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Kumar K, Ratnakumar R, Collin SM, Berrocal-Almanza LC, Ricci P, Al-Zubaidy M, Coker RK, Coleman M, Elkin SL, Mallia P, Meghji J, Ross C, Russell GK, Ward K, Wickremasinghe M, Sheard S, Copley SJ, Kon OM. Chest CT features and functional correlates of COVID-19 at 3 months and 12 months follow-up. Clin Med (Lond) 2023; 23:467-477. [PMID: 37775167 PMCID: PMC10541283 DOI: 10.7861/clinmed.2023-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Long-term pulmonary sequelae of Coronavirus 2019 (COVID-19) remain unclear. Thus, we aimed to establish post-COVID-19 temporal changes in chest computed tomography (CT) features of pulmonary fibrosis and to investigate associations with respiratory symptoms and physiological parameters at 3 and 12 months' follow-up. Adult patients who attended our initial COVID-19 follow-up service and developed chest CT features of interstitial lung disease, in addition to cases identified using British Society of Thoracic Imaging codes, were evaluated retrospectively. Clinical data were gathered on respiratory symptoms and physiological parameters at baseline, 3 months, and 12 months. Corresponding chest CT scans were reviewed by two thoracic radiologists. Associations between CT features and functional correlates were estimated using random effects logistic or linear regression adjusted for age, sex and body mass index. In total, 58 patients were assessed. No changes in reticular pattern, honeycombing, traction bronchiectasis/bronchiolectasis index or pulmonary distortion were observed. Subpleural curvilinear lines were associated with lower odds of breathlessness over time. Parenchymal bands were not associated with breathlessness or impaired lung function overall. Based on our results, we conclude that post-COVID-19 chest CT features of irreversible pulmonary fibrosis remain static over time; other features either resolve or remain unchanged. Subpleural curvilinear lines do not correlate with breathlessness. Parenchymal bands are not functionally significant. An awareness of the different potential functional implications of post-COVID-19 chest CT changes is important in the assessment of patients who present with multi-systemic sequelae of COVID-19 infection.
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Affiliation(s)
- Kartik Kumar
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and NIHR Imperial BRC clinical research fellow in respiratory medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ratnaprashanthika Ratnakumar
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and clinical research fellow in respiratory medicine and lung cancer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Simon M Collin
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Luis C Berrocal-Almanza
- NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | - Piera Ricci
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mustafa Al-Zubaidy
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Robina K Coker
- National Heart and Lung Institute, Imperial College London, London, UK, and honorary clinical senior lecturer, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Meg Coleman
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah L Elkin
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Patrick Mallia
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jamilah Meghji
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Clare Ross
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Katie Ward
- National Heart and Lung Institute, Imperial College London, London, UK, and honorary clinical senior lecturer, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Melissa Wickremasinghe
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah Sheard
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Susan J Copley
- National Heart and Lung Institute, Imperial College London, London, UK, and professor of practice (radiology), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Joint senior authors
| | - Onn Min Kon
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK and professor of respiratory medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Joint senior authors
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Kumar K, Ratnakumar P, Ricci P, Al-Zubaidy M, Srikanthan K, Agrawal S, Ahmedani I, Baxter I, Monem E, Coleman M, Elkin SL, Kon OM, Mallia P, Meghji J, Ross C, Russell GK. Recovering from COVID-19: lessons learnt from an intensive secondary care follow-up service. Future Healthc J 2022; 9:335-342. [PMID: 36561827 PMCID: PMC9761447 DOI: 10.7861/fhj.2021-0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In response to the first COVID-19 surge in 2020, secondary care outpatient services were rapidly reconfigured to provide specialist review for disease sequelae. At our institution, comprising hospitals across three sites in London, we initially implemented a COVID-19 follow-up pathway that was in line with expert opinion at the time but more intensive than initial clinical guidelines suggested. We retrospectively evaluated the resource requirements for this service, which supported 526 patients from April 2020 to October 2020. At the 6-week review, 193/403 (47.9%) patients reported persistent breathlessness, 46/336 (13.7%) desaturated on exercise testing, 167/403 (41.4%) were discharged from COVID-19-related secondary care services and 190/403 (47.1%) needed 12-week follow-up. At the 12-week review, 113/309 (36.6%) patients reported persistent breathlessness, 30/266 (11.3%) desaturated on exercise testing and 150/309 (48.5%) were discharged from COVID-19-related secondary care services. Referrals were generated to multiple medical specialties, particularly respiratory subspecialties. Our analysis allowed us to justify rationalising and streamlining provisions for subsequent COVID-19 waves while reassured that opportunities for early intervention were not being missed.
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Affiliation(s)
- Kartik Kumar
- ASt Mary's Hospital, London, UK and National Institute for Health and Care Research Imperial Biomedical Research Centre clinical research fellow in respiratory medicine, Imperial College London, London, UK
| | - Prashanthi Ratnakumar
- BSt Mary's Hospital, London, UK and clinical research fellow in respiratory medicine and lung cancer, Imperial College London, London, UK
| | | | | | | | | | | | | | - Enrique Monem
- DImperial College London Faculty of Medicine, London, UK
| | - Meg Coleman
- GSt Mary's Hospital, London, UK and honorary clinical senior lecturer, Imperial College London, London, UK
| | - Sarah L Elkin
- HSt Mary's Hospital, London, UK and honorary clinical senior lecturer, Imperial College London, London, UK
| | - Onn Min Kon
- ISt Mary's Hospital, London, UK and professor of respiratory medicine, Imperial College London, London, UK
| | - Patrick Mallia
- JSt Mary's Hospital, London, UK and clinical senior lecturer, Imperial College London, London, UK
| | - Jamilah Meghji
- KSt Mary's Hospital, London, UK and Medical Research Council skills development fellow, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Clare Ross
- LSt Mary's Hospital, London, UK and honorary clinical senior lecturer, Imperial College London, London, UK
| | - Georgina K Russell
- MSt Mary's Hospital, London, UK,Address for correspondence: Dr Georgina K Russell, Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK.
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3
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Baker JR, Fenwick PS, Koss CK, Owles HB, Elkin SL, Fine JS, Thomas M, Kasmi KC, Barnes PJ, Donnelly LE. Imbalance between IL-36 receptor agonist and antagonist drives neutrophilic inflammation in COPD. JCI Insight 2022; 7:155581. [PMID: 35763349 PMCID: PMC9462491 DOI: 10.1172/jci.insight.155581] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Current treatments fail to modify the underlying pathophysiology and disease progression of chronic obstructive pulmonary disease (COPD), necessitating alternative therapies. Here, we show that COPD subjects have increased IL-36γ and decreased IL-36 receptor antagonist (IL-36Ra) in bronchoalveolar and nasal fluid compared to control subjects. IL-36γ is derived from small airway epithelial cells (SAEC) and further induced by a viral mimetic, whereas IL-36RA is derived from macrophages. IL-36γ stimulates release of the neutrophil chemoattractants CXCL1 and CXCL8, as well as elastolytic matrix metalloproteinases (MMPs) from small airway fibroblasts (SAF). Proteases released from COPD neutrophils cleave and activate IL-36γ thereby perpetuating IL-36 inflammation. Transfer of culture media from SAEC to SAF stimulated release of CXCL1, that was inhibited by exogenous IL-36RA. The use of a therapeutic antibody that inhibits binding to the IL-36 receptor (IL-36R) attenuated IL-36γ driven inflammation and cellular cross talk. We have demonstrated a mechanism for the amplification and propagation of neutrophilic inflammation in COPD and that blocking this cytokine family via a IL-36R neutralizing antibody could be a promising new therapeutic strategy in the treatment of COPD.
