with high-dose inhaled corticosteroids (mean daily dose = 1430 mcg beclomethasone dipropionate ) to a one-year, randomised, double-blind, parallel group trial. Patients were allocated to receive either no alteration to their inhaled corticosteroid dose (control) or a 50% reduction in their dose if they met criteria for stable asthma (step-down). We compared asthma exacerbation rates, asthma related general practice and hospital visits, quality of life measures and corticosteroid dose between the two groups.
Findings: We found no significant difference in the asthma exacerbation rate between the two groups (step-down=31%, control=26%, p=0.354). Similarly, there were no significant differences in the numbers of general practice or hospital visits, or in disease specific and generic measures of health status over the one-year period. On average, the step-down group received 348 mcg (95% CI 202 to 494) of beclomethasone dipropionate less per day than the controls with no difference in the annual dose of oral corticosteroids between the two treatment regimes.
Interpretation: Our study provides convincing evidence that it is possible to step down high dose inhaled corticosteroids in patients with chronic stable asthma, without compromising asthma control.
1. The British Guidelines on Asthma Management: 1995 Review and Position Statement.
S31 A PLACEBO CONTROLLED COMPARISON OF FORMOTEROL, MONTELUKAST OR HIGHER DOSE OF INHALED CORTICOSTEROIDS IN SUBJECTS WITH SYMPTOMATIC ASTHMA DESPITE TREATMENT WITH LOW DOSE INHALED CORTICOSTEROIDS
R.H. Green, C.E. Brightling, S. McKenna, B. Hargadon, D. Parker, A.J. Wardlaw, I.D. Pavord. Institute for Lung Health, Glenfield Hospital, Leicester, UK
An important number of patients with asthma remain symptomatic despite treatment with low dose inhaled corticosteroids. There is relatively little data from placebo controlled studies directly comparing the different treatment options for this group of patients. We have performed a randomised, double blind, four way cross-over study comparing the effects of one months treatment with higher dose budesonide (400mcg bd), additional formoterol (12 mcg bd) and additional montelukast (10 mg od) with placebo in patients with asthma who remain symptomatic despite low dose inhaled corticosteroids (budesonide 100mcg bd). Patients were seen before and 12 hours after each treatment phase which was separated by a one month washout period during which they took budesonide 100mcg bd and prn salbutamol only. At each visit exhaled nitric oxide (NO), spirometry, methacholine PC20, visual analogue symptom scores (VAS), the Juniper Asthma Quality of Life questionnaire and induced sputum were performed. Patients recorded twice daily peak expiratory flow (PEF) throughout and the mean morning PEF was calculated for the final week of each treatment and washout period. 49 patients with symptoms consistent with asthma and objective evidence of variable airflow obstruction despite low dose inhaled corticosteroids were recruited. High dose budesonide was the most efficacious treatment resulting in significant improvements in global VAS (−21.3 mm; 95% CI −40.4 to −2.3) morning PEF (16.5 l/min; 95% CI 2.3 to 30.7), FEV1 (0.14 l; 95% CI 0.0 to 0.28) and exhaled NO (fold reduction 1.9; 95% CI 1.1 to 3.1) compared to placebo. Formoterol was the next most efficacious treatment with similar improvements in morning PEF (17.5 l/min, 95% CI 4.0 to 31.0). However the change in sputum eosinophil count with formoterol (2.4% to 3.8%; fold reduction 0.6, 95% CI 0.5 to 0.9) differed significantly from the change seen with placebo (2.8% to 2.5%; fold reduction 1.1, 95% CI 0.7 to 1.6; p=0.03) and high dose inhaled corticosteroids (2.7% to 1.6%; fold reduction 1.6, 95% CI 1.2 to 2.2; p<0.001). We conclude that treatment given in addition to low dose inhaled corticosteroids results in modest benefits. Despite similar effects on morning peak flow, long acting β2-agonists and high dose inhaled corticosteroids differ in their effects on eosinophilic airway inflammation.
Paediatric airways disease
S32 THE BRAVELUNG STUDY: BRONCHIOLITIS RSV AUDIT INTO VACCINATING FOR EARLY LUNGS
J. McCormick, M. Almaghrabi. Tayside Institute of Child Health, Ninewells Hospital, Dundee, UK
Background: Each winter season there are pervasive outbreaks of respiratory syncytial virus (RSV) bronchiolitis. Premature infants with CLD who are re-admitted with RSV utilise greater health service resources in the first two years of life after birth.1 Palivizumab, the humanised RSV monoclonal antibody has been shown to cause a relative reduction in re-admission rates in infants born at <35 weeks group by 55%.2
Objectives: To audit current protocols and practice into Palivizumab prescribing and Palivizumab funding in Scotland and Northern Ireland over the winter 2001—2002 season.
Design: Retrospective postal questionnaire.
Methods: Targeted questionnaire to lead neonatal or paediatric consultants in 27 units in Scotland and Northern Ireland following the end of the RSV season in late March/early April 2002.
Results: Response rate was 100% from units responsible for an estimated 72 400 births. 200 babies received a course of Palivizumab over the winter season (1 per 362 births) at an estimated cost of £490 000. Important regional variations were demonstrated; 1 in 179 babies born in Northern Ireland compared to 1 in 538 babies born in Scotland receive RSV prophylaxis. Six units using agreed guidelines prescribe 49% of the palivizumab in Scotland. Only 63% of respondents had an agreed protocol for palivizumab administration. Inclusion criteria for receiving palivizumab included; chronic lung disease (76%), home oxygen (71%), congenital cardiac abnormality (59%), specific gestation (53%), and consultant discretion (35%). The source of funding was described as Trust (50%), Health Board (32%), Directorate (14%) and 4 % from winter pressures money. There were three reports of “breakthrough” RSV infection (3% of treated babies) following immunisation.
Discussion: Palivizumab is prescribed 3 times more in Northern Ireland than Scotland. Should UK guidelines for palivizumab administration (like the US) now be the goal?
1. Greenough A, et al.
2. The IMpact-RSV Study Group.
S33 THE COMPLEX RELATIONSHIP BETWEEN ASTHMA AND AIRWAY RESPONSIVENESS THROUGHOUT CHILDHOOD
S.W. Turner, L.J. Palmer, P.J. Rye, N.A. Gibson, P.K. Judge, S. Young, J. Goldblatt, L.I. Landau, P.N. Le Souëf. Princess Margaret Hospital for Children, Perth, Australia
Introduction: The relationship between childhood asthma and increased airway responsiveness (AR) remains uncertain.
Aims: To investigate whether AR tracks from infancy through to childhood; to determine which factors influence AR and assess interactions with asthma.
Methods: From a cohort of 253 individuals, longitudinal assessments of AR and atopy were made at one, six and 12 months and at six and 11 years of age. AR was expressed as a dose response slope (DRS) or graded on a scale of 0 to 2.
Results: DRS was measured in 203 individuals aged one month, 174 at six months, 147 at 12 months, 103 at six years and 176 at 11 years of age. There were 22 asthmatics at six and 27 at 11 years of age. There was a positive relationship between the DRS in infants aged one month and in children who were not atopic aged 11 years (r=0.24, n=65, p=0.05). Atopy at six years of age was positively associated with grade of AR χ22=6.2, n=93, p<0.05). Atopy at six months and at 11 years of age was positively associated with the grade of AR aged 11 years χ22=6.8, n=150, p=0.03 and χ22=18.7, n=175, p<0.001, respectively). The DRS at six, but not 11, years of age was positively related to the urinary cotinine concentration at 12 months of age (r=0.45, n=32, p<0.001) and also the number of cigarettes currently smoked by parents (r=0.01, n=83, p=0.04). The DRS at 11, but not six, years of age was increased in the presence of lower respiratory tract infection (LRTI) in the first six months (n=79, p<0.001) but not the second six months of life. Adjusting for the presence of asthma, the DRS at six years of age was related to the urinary cotinine concentration aged 12 months (p=0.001) and current atopy (p=0.03); and the DRS at 11 years of age was related to atopy aged six months (p=0.001) and LRTI before six months of age (p=0.001).
Conclusions: The data suggested that the level of AR in childhood was determined in early infancy and then influenced in later infancy by factors that included atopy, tobacco smoke exposure and lower respiratory tract infections. Factors present in infancy are associated with increased childhood AR and these appear to act independently of asthma.
S34 TUMOUR NECROSIS FACTOR GENE POLYMORPHISMS AND CHILDHOOD WHEEZING
H. Bilolikar1 2, A. Rodriguez Nam3, M. Rosenthal1, D.C. Henderson2, I.M. Balfour-Lynn1 2. 1Dept. Paediatric Respiratory Medicine, Royal Brompton Hospital; 2Depts. Paediatrics and Immunology, Chelsea & Westminster Hospital; 3Dept. Clinical Immunology, Hammersmith Hospital, London, UK
Background: TNFα secretion is influenced by single nucleotide gene polymorphisms within the TNF gene cluster. Higher constitutive and inducible production of TNFα is associated with allele 2 of TNF-308 and allele 1 of an Nco1 polymorphism of the LTα gene. Since TNFα is associated with infant wheezing and asthma, a genetic predisposition to produce TNFα may be important. We compared the TNFα and LTα polymorphisms in controls with a group of infant wheezers, and childhood asthmatics of differing severity. We also measured nasal TNFα levels in the infants with acute wheezing to determine whether an association between phenotype (in vivo production) and genotype existed.
Methods: Asthmatic patients were identified in clinic with respiratory paediatrician-diagnosed asthma, which was defined as severe if they were on inhaled steroids >800 mcg/day (budesonide equivalent). Infant wheezers were inpatients with acute wheezing. Controls were school children with no asthma. Nasal lavage was performed in the infants using the inulin method to account for dilution, and nasal TNFα was measured by commercial ELISA. Genomic DNA was extracted from buccal smears using the Nucleon extraction kit. After amplification by PCR, the DNA was sized by electrophoresis.
Results: There were 88 asthmatics (mean age 6.1 yrs, 52 boys), 27 severe asthmatics (mean age 12.8 years, 17 boys), 55 wheezy infants (mean age 6.5 months, 35 boys) and 156 controls (mean age 10.2 years, 77 boys). All data were compared to the controls. In the presence of TNF1 homozygosity, the risk (95% CI) of being a wheezy infant was 3.2 (2–5) greater if they were also LTα AA than if one or two LTα G genes were present. For all asthma the risk was 2.0 (1.2–3.2) and for severe asthma risk was 2.4 (1.3–4.5). In the presence of 1 or 2 TNF2 genes, the co-presence of LTα AA gave a 12.6 (1.6–98) risk of being a wheezy infant than if there was a LTα G gene present. The risk for all asthma was 18 (2.4–128) and for severe asthma 13 (1.5–114). Although the positive predictive values were high, the sensitivity of the testing was relatively low. The haplotype TNF12/ LTα AA gives a positive predictive value for any wheezing of 96%, with sensitivity of 17%.
In the wheezy infants, nasal TNFα levels were not influenced by RSV status. Levels were significantly lower in the presence of a TNF2 gene (p=0.006), which was the opposite of that expected, and there was a trend (p=0.08) to higher levels if the LTα A gene was present (as expected).
Conclusions: The TNF2 allele is associated with wheezing whereas the LTα G gene had a protective effect. Clearly the TNF genotype influences the development of childhood wheezing. The results of nasal TNFα needs further elucidation.
S35 DEVELOPMENTAL CHANGES IN VENTILATION DISTRIBUTION IN HEALTH AND CF LUNG DISEASE
P. Aurora, H. Jungberg, C. Oliver, P. Gustafsson2, J. Stocks. 1Portex Respiratory Unit, Institute of Child Health, London, UK; 2Queen Silvia Children’s Hospital, Göteborg, Sweden
Longitudinal monitoring of airway function through childhood is often complicated by the need to correct results for age and body size.
Aims: In this study we investigated the relationship between age and lung clearance index (LCI), an index of ventilation inhomogeneity derived from multiple breath inert gas washout (MBW) (
), in cystic fibrosis (CF) and healthy control children aged from 0 to 18 years.
Methods: 131 children (64 with CF) were tested. Infants were measured whilst asleep, older children whilst awake. All performed 3 SF6 MBWs, and mean LCI was calculated for each child.
Results: LCI remained constant throughout childhood in healthy controls, but became progressively elevated with increasing age among those with CF. See table and figure.
Conclusion: The LCI can be used to assess airway function from infancy to adulthood and has potential for monitoring CF lung disease.
S36 CHEMOKINE PRODUCTION IN SEVERE RSV BRONCHIOLITIS
P.S. McNamara, G. Jeffers, B.F. Flanagan, P. Newlands, P.C. Ritson, C.A. Hart, R.L. Smyth. Institute of Child Health, Alder Hey Children’s Hospital, Liverpool, UK
Introduction: Respiratory syncytial virus (RSV) bronchiolitis is one of the most important causes of death and morbidity in infants worldwide. Factors that predispose to severe disease include prematurity. Neutrophils are the predominant cell-type within upper and lower respiratory tract secretions from infants with bronchiolitis and reach the airways along chemoattractant gradients. Our aim was to compare the pulmonary chemoattractant protein response in term and preterm infants ventilated with RSV bronchiolitis with that from a control group.
Subject/Methods: We collected non-bronchoscopic bronchoalveolar lavage (BAL) samples from 48 infants (25 born at term (≥37 weeks) and 23 born preterm (<37 weeks)) ventilated for RSV bronchiolitis. We also collected BAL samples from 13 “control” patients ventilated for non-respiratory causes. All samples were collected within 24 hours of being intubated. BAL protein concentrations were measured using ELISAs (R&D) according to the manufacturers instructions.
Results: Mean ages on admission were: term infants, 6.7 wks; preterm, 16.0 wks; control, 5.5 wks. Mean weights on admission were: term, 4.3kg; preterm, 3.5kg; control, 4.2kg. Mean gestational ages at birth were: term, 38.6 wks; preterm, 30.1 wks; control, 38.8 wks. Preterm infants were ventilated for twice as long as term infants (4.4 v 9.0 days, p=0.02).
MIP-1α, RANTES and Eotaxin concentrations all differed significantly between the three groups.
Conclusions: We have identified differences in the immunological response in the lungs of infants ventilated for RSV bronchiolitis compared to a control group. Our data also highlight for the first time differences in this response between term and preterm infants with RSV bronchiolitis which may relate to disease severity.
Study funded by Action Research
S37 SALMETEROL/FLUTICASONE COMBINATION (SFC) IS ASSOCIATED WITH IMPROVED COMPLIANCE IN CHILDREN COMPARED WITH INHALED CORTICOSTEROID (ICS) ALONE, OR CONCURRENT SALMETEROL + ICS
T.P. McCarthy, L. Rice, C.A. Blair. GlaxoSmithKline, Uxbridge UB11 1BT, UK
Introduction: Paediatric compliance with regular asthma medication is a concern, with levels of 55–58% being reported (
). It has been suggested that a combination of a long-acting β2 agonist (LAB) and an inhaled steroid in one inhaler—SFC (SeretideTM) may appeal to children in terms of convenience; and the LAB, providing a rapid improvement in lung function which will wear off after 24 hours, may serve as a reminder that the medication should be taken.
Method: To evaluate compliance in children <16 using prescribing data as a surrogate marker, DIN-LINK Data (CompuFile Ltd) were used to analyse prescription collection/year (P) from 100 GP practices, for SFC, fluticasone (F), salmeterol (S) and beclometasone (BDPI (dry powder inhalers)).
Results: 1031 asthma patients identified who had been prescribed SFC, F, S or BDPI over the 12 months January–December 2001. 99% of patients prescribed S for asthma were prescribed an ICS. Accordingly S may be taken to represent concurrent LAB (S) +ICS (p value SFC v S unchanged).
Discussion: Although prescribing data are only a surrogate for compliance, as patients may not collect or use all their prescriptions, this study found compliance with F and S in keeping with other studies. In contrast SFC achieved compliance that was significantly greater versus F, S, and BDPI. As 99% of patients on S are concurrently on ICS, SFC achieved significantly greater compliance compared with concurrent LAB and ICS therapy. In this study SFC was associated with greater compliance with treatment than is usually found in children on regular inhaled therapy for asthma.
S38 CAN ALL COPD PATIENTS COPE WITH PULMONARY REHABILITATION?
E. Roberts1, J. Goldman1, W.H. Williams2, D Egan1. 1Clinical Health Psychology, Torbay Hospital, Torquay TQ2 7AA, UK; 2School of Psychology, University of Exeter, Exeter EX4 4QG, UK
It has been suggested that hypoxemia may be responsible for intellectual difficulties observed in COPD patients. Research to date is inconclusive as to the nature of these difficulties and at what stage of disease they occur. This investigation aimed to establish what the difficulties are, which disease factors are involved and whether they are mediated by emotional well-being. Forty patients participated. Inclusion criteria were an established diagnosis of COPD; FEV1 <80% predicted, and an FEV1/FVC ratio of <70%. Those who were receiving LTOT, had suffered a severe head injury in the past, who had a learning disability or who had other medical conditions known to affect intellectual functioning were excluded. A control group of 22 healthy volunteers was also recruited. Blood gases and lung function measures were taken from the patients; oxygen saturation of haemoglobin was measured for all participants. A range of intellectual assessments measured verbal fluency, memory, attention processes and other skills associated with the frontal lobes of the brain. The HAD assessed anxiety and depression. Mean Pao2 was 8.6 (.97), mean Paco2 5.2 (.63). Oxygen saturation at rest was 93.4% (3.29) in patients. Percentage of predicted FEV1/FVC ratio was 45.8% (12.4). Independent t-tests showed that COPD patients performed significantly worse than controls on speed of information processing (t = −2.99, p<0.05), immediate memory (t =−3.24, p<0.01), divided attention (t = 2.60, p<0.01) and verbal fluency (t = −2.58, p<0.05). Significant correlations were obtained between these measures and some physiological measures: speed of information processing and % of predicted FEV1/FVC (r = −0.33, p<0.05); and immediate memory with Pao2 (r = 0.33, p<0.05); divided attention with Paco2 (r = −0.34, p<0.05) and with FVC (r = −0.27, p<0.05). Independent t tests showed patients scored significantly higher than controls on both anxiety and depression (t =−3.89, p<0.001 and t = 4.63, p<0.001 respectively) but were not correlated with any of the intellectual measures. These findings suggest that mildly hypoxemic patients show impairments in intellectual performance. There is some evidence for the contribution of severity of illness, although other factors related to COPD or chronic illness in general may be implicated. Future work could assess whether severe hypoxemia is accompanied by more intellectual deterioration. The presentation of rehabilitation programmes can be tailored to take account of patients’ difficulties.
S39 RESPONDER ANALYSIS OF PULMONARY REHABILITATION
R. Garrod1, K. Dix, C. Daly, M. Howard, P.W. Jones. 1School of Physiotherapy St George’s Hospital and Kingston University; St George’s Hospital NHS Trust, UK
Introduction: Research has shown improvements in exercise tolerance (ET) and health related quality of life (HRQoL) after pulmonary rehabilitation. However there are few reports of the effects of “real life” rehabilitation, in particular descriptors of response and non response behavior. This study reports on data from a 7 week, 2 × weekly exercise and education programme run at St George’s Hospital, London.
Methods: Outcome measures were spirometry, Shuttle walk test (SWT), HRQoL using SGRQ and mood state using the Hospital Anxiety and Depression Scale (HAD). 76 patients were admitted to the programme, 67 were available for follow up.
Results: There was a statistically significant improvement in SWT mean change; 52 m (84.4) (p = 0.0001) and in SGRQ; 5.2 (10.6) (n = 67). Responder analysis, based on a change >30mt for SWT and >4 points for SGRQ, showed that 37 patients were responders (R) for ET and 33 for HRQoL. 18 patients were characterised as non responders (NR) in both HRQoL and ET. 12 patients were NR for exercise tolerance but R for HRQoL, 17 patients were classified as R for SWT but NR for HRQoL and only 20 patients were classified as R in both aspects. In these 20 patients the change in SWT and SGRQ was large; 124 (71.4)m and 12 (6.2) respectively. There was a significant difference for SGRQ between R and NR; 57 (14.6) and 47 (14.4), p = 0.04 with Rs showing poorer QoL, similarly for depression 7.5 (3.2), 5.6 (2.4), p = 0.04. Rs showed a larger initial SWT compared to NR; 270 (139.2) and 217 (94.6) m although the difference was not significant (p =0.18). Baseline spirometry showed no significant difference, R and NR, mean (SD): 1.1 (0.5)l (n = 17) and 1.1 (0.5)l (n=15), respectively.
Conclusion: These data generate the testable hypothesis that greater exercise tolerance and poor HRQoL are associated with better improvements in pulmonary rehabilitation. Prospective randomised trials are warranted.
S40 SYMPTOMS LIMITING EXHAUSTIVE WALKING AND CYCLING EXERCISE IN COPD
J. Gearing, W.D-C. Man1, S.G. Radford, R.E. Atkins, A.J. Rossell, B.Gray1, M.I. Polkey2, J. Moxham1. Department of Physiotherapy and 1Respiratory Medicine, King’s College Hospital; 2Royal Brompton Hospital, London, UK
Background: Previous studies have shown that leg fatigue is a common symptom following exhaustive cycling in COPD patients. However cycling is not familiar to many COPD patients, and walking field tests may be more representative of everyday activities. We hypothesised that the symptoms limiting exhaustive exercise in COPD is dependent on the type of exercise performed.
Method: 50 stable patients with COPD (27M:23F, mean age 68.6 yrs, mean FEV1 0.95) were recruited. After an initial familiarisation period, each patient performed to exhaustion an incremental shuttle walk (ISW), an endurance shuttle walk (ESW), incremental cycle ergometry (ICE), and endurance cycle ergometry (ECE), on four separate visits. Patients were asked to name the predominant symptom limiting further exercise: shortness of breath (SOB), leg fatigue (LF), an equal combination of SOB and LF, or other symptoms.
Results: See table.
Discussion: SOB is by far the most common limiting symptom following exhaustive walking exercise, but is less important following exhaustive cycling exercise when LF becomes more prominent. It may be more appropriate to use walking tests to assess the effects of therapeutic interventions on exercise-induced dyspnoea.
WDCM is a Clinical Research Training Fellow of the MRC (UK).
S41 ASSESSING THE DETERMINANTS OF INCREMENTAL SHUTTLE WALKING DISTANCE
S. Dogan1, B. Watson2, W. Cochrane1 2, G. Dovey-Pearce1, G. Afolabi1, M. Heatley1, C. McAlpine1, G. Oliver1. 1Northumbria Healthcare NHS Trust, UK; 2Northumbria University, UK
Introduction: The shuttle test is a widely used outcome measure for pulmonary rehabilitation to assess a person’s exercise tolerance. To better understand what this outcome means we examined the relationship between incremental shuttle test walking distance and biomedical and psychological dimensions in people with COPD. These findings derive from the baseline data of a trial comparing pulmonary rehabilitation with solely exercise and psychological interventions.
Participants: All 218 participants had stable COPD. 60% reported MRC Dyspnoea grade 3, 29% grade 4, and 11% grade 5. 44% were male and mean (95% CI) age was 68.8 (67.8–69.7) years.
Methods: Incremental shuttle walking test was carried out. Spirometric and anthropometric measurements were recorded including Forced Expiratory Volume (FEV-1), weight, and four site skinfold thickness. Perceived health status, personal cognitions of illness and affect were assessed using the Chronic Respiratory Disease Questionnaire (CRDQ), the Illness Perceptions Questionnaire (IPQ) and the Hospital Anxiety and Depression Scale (HADS) respectively. Stepwise multiple linear regression was carried out with incremental shuttle walking test distance as the dependent variable.
Results: Mean (SD) incremental shuttle walking distance = 202.5 (111.3) meters. Independent variables included: predicted FEV-1 (mean (SD) = 52.7 (15.6)); fat free mass index (mean (SD) 17.6 (2.6)); CRDQ (mastery (median (IQR) = 19.0 (9.0)), fatigue (median (IQR) = 14.0 (8.0)), emotional function (median (IQR) = 32.0 (12.8)), dyspnoea (median (IQR) = 14.0 (7.8)); IPQ (timeline (median (IQR) = 21.0 (3.0)), consequences (median (IQR) = 19.5 (5.0)), personal control (median (IQR) = 20.0 (5.0)), treatment control (median (IQR) = 16.0 (4.0)), illness coherence (median (IQR) = 12.0 (6.0)); and HADS (anxiety (median (IQR) = 18.0 (5.0)), depression (median (IQR) = 15.0 (3.0)). In a model controlling for participant age and gender, and explaining 27.7% (p<0.001) of the variance in the dependent variable, fatigue (beta = 4.6 (p=0.004)) and mastery (beta = 3.5 (p=0.02)), as measured by the CRDQ, were the only significant variables entered.
Conclusion: In this population, these findings demonstrate that a person’s perception of their fatigue and their degree of control and confidence in managing their condition, play an important and independent role in promoting exercise performance. This suggests it is important to directly address these factors when providing pulmonary rehabilitation.
S42 EVALUATION OF MAINTENANCE PROGRAMMES AFTER PULMONARY REHABILITATION IN THE COMMUNITY SETTING
K. Dix, C. Daly, M. Howard, E. Porter, C.F.J. Rayner. St George’s Hospital NHS Trust, Tooting, London, UK
Introduction: The role of maintenance programmes (MP) in pulmonary rehabilitation is at present unknown. This data reports on the outcomes of a community based MP provided after a 7 week 2 × weekly out patient programme (OP) as part of “real life” clinical service.
Methods: After the 7 week out patient programme, patients self selected to either attend a 6 month MP (n = 10) or not (n= 15). The MP was provided once weekly in a local leisure centre. Assessments of Shuttle Walk Test (SWT) and St George’s Hospital Respiratory Disease Questionnaire (SGRQ) were made at the end of the 7 week out patient and after the 6 month period (n= 25).
Results: Descriptive data are provided, based on an improvement in SWT >30mt and >4 points for SGRQ. Of those who attended, 4 improved SWT, 5 stayed the same and 1 deteriorated; mean change post OP rehabilitation, 17m. Of those who did not, 7 improved, 6 stayed the same and 2 got worse, mean change 45m. For SGRQ in group attendees, 1 improved, 5 stayed the same and 4 got worse. In the non attendees, 6 improved SGRQ, 6 stayed the same and 4 got worse. There were no significant differences between the groups for SWT or SGRQ.
Conclusion: This early report of a clinical community MP suggests that patients who choose to attend the MP do as well as those who do not attend for exercise and health related quality of life. It is unknown whether these patients would maintain improvements without the opportunity of a maintenance programme. Long term studies are indicated.
S43 A FOCUS GROUP STUDY ON THE IMPACT OF THE DIFFERENT COMPONENTS OF PULMONARY REHABILITATION
M. Gray1, R.C.M. Jones1, M. Hyland2, J. Goldman3. 1Respiratory Research Unit, University of Plymouth, Devon; 2Department of Psychology, University of Plymouth, Devon, UK; 3The Heart and Lung Unit, Torquay Hospital, Torquay, Devon, UK
Background: Multi-professional pulmonary rehabilitation (PR) has been shown to improve exercise tolerance and quality of life. It is not known which aspects of PR (e.g. exercise versus education versus social support) are found to be most helpful by patients, and existing quality of life tools do not explore this issue.
Methods: Six focus groups were held 3 months after PR with patients recruited from 2 programmes. One being a typical intensive, hospital-based scheme, (Torquay), the other a short, once weekly programme based in various locations in the community (Plymouth).
Results: Perceived effects of education included reduced fear of dyspnoea, improved use of benefit system and improved drug compliance; perceived effects of social context included encouragement during exercise and smoking cessation, and new social activities amongst group members; exercise in a safe environment increased confidence in activity and also reduced fear of dyspnoea, leading to new activities (e.g. holidays, shopping trips etc.) Patients judged PR to be more helpful then medical interventions. There appeared to be more extra-curricula social contact in the community group.
Conclusions: Patients reported benefits of PR can be attributed to exercise, education, social context, supporting the use of multi-professional, multi-component PR programmes. Peer group support in both programmes appears to be an important factor in behavioral change.
Interstitial lung disease: From diagnosis to treatment
S44 AN ASSESSMENT OF REPRODUCIBILITY OF DIAGNOSIS IN DIFFUSE PARENCHYMAL LUNG DISEASES
A.G. Nicholson, A.R. Gibbs, B.J. Addis, S. Stewart, C.A. Clelland, N.B. Ibrahim, W.A. Wallace, P.S. Hasleton, B. Corrin, H. Bharucha, K.M. Kerr (UK-ILD panel), A.U. Wells. Departments of Histopathology, Royal Brompton, Llandough, Southampton, Papworth, John Radcliffe, Frenchay, Edinburgh, Wythenshawe, Royal Victoria Hospital, Belfast, Aberdeen Royal Hospitals, and Department Of Medicine, Royal Brompton Hospital, UK
There are very few inter-observer studies of histologic patterns of diffuse parenchymal lung disease (DPLD), and the reproducibility of the consensus ATS/ERS classification for interstitial pneumonias has not yet been tested. This study assesses inter-observer variation in the diagnosis of DPLDs, both for interstitial pneumonias and orphan lung diseases (OLDs). Cases referred for clinical assessment of DPLD between Jan 1996 and Dec 1997, in which a surgical lung biopsy was taken, were retrieved and H&E slides were circulated to 7 reviewers, with knowledge only of age and sex of patient and site of biopsy. As well as histologic patterns in the consensus classification, follicular bronchiolitis (FB), extrinsic allergic alveolitis (EAA), sarcoidosis, end-stage lung, normal, non-diagnostic, unclassifiable and “other” for OLDs were permitted. Reviewers provided a first choice diagnosis with a confidence rating of 1 (>95%), 2 (70–95%) or 3 (30–65%) for each lobe (n=133). The differential diagnosis for each lobe was also recorded along with its percentage likelihood, censored at 5%. The same procedure was applied for the gestalt diagnosis if patients (n=83) had more than one biopsy. Statistical analysis was performed using STATA software (CA, USA). A confidence level of >95% for diagnosis was made in 37% (range 22–47) of cases and >70% in 64% of cases (range 54–73). The overall kappa coefficient for first choice lobar diagnoses was 0.35. Examples for more commonly found patterns of interstitial pneumonias were UIP, 0.43; NSIP, 0.24; DIP, 0.51; OP, 0.53; DAD, 0.52; EAA, 0.32; sarcoidosis, 0.70. In cases with a high degree of confidence (n=79), the overall kappa value was 0.49, whilst for low confidence diagnoses (n=54) this was only 0.19. For UIP, the weighted kappa for lobar diagnosis was 0.55 rising to 0.59 for the gestalt diagnoses. Selected examples of weighted kappas for gestalt diagnosis were NSIP, 0.34; OP, 0.58; EAA, 0.50. These data suggest that the ATS/ERS consensus classification is sufficiently reproducible when used by pathologists with a specialist interest in pulmonary pathology.
S45 INCREASED SERUM LEVELS OF MUCIN KL-6, SURFACTANT PROTEIN-D(SP-D) AND ANTIBODY TO DIETRY ANTIGENS SUGGEST ALTERED MUCOSAL PERMEABILITY AMONG PIGEON FANCIERS
C. McSharry, K. Anderson, T. Ismail, F. Boyd, J. Burgon, K.B.M. Reid, G. Boyd. Department of Respiratory Medicine and Immunology, North Glasgow University Hospitals NHS Trust
Background: Increased clearance of inhaled 99mTc-DTPA in pigeon fanciers has been observed irrespective of symptoms. The aim of this study was to use serum levels of lung-epithelium-derived KL-6 and SP-D to assess lung epithelial permeability and antibody to dietary antigens to assess gut epithelial permeability in pigeon fanciers.
Methods: Serum KL-6, SP-D, antibody to inhaled avian antigens and to common dietary antigens was quantified by enzyme immuno-assay in 60 pigeon fanciers.
Results: The serum KL-6 levels in pigeon fanciers was (median, I-q range) = 422 (244–616) units/ml and the serum SP-D level was (mean (SD) = 201 (141) ng/ml). Both of these were significantly higher than normal. These levels were not significantly higher in those with EAA, but there was a significant correlation between the KL-6 levels and the IgG antibody to inhaled avian antigen (r=0.435, p=0.001) and between SP-D level and the IgG antibody (p=0.005). There were significantly higher than normal titres of IgG antibody to common dietary antigens among the pigeon fanciers suggesting increased gut permeability, but these did not correlate with either symptom category or antibody titre to avian antigens.
Conclusion: Increased lung mucosal permeability reflects local inflammation which could be the cause or the effect of antibody-associated events. The increased gut permeability in pigeon fanciers suggests either an inflammatory reaction in the gut to avian antigens in the diet or a pre-existing generalised increase in mucosal permeability.
S46 MACROPHAGE MIGRATION INHIBITORY FACTOR INDUCES PROLIFERATION AND HAS PRO-FIBROTIC EFFECTS IN PRIMARY HUMAN PULMONARY FIBROBLASTS
K.M.A. O’Reilly1, J.A. Baugh1, B.J. Plant1, M.X. Fitzgerald1, R. Bucala2, S.C. Donnelly1. 1Department of Medicine and Therapeutics, University College Dublin, Ireland; 2School of Medicine, Yale University, USA
Macrophage Migration Inhibitory Factor (MIF) is an important pro-inflammaory cytokine which has been linked to the development of fibro-proliferative or “chronic” acute respiratory distress syndrome (ARDS).1 This finding lead you to postulate that MIF might have direct pro-fibrogenic effects on fibroblasts, and therefore be an important effector in the development of pulmonary fibrosis from a variety of causes.
