151
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Keir HR, Dicker A, Lonergan M, Crichton M, Miller BE, Tal-Singer R, Chalmers JD. Clinical endotypes of exacerbation are associated with differences in microbial composition and diversity in COPD. Eur Respir J 2020; 56:13993003.00391-2020. [PMID: 32444406 DOI: 10.1183/13993003.00391-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/07/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Holly R Keir
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK.,These authors contributed equally
| | - Alison Dicker
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK.,These authors contributed equally
| | - Mike Lonergan
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
| | - Megan Crichton
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
| | - Bruce E Miller
- Medical Innovation, GSK Pharmaceuticals R&D, Value Evidence & Outcomes, Collegeville, PA, USA
| | - Ruth Tal-Singer
- Medical Innovation, GSK Pharmaceuticals R&D, Value Evidence & Outcomes, Collegeville, PA, USA
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
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152
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Oriano M, Gramegna A, Terranova L, Sotgiu G, Sulaiman I, Ruggiero L, Saderi L, Wu B, Chalmers JD, Segal LN, Marchisio P, Blasi F, Aliberti S. Sputum neutrophil elastase associates with microbiota and Pseudomonas aeruginosa in bronchiectasis. Eur Respir J 2020; 56:13993003.00769-2020. [PMID: 32499333 DOI: 10.1183/13993003.00769-2020] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/19/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Neutrophilic inflammation is a major driver of bronchiectasis pathophysiology, and neutrophil elastase activity is the most promising biomarker evaluated in sputum to date. How active neutrophil elastase correlates with the lung microbiome in bronchiectasis is still unexplored. We aimed to understand whether active neutrophil elastase is associated with low microbial diversity and distinct microbiome characteristics. METHODS An observational, cross-sectional study was conducted at the bronchiectasis programme of the Policlinico Hospital in Milan, Italy, where adults with bronchiectasis were enrolled between March 2017 and March 2019. Active neutrophil elastase was measured on sputum collected during stable state, microbiota analysed through 16S rRNA gene sequencing, molecular assessment of respiratory pathogens carried out through real-time PCR and clinical data collected. RESULTS Among 185 patients enrolled, decreasing α-diversity, evaluated through the Shannon entropy (ρ -0.37, p<0.00001) and Pielou's evenness (ρ -0.36, p<0.00001) and richness (ρ -0.33, p<0.00001), was significantly correlated with increasing elastase. A significant difference in median levels of Shannon entropy as detected between patients with neutrophil elastase ≥20 µg·mL-1 (median 3.82, interquartile range 2.20-4.96) versus neutrophil elastase <20 µg·mL-1 (4.88, 3.68-5.80; p<0.0001). A distinct microbiome was found in these two groups, mainly characterised by enrichment with Pseudomonas in the high-elastase group and with Streptococcus in the low-elastase group. Further confirmation of the association of Pseudomonas aeruginosa with elevated active neutrophil elastase was found based on standard culture and targeted real-time PCR. CONCLUSIONS High levels of active neutrophil elastase are associated to low microbiome diversity and specifically to P. aeruginosa infection.
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Affiliation(s)
- Martina Oriano
- University of Milan, Dept of Pathophysiology and Transplantation, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy.,Dept of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Andrea Gramegna
- University of Milan, Dept of Pathophysiology and Transplantation, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Leonardo Terranova
- University of Milan, Dept of Pathophysiology and Transplantation, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Imran Sulaiman
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Luca Ruggiero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Paediatric Highly Intensive Care Unit, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Benjamin Wu
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - James D Chalmers
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Leopoldo N Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Paola Marchisio
- University of Milan, Dept of Pathophysiology and Transplantation, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Paediatric Highly Intensive Care Unit, Milan, Italy
| | - Francesco Blasi
- University of Milan, Dept of Pathophysiology and Transplantation, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Stefano Aliberti
- University of Milan, Dept of Pathophysiology and Transplantation, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
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153
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O'Neill K, Ferguson K, Cosgrove D, Tunney MM, De Soyza A, Carroll M, Chalmers JD, Gatheral T, Hill AT, Hurst JR, Johnson C, Loebinger MR, Angyalosi G, Haworth CS, Jensen R, Ratjen F, Saunders C, Short C, Davies JC, Elborn JS, Bradley JM. Multiple breath washout in bronchiectasis clinical trials: is it feasible? ERJ Open Res 2020; 6:00363-2019. [PMID: 33083441 PMCID: PMC7553113 DOI: 10.1183/23120541.00363-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/19/2020] [Indexed: 01/22/2023] Open
Abstract
Background Evaluation of multiple breath washout (MBW) set-up including staff training, certification and central "over-reading" for data quality control is essential to determine the feasibility of MBW in future bronchiectasis studies. Aims To assess the outcomes of a MBW training, certification and central over-reading programme. Methods MBW training and certification was conducted in European sites collecting lung clearance index (LCI) data in the BronchUK Clinimetrics and/or i-BEST-1 studies. The blended training programme included the use of an eLearning tool and a 1-day face-to-face session. Sites submitted MBW data to trained central over-readers who determined validity and quality. Results Thirteen training days were delivered to 56 participants from 22 sites. Of 22 sites, 18 (82%) were MBW naïve. Participant knowledge and confidence increased significantly (p<0.001). By the end of the study recruitment, 15 of 22 sites (68%) had completed certification with a mean (range) time since training of 6.2 (3-14) months. In the BronchUK Clinimetrics study, 468 of 589 (79%) tests met the quality criteria following central over-reading, compared with 137 of 236 (58%) tests in the i-BEST-1 study. Conclusions LCI is feasible in a bronchiectasis multicentre clinical trial setting; however, consideration of site experience in terms of training as well as assessment of skill drift and the need for re-training may be important to reduce time to certification and optimise data quality. Longer times to certification, a higher percentage of naïve sites and patients with worse lung function may have contributed to the lower success rate in the i-BEST-1 study.
