A Rapid Sputum-based Lateral Flow Assay for Airway Eosinophilia using an RNA-cleaving DNAzyme Selected for Eosinophil Peroxidase

The first protein-binding allosteric RNA-cleaving DNAzyme (RCD) obtained by direct in vitro selection against eosinophil peroxidase (EPX), a validated marker for airway eosinophilia, is described. The RCD has nanomolar affinity for EPX, shows high selectivity against related peroxidases and other eosinophil proteins, and is resistant to degradation by mammalian nucleases. An optimized RCD was used to develop both fluorescence and lateral flow assays, which were evaluated using 38 minimally processed patient sputum samples (23 non-eosinophilic, 15 eosinophilic), producing a clinical sensitivity of 100 % and specificity of 96 %. This RCD-based lateral flow assay should allow for rapid evaluation of airway eosinophilia as an aid for guiding asthma therapy.

lncRNA-NEAT1 Sponges miR-128 to Promote Inflammatory Reaction and Phenotypic Transformation of Airway Smooth Muscle Cells

OBJECTIVE

Pediatric asthma is still a health threat to the children. Long noncoding RNA-NEAT1 (lncRNA-NEAT1) was reported to be positively correlated with the severity of asthma. We aimed to study the effects and mechanism of lncRNA-NEAT1on inflammatory reaction and phenotypic transformation of airway smooth muscle cells (ASMCs) in the bronchial asthma.

METHOD

The degree of lncRNA-NEAT1 and miR-128 mRNA in children with bronchial asthma and healthy individuals was tested by qRT-PCR. After the inflammatory reaction and phenotypic transformation of PDGF-BB-induced ASMCs, the expression of lncRNA-NEAT1 or miR-128 in the AMSC was disturbed in the AMSC. Subsequently, the expression of lncRNA-NEAT1 and miR-128 was detected by the way of qRT-PCR, and western blot was applied to measure the expression of MMP-2, MMP-9, α-SMA, calponin, NF-κB, and so on in the cells. The content of TNF-α, IL-1β, IL-6, and IL-8 in the cell culture supernatant was checked by ELISA. MTT, Transwell, and flow cytometry were used to detect cell proliferation, migration, and apoptosis. Further, the targeting relations between lncRNA-NEAT1 and miR-128 were evaluated by the dual-luciferase reporter assay.

RESULT

In the sputum of children with bronchial asthma, lncRNA-NEAT1 was significantly upregulated while miR-128 was rapidly downregulated. Besides, lncRNA-NEAT1 and miR-128 were competitively combined and, for their expression, negatively correlated.

CONCLUSION

lncRNA-NEAT1 sponges miR-128 to boost PDGF-BB-induced inflammatory reaction and phenotypic transformation of ASMCs to aggravate the occurrence and development of childhood bronchial asthma.

Duration of lead time in screening for lung cancer

BACKGROUND

Screening for lung cancer has used chest radiography (CR), low dose computed tomography (LDCT) and sputum cytology (SC). Estimates of the lead time (LT), i.e., the time interval from detection of lung cancer by screening to the development of symptoms, have been derived from longitudinal studies of populations at risk, tumor doubling time (DT), the ratio between its prevalence at the first round of screening and its annual incidence during follow-up, and by probability modeling derived from the results of screening trials.

OBJECTIVE

To review and update the estimates of LT of lung cancer.

METHODS

A non-systematic search of the literature for estimates of LT and screening trials. Search of the reference sections of the retrieved papers for additional relevant studies. Calculation of LTs derived from these studies.

RESULTS

LT since detection by CR was 0.8-1.1 years if derived from longitudinal studies; 0.6-2.1 years if derived from prevalence / incidence ratios; 0.2 years if derived from the average tumor DT; and 0.2-1.0 if derived from probability modeling. LT since detection by LDCT was 1.1-3.5 if derived from prevalence / incidence ratios; 3.9 if derived from DT; and 0.9 if derived from probability modeling. LT since detection of squamous cell cancer by SC in persons with normal CR was 1.3-1.5 if derived from prevalence/incidence ratios; and 2.1 years if derived from the DT of squamous cell cancer.

CONCLUSIONS

Most estimates of the LT yield values of 0.2-1.5 years for detection by CR; of 0.9-3.5 years for detection by LDCT; and about 2 years or less for detection of squamous cell cancer by SC in persons with normal CR. The heterogeneity of the screening trials and methods of derivation may account for the variability of LT estimates.

Time to sputum culture conversion and its predictors among patients with multidrug-resistant tuberculosis in Hangzhou, China: A retrospective cohort study

The objective is to investigate the time to initial sputum culture conversion (SCC) and its predictors among multidrug-resistant tuberculosis (MDR-TB) patients in Hangzhou, China.A retrospective cohort study was conducted among patients who initiated MDR-TB treatment from 2011 to 2015 in Hangzhou, China. Successful achievement of initial SCC was defined as 2 consecutive negative cultures taken at least 30 days apart after initiation of treatment of MDR-TB. Successful treatment outcomes included being cured and completing treatment, while poor treatment outcomes included treatment failure, loss to follow-up, and death. Time to initial SCC was analyzed using the Kaplan-Meier method, and Cox proportional hazards regression was used to identify predictors of SCC.Among 384 patients enrolled with MDR-TB, 359 (93.5%) successfully achieved initial SCC after a median of 85 days (interquartile range, 40-112 days). A higher rate of SCC was observed in participants with successful treatment outcomes than those with poor treatment outcomes (P<.01). Multivariate analysis showed that age 25 to 64 years (compared with age<25; adjusted odds ratio [AOR], 0.7; 95% confidence interval [CI], 0.5-0.9; P < .01), age ≥65 years (compared with age < 25; AOR, 0.5; 95% CI, 0.3-0.8; P < .01), and household registration in Hangzhou (compared with non-Hangzhou registration; AOR, 1.3; 95% CI, 1.0-1.5; P < .05) were found to be associated with SCC.Although high SCC and treatment success rates were observed among MDR-TB patients in Hangzhou, the prolonged duration to initial SCC underscores the importance of emphasizing measures for infection control. A new policy of shifting outpatient treatment to inpatient treatment in China may reduce the risk of transmission from patients in the time window prior to SCC.

Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) and receptors in type 1, type 2 and type 17 inflammation in cross-sectional asthma study

Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) reportedly promotes, or conversely, resolves inflammation in asthma. In this study of TRAIL and cell receptors in sputum, bronchoalveolar lavage and biopsy from subjects in the Severe Asthma Research Program at Wake Forest, the high TRAIL group had significant increases in all leucocytes, and was associated with increased type 1, type 2 and type 17 cytokines, but not type 9 interleukin 9. Two variants at loci in the TRAIL gene were associated with higher sputum levels of TRAIL. Increased TRAIL decoy receptor R3/DcR1 was observed on sputum leucocytes compared with death receptor R1/DR4, suggesting reduced apoptosis and prolonged cellular inflammation.

Airway dendritic cell maturation in children exposed to air pollution

Urban particulate matter (PM) enhances airway dendritic cell (DC) maturation in vitro. However, to date, there are no data on the association between exposure to urban PM and DC maturation in vivo. We sought to determine whether exposure of school-age children (8 to 14 y) to PM was associated with expression of CD86, a marker of maturation of airway conventional DCs (cDC). Healthy London school children underwent spirometry and sputum induction. Flow cytometry was used to identify CD86 and CCR7 expression on cDC subsets (CD1c+ cDC2 and CD141+ cDC1). Tertiles of mean annual exposure to PM ≤ 10 microns (PM10) at the school address were determined using the London Air Quality Toolkit model. Tertiles of exposure from the 409 children from 19 schools recruited were; lower (23.1 to 25.6 μg/m3, n = 138), middle (25.6 to 26.8 μg/m3, n = 126), and upper (26.8 to 31.0 μg/m3, n = 145). DC expression was assessed in 164/370 (44%) children who completed sputum induction. The proportion (%) of cDC expressing CD86 in the lower exposure tertile (n = 47) was lower compared with the upper exposure tertile (n = 49); (52% (44 to 70%) vs 66% (51 to 82%), p<0.05). There was a higher percentage of cDC1 cells in the lower tertile of exposure (6.63% (2.48 to 11.64) vs. 2.63% (0.72 to 7.18), p<0.05). Additionally; children in the lower exposure tertile had increased FEV1 compared with children in the upper tertile; (median z-score 0.15 (-0.59 to 0.75) vs. -0.21 (-0.86 to 0.48), p<0.05. Our data reveal that children attending schools in the highest areas of PM exposure in London exhibit increased numbers of "mature" airway cDCs, as evidenced by their expression of the surface marker CD86. This data is supportive of previous in vitro data demonstrating an alteration in the maturation of airway cDCs in response to exposure to pollutants.

BPI-ANCA is expressed in the airways of cystic fibrosis patients and correlates to platelet numbers and Pseudomonas aeruginosa colonization

BACKGROUND

Autoantibodies to bactericidal/permeability-increasing protein (BPI), BPI-ANCA, are often present in serum of patients with cystic fibrosis (CF), and correlate to airway colonization with Pseudomonas aeruginosa. The aim of the study was to investigate if BPI-ANCA IgA is also present in the airways of CF patients, and if its presence correlates with neutrophil counts, platelets, and P. aeruginosa DNA in sputum.

