Chronic obstructive pulmonary disease . 6: The aetiology of exacerbations of chronic obstructive pulmonary disease

Non-typeable Haemophilus influenzae protects human airway epithelial cells from a subsequent respiratory syncytial virus challenge

Respiratory syncytial virus (RSV) and the common commensal and opportunistic pathogen, non-typeable Haemophilus influenzae (NTHi) both serve as a frequent cause of respiratory infection in children. Although it is well established that some respiratory viruses can increase host susceptibility to secondary bacterial infections, few studies have examined how commensal bacteria could influence a secondary viral response. Here, we examined the impact of NTHi exposure on a subsequent RSV infection of human bronchial epithelial cells (16HBE14o-). Co-culture of 16HBE14o- cells with NTHi resulted in inhibition of viral gene expression following RSV infection. 16HBE14o- cells co-cultured with heat-killed NTHi failed to protect against an RSV infection, indicating that protection requires live bacteria. However, NTHi did not inhibit influenza A virus replication, indicating that NTHi-mediated protection was RSV-specific. Our data demonstrates that prior exposure to a commensal bacterium such as NTHi can elicit protection against a subsequent RSV infection.

Serum Procalcitonin as a Biomarker for the Prediction of Bacterial Exacerbation and Mortality in Severe COPD Exacerbations Requiring Mechanical Ventilation

BACKGROUND

Procalcitonin (PCT) is being used as a marker of bacterial infections. Although there are several studies showing the diagnostic yield of PCT to differentiate bacterial involvement in chronic obstructive pulmonary disease exacerbations (COPDE), the prognostic yield of PCT in severe COPDE has been studied less.

OBJECTIVES

The primary aim was to determine whether the level of serum PCT at admission in severe COPDE serves as a prognostic biomarker for hospital mortality. The secondary aim was to determine the role of PCT in identifying a bacterial exacerbation.

METHODS

A total of 63 COPDE patients (median age 71 years; male 58.7%) were retrospectively analyzed from our intensive care unit database.

RESULTS

The hospital mortality rate was 23.8%. Admission PCT levels were higher in patients who died during hospitalization (0.66 vs. 0.17 ng/ml; p = 0.014). This association between hospital mortality and serum PCT level remained significant in a multivariate analysis; for every 1 ng/ml increase in PCT level, hospital mortality increased 1.85 times (odds ratio; 95% confidence interval: 1.07-3.19; p = 0.026). The optimal admission PCT threshold was 0.25 ng/ml in order to discern patients who had bacterial exacerbation with a sensitivity of 63%, a specificity of 67%, and a negative predictive value of 80%. The negative predictive value increased to 89% when both the admission and follow-up PCT levels remained <0.25 ng/ml.

CONCLUSION

This study shows that admission PCT levels have a prognostic importance in estimating hospital mortality among patients with severe COPDE. A PCT level <0.25 ng/ml at the time of admission and during follow-up is suggestive of the absence of a bacterial cause of COPDE.

Club Cell-16 and RelB as Novel Determinants of Arterial Stiffness in Exacerbating COPD Patients

Background

Exacerbations of chronic obstructive pulmonary disease (COPD) are acute events of worsened respiratory symptoms that may increase the risk of cardiovascular disease (CVD), a leading cause of mortality amongst COPD patients. The utility of lung-specific inflammatory mediators such as club cell protein-16 (CC-16) and surfactant protein D (SPD) and that of a novel marker of CV outcomes in COPD- RelB- in predicting adverse cardiovascular events during exacerbation is not known.

Methods

Thirty-eight subjects with COPD admitted to the hospital for severe exacerbation were included in this analysis. Clinical, physiological and arterial stiffness measurements were performed within 72 hours of admission; this was followed by measurements taken every 3 days until hospital discharge, then once a week until 30 days after discharge, and then again at 90 and 180 days. Plasma concentrations of inflammatory mediators were measured from peripheral venous blood taken at admission, and at days 15, 30, 90 and 180.

Results

CC-16 and RelB concentrations were increased at day 15 of exacerbations whereas SPD concentrations were decreased. The course of change in CC-16 and RelB levels over time was inversely associated with that of carotid-femoral pulse wave velocity, the gold-standard measure of arterial stiffness. Increases in CC-16 could predict a decreased number of subsequent exacerbations during follow-up.

Conclusions

Lung-specific (CC-16) and novel (RelB) biomarkers are associated with systemic cardiovascular changes over time. CC-16 can predict subsequent exacerbations in subjects with severe COPD and may be an important biomarker of pulmonary and systemic stress in COPD.

Tumor necrosis factor-α driven inflammation in alpha-1 antitrypsin deficiency: a new model of pathogenesis and treatment

Alpha-1 antitrypsin (AAT) deficiency (AATD) has traditionally been thought of as a genetic disorder characterized by lung destruction and early emphysema in a low AAT, and high neutrophil elastase (NE) environment in the lungs of affected individuals. Recently, a growing body of evidence has emerged to support the hypothesis that tumor necrosis factor alpha (TNF-α) is essential in the pathogenesis of both genetic AATD and non-genetic chronic obstructive pulmonary disease (COPD). Reports have highlighted the importance of TNF-α driven immune cell dysfunction in the development of lung disease in AATD. The authors discuss the role of AAT as a key modulator of TNF-α signaling firstly in the setting of AATD and secondly in other conditions where AAT augmentation therapy has potential utility as a novel therapy.

Muscle dysfunction in chronic obstructive pulmonary disease: update on causes and biological findings

Respiratory and/or limb muscle dysfunction, which are frequently observed in chronic obstructive pulmonary disease (COPD) patients, contribute to their disease prognosis irrespective of the lung function. Muscle dysfunction is caused by the interaction of local and systemic factors. The key deleterious etiologic factors are pulmonary hyperinflation for the respiratory muscles and deconditioning secondary to reduced physical activity for limb muscles. Nonetheless, cigarette smoke, systemic inflammation, nutritional abnormalities, exercise, exacerbations, anabolic insufficiency, drugs and comorbidities also seem to play a relevant role. All these factors modify the phenotype of the muscles, through the induction of several biological phenomena in patients with COPD. While respiratory muscles improve their aerobic phenotype (percentage of oxidative fibers, capillarization, mitochondrial density, enzyme activity in the aerobic pathways, etc.), limb muscles exhibit the opposite phenotype. In addition, both muscle groups show oxidative stress, signs of damage and epigenetic changes. However, fiber atrophy, increased number of inflammatory cells, altered regenerative capacity; signs of apoptosis and autophagy, and an imbalance between protein synthesis and breakdown are rather characteristic features of the limb muscles, mostly in patients with reduced body weight. Despite that significant progress has been achieved in the last decades, full elucidation of the specific roles of the target biological mechanisms involved in COPD muscle dysfunction is still required. Such an achievement will be crucial to adequately tackle with this relevant clinical problem of COPD patients in the near-future.

HIV Infection Is Associated With Increased Risk for Acute Exacerbation of COPD

BACKGROUND

Poorly controlled HIV infection is associated with increased risk for chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are major contributors to morbidity and mortality. Little is known about the association between HIV infection and AECOPD.