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Affiliation(s)
- Jonathan R Baker
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Peter S Fenwick
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Carolin K Koss
- Boehringer Ingelheim Pharma GmbH & Co KG,, Biberach an der Riß, Germany
| | - Harriet B Owles
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London, United Kingdom
| | - Jay S Fine
- Immunology and Respiratory Diseases, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, United States of America
| | - Matthew Thomas
- Department of Immunology and Respiratory, Boehringer Ingelheim Pharma GmbH & Co KG,, Biberach an der Riß, Germany
| | - Karim C Kasmi
- Department of Immunology and Respiratory, Boehringer Ingelheim Pharma GmbH & Co KG,, Biberach an der Riß, Germany
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise E Donnelly
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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4
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Kumar K, Groom K, Martin L, Russell GK, Elkin SL. Educational opportunities for postgraduate medical trainees during the COVID-19 pandemic: deriving value from old, new and emerging ways of learning. Postgrad Med J 2022; 98:328-330. [PMID: 34344700 PMCID: PMC9046751 DOI: 10.1136/postgradmedj-2021-140603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/11/2021] [Indexed: 01/09/2023]
Abstract
The COVID-19 pandemic has had a significant impact on postgraduate medical training across all specialties. Although some traditional learning opportunities have been curtailed, there have been numerous examples of highly valuable educational experiences that have arisen during this time. Here, from a trainee perspective, we consider the educational merits of the re-emergence of 'firm-based' teams, new online learning opportunities, use of digital technologies and the rise of telephone clinics and new COVID-19 clinical services. As health services continue to recover from surges in COVID-19 cases, it is important to reflect on and recognise the value of these educational experiences so that helpful elements can be retained and embedded into training programmes for the benefit of both trainees and patients.
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Affiliation(s)
- Kartik Kumar
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK,National Heart and Lung Institute, Imperial College London, London, UK
| | - Katherine Groom
- Department of Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Laura Martin
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Georgina K Russell
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK,National Heart and Lung Institute, Imperial College London, London, UK
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5
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Ritchie AI, Brill SE, Vlies BH, Finney LJ, Allinson JP, Alves-Moreira L, Wiseman DJ, Walker PP, Baker E, Elkin SL, Mallia P, Law M, Donaldson GC, Calverley PMA, Wedzicha JA. Targeted Retreatment of Incompletely Recovered Chronic Obstructive Pulmonary Disease Exacerbations with Ciprofloxacin. A Double-Blind, Randomized, Placebo-controlled, Multicenter, Phase III Clinical Trial. Am J Respir Crit Care Med 2020; 202:549-557. [PMID: 32267724 DOI: 10.1164/rccm.201910-2058oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) exacerbations are prone to nonrecovery, but there are no data about the effectiveness of retreatment for these prolonged events. We examined whether further therapy with ciprofloxacin for incompletely resolved COPD exacerbations prolonged the time until the next event.Objectives: To assess whether incompletely recovered COPD exacerbations benefit from additional treatment with ciprofloxacin, at Day 14.Methods: In a multicenter, randomized double-blind placebo-controlled trial, we studied retreatment with oral ciprofloxacin 500 mg or matched placebo twice daily for 7 days in patients with Global Initiative for Chronic Obstructive Lung Disease stage II-IV COPD and persistent symptoms and/or serum C-reactive protein ≥8 mg/L initiated 14 (±3) days after an index COPD exacerbation. The primary outcome was the time to the next exacerbation within a 90-day period.Measurements and Main Results: Among 826 patients screened at four centers, 144 eligible participants with incomplete recovery were randomized to receive ciprofloxacin (n = 72) or placebo (n = 72). Within 90 days of randomization, 57% of the patients in the ciprofloxacin group and 53% in the placebo group experienced one or more exacerbations. The median time to the next exacerbation was 32.5 days (interquartile range 13-50) in the placebo arm and 34 days (interquartile range 17-62) in the ciprofloxacin arm, which was not significantly different (adjusted hazard ratio, 1.07; 95% confidence interval, 0.68-1.68; P = 0.76). No significant differences were seen in quality-of-life scores or lung function between the treatment groups.Conclusions: In patients with persistent symptoms and/or raised C-reactive protein 14 days after a COPD exacerbation, an additional course of ciprofloxacin resulted in no additional benefit compared with placebo. This suggests that nonrecovered exacerbations are not driven by ongoing bacterial infection and may potentially be targeted with antiinflammatory therapy.Clinical trial registered with www.clinicaltrials.gov (NCT02300220).
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Affiliation(s)
- Andrew I Ritchie
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Simon E Brill
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ben H Vlies
- School of Aging and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Lydia J Finney
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - James P Allinson
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Dexter J Wiseman
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Paul P Walker
- School of Aging and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Emma Baker
- Institute of Infection and Immunity, St. George's, University of London, London, United Kingdom
| | - Sarah L Elkin
- Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Patrick Mallia
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Martin Law
- Hub for Trials Methodology Research, Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Gavin C Donaldson
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Peter M A Calverley
- School of Aging and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Jadwiga A Wedzicha
- National Heart and Lung Institute, Imperial College, London, United Kingdom
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Bloom CI, Ramsey H, Alter M, Lakhani S, Wong E, Hickman K, Elkin SL, Majeed A, El-Osta A. Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK. J Asthma Allergy 2020; 13:429-437. [PMID: 33116651 PMCID: PMC7547777 DOI: 10.2147/jaa.s274943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022] Open
Abstract
Background Guidelines recommend that asthma treatment should be stepped down to the minimally effective dose that achieves symptom control to prevent medication side effects and reduce unnecessary costs. Little is known about the practice of stepping down and the challenges in primary care, where most asthma patients are managed. Objective To explore views, experiences, barriers and ideas, of doctors, nurses and pharmacists working in primary care, related to step down of asthma medication. Methods Primary care practitioners from across the UK participated in a survey and/or semi-structured interview. Questions explored four main areas: how asthma medication is reviewed, views on asthma guidelines, perceived barriers faced by healthcare workers and facilitators of stepping down. Qualitative content analysis enabled data coding of interview transcripts to identify major themes. Results A total of 274 participants responded to the survey, 29 participated in an interview (12 doctors, 9 nurses, and 8 pharmacists), working in GP practices from across the UK. Nearly half of the survey participants infrequently step down asthma medication (doctors=42.7%, nurses=46.3%). Four major themes related to barriers to stepping down were (i) lack of awareness of the need to step down, (ii) inertia to step down, driven by low confidence in ability, fear of consequences, and concern for who is responsible for stepping down, (iii) self-efficacy of ability to step down, influenced by lack of clear, applied guidance and limited training, and (iv) feasibility of step down, driven by a lack of systematic acceptance of stepping down and time. Strategies proposed to reduce overtreatment included education and training, improved gathering of evidence and guidance, and integrating step down into routine asthma care. Conclusion Failure to implement this guideline recommendation into everyday asthma management is influenced by several contributing factors. Future directions should include addressing evidence gaps, implementing clear and practical guidance, integration of step-down assessment into the asthma review, and education of professionals and patients.
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Affiliation(s)
- Chloe I Bloom
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Helen Ramsey
- Kent and Medway CCG, Swanscombe and Bean Partnership, Swanscombe Kent, UK
| | - Marsha Alter
- Middlesex Pharmaceutical Group of LPCs & Community Pharmacy Research Champion NIHR NWL CRN, London, UK
| | - Shivali Lakhani
- Middlesex Pharmaceutical Group of LPCs & Community Pharmacy Research Champion NIHR NWL CRN, London, UK
| | - Ernie Wong
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London, UK
| | - Katharine Hickman
- West Yorkshire & Harrogate Health and Care Partnership, Low Moor Medical Practice, West Yorkshire, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London, UK
| | - Azeem Majeed
- Department of Primary Care & Public Health School of Public Health, Imperial College London, London, UK
| | - Austen El-Osta
- Department of Primary Care & Public Health School of Public Health, Imperial College London, London, UK.,Self-Care Academic Research Unit (SCARU) Department of Primary Care & Public Health School of Public Health, Imperial College London, London, UK
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7
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Kumar K, Mak V, Groom K, Razak Y, Brown JL, Hyde T, Bokobza A, Coker RK, Parmar M, Wong E, Han LY, Elkin SL. Respiratory specialists working in different ways: Development of a GP hotline and respiratory support service during the COVID-19 pandemic. Future Healthc J 2020; 7:e88-e92. [PMID: 33094266 DOI: 10.7861/fhj.2020-0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Integration of primary and secondary care for the management of respiratory disease is a long-held ambition. Here, we describe how respiratory specialists at a large NHS trust, working with primary care clinicians in the area, set up a GP hotline and respiratory support service in response to the COVID-19 pandemic, with the aim of enhancing delivery of care to patients in this unprecedented time. Working across traditional organisational boundaries in this way confers benefits to patients and clinicians, illustrating the value of new, integrated models of care.