METHODS

BPI-ANCA IgA was quantified in serum and sputum samples from adult CF patients (n = 45) by ELISA. Sputum neutrophil counts, platelets, and platelet-neutrophil complexes were assessed by flow cytometry, and P. aeruginosa DNA was analysed with RT-PCR.

RESULTS

Serum BPI-ANCA IgA was present in 44% of the study participants, and this group also had significantly enhanced BPI-ANCA levels in sputum compared to serum negative patients. Sputum levels of BPI-ANCA IgA correlated with P. aeruginosa DNA (r = 0.63, p = 0.0003) and platelet counts in sputum (r = 0.60, p = 0.0002).

CONCLUSIONS

BPI-ANCA is expressed in the airways of CF patients and correlates with P. aeruginosa load and platelet counts, suggesting a link to airway inflammation and mucosal immunity.

Xiaoqinglong decoction (a traditional Chinese medicine) combined conventional treatment for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

A traditional Chinese medicine classic herbal formula named Xiaoqinglong decoction (XQLD) is widely used in China for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The efficacy and safety of XQLD for AECOPD was evaluated in this systematic review.

METHODS

Five databases, including the Cochrane Library, PubMed, China National Knowledge Infrastructure, Wanfang database, and Chinese Science and Technology Periodical Database were searched up to October 5, 2018 for randomized control trials in treating AECOPD with XQLD.

RESULT

Thirty-eight trials were identified. Compared with conventional therapy (CT), XQLD plus CT significantly improve the total clinical efficacy rate (Risk Ratio [RR] = 1.22, 95% confidence interval [CI] = 1.18-1.26, P < .00001). Forced expiratory volume in the first second (FEV1) (mean difference [MD] = 0.37, 95% CI = 0.27-0.46; P < .00001), FEV1%pre (MD = 4.52, 95% CI = 2.42-6.62; P < .00001), FEV1/forced vital capacity (MD = 5.11, 95% CI = 4.21-6.00; P < .00001), PaO2 (MD = 7.17, 95% CI = 4.80-9.54; P < .00001); lowered cough symptom score (MD = -0.65; 95% CI = -0.70 to -0.59; P < .00001), sputum symptom score (MD = -0.41; 95% CI = -0.45 to -0.37; P < .00001), wheezing symptom score (MD = -0.49; 95% CI = -0.60 to -0.38; P < .00001); reduce cough relief time (MD = -1.28; 95% CI = -1.53 to -1.02; P < .00001), sputum relief time (MD = -1.19; 95% CI = -1.42 to -0.96; P < .00001), wheezing relief time (MD = -1.65; 95% CI = -2.63 to -0.68; P = .0009), lassitude relief time (MD = -2.16; 95% CI = -3.44 to -0.89; P = .0009), and PaCO2 (MD = -7.63, 95% CI = -9.62 to -5.63; P < .00001). Benefit for interleukin (IL)-4 (MD = -9.20, 95% CI = -13.59 to -4.81; P < .00001), IL-6 (MD = -5.07, 95% CI = -8.14 to -2.01; P = .001), IL-8 (MD = -5.59, 95% CI = -6.09 to -5.08; P < .00001), tumor necrosis factor (TNF)-α (MD = -5.93, 95% CI = -6.97 to -4.89; P < .00001), Interferon (INF)-γ (MD = 18.03, 95% CI = 13.22-22.84; P < .00001), and C-reactive protein (MD = -3.93, 95% CI = -5.97 to -1.89; P = .0002). For adverse events, there were no difference between XILD plus CT and CT.

CONCLUSION

XQLD plus CT was more effective than CT alone for treating chronic obstructive pulmonary disease. Further higher quality trials are needed. The safety of XQLD remained uncertain.

Endotype-driven prediction of acute exacerbations in chronic obstructive pulmonary disease (EndAECOPD): protocol for a prospective cohort study

INTRODUCTION

Current strategies for the prevention of acute exacerbations in chronic obstructive pulmonary disease (COPD) are primarily based on clinical measurements but fail to target the pathophysiological mechanisms, namely endotypes, of the disease. Studies identifying endotypes underlying exacerbation susceptibility and discovering specific biomarkers may lead to the development of targeted therapeutics but are lacking. This study aims to assess a broad spectrum of biomarkers at multiple biological levels (genetics, airway inflammation and respiratory microbiome) for their ability in predicting acute exacerbations of COPD, thus enables high-resolution disease endotyping and may lead to precision treatment of the disease.

METHODS AND ANALYSIS

In this prospective cohort study, participants with stable COPD (n=600) will be recruited and assessed for demographics, symptom scores, spirometry, medication use and comorbidities at baseline. Blood will be obtained for genotyping variants in a panel of nine genes. Induced sputum will be collected for the profile of microbiota using 16S rRNA gene sequencing, quantification of bacterial load, inflammatory mediators assay and sputum cytometry. Participants will be followed up for their exacerbations till 12 months and reassessed for the clinical measurements as baseline. The primary outcomes are total number of exacerbations, severe exacerbations, moderate exacerbations and time to first exacerbation. The secondary outcomes are changes in lung function and symptom scores. The effect of biomarkers representing genetic variants, airway inflammation and respiratory microbiome on predicting the frequent exacerbator phenotype and exacerbation frequency will be analysed with multivariable modelling, and time to first exacerbation with a Cox regression model.

ETHICS AND DISSEMINATION

The study has been approved by the Clinical Trial and Biomedical Ethics Committee of West China Hospital of Sichuan University (No. 2018-298). The results of the study will be published on peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR1800019063.

Lessons learned from clinical trials of asthma

Exacerbations of persistent or intermittent asthma should be anticipated by physicians and health-care professionals. Patients who are likely to experience an exacerbation often have a history of an exacerbation in the previous year, and the absolute eosinophil count in peripheral blood is ≥ 400/μL. Similarly, expectorated or induced sputum eosinophilia of ≥2% is associated with exacerbations. These phenotypic findings have led to effective biologic therapies, which target eosinophils or immunoglobulin E or the T-helper type 2 phenotype, especially in children, adolescents, and adults with frequent exacerbations. In children, a reduced forced expiratory volume in the first second of expiration (FEV₁) to forced vital capacity ratio can be associated with future exacerbations, although the FEV₁ may be in the normal range, even with children who have persistent severe asthma. Asthma control questionnaires did not differentiate between children with or children without a future exacerbation. Alternatively, in adults, the lower baseline FEV₁ (2.3 L [74% predicted] versus 2.5 L [78% predicted]) identified patients more likely to have a future exacerbation compared with patients who were not having an exacerbation. After correcting for FEV₁, the asthma control questionnaire data were associated with exacerbations. In adolescents (ages ≥ 12 years) and adults with persistent mild asthma, most (73%) did not have sputum eosinophilia, and some of these patients responded well to the anticholinergic, tiotropium, which would argue differently from administration of an inhaled corticosteroid as first-line controller therapy. In a three-track study of patients with persistent mild asthma, as-needed budesonide-formoterol and scheduled budesonide were associated with approximately one-half of the annual exacerbation rate of as-needed albuterol. In patients with persistent moderate-to-severe asthma, tiotropium added to controller therapy caused an increase in FEV₁ without improving the asthma control questionnaire findings. There were two studies that explored whether either quadrupling or quintupling the inhaled corticosteroid at the first sign of loss of control of asthma would provide meaningful reductions of severe exacerbations of asthma, but the findings did not support this strategy. Both biologic therapies and environmental control (dust mite impermeable encasings) have resulted in reductions of exacerbations in patients with persistent moderate and severe asthma.

A Flow Cytometric Method for Isolating Cystic Fibrosis Airway Macrophages from Expectorated Sputum

Research to understand the contribution of macrophages to nonresolving airway inflammation in cystic fibrosis (CF) and other chronic suppurative airways diseases has been hindered by a lack of methods for isolating and studying these cells. With the development of technologies that can characterize small numbers of cells or individual cells, there is an even greater need for methodologies to isolate rare cells in heterogeneous specimens. Here, we describe a method that overcomes the technical obstacles imposed by sputum debris and apoptotic cells, and allows isolation of pure populations of macrophages from CF sputum. In addition to enhancing our ability to study human CF airway macrophages, this protocol can be adapted to study cells in sputum from other chronic suppurative lung diseases (e.g., chronic obstructive pulmonary disease) and used for isolation of individual cells for single cell analyses.

Charcot-Leyden crystal protein/galectin-10 is a surrogate biomarker of eosinophilic airway inflammation in asthma

Aim: Eosinophilic asthma is associated with more exacerbations and differential responses to treatment. The aim of this study was to assess if CLC/Gal-10 and MBP-1 are surrogate biomarkers of eosinophilic inflammation in asthma. Methods & results: Sputum induction was performed in patients with asthma and in healthy controls. Sputum analysis revealed higher (p < 0.001) levels of CLC/Gal-10 and MBP-1 in asthmatics versus healthy controls. CLC/Gal-10 levels were highly correlated (rs = 0.74; p < 0.001) with sputum eosinophils; MBP-1 approached significance (r = 0.44; p = 0.07). Conclusion: Increased CLC/Gal-10 and MBP-1 levels in the sputum were strongly correlated with sputum eosinophils in patients with asthma. CLC/Gal-10 and MBP-1 may be useful biomarkers for differentiation of eosinophilic airway inflammation in asthma.