Primary human pulmonary fibroblasts (CCD-19Lu) were transiently transfected with MIF, RNA extracted and an RNase protection assay (RPA) performed. Levels of transforming growth factor (TGF)-β, a cytokine known to be highly pro-fibrogenic, were found to be significantly up-regulated (336% above control levels (n=3)). Similarly, when the fibroblasts were stimulated with recombinant MIF, levels of secreted TGF-β (measured by ELISA) were increased by 295% compared to controls (n=3). In order to assess whether MIF had any direct effects on fibroblast proliferation, MIF was co-incubated with the primary pulmonary fibroblasts and cellular proliferation assessed by (H3)-thymidine incorporation. Fibroblast proliferation was increased by 210% over controls (n=9).
These data identify MIF as a cytokine which has the capacity to both significantly up-regulate TGF-β production and induce fibroblast proliferation; both key parameters which have the capacity to drive an exaggerated pathological fibro-proliferative response.
This work is supported by the Wellcome Trust.
S47 COLLAGENASE 1 (MATRIX METALLOPROTEINASE 1, MMP1) IS INVOLVED IN THE DEVELOPMENT OF CRYPTOGENIC FIBROSING ALVEOLITIS
A. Walne, P. Lympany, K. Welsh, R. du Bois. National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London
Cryptogenic Fibrosing Alveolitis (CFA) is a relentlessly progressive diffuse lung disease of unknown aetiology, characterised by fibroblast proliferation and extracellular matrix (ECM) accumulation. It is the most common of the diffuse lung diseases, affecting up to 10 adults per 100 000 in the UK and has a median survival time of only 3 years from diagnosis. Even though the existence of familial CFA suggests there may be a genetic component, there have been few large scale studies showing an association between any genetic marker and the development of CFA. The genetic component of CFA is likely to be complex, involving several genes each with a variable effect, acting in combination to determine the predisposition to lung fibrosis. In CFA, the pathological process is characterised by ECM accumulation and abnormal remodeling that may be due to a relative deficit in proteolysis.
In this study we fine mapped across collagenase-1, the gene coding for the main enzyme involved in type I collagen degradation. We examined 12 single nucleotide polymorphisms (four promoter, two 3=UTR, one intron 1/exon 1 boundary and five intronic) in 50 CFA patients and 225 Caucasian controls. The genotype, allele and allele carriage frequencies for the intron/exon boundary polymorphism (C/T) were significantly different between patients and controls (genotype pc= 0.01, allele pc=0.03, allele carriage for C pc=0.006). There were differences in the T allele carriage for the intron/exon polymorphism (p=0.016); in genotype frequency for one of the intronic polymorphisms (MMP1–3 p=0.036) and in allele carriage for one of the 3=UTR polymorphisms (G, p=0.045), but these differences became trends when corrected for the total number of polymorphisms studied.
The finding of an association between collagenase-1 polymorphisms and CFA may indicate a role for this enzyme in the pathogenesis of this disease, but at present, the functional consequences of these polymorphisms are unknown. They may affect mRNA splicing or stability; alternatively, they may be markers for other unidentified polymorphisms in this or other genes in the MMP cluster on chromosome 11q23. We conclude that a susceptibility marker for CFA maps to this MMP region.
S48 THE DEVELOPMENT OF LUNG FIBROSIS IN TRANSGENIC TGFβ1 MICE
Y. Haider, M.W.J. Ferguson, J. Egan. CID, Stopford Building, University of Manchester, Oxford Road, UK
TGFβ1 has been shown to be an important growth factor in the pathogenesis of lung fibrosis. It has been hypothesised that human genetic predisposition mediated via TGFβ1 may place some individuals at risk of developing lung fibrosis (
). We previously studied the natural history of a transgenic mouse colony that expressed high circulating plasma levels of active TGFβ1 and found that lung fibrosis was not present irrespective of the age of the mouse. This was despite histological evidence of liver fibrosis.
We proceeded to study the potential susceptibility of these mice to the development of lung fibrosis using a known chemical injury (bleomycin) and a suspected environmental pathogen (a herpes virus).
We bred two lines of transgenic mouse and confirmed their phenotype (Tr+) qualitatively (by tail DNA analysis) and quantitatively (by plasma TGFβ1 bioassay). We then analysed their lungs histologically after bleomycin injection (3000 IU intraperitoneal)(n=8), and after administration of herpesvirus (4 × 105 pfu of Murine gammaherpesvirus-68 intranasal)(n=8). Mice were killed after 6 weeks. A control population received the same treatment (n=8). Lung fibrosis was graded 0–3, based on a previously published grading system (
The Tr+ mice were confirmed to have higher circulating levels of active TGFβ1 compared to controls (p<0.05). Prior to bleomycin exposure, the lungs of the Tr+ and control mice were histologically normal. After bleomycin, control lung showed fibrosis (mean score 1.4) and Tr+ lung showed more severe and extensive fibrosis (mean score 2.7)(p<0.05). Prior to herpesvirus innoculation, the lungs of the Tr+ and control mice were normal. After herpesvirus, there was no evidence of lung fibrosis in either group. In conclusion plasma TGFβ1, while not causing de novo lung fibrosis, appears to predispose to lung fibrosis when exposed to an exogenous injury (e.g bleomycin). This may be a consequence of a compartmental disruption allowing passage of circulating TGFβ1 into lung tissue. Therefore lung injury may be of primary importance and individual susceptibility a secondary phenomenon.
S49 A DOUBLE BLIND RANDOMISED PLACEBO CONTROLLED PILOT STUDY OF SEPTRIN IN THE TREATMENT OF CRYPTOGENIC FIBROSING ALVEOLITIS
V. Varney, H. Parnell, D. Salisbury, S. Ratneepan, R. Tayar. Department of Respiratory Medicine, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 1AA, UK
Background: 14 patients with end stage pulmonary fibrosis were openly treated with oral Septrin. All made a dramatic clinical recovery and were discharged home. This prompted a double blind randomised placebo controlled pilot study in earlier stages of the disease when cough, dyspnoea and oxygen desaturations on exercise were present.
Method: 20 patients with pulmonary fibrosis (aged 49–84 years) underwent a detailed assessment of arterial blood gases, lung function, progressive shuttle walking tests with oxygen saturation monitoring, quality of life and diary cards etc. Randomisation was to Septrin or identical placebo for 3 months followed by 6 weeks of pulmonary rehabilitation (rehab) before decoding. 2 weekly reassessments of shuttle walk (etc) were made throughout the study.
Results: The first 16 cases have been decoded (8 Septrin, 8 placebo). The remaining patients will complete by September 2002.
Conclusion: Septrin produced a significant improvement in shuttle walking distance with improved arterial oxygen values, lung volumes and quality of life assessments. A fully decoded study by October 2002.
Acute respiratory distress syndrome
S50 CHARACTERISATION OF A MURINE MODEL OF OLEIC ACID-INDUCED ACUTE LUNG INJURY
K. Ulrich1, M. Stern1, M. Goddard2, D. Geddes1, M. Takata2 E. Alton1. 1Department of Gene Therapy, Faculty of Medicine at the National Heart and Lung Institute, Imperial College, London, UK; 2Department of Anaesthetics and Intensive Care, Faculty of Medicine at the Chelsea and Westminster Hospital, Imperial College, London, UK
We are developing a programme of gene therapy for acute respiratory distress syndrome (ARDS). Oleic acid-induced lung injury has been suggested as the optimal animal model, but has not been characterised in mice. Current gene therapy studies focus on this species, and we have therefore developed a mouse model of oleic acid-induced lung injury. BalbC mice were anaesthetised, ventilated and injected with either oleic acid (OA, 0.2 or 0.4 ml/kg body weight) or saline. One hour after OA administration (0.2 ml/kg), mouse lungs had significantly (p<0.01) higher wet-to-dry weight ratios (6.9 (0.3) compared to 4.9 (0.04)). Analysis of BAL fluid from treated animals demonstrated significant (p<0.005) increases in total protein (2.9 (0.4) and 5.9 (0.6) μg/μl respectively for 0.2 and 0.4 ml/kg OA compared to 0.2 (0.03) in the PBS control group). Albumin was also detected in BALF from all OA-treated animals (0.2 (0.0) μg/μl). Total cell numbers (1.4 (0.3) ×106 and 1.9 (0.3) × 106/ml for the two doses compared to 0.4 (0.1) ×106/ml in control) and the marker of cell damage, lactate dehydrogenase (LDH) activity (156 (40) and 446 (117) U/l compared to control 4.9 (1.3) U/l) were also significantly increased. MIP-2, isolated from lung homogenates, revealed a significant (p=0.005) increase in mice treated with the lower dose of OA compared to control. OA treatment resulted in substantial hypoxemia (Pao2 at Fio2 1.0 decreased from 425 (28) to 68 (6) mmHg) with decreased respiratory system compliance (69.7 (5.6) %, n=4). Electron microscopy demonstrated the presence of intra-alveolar fibrin and haemorrhage, type I alveolar epithelial cell necrosis and destruction of alveolar architecture. Histological quantification of the above lung damage parameters revealed a dose dependent increase in patchy lung damage with treated mice having 34.7 (7) and 48.9 (3.6) % damage compared to 14.9 (2.9) % in control animals, p=0.05 and 0.005 respectively). Correlation of these physiological, histological and clinically relevant parameters in the OA mouse provides a model for further investigation of treatments for ARDS.
S51 REGULATION OF NEUTROPHIL FATE BY HYPOXIA
S.R. Walmsley, A. Cowburn, J. Deighton, K.I. Mecklenburgh, E.R. Chilvers. Respiratory Medicine Division, Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s and Papworth Hospitals, Cambridge CB2 2QQ, UK
Introduction: Neutrophil apoptosis represents a major mechanism involved in the resolution of acute inflammation. In contrast to many other cell types, we have previously shown that hypoxia (0–3.5 kPa O2) has the ability to inhibit apoptotic cell death in neutrophils when aged in vitro. This may be of physiological importance given the significant drop in local oxygen tension at sites of inflammation. We therefore sought to elucidate the oxygen sensing pathways involved in this regulation of neutrophil apoptosis.
Methods: Human neutrophils were purified from the peripheral blood of healthy volunteers by dextran sedimentation followed by centrifugation through discontinuous plasma-Percoll gradients. Cells were cultured in supplemented MDM +/- test reagents in normoxic (19 kPa), hypoxic (3 kPa) or anoxic (0 kPa) environments. Apoptosis was assessed by cell morphology and flow cytometry with annexin V and propidium iodide. Cytokine release was measured by ELISA, and cytosolic and nuclear protein expression by western blotting.
Results: Oxygen deprivation profoundly inhibited constitutive apoptosis in human neutrophils from 59% to 29% (p=0.0025). Conditioned medium from oxygen deprived neutrophils also induced cell survival in normoxia but this was independent of GM-CSF, IL-1β, IL-6 and TNFα. Furthermore, the hypoxic inhibition of neutrophil apoptosis was unaffected by the PI3 kinase inhibitors LY294002 (10 μM) or wortmannin (100 nM). The hypoxic survival of neutrophils previously shown to be mimicked by the iron chelators desferrioxamine and hydroxypyridone (Mecklenburgh KI et al. Blood 2002; in press) was replicated with the novel prolyl hydroxylase inhibitor dimethyl oxaloylglycine at HIF stabilising concentrations (1 mM).
Conclusion: Our results indicate that neutrophils have a ferro-protein oxygen sensing mechanism involving prolyl hydroxylase domain (PHD) containing proteins which can regulate the hypoxic inhibition of neutrophil apoptosis. This survival effect is independent of the PI3-kinase pathway. Moreover neutrophils cultured under hypoxic conditions secrete an apparently novel factor that has a profound survival effect on neutrophils cultured in normoxic conditions.
Research funded by the MRC, and Sackler studentship.
S52 TOLL-LIKE RECEPTOR EXPRESSION IN ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS): A ROLE FOR TLR-2?
L. Armstrong, A.R.L. Medford, K.M. Uppington, A.B. Millar. Lung Research Group, University of Bristol Division of Medicine, UK
ARDS is a condition commonly associated with sepsis. Recently the toll-like receptor family has been identified on the basis of homology with the type I IL-1 receptor. 10 members have been described, but only 3 of them have a known function: TLR-4 is a component of the LPS receptor and is essential for gram negative responses, TLR-2 is a receptor for gram positive lipoproteins but may also cross-signal in response to LPS with TLR-4. TLR-9 recognises CpG bacterial motifs. We have looked at the expression of TLR-2 and TLR-4 on monocytes from patients with gram negative (n=20) and gram positive sepsis (n=20), compared to non-septic ITU controls (n=15). TLR expression was also determined on alveolar neutrophils and macrophages. We also looked at the relationship between TLR expression and the development of ARDS. Monocytes were isolated from whole blood by density gradient centrifugation and adherence. Total RNA was isolated after 2 hours in culture and RT-PCR was performed for TLR-2, TLR-4 and GAPDH transcripts. TLR protein expression was determined by flow cytometry on whole blood, dual stained with CD14-FITC and specific TLR-2 and TLR-4 monoclonal antibodies, or on ungated macrophages and neutrophils. Expression of both TLR-2 and TLR-4 mRNA (% GAPDH) was significantly increased in sepsis (126 and 87.5 % respectively) versus non-sepsis controls (96 and 68% respectively) (p<0.05). This was reflected at the protein level; TLR-2 expression (above isotype control) on monocytes was 15.44 versus 0.13 for non-sepsis controls (p<0.05). TLR-4 expression was 3.77 versus 0.59 non-sepsis controls. Both TLR mRNAs significantly correlated with TNF-α mRNA suggesting increased function. In ARDS subjects there was no significant differences in TLR-4 expression. However, monocytes from ARDS subjects had significantly lower levels of TLR-2 mRNA (83% of GAPDH for ARDS subjects vs 126% for non-ARDS subjects, p<0.001). Similarly TLR-2 mRNA was lower in patients who died (103%) versus survivors (144%). In the lung, alveolar neutrophils and macrophages both express high levels of TLR-2 and TLR-4. We hypothesise that reduced levels of TLR-2 may influence development of ARDS in sepsis populations by increasing the availability of LPS for TLR-4 receptor ligation and signalling.
S53 ELEVATION OF THIOREDOXIN CONCENTRATIONS IN PLASMA AND BRONCHO-ALVEOLAR LAVAGE FLUID FROM PATIENTS WITH THE ACUTE RESPIRATORY DISTRESS SYNDROME
M.E.J. Callister1, A. Burke-Gaffney1, G.J. Quinlan1, H. Nakamura2, J. Yodoi2, T.W. Evans1. 1Unit of Critical Care, National Heart and Lung Institute, Imperial College Faculty of Medicine, Royal Brompton Hospital, London, UK; 2Department of Biological Responses, Institute of Virus Research, University of Kyoto, Japan
Introduction: The acute respiratory distress syndrome (ARDS) is characterised by refractory hypoxaemia secondary to alveolar derecruitment and disordered ventilation-perfusion matching. Oxidative stress and inflammation are key features that contribute to the pathogenesis of ARDS. Thioredoxin (Trx) is an intracellular redox active protein involved in maintaining cellular redox balance, and is actively secreted into the extracellular space in response to clinical conditions associated with oxidative stress and inflammation. Extracellular Trx may have profound implications for the inflammatory response by virtue of its reported chemokine/cytokine properties. We therefore measured Trx levels in plasma and broncho-alveolar lavage fluid (BALF) from 30 patients with ARDS and 18 healthy controls.
Results: Trx levels were significantly elevated in ARDS patients v controls in plasma (45.9 (27.9) ng/ml v 23.6 (13.4) ng/ml, p<0.002) and BALF (103.8 (116.0) ng/ml v 17.4 (9.6) ng/ml, p<0.0001). There were significant positive correlations between Trx concentration and IL-8 concentrations (p<0.001, r=0.631) and IL-1β concentrations (p<0.05, r=0.448) in BALF from the ARDS population. BALF Trx concentrations were higher in patients with ARDS of pulmonary compared to extrapulmonary aetiology (132.3 (129.2) ng/ml v 39.7 (26.9) ng/ml, p<0.01). BALF from patients with pulmonary ARDS also had significantly higher concentrations of IL-8 (p<0.05) and a greater percentage neutrophil count (p<0.05) compared to BALF from patients with extrapulmonary ARDS. Plasma and BALF Trx levels were not significantly different between surviving and non-surviving patients and there was no relationship between Trx levels and the sequential organ failure assessment (SOFA) score when all patients were considered. However, in cases of pulmonary ARDS, there was a significant association between SOFA score and plasma Trx levels (p<0.05, r=0.482).
Discussion: These results demonstrate that concentrations of Trx are increased in BALF and plasma in patients with ARDS. Trx has been shown to have profound effects on the inflammatory response and the correlation between levels of Trx and pro-inflammatory cytokines suggests a link between Trx and the inflammatory response in this condition, although the exact nature of the role of increased extracellular Trx in ARDS remains to be evaluated.
Research Funded by the Wellcome Trust.
S54 PLASMA VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) LEVELS AND THE VEGF +936 C/T POLYMORPHISM IN ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
A.R.L. Medford1, L.J. Keen2, D.R. Thickett1, K.J. Hunter1, A.B. Millar1. 1Lung Research Group, University of Bristol Division of Medicine, Southmead Hospital, Bristol, UK; 2Department of Pathology and Microbiology, University of Bristol, Homeopathic Hospital Site, Bristol, UK
Previous work in our laboratory suggested a role for VEGF in the pathogenesis of ARDS (
). There is considerable interindividual variation in plasma VEGF levels and the +936 C/T polymorphism (CT or TT genotypes) is associated with low plasma VEGF levels (
). Because of the possible functional role of VEGF, we hypothesised that the frequency of this polymorphism would be altered in ARDS. DNA was extracted from healthy subjects (n=50) as well as ARDS patients (n=45) and ventilated at risk patients in intensive care (n=38). A 120 base pair fragment of the VEGF gene containing the polymorphism was amplified and cross-matched with an internal heteroduplex generator containing a polyA insert adjacent to the polymorphism. Artificial heteroduplex formation was analysed on a 15% polyacrylamide gel. ELISA was performed to measure VEGF levels in matched plasma samples from the ARDS and at risk groups. The abnormal (CT or TT) genotypes occurred in 31.3% of at risk patients, 28.9% of ARDS patients and 24% of normal subjects. In ARDS patients, those with an abnormal genotype had a significantly higher 30 day mortality than those with a normal genotype. In the at risk groups, plasma VEGF levels were lower in those with abnormal genotypes compared to normal genotype (129 pg/ml versus 305 pg/ml) but this was not observed in ARDS (337 pg/ml versus 309 pg/ml). The +936C/T polymorphism occurs more frequently in at risk and ARDS patients than normal subjects indicating a possible functional significance in intensive care patients. The normal relationship between plasma VEGF level and genotype appears to be disrupted in ARDS suggesting additional regulatory mechanisms may be important in these patients.
Asthma mechanisms I
S55 EXPRESSION OF TRANSFORMING GROWTH FACTOR ISOFORMS IN HUMAN AIRWAY SMOOTH MUSCLE AND NORMAL LUNG TISSUE
B. Islam, D. Bradbury, L. Corbett, I. Soomro, J. Ronan, A. Knox. 1Division of Respiratory Medicine; 2Histopathology, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
Introduction: transforming growth factor beta (TGF-β) is an immunomodulatory cytokine regulating the proliferation and differentiation of various cell types. It also contribute to the maintenance of tissue architecture by influencing the production of extracellular matrix components. In this study we examined the expression of TGF-β isoforms in human airway smooth muscle cells (HASMC) and normal lung tissues by rt-PCR, bioassay and immunohistochemical staining.
Methods: HASMC were obtained from post-mortem samples of human lung and studied at passage 6. Normal lung tissues were obtained from lung biopsy samples and thoracic surgery. Mink lung epithelial cells (Mv1Lu) were obtained commercially. Recombinant TGF-β-1 and neutralising antibodies to TGF-β-1,-2,-3 were obtained from R&D Systems. TGFβ isoforms mRNA were measured by rt-PCR using primers designed from the human sequences of TGFβ-1,-2,-3 genes and GAPDH as control. The presence of bioactive TGF-β in HASM-conditioned medium was determined using a bioassay that is based on the ability of TGF-β to inhibit proliferation of the Mv1LU cells. Immunohistochemical localisation of TGF-β-1,-2,-3 in normal lung sections was assessed using avidin-biotin-peroxidase and antibody to the TGFβ Bisoforms.
Results: Messenger RNA transcripts for TGF-β-1,-2,-3 were all expressed in the HASMC. The conditioned medium shows presence of bioactive TGF-β in the acid treated sample and by using the neutralising antibodies it demonstrated that all three isoforms are present in the conditioned medium. Very little TGFβ was present in the non-acid treated medium, implying that majority of the TGFβ secreted by the HASMC is in the biologically non-active form. The TGF-β bioactivity was significantly abrogated by panspecific antibody to TGF-β. Immunohistochemistry showed that all three isoforms of TGFβ were detected in the epithelial cells, smooth muscle cells, and macrophages.
Conclusion: This study demonstrates the expression of TGF-β isoforms in the lung, and suggest that autocrine/paracrine release of TGF-β by HASMC could play an important role in the remodelling of airway smooth muscle in asthma.
S56 IL-4 EXPRESSION IS INCREASED AND CO-LOCALISED TO MAST CELLS WITHIN THE AIRWAY SMOOTH MUSCLE IN ASTHMA
C.E. Brightling, F.A. Symon, S.T. Holgate1, A.J. Wardlaw, I.D. Pavord, P. Bradding. Division of Respiratory Medicine, Institute for Lung Health, Leicester, UK; 1University of Southampton, Southampton General Hospital, UK
Airway smooth muscle infiltration by mast cells is a key feature of asthma and not eosinophilic bronchitis (
). In asthma Th2 cytokines have been implicated as playing a critical role in the development of airway inflammation, but whether inflammatory cells within the airway smooth muscle release these cytokines is unknown.
We have undertaken a comparative immunohistochemical study in bronchial biopsies from 14 subjects with asthma, 10 with eosinophilic bronchitis and 8 normal controls recruited from two centres.
The median cells/mm2 smooth muscle were significantly higher in the subjects with asthma than eosinophilic bronchitis and normal controls for IL-4 (3H4)+ cells (2.4, 0, 0 respectively; p=0.001), and IL-4 (4D9)+ cells (1.6, 0, 0 respectively; p=0.02). There were significant differences in the median (range) cells/mm2 smooth muscle IL-5+ cells in the subjects with asthma 0 (0–1.7), eosinophilic bronchitis 0 (0–1.4) and normal controls 0 (0–0.3) (p=0.31). 94% of the cells expressing IL-4 (3H4) and 92% of those expressing IL-4+ (4D9) in the airway smooth muscle were mast cells. 55% of the mast cells within the airway smooth muscle co-localised to IL-4 (3H4) and 29% to IL-4 (4D9).
In asthma mast cells localised within the airway smooth muscle express IL-4 but not IL-5, suggesting that IL-4 may play an important role in mast cell-airway smooth muscle interactions.
Supported by the National Asthma Campaign.
S57 EFFECTS OF LONG ACTING β AGONISTS AND STEROIDS ON CYTOKINE EXPRESSION
H. Yanagawao, I.M. Adcock1, A.L. Hewitt2, H. Buck21National Heart and Lung Institute, Imperial College London, UK; 2Innovata Biomed Ltd, St Albans, UK
Rationale: In bronchial asthma treatment, combination therapy with inhaled corticosteroids and long acting β agonists (LAβA) can improve disease control. Since research suggests that ligand-independent activation of the glucocorticoid receptor (GR) by LAβA may aid steroid anti-inflammatory action, the functional consequence of GR nuclear translocation was examined via the effect of LAβA and steroids on cytokine production.
Methods: U937 cells were incubated with fluticasone, budesonide, formoterol and salmeterol, alone and in combination (10-6B10-11M), for 1 hour prior to lipopolysaccharide (LPS) stimulation. Secreted cytokines (GM-CSF, TNF-α, IL-1ra and IL-10) were quantified by ELISA.
Results: Addition of formoterol or salmeterol to steroid gave greater suppression of LPS-induced GM-CSF and TNF-α release compared with that observed with budesonide or fluticasone alone, although neither LAβA altered the steroid concentration-response curve. Additionally, both LAβA prevented steroid-induced repression of IL-1ra release. The actions of the LAβA differed with IL-10, where formoterol, in combination with fluticasone, enhanced production, whilst salmeterol did not increase LPS-induced IL-10 production compared with fluticasone alone.
Conclusions: These data indicate that the added benefit of formoterol may relate to the anti-inflammatory gene-inducing action of steroids rather than in enhancing the repressive functions of steroids towards inflammatory cytokines.
This study was sponsored by Innovata Biomed Ltd.
S58 LEUKOTRIENE RECEPTORS ON HUMAN EOSINOPHILS
H. Rupani, I. Hao, A.P. Sampson. Respiratory Cell and Molecular Biology Division University of Southampton School of Medicine
Cysteinyl-leukotrienes are potent bronchoconstrictor mediators and eosinophilotaxins released by mast cells and eosinophils within the asthmatic airway. These actions are thought to be mediated by CysLT1 receptors, with vascular effects mediated by CysLT2 receptors. CysLT1 expression on human eosinophils may be regulated by cytokines, but the effects of asthma therapies including corticosteroids and methylxanthines are unknown. Recently, eosinophils were reported to transcribe larger amounts of mRNA for CysLT2 than for CysLT1 (
). We investigated firstly whether CysLT1 on eosinophils is modulated by dexamethasone or theophylline, and secondly whether eosinophils also express CysLT2 receptors on their cell surface. Immunomagnetically-purified human blood eosinophils of normal and mild atopic volunteers were cultured in HEPES-buffered RPMI 1640 with 10% FCS for 22 hours in the presence or absence of dexamethasone (0.01–10μM) or theophylline (0.01–1mM). Basal expression of CysLT1 mRNA and protein was confirmed by RT-PCR, flow cytometry, immunocytochemistry, and immunoblotting. Flow cytometric expression of cell-surface CysLT1 declined during 22 hours culture from a median fluorescence intensity (MFI) of 4.96 (0.50) to 2.87 (0.23) arbitrary units (p<0.009; n=9). This decline was not observed in the presence of dexamethasone (1μM), with an MFI value of 4.01 (0.36) at 22 hours (p=0.044 v untreated). Theophylline (0.1mM) provided similar protection but this did not achieve statistical significance (p=0.056). In contrast to CysLT1, no CysLT2 expression was detectable by flow cytometry on the surface of live eosinophils, although these cells transcribed mRNA for CysLT2. Flow cytometry readily detected surface expression of CysLT1 and the chemokine receptor CCR-3 on eosinophils, while CysLT2 surface expression was detected on autologous blood monocytes and T-cells. We conclude firstly that dexamethasone may upregulate eosinophil expression of CysLT1 receptors, a paradoxical effect also observed for the LT-synthesising enzymes (
). Secondly, while CysLT2 mRNA may be transcribed, the receptor protein does not appear to be expressed on the surface of blood eosinophils from healthy donors.
S59 CAT-213, AN ANTI-EOTAXIN (CCL11) ANTIBODY, REVEALS A ROLE FOR EOTAXIN IN THE EOSINOPHIL CHEMOTACTIC ACTIVITY OF ASTHMATIC SPUTUM
G. Dent1, C. Hadjicharalambous1, J. Ward1, T. Yoshikawa1, G. Angco, D.E. Davies1, R. Louis2, R.L.C. Handy3, J. Powell3, I.K. Anderson3, R. Dukanović1. 1Respiratory Cell & Molecular Biology, University of Southampton School of Medicine, Southampton; 2Department of Pneumonology, University of Liége, Liége, Belgium; 3Cambridge Antibody Technology, Melbourn, Cambridgeshire, UK
To understand the mechanisms underlying eosinophilic airways inflammation in asthma, it is necessary to characterise the chemoattractants mediating eosinophil recruitment. The CC chemokines eotaxin (CCL11), eotaxin-2 (CCL24), RANTES (CCL5) and monocyte chemotactic proteins 2, 3 and 4 (CCL8, CCL7, CCL13) are potent eosinophil chemoattractants and are believed to play an important role in eosinophilic inflammation (
). Of these, eotaxin and eotaxin-2 act exclusively via the CC chemokine receptor CCR3 upon a restricted set of cells: namely eosinophils, basophils and Th2 lymphocytes. We have investigated the role of eotaxin in the eosinophil chemotactic activity of asthmatic airway secretions using a specific anti-eotaxin antibody, CAT-213.
Sputum samples were collected from 60 volunteers: 11 healthy controls, 12 mild asthmatics, 12 stable moderate asthmatics, 12 unstable moderate asthmatics and 13 severe asthmatics. Sputum was processed by thorough mixing with 4 volumes of phosphate-buffered saline (PBS) containing protease inhibitors. Cells and mucus were precipitated by centrifugation and supernatants were assayed for immunoreactive eotaxin by ELISA and for eosinophil chemotactic activity in a fluorescence-based modified Boyden chamber assay.
Sputum eotaxin concentration differed significantly among the subject groups (p=0.0096, ANOVA); group mean eotaxin concentration showed a significant linear trend v group number when groups were sorted by disease severity (P=0.0006), rising from 3.71 (1.07) pmoll-1 (mean (SEM)) in healthy controls to 35.9 (11.4) pmol l-1 in severe asthmatics. Eosinophil chemotactic activity also differed among groups (P=0.0073, Kruskal-Wallis) and showed a significant increase over healthy control in both moderate groups (P<0.05, Dunn=s test) and the severe asthmatic group (P<0.01). There was a significant linear correlation between chemotactic index and eotaxin concentration (P=0.008). CAT-213 (100 nm) caused significant inhibition of sputum chemotactic activity in the unstable moderate and severe asthmatic groups (P<0.001, paired ANOVA and Dunnett’s test), with a mean inhibition of 80 (13) % in the severe asthmatic group.
We conclude that eotaxin contributes significantly to the eosinophil chemotactic activity of asthmatic sputum. This contribution increases with disease severity. CAT-213 may provide therapeutic benefit in the treatment of severe asthma.
S60 DIFFERENTIAL ACTIONS OF PHOSPHATIDYINOSITOL 3-KINASE INHIBITORS ON HUMAN EOSINOPHIL CHEMOTACTIC RESPONSES TO PLATELET-ACTIVATING FACTOR AND EOTAXIN (CCL11)
R. Mishra, B.C. Gray, R. Djukanović, G. Dent. Respiratory Cell & Molecular Biology, University of Southampton School of Medicine, Southampton, UK
The signal transduction pathways that lead to chemotaxis of human eosinophils are incompletely understood but are believed to involve protein tyrosine kinase(s) and MAP kinase(s) but not protein kinase C (
). As MAP kinase activation by eotaxin in human eosinophils has been shown to occur downstream of phosphatidylinositol 3-kinase (PI-3K) activation (
), we investigated a possible role for PI-3K in the induction of eosinophil chemotaxis using the inhibitors wortmannin and LY294002 in human eosinophils stimulated with platelet-activating factor (PAF) or eotaxin (CCL11).
Eosinophils were isolated from the blood of atopic, non-asthmatic donors and chemotaxis was evaluated in a fluorescence-based 96-well blind-chamber assay. Calcein-labelled eosinophils (2H105) were pre-incubated for 30 min at 37EC in the absence and presence of wortmannin (0.1–100 nM) or LY294002 (0.1–100 μM) and placed in the upper wells of the chemotaxis chamber. Migration through 8-μm pore-size PVP-coated polycarbonate filters in response to PAF or eotaxin (both at 30 nM in the lower wells) was measured after 1 h as cell-associated fluorescence (λem=485 nm, λex=530 nm) in the lower wells.
PAF and eotaxin caused chemotaxis of eosinophils (geometric mean 19,140 (14,060–26,060) and 27,010 (15,310–47,640) cells well-1, respectively, above the background level of migration; n=12). Wortmannin caused concentration-dependent inhibition of PAF-induced eosinophil chemotaxis (IC50=1.24 nM (0.092–16.6 nM); n=6), with significant inhibition observed at 1 nM (P<0.0001), while responses to eotaxin were inhibited substantially less potently (IC50=17.6 nM (1.06–292 nM); n=6), with significant inhibition observed only at 100 nM (P<0.05). LY294002 also inhibited PAF-induced chemotaxis (IC50=0.76 μM (0.026–22.1 μM); n=6) but had no effect on responses to eotaxin (<50% inhibition at 100 μM; n=6).
We conclude that, although PAF and eotaxin both induce MAP kinase activation and chemotaxis in human eosinophils, PAF-induced chemotaxis is dependent upon the activation of PI-3K while the response to eotaxin involves PI-3K to a much lesser extent. This may indicate alternative pathways of activation of MAP kinases and chemotactic responses.
Ongoing management issues in cystic fibrosis
S61 STENOTROPHOMONAS MALTOPHILIA ACQUISITION IN CYSTIC FIBROSIS; A COMPLICATION OF ASPERGILLUS FUMIGATUS?
A. Equi, V. Marchac, C. Le Bihan-Benjamin, M. Hodson, A. Bush. Department of Respiratory Paediatrics and Department of Cystic Fibrosis Royal Brompton Hospital, London, UK; Service de Pneumologie et D’Allergologie et Bio-statistique et Informatique Medicale, Hopital Necker- Enfants Malades, Paris, FranceStenotrophomonas maltophilia (SM) is a Gram negative bacillus which is resistant to many antibiotics. Its role as a pulmonary pathogen in CF is still being defined.
Methods: The aim of this study was to use a case control design to describe the characteristics of CF patients isolating SM in sputum, to assess risk factor for acquisition of SM and to assess clinical outcomes. Data were collected on patients and controls between 1991 and 1999. A control patient had never isolated SM in sputum and was matched for age, sex and FEV1 (±10%). The following data were collected: FEV1, FVC; height and weight; sputum culture and antibiotic sensitivity; antibiotic use; oral steroid use.
