Predictors of cardiovascular events in patients with primary systemic vasculitis: a 5-year prospective observational study

Introduction

Granulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA)-associated systemic vasculitis and is characterised by necrotizing inflammation of small/medium-sized blood vessels. Systemic vasculitis exhibits an enhanced cardiovascular morbidity and cardiovascular disease (CVD) has become a leading cause of death in this group of patients.

Objectives

The aim of the present study was to assess the prevalence of clinical manifestation of atherosclerosis and its relation with classic risk factors for atherosclerosis, echocardiographic parameters and laboratory findings in GPA patients.

Patients and methods

The group of consecutive patients with GPA were followed in the study. In all patient's echocardiography and laboratory tests were performed.

Results

One hundred six patients with GPA (mean age 50.4±14.9 yrs, 67 female) were prospectively followed for 5.1±1.6 yrs. In 19 patients (18%) cardiovascular disease (9 acute coronary syndromes, 4 symptomatic peripheral vascular diseases and 6 strokes) occurred in association with GPA. Analysis showed that the levels of hs-CRP on both visits correlated with BVAS, PR3-ANCA, D-dimer and creatinine. In a multivariate model, only age was predictive of cardiovascular events in this group of patients (OR=1.078, 95% CI: 1.025–1.134, p=0.003). During observation in patients without CVD the level of hs-CRP and D-dimer were significantly reduced on the follow-up visit (p=0.041, p=0.0002). On the other hand, in patients with CV events there was no significant differences in both markers' concentrations despite clinical remission.

Conclusions

Patients with granulomatosis with polyangiitis have high risk of cardiovascular disease. The age was the only independent predictor of cardiovascular events. Persistent elevation of inflammatory and prothrombotic markers despite clinical remission of the disease could be an indicator of premature atherosclerosis development in patients with systemic vasculitis.

Funding Acknowledgement

Type of funding sources: None.

P1803 Incidence of venous thromboembolism in patients with granulomatosis with polyangiitis (Wegener"s granulomatosis)

Funding Acknowledgements

none

Background

Granulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA) – associated vasculitis. This primary systemic vasculitis is multisystem disorder characterized by inflammation and necrosis of small and medium sized blood vessels. An increased risk of cardiovascular mortality and incidence of various cardiovascular events has been described among GPA patients.

Purpose

The aim of the present study was to assess the incidence of venous thromboembolism (VTE) and its correlation with echocardiographic parameters and laboratory findings in GPA patients.

Methods

The group of consecutive patients with GPA were followed in the study. In all patients echocardiography and laboratory tests were performed.

Results

One hundred four patients with GPA (mean age 51.6 ± 13.2 yrs) were followed for an average of 4,5 ± 1,9 years. In 24 patients venous thromboembolism was diagnosed during observation, however in majority of them (57%) VTE occurred during first year after diagnosis of GPA. There were no significant differences in creatinine, troponin T and CRP levels between patients with and without VTE. In patients with VTE there were larger right ventricle diameter (29.1 ± 4.4 vs. 32.1 ± 5.6; p = 0.04) and higher right ventricle systolic pressure (32.6 ± 5.4 vs. 37.3 ± 5.9; p = 0.02) observed. In this study group D-dimer was elevated in majority (56%) of patients. In patients with VTE D-dimer correlated positively with age (r = 0.5, p = 0.02), right ventricle diameter (r = 0.63, p = 0.001), right ventricle systolic pressure (r = 0.44, p = 0.04), and negatively with pulmonary artery acceleration time (r= -0.43, p = 0.05).

Conclusions

Venous thromboembolism is a common complication in patients with granulomatosis with polyangiitis, especially during first year after diagnosis. This finding is likely to be associated with changes in endothelial function and with induction of hypercoagulability resulting from changes in pro and anticoagulant factors associated with inflammation and its therapy.

P4443Elevated levels of D-dimer are associated with inflammation and disease activity rather than risk of venous thromboembolism in patients with granulomatosis with polyangiitis

Background

Granulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA) – associated vasculitis. The disease is characterized by necrotising inflammation of small vessels causing tissue ischemia in a variety of organs with a wide range of clinical presentations. It has been established that active GPA is associated with a very high risk of venous thromboembolic events (VTEs).

Purpose

The aim of the present study was an evaluation of inflammation, coagulation and fibrinolysis markers, and their association with various clinical and laboratory parameters in GPA patients.

Methods

The group of 100 consecutive patients with GPA was prospectively followed in the study. In all patients echocardiography and laboratory tests were performed.

Results

The patients were followed up for an average of 4.0±1.9 years. In this group, D-dimer was elevated in majority (56%) of patients. The circulating levels of D-dimer were significantly higher in GPA patients in active stage of disease compared with those in remission (652 vs. 405 ng/ml, p=0.0002). In 23 patients venous thromboembolism was diagnosed during observation. However, there was no difference in D-dimer concentration between patients with and without VTE either in active stage or in remission. Among the 100 GPA patients higher D-dimer levels were observed in patients with coronary artery disease (p=0.04), atherosclerosis (p=0.01), hypertension (p=0.0049), diabetes (p=0.0065) and hypercholesterolemia (p=0.03). Moreover, correlation analysis showed that the levels of D-dimer correlated with hs-CRP (r=0.42; p<0.0001) and creatinine (r=0.58; p<0.0001). In patients with VTE, D-dimer levels correlated positively with age (r=0.5, p=0.02), right ventricle diameter (r=0.63, p=0.0017), right ventricle systolic pressure (r=0.44, p=0.04), and negatively with pulmonary artery acceleration time (r=−0.43, p=0.05).