Metabolomic Analysis of Serum Glycerophospholipid Levels in Eosinophilic and Neutrophilic Asthma

OBJECTIVE

To compare the serum glycerophospholipid levels in the inflammatory subtypes of asthma by using targeted metabolomic analysis.

METHODS

Demographic and clinical data were collected from 51 patients with asthma between January 2015 and December 2015. Routine blood and sputum induction tests were performed. Eosinophilic asthma was defined as induced sputum containing ⪖ 3% eosinophils, and neutrophilic asthma, as induced sputum containing ⪖ 71% neutrophils. Serum metabolic glycerophospholipid profile was determined by liquid chromatography-mass spectrometry. Differences in glycerophospholipid levels between eosinophilic and non-eosinophilic asthma and between neutrophilic and non-neutrophilic asthma were analyzed using partial least squares discriminant analysis.

RESULTS

The serum lysophosphatidylglycerol level was significantly higher in the group with ⪖ 3% eosinophils in sputum than in the group with < 3% eosinophils in sputum. The area under the receiver-operating characteristic curve was ⪖ 70%. There was no significant difference in the serum metabolic glycerophospholipid profile between the group with sputum neutrophils ⪖ 71% and the group with sputum neutrophils < 71%.

CONCLUSION

Serum lysophosphatidylglycerol is produced abundantly in eosinophilic asthma and may be a biomarker of eosinophilic asthma. This information is helpful for identifying and tailoring treatment for the common asthma subtypes.

Vitamin D3 supplementation in adults with bronchiectasis: A pilot study

Vitamin D supplementation prevents acute respiratory infections and, through modulating innate and adaptive immunity, could have a potential role in bronchiectasis management. The primary aims of this pilot study were to assess serum 25-hydroxyvitamin D (25(OH)D) levels in New Zealand adults with bronchiectasis, and their 25(OH)D levels after vitamin D3 supplementation. Adults with bronchiectasis received an initial 2.5 mg vitamin D3 oral loading dose and 0.625 mg vitamin D3 weekly for 24 weeks. The primary outcome was serum 25(OH)D levels before and after vitamin D3 supplementation. Secondary outcomes (time to first infective exacerbation, exacerbation frequency, spirometry, health-related quality of life measures, sputum bacteriology and cell counts and chronic rhinosinusitis) were also assessed. This study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12612001222831). The initial, average 25(OH)D level was 71 nmol/L (95% confidence interval (CI): [58, 84]), rising to 218 nmol/L (95% CI: [199, 237]) at 12 weeks and 205 nmol/L (95% CI: [186, 224]) at 24 weeks. The initial serum cathelicidin level was 25 nmol/L (95% CI: [17, 33]), rising to 102 nmol/L (95% CI: [48, 156]) at 12 weeks and 151 nmol/L (95% CI: [97, 205]) at 24 weeks. Over the 24-week study period, we observed statistically significant changes of 1.11 (95% CI: [0.08, 2.14]) in the Leicester Cough Questionnaire and -1.97 (95% CI: [-3.71, -0.23]) in the Dartmouth COOP charts score. No significant adverse effects were recorded. Many New Zealand adults with bronchiectasis have adequate 25(OH)D levels. Weekly vitamin D3 supplementation significantly improved 25(OH)D levels.

Diagnostic value of fractional exhaled nitric oxide for asthma-chronic obstructive pulmonary disease overlap syndrome

To examine the difference in the fractional exhaled nitric oxide (FeNO) between chronic obstructive pulmonary disease (COPD) patients with asthma-COPD overlap syndrome (ACOS) and patients with Non-ACOS COPD (Non-ACOS) and to investigate the correlation between FeNO levels and the differential cell counts of eosinophils in induced sputum, in order to explore the diagnostic value of FeNO in ACOS.A prospective, case-control study was performed on 53 cases of ACOS group and 53 cases of Non-ACOS group in the Respiratory Medicine Outpatient of Zhangzhou Municipal TCM Hospital, Affiliated to Fujian University of Traditional Chinese Medicine. The FeNO levels and induced sputum cell counts were determined and the correlation between FeNO levels and eosinophile percentage was analyzed by Pearson linear correlation analysis.The FeNO levels in patients with ACOS (37[24.5-53.0]) ppb were significantly higher than those of patients with Non-ACOS (20 [15.5-24.5] ppb) (P < .01). Also, the percentage of eosinophils in induced sputum in the ACOS group (5.70 [1.50-17.62]%) were significantly higher than those of the Non-ACOS group (0.50 [0.00-1.00]%) (P < .01). FeNO in both groups correlated positively with the percentage of eosinophils in induced sputum (P < .01), with a correlation coefficient r of 0.521. The area under the receiver operating curve of FeNO for the diagnosis of ACOS phenotype was 0.815 (P < .01), the sensitivity and specificity reach highest when the cut off value was 25.50 ppb.The FeNO in patients from the ACOS group were significantly higher than those in Non-ACOS group and were moderately correlated with the percentage of eosinophils in induced sputum. The results indicated that FeNO may be used as a diagnostic index for ACOS, in addition to the induced sputum.

Chronic obstructive pulmonary disease (COPD): neutrophils, macrophages and lymphocytes in patients with anterior tuberculosis compared to tobacco related COPD

OBJECTIVE

The inflammatory profile of chronic obstructive pulmonary disease (COPD) related to tobacco is known in certain studies while that of the post tuberculosis form is not yet known. This study aimed to evaluate the levels of neutrophils, macrophages and lymphocytes cells in sputum of COPD patients with history of smoking or anterior tuberculosis. Enumeration of cells in samples was analyzed using standard microscopy.

RESULTS

We enrolled 92 participants, 46 (50%) were COPD subjects comprising 22 (47.83%) smokers and 24 (52.17%) with anterior tuberculosis while 46 (50%) healthy persons constituted the control group. The levels of neutrophils, lymphocytes and monocytes were statistically higher in COPD patients compared to the control group with p-values of 0.0001 respectively. Neutrophils levels were higher in COPD patients with history of tobacco than in COPD patients with anterior tuberculosis with a mean rate of 4.72 × 106/ml and 2.48 × 106/ml respectively (p = 0.04). The monocytes and lymphocytes levels were not statistically different between the two sub-groups of COPD patients with p-value of 0.052 and 0.91 respectively. Neutrophils are the only inflammatory cells that were significantly higher in COPD patients with history of smoking as compared to COPD patients with anterior tuberculosis.

Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD

Purpose

Chest physiotherapy is an important tool in the treatment of COPD. Intrapulmonary percussive ventilation (IPV) and high-frequency chest wall oscillation (HFCWO) are techniques designed to create a global percussion of the lung which removes secretions and probably clears the peripheral bronchial tree. We tested the hypothesis that adding IPV or HFCWO to the best pharmacological therapy (PT) may provide additional clinical benefit over chest physiotherapy in patients with severe COPD.

Methods

Sixty patients were randomized into three groups (20 patients in each group): IPV group (treated with PT and IPV), PT group with (treated with PT and HFCWO), and control group (treated with PT alone). Primary outcome measures included results on the dyspnea scale (modified Medical Research Council) and Breathlessness, Cough, and Sputum scale (BCSS), as well as an evaluation of daily life activity (COPD Assessment Test [CAT]). Secondary outcome measures were pulmonary function testing, arterial blood gas analysis, and hematological examinations. Moreover, sputum cell counts were performed at the beginning and at the end of the study.

Results

Patients in both the IPV group and the HFCWO group showed a significant improvement in the tests of dyspnea and daily life activity evaluations (modified Medical Research Council scale, BCSS, and CAT) compared to the control group, as well as in pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory volume in 1 second/forced vital capacity%, total lung capacity, residual volume, diffusing lung capacity monoxide, maximal inspiratory pressure, maximal expiratory pressure) and arterial blood gas values. However, in the group comparison analysis for the same variables between IPV group and HFCWO group, we observed a significant improvement in the IPV group maximal inspiratory pressure, maximal expiratory pressure, BCSS, and CAT. Similar results were observed in changes of sputum cytology with reduction of inflammatory cells (neutrophils and macrophages).

Conclusion

The two techniques improved daily life activities and lung function in patients with severe COPD. IPV demonstrated a significantly greater effectiveness in improving some pulmonary function tests linked to the small bronchial airways obstruction and respiratory muscle strength and scores on health status assessment scales (BCSS and CAT) as well as a reduction of sputum inflammatory cells compared with HFCWO.

[Airway metaplasia related to smoking and environmental pollution through sputum]

BACKGROUND

Both environmental pollution and smoking affect the respiratory epithelium, causing cellular adaptation changes. Therefore, this work explores the presence of metaplasia in smokers compared with non-smokers from Mexico City.