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Affiliation(s)
- Katherine O'Neill
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University - Belfast, Belfast, UK.,On behalf of the BRONCH-UK consortium.,On behalf of the i-BEST-1 Trial Team
| | | | | | - Michael M Tunney
- School of Pharmacy, Queen's University - Belfast, Belfast, UK.,On behalf of the i-BEST-1 Trial Team
| | - Anthony De Soyza
- Newcastle University, Newcastle upon Tyne, UK.,On behalf of the BRONCH-UK consortium
| | - Mary Carroll
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,On behalf of the BRONCH-UK consortium
| | - James D Chalmers
- University of Dundee, College of Medicine, Dundee, UK.,On behalf of the BRONCH-UK consortium.,On behalf of the i-BEST-1 Trial Team
| | - Timothy Gatheral
- Department of Respiratory Medicine, University Hospitals of Morecambe Bay NHS Foundation Trust, Morecambe Bay, UK.,On behalf of the BRONCH-UK consortium
| | - Adam T Hill
- Royal Infirmary and University of Edinburgh, Edinburgh, Scotland, UK.,On behalf of the BRONCH-UK consortium
| | - John R Hurst
- UCL Respiratory, University College London, London, UK.,On behalf of the BRONCH-UK consortium
| | - Christopher Johnson
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK.,On behalf of the BRONCH-UK consortium
| | - Michael R Loebinger
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK.,On behalf of the BRONCH-UK consortium.,On behalf of the i-BEST-1 Trial Team
| | - Gerhild Angyalosi
- Novartis Pharma AG, Basel, Switzerland.,On behalf of the i-BEST-1 Trial Team
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK.,On behalf of the i-BEST-1 Trial Team
| | | | | | - Clare Saunders
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Christopher Short
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - J Stuart Elborn
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University - Belfast, Belfast, UK.,On behalf of the BRONCH-UK consortium.,On behalf of the i-BEST-1 Trial Team
| | - Judy M Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University - Belfast, Belfast, UK.,On behalf of the BRONCH-UK consortium.,On behalf of the i-BEST-1 Trial Team
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154
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Chalmers JD, Cipolla D, Thompson B, Davis AM, O'Donnell A, Tino G, Gonda I, Haworth C, Froehlich J. Changes in respiratory symptoms during 48-week treatment with ARD-3150 (inhaled liposomal ciprofloxacin) in bronchiectasis: results from the ORBIT-3 and -4 studies. Eur Respir J 2020; 56:13993003.00110-2020. [PMID: 32554534 DOI: 10.1183/13993003.00110-2020] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/21/2020] [Indexed: 12/15/2022]
Abstract
It is not known if inhaled antibiotics improve respiratory symptoms in patients with bronchiectasis. In the recent phase-3 ORBIT trials, 48 weeks' treatment with ARD-3150 (inhaled liposomal ciprofloxacin) did not significantly improve symptoms using the prespecified method of analysis comparing baseline symptoms to those after 48 weeks, when patients had been off treatment for 28 days. This method of analysis does not take account of possible improvements in symptoms while on active treatment.A post hoc analysis of two identical randomised trials of ARD-3150 (ORBIT-3 and -4) administered 28 days on and 28 days off in patients with bronchiectasis and chronic Pseudomonas aeruginosa infection. The quality-of-life bronchiectasis respiratory symptom scale (QOL-B-RSS), which has a one-week recall period, was administered every 28 days. We examined whether respiratory symptoms improved during on-treatment periods and the relationship of changes in QOL-B-RSS to changes in bacterial load using a mixed-model repeated measures approach.ARD-3150 treatment resulted in a significant improvement in respiratory symptoms during the on-treatment periods with concordant results between ORBIT-3 (estimate 1.4 points, se 0.49; p=0.004) and ORBIT-4 (estimate 1.1 point, se 0.41; p=0.006). The proportion of patients achieving a symptom improvement above the minimum clinically important difference was higher with ARD-3150 compared with placebo during on-treatment cycles (p=0.024). Changes in respiratory symptoms were correlated with changes in bacterial load in the treatment group (r=-0.89, p<0.0001). Individual estimates for decrements in the QOL-B RSS during exacerbation were -9.4 points (se 0.91) in ORBIT-3 and -10.8 points (0.74) in ORBIT-4 (both p<0.0001).Inhaled ARD-3150 resulted in significant improvements in respiratory symptoms during the on-treatment periods which were lost during off-treatment periods. These results supports the concept that reducing bacterial load can improve respiratory symptoms in patients with bronchiectasis.