D-dimer – normal D-dimer – elevated p Inclusion – active stage n=44 (44%) n=56 (56%) Elevated creatinine 1 (2.27%) 25 (44.6%) <0.0001 Elevated CRP 5 (11.3%) 22 (39.2%) 0.0015 Venous thromboembolism 7 (15.9%) 16 (28.6%) 0.0712 CRP: C-reactive proteine.

Conclusion

In patients with Granulomatosis with polyangiitis elevated levels of D-dimer are associated with disease activity and inflammation, rather than with risk of venous thromboembolism. D-dimer is not a useful marker of venous thromboembolism episodes in patients with small vessel vasculitis.

Antibiotic Treatment of Hospitalized Patients with Pneumonia Complicated by Clostridium Difficile Infection

Clostridium difficile infection (CDI) is one of the most common gastrointestinal complication after antimicrobial treatment. It is estimated that CDI after pneumonia treatment is connected with a higher mortality than other causes of hospitalization. The aim of the study was to assess the relationship between the kind of antibiotic used for pneumonia treatment and mortality from post-pneumonia CDI. We addressed the issue by examining retrospectively the records of 217 patients who met the diagnostic criteria of CDI. Ninety four of those patients (43.3 %) came down with CDI infection after pneumonia treatment. Fifty of the 94 patients went through severe or severe and complicated CDI. The distribution of antecedent antibiotic treatment of pneumonia in these 50 patients was as follows: ceftriaxone in 14 (28 %) cases, amoxicillin with clavulanate in 9 (18 %), ciprofloxacin in 8 (16.0 %), clarithromycin in 7 (14 %), and cefuroxime and imipenem in 6 (12 %) each. The findings revealed a borderline enhancement in the proportion of deaths due to CDI in the ceftriaxone group compared with the ciprofloxacin, cefuroxime, and imipenem groups. The corollary is that ceftriaxone should be shunned in pneumonia treatment. The study demonstrates an association between the use of a specific antibiotic for pneumonia treatment and post-pneumonia mortality in patients who developed CDI.

Clostridium Difficile Infection Due to Pneumonia Treatment: Mortality Risk Models

One of the most common gastrointestinal infection after the antibiotic treatment of community or nosocomial pneumonia is caused by the anaerobic spore Clostridium difficile (C. difficile). The aim of this study was to retrospectively assess mortality due to C. difficile infection (CDI) in patients treated for pneumonia. We identified 94 cases of post-pneumonia CDI out of the 217 patients with CDI. The mortality issue was addressed by creating a mortality risk models using logistic regression and multivariate fractional polynomial analysis. The patients' demographics, clinical features, and laboratory results were taken into consideration. To estimate the influence of the preceding respiratory infection, a pneumonia severity scale was included in the analysis. The analysis showed two statistically significant and clinically relevant mortality models. The model with the highest prognostic strength entailed age, leukocyte count, serum creatinine and urea concentration, hematocrit, coexisting neoplasia or chronic obstructive pulmonary disease. In conclusion, we report on two prognostic models, based on clinically relevant factors, which can be of help in predicting mortality risk in C. difficile infection, secondary to the antibiotic treatment of pneumonia. These models could be useful in preventive tailoring of individual therapy.

Prevalence of Olfactory Impairment in Granulomatosis with Polyangiitis

Granulomatosis with Polyangiitis (GPA) is a rare disease of unknown origin. It may damage all organs and systems, even olfactory and taste sense. The aim of the study was to determine the sense of smell in patients with GPA and to identify factors related to disease course, activity, and duration, which may be associated with olfactory dysfunction. The comparison of olfactory function screening scores with Sniffin' Sticks standardized norms showed that 74% of the investigated patients had olfactory dysfunction. The olfactory performance was diminished in all parts of Sniffin' Sticks test: threshold scores 4.4 vs. 7.1 (p = 0.007); odor discrimination 9.0 vs. 11.9 (p = 0.008); and olfactory identification 9.8 vs. 12.2 (p = 0.011) in the GPA patients vs. control subjects, respectively. Scores acquired during all three parts of the test were combined to assess the TDI-score. The median TDI-score in the GPA group (27.5) was significantly lower than that in the control group (32.0) (p = 0.002). Active nasal and paranasal sinus inflammation in GPA leads to olfactory dysfunction, the patients are often unaware of. The dysfunction is permanent and does not abates along with decreasing intensity of the inflammatory process. GPA therapy should include recommendations on nutrition, personal hygiene, and food poisoning prevention.

Sleep-Related Breathing Disorders and Bruxism

Obstructive sleep apnea (OSA) syndrome is a sleep-related breathing disorder, due mainly to peripheral causes, characterized by repeated episodes of obstruction of the upper airways, associated with snoring and arousals. The sleep process fragmentation and oxygen desaturation events lead to the major health problems with numerous pathophysiological consequences. Micro-arousals occurring during sleep are considered to be the main causal factor for night jaw-closing muscles activation called bruxism. Bruxism is characterized by clenching and grinding of the teeth or by bracing or thrusting of the mandible. The causes of bruxism are multifactorial and are mostly of central origin. Among central factors there are secretion disorders of central nervous system neurotransmitters and basal ganglia disorders. Recently, sleep bruxism has started to be regarded as a physiological phenomenon occurring in some parts of the population. In this article we present an evaluation of the relationship between OSA and sleep bruxism. It has been reported that the frequency of apneic episodes and that of teeth clenching positively correlates in OSA. However, clinical findings suggest that further studies are needed to clarify sleep bruxism pathophysiology and to develop new approaches to tailor therapy for individual patients with concomitant sleep bruxism and OSA.