METHODS

A prospective cohort study was performed. The sample was performed through a home interview covering the five Mexico City zones delimited to the study and monitoring of air quality. We searched metaplastic cells and inflammation in sputum cytology stained with Papanicolaou technique, and we assessed the air quality in Mexico City. We calculated relative risk (RR) and attributable risk (AR) in relation to the presence of metaplasia and smoking.

RESULTS

We performed 1897 home interviews obtaining a final sample of 30 participants. There were no significant differences between smokers and non-smokers with the presence of metaplastic cells (p = 0.269), although the association of metaplastic cells and inflammation showed a significant difference in the non-smokers group (p = 0.010). The RR in association with the presence of metaplasia in sputum cytology and smoking was 1.6, and the RA was 0.2.

CONCLUSIONS

The air quality in this city has led the population to undergo changes of cellular adaptation in the respiratory epithelium by the simple fact of being exposed to environmental pollution. Metaplastic changes in non-smokers suggest strongly that pollution causes the same effect as smoking.

Association of sputum and blood eosinophil concentrations with clinical measures of COPD severity: an analysis of the SPIROMICS cohort

BACKGROUND

Increased concentrations of eosinophils in blood and sputum in chronic obstructive pulmonary disease (COPD) have been associated with increased frequency of exacerbations, reduced lung function, and corticosteroid responsiveness. We aimed to assess whether high eosinophil concentrations in either sputum or blood are associated with a severe COPD phenotype, including greater exacerbation frequency, and whether blood eosinophils are predictive of sputum eosinophils.

METHODS

We did a multicentre observational study analysing comprehensive baseline data from SPIROMICS in patients with COPD aged 40-80 years who had a smoking history of at least 20 pack-years, recruited from six clinical sites and additional subsites in the USA between Nov 12, 2010, and April 21, 2015. Inclusion criteria for this analysis were SPIROMICS baseline visit data with complete blood cell counts and, in a subset, acceptable sputum counts. We stratified patients on the basis of blood and sputum eosinophil concentrations and compared their demographic characteristics, as well as results from questionnaires, clinical assessments, and quantitative CT (QCT). We also analysed whether blood eosinophil concentrations reliably predicted sputum eosinophil concentrations. This study is registered with ClinicalTrials.gov (NCT01969344).

FINDINGS

Of the 2737 patients recruited to SPIROMICS, 2499 patients were smokers and had available blood counts, and so were stratified by mean blood eosinophil count: 1262 patients with low (<200 cells per μL) and 1237 with high (≥200 cells per μL) blood eosinophil counts. 827 patients were eligible for stratification by mean sputum eosinophil percentage: 656 with low (<1·25%) and 171 with high (≥1·25%) sputum eosinophil percentages. The high sputum eosinophil group had significantly lower median FEV1 percentage predicted than the low sputum eosinophil group both before (65·7% [IQR 51·8-81·3] vs 75·7% [59·3-90·2], p<0·0001) and after (77·3% [63·1-88·5] vs 82·9% [67·8-95·9], p=0·001) bronchodilation. QCT density measures for emphysema and air trapping were significantly higher in the high sputum eosinophil group than the low sputum eosinophil group. Exacerbations requiring corticosteroids treatment were more common in the high versus low sputum eosinophil group (p=0·002). FEV1 percentage predicted was significantly different between low and high blood eosinophil groups, but differences were less than those observed between the sputum groups. The high blood eosinophil group had slightly increased airway wall thickness (0·02 mm difference, p=0·032), higher St George Respiratory Questionnaire symptom scores (p=0·037), and increased wheezing (p=0·018), but no evidence of an association with COPD exacerbations (p=0·35) or the other indices of COPD severity, such as emphysema measured by CT density, COPD assessment test scores, Body-mass index, airflow Obstruction, Dyspnea, and Exercise index, or Global Initiative for Chronic Obstructive Lung Disease stage. Blood eosinophil counts showed a weak but significant association with sputum eosinophil counts (receiver operating characteristic area under the curve of 0·64, p<0·0001), but with a high false-discovery rate of 72%.

INTERPRETATION

In a large, well characterised cohort of former and current smoking patients with a broad range of COPD severity, high concentrations of sputum eosinophils were a better biomarker than high concentrations of blood eosinophils to identify a patient subgroup with more severe disease, more frequent exacerbations, and increased emphysema by QCT. Blood eosinophils alone were not a reliable biomarker for COPD severity or exacerbations, or for sputum eosinophils. Clinical trials targeting eosinophilic inflammation in COPD should consider assessing sputum eosinophils.

FUNDING

National Institutes of Health, and National Heart, Lung, and Blood Institute.

Effectiveness of inhaled corticosteroids in real life on clinical outcomes, sputum cells and systemic inflammation in asthmatics: a retrospective cohort study in a secondary care centre

OBJECTIVES

The impact of inhaled corticosteroids (ICS) on eosinophilic inflammation in asthma is well established, but their effect in a real-life setting has not been extensively studied. Our purpose was to investigate the effect of ICS on airway and systemic inflammation as well as on clinical outcomes in patients with asthma from clinical practice.

DESIGN, SETTING AND PARTICIPANTS

We conducted a retrospective analysis on asthmatics from a secondary care centre in whom ICS were initiated/increased (n=101), stopped/decreased (n=60) or remained stable (n=63, used as a control group) between two visits with available sputum and blood cell counts.

RESULTS

The median time between both visits ranged from 1 to 2 years. Initiating or increasing ICS (median variation (IQR): 800 (400-1200) µg beclomethasone equivalent dose per day) reduced sputum eosinophils and fractional exhaled nitric oxide (P<0.0001) and to a lesser extent blood eosinophils (P<0.0001), while withdrawing or decreasing ICS (median variation (IQR): 900 (500-1200) µg beclomethasone equivalentdose per day) resulted in increased sputum eosinophils (P=0.008). No change was found in patients with a stable dose. The effectiveness of ICS in improving asthma control, quality of life, forced expiratory volume in 1 s (FEV₁), bronchial hyper-responsiveness and exacerbation rate was only observed in the eosinophilic phenotype (sputum eosinophils ≥3%, n=79). In non-eosinophilic asthmatics, stepping-down ICS resulted in an improvement in asthma control and quality of life, without any significant change in FEV₁ (n=38).

CONCLUSIONS

Our results confirm the effectiveness of ICS on eosinophilic inflammation in real life and demonstrate that their clinical benefit seems to be restricted to eosinophilic asthmatics. Our data also support a try for stepping-down ICS in non-eosinophilic asthmatics.

Comparison Of Ziehl-Neelsen Based Light Microscopy With Led Fluorescent Microscopy For Tuberculosis Diagnosis: An Insight From A Limited Resource-High Burden setting

BACKGROUND

Microscopy is the most widely used tool for Tuberculosis screening. Conventionally, Ziehl-Neelsen (ZN) staining has been the widely used for staining Acid-Fast Bacilli (AFB) but with the advent of Fluorescent staining, Auramine O stain is now being adapted as the preferred method for setups with high workload as it has the advantage of being less laborious, since bacteria fluoresce in front of a dark background and are easier to count. This study was performed to compare the efficiency of the two methods in a high-burden, limited resource setting to see the magnitude of diagnostic accuracy between ZN and Fluorescent Microscopy, using culture as the standard..

METHODS

Altogether 987 culturally confirmed cases were considered from the period 36 months during January 2011 to December 2013 and data were compiled from the records maintained at the Provincial Tuberculosis Reference Laboratory at Ojha Institute of Chest Diseases, Dow University of Health Sciences, Karachi. The results from 523 cases examined using ZN and 464 cases using Fluorescent staining method were compared for diagnostic accuracy on the basis of Mycobacterial culture results. Smears are prepared from the clinical samples obtained from presumptive tuberculosis patients.

RESULTS

The results of ZN method showed 94.23% [95% CI 91.32-96.39%] sensitivity and 84.91% [95% CI 78.38-90.08%] specificity. While FM showed a sensitivity of 97.15% [95% CI 94.82-98.63%] and specificity of 83.19% [95% CI 74.99-89.56%]..

CONCLUSIONS

The results showed that Fluorescent microscopy was slightly more sensitive than ZN light Microscopy, while specificity of both the methods were comparable.

Airway basophils are increased and activated in eosinophilic asthma

BACKGROUND

The impact of basophils on asthma pathogenesis remains largely unexplored, particularly in humans. Here, we evaluated the frequencies and activation status of basophils in the sputum of adult asthmatic patients and related our findings to other parameters of eosinophilic airway inflammation.

METHODS

We enrolled 44 adult asthmatic patients who were being treated with inhaled corticosteroids (ICS). Analysis of the induced sputum, exhaled nitric oxide fraction (FeNO) measurement, and asthma control test (ACT) were carried out together with standard blood and pulmonary function tests. The cellular composition of the sputum was examined by flow cytometry, and the phenotypes of blood and sputum basophils were compared.

RESULTS

Basophils were increased in the sputum of asthmatic patients. The expression of CD203c on sputum basophils was significantly higher than that on blood basophils. The percentage of sputum basophils was positively correlated with those of eosinophils and mast cells; it was also correlated with that of blood eosinophils and FeNO. However, sputum basophils were not correlated with serum IgE, lung function, or the percentage of blood basophils. A receiver-operating characteristic (ROC) curve showed the superiority of sputum basophils as a surrogate marker of the percentages of sputum eosinophils compared with absolute numbers of blood eosinophils and FeNO.