Results: 63 patients isolated SM at least once. Controls were found for 52 patients. Prevalence of SM rose from 3.3 to 15% by 1999. Isolation of Aspergillus fumigatus (AF) was much more frequent in SM patients than controls, 51% v 8.9% (p=0.001, OR 5.9 (95% CI 2.0–17.8). The effect of AF was independent of steroid use. Post acquisition there was no difference between the two groups in mortality, antibiotic use, lung function or nutritional status. Antibiotic treatment had no impact on future isolation of SM.
Conclusions: This is the first documentation of an association of SM with AF isolation. We also can reassure patients that SM acquisition is unlikely to cause accelerated decline in clinical status.
S62 GENOTYPING PSEUDOMONAS AERUGINOSA IN CYSTIC FIBROSIS CLINICS: IMPLICATIONS FOR SEGREGATION
F.P. Edenborough, H.R. Stone, S.J. Kelly, P. Zadik1, J.R.W. Govan2. Adult Cystic Fibrosis Unit and 1Public Health Laboratory, Northern General Hospital, Sheffield, UK; 2Department of Medical Microbiology, University of Edinburgh, UK
We were concerned that the antiobiograms from patients harbouring Pseudomonas aeruginosa appeared to show increasing resistance, despite segregation policies initiated early in 1999. Genomic finger printing was performed on P aeruginosa isolates from 40 patients attending the clinic.
Twenty three (57%) had unique strains, 10 (25%) had strains indistinguishable from the “Liverpool” epidemic strain and 7 (17%) shared a common strain not previously seen, henceforth referred to as the “Sheffield” epidemic strain. 4/10 patients with the Liverpool strain had multiresistant (MR) organisms, compared to all 7 patients with Sheffield strain and only 1 patient (4%) out of the 23 with a unique strain. One patient harboured both Sheffield and Liverpool MR strains.
Those with the Sheffield MR strain were younger with poorer FEV1 and weight together with a higher proportion of F/F genotype, pancreatic insufficiency, diabetes mellitus and liver disease vs unique strains. Consequently numbers of clinic visits, days in hospital and time on intravenous antibiotics were increased. Comparison of Liverpool MR with Liverpool non-MR showed a similar pattern.
9/10 with Liverpool strains had been transferred from the paediatric unit since July 2000. MR strains being detected on the sputum sample taken when or in some cases before the patient first attended the CF Unit. Four of 7 Sheffield MR patients had also been transferred but all have been inpatients in the adult centre at the same time as subjects who were found to have Sheffield MR strains already (including 1 sibling pair). We suspect we have “imported” the Liverpool strain, which is known to become multiresistant from the paediatric unit, but the Sheffield strain is our own and is transmissible. If MR confers poor prognosis we believe these groups should be segregated from each other and those with unique strains, both as inpatients and in the outpatient clinic and have acted accordingly.
S63 RE-AUDIT OF THE SCREENING PROTOCOL FOR CYSTIC FIBROSIS RELATED DIABETES (CFRD) IN AN ADULT CENTRE
A. Verma, A. Claridge, T. Havelock, J. Biesty, D. McMenna, A.K. Webb. Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester M23 9LT, UK
Introduction: The average age of onset of CFRD is 18–21 years and is associated with a 6-fold increase in mortality and associated co-morbidity.1 Yung et al described annual oral glucose tolerance testing (OGTT) as being time and resource consuming for patients and staff.2 An earlier audit at our centre, using these selective screening criteria for OGT testing found that, the identified incidence of 1.9% was significantly less than the expected (4–6%) and concluded that only 52% of patients with CFRD would have been identified.3 Hence all patients were offered routine annual OGT testing.
Aims: To assess whether all patients received annual OGTT between 3.00–3.01. To assess the true incidence of CFRD at the Centre. To identify the CFRD patients who would have been “missed” if the old screening protocol were still in place. To calculate the sensitivity and specificity of the selection criteria in our population
Method: A retrospective review of case notes using the OGTT and HbA1c databases. 242 patients were identified but 91 patients excluded due to pre-existing CFRD at 01/03/2000 (n= 52), referred after 01/03/00 (n=13), care transferred to other centre (n=18), post-transplant (n=7), not CF (n=1).
Results: 89 OGTT were performed on 151 patients. The incidence was found to be 4.4% and the prevalence 26.9%. Using the previous selective screening protocol, 6 patients with CFRD and 10 patients with impaired glucose tolerance would have been missed. The total sensitivity and specificity of the screening criteria would only have been 70% and 51% respectively.
Conclusions: In view of the need for early diagnosis and treatment of CFRD, annual OGT testing is essential for all CF centres especially for adult patients. Selective screening does not identify all patients who need to be tested.
1. Moran et al.
2. Yung et al.
3. Verma et al. J of CF 2001;PS138.
S64 LUNG TRANSPLANTATION OUTCOME IN CYSTIC FIBROSIS PATIENTS WITH PREVIOUS PLEURAL PROCEDURES
H.J. Curtis, S.J. Bourke, P.A. Corris, J.H. Dark. Cardiothoracic Centre, Freeman Hospital, University of Newcastle upon Tyne, UK
Background: High post-operative mortality secondary to haemorrhage from pleural adhesions as a consequence of previous invasive pleural procedures (IPP) was reported in the early experience of lung transplantation. This observation led to IPP becoming a relative/absolute contra-indication to transplantation in some centres.
Aim: Comparison of post-operative outcome in patients with and without previous IPP, undergoing single sequential lung transplant (SSLT).
Method: Retrospective review of 3 groups of patients undergoing SSLT at this centre from 1989–2002. Group A: 17 cystic fibrosis (CF) patients with a history of previous pneumothorax (PTX) +/- IPP. Group B: 17 CF patients with no history of PTX. Group C: 17 non-CF/non-bronchiectatic (emphysema, fibrosing alveolitis or obliterative bronchiolitis) patients with no history of PTX. Patients were matched for year of transplantation to allow for changes in surgical technique. Measured outcomes included: pre- and post-operative haemoglobin; blood products given intra-operatively; operation and cardiopulmonary bypass times; post-op haemorrhage; times to extubation, ITU discharge and hospital discharge; FEV1 at 6 months; 30 day mortality; and adhesions scored descriptively via pathology reports.
Conclusion: Patients with CF and previous PTX +/- IPP undergoing SSLT have more dense pleural adhesions and increased requirement for blood transfusion. However this does not significantly affect surgical outcome. Patients with emphysema, fibrosing alveolitis or obliterative bronchiolitis were significantly more likely to be free of pleural adhesions at operation B suggesting that the inflammatory/chronic infective component of CF independently contributes to the increased pleural adhesions. Previous IPP for PTX should not be considered a contra-indication in the assessment of suitability for lung transplantation.
S65 PULMONARY ARTERY PRESSURE AND RIGHT VENTRICULAR FUNCTION IN CYSTIC FIBROSIS ADULTS
R.J. Bright-Thomas1, M.I. Burgess2, M.E. Dodd1, S.G. Ray2 , A.K. Webb1. 1Adult Cystic Fibrosis Centre; 2Department of Cardiology, Wythenshawe Hospital, Manchester, UK
Introduction: Pulmonary hypertension has been reported as a poor prognostic marker in adult CF patients with severe disease. We evaluated the association between clinical status, oxygen status, pulmonary artery pressure and right ventricular (RV) function in a cross-section of CF adults.
Methods: CF adults and healthy volunteers were studied. Demographic and clinical data collected. Patients were stable at the time of study. All subjects underwent echocardiographic examination by a trained operator (RBT). Pulmonary artery systolic pressure (sPAP) was measured from the peak velocity of tricuspid regurgitant jets. Systolic function of the RV assessed via measurement of RV dimensions and tricuspid long axis motion (TLAM) and diastolic function via measurements of transtricuspid flow profile.
Results: 65 CF adults age, mean (SD), 26.1(7.1) years and 25 healthy controls age 27.7 (8.8) years were studied. Partial pressure of oxygen (PO2)(mmHg) 68.8 (12.2) v 90.1 (9.7) (p<0.001) and FEV1 percentage predicted (FEV1%) 47.0 (21.7) v 98.1 (9.8) (p=<0.001) respectively. sPAP(mmHg) was 35.8 (9.7) in CF patients and 21.6(3.2) in controls (p<0.001). 36 patients and 0 controls had sPAP>30mmHg. There was no significant difference in RV dimensions between groups. TLAM(cm) was reduced in CF patients compared to controls 2.1 (0.4) v 2.5 (0.3) (p<0.001). There was a significant difference in the diastolic variables A wave velocity and E/A ratio between patients and controls; values (CF v control): Avel(cm/sec) 45 (13) v 29 (6) (p<0.001), E/A ratio 1.4 (0.5) v 1.8 (0.3) (p<0.001). Pearson correlation of CF patient data identified significant correlations between both PO2 and FEV1% with sPAP (r=-0.516, p<0.001; r=−0.432, p=0.001) and TLAM (r=0.459, p<0.001; r=0.620, p<0.001) respectively. An association was also found between diastolic variables and PO2 and FEV1%: Avel (r=−0.311, p=0.012; r=−0.420, p=0.001), E/A ratio (r=0.302, p=0.015; r=0.412, p=0.001) respectively.
Conclusion: Pulmonary artery pressure is raised in adult CF patients. RV dimensions are normal in CF but there is evidence of deranged RV systolic and diastolic function. Both PO2 and FEV1% correlate with sPAP and measures of RV function. Whether the abnormal RV function is due to the effect of hypoxia on the RV or due to pulmonary hypertension is unclear.
S66 INCREASED ENERGY COSTS DURING UPPER AND LOWER LIMB ACTIVITIES IN ADULTS WITH CYSTIC FIBROSIS
A.A. Jonescu, T.D. Mickleborough1, K. Chatham, M. Lindley1, R. Colasanti2, I.S. Nixon, C.E. Bolton, D.J. Shale. 1Section of Respiratory Medicine, School of Sports Science, University of Wales Institute Cardiff and School of Applied Sciences; 2University of Glamorgan, University of Wales College of Medicine, Cardiff, UK
Patients with Cystic Fibrosis (CF) have increased resting energy expenditure, which may be associated with altered body composition. We hypothesised that adults with CF have increased energy costs during skeletal muscle work. Twelve patients were studied after 2 weeks treatment for an exacerbation (to assess them with their best lung function); mean (95%CI) age 24.6 (21.4, 27.8) years, FEV1 51.3 (36.3, 66.2) % predicted, body mass index 21.5 (20.8, 22.2) kg/m2. Fat free mass index (FFMI, kg/m2) was assessed by anthropometrics. Ten healthy subjects were studied, age 32.1 (27.9, 36.1) years. Energy expenditure (EE, kJoule (kJ)/kg/min) was calculated from breath by breath O2 uptake and CO2 output measured with a mask (K4b, Cosmed). Subjects completed the following: 10 handgrips (HG, force in cm H2O), 1/second; 10 steps (20 cm high), 1/second, and 10 lifts of a 1 kg weight through 80 cm height, 1every 2 seconds. EE ratio to the work performed and the recovery time after each activity were calculated.
EE ratio to the work performed during HG and stepping, but not during lifting were greater in patients (table). The recovery time was greater for patients than healthy subjects for HG (46.4 (29.9 to 62.9) and 21.6 (10.9 to 32.3) seconds, p=0.02) and stepping (70.7 (47.2 to 94.2) and 28.9 (16.6 to 41.2), p=0.002), but not lifting (35.9 (26.7 to 45.1) and 28.6 (17.7 to 39.4), p=0.3). FFMI was inversely related to EE during HG, (r=−0.75, p=0.005).
Adults with CF have greater energy expenditure for upper and lower limb muscle work. This excess energy expended for tasks similar to those of daily living suggests physical activity in such patients adds to the potential for negative energy balance and weight loss.
Supported by the Cystic Fibrosis Trust UK.
Issues in paediatric lung disease
S67 EFFECT OF β-2 ADRENOCEPTOR (β2-AR) POLYMORPHISMS ON NEONATAL LUNG FUNCTION AND ASTHMA IN SCHOOL CHILDREN
N.M. Wilson1, J.C.W. Mak2, J. Lamprill, H. Bilolikar, J.R. Clarke, A. Bush, M. Silverman3. 1Department of Paediatrics and 2Respiratory Medicine, Royal Brompton Hospital, Imperial School of Medicine, London, UK; 3Department of Child Health, University of Leicester, Leicester, UK
An association between neonatal bronchial responsiveness (BR) and lung function at 11 yr, related to β-2AR gene influence, has been reported (
). Polymorphisms of β2-AR at amino-acid (aa) 27 and aa16 have also been shown to be related to bronchial BR and childhood asthma. To assess the effect of these polymorphisms on the development of wheeze, lung function and BR, we genotyped from blood or buccal cells 41 children at risk of atopy, in whom maximal flows at FRC (VmaxFRC) and BR had been measured in the first month of life using the “squeeze” technique. They were followed prospectively and reviewed at age 10 yr (SD 0.8), when lung function (FEV1) and BR were repeated. We also genotyped 166 local school children from buccal cells
Neonatal BR correlated significantly with FEV1 (p=0.03) but not BR at 10 yr. VmaxFRC varied according to aa27 genotype (ANOVA p=0.023); it was significantly increased in those homozygous for glutamate at aa27 (p=0.01), but had no effect on history of wheeze. No effect of aa16 was found on lung function or BR at either age, but homozygous glycine at aa16 was seen more frequently in those wheezing beyond 4 years, when compared to local school children (Fischer’s exact test p=0.05).
We have shown for the first time an effect of β2-AR polymorphism at aa27 on neonatal lung function, and confirmed the association of β2-AR polymorphism at aa16 with childhood asthma, as wheeze beyond 4 years was strongly related to atopy and increased BR at 10 yr.
S68 PNEUMOCOCCAL SEROTYPES IN CHILDREN WITH CULTURE NEGATIVE EMPYEMA
K.M. Eastham1, R. Freeman2, A. Kearns2, G. Eltringham2, J.P. Leeming3, J. Clark4, D.A. Spencer1 . 1Freeman Hospital, Newcastle Upon Tyne, 2Newcastle Public Health Laboratory , 3Bristol Public Health Laboratory, 4Newcastle General Hospital, Newcastle Upon Tyne, UK
Background:Streptococcus pneumoniae serotype 1 accounts for up to 50% of pneumococcus culture positive childhood empyema in the USA.1 This organism has been a relatively uncommon cause of invasive pneumococcal disease in the under 5 age group in England and Wales.2
Aim: To describe the pneumococcal serotype distribution and penicillin susceptibility of consecutive cases of parapneumonic effusion and empyema presenting to a Tertiary Referral Centre over a 4.5 year period.
Method: 43 pleural fluid specimens, negative for pneumococcus on routine culture, were analysed for pneumococccal DNA by real-time polymerase chain reaction (PCR). Penicillin susceptibility was determined by a complementary PCR assay. Capsular serotype specific antigen detection was by Enzyme Immuno-Assay (EIA) using monoclonal antibodies to types 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F.
Results: The median age was 5.6 years (0.6–16.9 years). All pneumococcal DNA positive specimens were penicillin sensitive.
Conclusions: Pneumococcus is the major pathogen in childhood empyema, accounting for 75% of culture negative cases. Capsular antigen detection indicates that 63% of are serotype 1, paralleling culture-based studies.1 These data have implications for vaccine development strategy, as the new 7-valent pneumococcal vaccine does not protect against serotype 1. Penicillin resistance does not appear to be a problem in our population.
1. Byington CL, et al.
2. George AC, Melegaro A.
S69 RESPIRATORY DISEASE IN CHRONIC GRANULOMATOUS DISEASE
L. Jones1, T.J. Flood2, P. McGrogan1, L. Morton3, L. Parker1, D. Goldblatt3, A. Thrasher3, A.J. Cant2. 1Department of Child Health, University of Newcastle; 2Department of Paediatric Immunology, Newcastle General Hospital; 3Institute of Child Health, Great Ormond Street Hospital, University College London, UK
Chronic Granulomatous Disease (CGD) is a rare primary immunodeficiency due to defective phagocytic cell oxidative burst, rendering patients susceptible to severe recurrent bacterial and fungal infections. Recurrent respiratory infection is a common presenting feature.
Objectives: To describe the common pathogens causing pneumonia in these patients in the UK and review their lung function.
Methods: The first national survey of CGD patients was started in 2000 and aimed to characterise the epidemiological and clinical features of CGD.
Results: Of 82 patients analysed to date, aged 0–60 years, 39 (48%) have suffered from pneumonia and 7 (9%) from lung abscesses. 85 episodes of probable pneumonia were recorded with x ray changes documented in 65 (77%) of these. Organisms were isolated in 37 cases (44%). However Staphylococcus aureus and Burkholderia, respiratory pathogens previously reported in other series,1 only accounted for 5 cases. Aspergillus was isolated in 10 and suspected in a further 12 cases. Of the 11 documented cases of lung abscess, Staphylococcus species and Aspergillus species were isolated in 4 cases, however Streptococcus milleri was also isolated from 2 patients. 4 patients suffered from their first episode of pneumonia before the age of 1 year, a further 5 before the age of 5 years and a further 14 before the age of 15. Lung function is documented in 15 patients who had pneumonia (39%) and in an additional 7 patients. Of the 16 patients for whom heights are available, 3 demonstrated a restrictive pattern, 3 an obstructive pattern and 10 had normal lung function.
Conclusion: Pneumonia is the most common infection encountered in patients with CGD across all age groups and is typically caused by Staphylococcus aureus, Burkholderia cepacia, and Aspergillus species. Surprisingly Burkholderia accounted for only 2 cases in this series. Monitoring lung function is essential in CGD and further prospective studies to delineate the extent of occult pulmonary morbidity are indicated.
1. Winkelstein JA, et al. Medicine 2000,79:155–69.
S70 EXERCISE LIMITATION IN CF AND NON-CF BRONCHIECTASIS
I. Narang, E. Edwards, A. Li, D. Hansell, M. Rosenthal, A. Bush. Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
Non-CF bronchiectasis (Bx) is an orphan disease; little is known about exercise physiology.
Aims: (1) To compare factors limiting exercise in CF and non-CF Bx compared to normals; (2) To establish whether chest CT is a useful indicator of functional capacity in either disease.
Methods: Clinical assessment, spirometry, chest CT and incremental exercise test using cycle ergometry and respiratory mass spectrometer were performed at a time of disease stability. We measured effective pulmonary blood flow (Qeff), oxygen consumption (VO2), effective stroke volume (SV), alveolar ventilation (VA), transfer factor (DLCO), and functional residual capacity (FRC). Heart rate (HR) and oxygen saturations (SaO2) were measured by continuous pulse oximetry. The CT scans were scored using a modification of the Bhalla system.
Results: We compared 18 children with CF (7 males; median age 13 years (range 10.7–17) median FEV1 76% predicted (range 40–95%), and 17 children with non-CF Bx (7 males; median age 13 years (range 10.6–17.1) median FEV1 74% predicted (range 47–90%). Data are expressed as mean z scores derived from normal values at rest and at maximum exercise (MEX) in 106 normal children:
Conclusions: In both groups Qeff was abnormally low at rest and did not increase normally during exercise in spite of an increased heart rate, due to SV limitation during exercise. A low Qeff with a high VA and a low FRC is evidence of significant mismatching during exercise. There was no correlation between CT and any exercise parameter in either group. Since the haemodynamic and functional impairment is similar in non CF BX as in CF. More attention should be paid to this neglected disease.
S71 RESPIRATORY SYMPTOMS IN CHILDREN WITH DOWN’S SYNDROME
N. John1, K. Williams2, I.J.M. Doull1. 1Cystic Fibrosis/Respiratory Unit, Department of Child Health, University Hospital of Wales, Cardiff, UK; 2University of Leeds, UK
Background: Children with Down’s syndrome (DS) are at increased risk of hospitalisation due to respiratory disorders. Although anecdotally they report frequent respiratory symptoms, objective evidence is lacking.
Aims: To compare parental reported respiratory symptoms of children with DS with normal controls.
Methods: Questionnaire survey of all children with DS under 12 years of age in the Bro Tâf Health Authority. Families completed questionnaires for any unaffected sibling(s) as controls. The questionnaire was based on the ISAAC core questions, with additional sections on upper airway and cardiac disease.
Results: Questionnaires were received on 65 children with DS (38 male) and 35 controls (24 male). There was no significant difference in mean age between the 2 groups: DS mean (SD) 6.5 (2.8) years (range 1.4–11.1); controls 5.6 (2.9) years (range 0.3–10.8). Children with DS had significantly greater ever wheeze (OR 10.1; 95% CI 3.8–26.6); wheeze in the preceding 12 months (OR 10.2; 95% CI 3.5–29.9); wheeze during exercise (OR 4.2; 95% CI 1.1–15.6); use of anti asthma medication (OR 3.5; 95% CI 1.3–9.6), but were no more likely to be labelled asthmatic. Children with DS had significantly greater chest congestion or phlegm with (OR4.1; 95% CI 1.7–10.0) or without (OR 18.3; 95% CI 2.3–143) a cold, were receiving nasal medications (OR 8.3; 95% CI 2.6–26) but were no more likely to be labelled rhinitic. Twenty-one DS and 1 control reported a cardiac condition. After excluding these cases, most relationships with wheeze, chest congestion, and coughing up phlegm with or without a cold persisted.
Conclusions: Children with DS have significantly greater respiratory symptoms than normal—wheeze, chest congestion, and coughing up phlegm with or without a cold. The aetiology of symptoms is unclear, but do not appear related to cardiac conditions.
S72 ESTIMATES OF PLETHYSMOGRAPHIC FRC EXCEED THOSE BY GAS DILUTION IN INFANTS WITH CYSTIC FIBROSIS (CF) BUT NOT IN HEALTHY CONTROLS
H. Ljungberg2, G Hulskamp2, A.-F. Hoo2, J. Pillow2, S. Lum2, P. Gustafsson2, J. Stocks1. 1Portex Respiratory Unit, Institute of Child Health, London, UK; 2Queen Silvia Children’s Hospital, Göteborg, Sweden
Involvement of the peripheral airways is an early feature of CF lung disease and may result in pathological gas trapping. This is reflected by the difference between plethysmographic and gas dilution estimates of functional residual capacity (FRC) in older children and adults.
Aim: To compare paired measures of FRC using plethysmography (FRCp) and multiple breath inert gas washout (FRCmbw) in infants with recently diagnosed CF and healthy control infants.
Methods: 21 infants with CF, median age (range) 36 (10–83)w, and 20 healthy control (HC) infants 42 (5–91)w were studied during quiet sleep. FRCmbw was measured using a respiratory mass spectro-meter with SF6 as the tracer gas, and determined from the cumulative volume of expired gas divided by the difference between end-tidal gas concentration at start and at the end of the washout. FRCp was measured immediately afterwards according to ERS/ATS guidelines (
) using commercially available equipment (Jaeger MasterScreen BabyBodyplethysmograph).
Results: The mean within-subject coefficient of variation for FRCmbw and FRCp was 3.0% and 2.9% respectively.
Summary: In healthy infants, there was no difference in FRC as measured by plethysmography and inert gas washout, and there was no difference in FRCmbw when comparing HC and CF. In infants with CF, however, the FRCp was significantly elevated not only compared to HC (p=0.001), but also compared to FRCmbw in the CF group itself (p=0.01).
These findings may be explained by pathological gas trapping. Paired measurements of FRC using these two techniques may provide a sensitive and useful method for early detection of pulmonary changes in CF.
Henrik Ljungberg is supported by an ERS Long Term Research Fellowship.
Mechanisms of cough
S73 RELATIONSHIP BETWEEN CAPSAICIN COUGH SENSITIVITY AND QUALITY OF LIFE IN PATIENTS WITH CHRONIC COUGH
S.S. Birring, B. Prudon, I.D. Pavord. Institute for Lung Health, Respiratory Medicine, Glenfield Hospital, Leicester, UK
Most patients with a chronic cough have a heightened cough reflex. Little is known about how this relates to patients perception of cough severity or the degree to which the cough impacts on quality of life. We have assessed the relationship between capsaicin cough sensitivity, cough visual analogue score and quality of life in 26 patients with chronic cough presenting to our outpatient clinic. All patients had (1) capsaicin cough reflex sensitivity measured using a dosimeter with the results expressed as the concentration of capsaicin (ìmol/L) causing 2 (C2) and 5 (C5) coughs, (2) cough visual analogue score (VAS; 0–100mm), (3) cough specific quality of life measurement using the Leicester Cough Questionnaire (LCQ). The LCQ is a 19-item self-administered health related quality of life questionnaire for patients with chronic cough that has 3 domains (physical, psychological and social; domain score range 1–7, total score 3–21; higher score indicated better quality of life) and a 7-point Likert response scale. We have previously shown that the LCQ is a fully validated, reliable, repeatable and responsive instrument that is brief and easy to administer. The patients were 62% female, mean (SEM) age 57 (3) years and had a mean (SEM) cough duration of 69 (23) months. The mean (SEM) cough VAS score was 53 (6) mm; logC2: 0.57 (0.08); logC5 1.41 (0.18) μmol/L; physical domain score: 4.7 (0.3); psychological domain score: 4.8 (0.3); social domain score: 4.8 (0.3); LCQ total score: 14.4 (0.8). There was no correlation between logC2 and logC5 and the LCQ total score (r=0.19 and 0.23 respectively), the individual LCQ domain scores or the cough VAS score (r = −0.32 and B0.34 respectively). In conclusion, we found no relationship between quality of life or symptom scores and capsaicin cough reflex sensitivity in patients with chronic cough. Our results suggest factors other than a heightened cough reflex are important in how a patient perceives the severity of their cough, or how it impacts on their quality of life. These measures assess different aspects of cough and therefore may provide complimentary information.
Supported by the British Lung Foundation and University Hospitals of Leicester NHS Trust.
S74 REPEATABILTY OF CAPSAICIN COUGH REFLEX SENSITIVITY MEASUREMENT
B. Prudon, S.S. Birring, D.D. Vara, I.D. Pavord. Institute for Lung Health, Department of Respiratory Medicine, Glenfield Hospital, Leicester, UK
Although widely used in clinical practice and research, little is known about the validity and repeatability of capsaicin cough sensitivity in healthy adults and patients with chronic cough. We measured capsaicin cough reflex sensitivity in 134 healthy subjects and 85 patients with an isolated chronic cough using a KoKo Digidoser with an inspiratory flow regulator valve (0.5L/s). Two-week repeatability was assessed in 15 healthy subjects and 15 patients with chronic cough. Healthy subjects (mean age 42 years (range 20–78), female 62%) had a wide variation of capsaicin cough sensitivity (mean log capsaicin concentration that causes 2 coughs C2 (SD) 1.2 (0.8) and 5 coughs (C5) 2.7 (1.8) μmol/L). There was no correlation between age and logC2 (r=−0.1) or logC5 (r=−0.1). Females had significantly raised capsaicin cough sensitivity compared to males (logC2: 1.0 v 1.4; mean difference 0.4; 95% confidence interval 0.1 to 0.8; p=0.01 and logC5: 2.3 v 3.3; mean difference 1.0; 95% CI 0.2 to 1.8 μmol/L; p=0.01). Patients with chronic cough were significantly more sensitive than healthy subjects (mean age 59 (range 27–83), female 64%; logC2: 0.5 v 1.2; mean difference 0.7; 95% CI 0.5 to 0.9; p<0.001 and log C5: 1.3 v 2.7; mean difference 1.4; 95% CI 0.9 to 1.8; p<0.001). The capsaicin cough reflex sensitivity measurement was repeatable over 2 weeks in both healthy subjects (mean of difference (within subject SD): logC2 −0.2 (0.2), logC5 −0.4 (0.5) μmol/L; intraclass correlation coefficients 0.9 and 0.9 respectively), and patients with chronic cough (mean of difference (within subject SD): logC2 B0.1 (0.2), logC5 B0.3 (0.5); intraclass correlation coefficients 0.6 and 0.7 respectively). We have shown a wide variation of capsaicin cough reflex sensitivity in health which potentially limits the use of this method as a discriminatory test. We have also demonstrated an effect of gender but not age on capsaicin cough reflex sensitivity measurement highlighting the importance of matching subjects when making comparisons using this test. Capsaicin cough reflex sensitivity measurement is a repeatable test over 2 weeks (C2 more than C5) in both healthy subjects and patients with chronic dry cough. These data would be useful for powering clinical studies of antitussive drugs.
Supported by BLF and PPP Healthcare Trust.
S75 UPPER AIRWAY SENSITIVITY IN SUBJECTS WITH A CHRONIC NON-PRODUCTIVE COUGH
B. Prudon1, S.S. Birring1, A.P. Hall2, J.P. Thompson2, I.D. Pavord1. 1Institute for Lung Health, Respiratory Medicine, Glenfield Hospital, Leicester, UK; 2Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK
Subjects suffering from a chronic non-productive cough usually have a heightened cough reflex compared to healthy subjects. Whether this phenomenon is confined to the cough reflex, or whether other upper airway reflexes are also abnormal is unknown. We measured the sensitivity of the “Glottic-stop reflex” (a reflex closure of the vocal cords in response to inhaled irritants), and the capsaicin cough reflex sensitivity in 16 healthy subjects and 14 subjects with a chronic cough (cough subjects were predominantly female (81%) and the causes of cough were idiopathic chronic cough (11), cough variant asthma (1), rhinitis (1) and rhinitis and gastro-oesophageal reflux (1). Glottic stop sensitivity was measured using a previously validated non-invasive technique1 in which subjects inhaled single breaths of increasing concentrations of ammonia and adduction of the vocal cords was detected using a pneumotachograph. Cough sensitivity was measured at the same time of day on a different occasion greater than 1 week apart with a single-breath dosimeter method, using capsaicin as the tussive agent and results expressed as the log of concentration (μmol/L) required to cause 2 coughs (C2). Cough subjects had a significantly more sensitive glottic stop reflex and capsaicin cough reflex sensitivity compared to age and sex matched healthy subjects (mean glottic reflex sensitivity threshold: 483 v 1029 ppm; mean difference 546ppm, (95% Confidence Interval 137 to 954], p=0.01; logC2: 0.3 v 1.1; mean difference 0.7, (95% CI 0.4 to 1.1), p<0.001). Glottic stop reflex sensitivity correlated significantly with cough reflex sensitivity (r=0.5, p=0.006). These results suggest that the cough reflex and the glottic stop reflex share a common pathway, or that subjects who have a chronic cough have a global abnormality of upper airway reflexes. Further investigation of possible common mechanisms sensitising these two reflexes may lead to a greater understanding of chronic cough, and lead to new targets for antitussive medications.
1. Langton JA, et al.
S76 ASSOCIATION BETWEEN COUGH AND REFLUX EVENTS IN PATIENTS WITH CHRONIC COUGH WITH AND WITHOUT GASTRO-OESOPHAGEAL REFLUX
J.A. Kasterlik, I.P.A. McGarvey, S.A. Mulrennan, B. Johnston, J.C. Ojoo1, A.E. Redington1, A.H. Morice1. 1Academic Department of Medicine, University of Hull, Castle Hill Hospital, Cottingham, UK; 2Department of Medicine, Queen’s University Belfast, UK
Background: Gastro-oesophageal reflux (GOR) is a common cause of chronic cough, but the mechanisms of GOR related cough are not fully understood.
Aim: To determine the association between cough and reflux events in patients with chronic cough due to GOR and due to causes other than GOR.
Methods: 60 patients with undiagnosed chronic cough aged mean (IQR) 55 (49–62) yr with cough duration 8 (1.5–10) yr underwent 24-h pH monitoring during which cough and reflux events were recorded. GOR related cough was diagnosed when pH<4 was recorded for >4% of total time and when cough improved with subsequent antireflux therapy. A reflux event was defined as a drop of pH<4 for >12 sec. Cough was considered associated with reflux when it occurred within 5 min from reflux.
Results: 29 patients had GOR related cough. The other 31 patients had normal 24-pH monitoring, and cough was either due to asthma or rhinosinusitis or was idiopathic. The total number of coughs did not differ significantly (p=0.85) between patients with GOR (9 (5–17)/24 hr) and without GOR (8 (6–16)/24hr). Patients with GOR related cough had 20 (10–31)% of coughs associated with reflux, compared with 0(0–7)% in patients without GOR (p<0.001). In patients with GOR related cough, 7 (1–10)% of total reflux events occurred within 5 minutes before cough, compared with 1 (0–2)% in patients without GOR (p<0.001). In patients with GOR related cough 6 (4–6)% of reflux events occurred within 5 min after cough, compared with 3 (0–2)% in patients without GOR (p=0.002).
Conclusions: In GOR related chronic cough, reflux and cough events are frequently associated. In patients with other causes of chronic cough, in contrast, this association is infrequent.
S77 SMOKING, SALBUTAMOL, AND THE COUGH REFLEX
S.A. Mulrennan1, J.C. Ojoo1, J.A. Kastelik1, C. Wright1, R.H. Thompson1, A.E. Redington1, P. Goustas2, A.H. Morice1. 1Academic Department of Medicine, University of Hull, Castle Hill Hospital, Cottingham, UK; 2GlaxoSmithKline, Stockley Park West, Uxbridge, Middlesex, UK
Background: Smokers have an increased prevalence of chronic cough. Patients frequently complain of exacerbation of cough when attempting smoking cessation.
Hypothesis: Do cigarettes affect cough in smokers and does salbutamol have antitussive properties in smoking related cough?
Methods: A randomised double blinded crossover study to determine the efficacy of 400 μg salbutamol via MDI plus spacer versus placebo on cough before and after the first cigarette of the day in healthy adult smokers. Medication was given at time 0 minutes. Number of coughs were recorded from 0–10 and 10–20 min using a voice activated analogue tape recorder. Coughs following a cigarette at 20 minutes were observed at 20–40 and 40–60 min. Citric acid cough challenge was performed at 60 minutes after medication.