Atherosclerotic factors in PR3 pulmonary vasculitis

Autoimmune disease such as systemic lupus erythematosus or rheumatoid arthritis are connected with higher risk of atherosclerosis and cardiovascular complications and mortality. This results from inflammatory damage to the vessel wall by vasculitis. The aim of the present study was to evaluate whether patients with Wegener's granulomatosis (WG) and pulmonary involvement have an increased prevalence of atherosclerotic disease as characterized traditional risk factors. Twenty one patients with WG in remission and 15 control subject were entered to the study. Traditional risk factor for cardiovascular disease such as hyperglycemia, hypertension, smoking, obesity, and dyslipidemia were assessed. Both systolic and diastolic blood pressure were higher in WG patients (p<0.025). Total cholesterol, LDL and TG levels were markedly elevated in 18 of the 21 in pulmonary WG patients. Compared with controls, plasma levels of hsCRP were raised in WG patients; 3.68 (0.79-9.75) mg/l vs. 0.14 (0.12-0.59) mg/l (p<0.01). We conclude that non-pharmacological and pharmacological treatments of traditional risk factors are crucial to prevent cardiovascular disease in WG patients and thus should be part of therapy to control WG activity and damage caused by it.

Antiendothelial cells antibodies in patients with systemic sclerosis in relation to pulmonary hypertension and lung fibrosis

Although scleroderma is generally considered a fibrosing disease, it is now recognized that the underlying vascular pathology is playing a fundamental role in its pathogenesis. The present study was aimed at testing the prevalence of anti-endothelial cell antibodies (AECA) in systemic scleroderma (SSc) patients with and without pulmonary hypertension (PH) and in relation to the presence of pulmonary fibrosis. Fifty four SSc patients (50 females and 4 male, mean age 55.7 ± 16.3 years) were prospectively screened. All patients underwent transthoracic echocardiography with the estimation of pulmonary artery pressure (PAP) and tricuspid regurgitant peak gradient (TRPG). All patients suspected to have pulmonary hypertension were referred for right heart catheterization. Restrictive lung disease was confirmed by HRCT. A healthy control group included (n = 27; 7 men and 20 women, mean age 49.8 ± 12.1 years). The study of AECA was performed using the indirect immunofluorescence method on commercially available human umbilical vein endothelial cells. The HRCT scans in patients with suspected interstitial lung disease revealed signs of lung fibrosis in 15 (out of the 36 examined patients). TRPG at rest of 31 mmHg was demonstrated in 14 (21%) patients. During cardiac catheterization, arterial PH was found in two patients. Resting venous PH was found in one patient and an excessive post capillary PAP elevation at rest was demonstrated in 11 patients. At the baseline, 14/54 patients (26%) were positive for AECA. In the control group, the frequency of the antibodies was 3/27 (11%). No statistical correlation between antibody titter and the presentation of the disease existed. AECA were highly prevalent in a subgroup of patients suffering from interstitial pulmonary fibrosis. Out of the 15 patients suffering from lung fibrosis, 7 were AECA positive. The presence of AECA correlated very well with antinuclear antibodies (ANA), but was not related to the profile of ANA. Our findings support evidence that endothelial cell damage is involved in SSc, as there was increased prevalence of circulating AECA of the IgG isotype in SSc patients. AECA may also be related to the complications of SSc, like pulmonary fibrosis.

Influence of sera from interstitial lung disease patients on angiogenic activity of mononuclear cells

Chronic inflammation stimulates of neovascularization. The aim of this study was to evaluate the effect of sera from interstitial lung diseases (ILD) patients on angiogenic capabilities of different subsets of mononuclear cells. Serum samples were obtained from 22 patients with sarcoidosis, 20 with hypersensitivity pneumonitis, 20 with idiopathic pulmonary fibrosis, 9 with systemic sclerosis, 6 with pulmonary Langerhans cells histiocytosis, and from 20 healthy volunteers. Animal model of leukocyte induced angiogenesis assay was used as an angiogenic test. The pattern of angiogenic reaction was different in different diseases. Sera from systemic sclerosis and pulmonary Langerhans cells histiocytosis patients exerted inhibitory effects on angiogenesis, but sera from sarcoidosis, hypersensitivity pneumonitis, and idiopathic pulmonary fibrosis patients stimulated angiogenesis. Sera from sarcoidosis and pulmonary Langerhans cells histiocytosis primed monocytes for the production of angiogenic factors. The number of microvessels created after incubation of mononuclear cells depleted of monocytes with sera from systemic sclerosis patients significantly decreased. We conclude that the role of monocytes in the modulation of angiogenesis varies depending on the type of ILD. Sera from sarcoidosis stimulate and from pulmonary Langerhans cells histiocytosis patients inhibit neovascularization induced by monocyte mediators. Sera from systemic sclerosis inhibit angiogenesis induced by lymphocyte products.

Influenza vaccine coverage among children under the age of 5 years in Poland during 2004-2008

Introduction

Influenza is a considerable health problem all over the world. The most important group for influenza vaccination are children: the highest attack rate during community out-breaks of influenza can be found among school-aged children or their family members; children bear a considerable risk for complications due to influenza, leading to an increased need for healthcare resources (including hospitalization). The high level of vaccine coverage among school children could provide protection against influenza among households and could reduce mortality rates among older individuals.

Objective

The aim of this study was to estimate the influenza vaccine coverage among children younger than 5 years and to find any trends in influenza vaccine coverage in 2004-2008 in Poland.

Material and methods

Official data (number of administrated vaccines and the age of vaccinated individuals) collected by the National Institute of Hygiene, the National Institute of Public Health, and the Central Statistical Office in Poland were analyzed. This data are reported by physicians and collected from reports prepared annually by the Sanitary-Epidemiological Stations at a local level. The vaccine coverage rate was calculated as a percentage of vaccinated individuals among all children under the age of 5 years.

Results

The influenza vaccine coverage among children younger than 5 years varied from 1% (2007 and 2008) to 1.9% (2005). The proportion of vaccinated children aged less than 5 compared with the total number of flu shots administrated irrespective of age also varied from 1.4% (2007) to 2% (2005).