METHODS

We identified 167 individuals with spirometry-confirmed COPD from a longitudinal study of current or former injection drug users at risk or with HIV infection. AECOPD, defined as self-report of worsening breathing requiring treatment with antibiotics or steroids, was assessed at 6-month study visits. Multivariable logistic regression identified factors associated with AECOPD.

RESULTS

Of 167 participants, the mean age was 52 years; 89% were black, 30% female, and 32% HIV infected (median CD4 count: 312 cells per milliliter, 46% with detectable HIV RNA). After adjusting for age, gender, smoking history, comorbidity treatment, and airflow obstruction severity, HIV was independently associated with a 2.47 increased odds of AECOPD [95% confidence interval (CI): 1.22 to 5.00]. Compared with HIV-uninfected persons, HIV-infected persons with undetectable (<50 copies/mL) HIV RNA levels and those with a CD4 count ≥350 cells per cubic millimeter demonstrated increased AECOPD (odds ratio, 2.91; 95% CI: 1.26 to 6.71; odds ratio, 4.16; 95% CI: 1.87 to 9.27, respectively). Higher AECOPD risk was observed with higher CD4 counts irrespective of treatment for comorbid diseases.

CONCLUSIONS

HIV infection is independently associated with increased odds of AECOPD, potentially due to differences in treatment access and to variable disease manifestation by immune status. Providers should be aware that HIV infection may increase risk for AECOPD and that symptom may be more discernible with intact immune function.

Antibiotic treatment of severe exacerbations of chronic obstructive pulmonary disease with procalcitonin: a randomized noninferiority trial

Background

The duration of antibiotic treatment of exacerbations of COPD (ECOPD) is controversial. Serum procalcitonin (PCT) is a biomarker of bacterial infection used to identify the cause of ECOPD.

Methods and Findings

We investigated whether a PCT-guided plan would allow a shorter duration of antibiotic treatment in patients with severe ECOPD. For this multicenter, randomized, non-inferiority trial, we enrolled 184 patients hospitalized with ECOPD from 18 hospitals in Italy. Patients were assigned to receive antibiotics for 10 days (standard group) or for either 3 or 10 days (PCT group). The primary outcome was the rate of ECOPD at 6 months. Having planned to recruit 400 patients, we randomized only 183: 93 in the PCT group and 90 in the standard group. Thus, the completed study was underpowered. The ECOPD rate at 6 months between PCT-guided and standard antibiotic treatment was not significant (% difference, 4.04; 90% confidence interval [CI], −7.23 to 15.31), but the CI included the non-inferiority margin of 15. In the PCT-guided group, about 50% of patients were treated for 3 days, and there was no difference in primary or secondary outcomes compared to patients treated for 10 days.

Conclusions

Although the primary and secondary clinical outcomes were no different for patients treated for 3 or 10 days in the PCT group, the conclusion that antibiotics can be safely stopped after 3 days in patients with low serum PCT cannot be substantiated statistically. Thus, the results of this study are inconclusive regarding the noninferiority of the PCT-guided plan compared to the standard antibiotic treatment. The study was funded by Agenzia Italiana del Farmaco (AIFA-FARM58J2XH). Clinical trial registered with www.clinicaltrials.gov (NCT01125098).

Trial Registration

ClinicalTrials.gov NCT01125098

A prospective study on bacterial and atypical etiology of acute exacerbation in chronic obstructive pulmonary disease

ABSTRACT 

Aim: The bacterial and atypical etiology of acute exacerbations of chronic obstructive pulmonary disease was investigated and the diagnostic techniques used were compared among 92 hospitalized patients. Materials & methods: Sputum specimens were investigated using culture and PCR, serological status evaluation was performed and the inflammatory profile was associated with the microbiological results. Results & conclusion: The majority of the patients (65.2%) had very severe airway obstruction. The most common bacteria were Haemophilus influenzae and Pseudomonas aeruginosa (23.9 and 14.1%, respectively). Acinetobacter baumannii- and P. aeruginosa-positive cultures were associated with prolonged hospitalization and severe airway obstruction (p = 0.03 and 0.031, respectively). Chlamydia pneumoniae or Mycoplasma pneumoniae infection was diagnosed in four and two patients, respectively. Discrepant results were detected between PCR and serology, especially regarding C. pneumoniae.

The Most Common Detected Bacteria in Sputum of Patients with the Acute Exacerbation of COPD

INTRODUCTION

Acute exacerbation of COPD (AECOPD) may be triggered by infection with bacteria or viruses or by environmental pollutants; the cause of about one-third of exacerbations cannot be identified.

OBJECTIVE

To determine the most common bacteria in sputum culture of patients with AECOPD hospitalized in Intensive care unit of Clinic for pulmonary disease and TB "Podhrastovi" in the 2012.

MATERIAL AND METHODS

This is a retrospective analysis of sputum bacterial cultures of patients with AECOPD treated in the Intensive care unit of Clinic for pulmonary disease and TB "Podhrastovi" during 2012 .year. Each patient was required to give two sputum for bacterial examination. Each patient was treated with antibiotics prior to admission in Clinic "Podhrastovi". The results of sputum bacterial culture findings are expressed in absolute number and percentage of examined patients.

RESULTS

In 2012, 75 patients with AECOPD were treated in Intensive care unit of Clinic for pulmonary disease and TB"Podhrastovi". 44 (58.66%) of patients had normal -nonpathogenic - usual bacterial flora isolated in sputum cultures, 31 (41.34%) had a pathogen bacteria in sputum culture as follows: 7 had Streptoccocus pneumoniae, 8 had Klebsiella pneumoniae (2 with Streptococcus pneumoniae, one with Acinetobacter baumani) ,4 Escherichia colli, others are one or two cases with other bacteria.

CONCLUSION

Bacterial airway infections play a great role in many, but not in all, of cases of AECOPD. So there is the need to do a sputum bacterial culture examination in each patient with AECOPD and with appropriate antibiotics to contribute to curing of them.

The host immune response contributes to Haemophilus influenzae virulence

BACKGROUND

There is compelling evidence that infections with non-typeable Haemophilus influenzae (NTHi) are associated with exacerbations in COPD patients. However, NTHi has also been isolated frequently during clinically stable disease. In this study we tested the hypothesis that genetically distinct NTHi isolates obtained from COPD patients differ in virulence which could account for dissimilarities in the final outcome of an infection (stable vs. exacerbation).

RESULTS

NTHi isolates (n = 32) were obtained from stable COPD patients, or during exacerbations. Genetically divergent NTHi isolates were selected and induction of inflammation was assessed as an indicator of virulence using different in vitro models. Despite marked genomic differences among NTHi isolates, in vitro studies could not distinguish between NTHi isolates based on their inflammatory capacities. Alternatively, when using a whole blood assay results demonstrated marked inter-, but not intra-individual differences in cytokine release between healthy volunteers irrespective of the origin of the NTHi isolate used.

CONCLUSION

Results suggest that the individual immune reactivity might be an important predictor for the clinical outcome (exacerbation vs. no exacerbation) following NTHi infection.

Bacterial profile, antibiotic sensitivity and resistance of lower respiratory tract infections in upper egypt

Background

Lower respiratory tract infections (LRTI) account for a considerable proportion of morbidity and antibiotic use. We aimed to identify the causative bacteria, antibiotic sensitivity and resistance of hospitalized adult patients due to LRTI in Upper Egypt.