Results: 44 healthy smoking subjects (13 females), mean age 34 (range 20–61) were recruited. Cigarettes significantly reduced cough in those on placebo. Mean cough frequency per minute 20 minutes pre cigarette was 0.3 compared to 0.2 post cigarette (p=0.02). Cough frequency did not reduce significantly pre and post cigarette in those taking salbutamol. Mean 0.23 versus 0.19 respectively (p=0.116). The citric acid concentration causing two coughs (C2) at 60 minutes increased on salbutamol. Geometric mean 278.8 compared to 190.4 mM on placebo (p=0.03).
Conclusions: Cough is reduced by the morning cigarette and this corroborates smokers observations of increased cough on smoking cessation and the “beneficial” effect of smoking on that symptom. The absence of a significant difference in cough before and after smoking a cigarette and the increase in C2 suggests that β agonists may be useful in cough associated with cigarette abstinence. The effect of salbutamol is however small and other more potent and longer acting agents may prove more effective.
Funded by GlaxoSmithKline.
S78 CHOCOLATE, CHILLI PEPPER, AND COUGH
O.S. Usmani, H.J. Patel, M.G. Belvisi, P.J. Barnes. Department of Thoracic Medicine, National Heart and Lung Institute, Imperial College School of Medicine, London, UK
Cough is the most common respiratory symptom for which medical attention is sought. It may become debilitating and socially distressing, and a recent meta-analysis showed that most OTC remedies were ineffective against cough. Opiods are often used, but have unpredictable efficacy and side-effects. There is great need for effective therapies. Capsaicin, derived from chilli peppers, is a well-established, reproducible, tussive stimulant widely used in clinical research to test the efficacy of new cough treatments. We describe theobromine, a methylxanthine derivative present in cocoa and chocolate, as an effective anti-tussive agent able to elevate the capsaicin induced cough threshold in healthy volunteers.
Ten healthy non-smoking subjects participated in a randomised double blind cross-over study. The anti-tussive effect of a single-dose of theobromine (1000mg) was compared to codeine phosphate (60mg) and placebo. The main outcome measure was the capsaicin concentration required to induce five coughs (C5). Subjects had their screening C5 value established, and at each treatment visit their C5 threshold was determined 2 hours post-dosing. The mean C5 values between treatments were compared using two-way ANOVA.
Theobromine was markedly able to increase the cough threshold when compared to codeine phosphate (p=0.07) and placebo (p<0.01). There was no significant difference between codeine and placebo (p=0.25). The C5 variability was similar between the placebo and screening values, supporting the reproducibility of the capsaicin challenge in this subject group. No adverse effects, particularly CVS or CNS, were observed.
Although the anti-tussive mechanisms remain unknown, preliminary data have shown direct inhibition of sensory nerve depolarisation in isolated guinea-pig vagus. Theobromine has been shown to possess anti-angiogenic properties through its action on adenosine (A2) receptors, and it also has weak phosphodiesterase inhibiting activity. It may act on the capsaicin vanilloid receptor (VR1). Elucidation of the molecular targets using in vitro and animal models, will help development of novel therapeutic entities.
In conclusion, the data suggest a significant anti-tussive effect of theobromine in healthy subjects when compared to placebo. Further studies are needed in select patient categories to see whether these phase I effects are borne out.
Issues in non-invasive ventilation
S79 A SURVEY OF HOME MECHANICAL VENTILATION IN THE UK
S.J. Lloyd-Owen1, M.W. Elliott2, A.K. Simonds3, J.A. Wedzicha1. European Union Concerted Action on Home Respiratory Ventilation, 1St Bartholomew’s Hospital, London; 2St James’s University Hospital, Leeds; 3Royal Brompton Hospital, London
As part of a European-wide Project, a survey of custom and practice in Home Mechanical Ventilation (HMV) was carried out in the UK. 80 known and possible HMV centres were targeted with initial requests, of which 65 responded. 13 of these did not have any HMV users. Full surveys were received from 47 centres (at least 70% response rate). 7 of these were paediatric centres. The answers reflected the situation on the 1st July 2001. A total of 2842 HMV users were identified in the UK by the 47 centres. The median size of the units was 18 users (IQR 6.5 to 46.5), with 7 centres having more than 100 users. 96% of the users had their HMV initiated at that centre with 13% having some form of shared care between units. 27 centres described themselves as University hospitals (57%) with 18 non-University hospitals (38%) and 1 Outpatient facility (no data for 1 centre). 26 of the centres took referrals, either regional only (18) or regional and national (8). The median year of each centre starting HMV was 1992 (IQR 1987 to 1996). The users’ characteristics were: 55% male, 45% female; ages: 16 years or less: 7%, 17 to 25 years: 7%, 26 to 65 years: 59%, 66 years or more: 27%. 21% had been on HMV for less than 1 year, 52% for 1 to 5 years, 23% for 6 to 10 years and 4% for more than 10 years. The conditions requiring ventilation were categorised into 3 groups with lung and airways diseases (LA) in 26%, thoracic cage (TC) problems in 35% and 39% neuromuscular (NM). Pressure preset positive pressure ventilators (PP) were used most often (92% overall) with relatively more volume preset ones (VP) in the TC and NM groups (LA: 95% PP, 5% VP; TC: 91% PP, 9% VP; NM: 89% PP, 11% VP). Nasal (N) and facial (F) masks were predominant in all groups with tracheostomy (T) used more frequently in the NM group (LA: 77% N, 22% F, 1% T; TC: 86% N, 13% F, 1% T; NM: 65% N, 18% F, 17% T). 24 hour ventilation was also commoner in the NM group (12% compared to 1% for LA and TC). Concomitant oxygen use was more frequent in the LA group (LA: 61%; TC: 16%; NM: 8%). Indications for ventilation and tracheostomy use and investigations were consistent across centres, but there was variability in the provision of follow up, training and homecare.
Funded by the European Commission.
S80 RESPIRATORY FAILURE: EARLY NON-INVASIVE VENTILATION (NIV) USE IN A DISTRICT GENERAL
R. Rabanni, W. Heberlein, J. Wilson, R. Hayton1, M. Al-Jibry, H. Moudgil. Departments of Respiratory Medicine and 1Clinical Audit, Princess Royal Hospital NHS Trust, Telford, UK
Severe respiratory acidosis ([H+] >55 mmol, pH<7.26) predicts mortality in exacerbation of chronic obstructive pulmonary disease (COPD). Non-invasive ventilation (NIV) is an effective alternative to intubation and mechanical ventilation and is justified in milder respiratory acidosis (pH 7.35 to 7.26) associated with exacerbation of COPD. To assess our use in the first year since introduction (to December 2001) we have retrospectively audited our management of patients with hospital discharge codes for COPD or respiratory failure. Where results from arterial blood gas (ABG) samples were available (n=239, 46%), 60 had type 2 respiratory failure complicated by acidosis. Of the others, 74 had type 1 respiratory failure, 48 had compensated type 2 respiratory failure, 10 had metabolic acidosis, 2 had hyperventilation, and 45 had no respiratory failure. Of those with respiratory acidosis (n=60), 15 were excluded from NIV; reasons included post-arrest, respiratory depression with drugs, pneumothorax, brainstem stroke, and immediate self-correction of acidosis. Of the remaining 45, 24 had a review by the anesthetists (ITU) who further excluded four as inappropriate, offered NIV to 17 patients and intubation with mechanical ventilation to three. Of those initiated on NIV, 11 satisfied criteria for mild acidosis with six others more acidotic (range 7.0 to 7.24). Of the 17 offered NIV, 10 had successful correction of acidosis with mean duration of assisted therapy over 3.3 days (range 1 to 9 days); one subsequently required re-ventilation and one died. Of the seven who failed a trial of NIV, length of time on NIV was at a mean of 0.7 days (range 0 to 2 days); three had been intubated within two hours and three died. Of the original group with respiratory acidosis (n=45) but not given additional ventilatory support (n=25), no ITU input was requested for 21 and only one set of ABGs had been requested on 15 (with 14/15 patients within the mild category for acidosis); five in this group had contraindications to NIV, and in total five died. We find that (1) not all patients are being assessed by formal ABGs, (2) not all patients satisfying the criteria for NIV were being offered that provision, and (3) there has been inappropriate use of NIV in some patients with more severe acidosis who possibly should have been intubated as a first measure.
S81 TITRATION OF NON-INVASIVE VENTILATION IN COPD
J.M. Tuggey, M.W. Elliott. St James’s University Hospital, Leeds, UK
Introduction: The settings used in establishing a patient on NIV are often somewhat arbitrary, often defined by patient comfort and improvement in arterial blood gas settings. There is contention that higher levels of IPAP simply result in greater leak with no improvement in minute ventilation. The aim of this study was to identify the relationship between set pressure, delivered minute ventilation (MVe) and mask interface leak.
Method: We measured the effects of varying IPAP levels in 9 patients (mean age 60, mean FVC 1.7 l) with COPD already using NIV at home. Using a pneumotachometer connected adjacent to the nasal mask, measurements of delivered tidal volume (Vti), expired tidal volume (Vte) and respiratory rate (fR) were made once Vte was stable for each pressure setting. Minute leak (Min leak) was measured as the difference between inspiratory and expiratory tidal volume multiplied fR. Recordings were repeated at least three times for each combination of settings.
Results: MVe is expressed as percentage of spontaneous ventilation. Leak varies considerably from patient to patient depending on mask fit. To allow for this, leak is expressed as change from that measured at 15cmH2O in each subject. The data from 9 subjects is presented in the figure.
Conclusion: Whilst minute ventilation increases linearly with set pressure, minute leak increases exponentially, particularly above 20cmH2O. Some patients will benefit from increased minute ventilation at higher pressures, but may suffer intolerable leak.
JT is funded by NHS Northern & Yorkshire Executive.
S82 FACTORS WHICH MIGHT INFLUENCE MEDIUM TERM PROGNOSIS IN SUBJECTS WITH ACUTE VENTILATORY FAILURE TREATED WITH NON-INVASIVE VENTILATION
S. Nadeem, P. George, M. Healy, M.J. Doherty. Dudley Group Of Hospitals, Dudley, West Midlands, UK
Subjects treated with NIV for acute ventilatory failure have been shown to have a reasonable medium term prognosis. We examined if any easily attainable data help to suggest a good medium term prognosis. Survival data were obtained on a group of 47 consecutive patients treated with NIV (Mean age 72 (7) years, 24 males, 38 main diagnosis COPD, mean pre NIV arterial blood gases pH 7.23 (0.09), Pao2 8.2 (2.4), Paco2 11.8 (2.5), bic 35 (8). This was collected 2 to 3 years after the initial illness by review of the case notes and contact with the relevant GP. Data on severity of ventilatory failure, stable % predicted FEV1, reported exercise tolerance, diagnosis, etc were compared between those still alive and those dead at two time points, 2–3 years post treatment and one year post treatment, using Wilcox an and χ2. Survival at one year was 60%. There was no difference between survivors and non-survivors in terms of age 71 (8) v 73 (7) p=0.3, sex (53 v 54% males), mean % predicted FEV1 45 (21) v 35 (16) p=0.08 or severity of initial ventilatory failure pH 7.24 (0.1) v 7.23 (0.08) p=0.22 or by diagnosis (33 of those still alive v 66% of dead subjects did not have COPD as the cause of their ventilatory failure, p=0.08). The only factor which significantly varied between the two groups was reported exercise tolerance 150 (230) v 54 (79) metres, p=0.016. At the end of a mean follow up of 26 months 45% of subjects were still alive. There was no difference between those who survived and those that did not in terms of sex or initial blood gases pH (p=0.22), Paco2 (p=0.14), bic (p=0.5). However the difference almost reached significance in terms of age 70(6.7) v 73.5 (7) p = 0.057 and % predicted FEV 1 45 (17) v 39 (7) p=0.058. There were significant differences in terms of reported exercise tolerance 180 (255) v 57 (84) metres, p=0.022 and diagnosis, all patients who did not have COPD being dead at the end of follow up compared to 45% of patients with COPD being dead. In summary in the medium term survival in this group was related to the subjects usual chronic state rather than the severity of ventilatory failure at presentation. Reported exercise tolerance was the only factor which varied between survivors and non survivors at both time points.
S83 PREDICTORS OF BENEFIT FROM, AND COMPLIANCE WITH, NON-INVASIVE VENTILATION IN MOTOR NEURONE DISEASE
S.C. Bourke, G.J. Gibson. University Of Newcastle, UK
Background: In motor neurone disease (MND), there is considerable variation in the reported tolerance of, and benefit from, non-invasive ventilation (NIV).
Methods: NIV was initiated in 11 subjects with MND and orthopnoea due to respiratory muscle weakness. Maximum inspiratory pressure (PImax), Paco2, bulbar score (amyotrophic lateral sclerosis functional rating scale), limb and axial muscle score and quality of life (QoL; SF-36) were assessed at baseline. Subsequently, the SF-36 was completed every two months until death in all subjects. Relations between 1) survival, and 2) the duration the SF-36 mental component summary (SF-36 MCS) was maintained above baseline, and each of: NIV compliance, age, gender, PImax, Paco2, bulbar score, and limb and axial muscle score were evaluated by univariate and multivariate analysis. Relations between compliance and subject characteristics at initiation of NIV were also assessed. Variables were included in the multivariate analysis only if they showed a relation with the dependent variable on univariate analysis (p<0.1).
Results: Duration of survival correlated with NIV compliance (r=0.70 p=0.016) only. In univariate analysis, duration of QoL benefit (SF-36 MCS) correlated with NIV compliance (r=0.86, p<0.001) and age (r= −0.61, p=0.048), however in multivariate analysis, NIV compliance was the only independent predictor of QoL benefit. In univariate analysis, NIV compliance correlated with age (r = −0.62 p = 0.042) and upper limb muscle score (r=0.67 p<0.05), and showed a trend towards correlation with ALSFRS bulbar score (r=0.58 p=0.06) and PImax (r= −0.56 p=0.07). In multivariate analysis the only independent predictors of compliance were age and upper limb muscle score (adjusted r2 = 0.76).
Conclusions: In MND subjects with symptomatic respiratory compromise, NIV compliance was the sole independent predictor of survival and duration of QoL benefit. Younger patients with relatively preserved upper limb function (more likely to be able to fit and remove their mask independently), were more likely to comply with, and benefit from, NIV.
S84 AN AUDIT OF NON-INVASIVE VENTILATION DELIVERED BY A CRITICAL CARE OUTREACH TEAM IN A DISTRICT GENERAL HOSPITAL
C.D. Shee, M. Green, H. Hackwood, A. Cook. Queen Mary’s Sidcup NHS Trust, Sidcup, Kent DA14 6LT, UK
In March the British Thoracic Society published guidelines on non-invasive ventilation (NIV) in acute respiratory failure (
) and recommended regular audit. We have audited NIV used in medical patients in our hospital in the three months prior to publication of the guidelines. We have excluded patients where NIV was started on the intensive care unit (ICU) or on surgical wards. The NIV service is available 24 hours per day and is supervised by a critical care outreach team led by a nurse consultant who is supported by five clinical nurse specialists, ICU senior house officers and the senior respiratory physiotherapist. Patients at risk are notified to the team by the accident and emergency department (A&E), ward nurses, doctors or physiotherapists.
In the three months, 35 patients (18 male) received NIV. The mean age was 72 years (range 18–86) with 13 (37%) over 80 years. Geriatricians looked after 17 patients (49%), chest physicians 7, and other physicians 11. Only 14 patients (40%) were treated for an exacerbation of COPD (mean arterial pH 7.25; mean Paco2 11.2 kPa). The other groups were: pulmonary oedema, n=10 (pH 7.22, Paco2 9.0); neuromuscular, n=4 (pH 7.34, Paco2 6.2); bronchopneumonia, n=7 (pH 7.26, Paco2 6.3). NIV was started on admission in 17 patients, and in 18 on a mean of nine days post-admission. NIV was started in A&E in five patients and on general wards in 30 patients. Most patients were documented as not for intubation/ventilation (n=26; 74%), of whom 12 (46%) survived. Seven of nine patients (78%) for full active resuscitation survived. The overall survival figures for COPD were 8/14 (57%); for pulmonary oedema 7/10 (70%); for neuromuscular problems 3/4 (75%), but for bronchopneumonia (including three patients with lymphoma) only 1/7 (14%).
Although NIV was probably life-saving in some patients, in many it could be considered a “palliative” intervention to help symptoms. Provision of a comprehensive hospital-wide NIV service is feasible when run by a critical care outreach team. However, patients referred to such a team are likely to be older and frailer and with a wider range of diagnoses, and less likely to be for intubation/resuscitation than the usual patients treated by a respiratory-led NIV team.
Neutrophil and epithelial cell biology
S85 EFFECT OF NEUTROPHIL PRIMING AND ACTIVATION ON 18F-DEOXYGLUCOSE (18FDG) UPTAKE IN VITRO
J.F. White, J.R. Ballinger, K.C. Cadwallader, H.A. Jones, A.M. Peters, E.R. Chilvers. Departments of Medicine and Nuclear Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke’s and Papworth Hospitals, Cambridge CB2 2QQ, UK
Priming describes up-regulation of the neutrophils response to a secretogogue agonist following prior exposure to a priming agent. 18FDG is used in PET to identify areas of infection and inflammation. This study addresses the mechanisms underlying 18FDG accumulation in vitro in human neutrophils and monocytes. Time courses of 18FDG accumulation for both reversible priming agent platelet activation factor (PAF) and priming/activating agents GM-CSF and fMLP were undertaken. 18FDG uptake by neutrophils and monocytes was compared.
Methods: Isolated human neutrophils and monocytes were resuspended in PBS with calcium and magnesium and incubated with 0.1 MBq 18FDG and 200U/ml TNF-α, 100 ng/ml GM-CSF, 100 nM fMLP and 1 nM PAF. Reactions were terminated by addition of iodoacetic acid and cold PBS. Differential counts in the cell pellet and supernatant were compared.
Results: Neutrophils took up more 18FDG than monocytes. In neutrophils incubated for 35 mins 18FDG accumulation increased from 20.2 (3.7) % (mean (SEM)) in control conditions to 49.3 (3.1) % when primed with TNF-α (p<0.05) and 48.2 (4.9) % when fully activated with TNF-α followed by fMLP (p<0.05). Uptake by monocytes increased from 2.8 (1.0) % at basal conditions to 13.5 (4.3) % when fully activated. 18FDG uptake in cells treated with either GM-CSF or fMLP peaked at 60 mins with accumulations of 60.6 (1.9) % and 59.9 (3.5) % respectively. Neutrophils incubated with PAF showed faster initial uptake of 18FDG although the final uptake was less at only 13.3 (2.7) %.
Conclusions: Our data correlate well with in vivo autoradiography studies where neutrophils rather than monocytes take up 18FDG at sites of inflammation/infection (
). Time courses of 18FDG uptake mirror previously documented shape change responses and priming of the oxidative burst. Priming, in isolation from superoxide anion release or degranulation, requires glucose uptake. Furthermore agents vary in the rate and amount of 18FDG accumulation in line with their demonstrated priming efficacy.
S86 DIMINISHED NEUTROPHIL RESPONSES IN MICE LACKING THE REGULATORY SUBUNIT OF PHOSPHOINOSITIDE 3-HYDROXYKINASE γ (PI3Kγ)
A.M. Condliffe1,2, G.J. Ferguson1,2, E.R. Chilvers2, P.T. Hawkins1, L.R. Stephens1. 1Babraham Institute, Babraham, Cambridge CB2 4AT, UK; 2Department of Medicine, Addenbrookes’ Hospital, Cambridge CB2 2QQ, UK
Protection from infection is conferred by the coordinated and regulated response of the non-specific and specific arms of the immune response. Excessive or dysregulated immune responses may cause tissue injury. Neutrophils, recruited rapidly and in large numbers to inflammatory foci, have been implicated in the pathogenesis of a number of diseases, including the acute respiratory distress syndrome (ARDS) and bronchiectasis. Neutrophil-mediated tissue injury is produced by release of reactive oxygen species e.g. superoxide (O2-) and histotoxic enzymes (e.g. elastase), both processes requiring the enzyme phosphoinositide 3-hydroxykinase (PI3K). The isoform PI3Kγ, activated by G-protein linked agonists such as activated complement (C5a) and bacterial formylated peptides (fMLP), is thought to mediate aspects of neutrophil activation, with a possible role for its unique regulatory subunit, p101.
To clarify these issues, we have engineered mice lacking p101 (p101-/- mice). These mice are healthy and fertile, with normal expression of the p110γ catalytic subunit of PI3Kγ. Analysis of β-galactosidase (introduced by the targeting process) confirmed that p101 is expressed predominantly by cells of the myeloid lineage. Bone marrow-derived neutrophils displayed reduced formation of phosphatidylinositol 3,4,5-trisphosphate (the second messenger product of PI3K) when stimulated by C5a (36±3% and 52±6% of wild type values for 5 and 100 nM C5a respectively, n=3 at 10 seconds). Activation of protein kinase B was also substantially reduced (27±5% and 23±8% of wild type values for 5 and 100 nM C5a, n=4 at 5 minutes), but activation of mitogen-activated protein kinase and c-jun N-terminal kinase were unaffected. p101-/- neutrophils exhibited reduced chemotaxis towards several G-protein coupled agonists, but equivalent formation of reactive oxygen species compared to wild type controls. Baseline rates of apoptosis were unaffected, but C5a, which did not affect apoptosis in wild-type bone marrow-derived neutrophils, was pro-apoptotic when applied to p101-/- cells. We conclude that p101 enhances the catalytic activity of PI3Kγ in vivo, and that this reaction is important in fundamental neutrophil responses.
S87 THE EFFECT OF SALBUTAMOL ON NEUTROPHIL ADHESION MOLECULE EXPRESSION
G.D. Perkins1, W. Rea2, F. Gao1 , D.R. Thickett2. 1Birmingham Heartlands Hospital, Birmingham B9 5SS, UK; 2Queen Elizabeth Hospital, Birmingham B15 2TH, UK
Background: Neutrophil activation and recruitment to the alveolar space are important steps in the development of the Acute Respiratory Distress Syndrome (ARDS). Neutrophil emigration from the pulmonary circulation has been shown to occur by CD11/18 dependent and independent pathways. Furthermore blockade of the CD11/18 pathway can reduce lung injury and improve survival in animal models of ARDS. β-Agonists have already been proposed as a potential therapy for ARDS through their ability to accelerate alveolar fluid clearance. These drugs also affect a variety of neutrophil functions including chemotaxis. The aim of this study was to investigate the effects of in vitro incubation of whole blood with physiological doses of salbutamol on neutrophil adhesion molecule expression.
Methods: Whole blood from 10 healthy volunteers was incubated with RPMI or salbutamol (10-5M or 10-9M) at room temperature for 15 minutes. Unstimulated or FMLP (10-6M) stimulated samples were then stained with CD 11b, CD18, CD 62(L) or Mab 24 (an activation dependent epitope of LFA-1). Samples were analysed by flow cytometry and data collected as median flouresence intensity and analysed using Wilcoxon signed rank test.
Results: See table.
Conclusions: The effects of β-agonists on neutrophil chemotaxis and adhesion may be unrelated to changes in the adhesion molecule expression (CD 11b, CD18, Mab 24). L-selectin expression. which falls with neutrophil activation, was significantly reduced by salbutamol only at the higher end of the physiological dose range, suggesting that these agents may have some role in reducing neutrophil activation.
S88 CO-LOCALISATION OF MMP-9 WITH NEUTROPHILS IN STABLE LUNG TRANSPLANT RECIPIENTS—A POTENTIAL ROLE IN BRONCHIOLITIS OBLITERANS
I.A. Forrest1, C. Ward1, G. Pritchard1, A.D. Rowan2, T.E. Cawston2, P.A. Corris1. 1 Lung Biology and Transplantation Group; 2 Department of Rheumatology, University of Newcastle-upon-Tyne and The Freeman Hospital, Newcastle-upon-Tyne ne7 7dn, UK
Background: Chronic rejection of lung allografts is manifest by Bronchiolitis Obliterans Syndrome (BOS), occurring in up to 50% of lung transplant recipients by 2 years. This is an inflammatory/fibrotic process resulting in collagen deposition, luminal obliteration of airways and resultant fall in lung function. Increased airway neutrophilia is recognised as a predictive feature of those at risk of BOS. Matrix Metalloproteinases (MMPs) and their inhibitors (TIMPs) tightly regulate the turnover of the extracellular matrix. There has been recent interest in the role of MMPs in airway diseases characterised by remodelling, such as asthma. The MMP/TIMP system may offer novel therapeutic targets.
Hypothesis: MMPs are effector mechanisms in the remodelling of the airway associated with BOS and other airway diseases.
Methods: Stable lung transplant recipients (n=27), more than three months post transplant and without evidence of acute rejection, infection or BOS underwent standardised bronchoalveolar lavage (BAL 3×60mls) and large airway endobronchial biopsy.
Results: BAL showed a significant neutrophilia (4%±0.8) compared to normal controls (n=34) (1.6%±0.2) (Mean±SEM, p<0.005) Immunohistochemistry (Mouse anti-human MMP-9) of endobronchial biopsies demonstrated apparent cellular localisation of MMP9 to neutrophils. Migrating neutrophils were demonstrable within bronchial epithelium as well as the sub basement membrane area. Gelatin zymography performed on lavage supernatant confirmed the presence of significant activity at 92kDa with lesser activity at 72 kDA, suggesting pro-MMP-9 to be the predominant gelatinase. In addition a 125kDa mw band was apparent, likely relating to a complex of MMP9 and Neutrophil Gelatinase Associated Lipocalin.
Conclusions: Neutrophils are present in significant numbers in apparently stable lung transplant recipients and are the primary source of MMP-9. The local balance of MMPs/TIMPs in the pericellular space is likely integral to airway remodelling. An ongoing prospective longitudinal study relating architectural changes of the airway and clinical outcomes will help clarify the role of MMPs in BOS.
S89 DETERMINANTS OF CYTOTOXICITY OF RESIDUAL OIL FLY ASH (ROFA) ON BRONCHIAL EPITHELIAL CELLS
P.A.B. Wark, S.M. Puddicombe, A.J. Frew, S.T. Holgate, D.E. Davies. Brooke Laboratories, School of Medicine, University of Southampton, UK
Rationale: Epidemiologic studies have demonstrated associations between particulate air pollution and increased asthma symptoms. Epithelial damage is a pathological feature of asthma and is associated with pro-inflammatory responses. Residual oil fly ash (ROFA) is an emission particle with in vitro toxicity to epithelial cells.1 We hypothesised that less confluent epithelial cell cultures would be more prone to injury by ROFA.
Methods: 16 HBE bronchial epithelial cells were cultured and treated for up to 48 hours with concentrations of ROFA 10 and 100μg/mL at 80% confluence or at 60% culture confluence. Cells were exposed in the absence or presence of TNF-α 10ng/ml. Cells were photographed using phase contrast microscopy, cultures were then fixed and the supernatant removed. Cell biomass was measured using a methylene blue assay, cell necrosis by lactate dehydrogenase (LDH) activity and interleukin (IL)-8 release by ELISA.
Results: Cells treated with either dose of ROFA showed a significant increase in IL-8 secretion by 8 hours, peaking at 24 hours. Cells at 80% confluence treated with high dose ROFA showed a 40% reduction in cell number as compared with controls (p=0.03), while those treated at 60% confluence had a 70% reduction compared to controls (p=0.004). An increase in LDH activity was seen at both 80% and 60% confluence by 24 hours. In contrast confluent cells treated with low dose ROFA showed reduced LDH activity even at 48 hours while those also treated with TNF had an increase in cell biomass of 16% above controls (p=0.03). This effect was not seen in cells treated with ROFA 10μ/ml at 60% confluence.
Conclusion: Exposure of 16 HBE cells to ROFA leads to an early dose dependent inflammatory response with IL-8 release and dose and time dependent cell necrosis which is more pronounced in less confluent cell cultures, suggesting damage to cells is cumulative and related to pre-existing cell numbers. The addition of TNF to confluent cells exposed to low dose ROFA appears to be partially protective to the cytotoxic effects of ROFA and appears to be associated with cell proliferation.
NHMRC (Australia) and British Medical Association.
1. Jiang, et al.
S90 DOXYCYCLINE INHIBITS CIGARETTE SMOKE STIMULATED IL-8 RELEASE FROM NCI-H292 CELLS
T. Howell, A. Richter, S.T. Holgate, D.E. Davies. Division of Infection, Inflammation and Repair, Brooke Laboratory, Level F, South Block (888), Southampton General Hospital, Southampton SO16 6YD, UK
Cigarette smoke (CS) has been shown to cause phosphorylation and activation of the epidermal growth factor receptor (EGFR) leading to upregulation of mucin expression in bronchial epithelial cells. It has been suggested that this occurs via an oxidant-mediated, ligand-independent mechanism (
). However, we have shown recently that CS stimulated the transcription and release of EGFR ligands from NCI-H292 bronchial epithelial cells (
). Moreover, CS also induced the production of IL-8 from H292 cells and this response was mediated via the EGFR. Therefore upregulation of EGFR signalling may underlie some of the long-term effects of CS on bronchial epithelium such as chronic inflammation and goblet cell hyperplasia.
EGFR ligands are cleaved from transmembrane precursors by Zn2+-dependent metalloproteinases (MP) of the A-Disintegrin and Metalloprotease (ADAM) family to generate active soluble peptides. The antibiotic doxycycline has been reported to inhibit MP activity independently of its antimicrobial properties (
). Therefore we tested its ability to reduce EGFR ligand shedding and inhibit IL-8 production in NCI-H292 cells exposed to CS. Firstly, we determined the toxicity of doxycycline to in vitro cultures of H292 cells. We then exposed the cells to an aqueous extract of cigarette smoke (CSE) in the presence or absence of sub-toxic doses of doxycycline. We used enzyme-linked immunoassay to determine the concentration of EGFR ligands and IL-8 in the culture medium 6 and 24 hr post exposure. We measured their level of mRNA expression 6 hr post exposure by quantitative real-time PCR.
CSE stimulated the release of EGFR ligands and IL-8 and these responses were inhibited by doxycycline in a dose dependent manner. Doxycycline also blocked CSE-induced ligand and IL-8 mRNA transcription. We propose that CSE acts initially by promoting the shedding of EGFR ligands. This causes autocrine activation of the EGFR and, subsequently, increases the gene transcription of EGFR ligands and IL-8. Doxycycline, by acting as an MP inhibitor, prevents the shedding of EGFR ligands hence and blocks EGFR activation by CSE.
Infections: From bench to bedside
S91 THE MAIN SITE OF iNOS ACTIVITY INDUCED BY GRAM POSTIVE STAPHYLOCOCCUS AUREUS MAY BE BLOOD VESSELS AND NOT MACROPHAGES: COMPARISONS WITH GRAM NEGATIVE ESCHERICHIA COLI
E. Belcher, T.W. Evans, S. Sriskandan, J.A. Mitchell. Unit of Critical Care Medicine, Royal Brompton Hospital, NHLI Imperial College School of Medicine, Dovehouse Street, London SW3 6LY, UK
Sepsis and septic shock caused by either Gram positive or Gram negative bacteria is associated with a mortality rate of 40–70%. We, and others have hypothesised that such adverse outcomes result from an unchecked immune response mounted initially by neutrophils and macrophages in order to kill the invading pathogen. As sepsis develops, endothelium and vascular smooth muscle become activated to express inducible (i) inflammatory genes such as that encoding for nitric oxide synthase (iNOS), leading to the production of large amounts of NO, rendering the vessel hyporesponsive to constrictor agents. This contributes significantly to the profound decline in blood pressure that typifies septic shock. However, the ability of bacteria to induce iNOS activity in immune cells (e.g. macrophages) versus vascular tissue remains unclear. Secondly, a comparison between the ability of Gram positive and Gram negative bacteria to induce iNOS in these tissues has not been made. We therefore assessed the ability of heat killed S aureus or E coli to induce iNOS (indexed by the ability of tissue to release nitrite, measured by Griess assay) in murine macrophages (J774.2) versus murine blood vessel (aorta) in cell and organ culture respectively. E coli induced concentration-dependent increases in NO release in J774 macrophages, to a maximum of 24FM. By contrast, S aureus induced only low levels of NO release (2FM). E coli induced significant NO release from aorta, but similar in magnitude to that produced by S aureus (figure 6). E coli induced NO release from both immune modulating cells (macrophages) and vascular tissue. By contrast, S aureus caused NO release only in aorta. The inflammatory response to bacterial infection may be dictated by the inflammatory stimulus.
Work supported by the MRC.
S92 THE PRESENCE OF QUORUM SENSING SIGNAL MOLECULES IN CLINICALLY STABLE LUNG ALLOGRAFT RECIPIENTS SUGGESTS BACTERIAL BIOFILM BIOLOGY
C. Ward, M. Cámara1, I. Forrest, B. Rutherford, G. Pritchard, M. Daykin1, A. De Soyza, A.J. Fisher, P. Williams1 2, P.A. Corris. Lung Biology and Transplantation Group, University of Newcastle upon Tyne and The Freeman Hospital, 1School of Pharmaceutical Sciences; 2Institute of Infections and Immunity, University Park, University of Nottingham, UK
Introduction: Infection with bacteria such as Pseudomonas is common in lung allograft recipients, particularly during chronic rejection. Analysis of sputum samples from CF patients infected with Pseudomonas aeruginosa or Burkholderia cepacia have indicated the presence of the bacterial N-acylhomoserine lactones (AHLs) quorum sensing signaling molecules. AHLs not only control the expression of bacterial virulence genes but are also involved in stimulating the maturation of antibiotic resistant biofilms.
Hypothesis: AHL activity may be detected even in clinically stable lung transplant recipients free of clinical infection or rejection.