Conclusions

The influenza vaccination coverage among Polish children aged less than 5 years is low and has persisted at the same level. More educational activities directed both to patients (parents) and healthcare workers would be needed to improve a general knowledge about influenza vaccination benefits among young children.

Clinical manifestations of influenza caused by A/H1N1v virus among children and teenagers consulted in general practice

BACKGROUND

Children and young adults are more susceptible to pandemic A/H1N1v infection than older people. There are some publications concerning the course of the pandemic influenza among pediatric population but mostly from hospital or from emergency units. There are very few observations of the course of pandemic influenza from primary care settings.

OBJECTIVE

The aim of the study was to describe clinical manifestations of influenza caused by a pandemic strain A/H1N1v among children and teenagers younger than 14 years who were observed, diagnosed, and treated in general practice.

MATERIAL AND METHODS

The observations were conducted among patients with symptoms of an acute respiratory tract infection in an urban area of Warsaw, Poland in November 2009. The inclusion criteria for performing a rapid influenza diagnostic test (RIDT) were established using the CDC definition of 'influenza-like illness' (ILI): fever >38.7°C plus cough and/or sore throat in the absence of another known cause of illness. In patients who met ILI criteria, nasopharyngeal swabs were taken for RIDT and RT-PCR. -

RESULTS

433 patients were consulted by a general practitioner and reported symptoms of an acute respiratory tract infection, 128 (30%) of them met inclusion criteria for ILI and were tested with RIDT: 31 children younger than 14 years and 97 adults. All 31 children suspected of ILI also were tested by RT-PCR. 20 children had a positive result of the rapid influenza test. For all children tested negative, RT-PCR was also negative, and out of 20 children with the presumptive diagnosis of influenza established after rapid influenza test, the diagnosis was confirmed by RT-PCR in 18; their median age was 6.6 years and ranged from13 months to 14 years. The most common symptoms of influenza A/H1N1v were: high fever (>39°C) - 96% of patients, dry cough - 86% of patients, malaise - 78% of patients, headache - 66% of patients, and diarrhea or vomiting - 28% of patients. Two children received treatment with oseltamivir (one boy with congenital heart defect and Down's syndrome and another with severe bronchial asthma). The duration of symptoms ranged from 1 to 13 days (mean of 6.6 days). No patients required hospitalization either due to primary influenza infection or secondary complications.

CONCLUSIONS

The course of influenza caused by virus A/H1N1v in children younger than 14 years observed in a primary care setting was mild and self-limited without the necessity of antiviral treatment in most cases. A rapid influenza diagnostic test is helpful in diagnosing pandemic influenza.

Angiogenic activity of sera from interstitial lung disease patients in relation to pulmonary function

OBJECTIVE

Chronic inflammation and fibrosis are characteristic of interstitial lung diseases (ILD) and are accompanied by neovascularisation. The aim of this study was to examine the relationship between the angiogenic activity of sera from ILD patients and pulmonary function tests.

MATERIAL AND METHODS

Serum samples were obtained from 225 ILD patients: 83 with sarcoidosis, 31 with idiopathic pulmonary fibrosis, 29 with extrinsic allergic alveolitis, 16 with collagen vascular diseases, 13 with scleroderma with pulmonary manifestations (SCL), 14 with Wegener's granulomatosis (WG), 12 with silicosis, 12 with pulmonary Langerhans cells histiocytosis, 10 with drug-induced pulmonary fibrosis, 5 with cryptogenic organizing pneumonia, and 36 healthy volunteers. An animal model of leukocyte induced angiogenesis assay was used as an angiogenic test. In all patients spirometry, whole body plethysmography, static lung compliance, and single breath diffusing capacity of the lungs for carbon monoxide (DLco) were performed.

RESULTS

The angiogenic properties of sera from ILD differed, depending on the disease. In the examined ILD, the most important functional disturbances were decreases in static compliance and DLco. The correlation between DLco and angiogenic activity of sera was observed (P<0.05).

CONCLUSIONS

The data show that sera from ILD patients constitute a source of mediators modulating angiogenesis. Angiogenic activity of sera of ILD patients is related to DLco.

Knowledge, attitudes, and influenza vaccination of medical students in Warsaw, Strasbourg, and Teheran

OBJECTIVE

Influenza vaccinations are recommended for health professionals by the WHO and the CDC. Medical students are important health professionals not only as future physicians, but also due to their frequent contact with patients during their education. The aim of this study was to compare the knowledge, attitudes, motivations and influenza vaccinations of medicine students in three different countries: Poland, France, and Iran.

MATERIAL AND METHODS

1045 self-reported questionnaires were given to medical students of Warsaw Medical University (n = 502), the Faculty of Medicine of Strasbourg University (n = 371) and Teheran University of Medical Sciences (n = 172). In France, students working in a hospital can be vaccinated free of charge. In Poland and Iran students are required to pay for the vaccine and have to arrange the administration of the vaccine on their own.

RESULTS

Vaccination of students during the year of the study time was generally infrequent: the highest was in Strasbourg 29.7%; it was lower in Warsaw 15.2%, and lowest in Teheran at 4.7%. Similarly, 60% of medical students in Strasbourg, 65% of students in Warsaw and 86% of students in Teheran have never been vaccinated. The percentage of students knowing that they belong to the group of people that have strong indications for being vaccinated was 78% in Strasbourg, 48% in Warsaw and 40% in Teheran. The main reasons for obtaining a shot, cited by students, were to protect from influenza and the fear of disease sequelae. The most important reasons for not being vaccinated were laziness, lack of time, and also lack of knowledge of the indications in favor of being vaccinated. Being vaccinated at least once in the past is the most important predictor of the vaccination in the current season.