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Affiliation(s)
- Kartik Kumar
- Imperial College Healthcare NHS Trust, London, UK and NIHR Imperial BRC clinical research fellow in respiratory medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Vincent Mak
- Imperial College Healthcare NHS Trust, London, UK and clinical director of the London Respiratory Strategic Clinical Network
| | | | | | | | - Toby Hyde
- Imperial College Healthcare NHS Trust, London, UK
| | - Anna Bokobza
- Imperial College Healthcare NHS Trust, London, UK
| | - Robina K Coker
- Imperial College Healthcare NHS Trust, London, UK and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Mohini Parmar
- Barnabas Medical Centre, London, UK and chair, NHS Ealing Clinical Commissioning Group
| | - Ernie Wong
- Imperial College Healthcare NHS Trust, London, UK and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Sarah L Elkin
- Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
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8
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Gupta A, Jayes LR, Holmes S, Sahota O, Canavan M, Elkin SL, Lim K, Murphy AC, Singh S, Towlson EA, Ward H, Scullion J, McKeever TM, Bolton CE. Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement. Int J Chron Obstruct Pulmon Dis 2020; 15:1377-1390. [PMID: 32606647 PMCID: PMC7311204 DOI: 10.2147/copd.s233398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD. Methods A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like. Results The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required. Conclusion There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required.
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Affiliation(s)
- Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Leah R Jayes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Steve Holmes
- General Practitioner, Park Medical Partnership, Shepton Mallet, UK
| | - Opinder Sahota
- Department of Geriatric Medicine, Nottingham University Hospitals Trust, Nottingham, UK
| | - Melissa Canavan
- Department of Respiratory, Respiratory Care Solutions, Leeds, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London W2 1NY, UK; Airways Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Kelvin Lim
- Eastwood Primary Care Centre, Eastwood, Nottingham, UK
| | - Anna C Murphy
- Department of Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Singh
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Science, University of Leicester, Leicester, UK
| | | | - Helen Ward
- Faculty of Medicine, The Royal Wolverhampton NHS Trust, West Midlands, UK
| | - Jane Scullion
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
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9
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Finney LJ, Padmanaban V, Todd S, Ahmed N, Elkin SL, Mallia P. Validity of the diagnosis of pneumonia in hospitalised patients with COPD. ERJ Open Res 2019; 5:00031-2019. [PMID: 31249841 PMCID: PMC6589445 DOI: 10.1183/23120541.00031-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/14/2019] [Indexed: 01/01/2023] Open
Abstract
Rationale Exacerbations of chronic obstructive pulmonary disease (COPD) and pneumonia are two of the most common reasons for acute hospital admissions. Acute exacerbations and pneumonia present with similar symptoms in COPD patients, representing a diagnostic challenge with a significant impact on patient outcomes. The objectives of this study were to compare the prevalence of radiographic consolidation with the discharge diagnoses of hospitalised COPD patients. Methods COPD patients admitted to three UK hospitals over a 3-year period were identified. Participants were included if they were admitted with an acute respiratory illness, COPD was confirmed by spirometry and a chest radiograph was performed within 24 h of admission. Pneumonia was defined as consolidation on chest radiograph reviewed by two independent observers Results There were 941 admissions in 621 patients included in the final analysis. In 235 admissions, consolidation was present on chest radiography and there were 706 admissions without consolidation. Of the 235 admissions with consolidation, only 42.9% had a discharge diagnosis of pneumonia; 90.7% of patients without consolidation had a discharge diagnosis of COPD exacerbation. The presence of consolidation was associated with increased rate of high-dependency care admission, increased mortality and prolonged length of stay. Inhaled corticosteroid use was associated with recurrent pneumonia. Conclusions Pneumonia is underdiagnosed in patients with COPD. Radiographic consolidation is associated with worse outcomes and prolonged length of stay. Incorrect diagnosis could result in inappropriate use of inhaled corticosteroids. Future guidelines should specifically address the diagnosis and management of pneumonia in COPD. Pneumonia is common in hospitalised COPD patients but is frequently not recognised and underdiagnosed. This has implications for the correct risk stratification and treatment of COPD patients.http://bit.ly/2HTfIKo
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Affiliation(s)
- Lydia J Finney
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - Samuel Todd
- Imperial College Healthcare NHS Trust, London, UK
| | - Nadia Ahmed
- National Heart and Lung Institute, Imperial College, London, UK
| | - Sarah L Elkin
- Imperial College Healthcare NHS Trust, London, UK.,These authors contributed equally
| | - Patrick Mallia
- National Heart and Lung Institute, Imperial College, London, UK.,Imperial College Healthcare NHS Trust, London, UK.,These authors contributed equally
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10
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Calderazzo MA, Trujillo-Torralbo MB, Finney LJ, Singanayagam A, Bakhsoliani E, Padmanaban V, Kebadze T, Aniscenko J, Elkin SL, Johnston SL, Mallia P. Inflammation and infections in unreported chronic obstructive pulmonary disease exacerbations. Int J Chron Obstruct Pulmon Dis 2019; 14:823-832. [PMID: 31114182 PMCID: PMC6497477 DOI: 10.2147/copd.s191946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/22/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose: COPD patients often do not report acute exacerbations to healthcare providers – unreported exacerbations. It is not known whether variances in symptoms, airway obstruction, aetiology and inflammatory responses account for differences in reporting of COPD exacerbations. The aims of the study were to compare symptoms, lung function changes, aetiology and inflammatory markers between exacerbations that were reported to healthcare providers or treated, with those that were unreported and untreated. Patients and methods: We recruited a cohort of COPD patients and collected clinical data and blood and airway samples when stable and during acute exacerbations. Virological and bacterial analyses were carried out and inflammatory markers measured. Results: We found no differences in symptoms, lung function, incidence of infection and inflammatory markers between reported and unreported exacerbations. Subjects who reported all exacerbations had higher BODE scores, lower FEV1 and more exacerbations compared with those who did not. Conclusion: The failure to report exacerbations is not related to the severity, aetiology or inflammatory profile of the exacerbation. Patients with less severe COPD and less frequent exacerbations are less likely to report exacerbations. The decision to report an exacerbation is not an objective marker of exacerbation severity and therefore studies that do not count unreported exacerbations will underestimate the frequency of clinically significant exacerbations. A better understanding of the factors that determine non-reporting of exacerbations is required to improve exacerbation reporting. Trial registration: ClinicalTrials.gov Identifier: NCT01376830. Registered June 17, 2011
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Affiliation(s)
| | - Maria-Belen Trujillo-Torralbo
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | - Vijay Padmanaban
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Tatiana Kebadze
- National Heart and Lung Institute, Imperial College, London, UK
| | - Julia Aniscenko
- National Heart and Lung Institute, Imperial College, London, UK
| | - Sarah L Elkin
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Sebastian L Johnston
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Patrick Mallia
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
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11
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Abstract
Background Over the past two decades, there have been significant changes in the pharmacological management of COPD, due to an explosion of inhaler trials, and timely updation of national and international guidelines. We sought to describe temporal changes in prescribing practices in the United Kingdom, and some of the factors that may have influenced them. Patients and methods COPD patients were identified from UK primary care nationally representative electronic healthcare records (Clinical Practice Research Datalink), between 2000 and 2016. Prescription data were described by the three maintenance inhaled medication classes used, inhaled corticosteroids (ICS), long-acting beta agonist (LABA), long-acting muscarinic antagonist (LAMA), and their combinations, dual LABA-ICS, dual LAMA-LABA, or triple therapy LABA-ICS-LAMA. Differing patient characteristics across the six different therapy regimens were measured in 2016. Results COPD patients were identified: 187,588 prevalent and incident inhaler users and 169,511 incident inhaler users. Since 2002, LAMA showed increasing popularity, while ICS alone exhibited an inverse trend. Triple therapy prescriptions rapidly increased as the first-line therapy until 2014 when LAMA-LABA prescriptions started to increase. By 2014, 41% of all COPD patients were maintained on triple therapy, and 13% were maintained on LAMA only. Characterizing the patients in 2016 revealed that those on triple therapy were more likely to have more severe disease, yet, over a third of patients on triple therapy had only mild disease. Conclusion UK prescribing practices were not in keeping with national guidelines but did appear to align with evidence from major drug trials and updated international guidelines. There has been a huge upsurge in triple therapy but incident data show this trend is beginning to reverse for initial management.