Methods: A standardised 3×60mL Bronchoalveolar lavage (BAL) taken from 9 stable, non smoking lung transplant recipients, 3 B12 months post transplant. Detection of AHLs was carried out on dichloromethane extracted supernatants, using the bioluminescence-based AHL reporter plasmid pSB1075. This responds to AHLs with long acyl chains (10–14C), generating light. Synthetic AHLs were included as +ve controls.
Results: From the 9 BAL supernatants, 5 exhibited AHL activity, suggesting the presence of long chain AHLs. There was no correlation between the levels of AHLs detected (+,++,+++), or their absence, BAL microbiology or pre transplant diagnosis.
Discussion: We provide the first evidence of AHL quorum sensing signals in human lung allograft recipients, with activity even in subjects with no rejection or infection. Longitudinal studies are required of AHL levels, to elucidate potential links with infection, rejection, and allograft deterioration.
S93 HEME OXYGENASE INDUCTION IN ISOLATED NEUTROPHILS STIMULATED WITH LPS, OR FROM PATIENTS WITH SEPSIS DUE TO NOSOCOMIAL PNEUMONIA
R.L. Upton, J.H. Cranshaw, G.J. Quinlan, T.W. Evans. Unit Of Critical Care, National Heart And Lung Institute, Dovehouse Street, London SW3 6LY, UK
Rationale: Evidence suggests that macrophages are a source of Heme Oxygenase (HO) protein and activity during inflammatory processes. HO enzymes have anti oxidant potential and may confer anti-inflammatory protection. However, few data relate to the induction of this enzyme in other inflammatory cell types, such as neutrophils, which are recruited initially to sites of infection or injury. We therefore evaluated the potential for human neutrophils to produce HO under contrasting inflammatory conditions.
Methods: Neutrophils were isolated from whole human blood and stimulated with LPS (10μg/ml) in 6 well plates at a concentration of 5 × 106 cells/well for 8, 16 and 24 hours, harvested and lysed. HO-1 and HO-2 protein expression was measured by Western blot. Stimulated cells were compared to un-stimulated neutrophils at time zero, 8, 16 and 24 hours. Blood (with cycloheximide 1mg/ml) was also taken from patients with Gram-negative septic shock (n=6) and from healthy volunteers (n=5). In four of the six patients with septic shock microbiological culture identified the lung as a site of infection. Neutrophils were isolated and 5 × 106 cells were harvested and lysed. HO-1 and HO-2 protein expression was measured as before.
Results: In vitro, HO-1 levels were elevated 8 hours after LPS by comparison to baseline and unstimulated cells (199.2% ± 42%, n=9, p<0.05). HO-1 levels in cells 16 and 24 hours after LPS were not significantly different from levels in untreated cells because of non-specific induction of HO-1 in the unstimulated cells (115.8 (21.19), n=9 and 94.94 (12.58), n=9 respectively). HO-2 levels were not significantly altered at any of the timepoints between the LPS stimulated and non-stimulated cells.
By contrast, in vivo, HO-1 protein was lower in septic patients compared to normal controls (60.97 (24.5), n=6 and 125.7 (34.4), n=5 respectively). HO-2 levels were not changed between the two groups.
Conclusion: HO-1 production can be induced by LPS in neutrophils, and is also present in neutrophils from patients with sepsis. However, HO-1 levels in septic patients are lower than controls. The anti oxidant potential of HO-1 may therefore be reduced in the neutrophils of these patients, which has implications for neutrophil mediated tissue damage in this population.
This work was supported by The British Lung Foundation and The Dunhill Trust.
S94 THE EFFECT OF AIRWAY BACTERIAL LOAD ON EXACERBATION SEVERITY IN PATIENTS WITH COPD
T.M.A. Wilkinson, I.S. Patel, A.C. Whiley, M. Wilks, J.A. Wedzicha. Academic Unit of Respiratory Medicine, St Bartholomew’s and the Royal London School of Medicine and Dentistry, London, UK
COPD exacerbations are an important cause of morbidity and mortality. In the majority of these episodes infective agents including both bacteria and viruses can be identified. However bacteria can also be isolated from the lower airway of many stable COPD patients and the type and number of these bacteria affects the level of airway inflammation in these colonised patients in the stable state. The changes between bacterial load and type seen at exacerbation and at baseline and how these changes may affect the deterioration in lung function seen at exacerbation are poorly described.
75 patients (mean (SD) FEV1 1.00 (0.38) l, FEV1 % predicted 38 (16.8), FVC 2.57 (0.93) l, Pao2 10.2 (1.1) kPa, Paco2 6.22 (0.9) kPa, age 67.4 (11.8) yrs, m 40, 28 current smokers) completed daily diary cards of respiratory symptoms were followed up for 12 months and reported symptoms of exacerbation to our study team. Sputum was initially sampled in the stable state and later within 48 hours of the onset of exacerbation (before antibiotic treatment was commenced) and analysed for quantitative and qualitative bacteriology. Contemporaneous lung function measurement was performed by spirometry. 55 satisfactory paired samples were obtained, the relative frequency of bacterial isolates being: Haemophilus influenzae in 12% of stable samples (1) and 31% of exacerbation samples (2), Streptococcus pneumoniae ((1) 9%, (2) 11%), Haemophilus parainfluenzae ((1) 12.5%, (2) 2%), Branhamella catarrhalis ((1) 7%, (2) 13%) and Pseudomonas aeruginosa ((1) 5%, (2) 5%) with Non specific growth in (1) 48% and (2) 25%. The mean (SD) stable bacterial load was 107.49 (101.26) log cfu ml-1 rising to 108.00 (101.02) cfu ml-1 at exacerbation p=0.0001. The mean (SD) stable FEV1 was 0.99(0.38) l falling to 0.90 (0.31) l at exacerbation. The percentage fall in FEV1 at exacerbation was related to the rise in airway bacterial load rho=0.411 p=0.018. Linear regression analysis confirmed that a rise in bacterial load contributed to a fall in FEV1 p=0.034, 95% CI (0.006–0.141). Both airway bacterial load and the prevalence of potentially pathogenic organisms increase at exacerbation. Exacerbation severity as measured by the acute deterioration in FEV1 is directly related to the rise in airway bacterial load seen at exacerbation.
Supported by The Joint Research Board, St Bartholomew’s Hospital.
S95 HOW USEFUL ARE THE BTS COMMUNITY ACQUIRED PNEUMONIA (CAP) GUIDELINES IN MANAGING URBAN ELDERLY PATIENTS
J. Harbison, R. Shepherd, S.K. Bansal. Dept of Geriatric Medicine, Sunderland Royal Hospital, UK
Introduction: In 2001 the BTS published guidelines for the recognition and management of adult community acquired pneumonia (CAP) in which it is stated that elderly patients “more frequently present with non-specific symptoms” and “are less likely to have a fever specific symptoms and pyrexia” with CAP. However both presence of specific symptoms and pyrexia are included in the clinical diagnostic criteria in the guidelines. SRH has an age related admissions policy, patients ≥70 years being admitted under Geriatric physicians and the BTS guidelines being used in their care.
Purpose of study: We sought to determine the utility of the BTS CAP guidelines in the management of consecutive admissions with a primary diagnosis of lower respiratory tract infection. Subjects with carcinoma, tuberculosis or non-CAP were excluded.
Results: 81 subjects (average age 78yrs, 39 F) were admitted over the 6-week study period. 55 (68%) had a previous diagnosis of COPD or Asthma. 17 subjects (21% (CI 12–30%)) had CAP according to the guidelines’ clinical diagnostic criteria. In contrast, 48 (59%, 95% CI 54–64%) had pneumonia identified on admission radiograph. Radiographic and clinical diagnoses agreed in only 38 cases (Pneumonia agreed present in 11, absent in 27. Kappa 0.041, very poor agreement).
Core adverse prognostic features used for severity assessment in the guidelines (new confusion, Urea ≥7mmol/l, respiratory rate ≥30, Systolic BP <90mmHg or diastolic ≤60mmHg) were recorded in the 48 subjects with radiographic evidence of CAP. 13 subjects had no features, 31 had one and 3 had two. As guideline advice for those ≥50 years of age with no or one feature is to “Use Clinical Judgement” with regard to admission and specific management, the guidelines directed management in only 3 patients (6% CI 0–13%). Of note 26% (54%) of subjects had an elevated Urea and 7 (15%) had evidence of hypotension, the causes of which were multifactorial.
Conclusions: The clinical diagnostic criteria for community acquired pneumonia in the BTS guidelines are unsuitable for use in an urban elderly population. This could be expressed more explicitly in the text. The severity assessment flow chart in the guidelines is of limited use in the majority of elderly subjects with community acquired pneumonia. Consideration should be given to the development of specific guidelines for the management of lower respiratory tract infection and pneumonia in the elderly.
Procedures in respiratory medicine
S96 BTS GUIDELINES FOR BRONCHOSCOPY: PHYSICIANS APPROACH TO THE NON-EVIDENCE BASED RECOMMENDATIONS
A. Mirakhur, M. Al-Aloul, D. Russell, M.J. Ledson, M.J. Walshaw, C. Smyth. Liverpool Lung Cancer Unit, The Cardiothoracic Centre, Liverpool, UK
In March 2001 the BTS published guidelines for the practice of diagnostic flexible bronchoscopy. However, it was apparent that many of the recommendations were not evidence based (27 of 68 (40%) were SIGN Grade C), and we had the impression that they were not routinely practiced by chest physicians within the UK. We therefore compared the SIGN Grade C recommendations in these guidelines with the routine practice of chest physicians as described by a postal questionnaire sent to 548 UK chest physicians in 2000. Three hundred and twenty eight questionnaires (60%) were returned. Based on these, prior to bronchoscopy 227 physicians (69%) routinely measured spirometry and 117 (37%) pulse oximetry. Whilst only 7 physicians (2%) measured blood gases in all patients, 70 (21%) did so depending upon spirometry, 48 (15%) upon the patient’s clinical status, and 35 (11%) when the SpO2 < 93%. Overall, 122 physicians (37%) did not measure blood gases prior to bronchoscopy under any circumstances. For patients theoretically at risk from bacteraemia during bronchoscopy, only 192 physicians (59%) routinely gave prophylactic antibiotics. Prior to transbronchial biopsy, 281 physicians (86%) checked the platelet count, but only 273 (83%) checked clotting parameters. Two hundred and eighty operators (85%) always used prophylactic venous access, and 26 (8%) occasionally. Thus, 14 physicians (7%) carried out bronchoscopy with no routine venous access. Nearly all physicians (324, 99%) monitored pulse oximetry during bronchoscopy, but 180 (56%) did not monitor ECG or blood pressure. In 19 centres (6%), the physician carried out bronchoscopy with only 1 endoscopy assistant and in 2 (1%) no trained nurse was present. In terms of operator safety, for routine bronchoscopy, (315, 96%) wore gloves, but only 197 (60%) wore gowns and very few goggles (45, 14%) or a facemask (80, 24%). However, for “high risk” bronchoscopy, these figures improved to 321 (98%), 290 (88%), 228 (69%), and 290 (88%), respectively. Thus, based upon this postal survey, it is apparent that there are wide discrepancies between current practice and the guideline recommendations for diagnostic flexible bronchoscopy that are not evidence based.
S97 PROSPECTIVE RANDOMISED TRIAL OF ABRAM’S PLEURAL BIOPSIES VERSUS CT GUIDED CUTTING NEEDLE BIOPSIES IN UNDIAGNOSED PLEURAL EFFUSIONS
N.A. Maskell, F.V. Gleeson, R.J.O. Davies. Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
Introduction: Approximately 180 000 people in the U.K., develop a pleural effusion each year, of which 40 000 will turn out to be due to malignancy. Unfortunately, cytological examination alone has a sensitivity for malignancy of only 60%, necessitating further more invasive investigations in many cytology negative pleural effusions. With the rising incidence of mesothelioma (where track invasion by tumour is common), the minimum number of invasive investigations to obtain a diagnosis is desirable. We have assessed whether CT guided pleural biopsy is more sensitive than blind Abram’s biopsy in these patients.
Methods: 50 consecutive patients with undiagnosed exudative effusions, negative pleural fluid cytology, but possible pleural malignancy, were recruited. All received a contrast enhanced CT thorax, with the degree of pleural thickening recorded. Patients were randomised to blind Abram’s pleural biopsy or CT guided cutting needle biopsy. The Abram’s pleural biopsy was performed by NAM without knowledge of the CT findings. The CT guided biopsy was performed by FVG.
Results: Of the 50 patients, 3 did not have a biopsy (1 withdrew consent, 1 pleural effusion resolved and 1 had deranged blood clotting). There was one chest wall haemtoma in the Abram’s group. The median age was 72 (range 25–88) in the CT group and 73 (41–85) in the Abram’s group. The maximal pleural thickening on CT was <5mm in 17/25 patients in the radiology group and in 17/25 of the Abram’s group. The final diagnosis was confirmed with a minimum follow up of 1 year. Abram’s blind biopsy gave the true positive (TP) diagnosis of malignancy in 8/17 cases, Sensitivity 47%, Specificity 100% and Negative predicted value (NPV) 44%. In the CT group, TP rate for malignancy was higher at 13/15 (p=0.02, χ2), Sensitivity 87%, Specificity 100%, NPV 80%. 7 of the 8 cases of mesothelioma in the radiology group were established by biopsy, Sensitivity 88%, Specificity 100%, NPV 94%. This compared with only 6 of the 11 cases in the Abram’s group, Sensitivity 55%, Specificity 100%, NPV 72%.
Conclusion: In cytology negative pleural effusions CT guided pleural biopsy has a significantly higher sensitivity for malignancy and should be the biopsy method of choice in patients unable to tolerate thoracoscopy.
S98 THE COMPLICATION RATE OF PERCUTANEOUS IMAGE-GUIDED CHEST DRAIN INSERTION
J.C. Hillier1, C.L. Davies2, R.J.O. Davies2, Z.C. Traill2, F.V. Gleeson2. 1Department of Radiology, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK; 2Department of Radiology, Churchill Hospital, Oxford Radcliffe Hospitals, Old Road Headington, Oxford OX3 7IJ, UK
Purpose: The aim of this study was to assess prospectively the success and complication rate associated with image-guided percutaneous pleural drainage.
Materials/Methods: A prospective single institution study of all image-guided chest drains placed over a 36-month period was carried out. All drains were inserted using the Seldinger technique. Data collected included, indication for drain insertion, size of drain, type of image-guidance used (CT or ultrasound), demographic data, nature and amount of fluid aspirated, success rate, duration of drainage and complications.
Results: 352 drains were inserted into 273 patients. 121 patients were male and 152 female. 149 were inserted on the left and 203 on the right. The majority of drains were 12 French, (256), other drain sizes were 8 French (90), 10 French (2) to 14 French (3) 16 French (1). 333 drains were placed under ultrasonic guidance and 19 under CT. Indications included 236 malignant effusions 94 empyemas and 22 benign non-infective effusions. 350 drains were successfully inserted. Two patients suffered significant immediate complications of haemorrhage during drain placement due to intercostal artery laceration. Both drains were inserted posteriorly. Both patients underwent percutaneous artery embolisation. One procedure was successful; unfortunately one procedure was unsuccessful and the patient died within 24 hours of drain insertion of intrathoracic haemorrhage. Both of these patients had drain insertion for a current empyema, had a history of chronic renal failure and a prior empyema.
Conclusion: Percutaneous image-guided drain placement is successful in the majority of patients (99%). Posteriorly inserted drains may have a higher and more significant complication rate compared to other drain position. Patients with renal impairment appear at greater risk.
S99 TALC BUT NOT TETRACYCLINE PLEURODESIS INDUCES HYPOXIA AND INCREASED DTPA CLEARANCE OF THE CONTRA-LATERAL LUNG
N.A. Maskell, Y.C.G. Lee, E. Jones, F.V. Gleeson, R.J.O. Davies. Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
Introduction: Talc slurry is the most commonly used and effective pleurodesis agent in the UK. There are concerns about its safety and it is associated with at least 34 reported cases of severe lung inflammation leading to Adult Respiratory Distress Syndrome (ARDS). It is not known if milder generalised lung inflammation is a consistent feature of talc pleurodesis. 99mTc-DTPA lung clearance is a very sensitive marker of lung inflammation. This study assesses whether DTPA clearance from the lung contra-lateral to a pleural effusion is changed by talc or tetracycline pleurodesis used to control the effusion.
Methods: 31 patients with recurrent symptomatic effusion consented to the study. 11 were excluded (5 with trapped lung, 3 unable to perform baseline DPTA , 1 M.I. pre pleurodesis, 2 chest tube displacements). 20 were randomised to 4g talc slurry (10) or 20mg/Kg tetracycline (10) balanced by type of malignancy and pleural pH. Oxygen saturation breathing air, serum C-reactive protein (CRP), limited HRCT and DTPA scan were performed before and 48 hours after pleurodesis. Pleural fluid IL-8 was measured at before and 24 hours after pleurodesis.
Results: DTPA t1/2 of the contra-lateral lung fell significantly after talc but rose after tetracycline. Talc 64.4 minutes (90% range 40–111.1) to 59.5 (35.3–84.8) difference B8.95 (-35.2–12.4), tetracycline 60.1 (26.1–119) to 83.6 (27.8–189.2) difference 2.85 (-16.3–75.1), p<0.03 Mann-Whitney. No changes were detected on limited HRCT. CRP rise was significantly higher in the talc than tetracycline group. Talc 198 (SD 79) v Tetracycline 74 (SD 79) p=0.004. SaO2 also fell significantly more in the talc group. Talc 95.5 (2.3) to 92.2 (2.6) difference 3.2 (SD 1.6) , tetracycline 94.0 (4.7) to 93.3 (4.9) diff 0.7 (SD 1.5) p=0.003. There was also a trend towards a greater increase in pleural fluid IL-8 levels in the talc group: Talc 12618 (258–29911) vs Tetracycline 50 (-1657–29919) p=0.13.
Conclusion: Talc pleurodesis induces a greater systemic inflammatory response than tetracycline quantified by CRP. Increased aerosol DTPA clearance from the contra-lateral lung and greater hypoxaemia are induced by talc but not by tetracycline. This suggests that occasional severe ARDS induced by talc is the severe extreme of a spectrum and not an idiosyncratic adverse reaction.
S100 TRANSBRONCHIAL NEEDLE ASPIRATION (TBNA)—AN ADDITIONAL TOOL TO INCREASE THE DIAGNOSTIC YIELD OF BRONCHOSCOPY
J. Mills, P. Nuttall, S. Kearney, J. Edwards, M. Munavvar. Royal Preston Hospital, Preston, Lancashire, UK
Introduction: In patients with essentially extrinsic or submucosal disease on Bronchoscopy, the positive diagnostic rate of conventional sampling with endobronchial biopsy, brush and wash (CS) remains relatively low (
). TBNA is reported to increase the pick up rate in this group, and also in necrotic endobronchial tumours, but is not widely used (
Methods: We prospectively recorded the results of TBNA in addition to appropriate conventional sampling in 23 patients over a 12 month period. All the sampling was done by a single operator, and during regular bronchoscopy lists. 22G Olympus and Millrose-Wang needles were used.
12 patients had submucosal/ extrinsic disease and 7 had necrotic endobronchial lesions. Bronchoscopy was normal in 4 patients. CT scans were performed prior to the bronchoscopy in 13 patients.
Results: TBNA was positive in 21/23 patients (91%), whereas conventional samples were positive in 16/22 patients (73%). Biopsy was positive in 13/15, Brush in 12/15 and wash in 9/22 patients respectively. TBNA was the only positive diagnostic test in 5 patients (22%). The diagnosis was non-small cell malignancy in 15 and small cell carcinoma in 5 patients. One patient presented with isolated subcarinal adenopathy, and acid fast bacilli were demonstrated on the FNA sample. There were no significant complications during or after the procedure.
In short, with the addition of TBNA, the diagnostic yield of bronchoscopy went up from 73% to 91%.
Conclusions: TBNA is a cost-effective and safe technique to improve the diagnostic yield of bronchoscopy, particularly in patients with (a)extrinsic/submucosal disease (b) normal bronchoscopy but CT scan evidence of peribronchial disease or medistinal abnormality and (c) necrotic, haemorrhagic endobronchial lesions. It can also be used to diagnose benign disease. TBNA can be performed during a standard flexible bronchoscopy list, and could potentially reduce the need for a surgical biopsy.
S101 FLUORESCENCE BRONCHOSCOPY IN CLINICAL PRACTICE
A.K. Banerjee,1 P.H. Rabbitts1, P.J.M. George2. 1Molecular Oncology Group, University of Cambridge, UK; 2The Middlesex Hospital, London, UK
Introduction: Autofluorescence bronchoscopy (AFL) uses the fluorescence properties of bronchial mucosa to enhance the real-time detection of abnormal endobronchial lesions. This study assesses the efficacy of the Storz bronchoscope in a UK population of patients.
Methods: Patients with suspected lung cancer attending for diagnostic bronchoscopy underwent AFL during the same procedure. Conventional white light followed by AFL was performed. Biopsies of all abnormal areas and control biopsies from bronchoscopically normal areas were obtained. The bronchoscopic and histological findings were compared.
Results: 53 patients have undergone AFL (41 male), mean age 63.8 yrs (range 35–79 yrs). Controls: 106 areas were biopsied as controls. 3.7% showed high grade pre-invasive lesions (carcinoma-in-situ & severe dysplasia). The remaining areas showed no abnormality or low-grade pre-invasive lesions. Bronchoscopically abnormal areas: The table shows the histology and bronchoscopic findings of the 133 areas biopsied. Compared toconventional white light bronchoscopy, autofluorescence improved the detection of high-grade pre-invasive lesions. 7 early-stage microinvasive carcinomas were detected by AFL alone. The false negative rate for AFL detection of high-grade pre-invasive lesions was 3.7% and the false positive rate 38.3%.
Conclusions: The addition of AFL to conventional bronchoscopy improves the sensitivity of high-grade pre-invasive lesion and importantly invasive carcinoma detection. Detection of microinvasive carcinoma at a radiologically occult stage allows intervention with potentially a 90% 5 year survival. The dilemma of pre-invasive lesion management is also raised. Not all pre-invasive lesions become invasive carcinomas, and so intervention is not justified for all lesions. Further information on the natural history of such lesions is needed. The high false positive rate is similar to that found in other studies and suggests that abnormal findings must be confirmed histologically and that approaches to improve specificity are required.
Lung cancer targets
S102 AUDIT IMPROVES DIAGNOSTIC DELAYS IN LUNG CANCER MANAGEMENT
J. Walker, J.S. Sarvesvaran, M. Patel, A. Coote, K.R. Patel. Department of Respiratory Medicine, Gartnavel General Hospital, Glasgow, UK
Aim: Delays in diagnosis are often causes of distress to patients, and may have a detrimental effect on therapeutic options and overall prognosis. The aim was to prospectively audit the time taken to diagnose patients with suspected lung cancer in a large teaching hospital with reference to established national guidelines of best practice.
Method: From January 1999, all available data required for the Scottish Intercollegiate Guidelines Network (SIGN) and Royal College of Physicians (RCP) minimum dataset for lung cancer, was collected from case notes of patients managed by the lung cancer team at Gartnavel hospital. This was prospectively entered into Microsoft access and SPSS databases.
Results: 518 patients were identified between 1999 and 2001. Histological evidence of lung or other malignancy was obtained in 474 (91.5%) patients. The time taken to see a respiratory physician, for the investigations to be performed and to obtain a definitive diagnosis is presented below, with the p-values for differences between the time taken in 1999 and 2001.
Conclusion: Simple organisational changes following clinical audit have significantly reduced the time taken for CT imaging of thorax, and have improved diagnostic delays, in patients with lung cancer.
S103 THERAPEUTIC DELAYS IN LUNG CANCER MANAGEMENT
A. Coote, K.R. Patel, J.S. Sarvesvaran, J. Walker, M. Patel. Department of Respiratory Medicine, Gartnavel General Hospital, Glasgow, UK
Aim: As lung cancer is such an aggressive disease with poor prognosis, following the diagnosis, an appropriate member of the multidisciplinary team should initiate treatment quickly. To identify any therapeutic delays in lung cancer management, a prospective audit was set up in Jan 1999.
Method: A SPSS database was constructed and all available data required for the Scottish Intercollegiate Guidelines Network(SIGN) and Royal College of Physicians (RCP) minimum dataset entered prospectively by a part time data manager.
Results: During the period Jan 1999 to Dec 2001, the lung cancer team at Gartnavel General hospital managed 518 patients. 96 (18.5%) patients were diagnosed with small cell lung cancer (SCLC), 335 (64.7%) were non-small cell lung cancer (NSCLC). The times taken for patients to receive the different modalities of lung cancer treatment are shown in the table.
Conclusion: Chemotherapy for SCLC is prescribed primarily by respiratory physicians and is administered promptly. Similarly patients with NSCLC who are fit for surgery have the procedure within the recommended period. Although oncology review of patients is rapid, patients receiving chemotherapy for NSCLC, face a slight delay. This may be due in part to patients requiring time to consider therapeutic options but administrative delays due to treatment being administered at another hospital site cannot be excluded. The significant delay particularly for radical radiotherapy is of concern as it may have a detrimental effect on overall survival.
S104 MEETING GOVERNMENT LUNG CANCER TARGETS: DOES LUNG CANCER PRESENTATION HAVE A SEASONAL VARIATION?
A. Bastin, A.G. Davison, D. Eraut, A. Hutchings, A.S. Haque, A. Lamont, C. Trask. Southend Associate University Teaching Hospital, Southend on Sea, Essex SS0 0RY, UK
Currently the Government target for seeing a patient with suspected lung cancer is within 2 weeks of referral and from 2005 the target time for starting treatment is to be within one month of diagnosis. It is known that exacerbations of COPD vary seasonally and are more common in winter months. COPD is very common in patients with lung cancer. The knowledge of any seasonal variation in lung cancer presentation is important for service planning and to allow Government targets to be met.
We have analysed the 2127 new cancer cases presenting over a ten year period from 1990 to 1999 from the Southend Lung Cancer Study. This includes every case in a well defined population of 325 000. Winter (W) months are defined as December, January, and February, and Summer (S) months are June, July, and August. The number presenting in S (561) was slightly higher than W (494). There was a lack of evidence that presence of cough at diagnosis differed by season (66% had a cough in W, compared to 70% in S) (p=0.14). There was a lack of evidence that dyspnoea at diagnosis differed by season (59% in W, compared to 63% in S) (p=0.25). There was a lack of evidence that the presence of COPD in those presenting with lung cancer (using the BTS COPD Guidelines criteria for diagnosis and severity) differed by season (74% in W compared to 71% in S), nor that there was any difference in the severity of COPD at presentation according to season (p= 0.6). Similar results were found when those presenting in the 6 months of October through to March were compared to those presenting in the 6 months of April through to September.
Conclusion: There is no increase, unlike COPD, in the presentation of lung cancer in the W months. Even patients with severe COPD and lung cancer do not present more commonly in W. There is no difference in the respiratory symptoms in lung cancer patients presenting in the W or S. These results have important implications for the planning of lung cancer services. Diagnostic services, e.g. outpatient 2 week lung cancer slots, MDTs, bronchoscopy, CT scanning, histology etc, and treatment services, surgery, radiotherapy, and chemotherapy need to be provided on a continual basis throughout the year. In particular in order to meet Government targets they will need to be maintained in the summer, the traditional holiday period for staff.
S105 LUNG CANCER: ARE THE NSF TARGETS FOR RESECTION AND RADICAL RADIOTHERAPY ACHIEVABLE?
N.J. Ali1, G.A. Cox1, A. Hastings1, S. Brauer1, C. Butcher1, D. Fyfe2, D. Beggs2, M. Curtis1, J. Morley1. 1Kings Mill Hospital, Sutton in Ashfield, UK; 2Nottingham City Hospital, UK
The NSF for Lung Cancer has set targets for histology and resection rates for lung cancer against which services can be judged. One report from a tertiary referral centre suggested that resection rates of 25% were achievable (
). We set out to review the demographics and staging of lung cancer patients diagnosed at our DGH (Kings Mill Hospital) to examine the reasons for not obtaining a pathological diagnosis and not operating on patients with stage I and II disease. We have prospectively collected the full BTS/RCP audit data set on all patients diagnosed with lung cancer at our hospital since April 1999. These results are presented.
Over three years between 04/99 and 03/02 we diagnosed 441 cases of lung cancer. The rate of histological confirmation overall was 83.5%. More than 85% had their management discussed at the weekly Multi Disciplinary Meeting, which included respiratory physicians, a thoracic surgeon and an oncologist.
Small cell lung cancer (SCLC) accounted for 14% of all cases.
Of the 379 remaining patients 310 had confirmed Non Small Cell Lung Cancer (NSCLC). 299 of these (96%) were formally staged. The stage distributions are shown below and compared with those reported by Mountain (
Of those with stages I and II, the surgical resection rate was 42% and radical radiotherapy rate 28%. Co-morbidity prevented the remaining 30% from receiving potentially curative treatment. The resection rate for pathologically confirmed NSCLC was 32/310=10.3% or 32/379=8.4% if those without pathologically confirmed disease are included. Our results show that at our hospital patients with lung cancer present with later stage disease than those reported from tertiary referral centers. Selection bias may explain the differences between our results and those previously reported (see above). Even if all those with stage I and II disease underwent surgery we would barely achieve 15% resection rate.
S106 SURGICAL REFERRAL AND RESECTION RATE FOR NSCLC AT QUEEN ELIZABETH HOSPITAL OVER A 5 YEAR PERIOD: WHY IS IT SO LOW?
J.I. Whitehouse, N. Jahan, J.R. Webb, T.C. Stokes. Department of Respiratory Medicine, Queen Elizabeth Hospital, Stadium Road, Woolwich, London SE18 4QH, UK
Aim: to analyse the referral rate for surgery in stage I and II NSCLC in Queen Elizabeth Hospital Woolwich, from September 1997 up to April 2002.
A total of 746 patients were diagnosed with lung cancer between 1997 and 2002. Of these, 458 had histologically proven non-small cell lung cancer (NSCLC). All were staged and discussed at a multidisciplinary meeting, which does not have the input of a surgeon. Reasons for non-referral of stage I and II patients included poor lung function (13), age (10), WHO health status (5) patient refusal (5) other diseases (3) or a combination of the above (11). The median age for those referred relative to those not referred was 66 and 76, respectively (p<0.0001, Wilcoxon rank sum). Of the 60 stage I and II patients referred for surgery, 40% were deemed to be inoperable. Reasons were upstaging by PET scanning (9), age/lung function (3), upstaging at mediastinoscopy/thoracoscopy (5) and surgical opinion (7).
Conclusions: the surgical referral and resection rates for patients with operable cancer on staging criteria remains low. Despite the initiation of multidisciplinary meetings in 1997, fewer than half of the potentially operable patients (stages I, II and IIIA) were referred for surgery. However, nearly half of all stage I and II patients referred for a surgical opinion were refused, predominantly after upstaging. The introduction of a telemedicine link with cardiothoracic surgeons may improve referral rates.
S107 WHAT’S IN I.T. FOR US? USE OF AN I.T. SYSTEM TO INFORM AND IMPROVE A LUNG CANCER SERVICE
J.M. Hill, A. Lally, P.B. Anderson, B.J. Hutchcroft, P.M. Fisher, B. Entwistle. Chest Clinic, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
Background: An audit of 100 lung cancer case records in our institution in 1999 demonstrated that only 18% of cases had an MDT discussion and decision recorded in the medical records, and no regular outcome data were available.
Process: During 2 timeout sessions in 1999 and 2000 lead clinicians in the lung cancer services (diagnostics, thoracic surgery, oncology) mapped the lung cancer care pathway and clinical processes, and identified key stages of the patients care journey. This work was influenced by the need for performance target data and clinical minimum data sets.
In 2000 the Infoflex™ system was chosen to support the lung cancer services. The implementation required clinicians to define information requirements and outputs.
Outcome: The use of the Infoflex system coincided with the development of a weekly combined lung cancer clinic (Respiratory Medicine, Clinical Oncology and Palliative Care). Prior to the weekly Lung Cancer clinic (t=0 days) a first visit proforma and faxable immediate GP letter are printed, incorporating patient demographics from the hospital PAS system. Data from the proforma are entered on to the Infoflex system immediately after the clinic. Bronchoscopy findings are entered live onto the Infoflex system by clinicians and a bronchoscopy report, GP letter, and histopathology request form are printed. Prior to the MDT meeting (t=10 days) the results of investigations are entered onto the system and an MDT summary sheet is produced. The summary sheet aids decision making in the MDT meeting and serves as a referral letter between specialities. A second clinic visit proforma and immediate faxable GP letter are prepared for the second clinic visit (t=14 days).
The initial 12 months of complete data demonstate that 92% of patients diagnosed with lung cancer have an MDT discussion and decision recorded. Reports for any time frame are readily accessible, and present a realtime position of all suspected lung cancer referrals, their progress and outcome. Future plans include the use of projection equipment in the MDT meeting to view the discussion sheet and record decisions realtime, and the use of Infoflex for comparison of data with other units, primarily to ascertain reasons for differences in resection rate.