CONCLUSIONS

Few medical students in all of the examined countries are immunized against influenza. Data indicate that providing access to free vaccinations, although very important, cannot alone solve the problem. Strengthening educational efforts seems crucial, although no immediate effects should be expected due to remarkable inertia. Influencing attitudes at an earlier stage can be more advantageous.

Co-trimoxazole and prevention of relapses of PR3-ANCA positive vasculitis with pulmonary involvement

Background

Bacterial and viral respiratory tract infections may trigger relapses in patients with PR3-positive vasculitis. Data have suggested that treatment with co-trimoxazole may be beneficial, because this antibiotic could act by eliminating the offending microbe and thereby stopping the initiating stimulus.

Goal and methods

Prospective, randomized, placebocontrolled study of the efficacy of co-trimoxazole given 960 mg thrice weekly for 18 months in preventing relapses in patients with Wegener's granulomatosis (WG) in remission, after treatment with cyclophosphamide and prednisolone was conducted. Relapses and infections were assessed with predefined criteria based on clinical, laboratory, serological, microbiological, and histopathological findings. Sixteen patients were assigned to receive co-trimoxazole and 15 to receive placebo.

Results

Seventy five percent of the patients in the co-trimoxazole group remained in remission at 18 months and 55% of those in the placebo group. A proportional hazard regression analysis identified a positive PR3-ANCA test at the start of treatment, chronic nasal crusting, and Staphylococus aureus infection as risk factors for relapse. Furthermore, the analysis identified treatment with co-trimoxazole as an independent factor associated with prolonged diseasefree interval.

Conclusion

Treatment with co-trimoxazole reduces the incidence of relapses in patients with Wegener's granulomatosis in remission.

Angiogenic activity of sera from interstitial lung disease patients in relation to clinical and radiological changes

Objective

Clinical symptoms and radiological changes are useful in monitoring patients with interstitial lung diseases (ILD). Neovascularization participates in the pathogenesis of idiopathic pulmonary fibrosis and other ILD. The objective of the study was to examine the relationships between angiogenic activity of sera from ILD patients and clinical or radiological status.

Material and methods

Serum samples were obtained from 83 patients with sarcoidosis, 31 with idiopathic pulmonary fibrosis (IPF), 29 with hypersensitivity pneumonitis (HP), 16 with collagen diseases with pulmonary manifestation (CD), 13 with scleroderma (SCL), 14 with Wegener's granulomatosis (WG), 12 with pulmonary Langerhans cell histiocytosis (HIS), 12 with pneumoconiosis (PNC), 10 with drug-induced lung disease (DLD), 5 with cryptogenic organizing pneumonia (COP), and from 36 healthy volunteers. As an angiogenic test we used a cutaneous angiogenesis assay according to Sidky and Auerbach. Clinical status was evaluated using a special questionnaire. In all patients chest radiographs were performed.

Results

The angiogenic properties of sera from ILD differed depending on the clinical diagnosis. The strongest proangiogenic effect was induced by sera from patients with HP (mean number of new vessels 16.8), CD (16.6), sarcoidosis (16.3), IPF (16.2), and PNC (15.7). In the case of DLD (13.2), the effect was comparable to healthy controls (13.5). In contrast, sera from SCL (mean number of the vessels 10.5) and HIS patients (10.8) significantly inhibited angiogenesis compared with controls. The angiogenic activity of sera from patients with hilar or mediastinal lymph nodes involvement was higher than that of sera from patients with lung fibrosis. There were also differences in the serum angiogenic activity in relation to the severity of dyspnea.

Conclusions

The data showed that sera from ILD patients constitute a source of mediators modulating angiogenesis, but the pattern of reaction is different in various diseases. Sera from HP, sarcoidosis, IPF, and CD patients demonstrated the strongest proangiogenic activity. However, sera from SCL and HIS inhibit angiogenesis. Angiogenic activity of examined sera was related to the clinical and radiological changes.

Angiogenic activity of sera from patients with systemic autoimmune diseases in relation to clinical, radiological, and functional pulmonary status

Systemic autoimmune diseases, such as vasculitis and collagen diseases, are characterized by chronic inflammation. Mutual interrelationship between angiogenesis and chronic inflammation has already been demonstrated. The aim of the study was to examine the effect of sera from patients with systemic autoimmune diseases on angiogenesis induced by human mononuclear cells. The study population consisted of 43 patients with a systemic autoimmune disease associated with pulmonary manifestations, divided into three groups: 14 with Wegener's granulomatosis (WG), 13 with systemic sclerosis (SS), and 16 with collagen vascular diseases (CVD) such as rheumatoid arthritis, systemic lupus erythematosus, and dermatomyositis. The control group consisted of 15 healthy volunteers. Clinical status was evaluated using a questionnaire. Standard chest radiographs were performed in all patients. Pulmonary function tests were performed according to the ERS standards. An animal model of a leukocyte-induced angiogenesis assay was used as an angiogenic test. Sera from WG and CVD patients significantly stimulated angiogenesis compared with healthy subjects (P<0.001). On the other hand, sera from healthy donors exerted a proangiogenic effect compared with PBS. In contrast, sera from SS patients significantly (P<0.001) inhibited angiogenesis compared with sera from healthy subjects and PBS. Proangiogenic effect of sera from systemic diseases patients depended on radiological changes. No significant correlation between a degree of dyspnea or functional pulmonary tests and the number of new vessels or angiogenesis index was found. Sera from patients with systemic autoimmune diseases and healthy people constitute the source of mediators modulating angiogenesis. These modulatory effects differ depending on the disease entity.