Methods

A multicentre prospective study was performed at 3 University Hospitals for 3 years. Samples included sputum or bronchoalveolar lavage (BAL) for staining and culture, and serum for serology. Samples were cultured on 3 bacteriological media (Nutrient, Chocolate, MacConkey's agars). Colonies were identified via MicroScan WalkAway-96. Pneumoslide IgM kit was used for detection of atypical pathogens via indirect immunofluorescent assay.

Results

The predominant isolates in 360 patients with CAP were S. pneumoniae (36%), C. pneumoniae (18%), and M. pneumoniae (12%). A higher sensitivity was recorded for moxifloxacin, levofloxacin, macrolides, and cefepime. A higher of resistance was recorded for doxycycline, cephalosporins, and β-lactam-β-lactamase inhibitors. The predominant isolates in 318 patients with HAP were, methicillin-resistant Staphylococcus aureus; MRSA (23%), K. pneumoniae (14%), and polymicrobial in 12%. A higher sensitivity was recorded for vancomycin, ciprofloxacin, and moxifloxacin. Very high resistance was recorded for β-lactam-β-lactamase inhibitors and cephalosporins. The predominant organisms in 376 patients with acute exacerbation of chronic obstructive pulmonary diseases (AECOPD) were H. influnzae (30%), S. pneumoniae (25%), and M. catarrhalis (18%). A higher sensitivity was recorded for moxifloxacin, macrolides and cefepime. A higher rate of resistance was recorded for aminoglycosides and cephalosporins.

Conclusions

The most predominant bacteria for CAP in Upper Egypt are S. pneumoniae and atypical organisms, while that for HAP are MRSA and Gram negative bacteria. For acute exacerbation of COPD, H. influnzae was the commonest organism. Respiratory quinolones, macrolides, and cefepime are the most efficient antibiotics in treatment of LRTI in our locality.

K. Jindal for the COPD Guidelines Working Group. Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Although several International guidelines for diagnosis and management of COPD are available, yet there are lot of gaps in recognition and management of COPD in India due to vast differences in availability and affordability of healthcare facilities across the country. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have joined hands to come out with these evidence-based guidelines to help the physicians at all levels of healthcare to diagnose and manage COPD in a scientific manner. Besides the International literature, the Indian studies were specifically analyzed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (a) definitions, epidemiology, and disease burden; (b) disease assessment and diagnosis; (c) pharmacologic management of stable COPD; (d) management of acute exacerbations; and (e) nonpharmacologic and preventive measures. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Pancreatic stone protein predicts positive sputum bacteriology in exacerbations of COPD

BACKGROUND

Pancreatic stone protein/regenerating protein (PSP/reg) serum levels are supposed to be increased in bacterial inflammation. PSP/reg levels also might be useful, therefore, as a predictor of bacterial infection in COPD.

METHODS

Two hundred consecutive patients presenting to the ED due to acute exacerbation of COPD were prospectively assessed. Patients were evaluated based on clinical, laboratory, and lung functional parameters at admission (exacerbation) and after short-term follow-up (14-21 days). PSP/reg serum values were measured by a newly developed enzyme-linked immunosorbent assay.

RESULTS

PSP/reg levels were elevated in subjects with COPD exacerbation (23.8 ng/mL; 95% CI, 17.1-32.7) when compared with those with stable disease (19.1 ng/mL; 95% CI, 14.1-30.4; P 5 .03) and healthy control subjects (14.0 ng/mL; 95% CI , 12.0-19.0; P , .01). Higher PSP/reg values were observed in exacerbations with positive sputum bacteriology compared with those with negative sputum bacteriology (26.1 ng/mL [95% CI, 19.2-38.1] vs 20.8 ng/mL [95% CI , 15.6-27.2]; P , .01). Multivariate regression analysis revealed PSP/reg level as an independent predictor of positive sputum bacteriology. A combination of a PSP/reg cutoff value of . 33.9 ng/mL and presence of discolored sputum had a specificity of 97% to identify patients with pathogenic bacteria on sputum culture. In contrast, PSP/reg levels , 18.4 ng/mL and nonpurulent sputum ruled out positive bacterial sputum culture (sensitivity, 92%). In survival analysis, high PSP/reg levels at hospital admission were associated with increased 2-year mortality.

CONCLUSIONS

Serum PSP/reg level might represent a promising new biomarker to identify bacterial etiology of COPD exacerbation.

Exacerbations among chronic bronchitis patients treated with maintenance medications from a US managed care population: an administrative claims data analysis

PURPOSE

Chronic obstructive pulmonary disease (COPD) exacerbations are the leading cause of hospital admission and death among chronic bronchitis (CB) patients. This study estimated annual COPD exacerbation rates, related costs, and their predictors among patients treated for CB.

METHODS

This was a retrospective study using claims data from the HealthCore Integrated Research Database (HIRD(SM)). The study sample included CB patients aged ≥ 40 years with at least one inpatient hospitalization or emergency department visit or at least two office visits with CB diagnosis from January 1, 2004 to May 31, 2011, at least two pharmacy fills for COPD medications during the follow-up year, and ≥2 years of continuous enrollment. COPD exacerbations were categorized as severe or moderate. Annual rates, costs, and predictors of exacerbations during follow-up were assessed.

RESULTS

A total of 17,382 individuals treated for CB met the selection criteria (50.6% female; mean ± standard deviation age 66.7 ± 11.4 years). During the follow-up year, the mean ± standard deviation number of COPD maintenance medication fills was 7.6 ± 6.3; 42.6% had at least one exacerbation and 69.5% of patients with two or more exacerbations during the 1 year prior to the index date (baseline period) had any exacerbation during the follow-up year. The mean ± standard deviation cost per any exacerbation was $269 ± $748 for moderate and $18,120 ± $31,592 for severe exacerbation. The number of baseline exacerbations was a significant predictor of the number of exacerbations and exacerbation costs during follow-up.

CONCLUSION

Exacerbation rates remained high among CB patients despite treatment with COPD maintenance medications. New treatment strategies, designed to reduce COPD exacerbations and associated costs, should focus on patients with high prior-year exacerbations.

Chronic bronchial infection in COPD. Is there an infective phenotype?

Microorganisms, particularly bacteria, are frequently found in the lower airways of COPD patients, both in stable state and during exacerbations. The host–pathogen relationship in COPD is a complex, dynamic process characterised by frequent changes in pathogens, their strains and loads, and subsequent host immune responses.

Exacerbations are detrimental events in the course of COPD and evidence suggests that 70% may be caused by microorganisms. When considering bacterial exacerbations, recent findings based on molecular typing have demonstrated that the acquisition of new strains of bacteria or antigenic changes in pre-existing strains are the most important triggers for exacerbation onset.

Even in clinically stable COPD patients the presence of microorganisms in their lower airways may cause harmful effects and induce chronic low-grade airway inflammation leading to increased exacerbation frequency, an accelerated decline in lung function and impaired health-related quality of life. Besides intraluminal localisation in the distal airways, bacteria can be found in the bronchial walls and parenchymal lung tissue of COPD patients. Therefore, the isolation of pathogenic bacteria in stable COPD should be considered as a form of chronic infection rather than colonisation. This new approach may have important implications for the management of patients with COPD.