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Affiliation(s)
- Chloe I Bloom
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK,
| | - S L Elkin
- Department of Respiratory Medicine, Imperial College NHS Trust, London, UK
| | - J K Quint
- National Heart and Lung Institute, Imperial College London, London SW3 6LR, UK,
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12
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Mallia P, Webber J, Gill SK, Trujillo-Torralbo MB, Calderazzo MA, Finney L, Bakhsoliani E, Farne H, Singanayagam A, Footitt J, Hewitt R, Kebadze T, Aniscenko J, Padmanaban V, Molyneaux PL, Adcock IM, Barnes PJ, Ito K, Elkin SL, Kon OM, Cookson WO, Moffat MF, Johnston SL, Tregoning JS. Role of airway glucose in bacterial infections in patients with chronic obstructive pulmonary disease. J Allergy Clin Immunol 2018; 142:815-823.e6. [PMID: 29310905 PMCID: PMC6127032 DOI: 10.1016/j.jaci.2017.10.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/03/2017] [Accepted: 10/11/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) have increased susceptibility to respiratory tract infection, which contributes to disease progression and mortality, but mechanisms of increased susceptibility to infection remain unclear. OBJECTIVES The aim of this study was to determine whether glucose concentrations were increased in airway samples (nasal lavage fluid, sputum, and bronchoalveolar lavage fluid) from patients with stable COPD and to determine the effects of viral infection on sputum glucose concentrations and how airway glucose concentrations relate to bacterial infection. METHODS We measured glucose concentrations in airway samples collected from patients with stable COPD and smokers and nonsmokers with normal lung function. Glucose concentrations were measured in patients with experimentally induced COPD exacerbations, and these results were validated in patients with naturally acquired COPD exacerbations. Relationships between sputum glucose concentrations, inflammatory markers, and bacterial load were examined. RESULTS Sputum glucose concentrations were significantly higher in patients with stable COPD compared with those in control subjects without COPD. In both experimental virus-induced and naturally acquired COPD exacerbations, sputum and nasal lavage fluid glucose concentrations were increased over baseline values. There were significant correlations between sputum glucose concentrations and sputum inflammatory markers, viral load, and bacterial load. Airway samples with higher glucose concentrations supported more Pseudomonas aeruginosa growth in vitro. CONCLUSIONS Airway glucose concentrations are increased in patients with stable COPD and further increased during COPD exacerbations. Increased airway glucose concentrations might contribute to bacterial infections in both patients with stable and those with exacerbated COPD. This has important implications for the development of nonantibiotic therapeutic strategies for the prevention or treatment of bacterial infection in patients with COPD.
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Affiliation(s)
- Patrick Mallia
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom; Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - Jessica Webber
- Cardiff University School of Medicine, UHW Main Building Heath Park Cardiff, Cardiff, United Kingdom
| | - Simren K Gill
- Mucosal Infection and Immunity Group, Section of Virology, Imperial College London, St Mary's Campus, London, United Kingdom
| | | | - Maria Adelaide Calderazzo
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Lydia Finney
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Eteri Bakhsoliani
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Hugo Farne
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Aran Singanayagam
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom; Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - Joseph Footitt
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Richard Hewitt
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Tatiana Kebadze
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Julia Aniscenko
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Vijay Padmanaban
- Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - Philip L Molyneaux
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ian M Adcock
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Peter J Barnes
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Kazihuro Ito
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Sarah L Elkin
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom; Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - Onn Min Kon
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom; Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - William O Cookson
- Molecular Genetics and Genomics Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Miriam F Moffat
- Molecular Genetics and Genomics Section, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, United Kingdom; Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - John S Tregoning
- Mucosal Infection and Immunity Group, Section of Virology, Imperial College London, St Mary's Campus, London, United Kingdom.
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13
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Kruis AL, Soljak M, Chavannes NH, Elkin SL. COPD Multidisciplinary Team Meetings in the United Kingdom: Health Care Professionals' Perceptions of Aims and Structure. COPD 2017; 13:639-41. [PMID: 26263193 DOI: 10.3109/15412555.2015.1007930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Over the last 10 years, community and hospital-based multidisciplinary teams (MDTs) have been set up for the management of patients with chronic obstructive pulmonary disease (COPD) in the UK. Meetings of the MDTs have become a regular occurrence, mostly on healthcare professionals' own initiatives. There are no standardized methods to conduct an MDT meeting, and although cancer MDT meetings are widely implemented, the value and purpose of COPD MDT meetings are less clear. Therefore, the aim of this study was to conduct a cross-sectional descriptive online survey to explore COPD MDT members' perceptions of the purpose and usefulness of MDT meetings, and to identify suggestions or requirements to improve the meetings. In total, we received 68 responses from 10 MDTs; six teams (n = 36 members) were located in London and four (n = 32 members) outside. Analysis of the replies by two independent researchers found that MDT meetings aim to optimise management and improve pathways for respiratory patients by improving communication between providers across settings and disciplines. Education of the MDT members also occurs with the aim of safer practice. Discussed patients are characterised by (multiple) co-morbidities, frequent exacerbations and admissions, social and mental health problems, unclear diagnosis and suboptimal responses to interventions. Members reported participating in a COPD MDT as very useful (74%) or useful (20%). Meetings could be improved by ensuring attendance through requirement in job plans, by clear documentation and sharing of derived plans with a wider audience including general practitioners and patients.