CONCLUSION

The number of activated basophils was increased in the sputum of patients with eosinophilic asthma and correlated with airway and blood eosinophils. Our observations suggest that sputum basophils may serve as a biomarker to monitor new therapeutic approaches for the treatment of eosinophilic asthma.

Sputum cell count: biomarkers in the differentiation of asthma, COPD and asthma-COPD overlap

INTRODUCTION

Cell count in induced sputum is a noninvasive biomarker to assess airway inflammation phenotypes. Accordingly, sputum cell counts are extensively used in the treatment of asthma and COPD. Nevertheless, the clinical application of sputum cell counts in patients with asthma-COPD overlap (ACO) remains elusive. The aim of this study was to investigate sputum cell counts in patients with ACO which are different from those in patients with asthma and COPD and also to examine the relationship between sputum cell counts in bronchial reversibility and bronchial hyperresponsiveness (BHR).

PATIENTS AND METHODS

A total of 374 patients participated in the study, including 142 patients with asthma, 160 patients with COPD and 72 patients with ACO. All patients underwent the following tests on the same day: pulmonary function test (PFT), BHR test or bronchodilator reversibility test and inducing sputum. They were classified into the asthma group, COPD group or ACO group based on a clinical history, PFT values and BHR test or bronchodilator reversibility test.

RESULTS

The three groups had different PFT values (p<0.001) except for forced vital capacity (FVC) between the asthma and ACO groups (p=0.378). The sputum levels of eosinophil% were decreased in patients with COPD when compared with those in patients with asthma and ACO (p<0.001 and p<0.001, respectively). There was a difference in sputum neutrophil% and macrophage% counts among the three groups (p<0.001 and p<0.001, respectively); there was no difference in sputum eosinophil% counts between patients with ACO and asthma (p=0.668) and there was no difference in the percentage of induced sputum cells between the stage of airway obstruction and the stage of BHR.

CONCLUSION

The clinical relevance of this study provides evidence that sputum cell counts as an inflammatory biomarker could carry some information to distinguish ACO, asthma and COPD, and these biomarkers need more studies to provide diagnostic value in the differentiation between ACO, asthma and COPD.

Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults

BACKGROUND

Asthma severity and control can be measured both subjectively and objectively. Sputum analysis for evaluation of percentage of sputum eosinophilia directly measures airway inflammation, and is one method of objectively monitoring asthma. Using sputum analysis to adjust or tailor asthma medications is potentially superior to traditional methods based on symptoms and spirometry.

OBJECTIVES

To evaluate the efficacy of tailoring asthma interventions based on sputum analysis in comparison to traditional methods (usually symptom-based with or without spirometry/peak flow) for asthma-related outcomes in children and adults.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials' registries, and reference lists of articles. The last search was conducted in February 2017.

SELECTION CRITERIA

All randomised controlled comparisons of adjustment of asthma therapy based on sputum eosinophils compared to traditional methods (primarily clinical symptoms and spirometry/peak flow).

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. In this update, two reviewers selected relevant studies, independently assessed trial quality and extracted the data. We contacted authors for further information when relevant. We analysed data as 'treatment received' and performed sensitivity analyses.

MAIN RESULTS

Three new studies were added in this update, resulting in a total of six included studies (five in adults and one involving children/adolescents). These six studies were clinically and methodologically heterogeneous (use of medications, cut-off for percentage of sputum eosinophils and definition of asthma exacerbation). Of 374 participants randomised, 333 completed the trials. In the meta-analysis, there was a significant reduction in the occurrence of any exacerbations when treatment was based on sputum eosinophil counts, compared to that based on clinical symptoms with or without lung function; pooled odds ratio (OR) was 0.57 (95% confidence interval (CI) 0.38 to 0.86). The risk of having one or more exacerbations over 16 months was 82% in the control arm and 62% (95% CI 49% to 74%) in the sputum strategy arm, resulting in a number needed to treat to benefit (NNTB) of 6 (95% CI 4 to 13).There were also differences between the groups in the rate of exacerbation (any exacerbation per year) and severity of exacerbations defined by requirement for use of oral corticosteroids and hospitalisations: the risk of one or more hospitalisations over 16 months was 24% in controls compared to 8% (95% CI 3% to 21%) in the sputum arm. Data for clinical symptoms, quality of life and spirometry were not significantly different between groups. The mean dose of inhaled corticosteroids per day was also similar in both groups. However sputum induction was not always possible. The included studies did not record any adverse events.One study was not blinded and thus was considered to have a high risk of bias. However, when this study was removed in a sensitivity analysis, the difference between the groups for the primary outcome (exacerbations) remained statistically significant between groups. The GRADE quality of the evidence ranged from moderate (for the outcomes 'Occurrence of any exacerbation' and 'Hospitalisation' ) to low (for the outcome 'Mean dose of inhaled corticosteroids per person per day') due to the inconsistency in defining exacerbations and the small number of hospital admissions.

AUTHORS' CONCLUSIONS

In this updated review, tailoring asthma interventions based on sputum eosinophils is beneficial in reducing the frequency of asthma exacerbations in adults with asthma. Adults with frequent exacerbations and severe asthma may derive the greatest benefit from this additional monitoring test, although we were unable to confirm this through subgroup analysis. There is insufficient data available to assess tailoring asthma medications based on sputum eosinophilia in children.Further robust RCTs need to be undertaken and these should include participants with different underlying asthma severities and endotypes.

The success and safety profile of sputum induction in patients with chronic obstructive pulmonary disease: An Indian experience

BACKGROUND

Neutrophilic inflammation is common in chronic obstructive pulmonary disease while Asthma COPD overlap syndrome has eosinophilic predominance. Identifying the type of inflammation will aid in better management of COPD, but published studies show that induced sputum examination is more frequently used in asthma than COPD, with safety being the limiting factor. We aimed to determine the success and safety of sputum induction (SI) in COPD patients.

METHODS

116 stable COPD patients underwent SI. Success was defined as adequate sputum sample resulting in a cytospin sufficient to assess differential count while safety by the fall in FEV₁.

RESULTS

The mean (SD) FEV₁% predicted post bronchodilator was 58.8 (17.8) and 59 (51.8%) patients had moderate COPD. Success was 98.28%. The procedure was safe with overall fall in FEV₁ of 11.1% (5.1, 15.2). ≥20% fall was noted in 13 (11.4%) patients, 10-20% in 24 (21.0%) patients, and less than 10% in 29 (25.4%) patients while 48 (42.1%) had no fall. There was an inverse correlation between reversibility in FEV₁ and percentage fall in FEV1; r=-0.437 and p=0.001. Stepwise multivariate linear regression showed reversibility as an independent predictor of fall in FEV₁; R²=0.137.

CONCLUSIONS

Sputum induction is successful and safe in COPD. Even a fall in FEV₁>20% is reversible.

Race is associated with differences in airway inflammation in patients with asthma

BACKGROUND

African American subjects have a greater burden from asthma compared with white subjects. Whether the pattern of airway inflammation differs between African American and white subjects is unclear.

OBJECTIVE

We sought to compare sputum airway inflammatory phenotypes of African American and white subjects treated or not with inhaled corticosteroids (ICSs; ICS+ and ICS-, respectively).

METHODS

We performed a secondary analysis of self-identified African American and white subjects with asthma enrolled in clinical trials conducted by the National Heart, Lung, and Blood Institute-sponsored Asthma Clinical Research Network and AsthmaNet. Demographics, clinical characteristics, and sputum cytology after sputum induction were examined. We used a sputum eosinophil 2% cut point to define subjects with either an eosinophilic (≥2%) or noneosinophilic (<2%) inflammatory phenotype.

RESULTS

Among 1018 participants, African American subjects (n = 264) had a lower FEV1 percent predicted (80% vs 85%, P < .01), greater total IgE levels (197 vs 120 IU/mL, P < .01), and a greater proportion with uncontrolled asthma (43% vs 28%, P < .01) compared with white subjects (n = 754). There were 922 subjects in the ICS+ group (248 African American and 674 white subjects) and 298 subjects in the ICS- group (49 African American and 249 white subjects). Eosinophilic airway inflammation was not significantly different between African American and white subjects in either group (percentage with eosinophilic phenotype: ICS+ group: 19% vs 16%, P = .28; ICS- group: 39% vs 35%, P = .65; respectively). However, when adjusted for confounding factors, African American subjects were more likely to exhibit eosinophilic airway inflammation than white subjects in the ICS+ group (odds ratio, 1.58; 95% CI, 1.01-2.48; P = .046) but not in the ICS- group (P = .984).

CONCLUSION

African American subjects exhibit greater eosinophilic airway inflammation, which might explain the greater asthma burden in this population.

Is the Morning Sputum Sample Superior to the Fresh Sputum Sample for the Detection of Malignant Cells?

INTRODUCTION

Sputum cytology is a well-established technique for the detection of lung malignancies. Generally, random or morning samples are used.

OBJECTIVES

To evaluate the diagnostic yield of morning sputum and compare it with that of fresh samples.