An adjunct intervention for management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD)

OBJECTIVES

Application of transcutaneous electrical nerve stimulation over acupuncture points (Acu-TENS) is a noninvasive intervention that has recently been shown to alleviate dyspnea in patients with stable chronic obstructive pulmonary disease (COPD). This case report aims to explore the role of Acu-TENS in patients diagnosed with COPD during the acute exacerbation.

STUDY DESIGN

The study design was a case report.

SETTING

The study was conducted in an inpatient setting.

SUBJECT

The subject was a 74-year-old man admitted to the hospital due to acute exacerbation of COPD (AECOPD).

INTERVENTION

Treatment consisted of application of TENS on EX-B1 (Dingchuan) for 45 minutes.

OUTCOME MEASURES

Oxygen saturation, heart rate, and dyspnea score were measured before, immediately after, and 45 minutes after Acu-TENS intervention. Other than the physiologic measures, 10 mL of venous blood was taken from the cubital vein for assessment of β-endorphin level, white blood cell count, tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) level before and immediately postintervention.

RESULTS

Postintervention, improved oxygen saturation, and reduction in heart rate and dyspneic sensation were observed accompanied by a raised blood β-endorphin level but the level of white blood cell count, TNF-α, and CRP remain unchanged.

CONCLUSIONS

Application of 45 minutes Acu-TENS appeared to alleviate symptoms in a patient with AECOPD. The role of adjunctive Acu-TENS therapy during acute exacerbation warrants further investigation.

Assessment of some inflammatory biomarkers as predictors of outcome of acute respiratory failure on top of chronic obstructive pulmonary disease and evaluation of the role of bacteria

Objective. To study the value of the inflammatory markers (interleukin-6 (IL-6), interleukin-8 (IL-8), and C-reactive protein (CRP)) in predicting the outcome of noninvasive ventilation (NIV) in the management of acute respiratory failure (ARF) on top of chronic obstructive pulmonary disease (COPD) and the role of bacteria in the systemic inflammation. Methods. Thirty three patients were subjected to standard treatment plus NIV, and accordingly, they were classified into responders and nonresponders. Serum samples were collected for IL-6, IL-8, and CRP analysis. Sputum samples were taken for microbiological evaluation. Results. A wide spectrum of bacteria was revealed; Gram-negative and atypical bacteria were the most common (31% and 28% resp.; single or copathogen). IL-8 and dyspnea grade was significantly higher in the non-responder group (P = 0.01 and 0.023 resp.). IL-6 correlated positivity with the presence of infection and type of pathogen (P = 0.038 and 0.034 resp.). Gram-negative bacteria were associated with higher significant IL-6 in comparison between others (196.4 ± 239.1 pg/dL; P = 0.011) but insignificantly affected NIV outcome (P > 0.05). Conclusions. High systemic inflammation could predict failure of NIV. G-ve bacteria correlated with high IL-6 but did not affect the response to NIV.

Microbiological study of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and the usefulness of analytical and clinical parameters in its identification (VIRAE study)

Purpose

Respiratory infection is the most common cause for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The aim of this work was to study the etiology of the respiratory infection in order to assess the usefulness of the clinical and analytical parameters used for COPD identification.

Patients and methods

We included 132 patients over a period of 2 years. The etiology of the respiratory infection was studied by conventional sputum, paired serology tests for atypical bacteria, and viral diagnostic techniques (immunochromatography, immunofluorescence, cell culture, and molecular biology techniques). We grouped the patients into four groups based on the pathogens isolated (bacterial versus. viral, known etiology versus unknown etiology) and compared the groups.

Results

A pathogen was identified in 48 patients. The pathogen was identified through sputum culture in 34 patients, seroconversion in three patients, and a positive result from viral techniques in 14 patients. No significant differences in identifying etiology were observed in the clinical and analytical parameters within the different groups. The most cost-effective tests were the sputum test and the polymerase chain reaction.

Conclusion

Based on our experience, clinical and analytical parameters are not useful for the etiological identification of COPD exacerbations. Diagnosing COPD exacerbation is difficult, with the conventional sputum test for bacterial etiology and molecular biology techniques for viral etiology providing the most profitability. Further studies are necessary to identify respiratory syndromes or analytical parameters that can be used to identify the etiology of new AE-COPD cases without the laborious diagnostic techniques.

Bacterial co-infection with H1N1 infection in patients admitted with community acquired pneumonia

BACKGROUND

Bacterial co-infection is an important contributor to morbidity and mortality during influenza pandemics .We investigated the incidence, risk factors and outcome of patients with influenza A H1N1 pneumonia and bacterial co-infection.

METHODS

Prospective observational study of consecutive hospitalized patients with influenza A H1N1 virus and community-acquired pneumonia (CAP). We compared cases with and without bacterial co-infection.

RESULTS

The incidence of influenza A H1N1 infection in CAP during the pandemic period was 19% (n, 667). We studied 128 patients; 42(33%) had bacterial co-infection. The most frequently isolated bacterial pathogens were Streptococcus pneumoniae (26, 62%) and Pseudomonas aeruginosa (6, 14%). Predictors for bacterial co-infection were chronic obstructive pulmonary disease (COPD) and increase of platelets count. The hospital mortality was 9%. Factors associated with mortality were age ≥ 65 years, presence of septic shock and the need for mechanical ventilation. Although patients with bacterial co-infection presented with higher Pneumonia Severity Index risk class, hospital mortality was similar to patients without bacterial co-infection (7% vs. 11%, respectively, p = 0.54).

CONCLUSION

Bacterial co-infection was frequent in influenza A H1N1 pneumonia, with COPD and increased platelet count as the main predictors. Although associated with higher severe scales at admission, bacterial co-infection did not influence mortality of these patients.

Antibiotic resistance in sputum isolates of Streptococcus pneumoniae in chronic obstructive pulmonary disease is related to antibiotic exposure

Streptococcus pneumoniae (S. pneumoniae) is recovered from sputum of patients with chronic obstructive pulmonary disease (COPD) during stable disease and exacerbations. In patients with community acquired pneumonia, antibiotic exposure in the prior 3-6 months is associated with recovery of antibiotic resistant isolates of S. pneumoniae. Whether the same relationship is seen in COPD is not known. From April 1994 to June 2004, 127 adults with COPD were enrolled in a prospective longitudinal study. Sputum isolates of S. pneumoniae were characterized with susceptibility testing and pulsed-field gel electrophoresis (PFGE). The relationship between antibiotic use in the previous 3 and 6 months with either new acquisition of a resistant pneumococcal isolate or development of resistance (4-fold increase in MIC) in a pre-existing colonizing pneumococcal strain was determined. A total of 194 pneumococcal isolates were recovered from 38 patients. Among 71 newly acquired and 4 resistance-emergent strains analyzed further, rates of resistance to penicillin (MIC ≥2), erythromycin (MIC ≥1), tetracycline (MIC ≥8) and trimethoprim/sulfamethoxazole (MIC ≥4) were 8%, 24%, 17% and 16% respectively. Flouroquinolone resistance was not seen. Among strains isolated from patients exposed to a macrolide within 6 months, 53.6% displayed erythromycin resistance vs. 14% of strains without such exposure (p = 0.00085). Similar associations were not seen for other antibiotics. Macrolide use in the previous 6 months is associated with macrolide resistance in sputum isolates of S. pneumoniae. Recent antibiotic exposure may help in determining appropriate antibiotic treatment in these patients.