Modulatory effect of sera from patients with various types of pulmonary fibrosis on mononuclear cell induced angiogenesis in relation to pulmonary function

Angiogenesis plays an important role in the pathogenesis of idiopathic pulmonary fibrosis. Pulmonary fibrosis occurs also in many diseases, such as other types of interstitial pneumonias or drug-induced pulmonary fibrosis. The aim of the study was to examine the effect of sera from patients with various types of pulmonary fibrosis on angiogenesis induced by human mononuclear cells (MNC) in relation to lung functions. The study population consisted of 32 patients with idiopathic pulmonary fibrosis (IPF), 11 patients with drug-induced pulmonary fibrosis (DIPF), 6 with cryptogenic organizing pneumonia (COP), and 20 healthy volunteers. An animal model of leukocyte-induced angiogenesis assay was used as an angiogenic test. Spirometry, whole-body plethysmography, static lung compliance (Cst), and diffusing capacity of the lung for CO (DL(CO)) were performed in all patients. Sera from IPF and COP patients significantly stimulated angiogenic activity of MNC, compared with sera from healthy donors and from DIPF patients (P<0.001). However, sera from healthy donors and DIPF significantly stimulated angiogenic activity of MNC compared with the control group with PBS (P<0.001). In all groups, a decrease in the mean value of Cst and DL(CO) was observed, but no significant correlation between VC, FEV(1), DL(CO), Cst, and angiogenic activity of sera from examined patients was found. Sera obtained from patients with pulmonary fibrosis constitute a source of mediators modulating angiogenesis, but the pattern of reaction is different in various diseases. The strongest reaction is observed in IPF and the weakest one in DIPF. The angiogenic activity of sera did not correlate with the pulmonary function of patients with pulmonary fibrosis.

Correlation between Helicobacter pylori infection and pulmonary Wegener's granulomacytosis activity

Wegener's granulomatosis is a clinicopathologic entity of unknown origin characterized histologically by necrotizing granulomatous angiitis that affects any organ system. The disease most commonly involves the upper and lower respiratory tract and kidneys. Wegener's granulomatosis is a disease which requires a long-term use of steroids and NSAIDs. Because of that patients frequently develop gastroduodenal mucosal lesions and concurrent Helicobacter pylori infection. The aim of the study was to assess the impact of H. pylori infection on clinical features in patients with Wegener's granulomatosis treated with non-steroidal anti-inflammatory drugs, steroidal drugs, and cyclophosphamide. Thirty six patients with systemic Wegener's granulomatosis were tested for the presence of H. pylori infection and 25 of them turned up H. pylori positive. The severity of Wegener's granulomatosis disease, prevalence of gastroduodenal lesions, and the type and duration treatment seem to depend upon H. pylori infection.

Procalcitonin as an indicator of systemic response to infection in active pulmonary Wegener's granulomacytosis

Differential diagnosis of infection during active immune disease, such as Wegener's granulomatosis (Wegener's granulomatosis), is a major clinical challenge. Laboratory measures, erythrocyte sedimentation rate or C-reactive protein, can be elevated in infections that supervene, or coinciding with, in active Wegener's granulomatosis, and thus are nonspecific. The aim of the study was to compare the serum levels of procalcitonin (PCT) in patients with active and inactive disease. Twenty two sera were tested from 10 patients with active, generalized, and biopsyproven Wegener's granulomatosis, with pulmonary involvement, and 12 patients with nonactive one. PCT levels were measured using an immunoluminometric assay. The PCT level was markedly elevated (1.2-3.6 ng/ml) in 9 of the 10 sera from active and 2 of the 12 sera from nonactive Wegener's granulomatosis. PCT levels were in the normal range (0.28-0.56 ng/ml) in the remaining patients with nonactive Wegener's granulomatosis. We conclude that serum procalcitonin levels may be a potentially useful marker in the diagnosis of bacterial infection supervening in active Wegener's granulomatosis.

Prevalence of latent tuberculosis infection in health care workers in Poland assessed by interferon-gamma whole blood and tuberculin skin tests

Health care workers (HCWs) are at risk for developing active tuberculosis (TB). The prevalence of latent tuberculosis infection (LTBI) in this group is unknown in Poland, due largely to the problems associated with the interpretation of the tuberculin skin test (TST) in BCG immunized population. The goal of the present study was to assess the prevalence of LTBI in both clinical and non-clinical 155 HCWs (120 females and 35 males) and to compare the groups at different levels of risk. All participants were interviewed using a questionnaire and underwent interferon-gamma whole blood assay (Quantiferon-Tb-Gold) (QTF) and TST. The questionnaire provided information on possible risk factors for LTBI, including demographic and socioeconomic details, the presence of BCG scars, and the degree of occupational exposure. We found that the prevalence of LTBI among HCWs was, on average, 27.1%. A higher risk of acquiring LTBI was associated with certain work locations (TB lab workers--prevalence 50%, TB ward clinicians--34%, nurses--30%). The prevalence in analytical lab technicians was 20%, in administration staff was 15%. The HCWs with positive QTF test results were older and worked longer than those who had negative results. There was a significant correlation between the level of IFN-gamma and both age (P<0.001) and length of employment (P<0.01). The correlation between the diameter of skin test induration and the magnitude of the INF-gamma response also was significant (P<0.001). We conclude that HCWs are at increased risk of infection, suggesting that appropriate preventive strategies should be undertaken. IFN-gamma test is a useful tool in detecting LTBI cases in a country where BCG vaccination is a national policy.

Chronic crusting, nasal carriage of Staphylococcus aureus and relapse rate in pulmonary Wegener's granulomatosis

Wegener's granulomatosis is a systemic disease characterized by necrotizing granulomatous inflammation of the upper and lower respiratory tract and necrotizing crescentic glomerulonephritis. Nasal carriage of S. aureus is considered a risk factor for S. aureus infections. The aim was to examine possible risk factors for relapse including refractory nasal carriage of Staphylococcus aureus in patients with Wegener's granulomatosis. Swab cultures from anterior nares for S. aureus were taken in consecutive patients (n=28), with limited (n=15) and systemic forms (n=13) of biopsy-proven Wegener's granulomatosis. The occurrence of infection and relapses were identified according to defined criteria. Seventeen of the 28 patients (60%: 95% Cl, 41-76%) were found to be chronic nasal carriers of S. aureus (> or =80% of nasal cultures positive for S. aureus). A hazard regression analysis identified chronic nasal carriage of S. aureus as independent risk factor for relapse (HR-4.56; Cl 2.45-7.65) in patients with limited Wegener's granulomatosis. Chronic nasal carriage of S. aureus characterized patients with Wegener's granulomatosis, who are more prone to relapses.