MATERIALS AND METHODS

Patients were instructed to bring a morning sputum sample to the laboratory in a clean plastic container, without any fixative and within 2-3 h of collection. Fresh sputum was then collected in the laboratory from these same patients. Two smears were prepared from each sample by the "pick and smear" technique and then stained by the Papanicolaou method. One hundred samples from each method (total 200 samples; 400 slides) were evaluated by 3 investigators for their adequacy, preservation, and yield of diagnostic cells. The results were analyzed by using the Pearson χ2 test.

RESULTS

Cytomorphological details were preserved in 82/84 satisfactory morning samples and in 80/81 satisfactory fresh samples, respectively. Malignancy was detected in 37 morning samples (44%) and 25 fresh samples (30.8%). In the malignant samples, there were more abundant tumor cells in the morning samples than in the fresh samples (65 and 40%, respectively) with a 2+ cellularity in the morning samples. The morning samples showed a better cell yield (25% more), with a 13% increase in the rate of detection of malignancy and an increased sensitivity of 19.68% compared to the fresh samples.

CONCLUSIONS

Adequacy and preservation was similar in both sample types. While the morning samples showed a higher sensitivity and a larger number of tumor cells than the fresh samples, the difference was not statistically significant (p < 0.054).

Sputum biomarkers in IPF: Evidence for raised gene expression and protein level of IGFBP-2, IL-8 and MMP-7

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a rare lung disease of unknown origin leading rapidly to death. This paper addresses the issue of whether sputum induction is a suitable tool to study respiratory tract inflammation and potential biomarkers in IPF compared to COPD, a fibrosing airway wall disease.

METHODS

In a cross-sectional analysis, 15 IPF patients, 32 COPD and 30 healthy subjects underwent sputum induction. Total sputum cell counts and the amount of TGF- β, IGF-1, IGF-2, IGFBP-1, IGFBP-2, IGFBP-3, IL-8, IL-13, MMP-7, MMP-9, YKL-40, TNF-α and KL-6 in sputum supernatant were analysed. We also profiled gene expression of cells in the induced sputum for TGF-β, MMP-7, YKL-40, IGFBP-2, IL-6, IL-8 and TNF-α.

RESULTS

IPF patients, like COPD, had increased sputum absolute number of neutrophils, eosinophils, macrophages and epithelial cells compared to HS. IPF sputum supernatants had increased concentrations of IGFBP-2, IL-8, TGF-β, MMP-7, MMP-9 and KL-6 (p<0.05, p<0.0001, p<0.05, p<0.05, p<0.0001, p<0.05 respectively) when compared to healthy subjects where COPD had higher IL-6 and TNF-α levels than IPF (p<0.05 and p<0.05 respectively) and HS (p<0.0001 and p<0.001 respectively) and higher IL-8 and MMP-9 than HS (p<0.0001 and p<0.001 respectively). Conversely to IL-6 and TNF-α, MMP-7 was increased in IPF compared to COPD (p<0.05). The KL-6 and MMP-7 protein levels in sputum were inversely correlated with total lung capacity (TLC, % of predicted) in IPF patients (r = -0.73 and r = -0.53 respectively). Sputum gene expression analysis identified a significant increase for IGFBP-2, IL-6, IL-8 and MMP-7 in IPF compared to HS (p<0.05, p<0.01, p<0.05 and p<0.0001 respectively) and for IGFBP-2, YKL-40, IL-6, IL-8 and MMP-7 compared to COPD (p<0.01, p<0.01, p<0.05, p<0.01 and p<0.0001 respectively). Furthermore, gene expression of TGF-β was increased in IPF compared to COPD (p<0.001) but not to HS.

CONCLUSION

Our data show clear increase in expression and production of IGFBP-2, IL-8 and MMP-7 in sputum from patients with IPF that may contribute to the disease.

Eosinophilic airway inflammation in asthmatic patients is associated with an altered airway microbiome

BACKGROUND

Asthmatic patients have higher microbiome diversity and an altered composition, with more Proteobacteria and less Bacteroidetes compared with healthy control subjects. Studies comparing airway inflammation and the airway microbiome are sparse, especially in subjects not receiving anti-inflammatory treatment.

OBJECTIVE

We sought to describe the relationship between the airway microbiome and patterns of airway inflammation in steroid-free patients with asthma and healthy control subjects.

METHODS

Bronchoalveolar lavage fluid was collected from 23 steroid-free nonsmoking patients with asthma and 10 healthy control subjects. Bacterial DNA was extracted from and subjected to Illumina MiSeq sequencing of the 16S rDNA V4 region. Eosinophils and neutrophils in the submucosa were quantified by means of immunohistochemical identification and computerized image analysis. Induced sputum was obtained, and airway hyperresponsiveness to mannitol and fraction of exhaled nitric oxide values were measured. Relationships between airway microbial diversity and composition and inflammatory profiles were analyzed.

RESULTS

In asthmatic patients airway microbial composition was associated with airway eosinophilia and AHR to mannitol but not airway neutrophilia. The overall composition of the airway microbiome of asthmatic patients with the lowest levels of eosinophils but not asthmatic patients with the highest levels of eosinophils deviated significantly from that of healthy subjects. Asthmatic patients with the lowest levels of eosinophils had an altered bacterial abundance profile, with more Neisseria, Bacteroides, and Rothia species and less Sphingomonas, Halomonas, and Aeribacillus species compared with asthmatic patients with more eosinophils and healthy control subjects.

CONCLUSION

The level of eosinophilic airway inflammation correlates with variations in the microbiome across asthmatic patients, whereas neutrophilic airway inflammation does not. This warrants further investigation on molecular pathways involved in both patients with eosinophilic and those with noneosinophilic asthma.

Indoor particulate matter exposure is associated with increased black carbon content in airway macrophages of former smokers with COPD

INTRODUCTION

Exposure to fine particulate matter (PM2.5) is associated with worse morbidity in individuals with COPD. Inhaled PM is phagocytosed by airway macrophages (AM), and black carbon measured in AM may serve as a biomarker of air pollution exposure. As there is little data on how indoor PM exposure may influence AM black carbon content in those with respiratory disease, we investigated the association of indoor PM2.5 concentration to AM black carbon content in adults with COPD.

METHODS

Former smokers (>10 pack-years smoking history, quit date >1 year prior to enrollment) older than 40 years of age with moderate-severe COPD were eligible. Indoor air PM2.5 concentrations were measured over 5-7 days at baseline, 3 month, and 6 month intervals. Sputum induction was performed during clinic visits concordant with home monitoring. A total of 50 macrophages per sputum specimen were photographed and quantified using appropriate software by trained staff blinded to PM concentrations. Longitudinal analyses using generalized estimating equations were used to assess the relationship between indoor PM exposure and AM black carbon content.

RESULTS

Participants (n=20) were older (mean (SD) age 67 (4) years), predominantly Caucasian (85%) and male (70%), with an average smoking history of 52 pack-years and mean (SD) quit date of 13 (9) years prior to enrollment. The majority of daily time was reported to be spent indoors (>23h). Mean indoor PM2.5 concentration was 12.8 (13.5)µg/m(3). The mean area of black carbon quantified in airway macrophages was 1.2 (0.7)µm(2). In multivariate cross-sectional and longitudinal analyses, each 10µg/m(3) increase in indoor PM2.5 was significantly associated with a 0.26µm(2) and 0.19µm(2) increase in airway macrophage black carbon total area, respectively (p<0.05).

CONCLUSION

Higher indoor PM2.5 concentration is associated with an increase in black carbon content of AM in individuals with COPD. These data support the potential for AM black carbon content to be a useful non-invasive biomarker of exposure to indoor PM.

Assessment of anti-inflammatory effect from addition of a long-acting beta-2 agonist to inhaled corticosteroid

BACKGROUND

Inhaled corticosteroids (ICS) and long-acting beta-2 agonists (LABA) are thought to enhance the pharmacologic action of one another by a synergistic effect.

OBJECTIVE

We compared a group of patients who used ICS monotherapy with a group treated with ICS/LABA combination and evaluated the LABAs with regard to the synergistic effect on the anti-inflammatory action of the ICS.

METHODS

This study was conducted with 107 adult patients with mild-to-moderate bronchial asthma. The patients were randomly assigned to either ICS monotherapy (n = 55) or an ICS/LABA combination (n = 52). Both groups were assessed for respiratory function, fractional exhaled nitric oxide, induced sputum, and airway hyperresponsiveness before and after 6 months of treatment.

RESULTS

The ICS/LABA combination group showed significantly greater improvement than the ICS monotherapy group in the forced expiratory volume in 1 second/forced vital capacity (p < 0.01), forced expiratory volume in 1 second % predicted (p < 0.05), % predicted maximal expiratory flow at 50% (p < 0.01), % predicted maximal expiratory flow at 25% (p < 0.05), and airway hyperresponsiveness (p < 0.01). However, the two groups did not show significant differences in changes in the fractional exhaled nitric oxide (p = 0.47) or the percentage of eosinophils in the central (p = 0.85) or peripheral sputum (p = 0.98).

CONCLUSION

The significant improvement in respiratory function in the ICS/LABA combination treatment group compared with the ICS monotherapy group indicated an additive bronchodilator effect of the LABA. However, the two groups did not differ in airway inflammation, which indicated that a synergistic effect of the LABA on enhancing the anti-inflammatory action of the ICS was not clinically apparent.