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Affiliation(s)
- Annemarije L Kruis
- a Department of Public Health and Primary Care , Leiden University Medical Centre , Leiden , the Netherlands.,b Department of Primary Care & Public Health , Imperial College London , London , United Kingdom
| | - Michael Soljak
- b Department of Primary Care & Public Health , Imperial College London , London , United Kingdom
| | - Niels H Chavannes
- a Department of Public Health and Primary Care , Leiden University Medical Centre , Leiden , the Netherlands
| | - Sarah L Elkin
- c Imperial Healthcare NHS Trust , St Mary's Hospital , London , United Kingdom
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14
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Upton N, Jackson DJ, Nikonova AA, Hingley-Wilson S, Khaitov M, del Rosario A, Traub S, Trujillo-Torralbo MB, Habibi M, Elkin SL, Kon OM, Edwards MR, Mallia P, Footitt J, Macintyre J, Stanciu LA, Johnston SL, Sykes A. Rhinovirus induction of fractalkine (CX3CL1) in airway and peripheral blood mononuclear cells in asthma. PLoS One 2017; 12:e0183864. [PMID: 28859129 PMCID: PMC5578648 DOI: 10.1371/journal.pone.0183864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 08/12/2017] [Indexed: 12/21/2022] Open
Abstract
Rhinovirus infection is associated with the majority of asthma exacerbations. The role of fractalkine in anti-viral (type 1) and pathogenic (type 2) responses to rhinovirus infection in allergic asthma is unknown. To determine whether (1) fractalkine is produced in airway cells and in peripheral blood leucocytes, (2) rhinovirus infection increases production of fractalkine and (3) levels of fractalkine differ in asthmatic compared to non-asthmatic subjects. Fractalkine protein and mRNA levels were measured in bronchoalveolar lavage (BAL) cells and peripheral blood mononuclear cells (PBMCs) from non-asthmatic controls (n = 15) and mild allergic asthmatic (n = 15) subjects. Protein levels of fractalkine were also measured in macrophages polarised ex vivo to give M1 (type 1) and M2 (type 2) macrophages and in BAL fluid obtained from mild (n = 11) and moderate (n = 14) allergic asthmatic and non-asthmatic control (n = 10) subjects pre and post in vivo rhinovirus infection. BAL cells produced significantly greater levels of fractalkine than PBMCs. Rhinovirus infection increased production of fractalkine by BAL cells from non-asthmatic controls (P<0.01) and in M1-polarised macrophages (P<0.05), but not in BAL cells from mild asthmatics or in M2 polarised macrophages. Rhinovirus induced fractalkine in PBMCs from asthmatic (P<0.001) and healthy control subjects (P<0.05). Trends towards induction of fractalkine in moderate asthmatic subjects during in vivo rhinovirus infection failed to reach statistical significance. Fractalkine may be involved in both immunopathological and anti-viral immune responses to rhinovirus infection. Further investigation into how fractalkine is regulated across different cell types and into the effect of stimulation including rhinovirus infection is warranted to better understand the precise role of this unique dual adhesion factor and chemokine in immune cell recruitment.
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Affiliation(s)
- Nadine Upton
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Randall Division of Cell and Molecular Biophysics, Kings College London, London, United Kingdom
| | - David J. Jackson
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alexandra A. Nikonova
- NRC institute of Immunology FMBA, Moscow, Russian Federation
- Mechnikov Research Institute for Vaccines and Sera, Moscow, Russian Federation
- * E-mail:
| | - Suzie Hingley-Wilson
- Respiratory Infection Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Musa Khaitov
- NRC institute of Immunology FMBA, Moscow, Russian Federation
| | - Ajerico del Rosario
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Stephanie Traub
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Maria-Belen Trujillo-Torralbo
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Max Habibi
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Respiratory Infection Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Sarah L. Elkin
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Onn M. Kon
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael R. Edwards
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Patrick Mallia
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Joseph Footitt
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jonathan Macintyre
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Luminita A. Stanciu
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Sebastian L. Johnston
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Annemarie Sykes
- Airway Disease Infection Section, National Heart & Lung Institute, Imperial College London, London, United Kingdom
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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15
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Footitt J, Mallia P, Durham AL, Ho WE, Trujillo-Torralbo MB, Telcian AG, Del Rosario A, Chang C, Peh HY, Kebadze T, Aniscenko J, Stanciu L, Essilfie-Quaye S, Ito K, Barnes PJ, Elkin SL, Kon OM, Wong WSF, Adcock IM, Johnston SL. Oxidative and Nitrosative Stress and Histone Deacetylase-2 Activity in Exacerbations of COPD. Chest 2016; 149:62-73. [PMID: 25790167 PMCID: PMC4700054 DOI: 10.1378/chest.14-2637] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Respiratory virus infections are commonly associated with COPD exacerbations, but little is known about the mechanisms linking virus infection to exacerbations. Pathogenic mechanisms in stable COPD include oxidative and nitrosative stress and reduced activity of histone deacetylase-2 (HDAC2), but their roles in COPD exacerbations is unknown. We investigated oxidative and nitrosative stress (O&NS) and HDAC2 in COPD exacerbations using experimental rhinovirus infection. METHODS Nine subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease stage II), 10 smokers, and 11 nonsmokers were successfully infected with rhinovirus. Markers of O&NS-associated cellular damage, and inflammatory mediators and proteases were measured in sputum, and HDAC2 activity was measured in sputum and bronchoalveolar macrophages. In an in vitro model, monocyte-derived THP-1 cells were infected with rhinovirus and nitrosylation and activity of HDAC2 was measured. RESULTS Rhinovirus infection induced significant increases in airways inflammation and markers of O&NS in subjects with COPD. O&NS markers correlated with virus load and inflammatory markers. Macrophage HDAC2 activity was reduced during exacerbation and correlated inversely with virus load, inflammatory markers, and nitrosative stress. Sputum macrophage HDAC2 activity pre-infection was inversely associated with sputum virus load and inflammatory markers during exacerbation. Rhinovirus infection of monocytes induced nitrosylation of HDAC2 and reduced HDAC2 activity; inhibition of O&NS inhibited rhinovirus-induced inflammatory cytokines. CONCLUSIONS O&NS, airways inflammation, and impaired HDAC2 may be important mechanisms of virus-induced COPD exacerbations. Therapies targeting these mechanisms offer potential new treatments for COPD exacerbations.
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Affiliation(s)
- Joseph Footitt
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England; Centre for Respiratory Infection, Imperial College, London, England
| | - Patrick Mallia
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England; Centre for Respiratory Infection, Imperial College, London, England
| | - Andrew L Durham
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, England
| | - W Eugene Ho
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore
| | - Maria-Belen Trujillo-Torralbo
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England
| | - Aurica G Telcian
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England
| | - Ajerico Del Rosario
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England
| | - Cheng Chang
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore
| | - Hong-Yong Peh
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore
| | - Tatiana Kebadze
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England
| | - Julia Aniscenko
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England
| | - Luminita Stanciu
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England
| | - Sarah Essilfie-Quaye
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, England
| | - Kazuhiro Ito
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, England
| | - Peter J Barnes
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, England
| | - Sarah L Elkin
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England
| | - Onn M Kon
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England; Centre for Respiratory Infection, Imperial College, London, England
| | - W S Fred Wong
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University Health System, Singapore
| | - Ian M Adcock
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, England
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College, London, England; Imperial College Healthcare NHS Trust, London, England; Centre for Respiratory Infection, Imperial College, London, England.
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16
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Boshier PR, Mistry V, Cushnir JR, Kon OM, Elkin SL, Curtis S, Marczin N, Hanna GB. Breath metabolite response to major upper gastrointestinal surgery. J Surg Res 2015; 193:704-12. [DOI: 10.1016/j.jss.2014.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 12/28/2022]
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17
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Finney L, Berry M, Singanayagam A, Elkin SL, Johnston SL, Mallia P. Inhaled corticosteroids and pneumonia in chronic obstructive pulmonary disease. Lancet Respir Med 2014; 2:919-932. [PMID: 25240963 DOI: 10.1016/s2213-2600(14)70169-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Inhaled corticosteroids are widely used in chronic obstructive pulmonary disease (COPD) and, in combination with long-acting β2 agonists, reduce exacerbations and improve lung function and quality of life. However, inhaled corticosteroids have been linked with an increased risk of pneumonia in individuals with COPD, but the magnitude of this risk, the effects of different preparations and doses, and the mechanisms of this effect remain unclear. Therefore, making informed clinical decisions--balancing the beneficial and adverse effects of inhaled corticosteroids in individuals with COPD--is difficult. Understanding of the mechanisms of increased pneumonia risk with inhaled corticosteroids is urgently needed to clarify their role in the management of COPD and to aid the development of new, safer therapies.
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Affiliation(s)
- Lydia Finney
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Matthew Berry
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Aran Singanayagam
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Sarah L Elkin
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Sebastian L Johnston
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK
| | - Patrick Mallia
- Airway Disease Infection Section, National Heart and Lung Institute, Imperial College and Imperial College Healthcare NHS Trust, London, UK.