Environmental and Occupational Health Risks Among Agricultural Workers Living in a Rural Community Near Petroleum Refinery and Motorway in Skopje Region

To assess health risks in agricultural workers associated with environmental exposure to pollutants released from a petroleum refinery and from traffic, we performed a cross-sectional study that included 119 randomly selected subjects divided in two groups. Group 1 included 60 agricultural workers living in a rural community near the petroleum refinery and a motorway overpass, whereas Group 2 consisted of 59 agricultural workers performing similar activities and living in a rural community with no exposure to industrial and traffic pollutants. Risk assessment included a questionnaire, blood pressure measurement, spirometry, laboratory tests, and toxicological analysis. The groups showed a similar prevalence of health problems, with exception of muscle pain in the extremities, headache, and fatigue, which were significantly more common in Group 1. Diastolic blood pressure was higher in Group 1, but not significantly (p=0.057). The same is true for blood carbon monoxide. Significantly higher in Group 1 were blood haemoglobin (p=0.001) and blood lead (p<0.001). Serum cholinesterase activity was similar in both groups. Our findings indicate the need of regular medical exams, ambient monitoring and environmental impact assessment in agricultural population in order to detect individuals at risk and to institute adequate preventive measures.

Procalcitonin vs C-reactive protein as predictive markers of response to antibiotic therapy in acute exacerbations of COPD

BACKGROUND

Rational prescription of antibiotics in acute exacerbations of COPD (AECOPD) requires predictive markers. We aimed to analyze whether markers of systemic inflammation can predict response to antibiotics in AECOPD.

METHODS

We used data from 243 exacerbations out of 205 patients from a placebo-controlled trial on doxycycline in addition to systemic corticosteroids for AECOPD. Clinical and microbiologic response, serum C-reactive protein (CRP) level (cutoffs 5 and 50 mg/L), and serum procalcitonin level (PCT) (cutoffs 0.1 and 0.25 μg) were assessed.

RESULTS

Potential bacterial pathogens were identified in the majority of exacerbations (58%). We found a modest positive correlation between PCT and CRP (r = 0.46, P < .001). The majority of patients (75%) had low PCT levels, with mostly elevated CRP levels. Although CRP levels were higher in the presence of bacteria (median, 33.0 mg/L [interquartile range, 9.75-88.25] vs 17 mg/L [interquartile range, 5.0-61.0] [P = .004]), PCT levels were similar. PCT and CRP performed similarly as markers of clinical success, and we found a clinical success rate of 90% in patients with CRP ≤ 5 mg/L. A significant effect of doxycycline was observed in patients with a PCT level < .1 μg/L (treatment effect, 18.4%; P = .003). A gradually increasing treatment effect of antibiotics (6%, 10%, and 18%), although not significant, was found for patients with CRP values of ≤ 5, 6-50, and > 50 mg/L, respectively.

CONCLUSIONS

Contrary to the current literature, this study suggests that patients with low PCT values do benefit from antibiotics. CRP might be a more valuable marker in these patients.

Surfactant lipids regulate LPS-induced interleukin-8 production in A549 lung epithelial cells by inhibiting translocation of TLR4 into lipid raft domains

In addition to providing mechanical stability, growing evidence suggests that surfactant lipid components can modulate inflammatory responses in the lung. However, little is known of the molecular mechanisms involved in the immunomodulatory action of surfactant lipids. This study investigates the effect of the lipid-rich surfactant preparations Survanta, Curosurf, and the major surfactant phospholipid dipalmitoylphosphatidylcholine (DPPC) on interleukin-8 (IL-8) gene and protein expression in human A549 lung epithelial cells using immunoassay and PCR techniques. To examine potential mechanisms of the surfactant lipid effects, Toll-like receptor 4 (TLR4) expression was analyzed by flow cytometry, and membrane lipid raft domains were separated by density gradient ultracentrifugation and analyzed by immunoblotting with anti-TLR4 antibody. The lipid-rich surfactant preparations Survanta, Curosurf, and DPPC, at physiological concentrations, significantly downregulated lipopolysaccharide (LPS)-induced IL-8 expression in A549 cells both at the mRNA and protein levels. The surfactant preparations did not affect the cell surface expression of TLR4 or the binding of LPS to the cells. However, LPS treatment induced translocation of TLR4 into membrane lipid raft microdomains, and this translocation was inhibited by incubation of the cells with the surfactant lipid. This study provides important mechanistic details of the immune-modulating action of pulmonary surfactant lipids.

Antibiotics in addition to systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

RATIONALE

The role of antibiotics in acute exacerbations is controversial and their efficacy when added to systemic corticosteroids is unknown.

OBJECTIVES

We conducted a randomized, placebo-controlled trial to determine the effects of doxycycline in addition to corticosteroids on clinical outcome, microbiological outcome, lung function, and systemic inflammation in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease.

METHODS

Of 223 patients, we enrolled 265 exacerbations defined on the basis of increased dyspnea and increased sputum volume with or without increased sputum purulence. Patients received 200 mg of oral doxycycline or matching placebo for 7 days in addition to systemic corticosteroids. Clinical and microbiological response, time to treatment failure, lung function, symptom scores, and serum C-reactive protein were assessed.

MEASUREMENTS AND MAIN RESULTS

On Day 30, clinical success was similar in intention-to-treat patients (odds ratio, 1.3; 95% confidence interval, 0.8 to 2.0) and per-protocol patients. Doxycycline showed superiority over placebo in terms of clinical success on Day 10 in intention-to-treat patients (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2), but not in per-protocol patients. Doxycycline was also superior in terms of clinical cure on Day 10, microbiological outcome, use of open label antibiotics, and symptoms. There was no interaction between the treatment effect and any of the subgroup variables (lung function, type of exacerbation, serum C-reactive protein, and bacterial presence).

CONCLUSIONS

Although equivalent to placebo in terms of clinical success on Day 30, doxycycline showed superiority in terms of clinical success and clinical cure on Day 10, microbiological success, the use of open label antibiotics, and symptoms. Clinical trial registered with www.clinicaltrials.gov (NCT00170222).

Pseudomonas aeruginosa in adults with chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Pseudomonas aeruginosa is isolated in sputum cultures from adults with chronic obstructive pulmonary disease (COPD) but the significance of the organism in this clinical setting is not well known. The purpose of this review is to critically review the literature in an effort to understand the role of P. aeruginosa in the course and pathogenesis of COPD.

RECENT FINDINGS

When examined longitudinally, two distinct patterns of carriage of P. aeruginosa are observed in adults with COPD: short-term colonization followed by clearance and long-term persistence. Acquisition of P. aeruginosa is associated with the occurrence of an exacerbation, indicating that the organism causes exacerbations. Exacerbations caused by P. aeruginosa are more likely to be seen in patients with more advanced COPD, those who have received recent antibiotic therapy and those who require mechanical ventilation for an exacerbation. A subset of adults with COPD becomes chronically colonized with P. aeruginosa, but whether such patients benefit from antimicrobial therapy is not yet known.