Responsiveness of blood and sputum inflammatory cells in Japanese COPD patients, non-COPD smoking controls, and non-COPD nonsmoking controls

PURPOSE

To compare pulmonary and systemic inflammatory mediator release, pre- and poststimulation, ex vivo, in cells from Japanese patients with chronic obstructive pulmonary disease (COPD), non-COPD smoking controls, and non-COPD nonsmoking controls (NSC).

PATIENTS AND METHODS

This was a nontreatment study with ten subjects per group. Inflammatory biomarker release, including interleukin (IL)-6 and -8, matrix metalloproteinase-9, and tumor necrosis factor (TNF)-α, was measured in peripheral blood mononuclear cells (PBMC) and sputum cells with and without lipopolysaccharide or TNF-α stimulation.

RESULTS

In PBMC, basal TNF-α release (mean ± standard deviation) was significantly different between COPD (81.6±111.4 pg/mL) and nonsmoking controls (9.5±5.2 pg/mL) (P<0.05). No other significant differences were observed. Poststimulation biomarker release tended to increase, with the greatest changes in the COPD group. The greatest mean increases were seen in the lipopolysaccharide-induced release of matrix metalloproteinase-9, TNF-α, and IL-6 from PBMC. Pre- and poststimulation data from sputum samples were more variable and less conclusive than from PBMC. In the COPD group, induced sputum neutrophil levels were higher and macrophage levels were lower than in either control group. Significant correlations were seen between the number of sputum cells (macrophages and neutrophils) and biomarker levels (IL-8, IL-6, and TNF-α).

CONCLUSION

This was the first study to compare cellular inflammatory mediator release before and after stimulation among Japanese COPD, smoking controls, and nonsmoking controls populations. Poststimulation levels tended to be higher in patients with COPD. The results suggest that PBMC are already preactivated in the circulation in COPD patients. This provides further evidence that COPD is a multicomponent disease, involving both airway and systemic inflammation.

Clinical and biochemical factors for response to aspirin desensitization in aspirin-induced asthma patients – pilot study

Aspirin desensitization is considered to be an effective and well-tolerated therapy for patients with Non-steroidal anti-inflammatory(NSAIDs)-Exacerbated Respiratory Disease (NERD). The aim of the present study was to investigate the influence of aspirin desensitization on inflammatory cell count in induced sputum and nasal lavage in fifteen NERD individuals subjected to one-year aspirin therapy. The decrease in induced sputum count of eosinophils and macrophages was observed. Clinical efficacy of aspirin therapy in improving nasal symptoms and quality of life in NERD patients was also confirmed.

Type 2 innate lymphoid cells: A novel biomarker of eosinophilic airway inflammation in patients with mild to moderate asthma

BACKGROUND

Eosinophilic airway inflammation can predict the exacerbation of asthma, and we can improve the management of asthma by monitoring the eosinophilic airway inflammation. Although induced sputum and sputum eosinophil count is the gold standard test for diagnosing eosinophilic asthma, a more accessible and receptive method is needed for clinical practice. Type 2 innate lymphoid cells (ILC2) have recently been proposed to play a crucial role in eosinophilic inflammation and have been identified in peripheral blood from patients with asthma.

OBJECTIVES

We sought to identify simple and feasible biomarkers which can predict eosinophilic airway inflammation in asthmatic patients.

METHODS

Sputum was induced for the assessment of eosinophils in 150 asthmatic patients. In parallel, the proportion of ILC2s of peripheral blood lymphocytes (%ILC2), blood eosinophil counts, total immunoglobulin E (IgE), fractional exhaled nitric oxide (FeNO) and lung function tests were measured. 42 healthy donors served as controls.

RESULTS

126 patients finished sputum induction and produced adequate sputum. The ILC2 level was significantly increased in eosinophilic asthmatic patients compared with non-eosinophilic asthmatic patients (0.117 ± 0.090versus0.035 ± 0.021, p < 0.001). A multiple regression model, including age, sex, BMI, blood eosinophil counts, FeNO, IgE and %ILC2, showed that %ILC2, blood eosinophil counts and FeNO were correlative factors of sputum eosinophil counts (p < 0.001, p = 0.037, p < 0.001, respectively) and %ILC2 was the most significant subset of airway eosinophilic inflammation (Estimate = 11.385). A receiver operating characteristic (ROC) analysis showed a sensitivity of 67.7% and a specificity of 95.3% for %ILC2 of 0.076 to distinguish eosinophilic asthmatic patients from non-eosinophilic asthmatic patients.

CONCLUSION

ILC2 is a surrogate marker of airway eosinophilic inflammation in patients with mild to moderate asthma and has great potential advantages for selecting the asthmatic patients most likely to benefit from therapeutics targeting Th2 inflammation.

A randomized, controlled, crossover study in patients with mild and moderate asthma undergoing treatment with traditional Chinese acupuncture

OBJECTIVES

This study sought to verify the effects of acupuncture as an adjuvant treatment for the control of asthma.

METHODS

This was a randomized, controlled, crossover trial conducted at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A total of 74 patients with mild/moderate, persistent asthma were randomized into two therapeutic groups: Group A - 31 patients underwent 10 real weekly acupuncture sessions, followed by a 3-week washout period and 10 sham weekly acupuncture sessions; and Group B - 43 patients underwent 10 sham weekly acupuncture sessions, followed by a 3-week washout period and 10 real weekly acupuncture sessions. Patients used short- and long-acting β-2 agonists and inhaled corticosteroids when necessary. Prior to treatment and after each period of 10 treatment sessions, the patients were evaluated for spirometry, induced sputum cell count, exhaled nitric oxide (NO) and with the Short Form 36 (SF-36) and Questionnaire on Quality of Life-Asthma (QQLA) questionnaires. Daily peak flow and symptom diaries were registered. The level of significance adopted was 5% (α=0.05).

RESULTS

In Group B, after real acupuncture, there was a decrease in eosinophils (p=0.035) and neutrophils (p=0.047), an increase in macrophages (p=0.001) and an improvement in peak flow (p=0.01). After sham acupuncture treatment, patients experienced less coughing (p=0.037), wheezing (p=0.013) and dyspnea (p=0.014); similarly, after real acupuncture, patients reported less coughing (p=0.040), wheezing (p=0.012), dyspnea (p<0.001) and nocturnal awakening episodes (p=0.009). In Group A, there was less use of rescue medication (p=0.043). After the sham procedure, patients in Group A experienced less coughing (p=0.007), wheezing (p=0.037), dyspnea (p<0.001) and use of rescue medication (p<0.001) and after real acupuncture, these patients showed improvements in functional capacity (p=0.004), physical aspects (p=0.002), general health status (p<0.001) and vitality (p=0.019). Sham acupuncture also led to significant differences in symptoms, but these were not different from those seen with real acupuncture. Spirometry and exhaled NO levels did not show a difference between sham and real acupuncture treatment. In addition, no significant difference was demonstrated between treatments regarding the quality of life evaluation.

CONCLUSION

Real and sham acupuncture have different effects and outcomes on asthma control. The crossover approach was not effective in this study because both interventions led to improvement of asthma symptoms, quality of life and inflammatory cell counts. Thus, sham acupuncture cannot serve as a placebo in trials with acupuncture as the main intervention for asthma.

An acoustofluidic sputum liquefier

We demonstrate the first microfluidic-based on-chip liquefaction device for human sputum samples. Our device is based on an acoustofluidic micromixer using oscillating sharp edges. This acoustofluidic sputum liquefier can effectively and uniformly liquefy sputum samples at a throughput of 30 μL min(-1). Cell viability and integrity are maintained during the sputum liquefaction process. Our acoustofluidic sputum liquefier can be conveniently integrated with other microfluidic units to enable automated on-chip sputum processing and analysis.

Bronchial hyperresponsiveness, airway inflammation, and reversibility in patients with chronic obstructive pulmonary disease

BACKGROUND

Bronchial hyperresponsiveness (BHR), sputum eosinophilia, and bronchial reversibility are often thought to be a hallmark of asthma, yet it has been shown to occur in COPD as well.

OBJECTIVES

To evaluate the relationship between BHR, lung function, and airway inflammation in COPD patients.

METHODS

Thirty-one, steroid-free patients with stable, mild and moderate COPD were studied. The following tests were carried out: baseline lung function, reversibility, provocative dose of methacholine causing a 20% fall in forced expiratory volume in 1 second, a COPD symptom score, and sputum induction.

RESULTS

Twenty-nine patients completed the procedures. About 41.4% had BHR, 31.0% had increased sputum eosinophils, and 37.9% had bronchial reversibility. Some of the patients had only one of these characteristics while others had two or the three of them. Patients with BHR had higher sputum eosinophils than patients without BHR (P=0.046) and those with sputum eosinophils ≥3% had more exacerbations in the previous year and a higher COPD symptom score than patients with sputum eosinophils <3% (P=0.019 and P=0.031, respectively). In patients with BHR, the cumulative dose of methacholine was negatively related to the symptom score and the number of exacerbations in the previous year. When patients with bronchial reversibility were considered, bronchodilation was positively related to sputum eosinophils.