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18
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Ross CL, Dimock R, Chotai A, Meeajan R, Wan T, Finney L, Elkin SL. P70 Management of pleural effusions: Are healthcare professionals adequately trained? Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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19
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Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, Greening NJ, Heslop K, Hull JH, Man WDC, Morgan MD, Proud D, Roberts CM, Sewell L, Singh SJ, Walker PP, Walmsley S. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013; 68 Suppl 2:ii1-30. [PMID: 23880483 DOI: 10.1136/thoraxjnl-2013-203808] [Citation(s) in RCA: 405] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Charlotte E Bolton
- Nottingham Respiratory Research Unit, University of Nottingham, City Hospital campus, Nottingham, UK.
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Loewenthal L, Thompson M, Elkin SL. Primary adenocarcinoma of the lung with a synchronous carcinoid tumour of the small intestine. JRSM Short Rep 2013; 4:18. [PMID: 23560217 PMCID: PMC3616297 DOI: 10.1177/2042533313476416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lola Loewenthal
- Department of Chest & Allergy, Imperial College Healthcare NHS Trust, St Mary's Hospital , Praed Street, London W1 1NY, UK
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Falzon C, Soljak M, Elkin SL, Blake ID, Hopkinson NS. Finding the missing millions - the impact of a locally enhanced service for COPD on current and projected rates of diagnosis: a population-based prevalence study using interrupted time series analysis. Prim Care Respir J 2013; 22:59-63. [PMID: 23344778 PMCID: PMC6442776 DOI: 10.4104/pcrj.2013.00008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/15/2012] [Accepted: 10/19/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many patients with chronic obstructive pulmonary disease (COPD) are not identified until their condition is relatively advanced and there is a considerable gap between the modelled and diagnosed prevalence of the disease. We have previously shown that, in the first year after the introduction of a locally enhanced service (LES) for COPD in 2008, there was a significant step-up in the diagnosed prevalence. AIMS To investigate whether this initial increase in prevalence was sustained, and the impact of this increase on future projected rates of COPD diagnosis. METHODS Using data from 2005-2011, we compared the prevalence of diagnosed COPD in the LES Primary Care Trust (LES-PCT) before and after it was introduced. Data were compared with a neighbouring PCT, the London Strategic Health Authority, and England. The true prevalence of COPD was estimated based on data from the Health Survey for England. Trends were extrapolated to estimate the proportion of patients that would be diagnosed in 2017. RESULTS The introduction of the LES was associated with a significant acceleration in the annual increase in diagnosed COPD (p<0.0001). By 2011 the prevalence was 1.17% in the LES-PCT compared with a predicted value of 0.91% (95% CI 0.86% to 0.95%) based on the pre-LES trend. There was no change in the rate of increase in COPD prevalence for the neighbouring PCT or for London as a whole. The LES-PCT would be expected to diagnose 55.6% of COPD patients by 2017 compared with only 27.3% without the LES, and only 33.3% would be diagnosed in the neighbouring PCT. CONCLUSIONS These data suggest that, with appropriate incentives, it is possible to achieve a sustained improvement in COPD case-finding in primary care and that such policies need to be implemented systematically.
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Affiliation(s)
- Christine Falzon
- Central London Community Healthcare, 64 Victoria Street, Westminster, London, UK
| | - Michael Soljak
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Sarah L Elkin
- Respiratory Medicine, Imperial College NHS Trust, London, UK
| | - Iain D Blake
- Central London Community Healthcare, 64 Victoria Street, Westminster, London, UK
| | - Nicholas S Hopkinson
- NIHR Respiratory Disease Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
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Kelly JL, Elkin SL, Fluxman J, Polkey MI, Soljak MA, Hopkinson NS. Breathlessness and skeletal muscle weakness in patients undergoing lung health screening in primary care. COPD 2012; 10:40-54. [PMID: 23272667 DOI: 10.3109/15412555.2012.727923] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Earlier diagnosis of COPD is a major public health challenge as symptoms may be attributed to the normal consequences of aging. The optimum strategy for identifying patients with COPD remains to be determined. People aged 35 and over (n = 1896) on a GP practice register were randomised to either invitation or an opportunistic lung health check which included spirometry, quadriceps strength and MRC dyspnoea score. Then, 101 participants subsequently completed the General Practice Physical Activity Questionnaire. A total of 335 attended over a 15-week period; 156 were in the invitation group and 179 from the opportunist group. In 25 persons, spirometry was unsatisfactory or contraindicated. Spirometry was normal in 204(65.8%) and restrictive in 36(11.6%). 70(22.6%) had airflow obstruction, corresponding to Global Initiative for Chronic Lung Disease (GOLD) stages I-IV in 18(5.8%), 35(11.3%), 14(4.5%) and 3(1.0%), respectively. The opportunist group were significantly more likely to have airflow obstruction 30.1% vs 14.3% (p = 0.001). Breathlessness was reported commonly (40.5%) and quadriceps strength correlated significantly with MRC dyspnoea score independent of age, sex, pack-years smoked, fat-free mass and FEV(1) percent predicted. This relationship was also present in the subgroup of healthy participants (n = 143). 51.5% of participants screened were classified as "inactive" and this group were weaker and more breathless than those who were more active. Airflow obstruction was more common in those screened opportunistically. Breathlessness and inactivity are common in patients taking part in spirometry screening. Breathlessness is significantly associated with leg strength independent of spirometry and should be amenable to interventions to increase physical activity.
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Affiliation(s)
- Julia L Kelly
- NIHR Respiratory Biomedical Research Unit at Royal Brompton and Harefield NHS Foundation Trust and, Imperial College, London, Royal Brompton Hospital, London, United Kingdom
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Falzon C, Soljak M, Elkin SL, Blake ID, Hopkinson NS. P289 Finding the missing millions – the impact of a locally enhanced service for COPD on current and projected rates of diagnosis. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Medical transition aims to safely steer children with chronic illness through adolescence and into adulthood, whilst maintaining optimal management of their underlying medical condition. It is an evolving process with ongoing research and development. Though it has not been proven to prolong life, evidence points to an improved quality of life via greater understanding and management of lifelong illness. The presumption is this will ultimately prevent or delay untimely loss of life and/or complications in those who have been stable throughout childhood. In this article we review the problems associated with adolescence, the current drive towards successful transition and the role of the adult physician in achieving this.
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Affiliation(s)
- Shelley A Srivastava
- Department of Respiratory Medicine, 5th floor, East Wing, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF.
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Mallia P, Footitt J, Sotero R, Jepson A, Contoli M, Trujillo-Torralbo MB, Kebadze T, Aniscenko J, Oleszkiewicz G, Gray K, Message SD, Ito K, Barnes PJ, Adcock IM, Papi A, Stanciu LA, Elkin SL, Kon OM, Johnson M, Johnston SL. Rhinovirus infection induces degradation of antimicrobial peptides and secondary bacterial infection in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2012; 186:1117-24. [PMID: 23024024 DOI: 10.1164/rccm.201205-0806oc] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Chronic obstructive pulmonary disease (COPD) exacerbations are associated with virus (mostly rhinovirus) and bacterial infections, but it is not known whether rhinovirus infections precipitate secondary bacterial infections. OBJECTIVES To investigate relationships between rhinovirus infection and bacterial infection and the role of antimicrobial peptides in COPD exacerbations. METHODS We infected subjects with moderate COPD and smokers and nonsmokers with normal lung function with rhinovirus. Induced sputum was collected before and repeatedly after rhinovirus infection and virus and bacterial loads measured with quantitative polymerase chain reaction and culture. The antimicrobial peptides secretory leukoprotease inhibitor (SLPI), elafin, pentraxin, LL-37, α-defensins and β-defensin-2, and the protease neutrophil elastase were measured in sputum supernatants. MEASUREMENTS AND MAIN RESULTS After rhinovirus infection, secondary bacterial infection was detected in 60% of subjects with COPD, 9.5% of smokers, and 10% of nonsmokers (P < 0.001). Sputum virus load peaked on Days 5-9 and bacterial load on Day 15. Sputum neutrophil elastase was significantly increased and SLPI and elafin significantly reduced after rhinovirus infection exclusively in subjects with COPD with secondary bacterial infections, and SLPI and elafin levels correlated inversely with bacterial load. CONCLUSIONS Rhinovirus infections are frequently followed by secondary bacterial infections in COPD and cleavage of the antimicrobial peptides SLPI and elafin by virus-induced neutrophil elastase may precipitate these secondary bacterial infections. Therapy targeting neutrophil elastase or enhancing innate immunity may be useful novel therapies for prevention of secondary bacterial infections in virus-induced COPD exacerbations.