SUMMARY

P. aeruginosa has several different manifestations in the setting of COPD. The organism is a colonizer that is cleared quickly, causes acute exacerbations and also may cause chronic infection in a subset of adults with COPD.

A Two-Stage Logistic Model Based on the Measurement of Pro-Inflammatory Cytokines in Bronchial Secretions for Assessing Bacterial, Viral, and Non-Infectious Origin of COPD Exacerbations

Exacerbations often complicate the progressive course of chronic obstructive pulmonary disease (COPD), mainly due to infectious agents. The precise role of bacterial infections in the course and the pathogenesis of COPD has been a source of controversy for decades. Also viruses and other non-infectious causes of exacerbation play a relevant role and also contribute to persisting airway inflammation. Usually, the etiologic identification of the infective causes of COPD require considerable time and costs. The development of more rapid, reliable, and widely applicable methods to promptly define the etiology of COPD exacerbations should represent a relevant issue in devising earlier and more specific strategies for their effective therapeutic control.

AIM

Of the study was to assess the predictive role of some pro-inflammatory cytokines measured in spontaneous bronchial secretions in discriminating the main infectious causes of COPD exacerbations.

METHODS

124 subjects with moderate COPD (51-79 y; mean basal FEV1 = 49.6% pred. +/- 4.6 sd; FEV1 reversibility +3.9% from baseline +/- 4.8 sd after salbutamol 200 mcg) were studied during acute exacerbation. Respiratory viruses were isolated from bronchial secretions in 21 cases; common bacteria (CFU > or = 10(6)/ml) in 28 cases; Pseudomonas Aeruginosa (Ps.Ae.; CFU > or = 10(6)/ml) in 20 cases. The cytokines IL1beta, IL8, and TNFalpha (pg/ml; Immulite; Diagnostic Product Corp, Los Angeles, CA, USA), and neutrophils (% total count) were measured in bronchial secretions of all patients.

STATISTICS

A two-stage logistic model was chosen for discriminating the different causes of COPD exacerbations (such as: non-infectious, or viral, bacterial, or due to Ps.Ae.).

RESULTS

At the first decisional step, the two-stage logistic model proved that TNFalpha levels in bronchial secretions recognise clearly patients belonging to the Ps.Ae. group from those of all other groups (Area under ROC curve = 0.96; 95% CI = 0.91-0.99), and that, at the second decisional step, IL8 + IL10 levels discriminate patients with bacterial causes (such as all bacteria) from the non-infected ones and from those with a viral cause of exacerbation (Area under ROC curve = 0.87; 95% CI = 0.77-0.94). Neutrophil percent count did not support any contribution in discriminating the different subgroups of COPD subjects.

CONCLUSIONS

When exacerbated, COPD subjects express different patterns of pro-inflammatory mediators in bronchial secretions, which appear modulated according to the etiological cause of the exacerbation. In particular, TNFalpha concentration per se enables recognition of COPD exacerbations due to Ps.Ae., while IL8 + IL1beta levels prove helpful in discriminating those to common bacteria from those to viral agents and to non-infectious causes. When present data are further confirmed, the use of a decisional rule based on cytokine measurements might be regarded as a helpful predictive tool. As measures of pro-inflammatory cytokines are low-cost, simple, and faster to perform, they could support rapid clinical decision making at the bedside regarding therapeutic strategy for COPD exacerbations, in particular when they are needed for severe COPD patients.

Pathogenesis of Bacterial Exacerbations of COPD

Acute exacerbations are significant events in the course of COPD. The pathogenesis of exacerbations was poorly understood, specifically, the role of bacteria was highly controversial. Recent observations have demonstrated that bacterial infection is involved in about half of the exacerbations. The predominant mechanism of bacterial exacerbation in COPD appears to be acquisition of new strains of bacterial pathogens from the environment that are able to establish infection in the tracheobronchial tree in COPD because of compromised innate lung defenses. These pathogens interact with airway cells, elicit an inflammatory response, which underlies the pathophysiology and symptoms characteristic of exacerbation. An immune response that can be mucosal, systemic or both develops to the infecting bacterial strain. This immune response contains the infectious process, could eradicate the infecting pathogen and prevent re-infection with the same strain. However, because of antigenic diversity among bacterial strains, this immunity tends to be strain-specific rather than widely protective. Other mechanisms, including increase in bacterial load and interaction with other etiologies such as viruses, also could contribute to bacterial exacerbations. Improved understanding of the host-pathogen interaction in the airways in COPD will lead to novel approaches to prevention and treatment of exacerbations.

Frequency and clinical relevance of human bocavirus infection in acute exacerbations of chronic obstructive pulmonary disease

Objective

Human bocavirus (HBoV) is a recently discovered parvovirus associated with acute respiratory tract infections in children. The objective of the present study was to determine the frequency and clinical relevance of HBoV infection in adult patients with acute exacerbation of chronic obstructive pulmonary disease (AE-COPD).

Methods

We retrospectively tested 212 COPD patients, 141 (66.5%) with AE-COPD and 71 (33.5%) with stable disease, of whom nasal lavage and induced sputum had been obtained for the presence of HBoV deoxyribonucleic acid (DNA). The specificity of positive polymerase chain reaction results was confirmed by sequencing.

Results

Two hundred two of 212 patients for whom PCR results were available both for nasal lavage and induced sputum samples were eligible for data analysis. HBoV DNA was detected in three patients (1.5%). Of those, only one patient had AE-COPD. Thus, the frequency of HBoV infection demonstrated to be low in both AE-COPD (0.8%) and stable COPD (2.9%). HBoV was found in two sputum and one nasal lavage sample in different patients, respectively. Sequencing revealed >99% sequence identity with the reference strain.

Conclusion

HBoV detection was infrequent. Since we detected HBoV in both upper and lower respiratory tract specimens and in AE-COPD as well as stable disease, a major role of HBoV infection in adults with AE-COPD is unlikely.

Bacteriology in acute exacerbation of chronic obstructive pulmonary disease in patients admitted to hospital

We investigated the bacterial flora and antimicrobial sensitivity in sputum from patients admitted to hospital with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in order to recommend the best empirical treatment for these patients. The survey was a retrospective study of all patients admitted to Hvidovre hospital with the diagnosis AECOPD during 2004. A total of 118 patients were included. Microscopy, culture and sensitivity testing investigated their sputums. Clinical and paraclinical features were collected from the patients' files. Among the 118 patients, 59 (50%) had a positive sputum culture. The group with positive cultures had a higher blood neutrophil count (p=0.03). There were no other clinical differences between the groups with and without positive sputum culture. The majority of patients with positive sputum cultures were infected with bacteria other than S. pneumonia, mostly H. influenzae and Moraxella catarrhalis. Patients with low FEV(1)<1.0 litre were more likely to be infected with Pseudomonas aeruginosa (p=0.03). The sensitivity patterns of the bacteria showed that the majority were resistant to penicillin. If antibiotics are initiated empirically for AECOPD we recommend either cefuroxime for intravenous treatment or amoxicillin-clavulanate for oral treatment.