Angiogenic activity of sera from silicosis and pulmonary Langerhans cell histiocytosis patients in relation to lung function tests

Angiogenesis has been implicated in the pathogenesis of interstitial lung diseases. A correlation between serum angiogenic cytokines level of patients with idiopathic pulmonary fibrosis and radiographic manifestations or functional pulmonary changes has been described, but the role of angiogenesis in the pathogenesis of other interstitial lung diseases such as silicosis and pulmonary Langerhans cell histiocytosis remains unclear. The aim of the study was to examine the effect of sera from silicosis and pulmonary Langerhans cell histiocytosis patients on angiogenesis induced by human mononuclear cells (MNC) in relation to pulmonary function. The study population consisted of 12 patients with silicosis, 12 patients with pulmonary Langerhans cell histiocytosis (PLH), and 14 healthy volunteers. Spirometry, whole-body plethysmography, static lung compliance (Cst), and diffusing capacity of the lung for CO (DL(CO)) were performed in all patients. As an angiogenic test, leukocyte induced angiogenesis assay according to Sidky and Auerbach was used. Sera from PLH patients exerted a significant inhibitory effect on angiogenesis (P<0.001). Sera from silicosis patients significantly (P<0.001) stimulated angiogenesis compared with sera from healthy donors. However, sera from healthy donors significantly stimulated the angiogenic activity of MNC compared with the control with PBS. The mean value of DL(CO) was significantly lower in the group of patients with PLH compared with patients with silicosis (P<0.05). A significant correlation between angiogenesis index and DL(CO) was observed (P<0.05). No significant correlation between the angiogenesis index and other functional parameters was found. Sera from interstitial lung diseases patients and healthy donors constitute a source of mediators modulating angiogenesis. Sera from silicosis patients stimulate neovascularization but sera from PLH patients exert an inhibitory effect on angiogenesis. A correlation between serum angiogenic activity and DL(CO) was found.

Association between clinical activity and high-resolution tomography findings in pulmonary Wegener's granulomacytosis

Wegener's granulomatosis is characterized histologically by necrotizing granulomatous angitis that most commonly involves the upper, lower respiratory tract, and kidneys, but may affect any organ system. The aim of the study was to assess the usefulness of high-resolution computed tomography (HRCT) for evaluating pulmonary disease activity in Wegener's granulomatosis patients. Pulmonary disease activity at the time of examination was scored in 66 patients with Wegener's granulomatosis according to clinical, radiological, and bronchoscopic findings: activity group (n=43, Group 1), past activity group (n=14, Group 2). Of 66 staging examinations, 57 (86%) revealed abnormal CT scans: masses or nodules (30 patients in Group 1 and 6 patients in Group 2, parenchymal opacifications (15 in Group 1 and 1 in Group 2), pleural irregularity (3 in Group 1 and 10 in Group 2). We conclude that HRCT may be a useful supplement to clinical scoring of disease activity in Wegener's granulomatosis with pulmonary involvement.

TNFalpha and INFgamma inducing capacity of sera from patients with interstitial lung disease in relation to its angiogenesis activity

Sera from interstitial lung diseases (ILD) constitute a source of mediators participating in angiogenesis. The nature of these mediators is unknown. The aim of our study was to asses whether preincubation with sera from ILD patients could influence TNFalpha and INFgamma production by normal mononuclear cells (MNC) challenged with LPS (for TNFalpha) or PHA (for INFgamma), and to correlate the cytokine levels with angiogenic properties of sera. The study population consisted of 53 patients with ILD, 16 with sarcoidosis (SAR), 11 with avian fanciers' lung (AFL), 10 with scleroderma with pulmonary manifestations (SCL), 9 with Wegener's granulomatosis (WG), and 7 with pulmonary Langerhans' cell histiocytosis (PLH). As a control, sera from 10 healthy volunteers were used. Neovascularization was measured by a leukocyte-induced angiogenesis assay according to Sidky and Auerbach. TNFalpha and INFgamma production was estimated by a one-step culture immunoassay CytoTraptrade mark TNFalpha DIA (Biosource Europe S.A.) after 3 h of incubation with LPS (TNFalpha) and 24 h incubation with PHA (INFgamma). Sera from sarcoidosis patients, WG patients, and AFL patients significantly stimulated angiogenesis in comparison with sera from healthy donors (P<0.001). Sera from PLH and SCL patients presented anti-angiogenic properties in comparison with sera from healthy donors and from each examined group (P<0.001). Comparing with other groups, preincubation with sera from AFL and WG patients led to a significant increase in TNFalpha production by normal MNC. Highly significant correlation between serum angiogenic activity and TNFalpha production by MNC was observed in SCL, WG, and AFL (r=0.74, P<0.01). we conclude that TNFalpha may play an important role in neovascularization in ILD.