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Affiliation(s)
- Patrick Mallia
- National Heart and Lung Institute, Imperial College London, Norfolk Place, London W2 1PG, UK
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Haworth CS, Sharples L, Hughes V, Elkin SL, Hodson ME, Conway SP, Etherington C, Elborn JS, Rendall J, Wheaton E, Kadri E, Elliott J, Barker HC, Bearcroft PW, Hlaing T, Compston JE. Multicentre trial of weekly risedronate on bone density in adults with cystic fibrosis. J Cyst Fibros 2011; 10:470-6. [DOI: 10.1016/j.jcf.2011.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/19/2011] [Accepted: 07/22/2011] [Indexed: 10/17/2022]
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Hopkinson NS, Englebretsen C, Cooley N, Kennie K, Lim M, Woodcock T, Laverty AA, Wilson S, Elkin SL, Caneja C, Falzon C, Burgess H, Bell D, Lai D. Designing and implementing a COPD discharge care bundle. Thorax 2011; 67:90-2. [PMID: 21846790 PMCID: PMC3240777 DOI: 10.1136/thoraxjnl-2011-200233] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
National surveys have revealed significant differences in patient outcomes following admission to hospital with acute exacerbation of COPD which are likely to be due to variations in care. We developed a care bundle, comprising a short list of evidence-based practices to be implemented prior to discharge for all patients admitted with this condition, based on a review of national guidelines and other relevant literature, expert opinion and patient consultation. Implementation was then piloted using action research methodologies with patient input. Actively involving staff was vital to ensure that the changes introduced were understood and the process followed. Implementation of a care bundle has the potential to produce a dramatic improvement in compliance with optimum health care practice.
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Affiliation(s)
- Nicholas S Hopkinson
- NIHR Collaboration for Leadership in Applied Health Research and Care for North West London, Chelsea and Westminster NHS Foundation Trust, London, UK.
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Affiliation(s)
- Sheree M Smith
- Imperial Clinical Respiratory Research Unit, Respiratory Infection and Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, University of Sheffield, London, England; School of Nursing and Midwifery, University of Sheffield, London, England; Lung Institute of Western Australia, University of Western Australia, Nedlands, WA, Australia.
| | - Aimee Brame
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, University of Sheffield, London, England
| | - Elena Kulinskaya
- Lung Institute of Western Australia, University of Western Australia, Nedlands, WA, Australia; School of Computing Sciences, University of East Anglia, Norwich, England
| | - Sarah L Elkin
- Department of Chest and Allergy, St Mary's Hospital, Imperial College Healthcare NHS Trust, University of Sheffield, London, England
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Abstract
INTRODUCTION Telemonitoring, telemedicine, clinical and medical informatics or telecare, are terms used to describe the use of technology along with local clinical protocols to monitor remotely a patient's medical condition in their own home. In respiratory medicine, where large numbers of people have long term conditions such as asthma and chronic obstructive pulmonary disease (COPD), the role of such monitoring technology in the management of patients is of great interest. AIM This review seeks to explore what evidence exists to support the deployment of technology to improve the care of people with respiratory conditions. METHOD Narrative review. RESULT A wide variety of technologies have been involved in asthma and COPD care, from management systems to self monitoring devices. Many studies report that staff and patients 'liked' the technology. The service, care and financial benefits to both patients and the health care system were less obvious. Many studies suffered from poor methodology and lacked clear endpoints. CONCLUSION There is an enormous potential for telemonitoring to assist in the provision of better care for those with long term lung diseases. However, evidence of benefit is unclear and there remains a need for robust studies and answers to clear research questions for specific patient populations before such technologies can be recommended for widespread implementation.
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Affiliation(s)
- Sheree M Smith
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Paddington, London, UK.
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31
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Vedi S, Elkin SL, Compston JE. A histomorphometric study of cortical bone of the iliac crest in patients treated with glucocorticoids. Calcif Tissue Int 2005; 77:79-83. [PMID: 16086108 DOI: 10.1007/s00223-004-0205-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Accepted: 03/10/2005] [Indexed: 11/26/2022]
Abstract
The effects of glucocorticoids on cancellous bone remodeling and structure are well documented but there are no reported histomorphometric studies in human cortical bone in glucocorticoid-treated patients. We have performed a histomorphometric analysis of iliac crest cortical bone in 14 patients treated with glucocorticoids, 9 females and 5 males, aged 18 to 48 years (34.1 +/- 7 years) (mean +/- standard deviation [SD]). The underlying disease was cystic fibrosis in 8 patients; asthma 3; and nephrotic syndrome; Crohn disease and inflammatory pseudotumor of the liver in one patient each. Results were compared with an age-matched control group of 10 premenopausal women and 4 men aged 22 to 38 years (30.1 +/- 4.8 years) who were not, however matched for underlying disease. Cortical bone indices were assessed by image analysis. Cortical width and area were similar in the two groups. However, cortical porosity, Haversian canal number, and density were higher in patients treated with glucocorticoids compared with controls (8.4 +/- 8.9% vs. 5.1 +/- 3.9%; P = 0.03) (45.9 +/- 23.2 vs. 31.9 +/- 24.4; P =0.003) (13.7 +/- 9.4 vs. 6.7 +/- 3.3/mm2; P = 0.00005). Haversian canal area did not differ significantly between groups. The mean wall width of the osteons, bone formation rate (microm2/microm/day) and mineral apposition rate (microm/day) were lower in treated patients compared to controls (48.8 +/- 7.1 microm vs. 59.8 +/- 12.9 microm; P = 0.01) (0.056 +/- 0.040 vs. 0.095 +/- 0.058; P = 0.05) and (0.59 +/- 0.12 vs. 0.75 +/- 0.11; P = 0.002). The proportion of canals with an eroded surface was lower in the treated compared with the control group, although this difference was not statistically significant. These results demonstrate that cortical porosity is increased in patients treated with long-term glucocorticoid therapy, due mainly to an increase in the number rather than size of Haversian canals. This may be because of increased bone resorption during the early stages of glucocorticoid therapy, in combination with long-term impairment of bone formation. Effects of the underlying disease on bone remodeling may also contributed to these changes and could not be excluded in the present study; since control subjects were not matched in terms of disease status.
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Affiliation(s)
- S Vedi
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK.