Iron behaving badly: inappropriate iron chelation as a major contributor to the aetiology of vascular and other progressive inflammatory and degenerative diseases

BACKGROUND

The production of peroxide and superoxide is an inevitable consequence of aerobic metabolism, and while these particular 'reactive oxygen species' (ROSs) can exhibit a number of biological effects, they are not of themselves excessively reactive and thus they are not especially damaging at physiological concentrations. However, their reactions with poorly liganded iron species can lead to the catalytic production of the very reactive and dangerous hydroxyl radical, which is exceptionally damaging, and a major cause of chronic inflammation.

REVIEW

We review the considerable and wide-ranging evidence for the involvement of this combination of (su)peroxide and poorly liganded iron in a large number of physiological and indeed pathological processes and inflammatory disorders, especially those involving the progressive degradation of cellular and organismal performance. These diseases share a great many similarities and thus might be considered to have a common cause (i.e. iron-catalysed free radical and especially hydroxyl radical generation).The studies reviewed include those focused on a series of cardiovascular, metabolic and neurological diseases, where iron can be found at the sites of plaques and lesions, as well as studies showing the significance of iron to aging and longevity. The effective chelation of iron by natural or synthetic ligands is thus of major physiological (and potentially therapeutic) importance. As systems properties, we need to recognise that physiological observables have multiple molecular causes, and studying them in isolation leads to inconsistent patterns of apparent causality when it is the simultaneous combination of multiple factors that is responsible.This explains, for instance, the decidedly mixed effects of antioxidants that have been observed, since in some circumstances (especially the presence of poorly liganded iron) molecules that are nominally antioxidants can actually act as pro-oxidants. The reduction of redox stress thus requires suitable levels of both antioxidants and effective iron chelators. Some polyphenolic antioxidants may serve both roles.Understanding the exact speciation and liganding of iron in all its states is thus crucial to separating its various pro- and anti-inflammatory activities. Redox stress, innate immunity and pro- (and some anti-)inflammatory cytokines are linked in particular via signalling pathways involving NF-kappaB and p38, with the oxidative roles of iron here seemingly involved upstream of the IkappaB kinase (IKK) reaction. In a number of cases it is possible to identify mechanisms by which ROSs and poorly liganded iron act synergistically and autocatalytically, leading to 'runaway' reactions that are hard to control unless one tackles multiple sites of action simultaneously. Some molecules such as statins and erythropoietin, not traditionally associated with anti-inflammatory activity, do indeed have 'pleiotropic' anti-inflammatory effects that may be of benefit here.

CONCLUSION

Overall we argue, by synthesising a widely dispersed literature, that the role of poorly liganded iron has been rather underappreciated in the past, and that in combination with peroxide and superoxide its activity underpins the behaviour of a great many physiological processes that degrade over time. Understanding these requires an integrative, systems-level approach that may lead to novel therapeutic targets.

Antibiotics

This chapter describes the optimal approach to antibiotic treatment of exacerbations recognizing these limitations. Such an approach relies upon an accurate diagnosis of an exacerbation, including judicious application of diagnostic tests. Determining the severity of an exacerbation follows this. If antibiotics are indicated, then a risk stratification approach is described to choose an appropriate antibiotic. An increase in airway inflammation from the baseline level in a patient appears central to the pathogenesis of most acute exacerbations. Airway inflammation measured in induced or expectorated sputum, bronchoalveolar lavage or bronchial biopsy has revealed that increased inflammation accompanies exacerbations and resolves with treatment. Potential pathogens in chronic obstructive pulmonary disease (COPD) exacerbations include typical respiratory bacterial pathogens, respiratory viruses, and atypical bacteria. The current model of bacterial exacerbation pathogenesis involves both host and pathogen factors. Acquisition of strains of bacterial pathogens that are new to the host from the environment is the primary event that puts the patient with COPD at risk for an exacerbation. The traditional aims of treatment of an exacerbation are improvement in clinical status and the prevention of complications. The role of antibiotics in the treatment of COPD exacerbations has been a matter of controversy. Even more contentious has been the issue whether antibiotic choice is relevant to clinical outcome of exacerbations. Recommendations for antibiotic use among published guidelines are inconsistent.

Chronic obstructive pulmonary disease: an update on diagnosis and management issues in older adults

Chronic obstructive pulmonary disease (COPD) is a debilitating disease of the elderly that causes significant morbidity and mortality. Despite being a treatable and preventable disease, the prevalence continues to rise because of the worldwide epidemic of smoking. COPD is associated with enormous healthcare costs. It has systemic effects, and common co-morbid conditions such as cardiovascular disease, muscle wasting and osteoporosis may all be linked through a common systemic inflammatory cascade. Depression, anxiety and malnutrition are also common in elderly COPD patients. These factors not only affect quality of life (QOL) but also compliance with therapy. Malnutrition is an independent predictor of mortality and poor outcome. Spirometry is essential for the diagnosis of COPD, but the criteria defining airflow limitation are not clear cut for elderly patients and could result in over-diagnosis. However, older patients perceive their symptoms differently, and COPD could also be under-diagnosed in this population. Acute exacerbations result in worsening symptoms that necessitate additional treatment, and may cause a more rapid decline in lung function and QOL. The management of elderly patients with COPD should encompass a multidisciplinary approach. An evaluation of patients' nutritional status and mental health should be undertaken, in addition to assessing their lung function and functional impairment. Significant underlying co-morbidities should be evaluated and treated to derive the maximal benefit of therapy. Specific therapy for COPD should start with cessation of exposure to the most important risk factor, tobacco smoke. Smoking cessation rates in the elderly have not declined, and this may reflect an underlying reluctance by physicians to counsel and offer smoking cessation therapies to the elderly. Unlike oxygen therapy in hypoxaemic patients, bronchodilators and corticosteroids do not decrease mortality in COPD patients and they are primarily directed towards symptom relief. However, they do have a positive effect on QOL and exacerbation rates. The choice of delivery devices for inhaled medications is important in the elderly, and patients' inhaler technique and manual dexterity should be frequently assessed. Pulmonary rehabilitation and nutritional supplementation are other important components of care. End-of-life issues should be adequately addressed in the elderly with COPD, and an approach integrating curative and palliative interventions is recommended.

Differences in COPD-related readmissions to primary and secondary care hospitals

OBJECTIVE

To study differences in readmissions to primary and secondary care hospitals for exacerbations of chronic obstructive pulmonary disease (COPD).

DESIGN

A register-based study.

SUBJECTS

The data were gathered from the hospital admissions register of the Finnish National Research and Development Centre for Welfare and Health. The data included all acute periods of treatment received by COPD patients aged over 44 years in 1996-2004 who had a principal or subsidiary diagnosis of COPD (ICD 10: J41-J44), respiratory infection (ICD 10: J00-J39, J85-J86) or cardiac insufficiency (ICD 10: I50), followed by an emergency readmission. Treatment had to have taken place in either a primary care hospital or a specialized ward for respiratory diseases or internal medicine in a secondary care hospital.

MAIN OUTCOME MEASURES

The risk of readmission within a week of discharge, analysed by site of care.