CONCLUSION

Our study showed that BHR, sputum eosinophilia, and bronchial reversibility were not clustered in one single phenotype of COPD but could be present alone or together. Of interest, BHR and airway eosinophilia were associated with clinical data in terms of exacerbations and symptoms. Further investigation is needed to clarify this topic.

Acceptability of sputum specimens for diagnosing pulmonary tuberculosis

The evaluation of the quality of a sputum specimen prior to bacterial culture has been an accepted practice. However, optimal sputum criteria for pulmonary tuberculosis (TB) are not well established. We investigated indicators for sputum acceptability in tuberculosis cultures and acid-fast bacilli (AFB) smear. A post-hoc analysis of a randomized trial with 228 sputum specimens from 77 patients was conducted. In the trial, pulmonary TB suspects were requested for collecting three sputum specimens. We performed both TB study (AFB smear and M. tuberculosis culture) and Gram staining in each specimen. By using generalized estimating equations, the association between sputum characteristics and positive TB testings were analyzed. Although acceptable specimens for bacterial pneumonia showed higher TB-culture positive rates than unacceptable specimens (adjusted odds ratio [aOR]=1.66; 95% confidence interval [CI]=1.11-2.49), a specimen with ≥25 white blood cells/low-power field was the better predictor for positive M. tuberculosis cultures (aOR=2.30; 95% CI=1.48-3.58) and acid-fast bacilli smears (aOR=1.85; 95% CI=1.05-3.25). Sputum leukocytosis could be an indicator of sputum acceptability for diagnosing pulmonary tuberculosis.

Effect of inhaled corticosteroids on bronchial asthma in Japanese athletes

BACKGROUND

Asthma has a higher prevalence in athlete populations such as Olympic athletes than in the general population. Correct diagnosis and management of asthma in athletes is important for symptom control and avoidance of doping accusations. However, few reports are available on asthma treatment in the athlete population in clinical practice. In this study, we focused on the clinical efficacy of inhaled corticosteroid (ICS) for asthma in a Japanese athlete population.

METHODS

The study subjects included athletes who visited the Niigata Institute for Health and Sports Medicine, Niigata, Japan for athletic tests and who were diagnosed with asthma on the basis of respiratory symptoms and positive results in a bronchodilator or bronchial provocation test such as exercise, hypertonic saline, or methacholine provocation. The athletes received ICS alone for at least 3 months, and the clinical background, sports type, and treatment efficacy were analyzed.

RESULTS

The study population comprised 80 athletes (59 men and 21 women) with a median age of 16.0 years. Regarding sports type, 28 athletes engaged in winter sports (35%), 22 in endurance sports (27.5%), and 25 in indoor sports (31.3%). Although ICS is the primary treatment in athlete asthma, 16.3% of the athletes showed an unsatisfactory response to treatment according to the Global Evaluation of Treatment Effectiveness (GETE). These subjects were characterized by a decreased response to methacholine and lower values for FEV1/FVC and type 2 helper T cell (Th2)-associated biomarkers relative to responsive athletes. In multivariate analysis, FEV1/FVC and the logarithm to the base 10 of the IgE level were independently associated with the ICS response.

CONCLUSIONS

These data suggest that ICS is effective for asthma in most athletes. However, certain asthmatic athletes are less responsive to ICS than expected. The pathogenesis in these subjects may differ from that of conventional asthma characterized by chronic allergic airway inflammation.

Airway inflammation in children and adolescents with bronchiolitis obliterans

BACKGROUND

Airway inflammation plays a major role in the progression of chronic lung diseases. The features of airway inflammation are not well defined among patients with cases of bronchiolitis obliterans (BO) that began in childhood.

OBJECTIVES

To investigate the sputum cell and cytokine profiles of stable cases of BO regarding lung function and the involvement of small airway disease (SAD).

METHODS

Twenty patients with BO (median age=14.5, range=7-23years) and 22 healthy controls (median age=16.5years, range=7-24years) were investigated. Lung function parameters and bronchial reversibility testing as well as sputum cell and cytokine profiles (IL-1β, IL-6, IL-8, TNF-α, IL-5, IFN-γ, and NFκB regulation) were analysed using quantitative RT-PCR and cytometric bead assay (CBA) in induced sputum.

RESULTS

Patients with BO had significantly lower lung function values, including FVC, forced expiratory volume (FEV1), the Tiffeneau index (FEV1/VC), and MEF25, but increased functional residual capacity (RV/TLC) values. Bronchial reversibility was found in five patients (25%). Moreover, airway inflammation (as indicated by total cells, neutrophils, IL-1β, IL-6, IL-8, TNF-α, and NFκB) was significantly increased among patients with BO compared with controls.

CONCLUSIONS

BO is predominantly a neutrophilic disease of the small bronchioles featuring elevated levels of pro-inflammatory cytokines leading to tissue remodelling and fibrosis of the small airways. Future therapies for patients with BO should more efficiently target the small airways.

Haemosiderin-laden sputum macrophages for diagnosis in pulmonary veno-occlusive disease

Aims

Pulmonary veno-occlusive disease (PVOD) is a rare condition of pulmonary arterial hypertension (PAH), in which post-capillary veins are affected. Since the therapeutic approach in PVOD differs from other forms of PAH, it is crucial to establish the diagnosis. Due to the fact that affected patients are often hemodynamically unstable, minimal invasive procedures are necessary for the diagnostic work-up. Chronic alveolar haemorrhage has been observed during bronchoalveolar lavage in PVOD cases. This study therefore investigates whether signs of alveolar haemorrhage can also be found in the sputum of these patients.

Methods and Results

Six patients suffering from PVOD were included in this analysis. As controls, patients with idiopathic PAH (n = 11), chronic thromboembolic PH (n = 9) and with sclerodermia-associated PH (n = 10) were assessed. Sputum from every patient was obtained by a non-invasive manner. The amount of haemosiderin-laden macrophages was determined using the Golde score. There were statistically significant more haemosiderin-laden macrophages in the sputum of patients suffering from PVOD as compared to the other groups (P<0.05). Assuming a cut-off of 200 on the Golde score, all of the 6 PVOD patients surpassed this value compared with only 1 out of the 30 cases with precapillary PH. Thus, sensitivity and specificity with respect to the diagnosis of PVOD was 100% and 97%, respectively.

Conclusion

The content of haemosiderin-laden macrophages in the sputum of patients suffering from PVOD is significantly higher as compared to other forms of PH and may be useful in the non-invasive diagnostic work-up of these patients.

Increased oxidative DNA damage and decreased expression of base excision repair proteins in airway epithelial cells of women who cook with biomass fuels

To investigate whether biomass burning causes oxidative DNA damage and alters the expression of DNA base excision repair (BER) proteins in airway cells, sputum samples were collected from 80 premenopausal rural biomass-users and 70 age-matched control women who cooked with liquefied petroleum gas. Compared with control the airway cells of biomass-users showed increased DNA damage in alkaline comet assay. Biomass-users showed higher percentage of cells expressing oxidative DNA damage marker 8-oxoguanine and lower percentages of BER proteins OGG1 and APE1 by immunocytochemical staining. Reactive oxygen species (ROS) generation was doubled and level of superoxide dismutase was depleted significantly among biomass-users. The concentrations of particulate matters were higher in biomass-using households which positively correlated with ROS generation and negatively with BER proteins expressions. ROS generation was positively correlated with 8-oxoguanine and negatively with BER proteins suggesting cooking with biomass is a risk for genotoxicity among rural women in their child-bearing age.

Biological clustering supports both "Dutch" and "British" hypotheses of asthma and chronic obstructive pulmonary disease

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases.

OBJECTIVE

We sought to determine, in terms of their sputum cellular and mediator profiles, the extent to which they represent distinct or overlapping conditions supporting either the "British" or "Dutch" hypotheses of airway disease pathogenesis.

METHODS

We compared the clinical and physiological characteristics and sputum mediators between 86 subjects with severe asthma and 75 with moderate-to-severe COPD. Biological subgroups were determined using factor and cluster analyses on 18 sputum cytokines. The subgroups were validated on independent severe asthma (n = 166) and COPD (n = 58) cohorts. Two techniques were used to assign the validation subjects to subgroups: linear discriminant analysis, or the best identified discriminator (single cytokine) in combination with subject disease status (asthma or COPD).

RESULTS

Discriminant analysis distinguished severe asthma from COPD completely using a combination of clinical and biological variables. Factor and cluster analyses of the sputum cytokine profiles revealed 3 biological clusters: cluster 1: asthma predominant, eosinophilic, high TH2 cytokines; cluster 2: asthma and COPD overlap, neutrophilic; cluster 3: COPD predominant, mixed eosinophilic and neutrophilic. Validation subjects were classified into 3 subgroups using discriminant analysis, or disease status with a binary assessment of sputum IL-1β expression. Sputum cellular and cytokine profiles of the validation subgroups were similar to the subgroups from the test study.

CONCLUSIONS

Sputum cytokine profiling can determine distinct and overlapping groups of subjects with asthma and COPD, supporting both the British and Dutch hypotheses. These findings may contribute to improved patient classification to enable stratified medicine.