The genetics of respiratory disease
S108 AGE-SPECIFIC EFFECT OF THE CYSTIC FIBROSIS MODIFIER GENE, MBL-2
J.C. Davies1 2, M. Johnson3, C. Booth3, K. Fidler3, A. Bush1, D.M. Geddes2, E.W.F.W. Alton2, M.W. Turner3, N. Klein3. 1Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, UK; 2Dept of Gene Therapy, Imperial College, UK; 3Immunobiology Unit, Institute of Child Health, University College, London, UK
The variable severity of cystic fibrosis lung disease, even in subjects with identical CFTR mutations, has led to the search for non-CFTR modifier genes. Mannose-binding lectin (MBL) is involved in innate defence, both through direct opsonic activity and complement activation. Low-expressing MBL-2 haplotypes were reported in two studies of older CF children and adults to lead to a poor outcome. We have looked for correlations with clinical status in 260 paediatric CF patients. Genomic DNA was analysed for structural mutations (designated 0; wild-type A) and the low (X) or high (Y) expressing promoter polymorphisms. Patients were grouped based on haplotype which correlated closely with MBL levels (measured by ELISA) into group 1 (A/A, 62.9%), group 2 (YA/O, 24%) and group 3 (XA/O or O/O, 13.1%). At the earliest time point available (7.0 (6.9–7.4) years), children in group 3 had a significantly (p<0.05) higher FEV1 than those in either of the other groups (gp 3: median [IQR] 105.5 (83;113)%; gp 2: 85.5 (78;103)%; gp1: 91 (76;105)%). At the age of 9, a similar trend was seen (p=0.055). At approximate ages of 11, 13 and 15 years, no difference was seen in either parameter between groups. Annual rate of decline was not affected by MBL status (gp 3: −3.4 (−6.7; 0.3)%; gp 2: −3.5 (−5.9; −0.8 % gp 1: −3.0 (−6.4; 0.7)%). Infection with P aeruginosa increased the rate of decline, but affected each group equally. In contrast to adult studies, low MBL is not detrimental in childhood CF. The surprising finding that children with the lowest MBL levels in fact have higher lung function early in life may relate to the complex role of this protein in the inflammatory response. The loss of effect later is likely due to the increased protease activity on the airway surface with advanced disease. The most obvious difference between our group and those previously reported relates to year of birth, other groups having been born up to 20 years earlier. Over this time, CF treatment has progressed rapidly, possibly reducing the importance of certain host factors. These results highlight the importance of considering such environmental and treatment factors when studying modifier genes in CF.
S109 POLYMORPHISMS IN THE HYDROPHILIC SURFACTANT PROTEINS A AND D ARE MODIFIERS OF LIVER INVOLVEMENT BUT NOT LUNG DISEASE IN CHILDREN WITH CYSTIC FIBROSIS
J.C. Davies1 3, P. Pantelidis2, A. Lagan2, R. Du Bois2, K. Welsh2, D.M. Geddes3, E.W.F.W. Alton3. 1Dept of Gene Therapy and 2Clinical Genomics Unit, Imperial College, UK; 3Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
The surfactant proteins A and D are members of the collectin family involved in the innate immune system. Polymorphisms within SP-A have been associated with infant respiratory distress syndrome and severe RSV bronchiolitis. We have explored a modifying effect of these proteins on disease phenotype in children with CF. A sequence specific primer-PCR methodology was employed which enabled the identification of all known allelic variants on SP-A1, SP-A2 and SP-D genes directly from genomic DNA samples. Clinical data collected included lung function at defined ages, infection with common CF pathogens, and the presence of liver disease on ultrasound. Data were avaliable on 241 children at a mean (SEM) age of 8.5 (0.3) years. No correlation was seen between any haplotype and lung function at any age, risk of infection, use of IV antibiotics or age at diagnosis. However, in children with liver disease (n=19) both the SPA-1 allele 6A2, and the SP-A2 allele, 1A0, were significantly overrepresented (6A2/6A2 68% v 33%, 6A2/non-6A2 32% v 47%, non6A2/non6A2 0% vs 19%, p<0.01; 1A0/1A0 63% v 34%, 1A0/non1A0 32% v 47%, non1A0/non1A0 5% v 18%, p<0.05). A significant but less pronounced relationship was seen with the SP-D group possessing both the 11T and 160A polymorphisms (p<0.05). The lack of an association between these proteins and lung disease may either reflect redundancy in the host defence system, or enzymatic destruction of these proteins after release. The association with liver disease was unexpected and is interesting. Inflammation has been described in CF liver disease, although whether this is primary or secondary remains uncertain. The surfactant proteins have recently been identified in many extra-pulmonary sites including the the gastrointestinal tract, to date, only SP-D has been found in the biliary tree. These data suggest a role for inflammation and host defence proteins in the development of CF liver disease, and if further work is confirmatory, may allow identification of a subgroup at risk of this complication.
S110 PRELIMINARY IDENTIFICATION OF GENETIC LOCI ASSOCIATED WITH HIGH ALTITUDE PULMONARY HYPERTENSION BY ASSOCIATION MAPPING
L. Long, A.A. Aldashev, A. Hensiek, S. Eddahibi, S. Adnot, R.C. Trembath, M.R. Wilkins, N.W. Morrell. University of Cambridge School of Clinical Medicine, Department of Medicine, Addenbrookes’ and Papworth Hospitals, Cambridge CB2 2QQ, UK
Hypoxia-induced pulmonary hypertension is observed in residents at high altitudes and in patients with hypoxic lung diseases, such as chronic obstructive pulmonary disease. Well documented differences between individuals, and between high altitude populations, in susceptibility to pulmonary hypertension in low oxygen environments, suggest that genetic factors may play a role. To identify genes conferring susceptibility to hypoxia-induced pulmonary hypertension in native highlanders, we performed an ECG survey of the inhabitants (age 16 to 75, n=741) of 3 villages in Kyrgyzstan, at an altitude of 2800 to 3100m above sea level. Subjects with and without ECG signs of cor pulmonale underwent echocardiography to define groups of highlanders with and without pulmonary hypertension (defined by mean pulmonary arterial pressure >25mmHg). DNA samples were obtained from 30 cases and 30 controls. We used a DNA pooling technique and performed a whole genome screen using 811 microsatellite markers (Applied Biosystems high density linkage mapping set LMS-HD5), allowing a resolution of 5–10cM across the genome. Association mapping identified alleles that occured with significantly different frequency between cases and controls. Fifteen markers showed significantly different frequencies (p<0.05) on chromosomes 1,3,5,6,7,8,15,17, and 20. An initial search for candidate genes identified the locus for the serotonin transporter (5HTT) lying in close proximity (2mB) to the marker on chromosome 17. A polymorphism in the promoter of the 5HTT gene (L/S) is known to alter the expression of 5HTT and is associated with primary pulmonary hypertension. The frequency of the LL genotype, which increases 5HTT expression and activity, was 24% in the group with high altitude pulmonary hypertension compared with 12% in the controls. These results require confirmation in a larger cohort of cases and controls, and refinement of the chromosomal loci to aid in the identification of further candidate genes. Nevertheless, this study provides a novel approach to the identification of genes that confer susceptibility to hypoxia-induced pulmonary hypertension.
Funding: Wellcome Trust and British Heart Foundation.
S111 SMOKING RELATED EMPHYSEMA AND SMALL AIRWAYS DISEASE HAVE INDEPENDENT GENETIC RISK FACTORS IN COPD
B.D. Patel, A. Tasker, N. Screaton, W. Anderson, S. Sharma, E.K. Silverman, D.A. Lomas. Departments of Medicine and Radiology, University of Cambridge, UK; GlaxoSmithKline, North Carolina, USA; Channing Laboratory, Brigham and Women’s Hospital, Boston, USA
We previously have shown that COPD clusters within families suggesting that shared genetic factors predispose some smokers to airflow obstruction. It is unknown whether these genetic factors contribute to the airway disease and/or emphysema components of COPD. This has been addressed as part of the GSK COPD Genetic International Network designed to identify the genes that predispose smokers to COPD. The network has recruited probands aged 45–65 with an FEV1 <60% predicted and >5 pack years smoking history in the absence of PiZ α1–antitrypsin deficiency. Siblings of the proband with a >5 pack year smoking history were screened by spirometry for airflow obstruction. An HRCT scan was conducted on all consenting probands and siblings and the extent and distribution of emphysema was quantified by two independent radiologists. To date the network has recruited approximately 2400 individuals from over 800 families. 350 individuals have been recruited from 105 families by the Cambridge centre and this cohort has been used to define the familial risk of airways disease and emphysema. Family phenotype was determined by the extent of airways disease or emphysema in the proband. A stronger correlation was found between pack years smoked and FEV1% (r=−0.62, p=0.003) in the 20 siblings from families in whom the proband had predominantly airways disease (<5% emphysema) than in the 84 sibs from families where the proband had significant emphysema (r=−0.32, p=0.0001). The familial risk for emphysema was assessed in 89 sibs (47 men and 42 women) from 49 families in whom the proband and at least 1 sibling had an HRCT. The siblings of probands with 10–25% emphysema had an increased risk for significant (>5%) emphysema (unadjusted OR 4.64, p=0.05) when compared to siblings of probands with <10% emphysema. This risk was independent of pack years smoked but was significantly greater in women (OR 3.58, p=0.03). In conclusion, our data show that individuals with COPD have a genetic susceptibility to airways disease that is dependent on the pack years smoked. However emphysema develops in genetically susceptible individuals who smoke in a manner that is less dose dependent than airways disease. Finally women may be more susceptible to emphysema than men if they smoke.
S112 IMMUNOGENETICS OF LABORATORY ANIMAL ALLERGY
H. Jeal, A. Draper, M. Jones, J. Harris, K. Welsh1, A. Newman Taylor, P. Cullinan. Department of Occupational and Environmental Medicine and 1Interstitial Lung Disease Unit, Imperial College (NHLI), London, UK
Laboratory animal allergy is a common occupational health problem affecting approximately 30% of the exposed population. Allergic reactions to rats or mice are most common, probably because these animals are most frequently used in experimental studies. HLA class II molecules are involved in the presentation of allergen to the T cell and are therefore likely candidates for controlling the immune response. We hypothesised that HLA class II molecules might be associated with sensitisation to rat urinary protein among individuals exposed to laboratory animals.
We undertook a cross sectional study of 741 employees in contact, at work, with laboratory rats at 6 pharmaceutical sites across the UK. 109 cases (defined as having a skin prick test wheal ≥3mm to rat urine and/or a rat urine RAST >2%binding) and 397 non-sensitised referents were HLA typed for DRB1 and DQB1 loci. Participants were asked to complete a questionnaire enquiring into symptoms, exposure, and job history.
After adjustment for independent risk factors, HLA-DR7 was found to be associated with sensitisation (OR 1.99 CI 1.91–3.27), work-related chest symptoms (OR 2.98 CI 1.66–5.36) and sensitisation with symptoms (OR 4.81 CI 2.29–10.13). HLA-DR3 was protective against sensitisation (OR 0.55 CI 0.31–0.98). Atopy and exposure proved to be more strongly associated with sensitisation and sensitisation with symptoms than HLA.
Amino acid analysis of the associated HLA molecules provides a biologically plausible explanation for these associations.
S113 MATERNAL BUT NOT PATERNAL GENETIC VARIATION IN GSTP1 IS ASSOCIATED WITH ASTHMA PHENOTYPES IN CHILDREN
F. Child1, W. Lenney1, S. Clayton1, S. Davies1, P.W. Jones2, J. Alldersea3, R.C. Strange3, A.A. Fryer3. 1Academic Department of Paediatrics, North Staffordshire Hospital, Stoke on Trent, UK; 2Department of Statistics, University of Keele, UK; 3School of Medicine, Keele University, North Staffordshire Hospital, Stoke on Trent, UK
Background: Maternal factors including atopy and smoking during pregnancy are associated with the risk of developing asthma in childhood. Suggested mechanisms include transmission of specific maternal alleles to the child and maternal influences on the intrauterine environment. We have previously shown that polymorphism in glutathione S-transferase, GSTP1 is associated with asthma, airway hyperresponsiveness (AHR) and atopy in adults. We now hypothesise that GSTP1 genotypes in the both mother and child, but not the father, mediate asthma phenotypes in the child.
Methods: 145 Caucasian families were recruited via an asthmatic proband aged 7–18 years. Atopy and asthma were assessed using a questionnaire, skin prick testing, total serum IgE, spirometry and methacholine challenge testing. Phenotypic data were analysed as continuous and categorical variables. Bronchial challenge data were corrected for age, gender, height and baseline lung function. GSTP1 genotyping was determined using PCR.
Results: GSTP1 Val105/Val105 genotype in the child was weakly associated with a reduced risk of atopy (p=0.038) and AHR (p=0.069). In mothers (p=0.026) but not fathers (p=0.407), GSTP1 Val105/Val105 was associated with a reduced risk of AHR in the child. This was independent of the child’s genotype, maternal and child atopic status, maternal smoking during pregnancy, and transmission of parental GSTP1 alleles.
Conclusion: For the first time, we have shown an association between maternal genotype and the child’s asthma phenotype that is not due to transmission of specific maternal alleles to the child. This suggests an in utero effect of maternal genotype on the child and adds new insights into the mechanisms by which maternal factors may influence the development of asthma in childhood.
Asbestos and the pleura
S114 DIFFUSE ASBESTOS-RELATED PLEURAL FIBROSIS; A POOR GUIDE TO HEAVY DUST EXPOSURE?
C McGavin, K Smith, L Sykes. Derriford Hospital, Plymouth, UK
There has been an assumption that diffuse pleural fibrosis (DPF) is an indicator of heavy dust exposure.1This has considerable implications in the decision as to whether a given lung cancer has been caused by asbestos. The UK Industrial Injuries Advisory Council2 consider that lung cancer in the presence of DPF is an industrial tumour, but not in the presence of pleural plaque (PP).
Method: We have tested the hypothesis that DPF is a marker of heavy exposure by comparing estimated asbestos burden in 192 workers from the Devonport Dockyard, 96 with PP and 96 with DPF (43 bilateral). Dust burden was calculated from previously published data of exposure to asbestos by individual trades within the Yard multiplied by years spent in that trade prior to 1972. Detailed occupational histories were taken by one experienced observer who had also read all the radiographs (C McG).
Results: There were no differences between the groups in terms of age or time since first exposure. There were no differences in estimated dust burden between men with PP and DPF (independent samples t test, DF adjusted for unequal variances, t=1.045, DF=179, p=0.3), nor between PP and unilateral and bilateral DPF analysed separately, using logs of asbestos burden because of unequal variances (F2, 189=2.56, p=0.08). However there was evidence that men with bilateral DPF had had more exposure than those with unilateral (t=2.86, DF=88, p=0.004, t-test adjusted for unequal variances).
Conclusion: We found no evidence that men with DPF have had a greater exposure to asbestos than men with PP, and conclude that there is no justification for using the presence of DPF as an indicator of heavy exposure, for example in qualifying a lung cancer for industrial status. Bilateral DPF suggests a heavier dust burden than unilateral.
1. International Expert Meeting on Asbestos, Asbestosis & Cancer: the Helsinki Critera.
2. IIAC. Asbestos-related disease without Asbestosis. HMSO 1984, C9184.
S115 TRANSFORMING GROWTH FACTOR BETA (TGFβ) INDUCES MITOGEN-ACTIVATED PROTEIN KINASE (MAPK) SIGNALLING IN MALIGNANT MESOTHELIOMA CELLS
M.K. Wood, K.S. Abayasiriwardana, G.J. Laurent, S.E. Mutsaers, R.J. McAnulty. Centre for Respiratory Research, University College London, London WC1E 6JJ, UK
Malignant Mesotheliomas (MM) are fibrous tumours containing abundant collagen. MM cells produce collagen as well as TGFβ, which is a potent inducer of collagen synthesis. We have shown that antibody neutralisation of TGFβ or inhibition of collagen synthesis using a proline analogue inhibits collagen production in MM cells and reduces tumour growth. TGFβ signals predominantly via the Smad pathway, but also through the MAPKs. Over-expression of Smad7, the natural inhibitor of the Smad pathway, blocks collagen production in fibroblasts. However, in MM cells, we demonstrated enhanced collagen production and tumour growth following transfection with Smad7. From these findings we hypothesised that TGFβ-induced collagen production by MM cells occurs via MAPK signalling. To assess this hypothesis we performed Western blotting to determine if TGFβ stimulated activation of two components of the MAPK pathway, ERK1/2 and p38 kinase, in MM cells. The effect of blocking these pathways, using specific inhibitors UO126 (10μM) and SB203580 (10μM) respectively, on collagen production was assessed by measuring hydroxyproline levels using HPLC (nmol hydroxyproline/105 cells±SEM).
Results: Exogenous TGFβ1 activated both ERK1/2 and p38 kinase in MM cells within 5min. Blocking ERK1/2 activity increased procollagen production basally (control 0.26±0.01, UO126 0.49±0.02, p<0.01) and after TGFβ1 stimulation (control 0.58±0.004, UO126 0.72±0.02, p<0.01). However the fold increase in collagen production in response to TGFβ1 was 2.3 and 1.5 times basal levels in control and UO126 treated groups respectively, suggesting a decrease in the response to TGFβ1. Blocking p38 kinase activity had a small inhibitory effect on collagen production basally (control 0.48±0.02, SB203508 0.39±0.02, p<0.01) and after TGFβ1 (control 0.59±0.01, SB203508 0.47±0.04, p<0.02).
Conclusions: (1) the ERK1/2 and p38 kinase MAPK pathways are rapidly activated by TGFβ1 in these cells, which may be important in MM tumorigenesis; (2) MAPKs appears to have a role in TGFβ stimulated collagen production by MM cells but do not appear to be the major route of signalling in this response. Further elucidation of the TGFβ signalling pathways involved in the regulation of collagen synthesis and the specific roles of the MAPKs in MM may identify unique pathways in this tumour, which might be exploited as potential therapeutic targets.
This work was funded by Cancer Research UK and British Lung Foundation.
S116 IMMUNOHISTOCHEMICAL PROGNOSTIC MARKERS IN MALIGNANT MESOTHELIOMA
N. Chaudhuri, I. Cawkwell, M.E. Cowen, A.P. Campbell, M.J. Lind. Academic Depts. of Oncology and Surgery, Castle Hill Hospital, Cottingham, UK
Objective: A nihilistic attitude exists towards malignant mesothelioma of the pleura (MMP) as most people die within a year of diagnosis regardless of treatment or palliation. Some patients do survive longer, multimodality treatment has increased survival in some centres and there are promising novel therapies on the horizon. Immunohistochemical markers have shown promise in predicting survival in other solid tumours and they could be used to select patients for further treatment in MMP.
Methods: Archival specimens were identified from a pathological database. Immunostaining was carried out with p53, proliferative markers—MIB1 and PCNA and apoptotic markers—Bcl2 and BAX. Up to 90 blocks analysed from 74 patients (M:F—66:8, median age 67.7 years) diagnosed with malignant mesothelioma between 1997 and January 2001.
Results: Median and mean survivals were 218 and 314 (SD331) days respectively. Patients were divided into two groups. See table.
Conclusions: Age and histological subtype influence survival in malignant mesothelioma as has been shown in other studies. In our study we found MIB1 could predict long-term survival in patients with MMP.
S117 SURVIVAL IN SURGICALLY DIAGNOSED PATIENTS WITH MALIGNANT MESOTHELIOMA IN CURRENT PRACTICE
C. Tan1, S. Swift2, C. Gilham3, S. Shaefi1, W. Fountain2, J. Peto3, T. Treasure1. 1Thoracic Unit, Guy’s Hospital, London, UK; 2Thoracic Unit, Harefield Hospital, Harefield, UK; 3Institute of Cancer Research, London, UK
Objective: There is an epidemic of malignant mesothelioma in Europe that presents a challenge to thoracic surgeons. The median survival is quoted as five months (150 days) but reports are from ten or more years ago. To evaluate results of new treatments we set out to establish survival statistics for current practice.
Methods: We searched back five years in the pathology database of our two hospitals for all pleural biopsies in which mesothelioma was diagnosed.
Results: We found a total of 426 cases and report on 409 where we know vital status (table). Survival was 174 days (82%) longer at one hospital than the other. This difference is not explained by histological type, sex, or age. Epithelioid type and age (younger) were associated with better survival as is consistently shown.
Conclusion: Claims for improved treatments are made with reference to historical data for the natural history of the disease. Not only are survival times (from diagnosis) longer than those quoted but the difference between two hospitals is far greater than the likely gain from any novel or more radical therapy. The possible explanations include lead time bias due to earlier referral in Harefield as opposed to Guy’s or differences in histological diagnostic threshold. Whatever the explanation it illustrates the need for a contemporaneous control group and our data emphasise the case for a randomised controlled trial.
S118 ACTIVATION OF PROTEASE ACTIVATED RECEPTOR-2 IN MESOTHELIAL CELLS: A NOVEL MECHANISM OF PLEURAL INFLAMMATION
Y.C.G. Lee, D.A. Knight, K.B. Lane, D.S. Cheng, M.A. Koay, I.R. Teixeira, P.J. Thompson, R.W. Light. Vanderbilt University and St. Thomas Hospital, Nashville, TN, USA; Wellcome Trust Centre for Human Genetics, Oxford University, UK; University of Sao Paulo, Brazil; Asthma and Allergy Research Institute and University of Western Australia, Australia.
Pleural inflammation underlies a vast range of pleural diseases, but its mechanism remains poorly understood. Protease activated receptor (PAR)-2 is a novel seven-transmembrane G protein-coupled receptor. We recently showed that PAR-2 are present in abundance on human pleural mesothelial cells, and stimulation of PAR-2 in vitro resulted in significant release of inflammatory cytokines (
We hypothesised that PAR-2 in mesothelial cells has a functional role in pleural inflammation in vivo.
C57BL/6 mice were given a single intrapleural injection of 10mg/kg of SLIGRL-NH2 (a specific PAR-2 activating peptide), or 10mg/kg of LSIGRL-NH2 (control peptide), or the vehicle, phosphate-buffered saline (PBS). At 4 hours, the mice were sacrificed. Cytokines were measured with ELISA. Neutrophils were counted on cytospin slides (Geimsa stains).
Pleural fluid MIP-2 levels were significantly higher in mice injected with SLIGRL-NH2 (2710±165pg/mL) than in those given control peptide (880±357pg/mL) or PBS (88±46pg/mL), p<0.001. Similarly, pleural fluid TNFα was significantly higher in the SLIGRL-NH2 group. In the SLIGRL group, the neutrophil counts in the pleural fluid were significantly higher than the control peptide (by 40 fold) and the PBS groups (by 26 fold). The MIP-2 and TNFα levels were 15- and 4-fold higher in the pleural fluid than in serum, consistent of local pleural production. There were no differences in the serum levels of these cytokines among the three groups. The MIP-2 and TNFα levels were strongly correlated in the pleural fluids (r=0.92, p<0.00001) and in serum (r=0.76, p<0.01). There were no differences in the pleural fluid volume or in its VEGF concentrations among the three groups.
This study is the first to show a functional role for PAR-2 in the pleura. Our results confirmed that activation of PAR-2 in mesothelial cells in vivo resulted in significant production of pro-inflammatory cytokines with resultant neutrophil recruitment into the pleural cavity.
Asthma mechanisms II
S119 INCREASED SUB-EPITHELIAL PROTEOGLYCANS IN THE AIRWAYS OF MICE FOLLOWING OVALBUMIN SENSITISATION AND CHALLENGE
A.K. Reinhardt, S.E. Bottoms, G.J. Laurent, R.J. McAnulty. Centre for Respiratory Research, University College London, London WC1E 6JJ, UK
The sub-epithelial thickening of asthmatic airways is manifested by increased fibroblast/myofibroblast proliferation and deposition of extra-cellular matrix components including collagens and proteoglycans. The degree of proteoglycan deposition has been correlated with airway responsiveness. Existing murine models of asthma, including our own, have demonstrated increased amounts of airway sub-epithelial collagen following ovalbumin sensitisation and challenge. However, we are not aware of any studies examining altered airway proteoglycan deposition in an asthma model. In this study we have investigated changes in proteoglycan deposition in sections of murine lung using a selective histological stain and computer-assisted image analysis.
Wild-type SV129/C57BL/6 mice were sensitised by intra-peritoneal injection of 10μg of ovalbumin in 0.1ml saline on two occasions 10 days apart. 21 days after the second sensitisation mice were challenged with 400μg of ovalbumin in 50μl saline by intra-tracheal instillation daily for 6 days. Control mice were sham sensitised/sham challenged. 12 days after the final challenge mice were killed. Lungs were inflated with a 1:3 embedding matrix:saline mixture at a pressure of 25cm water, set in embedding matrix and frozen in liquid nitrogen for histological analysis. 7μm frozen sections were stained overnight using cupromeronic blue and a critical electrolyte concentration of 250mM magnesium chloride. Sub-epithelial proteoglycan staining was quantitated using a computer-assisted image analysis system. Airways were selected using pre-defined criteria and each airway was examined using separate colour thresholding for lumen and sub-epithelial proteoglycans. Results were expressed as amount of proteoglycan per unit airway lumen perimeter.
Lung sections from a total of 19 animals were examined (10 ovalbumin sensitised/challenged and 9 controls). A total of 52 ovalbumin sensitised/challenged and 32 control airways were analysed. The mean area of proteoglycan/μm airway perimeter was 5.46±0.39μm2 in the ovalbumin sensitised and challenged group and 4.13±0.44μm2 in the sham sensitised/sham challenged group (p=0.03). This represents a mean increase of 32% in sub-epithelial proteoglycan deposition following ovalbumin sensitisation and challenge. Interestingly, in view of the association between proteoglycans and collagen fibril assembly, sub-epithelial collagen is increased by 33% using the same sensitisation/challenge protocol. We conclude that the increase in sub-epithelial proteoglycan and collagen deposition found in the airways of asthmatics can be reproduced in mice following ovalbumin sensitisation and challenge and that this may be a useful model to assess the mechanisms regulating sub-epithelial airway remodelling.
Work funded by the Wellcome Trust.
S120 WNT SIGNAL TRANSDUCTION IN ADULT BRONCHIAL EPITHELIAL CELLS
M.D. Steel, D.E. Davies, S.M. Puddicombe, S.T. Holgate, J.E. Collins. Division of Inflammation, Infection and Repair, School of Medicine, University of Southampton, Southampton, SO16 6YD, UK
Wnts are a highly conserved family of secreted glycoproteins that play a fundamental role in cell fate determination and tissue morphogenesis during embryonic development.1 Through binding to members of the Frizzled (Fzd) receptor family, class-1 Wnts induce the accumulation of hypophosphorylated β-catenin by inhibiting the GSK-3β/axin/APC destruction complex. Consequent translocation of β-catenin to the nucleus gives rise to activation of TCF/LEF-1 transcription factors, leading to expression of genes involved in cell migration (CD44, MMP7) and proliferation (c-myc, cyclin-D1). In mammalian embryonic lung, activation of this “canonical” pathway in airway epithelial cells has been implicated in the process of branching morphogenesis, and Wnt secretion by underlying mesenchymal cells is thought to play a key role.2 Despite reports that several WNT and FZD genes are expressed in adult human lung tissue, very little is known about which cells are involved, and their functional significance remains unclear. Using an RNAse protection assay, we have identified expression of FZD-2, -3, -5 and -6 in both H292 and primary bronchial epithelial cells. In addition, these cells also express the gene encoding secreted Frizzled receptor protein-1 (SFRP1), the product of which is capable of modulating Wnt signals in the extracellular compartment. Postulating that human airway epithelial cells retain the ability to transduce a canonical Wnt signal in adult life, we employed RT-PCR and observed expression of TCF-4 mRNA in primary cells, with weaker expression of TCF-3, but no detectable message for TCF-1 or LEF-1. Using a TCF reporter construct (TOPFLASH) in H292 cells, we demonstrate repression of TCF transcription at baseline, with activation induced by stimulation with lithium, an inhibitor of GSK-3β and mimicker of class-1 Wnt activity. Our data supports our hypothesis, and we speculate that reactivation of this morphogenetic pathway in adult human lung may play an important role in airway epithelial regeneration, as well as remodelling in airways disease.
This study is funded by: Medical Research Council (UK) G84/5708.
1. Wodarz, et al.
2. Tebar, et al.
S121 FACTORS INFLUENCING CROSS SECTIONAL AND LONGITUDINAL ASSOCIATIONS BETWEEN EXHALED NITRIC OXIDE AND INDUCED SPUTUM EOSINOPHIL COUNT IN ADULTS WITH ASTHMA
M.A. Berry, R.H. Green, A.J. Wardlaw, I.D. Pavord. Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
There is increasing evidence that a management approach that includes monitoring airway inflammation in asthma leads to an improved outcome. Induced sputum eosinophil count and exhaled nitric oxide (NO) concentration are both potential non-invasive measures of airway inflammation, although exhaled NO is more suited to serial measurements. Little is known about the relationship between these two measurements and the factors which influence it. We have investigated the relationship in 246 non-smoking and 75 smoking adults with stable asthma of variable severity who had both exhaled NO and induced sputum eosinophil counts measured on the same visit. We have also examined the relationship between change in sputum eosinophil count and exhaled NO in 75 patients with moderately severe asthma who were participating in a prospective longitudinal study and had 9 paired measurements over the period of one year. We found a significant positive correlation between exhaled NO and sputum eosinophil count in non-smokers (r=0.461, p<0.001) and between change in the variables (r=0.262, p<0.001). There was no significant correlation between the two measurements in smokers. Within the non-smoking group the correlation was stronger in: males (r=0.637, p<0001) than females (r=0.387, p<0.001), in those not on inhaled steroids (r=0.497, p<0.001) compared to those who were (r=0.385, p<0.001) and in atopic (r=0.605, p<0.001) compared to non-atopic patients (r=0.366, p<0.001). The relationship between change in sputum eosinophil count and exhaled NO was also stronger in males (r=0.303, p<0.001) than females (r=0.183, p=0.016). Smoking, gender, atopy and inhaled steroid use have a significant impact on the relationship between exhaled NO and sputum eosinophil counts in cross sectional analysis. In both cross sectional and longitudinal analysis there is a marked difference in the relationship between exhaled NO and sputum eosinophil count in males and females. This could be due to the effect of female sex hormones on NO-synthase. The relationship between the variables is much closer in cross sectional study than between change in the variables, suggesting that they identify a common airway abnormality but are regulated differently by factors that alter airway inflammation.
S122 SIMVASTATIN HAS AN ANTI-INFLAMMATORY EFFECT IN A MURINE MODEL OF ALLERGIC ASTHMA
A. McKay1 2, B.P. Leung1, I.B. McInnes1, S. Culshaw1, N.C. Thomson2, F.Y. Liew1. 1Departments of immunology and 2Respiratory Medicine, Western Infirmary and University of Glasgow, UK
Introduction: Asthma is an eosinophilic inflammatory airways disease. There is increasing evidence that statins, such as simvastatin, have anti-inflammatory properties which are unrelated to their lipid-lowering activity. We therefore wished to study the effect of simvastatin in a murine model of asthma.
Methods: BALB/c mice primed with ovalbumin (OVA) were re-challenged with OVA on three consecutive days. Simvastatin 40mg/kg or 4mg/kg or vehicle control were given intraperitoneally (i.p.) at the time of these challenges. Analysis was done one day after the last challenge.
Results: Simvastatin treatment at a dose of 40mg/kg i.p. resulted in a significant reduction in bronchoalveolar lavage (BAL) total cellularity (mean \” SD: simvastatin 17.9 \” 5.53 × 104/ml v vehicle control 39.4 (15.2) x 104/ml, p < 0.01) and eosinophilia (simvastatin 5.59 (3.17) × 104/ml v vehicle control 19.4 (9.92) × 104/ml, p < 0.01). Both high and low dose i.p. simvastatin treatment were associated with a reduction in BAL interleukin (IL)-4 and IL-5 levels and also in OVA-induced IL-4 and IL-5 production in thoracic lymph node (LN) cultures. See table.
Reduced inflammation was observed in lung histology in the simvastatin-treated mice. Serum OVA-specific IgG1, IgG2a, and total IgE levels were unaltered by simvastatin treatment.
Conclusion: These results demonstrate that simvastatin has anti-inflammatory effects in this murine model of allergic asthma.
S123 A CASE-CONTROL STUDY OF MEMBRANE FATTY ACIDS IN ASTHMA
E. Broadfield, A. Whitehead, N. Lawson, J. Britton, A. Fogarty. University of Nottingham, UK
Rationale: As substrates for eicosanoid production, it is hypothesised that omega-6 polyunsaturated fatty acids (PUFA) may increase the prevalence and/or severity of asthma. Furthermore as competitive antagonists of this process, omega-3 fatty acids may have a protective role. This study was designed primarily to explore whether asthmatics have increased levels of erythrocyte membrane omega-6 PUFA compared to non-asthmatics, and secondarily whether there are differences in the levels of the other main fatty acids between asthmatics and controls.
Method: Fasting blood samples were taken from 89 asthmatics on inhaled steroids and 89 community controls, matched for age, sex, and area of residence. Percentage levels of the 8 most abundant erythrocyte membrane fatty acids were measured using gas chromatography, and the levels in cases and controls compared using the paired t test.
Results: The levels of two PUFA (palmitoleic and eicosapentaenoic acids) were too small to be measured and were therefore excluded from the analysis. Cases were found to have significantly lower erythrocyte membrane levels of the omega-6 fatty acid linoleic acid and higher levels of the saturated fatty acid stearic acid. See table.
Conclusion: These findings are consistent with the hypothesis that dietary omega-6 PUFA may be involved in the aetiology of asthma, but not with a protective role for omega-3 fatty acids. The unexpected finding of increased levels of the erythrocyte membrane saturated fatty acid stearic acid warrants further investigation.
Drug therapy in cystic fibrosis
S124 SERUM AND SPUTUM CONCENTRATIONS FOLLOWING THE ORAL ADMINISTRATION OF LINEZOLID IN ADULT PATIENTS WITH CYSTIC FIBROSIS
D. Saralaya, D. Peckham, B. Hulme, C. Tobin, S. Conway. Regional Adult Cystic Fibrosis Unit, Seacroft Hospital, Leeds LS14 6UH, UK
Introduction: Linezolid is a new antibiotic with efficacy against methicillin resistant Staphylococcal aureus (MRSA). Although licensed for the treatment of respiratory tract infections, there are, as yet, no published trials of its use in cystic fibrosis (CF).