RESULTS

The risk of readmission within seven days of discharge is 1.74-fold for a patient treated in primary care compared with a patient treated in secondary care.

CONCLUSIONS

COPD patients discharged from primary care hospitals have a greater risk of readmission, particularly within a week, than those discharged from secondary care. This risk may be attributed to differences in treatment procedures and arrangement of subsequent care. Thus, in the future, more attention should be paid to primary healthcare resources and staff training.

Aging and the respiratory system

In the elderly, the chest without evident pathology is characterized by findings that occupy a sort of "no man's land" between the normal and the pathologic. Aging results in physiologic modifications that must be recognized so as not to be interpreted erroneously as pathologies. On the other hand, the elderly tend to become ill more frequently and multipathologies are more frequent. Image diagnostics is a key element in the clarification of often blurry clinical pictures, which may make early diagnosis possible, a great advantage to timely treatment. In this sense, knowledge of heart/lung interactions makes it possible to obtain, from the onset, radiologic and clinical signs of the two physiopathologic models prevalent in the elderly, the "cardiac lung" and the "pulmonary heart."

Assessing treatment effects of inhaled corticosteroids on medical expenses and exacerbations among COPD patients: longitudinal analysis of managed care claims

OBJECTIVE

To assess costs, effectiveness, and cost-effectiveness of inhaled corticosteroids (ICS) augmenting bronchodilator treatment for chronic obstructive pulmonary disease (COPD).

DATA SOURCES

Claims between 1997 and 2005 from a large managed care database.

STUDY DESIGN

Individual-level, fixed-effects regression models estimated the effects of initiating ICS on medical expenses and likelihood of severe exacerbation. Bootstrapping provided estimates of the incremental cost per severe exacerbation avoided.

DATA EXTRACTION METHODS

COPD patients aged 40 or older with > or = 15 months of continuous eligibility were identified. Monthly observations for 1 year before and up to 2 years following initiation of bronchodilators were constructed.

PRINCIPAL FINDINGS

ICS treatment reduced monthly risk of severe exacerbation by 25 percent. Total costs with ICS increased for 16 months, but declined thereafter. ICS use was cost saving 46 percent of the time, with an incremental cost-effectiveness ratio of $2,973 per exacerbation avoided; for patients > or = 50 years old, ICS was cost saving 57 percent of time.

CONCLUSIONS

ICS treatment reduces exacerbations, with an increase in total costs initially for the full sample. Compared with younger patients with COPD, patients aged 50 or older have reduced costs and improved outcomes. The estimated cost per severe exacerbation avoided, however, may be high for either group because of uncertainty as reflected by the large standard errors of the parameter estimates.

Tobramycin Nebulizer Solution in severe COPD patients colonized with Pseudomonas aeruginosa: effects on bronchial inflammation

INTRODUCTION

Airway colonization with Pseudomonas aeruginosa is frequent in severe chronic obstructive pulmonary disease (COPD) and may lead to progressive inflammatory damage. Inhaled Tobramycin Nebulizer Solution (TNS; a preservative-free formulation) is an effective therapy in chronic P aeruginosa infection in cystic fibrosis and bronchiectasis. In this study we aimed to investigate the effects of a TNS short course on inflammatory markers in bronchial secretions from multiresistant P aeruginosa-colonized patients with severe COPD. To the authors' knowledge, this is the first study to examine this in cases of severe COPD.

METHODS

Thirteen COPD patients (GOLD criteria 3-4; mean age 72.7+/- 8 years; mean basal forced expiratory volume in 1 second (FEV(1)) 34.8%+/-8.1%; mean FEV(1)/forced vital capacity 0.6+/-0.1) were enrolled. All patients were colonized with P aeruginosa and resistant to oral/intravenous specific antibiotics. Eosinophilic cationic protein (ECP), interleukin-1 beta (IL-1beta), interleukin-8 (IL-8), tumor necrosis factor alfa (TNF-alpha), and cell counts were measured in spontaneous secretions before and after a 2-week TNS course (300 mg twice daily).

RESULTS

The TNS course induced a significant reduction in IL-1beta (P<0.03), IL-8 (P<0.02), ECP (P<0.01) concentrations, and in eosinophil count (P<0.01). TNF-alpha levels, and neutrophil and lymphocyte counts were not significantly affected. The second week of treatment proved crucial in terms of efficacy. P aeruginosa density was lowered after 6 months; severe acute exacerbations were reduced by 42%.

CONCLUSION

TNS reduced the inflammatory impact of P aeruginosa in multiresistant, P aeruginosa-colonized patients with severe COPD. A therapeutic role for TNS can be strongly suggested in these particular conditions.

Airways inflammation and treatment during acute exacerbations of COPD

INTRODUCTION

Inflammation is a core feature of acute chronic obstructive pulmonary disease (COPD) exacerbations. It is important to focus on inflammation since it gives insight into the pathological changes causing an exacerbation, thereby possibly providing directions for future therapies which modify inflammation.

OBJECTIVES

To provide a cell-by-cell overview of the inflammatory processes during COPD exacerbations. To evaluate cell activation, and cytokine production, cellular interactions, damaging effects of inflammatory mediators to tissue, and the relation to symptoms at the onset of COPD exacerbations. To speculate on future therapeutic options to modify inflammation during COPD exacerbations.

RESULTS

During COPD exacerbations, there is increased airway wall inflammation, with pathophysiological influx of eosinophils, neutrophils, and lymphocytes. Although links have been suggested between the increase in eosinophils and lymphocytes and a viral etiology of the exacerbation, and between the increase in neutrophils and a bacterial aetiology, these increases in both inflammatory cell types are not limited to the respective aetiologies and the underlying mechanisms remain elusive.

CONCLUSION

Further research is required to fully understand the inflammatory mechanisms in the onset and development of COPD exacerbations. This might make inflammatory pathway-specific intervention possible, resulting in a more effective treatment of COPD exacerbations with fewer side effects.

Optimizing antibiotic selection in treating COPD exacerbations

Our understanding of the etiology, pathogenesis and consequences of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased substantially in the last decade. Several new lines of evidence demonstrate that bacterial isolation from sputum during acute exacerbation in many instances reflects a cause-effect relationship. Placebo-controlled antibiotic trials in exacerbations of COPD demonstrate significant clinical benefits of antibiotic treatment in moderate and severe episodes. However, in the multitude of antibiotic comparison trials, the choice of antibiotics does not appear to affect the clinical outcome, which can be explained by several methodological limitations of these trials. Recently, comparison trials with nontraditional end-points have shown differences among antibiotics in the treatment of exacerbations of COPD. Observational studies that have examined clinical outcome of exacerbations have repeatedly demonstrated certain clinical characteristics to be associated with treatment failure or early relapse. Optimal antibiotic selection for exacerbations has therefore incorporated quantifying the risk for a poor outcome of the exacerbation and choosing antibiotics differently for low risk and high risk patients, reserving the broader spectrum drugs for the high risk patients. Though improved outcomes in exacerbations with antibiotic choice based on such risk stratification has not yet been demonstrated in prospective controlled trials, this approach takes into account concerns of disease heterogeneity, antibiotic resistance and judicious antibiotic use in exacerbations.