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32
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Aris RM, Merkel PA, Bachrach LK, Borowitz DS, Boyle MP, Elkin SL, Guise TA, Hardin DS, Haworth CS, Holick MF, Joseph PM, O'Brien K, Tullis E, Watts NB, White TB. Guide to bone health and disease in cystic fibrosis. J Clin Endocrinol Metab 2005; 90:1888-96. [PMID: 15613415 DOI: 10.1210/jc.2004-1629] [Citation(s) in RCA: 273] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cystic fibrosis (CF) is the most common genetic disease within the Caucasian population and leads to premature respiratory failure. Approximately 60,000 individuals are currently living with CF in North America and Europe, 40% of whom are adults. The life span of these patients has increased from approximately 2 to 32 yr of age over the last three decades. Bone disease has emerged as a common complication in long-term survivors of CF. Some studies have observed that 50-75% of adults have low bone density and increased rates of fractures. Prevention and treatment of CF-related bone disease must address the myriad risk factors (decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic lung infection with increased levels of bone-active cytokines, physical inactivity, and glucocorticoid therapy) for poor bone health. This review is a condensed and updated summary of the Guide to Bone Health and Disease in Cystic Fibrosis: A Consensus Conference, a statement that evolved from a meeting convened by the Cystic Fibrosis Foundation in May 2002 to address the pathogenesis, diagnosis, and treatment of bone disease in CF. The goal of this conference was to develop practice guidelines for optimizing bone health in patients with CF.
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Affiliation(s)
- Robert M Aris
- CB 7020, 4131 Bioinformatics, University of North Carolina, Chapel Hill, North Carolina 27599-7524, USA.
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Elkin SL, Vedi S, Bord S, Garrahan NJ, Hodson ME, Compston JE. Histomorphometric analysis of bone biopsies from the iliac crest of adults with cystic fibrosis. Am J Respir Crit Care Med 2002; 166:1470-4. [PMID: 12406824 DOI: 10.1164/rccm.200206-578oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study reports the results of quantitative analysis of iliac bone histology in adults with cystic fibrosis (CF) and low bone mineral density (BMD). Twenty patients with CF had bone biopsies taken after double tetracycline labeling. Histomorphometric measurements were made by image analysis, and data were compared with those of healthy control subjects. Cancellous bone area was lower in the patients with CF (p = 0.003), and there was a trend towards a decrease in cancellous bone connectivity. Bone formation rate at tissue level was significantly lower in patients with CF (p = 0.0002). Wall width, representing the amount of bone formed within individual remodeling units, was decreased (p < 0.0001), as was mineralizing perimeter and mineral apposition rate. Analysis of resorption cavities revealed lower cavity area, reconstructed surface lengths, and cavity depths (p < 0.003) in patients with CF, whereas eroded surface area was higher (p = 0.0004). Our results demonstrate low cancellous bone volume in adult patients with CF with low BMD, the main cause of which appears to be low bone formation at tissue and cellular level. Osteomalacia was diagnosed in one patient. This condition should be excluded as a cause of low bone mineral density in patients with CF and vitamin D insufficiency corrected.
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Affiliation(s)
- Sarah L Elkin
- Department of Cystic Fibrosis, Royal Brompton Hospital, Imperial College, London.
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Elkin SL, Nicholson AG, du Bois RM. Desquamative Interstitial Pneumonia and Respiratory Bronchiolitis-Associated Interstitial Lung Disease. Semin Respir Crit Care Med 2001; 22:387-98. [PMID: 16088687 DOI: 10.1055/s-2001-17382] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Our understanding of the various types and patterns of diffuse lung disease that might result in fibrosis has evolved considerably over the last 50 years. Many entities now regarded as distinct had been previously "lumped'' together as a single disease, "lung fibrosis,'' and more recently misdiagnosed as idiopathic pulmonary fibrosis (IPF, synonymous with cryptogenic fibrosing alveolitis). In 1965 desquamative interstitial pneumonia (DIP) was first described, and later it was clearly demonstrated that the clinical and pathological features of DIP and IPF were different, particularly in terms of survival and response to therapy. They are not part of the same disease spectrum nor does DIP evolve into usual interstitial pneumonia (UIP). Later, in the mid-1980s, RBILD was described as a distinct clinicopathologic syndrome with features consistent with an interstitial lung disease among current or former smokers. In the recent histopathological classification of idiopathic interstitial pneumonia (IIP), DIP and RBILD have been included as separate entities, although there is some evidence that suggests they may lie at the two ends of a single spectrum. The debate bears similarities with the debate about DIP and UIP and is as yet unresolved. This article will give a broad and current overview of these two rarer forms of IIP, including issues that relate to diagnosis, imaging, histopathology, treatment, and prognosis.
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Elkin SL, Fairney A, Burnett S, Kemp M, Kyd P, Burgess J, Compston JE, Hodson ME. Vertebral deformities and low bone mineral density in adults with cystic fibrosis: a cross-sectional study. Osteoporos Int 2001; 12:366-72. [PMID: 11444084 DOI: 10.1007/s001980170104] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patients with cystic fibrosis (CF) have low bone mineral density (BMD). The clinical relevance of this is not clearly established. The aim of this study was to determine the prevalence of low BMD and vertebral deformities in CF adults with varied disease severity. One hundred and seven patients (58 men) aged 18-60 years underwent dual-energy X-ray absorptiometry scanning of the lumbar spine and hip, radiology of the spine and biochemical studies. Thirty-eight percent had a Z-score of < -1, with 13% having Z-scores < -2. Seventeen percent had evidence of vertebral deformity on radiography, mostly in the thoracic spine. Thirty-five percent reported past fractures, of which 9% were rib fractures. Percent predicted forced expiratory volume in 1 second (FEV1) and the amount of daily physical activity were positively related to BMD. The number of intravenous antibiotic courses in the previous 5 years was negatively related to BMD. Patients with a history of rib fracture and CF-related diabetes had significantly lower femoral neck BMD (p < 0.02). The median serum 25-hydroxyvitamin D was 28 nmol/l, with 36% of patients having levels below 25 nmol/l despite vitamin D supplementation. Forty-four percent had raised levels of urinary pyridinium crosslinks (NTx). In conclusion, fragility fractures and hypovitaminosis D occur commonly in adult patients with CF. Low BMD occurs in patients with more severe disease and significantly relates to FEV1, infective exacerbations and daily energy expended in physical activity.
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Affiliation(s)
- S L Elkin
- Department of Cystic Fibrosis, National Heart and Lung Institute, Royal Brompton Hospital, London.
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Elkin SL, Williams L, Moore M, Hodson ME, Rutherford OM. Relationship of skeletal muscle mass, muscle strength and bone mineral density in adults with cystic fibrosis. Clin Sci (Lond) 2000; 99:309-14. [PMID: 10995596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Few studies have investigated peripheral muscle strength and quality in patients with cystic fibrosis (CF). The present study tested the isometric and isokinetic strength of the quadriceps and hamstrings using an isokinetic dynamometer and a strength-testing chair in 25 CF adults and 25 controls. Total body and leg muscle mass were determined by dual-energy X-ray absorptiometry, and bone mineral density (BMD) was also measured. Both muscle strength and muscle mass (total body and leg) were decreased in the CF group. In both groups there was a highly significant relationship between quadriceps strength and leg muscle mass (CF, r=0.7, P=0.0002; controls, r=0.6, P=0.0013). When strength was normalized for muscle size, there was no significant difference between the two groups. Total body and leg BMD were significantly reduced in CF subjects compared with controls. However, when corrected for height, the differences disappeared. There was a significant relationship found between leg muscle mass and leg BMD. We conclude that CF adults are significantly weaker than controls. This is due to lower muscle mass, and not to a reduced force-generating capacity of the muscle, implying that there is no decrease in the quality of CF muscle. BMD is also reduced in CF subjects, and this appears to be related to shorter stature in this group.
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Affiliation(s)
- S L Elkin
- Department of Cystic Fibrosis at the Royal Brompton Hospital, Imperial College School of Medicine, Sydney Street, London SW3 6NP, UK.
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Abstract
Two cases of tuberculous mediastinal lymphadenopathy are presented in which the clinical features mimicked those of pulmonary embolism, causing striking abnormalities on radionuclide scintigraphy. It is concluded that tuberculous mediastinal lymphadenopathy should be included in the differential diagnosis of reduced lung perfusion due to proximal pulmonary artery occlusion.
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Affiliation(s)
- W M Drake
- Department of Respiratory Medicine, St Mary's Hospital, London, UK
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