Aim: The objective of the study was to evaluate the absorption and sputum penetration of oral Linezolid in with CF patients.
Methods: 10 (5 male & 5 female) adult CF patients were recruited over a 3 month period. The mean (range) age, BMI and % predicted FEV1 were 25.4 years (19–36), 20 (2.2) and 47.8% (22–90) respectively. Inclusion criteria included the absence of MRSA infection or significant liver disease. Treatment was administered under nursing supervision. Subjects received 600mg of Linezolid orally every 12 hours for 6 doses. Serum and sputum drug levels were measured before and at 2 hours after the final dose of Linezolid. A further serum level was measured at 4 hours. Serum and sputum levels were measured by High Performance Liquid Chromatography.
Results: Mean (SD) serum Linezolid levels were 2.3mg/l (1.5) at 12 hours following the 5th dose and 13.5 mg/l (4.3) and 8.1 mg/l (3.3) at 2 and 4 hours following the 6th dose. High sputum concentrations were obtained with mean (SD) levels of 3.6 mg/l (2.1) and 17.3 (6.9) at 2 and 4 hours following drug administration. Good sputum penetration was observed with mean sputum to plasma ratio of 1.4 at 2 hours. There was a significant variation in peak serum levels within the studied population. However, even the lowest peak concentration exceeded the MIC 90 for MRSA (2–4 mg/l). Serum levels in this study are slightly lower than levels obtained in non-CF historical controls.
Conclusion: The administration of 12 hourly ,600mg oral Linezolid to CF patients results in sputum levels that exceed the MIC90 of MRSA for almost the whole dosing period. Further clinical trials are needed to assess the efficacy of Linezolid against MRSA in this patient group.
S125 A PROSPECTIVE, DOUBLE-BLIND, RANDOMISED, PLACEBO CONTROLLED, CROSSOVER TRIAL OF AZITHROMYCIN IN PAEDIATRIC CYSTIC FIBROSIS
A. Equi, A. Bush, I.M. Balfour-Lynn, M. Rosenthal. Royal Brompton and Harefield NHS Trust, London, UK
Following significant improvements in lung function in a pilot study of seven patients with cystic fibrosis who received azithromycin daily for at least three months,1 we now report a prospective, double blind, placebo controlled, double blind, crossover trial of AZM in paediatric CF patients.2
Methods: 41 CF children aged 8 to 18 years, median expired volume in one second (FEV1) 61% (range 33 to 80%) participated in a 15 month randomised double-blind placebo controlled crossover trial receiving either Azithromycin (body weight <40kg: 250mg daily, >40kg: 500mg daily) or placebo for 6 months. Following 2 months washout, the treatments were crossed over. Spirometry, sputum cultures, sputum interleukin 8 and neutrophil elastase, exercise testing, quality of life, antibiotic usage and pulmonary exacerbation rates were outcome measures. Side effects were assessed by pure tone audiometry and liver function tests.
Results: The median relative difference in FEV1 between azithromycin and placebo was +5.4% (95% CI 0.8 to 10.5 %). 13/41 subjects improved by >13% and 5/41 deteriorated by >13% (p=0.059). The median relative difference between azithromycin and placebo was +11.5% (5.3 to 16.5) when not receiving concurrent rhDNAse (n=26) and −3.6% (−22 to +3.9) for the 15 receiving rhDNAse (Mann Whitney p=0.003). There was no significant overall change in forced vital capacity or mid expiratory flow rates but the effect of rhDNAse usage was similar for these measurements. Overall, 17/41 subjects had 24 fewer oral antibiotic courses when on azithromycin compared with placebo and 5 subjects had 6 extra courses (p<0.005). Of the 12/15 children on rhDNase, 11/15 needed intravenous antibiotics whilst on azithromycin compared with 6/15 when on placebo (p<0.05). There were no changes in sputum bacterial densities, inflammatory markers exercise tolerance or subjective well-being. There were no significant side effects.
Conclusions: A four to six month trial of azithramycin is justified in children with CF not responding to conventional therapy.
1. Jaffe A, et al. Long-term azithromycin may improve lung function in children with cystic fibrosis.
2. Equi A, Balfour-Lynn I, Bush A, et al. Long term azithromycin in children with cystic fibrosis: a randomised, placebo-controlled crossover trial.
S126 A DOUBLE-BLIND PLACEBO CONTROLLED CLINICAL TRIAL TO DETERMINE THE SAFETY OF ICODEXTRIN AND ITS EFFECT ON MUCOCILIARY CLEARANCE IN CYSTIC FIBROSIS
M. Stern1 4, T. Wodehouse1 4, A. Hasani2 , J. Davies1 4, D. Hansell1, M. Parry-Billings3, E. Peers3, M. Shott3, J. Agnew2, D.M. Geddes1 4, E.W.F.W. Alton1 4. 1Dept Gene Therapy, Imperial College at the NHLI; 2Dept Medical Physics, Royal Free Hospital & Medical School; 3Innovata Biomed Ltd, St Albans, Hertfordshire, UK; 4UK Gene Therapy Consortium
Cystic fibrosis (CF) may best be managed by therapy directed at restoring the volume of airway surface liquid (ASL). We tested a strategy to increase ASL, and hence mucociliary clearance, by providing an osmotic stimulus to the lower airways using icodextrin, a high molecular weight glucose polymer used in peritoneal dialysis to produce colloidal osmosis but never tested in the human lung. In a double-blind, placebo-controlled crossover study, 10 CF patients (≥18 yr, FEV1≥60% predicted) were randomised to receive either nebulised (Pari LC-65) icodextrin (10 ml, 200 mg/ml in normal saline) or placebo (10 ml normal saline). The second treatment was administered one week later. Following each treatment, measurements of lung function (spirometry and oximetry) made daily for 7 days as well as 2 serial high resolution CT scans of the lungs showed no evidence of icodextrin-associated pulmonary toxicity. There were no significant changes detected in serial full blood counts, ESR, CRP, renal and liver function tests, serum IL-6 and IL-8, supporting systemic safety. Baseline mucociliary clearance (MCC) was determined for a 4hour period using a radioaerosol/gamma camera technique and 5 m 99mTcpolystyrene particles. The same scanning protocol was repeated after each treatment. Compared to baseline (443.5±7.8 %/hour), icodextrin (401.5±11.8 %/hour), but not placebo (417.8±10.2 %/hour), was associated with a significant (p=0.01) increase in MCC as expressed by the area under the whole lung radioaerosol retention curve. The effect of icodextrin was most marked on tracheobronchial clearance rate after 150 and 180 minutes respectively when significantly (p=0.03) less radioaerosol (26.4±2.4% and 21.8±2.0%) was retained compared to baseline (43.2±4.8% and 34.2±4.1%). Whilst compared to placebo, icodextrin was associated with increased tracheobronchial radioaerosol clearance, the difference between icodextrin and placebo did not reach statistical significance at any time point measured. In conclusion, nebulised icodextrin appears to improve MCC in CF patients but further optimisation of dose and delivery may still be required to determine whether it offers any significant advantage over nebulised saline.
S127 INTERACTION BETWEEN AEROSOL DELIVERY SYSTEM AND BRONCHODILATORS IN CF PATIENTS TAKING COLISTIN
M.E. Dodd1, S. Conway2, R.J. Marsden3, P.H. Weller4. 1Wythenshawe Hospital, Manchester, UK; 2St. James’s Hospital, Leeds, UK; 3Profile Therapeutics, UK; 4The Birmingham Children’s Hospital, Birmingham, UK
Chest tightness is a recognised side effect of nebulised antibiotics (AB). We describe a sub group of patients who nebulised colistin in a clinical trial. Patients using nebulised AB and DNase for >90 days were randomised to use the HaloLite AAD system (AAD) or a conventional high output nebuliser (NEB) over a 182 day period (study MAL 25–70). All patients used bronchodilators, some of the patients in each nebuliser group used a pMDI or DPI (INHL) others used a solution (SLN) form through the study device. This abstract reports preliminary analysis of % predicted FEV1 mean change from baseline to day 28, and to day 182 for each combination of nebuliser (AAD or NEB) and bronchodilator (SLN or INHL).
Results: 189 of 259 patients used colistin. See table.
Two way anaysis of variance demonstrated a significant interaction between device type and bronchodilator type for change in FEV1 (p=0.001).
Conclusions: The use of a bronchodilator prior to nebulising antibiotics is recommended practice to prevent inhaled antibiotic induced chest tightness in adult and paediatric patients. These data suggest that the use of a bronchodilator solution with colistin in patients using AAD has a positive effect on maintaining both short and long-term FEV1. This effect was not seen in the NEB group, nor was it evident in patients using INHL.
This study was sponsored by Profile Therapeutics, UK.
S128 THE UTILITY OF SALIVARY LEVELS FOR MONITORING ONCE DAILY INTRAVENOUS AMINOGLYCOSIDES IN CHILDREN WITH CYSTIC FIBROSIS
H. Spencer, P. Webber, M. Chadwick, S. Makhechas, J. Kerr, J.C. Davies. The Royal Brompton Hospital, London, UK
First line intravenous antibiotic treatment for children with pulmonary exacerbations of cystic fibrosis (CF) includes an aminoglycoside (AG) such as gentamicin or tobramycin. The nephro and ototoxic side effect of these drugs make monitoring of levels mandatory. Two previous studies have reported the use of salivary trough levels to monitor once daily AGs in patients without CF. Although a correlation was shown between saliva and serum values, there was no confirmation that the method could reliably detect toxic levels. In view of this, and the fact that CF saliva is known to be abnormal, we have assessed the utility of this approach in children with CF. CF children prescribed once daily AGs (10–12 mg/kg) were eligible for inclusion if they were old enough to produce saliva, and if they and their parent consented to the study. 28 patients (21 gentamicin, 7 tobramycin, median (range) age9.97 years(3.89 to 16.75) had simultaneous serum and saliva samples immediately prior to the 3rd dose of drug. In the majority (n=25), a few crystals of citric acid were placed on the tongue to stimulate saliva production, up to 2 mls of which was collected into a sterile polystyrene container. Blood samples were taken by peripheral venepuncture. Saliva collection was well tolerated in all cases. 27/28 patients had a serum level of <1 (mg/L). In 24 of these (89%), the salivary level was also <1, but in 3 patients higher levels were obtained (8.96,4.98,4.3). Only one patient had a toxic serum level of 1.6; this patient also had a high salivary level (7.7).
This study demonstrates that both gentamicin and tobramycin can be detected in saliva. The salivary measure confirmed a safe serum level (<1mg/L) in 89% of children, but in a minority, salivary levels were spuriously high. With regards to safety of salivary monitoring, only one patient had a serum trough level that was considered toxic at >1 (mg/L). In this child, the saliva sample detected this and was also abnormally high. Although these data are promising, confirmation of safety will require evidence from further children that salivary levels are consistently raised in the presence of toxic serum levels.
S129 ALTERED TISSUE DISTRIBUTION IN ADULTS WITH CYSTIC FIBROSIS
C.E. Bolton, A.A. Ionescu, W.D. Evans, R. Pettit, D.J. Shale. Sections of Respiratory Medicine and Medical Physics, University of Wales College of Medicine, Llandough Hospital, Penarth, Cardiff CF64 2XX, UK
We studied the distribution of altered body composition in 51 adults with cystic fibrosis (CF) colonised with Pseudomonas aeruginosa and 18 age and sex matched healthy subjects. Using DEXA scanning we derived height indices for total fat mass (FMI), fat free mass (FFMI) and bone mineral content (BMCI) of the right arm, leg and trunk. Spirometry, height, weight, and physical activity (METS) data were determined.
In patients, FFMI of the arm and leg were less (p<0.05).The truncal FFMI difference was not significant (possibly due to group diversity or that viscera are classed as FFM). Amongst the patients, there was a greater deficit (compared with the mean control) of FFMI in the leg than arm than the trunk (18.19%, 14.86%, +0.09%, p<0.02).
For patients, FFMI for arm, leg and trunk were less (p<0.05) in the severe (FEV1 <45%) than the mild (FEV1 >65%) disease group. Amongst the severe group, there was (p<0.02) greater deficit of FFMI in leg (28.68%) than arm (23.76%) than trunk (3.93%). See table.
Patients with a normal BMI, low total FFM (n=10) had a lower (p<0.01) arm, leg and trunk FFMI than those with a normal BMI, normal total FFM (n=13).
The BMCI of the arm, leg, and trunk of patients were less (all p<0.001) than the controls. There was a lesser BMCI in the severe than the mild (p<0.03) disease. Patients with a normal BMI, low total FFM had a lower (p<0.03) arm, leg, and trunk BMCI than those with a normal BMI, normal total FFM. In all cases, there was no significant difference in the deficit of BMCI between arm, leg, and trunk. Fat mass in patients was not reduced.
Preferential loss of FFM occurs in adults with CF. Such loss is related to severity of lung disease and physical activity. It can occur in the presence of a normal weight/height ratio. A similar loss of BMC occurs with preservation of FM. A hierarchical pattern of FFM loss of legs > arms > trunk was demonstrated whilst bone mineral loss occurred generally.
Sponsored by the CF Trust, UK and the British Lung Foundation.
TNFα: Its role in respiratory disease
S130 GENETIC SUSCEPTIBILITY TO OZONE EXPOSURE
I.A. Yang1, O. Holz2, R.A. Jorres2, H. Magnussen2, S.J. Barton1, J.A. Cakebread1, J.W. Holloway1, S.T. Holgate1. 1Asthma Genetics Laboratory, Divisions ofHuman Genetics & IIR (Respiratory, Cell and Molecular Biology), University of Southampton, UK; 2Hospital Grosshansdorf, Center for Pneumology and Thoracic Surgery, Grosshansdorf, Germany
Ozone is a major air pollutant with adverse health effects, yet there is variability in response between individuals. Genetic determinants that modulate ozone-induced lung inflammation have been found in mice specifically inbred to be prone or resistant to ozone exposure.1 We hypothesised that polymorphisms in homologous human genes would influence response to ozone.
Methods: 37 participants (12 asthmatic, 25 healthy) who had undergone ozone challenge (intermittent exercise during inhalation of ozone ≥200 ppb) were genotyped using ARMS-PCR for tumour necrosis factor-α (TNF), glutathione peroxidase (GPX1), manganese superoxide dismutase (SOD2) and toll-like receptor 4 (TLR4) polymorphisms.
Results: There was no difference in lung function response between asthmatics and healthy participants. Mean change in FEV1 with ozone challenge was −9.0% baseline in TNF -308G/G individuals, compared to −0.6% baseline in TNF -308G/A or A/A individuals (95% CI for difference between means −14.5 to −2.3, p=0.008, t test). This difference remained significant even when only including 250 ppb exposures for 3h (p=0.007, Mann-Whitney U test, n=32). No significant differences were detected with GPX1 or SOD2, whereas the TLR4 polymorphism was too infrequent to analyse. No significant interactions between genotypes were observed (General Linear Model, SPSS V11).
Conclusions: This is the first study to extend the genetic linkage findings of ozone exposure in mice to clinical ozone challenges. These results suggest that the TNF locus is a genetic factor for susceptibility to ozone exposure, as it is in the mouse.1TNF haplotyping of larger cohorts and functional analysis of cellular models are required to confirm these findings.
Supported by: Allen+Hanburys/Thoracic Society of Australia and New Zealand Respiratory Research Fellowship
1. Kleeberger SR, et al. Linkage analysis of susceptibility to ozone-induced lung inflammation in inbred mice.
S131 POLYMORPHISMS IN THE PROMOTER OF TUMOR NECROSIS FACTOR (TNF) ALPHA GENE IN PATIENTS WITH SILICOSIS AND THE DEVELOPMENT OF PROGRESSIVE MASSIVE FIBROSIS
Y. Ohtsuka, X. Wang, K. Kimura1, T. Ishida, J. Saito, M. Munakata. Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushinma, Japan; 1Iwamizawa Rousai Hospital, Hokkaido, Japan
It is well known that there was pronounced individual variation in the severity of silicosis even in the same exposure environments. To explain this, we made our hypothesis that there might be an association between genetic polymorphisms of TNF-α promotor region and lung responses to silica particles in silicotic patients. To examine our hypothesis, we studied the association of TNFα promoter polymorphisms (−308, −238 and −376 ) with the roentgenological severity of silicosis in 124 sex-, smoking-, and exposure history - matched Japanese silicotic patients. Silicotic patients were divided into three groups, Pr (profusion rate) 1 (1/0–1/1, n=47), Pr3 (2/0–2/2, n=36), and PMF (progressive massive fibrosis) (4c, n=43) according to the ILO classification. We also examined 122 healthy controls within the same regional district. TNF-α promoter polymorphisms were determined using PCR-RFLP method. Results showed that frequency of A-308 (GA/AA) genotype is significantly higher in Pr 1 and Pr3 patients, (17% and 22%) as compared with PMF and controls (0% and 4%)(p<0.005). There were no significant differences at the −238 and −376 loci among the groups and controls. There are no linkage disequilibilium among these regions. From these results, the TNF promoter single nucleotide polymorphism (SNP) −308 might affect the development of silicosis.
S132 TNF PROMOTER REGION SINGLE NUCLEOTIDE POLYMORPHISM IN ARDS
A.L. Lagan, E. Beddow, S. Mumby, G.J. Quinlan, P. Goldstraw, J.D. Christie, P.N. Lanken, A.B. Fisher, R.M. Du Bois, K.I. Welsh, T.W. Evans. Unit of Critical Care, Dept Thoracic Surgery & Clinical Genomics Group, ILDU Imperial College Faculty of Medicine. Division of Pulmonary Medicine, Department of Medicine, University of Pennsylvania Medical School, Philadelphia, USA
Critical illness in adults frequently predisposes to, or is accompanied by acute lung injury (ALI), which in its most severe manifestation is termed the acute respiratory distress syndrome (ARDS). Therapy for ALI/ARDS is supportive and mortality rates remain high (30–70%). The incidence of ALI/ARDS in a given patient population is dependent in part upon the nature of the precipitating insult, and by inference upon individual susceptibility. Genetic variation may therefore contribute to the onset of ARDS in at risk populations. Acute inflammation is a major contributing factor to ARDS and TNF is a major mediator of the inflammatory response. We therefore performed a case control study to test the association of a TNF promoter region polymorphism (−857) with ARDS. Patients were consented and DNA extracted from whole blood and stored until time of analysis in sterile water at −20°C. Archived controls were used for comparison. The genotype of the biallelic single nucleotide polymorphism was determined by polymerase chain reaction in association with sequence-specific primers incorporating mismatches at the 3’ end.
Patients with established ARDS (15 UK patients, 28 USA patients) were typed for the TNF −857 promoter region polymorphism and compared with a normal control population (347 UK controls) and an at risk group of surgical lung resection patients (26 UK patients). A significant increase in the rarer −857 T allele was observed in the ARDS group when compared to controls (31% v 14%, p=0.01) and the at risk group (31% v 4%, p=0.006). These preliminary results indicate that variation in the expression of TNF a major pro-inflammatory cytokine may contribute to the onset of ARDS. However increased patient numbers and functionality studies will be required before firm conclusions can be drawn.
Work in part funded by the Dunhill Medical Trust and The British Lung Foundation.
S133 AUGMENTATION OF TNFα-INDUCED APOPTOSIS OF HUMAN NEUTROPHILS BY THE AMINOPEPTIDASE INHIBITORS BESTATIN AND ACTINONIN
A. Sobolewski, B.J. Reed, E.R. Chilvers. Department of Respiratory Medicine, University of Cambridge, School of Clinical Medicine, Addenbrookes’ and Papworth Hospitals, Hills Road, Cambridge, CB2 2QQ, UK
Neutrophil apoptosis plays an important role in the control of lung inflammation, resulting in cell clearance without a pro-inflammatory response. Therapeutic enhancement of this process therefore represents a major experimental goal. TNF is unique in its ability to induce both neutrophil apoptosis and priming. Aminopeptidase enzymes (AP) are involved in both protein maturation and degradation, and their inhibition has been shown to induce apoptosis in leukaemic cell lines. The aim of this study was to investigate the effect of aminopeptidase inhibition on TNFα-induced apoptosis in human neutrophils. Neutrophils were isolated from human blood using a Percoll separation. Cells were pre-incubated with AP inhibitors actinonin and bestatin (0.001–1mM,30min) in RPMI (10% autologous serum), prior to the addition of TNFα (100U/ml, 6h), and apoptosis assessed by morphology. FACS analysis was used to assess membrane TNFR55/75 following TNFα exposure (100U/ml,15min) +/- actinonin/bestatin (1mM). Shape change and superoxide assays were performed to study neutrophil priming and activation. To elucidate the nature of neutrophil APs, colorimetric enzyme-substrate assays were conducted on cell lysates in the presence of actinonin/bestatin. TNFα alone enhanced the rate of apoptosis (12±2%) compared to control levels (5±2%). Actinonin or bestatin alone had no effect, but in conjunction with TNFα, increased apoptosis to 21±3% and 20±2% respectively. Actinonin and bestatin did not affect neutrophil TNFR55/75 expression, shape change, or agonist induced superoxide anion generation. Enzyme-substrate inhibition profiles suggested the involvement of a basic AP. In conclusion, the AP inhibitors, actinonin and bestatin, augment TNFα-induced neutrophil apoptosis, independent of neutrophil priming, activation or altered TNFR55/75 expression. This effect is likely to be via inhibition of a specific aminopeptidase involved in maturation/degradation of a protein in the TNFα signalling cascade.
S134 TREATMENT OF CHRONIC SEVERE ASTHMA WITH A SOLUBLE TNF ALPHA RECEPTOR (ETANERCEPT)
K.S. Babu1, S.H. Arshad1, E.J. Bell1, S.D. McLoughlin1, P.H. Howarth1, A.J. Chauhan2, S.T. Holgate1. 1Respiratory Cell & Molecular Biology, Southampton General Hospital, Southampton, UK; 2Department of Respiratory Medicine, St. Mary’s Hospital, Portsmouth, UK
Tumor Necrosis Factor Alpha (TNF-α) is a pro-inflammatory cytokine implicated in the pathogenesis of asthma. TNF-α is increased in the airways of asthmatics and is involved in the production of IL-8, RANTES and GM-CSF by airway epithelial cells. Therefore there is a good case for blocking TNF-α as a therapeutic strategy in asthma. This open labelled study evaluated the efficacy of etanercept- a soluble TNF-α receptor (p75) linked to the Fc portion of human IgG1 in the treatment of chronic severe asthma.
Methods: 10 patients (18–65 years) with chronic severe asthma on regular oral corticosteroids (13 ± 10.1mg/day), high dose inhaled steroids, long acting inhaled β2 agonists and/or oral theophyllines were enrolled. They had an FEV1 of at least 50% of their predicted and demonstrated a reversibility of at least 9% with inhaled salbutamol. The study involved administration of 25mg of etanercept twice weekly for 12 weeks. Lung function measurements, methacholine response, and asthma control questionnaire were completed before and after the study.
Results: Treatment with etanercept resulted in clinically significant improvements in the lung function. FEV1 improved from 2.21L/sec (1.81–2.52), median (IQR) to 2.68 L/sec (1.77–2.75, p= 0.037) and the FEV1/FVC ratio improved from 75.63% (68.03–81.27) to 82.39% (69.64–88.75, p= 0.028). The mean asthma control symptom score improved from 26 (18.25–28.5) to 11.5 (4–16, p=0.005). Airway hyper-responsiveness as measured by methacholine dose response improved from 234.44 ml/mg to 9.21ml/mg (p=0.021). All patients successfully withdrew their nebulised β2 agonist medication from a mean dose of salbutamol 8.25 mg/day.
Conclusions: Etanercept improves FEV1, FEV1/FVC ratio, asthma control symptom scores, airway hyperresponsiveness and the use of rescue nebulised bronchodilator medication in patients with chronic severe asthma. Blocking the effects of TNF-α could prove to be an effective and novel therapeutic strategy for the treatment of patients with chronic severe corticosteroid dependent asthma.
This abstract was supported by Wyeth Laboratories, Berks, UK.
Epidemiology and ethnicity in respiratory disease
S135 DO VARIATIONS IN CHEST WALL DIMENSIONS EXPLAIN ETHNICITY-RELATED DIFFERENCES IN LUNG FUNCTION?
A.L. Whittaker1, A.J. Sutton2, C.S. Beardsmore1. 1Departments of Child Health1 and 2Epidemiology and Public Health, University of Leicester, UK
Introduction: Differences in lung function between people of varying ethnic origins may affect interpretation of individual results if inappropriate predicted values are used. Our aim was to characterise differences in spirometry in Asian (ethnic origins in the Indian Subcontinent) and white children and relate these to differences in chest dimensions. We hypothesised that Asian children would have smaller values for lung function and the differences would be explained by variations in chest size.
Methods: Children were seen in primary schools for measurements of FVC, FEV1, PEF, MMEF, FEF50, and FEF25, using a spirometer. Chest circumference, chest height, transverse diameter and A-P diameter were measured using an anthropometric tape measure and anthropometer. Relationships between standing height, lung function, chest dimensions, gender, and ethnicity were assessed using multiple linear regression analysis.
Results: Ninety-three white and 201 Asian children were included in the study. The final models explained 78% of the variability in FVC, 72% in FEV1 and 45% in PEF (adjusted R2 values). Standing height was the single most important predictor, however height squared, chest height, gender, and chest volume were also useful predictors for some outcomes. Ethnicity also remained an important predictor for all three measures, particularly FVC and FEV1, having adjusted for all other variables. FVC and FEV1 were smaller on average in the Asian children by 0.23L (95% CI 0.17 to 0.28) and 0.18L (95% CI 0.13 to 0.23) respectively. The average decrement in PEF in Asian children was 10L.min-1 (95% CI −0.2 to 20.6). The influence of chest dimensions (both singly and in combinations to represent the chest volume as a cylinder or a box) on the prediction was examined to see if they explained the ethnic differences in lung function. Only small differences in the regression coefficients for ethnicity were observed when variables related to chest volume were included in the model.
Conclusions: Equations taking account of ethnicity have been generated and can be used for the accurate prediction of spirometry. The influence of ethnicity on lung volumes is not explained by differences in chest dimensions. Further research in genetic and socio-economic factors is required in order to determine what factors are responsible for the ethnic differences in lung function reported here.
S136 NORMATIVE DATA FOR TOTAL SERUM IMMUNOGLOBULIN E MEASUREMENTS IN CHILDREN OF 3 ETHNICITIES
E.Y. Chan, S.A. McKenzie. Department of Paediatric Respiratory Medicine, Barts and the London NHS Trust, UK
Background: It is about 20 years since total immunoglobulin E (IgE) measurements were published for children without atopic disease. It is possible that the recent increase in atopic disease1 is reflected in altered measurement in subjects who have no clinical expression of atopy. If the measurement of IgE is to be used as a clinical test of atopy, contemporary normative data must be available.
Aim: To measure total serum IgE in healthy children of three ethnicities born and living in an inner city environment.
Method: Subjects were aged 1–12 years of Afro-Caribbean, Bangladeshi, and white British ethnicities with no personal history of atopic disease (asthma, eczema, hayfever, or food allergy). Extra blood (1ml) for the measurement of total IgE was collected when blood was taken for other purposes or when a surgical procedure was being undertaken.
Results: Measurements from 151 boys (median age 5.4 years) and 106 girls (median age 6.0 years) included 127 Bangladeshis, 58 Afro-Caribbeans, and 72 white British children. Log10 total IgE increased with age (Log10 IgE = 1.291+0.077*age; p<0.001) but was not related to gender or ethnicity. The data were significantly (6-fold) higher than previously published measurements.2
Conclusion: These contemporary normative data can be used to determine how useful IgE measurements are in separating healthy children from children with atopic illnesses.
1. Von Mutius E.
2. Kjellman N.
S137 EFFECT OF ETHNICITY ON ASTHMA PREVALENCE AND HEALTH SERVICE UTILISATION IN THE UK: A SYSTEMATIC REVIEW
G. Netuveli1, A. Sheikh1, B. Hurwitz3, M. Barnes4, M. Fletcher5, M. Levy6, S.R. Durham2. 1Dept of Primary Health Care; 2NHLI, ICSTM, London; 3Dept of English King’s College, London; 4 National asthma Campaign; 5National Respiratory Training Centre, Warwick; 6UK Kenton Bridge Medical Centre, London
Background: Healthcare providers perceive asthma prevalence to be higher in some ethnic minorities than in the white majority UK population but epidemiological studies to date have reached conflicting conclusions.
Objective: To review systematically the effect of minority ethnic status on asthma prevalence and service utilisation in Britain.
Methods: A systematic review of studies reporting prevalence of and/or hospitalisation for asthma were identified using the standard search strategies. Outcome variables were self reported asthma or wheeze. Only studies on populations living in the UK, reporting data on at least one minority ethnic group and the white majority and on children (below 16 years) were included. Differences in proportions and odds ratios, if reported, were pooled using both fixed and random effects models.
Results: Of the 36 studies identified, five studies reporting data on prevalence and two studies on hospital admission met the inclusion criteria. Meta-analysis of prevalence data was performed on the outcome measures and ethnicity separately using a random effects model. We found no significant difference in asthma or wheeze prevalence between whites and minority ethnic groups in the UK. The two studies reporting hospital admission rates could not be synthesized. Nevertheless, one group (5 to 14 years old) in one of the studies showed a greater odds ratio for Asians for hospitalisation for asthma (OR 2.03, 1.32 to 3.12).
Conclusions: There is no difference in the prevalence of asthma or wheeze between minority ethnic groups and the white majority in the UK. The dearth of data currently available does not allow conclusions to be reliably drawn regarding hospital admission rates for asthma.
Acknowledgments: A NHS R&D National Primary Care Fellowship supports AS. This work has been supported by a grant from the National Asthma Campaign, UK.
S138 MIND THE GAP! AGE AND SEX RELATED CHANGES IN THE EXPRESSION OF ASTHMA, ECZEMA, AND HAYFEVER
M. Osmano, P.J. Helmso, C. Simpson, M. Taylor1. Depts of Child Health and General Practice and 1Primary Care, University of Aberdeen, UK
Backgroun d: Asthma prevalence is higher in males during childhood reversing to a female predominance during adolescence. The timing of this “gender switch” and its relation to other atopic diseases in whole populations is less clear.
Methods: Prevalences of currently active asthma, eczema, and hayfever were identified from individuals who consulted their GP at least once for one or more of the above in the year April 1998–99. Records were extracted from 47 Scottish Morbidity Recording General Practices (population 252 538).
Results: Changes in the sex distribution were apparent during the adolescent period such that hayfever and asthma became more prominent in females. Females also had a higher prevalence of eczema in childhood that became more prominent in early adulthood. The gender switch for eczema precedes hayfever which in turn precedes that for asthma. See figure.
Conclusion: The similar, although differently phased, patterns in the adolescent gender switch suggests a shared underlying mechanism. Further studies on the relative contributions of sex hormones and socio-cultural influences seem justified.
S139 DO HOUSING IMPROVEMENTS IMPROVE RESPIRATORY HEALTH?
M Somerville1, M Basham1, C Foy2, A Barton1for the Torbay Healthy Housing Group. 1Plymouth and South Devon Research and Development Support Unit, University of Plymouth, Tamar Science Park, Plymouth, UK; 2Gloucestershire Research and Development Support Unit, UK
Cold, damp housing has been associated with poor respiratory health, but few studies have tried to evaluate the effect of improving housing on the occupants’ health.1 During a community development project in a deprived area of Torquay, local residents surveyed their council-owned homes and reported high levels of damp, mould, and respiratory illness. Torbay Council agreed to improve the houses over a two year period and funding was obtained for evaluation. Of the 142 houses on the estate, 119 agreed to randomisation, which was carried out at a public meeting; 50 houses were selected for improvement in the first year. Measurements of the indoor environment, general and respiratory health were taken at baseline and annually for the next two years in all houses and for all occupants.
At baseline, there were 480 people living in 119 houses. The population profile was young, with 58% aged 20 and under and 10% aged 50 and over. Bedroom and living room temperatures improved after renovation (central heating and insulation), but only bedroom temperatures showed a significant difference (p=0.002) between improved and unimproved houses at the end of the first year. Self-reported asthma prevalence in those aged under 18 years declined from 24% at baseline to 14% at the end of the study. Frequency of asthma symptoms2 reported in the month before each survey also reduced. The difference between those living in improved and unimproved houses at the end of the first year was not significant. Severity, as estimated by BTS asthma steps, remained unchanged in those continuing to report asthma. The study demonstrates the feasibility of evaluating the health effects of housing improvements. Further work is in progress to evaluate the social and economic impact of the renovations.
1. Thompson H, et al. Health effects of housing improvement: systematic review of intervention studies.
2. Steen N, et al. Development of a symptom-based outcome measure for asthma.
S140 FACTORS ASSOCIATED WITH QUALITY OF LIFE IN A COMMUNITY BASED SAMPLE OF YOUNG ADULTS WITH ASTHMA
W. Chaudhri1, J. Knox1, D. Jarvis1, B.D.W. Harrison2, R. Hall3, D. Seaton3, P. Burney1, S. Chinn1, C. Luczynska1. 1Dept of Public Health Sciences, Kings College, London, UK; 2Norfolk and Norwich Hospital, Brunswick Rd, Norwich, UK; 3Ipswich Hospital, Heath Road, Ipswich, UK
Quality of life (QOL) in asthma patients provides a measure of the effect of the disease on an individual’s everyday life but there is little information on factors associated with QOL in asthmatics in the UK. In 1997/1998 a short questionnaire was sent to 1140 subjects who took part in the East Anglia Respiratory Health Survey I (EARHS I) in 1991. Responders with symptoms suggestive of asthma (waking with shortness of breath OR having an asthma attack in last twelve months OR current use of asthma medication) completed the Marks’ QOL Questionnaire (4 domains—breathlessness, mood, social, and concerns). Regression analyses were conducted on the square root transformed QOL score to determine the difference in mean adjusted QOL score (MEAN DIFF) by gender, age-group, (<35, 35–44.9, ≥45), social class group, smoking status, and whether symptoms were present in EARHS I. To examine associations within each domain Mann Whitney tests were performed. Of the 983 who responded, 242 subjects aged between 27 and 53 years had symptoms of asthma and information on QOL. Worse QOL was reported by women (MEAN DIFF: 0.19; 95% CI 0.04,0.33) and those who had asthma in EARHS I (MEAN DIFF: 0.27; 95% CI 0.11,0.43). Worse QOL was observed in social class V and those with undetermined social class (housewives/students). Women had higher scores than men in the mood (p<0.01), social (p=0.02) and concern domains (p=0.04) but not in the breathlessness domain (p=0.14). Compared to those with “new onset asthma” those with asthma at EARHS I had higher scores in the breathlessness (p<0.01), social (p<0.01) and concern (p<0.01) domains but not in the mood domain (p=0.24). These findings show that amongst asthmatics, women and those who have had disease for a longer period of time report worse quality of life.