Antibody response to inactivated subunit influenza vaccine in patients with Wegener's granulomatosis

In the present study we investigated the humoral response to inactivated subunit influenza vaccine in patients with Wegener's granulomatosis, who were in clinical and serological remission after immunosuppressive treatment (Group I). The results were compared with patients with Wegener's granulomatosis who were treated immunosuppressively, but were not vaccinated (Group II) and with healthy persons who received the vaccine (Group III). After vaccination, antihemagglutinin and antineuraminidase antibody titers significantly increased in Groups I and Group III subjects when compared with the pre-vaccination values. Post-vaccination protection rates ranged from 51.4% to 74.3% in Group I patients and from 65.7% to 94.3% in Group III subjects. In Group II, the protection rates were between 0% and 21.4%. The response rates ranged from 60% to 74.3% in Group I patients and from 71.4% to 88.6% in Group III subjects. In Group II, the response rates were between 7.1% and 21.4%. The study confirmed the immunogenicity of influenza vaccine in patients with Wegener's granulomatosis and showed similar response in the patients to those present in healthy people.

Analysis of early death based on the prediction model in Wegener's granulomatosis with pulmonary and renal involvement

The prognosis for patients with Wegener's granulomatosis has improved considerably over the last decades. The aim of the study was to assess the early death risk based on the prediction model in a population-based cohort of 60 patients with Wegener's granulomatosis. Clinical analysis has been conducted using the disease extent index (DEI) and Birmingham Vasculitis Activity Score for Wegener's Granulomatosis (BVAS/WG) questionnaires for disease activity. Logistic regression analysis and a Wilcoxon test were included into the statistics. Survival time and death risk were assessed using the Kaplan-Meier estimator and the Cox proportional hazard model. An Receiver Operating Characteristic curve or ROC curve was employed to estimate the value of logistic regression. The early death risk was 16 times higher (P<0.02) in the dialyzed patients and 15 times higher (P<0.05) in the patients with cough as compared with the patients without those predicaments. Predictors of early death are: disease duration, hemoglobin concentration, necessity of dialysis and occurrence of cough. Simultaneous renal and respiratory tract involvement is associated with the highest early death risk.

The role ANCA and anti-GBM antibodies in pulmonary-renal syndrome due to Wegener's granulomatosis

Pulmonary-renal syndrome (PRS) is defined as a diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis. We present a retrospective study of 22 consecutive patients with Wegener's granulomatosis (WG). Logistic regression analysis and a Wilcoxon test were included in the statistics. Survival time death risk were assessed using the Kaplan-Meier estimator and the Cox proportional hazard model. At recognition, the median Birmingham Vasculitis Activity Score for Wegener's Granulomatosis (BVAS/WG) was 30.0 (23.0-32.5), PO2 on air was 5.8+/-0.5 kPa, creatinine level was 7.2+/-1.4 mg/dl. Fifteen patients were PR3 positive, among them 4 patients were also positive for anti-glomerular basement membrane antibodies (anti-GBM). Renal biopsy was performed in 16 patients. Histological examination reviled segmental necrotizing crescentic GN in 15 patients. Thirteen patients were initially dialysis-dependent, and 7 required ventilatory support. All patients were treated with methylprednisolone and cyclophosphamide (pulses). The patients were followed up for 24+/-8 months. Of the survivors, 55% and 31% were alive after 1 and 2 years. Early recognition and proper treatment may improve outcome in PRS.

Modulatory effect of sera from sarcoidosis patients on mononuclear cell-induced angiogenesis

Sarcoidosis (SAR) is a systemic granulomatous inflammatory disease characterized by recruitment and activation of peripheral blood mononuclear cells to the sites of disease. Neovascularisation is a principal vascular response in chronic inflammation and hypoxia. The aim of the study was to evaluate the effect of sera from sarcoidosis patients on angiogenic capability of different subsets of normal peripheral human mononuclear cells (MNC) in relation to IL-6 and IL-8 serum levels, to radiological stages of disease and to the presence of extrapulmonary changes. Serum samples obtained from 42 sarcoidosis patients were examined. There were 12 patients in stage I, 16 patients in stage II, and 14 in stage III. In order to quantify angiogenesis, a leukocyte-induced angiogenesis assay was performed by a method of Sidky and Auerbach. MNC were depleted in monocytes by glass adherence and phagocytosis of iron particles techniques. IL-6 and IL-8 in sera from sarcoidosis patients were evaluated by an ELISA-based assay. Sera from sarcoidosis patients enhanced angiogenic capability of normal MNC significantly stronger than sera from healthy donors (P<0.001). Angiogenic activity of sera in sarcoidosis depended on the stage of disease and appeared most pronounced in stage II (P<0.05). Sera from patients with extrapulmonary changes exerted stronger effect on angiogenesis than sera from patients with thoracic changes only (P<0.001). IL-6 and IL-8 serum level correlated with each other, but no correlation was found between IL-6 and IL-8 serum level and angiogenic activity of the examined sera. Removal of monocytes from MNC eliminated the effect of sera from sarcoidosis patients on angiogenesis compared with the effect of these sera on intact MNC (P<0.001). Sera from sarcoidosis patients and from healthy people constitute a source of mediators participating in angiogenesis. Sera from sarcoidosis patients prime monocytes for production of proangiogenic factors.

Antibody response to influenza vaccination in patients suffering from asthma

The aim of the study was to assess humoral response to influenza vaccination in 20 children with bronchial asthma vaccinated with split inactivated vaccine. Response to influenza hemagglutinin was assessed before vaccination and after 1 month by hemagglutination inhibition test. Antibody titers were significantly higher after vaccination than before vaccination. The mean fold increase of antibody levels ranged after vaccination from 12.2 to 53.7. The post-vaccination percentage of patients with protective antihemagglutinin antibody titers>or=40 ranged from 95% to 100%. The percentage of patients with at least a 4-fold increase of anthemagglutinin antibody titers ranged after vaccination from 90% to 100%. The results confirmed the immunogenicity and safety of inactivated influenza vaccine in children with asthma. The registered values of all parameters of the immunological response (mean fold increase, protection rate, response rate) fulfilled the requirements of the Committee for Proprietary Medicinal Products established for healthy people vaccinated against influenza.