Funded by the National Asthma Campaign.
Drug therapy in COPD
S141 BUDESONIDE/FORMOTEROL IN A SINGLE INHALER (SYMBICORT™) REDUCES SEVERE EXACERBATIONS IN PATIENTS WITH MODERATE TO SEVERE COPD
L.M. Campbell1, W. Szafranski2 on behalf of the study group. 1Department of Medicine, University of Glasgow, UK; 2Department of Lung Diseases, Voivodeship Specialist Hospital, Radom, Poland
The efficacy of budesonide/formoterol in a single inhaler (B/F, Symbicort™) on COPD exacerbations was evaluated in a placebo-controlled, parallel-group, multicentre study. 812 adult patients with established COPD (median 5 years since diagnosis, mean age 64 years, mean baseline FEV1 0.99 L (36% predicted)) received two inhalations of either B/F 160/4.5 μg (total delivered dose 320/9 μg), budesonide (B) 200 μg metered dose, formoterol (F) 4.5 μg delivered dose, or placebo (PL) bid for 12 months.
Numbers of severe exacerbations (requiring oral steroid course (OSC) and/or antibiotics and/or hospitalisation) were recorded. Mean severe exacerbation rates were 1.4, 1.6, 1.8, and 1.9 exac/patient/y in the B/F, B, F, and PL groups, respectively. Severe exacerbations were reduced by 24% (p=0.035), 15% (p=0.224) and 2% (p=0.895) v PL with B/F, B and F; B/F also reduced mean exacerbation rates by 23% v F (p=0.043). The lowest rates of OSC associated with exacerbations were in the B/F and B groups (0.74 and 0.76 OSC/patient/y v 1.04 and 1.07 with F and PL). B/F and B reduced the number of OSC by 31% and 29% v PL (both p<0.05), and B/F v F by 28% (p<0.05).
Thus, budesonide/formoterol in a single inhaler (Symbicort™) produced statistically and clinically significant reductions in severe exacerbations in patients with moderate to severe COPD and was more effective than either budesonide or formoterol alone.
S142 BUDESONIDE/FORMOTEROL IN A SINGLE INHALER (SYMBICORT™) PROVIDES EARLY AND SUSTAINED IMPROVEMENT IN LUNG FUNCTION IN MODERATE TO SEVERE COPD
P. Anderson on behalf of the study group. Dept. Respiratory Medicine, Sheffield Chest Clinic, Sheffield, UK
COPD patients (n=812, median 5 y since diagnosis, mean age 64 years, mean baseline FEV1 0.99 L (36% predicted)) received 2 inhalations of budesonide/formoterol (B/F, Symbicort™) 160/4.5 μg (total delivered dose 320/9 μg), budesonide (B) 200 μg metered dose, formoterol (F) 4.5 μg delivered dose or placebo (PL) bid for 12 months. Lung function was assessed by FEV1 and PEF.
All treatments significantly improved FEV1 vs PL. B/F increased FEV1 by 15% v placebo, 9% v B (both p<0.001) and 1% v F (ns). These improvements were maintained throughout the 12-month study. In the first day, B/F increased morning PEF (mean change from run-in) by 10.9 L/min (PL by 0.3 L/min, B −0.3 L/min; F 6.4 L/min; B/F v PL and B, p<0.001, B/F v F, p=0.081). After the first week, B/F increased morning PEF by 15.6 L/min (PL by 1.1 L/min, B 3.4 L/min, F 8.8 L/min; B/F v PL and B, p<0.001, B/F v F, p=0.002). At 12 months, B/F improved morning PEF by 26.4 L/min (PL by 2.4 L/min, B 10.6 L/min, F 14.7 L/min; B/F v PL, B, and F all p<0.001) and improved evening PEF by 23.1 L/min (PL by 3.0 L/min, B 8.6 L/min, F 11.8 L/min; B/F v PL, B and F all p<0.001).
Budesonide/formoterol (Symbicort™) provides rapid and sustained, clinically relevant improvements in lung function in patients with moderate to severe COPD, with greater improvements in PEF than placebo or either monocomponent.
S143 BUDESONIDE/FORMOTEROL IN A SINGLE INHALER (SYMBICORT™) PROVIDES SUSTAINED RELIEF FROM SYMPTOMS IN MODERATE TO SEVERE COPD
L.M. Campbell1, W. Szafranski2 on behalf of the study group. 1Department of Medicine, University of Glasgow, UK; 2Dept. Lung Diseases, Voivodeship Specialist Hospital, Radom, Poland
Symptom relief with budesonide/formoterol (B/F, Symbicort™), budesonide (B), formoterol (F) or placebo (PL) was compared in patients with moderate to severe COPD. 812 patients (mean age 64 years) received 2 inhalations of either B/F 160/4.5 μg (total delivered dose 320/9 μg), B 200 μg metered dose, F 4.5 μg delivered dose or PL bid for 12 months. Daytime symptom scores of shortness of breath, cough and chest tightness, night-time awakenings due to symptoms (all 0–4 [none to severe], total symptom score (0–16)) and reliever medication use were recorded. B/F decreased individual and total scores after 1 week v PL, B, and F (all p<0.001). At 12 months, B/F reduced the total scores vs PL, B and F by 1.12, 0.84 (both p<0.001) and 0.41 (p=0.043). B/F reduced shortness of breath scores by 0.36 v PL and 0.26 v B (both p<0.001), decreased chest tightness scores by 0.21 vs PL (p<0.001) and 0.13 v B (p=0.043), decreased cough scores by 0.19 v PL (p=0.002) and 0.22 vs B (p<0.001) and decreased awakening scores by 0.34 v PL (p<0.001), 0.20 v B (p=0.003) and 0.16 v F (p=0.019). B/F increased symptom-controlled days by 7% v PL (p=0.001), increased awakening-free nights by 14% v PL (p<0.001) and 10% v B (p=0.001), increased days free from shortness of breath by 12% v PL (p<0.001) and increased days free from chest tightness by 7.5% v PL (p=0.015). B/F reduced use of reliever medication by 1.3 and 0.7 inhalations/24h v PL and B (both p=0.001), and increased reliever-free days by 8.6% v PL (p=0.003). Budesonide/formoterol (Symbicort™) provides early and sustained relief from symptoms in patients with moderate to severe COPD.
S144 THE EFFECT OF 3 MONTHS ORAL CLARITHROMYCIN ON SPIROMETRY, SHUTTLE WALK DISTANCE AND HEALTH STATUS SCORES IN PATIENTS WITH MODERATE TO SEVERE STABLE COPD
D. Banerjee1 2, O.A. Khair1, D. Honeybourne2. 1Department of Respiratory Medicine, City Hospital NHS Trust, Dudley Road, Birmingham, UK. 2Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK
Introduction and aims: Macrolides antibiotics are commonly used in the treatment of acute exacerbations of COPD. This study looked at the possible effects of long-term oral clarithromycin on spirometry, shuttle walk distance and health status scores in patients with COPD during the stable clinical state.
Methods: Randomised, double-blind controlled trial of oral clarithromycin 500mg o.d. (Cl) vs Placebo (Pl) o.d. for 3 months in stable patients with moderate to severe COPD who have not had an exacerbation for 6 weeks. The St George respiratory questionnaire (SGRQ) and Short form—36 (SF-36) were measured. The mean changes in parameter for each group were compared using either a 2 independent group t test or a Mann-Whitney U test where appropriate.
Results: 67 patients were randomised to receive Cl (n= 31) or Pl (n=36). 46 (69%) were male, mean age (SD) was 66.7 (7.9) years and 27 (40%) were current smokers. Mean (SD) FEV1 and FEV1 % predicted were 1.12 (0.41) L and 43.2 (11.4) % respectively. All patients were taking inhaled corticosteroids. Data for 7 patients were unavailable and intention to treat analyses were performed on the Cl group (n=26) and the Pl group (n=34). There were no significant differences in spirometry or shuttle walk distance parameters. However, there was a statistically significant improvement in SGRQ symptom score and SF-36 physical functioning in the Cl group compared to the Pl group. Differences in the other health status parameters were not statistically significant.
Conclusion: In this study, long term oral clarithromycin improved symptom and physical functioning scores in moderate to severe stable COPD patients.
S145 EFFECT OF BUDESONIDE/FORMOTEROL ON SEVERE EXACERBATIONS AND LUNG FUNCTION IN MODERATE TO SEVERE COPD
P.M.A. Calverley on behalf of the Symbicort™ study group. University Hospital Aintree, Liverpool, UK
Inhaled corticosteroids (ICS) are recommended in the prevention of COPD exacerbations in patients with an FEV1 <50% predicted. Whether long-acting β-agonist therapy is equally effective as ICS, or the combination superior to the components, is not known. We studied 1022 adults (mean age 64 years; mean FEV1 0.99 L (36% predicted)) with a history of at least one exacerbation in the previous year. To ensure baseline stability, all received formoterol (F) 9 μg bid and oral prednisolone 30 mg od for two weeks. Patients were then randomised to receive either F 9 μg, budesonide (B) 400 μg, budesonide/formoterol in a single inhaler (B/F, 320/9 μg respectively) or an identical placebo (PL), all given bid for 12 months. Severe exacerbations (as episodes requiring oral corticosteroid and/or antibiotics and/or hospitalisation) and lung function on 6 occasions post-randomisation were measured. B/F prolonged time to the first exacerbation v F (p<0.01), B and PL (both p<0.05); B/F reduced the relative risk of exacerbating by 30% v F, 29% v PL (both p<0.01) and 23% v B (p<0.05). The mean number of exacerbations/patient/ year was 1.38, 1.60, 1.85 and 1.80 for B/F, B, F, and PL. The time to the first oral steroid course was increased and the number of oral steroid courses was reduced by B/F compared with all other treatments: reductions of 45% v PL (p<0.001), 28% v B (p<0.05) and 30% v F (p<0.05). In addition, significantly fewer patients withdrew while taking B/F (p=0.001 v PL and F; p<0.05 v B). Post-dose FEV1 increased significantly with B/F: 14% v PL (p<0.001), 11% v B (p<0.001) and 5% v F (p<0.01).
These data show that combining budesonide and formoterol produces a greater reduction in the severe exacerbation rate than either drug alone, even in moderate to severe COPD, and that this can be achieved with relatively modest doses of the inhaled corticosteroid.
S146 A DOUBLE BLIND DOUBLE CROSS OVER COMPARISON OF HIGH DOSE COMBINED β2 AGONIST AND ANTICHOLINERGIC BRONCHODILATORS DELIVERED BY NEBULISER OR BY INHALER AND SPACER IN MODERATE TO SEVERE STABLE COPD PATIENTS
S.C. Johnson1, E. Gardener2, S.P. Hanley3. 1Physiotherapy department, 2Department of Research and Development 3Medical Directorate, North Manchester General Hospital, M8 6RL, UK
Introduction: This abstract reports a comparison of high dose salbutamol + ipratropium bromide delivered by inhaler+spacer or by nebuliser in a group of moderate to severe COPD patients. The effects on breathlessness and peak flow are reported.
Methods: Study design: baseline assessment followed by two crossover treatment cycles of 28 days. The two treatment periods in each cycle, given in random order, comprised; (a) 14 days of nebulised 2.5mg salbutamol and 500mcg ipratropium bromide or (b) 14 days of Combivent™ (100mcg salbutamol +20mcg ipratropium bromide) 6 puffs via VolumaticJ spacer. A double dummy technique was used to blind patient and operator. The San Diego Shortness of Breath Questionnaire (SOBQ) was measured at the end of each treatment period. Peak flow (PEF) was recorded twice daily. Visual analogue score (VAS) of breathlessness was recorded each evening. Analysis: where possible analysis was undertaken on an intention to treat basis. Treatment order effect (whether treatment effect differed depending on the order of treatment) was assessed using a graphical technique. A two sample t test was used to detect any between treatment differences.
Results: Fifty patients entered the study, mean age 68 years (SD7.5) FEV1 0.8 litres (SD 0.31) FEV1% 34% (SD 11.7). Analysis revealed a treatment order effect for cycle 1 i.e. those randomised first to active nebuliser had a lower average SOBQ and higher average PEF for the cycle. This was not seen in cycle 2. As a consequence, further analyses was confined to cycle 2, n=36 (32 male). Missing data, due to hospital admission (n=2) and consent withdrawal (n=1), all during the active nebuliser phase, caused exclusion from the analysis. The differences were not significant between nebuliser v inhaler. They were: SOBQ (n=33) 2.5 (95%CI −1.3 to 6.4) t = 1.3 p =0.19: PEF (n=32) 2.8l/min (95%CI −3.8 to 9.3) t =0.9 p=0.40: VAS (n=32) −0.1cms (95%CI −4.2 to 0.2) t= −0.7 p =0.48.
Conclusions: Although patients often request nebuliser treatment, this study does not support its prescription in stable COPD patients.
Patient and physician viewpoints in COPD
S147 SURVEY OF ATTITUDE OF 100 PATIENTS WITH COPD TO ARTIFICIAL VENTILATION AND CARDIOPULMONARY RESUSCITATION
K.A. Gaber, M. Barnett, Y. Blanchant, C.R. McGavin. Chest Clinic, Derriford Hospital, Plymouth, UK
Doctors are being encouraged to discuss and document end of life decisions with vulnerable patients admitted to hospital as part of involving patients in their own management. We wanted to ascertain the views of COPD patients.
Method: Patients with COPD under follow up by Respiratory Nurse Specialists (RNS) and the Chest clinic (of Derriford Hospital) were surveyed. Patients were approached by letter and personally by RNS. Written information about COPD and its clinical management including Non Invasive Ventilation (NIV), Invasive Ventilation (IV), and Cardiopulmonary Resuscitation (CPR) were given and discussed with each patient. Consent was obtained. Patients were asked to fill in Quality Of Life Questionnaire (locally developed at Plymouth University). The following information were obtained; age, sex, spirometry, hospital admissions, or antidepressant usage in the last 12 months and oxygen usage. Patients were asked to consider scenario in which they were admitted to hospital and after standard treatment, failed to improve, continued to deteriorate or developed cardiopulmonary arrest, “Reaching that stage, would you wish to have NIV, IV or CPR?”
Results: 100 patients were surveyed (41 were males and 59 females), mean age of 74 (48—92) years. The mean FEV1 was 0.78 (0.41—1.3) l and FEV1% of 42.7% (11—96%). 50% of patients had FEV1 < 40% predicted and 35% had FEV1 between 40 and 59% predicted. 24 patients (24%) were on LTOT, 8 (8%) used antidepressant and 56 (56%) had been admitted to hospital over the last 12 months. 48 patients (48%) wanted all treatments (CPR, NIV and IV) and 12 (12%) wanted non. 19 patients (19%) said No” for CPR but “Yes” to NIV and IV. 10 patients (10%) said “No” for CPR and IV but “Yes” for NIV. The remaining 11 patients (11%) gave mixed answers. Using ANOVAR analysis and Chi Square test there were no significant statistical differences between the groups. Conclusion; The commonly available measurable parameters of COPD could not predict patients views on CPR, IV, or NIV. These issues should be discussed with vulnerable patients preferably before hospital admission.
S148 CHRONIC OBSTRUCTIVE PULMONARY DISEASE—ALIGNING PATIENT AND PHYSICIAN VIEWS
I. Murdoch1, I. Draffan1, M. Karavali2, V. Higgins2. 1AstraZeneca, Macclesfield, United Kingdom; 2Adelphi Group Products, Macclesfield, UK
COPD patients suffer many debilitating symptoms which ultimately impair their quality of life. A Respiratory Disease-Specific Programme was conducted in respiratory and primary care clinics in 5 European countries. Primary care physicians (PCPs) and Respiratory Specialists (RSs) (n=769) completed patient record forms (PRFs) prospectively, on the type and severity of COPD symptoms and impact of these on patients’ lifestyle in terms of ability to undertake activities of daily living (ADL). Similarly, patients returned a self-completion form (SCF), detailing the severity, frequency, and impact of their respiratory symptoms on ADL. A total of 2446 patients were diagnosed with COPD (diagnosis recorded as COPD, emphysema or chronic bronchitis) and 72% (n=1768) of these returned a SCF.
PRF data showed that the most commonly reported symptoms of patients diagnosed with COPD were breathlessness on exertion (86%), daytime cough (82%), sputum (75%), and nocturnal cough (67%). SCF data showed that patients also identified these as key symptoms, recorded as either a moderate or major problem in the previous 6 months for 71%, 70%, 64%, and 61% of patients reporting severity respectively.
For these 4 key symptoms and others (wheezing, breathlessness at rest, tightening of chest, and nocturnal wakening) COPD patients regarded these to be more severe than PCPs and RSs. Patients suggested that COPD restricts their ability to undertake ADLs (work/housework, leisure activities and ability to exercise) to a greater degree than that perceived by PCPs (p<0.01) and RSs (p<0.01).
These data demonstrate that breathlessness, cough and sputum production are frequent and important symptoms in patients with COPD, and that physicians may underestimate the severity and restrictive impact of these symptoms, and others, on COPD patients quality of life.
S149 WHAT DOES THE GENERAL PUBLIC KNOW ABOUT COPD?
D.M.G. Halpin1, C. Ferenbach2, D. Bellamy3, M. Rudolf4 on behalf of the BTS COPD consortium. 1Royal Devon & Exeter Hospital, 2St Mary’s Hospital, Portsmouth, UK; 3James Fisher Medical Centre, Bournemouth and 4Ealing Hospital
As part of continuing activities to promote the implementation of key messages contained in the BTS COPD guidelines the BTS COPD consortium undertook market research among the general population to help understand public knowledge about COPD and their attitude to chronic respiratory symptoms. MORI were commissioned to add a number of questions drafted by members of the Consortium to their weekly omnibus survey. A representative sample of 866 adults (age 15 and over) were interviewed in their own homes in 188 locations around the UK. 49% were lifelong non-smokers, 20% ex-smokers and 31% current smokers. Over 90% of respondents said that they had heard of asthma, Parkinson’s disease, cervical cancer, MS and chronic bronchitis. 79% had heard of emphysema but only 35% had heard of COPD. A larger proportion of smokers had heard of COPD (45%) compared with non-smokers (24%). Knowledge about smoking as a causative factor for various conditions was mixed. A majority of respondents (53%) thought that cervical cancer was the most common of these conditions. Only just over half of the respondents suggested that breathlessness on exertion or coughing could be the first signs of a serious lung disease. Many respondents had experienced persistent respiratory symptoms, but only just over half had consulted their GP about them. In 2 out of 3 cases this was because they were unconcerned or unaware that the symptoms may be important, and in nearly 1 in 4 cases this was because they thought they would simply be told to stop smoking. See table.
One in three members of the public state that they had heard of COPD, but many more recognise the terms chronic bronchitis and emphysema. Few were aware that COPD is common and is caused by smoking. Many individuals experience persistent respiratory symptoms but nearly half had not reported these to their GP often because they were unaware of their importance.
S150 WHERE DO COPD PATIENTS DIE?
M. Sridhar1, I. Grace2, M.R. Partridge1. 1Imperial College of Science, Technology and Medicine, NHLI Division; 2Department of Statistics at Charing Cross Hospital, London
Background: We analysed mortality statistics for England and Wales from the Office of National statistics to determine the place of death of patients certified as having died primarily due to COPD (COAD, chronic bronchitis or emphysema) between the years 1970 to 2000 (at 5 year intervals). Deaths were classified as having occurred in a hospital or other health care institution (nursing home, NHS Mental health Units) or at home (the usual residence of the deceased or other, including residential homes). As a comparison the place of death of patients certified as having died with asthma and all causes were also analysed.
Results: Over the years between 1970 and 2000 there was gradual and significant increase in the proportion of patients with COPD dying in hospitals. Examination of all-cause mortality figures showed a similar trend. See table.
The figures for asthma showed a less striking trend to increase but this increase was not evident in the younger age group (under 40), perhaps reflecting the problems with mis-certification of asthma deaths.
Conclusion: An ever increasing proportion of patients with COPD die in hospital, reflecting a trend in the population in general. The reason for this trend needs further investigation and the observation should inform discussions on resource allocation and end of life care for patients with COPD.
S151 MORTALITY PROJECTIONS FOR OBSTRUCTIVE LUNG DISEASE IN ENGLAND & WALES
A.L. Hansell1, L. Knorr-Held2, V. Schmid3. 1Dept Epidemiology & Public Health, Imperial College, London; 2Dept of Mathematics and Statistics, Lancaster University, UK; 3Dept of Statistics, Ludwig-Maximilians University, Munich, Germany
Obstructive lung disease is a leading cause of mortality and morbidity worldwide and accounts for 20% of respiratory mortality in the UK (British Thoracic Society. The Burden of Lung Disease. London: British Thoracic Society 2001). Few studies have attempted to project the future burden of disease and none of these related to the UK. Simple extrapolation from current rates is likely to be misleading due to strong cohort and period trends (
A recently developed Bayesian method was used to make 10 year mortality projections for chronic obstructive pulmonary disease (COPD) and asthma for those aged 45 years and over in England & Wales, by extrapolating age, period and cohort trends for 1945–1999. Particular advantages of the Bayesian method used are that a good fit to the data is ensured and statistical uncertainty intervals can be automatically provided. Different smoothing constraints were tested. The final model was selected on the basis of the best predictions for the last 10 years of data (1989–1999). Adjusting for changes in ICD versions made little difference to the accuracy of these predictions. Also, use of a smoking covariate as a period effect did not improve predictions. Cohort covariates were unlikely to have improved predictions as the data hold good information about cohort trends for the oldest cohorts, which experience the largest number of deaths.
Projections suggested a median fall in rates for males of 24% (95% CI: −52% to +14%) by 2009 on a 1999 baseline and corresponding 2% (95% CI: −40% to +65%) rise in rates for females. By five year age-groups, posterior median projections of rates fell in both sexes, except in older females: for those aged 75–79 years rates rose then fell, while rates rose throughout for aged 80 years and over. Numbers of female deaths were projected to rise to around 14 000 per year, equalling numbers of male deaths by the end of the decade. Credible intervals around projections were wide, reflecting marked yearly variations in the numbers of deaths.
Risk factors in allergic disease
S152 THE EFFECT OF MITE ALLERGEN CONTROL BY THE USE OF ALLERGEN-IMPERMEABLE COVERS IN ADULT ASTHMA: THE SMAC TRIAL
A. Custovic, L. Forster, E. Matthews, J. Martin, L. Letley, M. Vickers, J. Britton, D. Strachan, P. Howarth, D. Altmann, C. Frost, A. Woodcock and MRC GP research framework. MRC General Practice Research Framework at the MRC Clinical Trials Unit, Stephenson House, 158–160 North Gower Road, London NW1 2ND
There is a considerable controversy about the effectiveness of dust mite allergen avoidance in asthma. We carried out a randomised, parallel group, double-blind, placebo controlled trial of dust mite avoidance (allergen-impermeable covers for mattress, pillow, and quilt) in adult asthmatics. At entry, mite-specific IgE was determined, and patients were randomised with minimisation on smoking, pet ownership and mite-specific IgE. Patients and assessors were blind to the patients’ dust mite sensitivity status. From 2479 patients who were screened for eligibility, 1150 from 135 general practices were randomised to receive active (n=574) or placebo (n=576) bed covers. PEFR was recorded twice daily during a 4 week run-in period and during months 6 and 12 of the study. In the first 6 months of the trial patients took their usual inhaled steroid therapy. Following this, a controlled reduction of inhaled steroids was attempted until either all inhaled steroid has been discontinued, or until asthma control deteriorated (Months 7–12). Homes were visited at the start in all patients, and revisited at 6 and 12 months in a 10% random sample to collect mattress dust for measurement of Der 1. Der 1 was significantly lower in the active group at 6 months (p=0.023), but there was no difference between the groups at 12 months. 65.4% and 65.1% of patients were mite sensitive in the active and placebo group respectively. A total of 457 active and 459 placebo patients had PEFR data at both baseline and 6 months. PEFR improved significantly in both groups (active 409.7 to 417.7 l/min, p<0.0001; placebo 419.3 to 428.9 l/min, p<0.0001). After adjusting for baseline differences using analysis of covariance, there was no significant difference between the two groups (difference in means (95% CI), active v placebo: all subjects −2.11 (−6.55, 2.32), p=0.35; mite sensitive subjects −1.71 (−7.28, 3.85) p=0.55). There was no difference between the groups in complete cessation of inhaled steroids or the proportionate change in steroid dose during reduction at 12 months, either in all subjects or in mite sensitive subjects only. In conclusion, allergen-impermeable bed covers seem clinically ineffective for routine management of adult asthma in primary care in the UK.
S153 EXPOSURE TO INDOOR AEROALLERGENS AND SUBSEQUENT SENSITISATION AND WHEEZE IN AN ENGLISH BIRTH COHORT
J.M. Harris, P. Cullinan, P. Mills, S. Moffat, C. White, A.J. Newman Taylor. Occupational & Environmental Medicine, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, UK
A prospective cohort study of childhood asthma and allergic disease based in Ashford, Kent has been underway since 1993. A consecutive series of newly-pregnant women were recruited (93% of those eligible) and 642 babies were born. Eight weeks after birth samples of dust from the living room floor and infant’s beds were collected. Levels of indoor aeroallergens (Der p1, house dust mite, and Fel d1, cat fur) were measured.
Each child was visited annually, and at age 5–6 sensitivity to Der p1, Fel d1 and mixed grass pollens was measured in 552 (86%) children using skin prick tests. The prevalence of sensitisation (mean weal diameter 2mm+ greater than the negative control) to these allergens were 10%, 9% and 9% respectively; 92 (17%) of the children were atopic. Thirty nine atopic children (7% of cohort) were wheezing at this age. Rates of sensitisation and atopic, current wheezing by quartiles of exposure categories using measurements from the living room carpet were as shown in the table.
The patterns above suggest that the association between levels of Der p1 and Fel d1 experienced in early-life and subsequent sensitisation/wheeze has an “inverted u” shape. The reductions in risk at the highest exposure levels may be explained by an immunotolerance or by confounding determinants of sensitisation. Further investigations into these are underway 29.
S154 ATOPY, ASTHMA, HAYFEVER AND THE RESPONSE TO INTRADERMAL TESTING WITH ENVIRONMENTAL MYCOBACTERIA AMONG CHILDREN IN RURAL CRETE
C. Zekveld, P. Cullinan, I. Dimitroulis, A. Pedioti1, V. Bibaki-Liakou1, I. Bibakis1, J. Stanford,2 A. Newman Taylor. Department of Occupational and Environmental Medicine, Imperial College (NHLI), London; 1Anti-Tuberculosis Unit, Venezalion Hospital, Heraklion, Crete; 2Department of Medical Microbiology, University College Hospital, London
Subclinical infection with environmental mycobacteria (eMB) may exert a strong immuno-regulatory effect. Among 805 children aged between 8 and 18 years, and living in rural Crete, we examined skin responses to intradermal inoculation with four locally prevalent eMB species (M gordonae, M fortuitum, M intracellulare, and M chelonae) identified by pilot testing with 20 species in three villages. We compared the skin responses between children with or without atopy (as judged by skin prick testing), asthma or hayfever. Virtually all children had received BCG vaccination.
643 (80%) children had a positive response (3mm or more) to at least one eMB species; 147 (18%) reacted to all four. 182 (23%) children had a positive skin prick test to one or more local aeroallergens; the prevalences of current wheeze (4%) and seasonal rhinitis (5%) were much lower.
Intradermal responses to eMB were unrelated to any of the outcomes in this population. This was true for each or all of the eMB species; and also for stronger (10mm or more) responses. Moreover there was no evidence, among atopic children, of a relationship between eMB skin responses and the presence of absence of allergic symptoms. These findings do not support the suggestion that early infection with environmental mycobacteria is protective in the development of childhood allergic diseases.
S155 DOES VACCINATION INCREASE THE RISK OF DEVELOPING ALLERGIC DISEASE?: A BIRTH COHORT STUDY
T.M. McKeever, S.A. Lewis, C. Smith, R. Hubbard. Division of Respiratory Medicine, University of Nottingham, UK
Objectives: There has been a rise in allergic disease prevalence in the last couple of decades, and one hypothesis for this increase is the introduction of widespread immunisation against infectious diseases.
Methods: Using the West Midlands General Practice Research Database, we have used a previously established birth cohort to examine the effect of vaccination to diphtheria, polio, pertussis and tetanus (DPPT) or measles, mumps and rubella (MMR) on the incidence of doctor diagnosed asthma and eczema.
Results: In univariate analysis there was an association between vaccination and the development of allergic disease such that vaccination to DPPT increased risk of asthma (HR 14.0 95% CI 7.3–26.9) and eczema (HR 9.4 95% CI 5.9–14.9) and similar strong effects were seen for vaccination to MMR. However there were significant interactions between vaccination and consulting behaviour, such that the effect of vaccination was limited to those in the lowest level of consulting behaviour, and was no longer significant in subsequent levels of consulting behaviour, suggesting that the initial observed effects were due to ascertainment bias.
Conclusions: Our data suggest that it is unlikely that currently recommended routine vaccinations are a risk factor for asthma or eczema.
S156 REGULAR OILY FISH CONSUMPTION IS PROTECTIVE AGAINST SYMPTOMATIC ASTHMA
B. Patel, R. Luben, D. Lomas, N. Wareham. Departments of Public Health and Primary Care, and Department of Medicine, University of Cambridge, Hills Road, Cambridge
Oily fish is rich in n-3 polyunsaturated fatty acids (PUFAs). While n-6 PUFAs are the main substrate for the production of arachodonic acid (AA), n-3 PUFAs are competitive inhibitors of AA metabolism, and may reduce the production of 4-series leukotrienes and bronchoconstricting prostagladins such as PGD2 from AA.
To assess the association between oily fish consumption and symptomatic asthma, we conducted a nested case control study within the European Prospective Investigation of Cancer (EPIC)-Norfolk cohort. Between 1993 and 1998 all participants completed a baseline health and lifestyle questionnaire (HLQ). Cases were selected by a positive response and controls by a negative response to the question “has your doctor ever told you have asthma?” in the HLQ. Frequency of oily fish consumption was also recorded in the HLQ. In 1998 potential cases and matched controls were asked to complete the East Anglia Respiratory Questionnaire about respiratory symptoms experienced in the previous 12 months.
Complete data were available on 333 cases who reported wheeze in the previous 12 months, and 437 asymptomatic controls. Significantly more controls than cases reported eating oily fish at least twice a week (12.4 % v 7.5%, p=0.03). In logistic regression analysis, after adjusting for age, sex, BMI, social class and smoking, regular oily fish consumption (= twice a week) relative to rare (< than once a week) was associated with a reduced odds ratio (OR) for self-reported wheeze (OR 0.5, p=0.01), wheeze with breathlessness (OR 0.48, p=0.01), awakening with tightness in the chest (OR 0.41 p=0.08) and asthma attack (OR 0.57, p=0.08) in the preceding 12 months. Moreover, in a sub-analysis of 55 controls without diagnosed asthma who were excluded from the main analysis because of self-reported wheeze in the previous 12 months, only 7.3% reported eating oily fish twice a week or more. Relative to rare consumption, the adjusted OR for wheeze with regular oily fish consumption in this group was 0.54 (p=0.28).
In conclusion we have shown an association between oily fish consumption and symptomatic wheeze in people with diagnosed asthma and without diagnosed asthma. These data support the hypothesis that regular consumption of oily fish may be protective against symptomatic asthma.
S157 THE EFFECTS OF MATERNAL DIET AND EARLY ANTIBIOTIC USE ON ALLERGIC DISEASE IN THE SECOND YEAR OF LIFE
S. Fleming, G. McNeill, G. Devereux, A. Seaton. Department of Environmental and Occupational Medicine, University of Aberdeen, UK
The suggestion that maternal and early life influences may be important in the onset of allergic disease is being investigated. A cohort of 2000 pregnant women was identified and their diet assessed by food frequency questionnaire during pregnancy. Allergic disease was assessed in their children at 6, 12 & 24 months of age. Questionnaire data were available from 1371 children for the 2nd year of life. Wheeze and eczema were associated with male gender, maternal atopy, social class and maternal smoking but not with maternal dietary antioxidant vitamins. However when the analysis was restricted to atopic mothers only (n=714), an inverse association between maternal vitamin E intake and eczema was found as shown in the table.
There were positive associations between eczema and early antibiotic administration, which remained when the analysis was restricted to antibiotics given for non-skin conditions in the first 6 months and the development of eczema from 7–24 months (OR 1.33, p=0.038). A similar association with wheeze disappeared when restricted to antibiotics given for non-chest conditions. This may be an indication of the effect of early antibiotics on the development of atopy. Vitamin E intake during pregnancy and early introduction of antibiotics may be related to the onset of allergic disease in childhood.
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