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Affiliation(s)
| | - David Cipolla
- Insmed Incorporated, Bridgewater, NJ, USA.,Aradigm Corporation, Hayward, CA, USA
| | - Bruce Thompson
- Theta Hat Statistical Consultants LLC, Owings Mills, MD, USA
| | | | | | - Gregory Tino
- University of Pennsylvania, Philadelphia, PA, USA
| | - Igor Gonda
- Aradigm Corporation, Hayward, CA, USA.,Respidex LLC, Dennis, MA 02638, USA
| | - Charles Haworth
- Royal Papworth Hospital and Department of Medicine, University of Cambridge, Cambridge, UK
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155
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Spinou A, Chalmers JD. Using Airway Clearance Techniques in Bronchiectasis: Halfway There. Chest 2020; 158:1298-1300. [PMID: 33036071 DOI: 10.1016/j.chest.2020.07.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/31/2022] Open
Affiliation(s)
- Arietta Spinou
- Department of Population Health Sciences, Life Sciences and Medicine, King's College London, London, England.
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156
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Bai C, Chotirmall SH, Rello J, Alba GA, Ginns LC, Krishnan JA, Rogers R, Bendstrup E, Burgel PR, Chalmers JD, Chua A, Crothers KA, Duggal A, Kim YW, Laffey JG, Luna CM, Niederman MS, Raghu G, Ramirez JA, Riera J, Roca O, Tamae-Kakazu M, Torres A, Watkins RR, Barrecheguren M, Belliato M, Chami HA, Chen R, Cortes-Puentes GA, Delacruz C, Hayes MM, Heunks LMA, Holets SR, Hough CL, Jagpal S, Jeon K, Johkoh T, Lee MM, Liebler J, McElvaney GN, Moskowitz A, Oeckler RA, Ojanguren I, O'Regan A, Pletz MW, Rhee CK, Schultz MJ, Storti E, Strange C, Thomson CC, Torriani FJ, Wang X, Wuyts W, Xu T, Yang D, Zhang Z, Wilson KC. Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020). Eur Respir Rev 2020; 29:29/157/200287. [PMID: 33020069 PMCID: PMC7537943 DOI: 10.1183/16000617.0287-2020] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research. METHODS An International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion. RESULTS The Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder. CONCLUSIONS The Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.
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Affiliation(s)
- Chunxue Bai
- Dept of Pulmonary and Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China.,Shanghai Respiratory Research Institution, Shanghai, China
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jordi Rello
- Vall d'Hebron Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,CHU Nîmes, Nîmes, France
| | - George A Alba
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Leo C Ginns
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerry A Krishnan
- Dept of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Robert Rogers
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisabeth Bendstrup
- Center for Rare Lung Diseases, Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Pierre-Regis Burgel
- Dept of Respiratory Medicine, Cochin Hospital, Assistance Publique Hopîtaux de Paris, Université de Paris and Institut Cochin, Inserm U1016, Paris, France
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Abigail Chua
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Internal Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Kristina A Crothers
- Dept of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle WA, USA
| | - Abhijit Duggal
- Dept of Critical Care, Cleveland Clinic, Cleveland OH, USA
| | - Yeon Wook Kim
- Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - John G Laffey
- Dept of Anesthesia and Intensive Care Medicine, Galway University Hospitals, National University of Ireland, Galway, Ireland
| | - Carlos M Luna
- Dept of Medicine, Pulmonary Diseases Division, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Michael S Niederman
- Division of Pulmonary and Critical Care, Dept of Medicine, Weill Cornell Medicine, New York NY, USA
| | - Ganesh Raghu
- Dept of Medicine, University of Washington, Seattle WA, USA
| | - Julio A Ramirez
- Division of Infectious Diseases, Dept of Medicine, University of Louisville, Louisville KY, USA
| | - Jordi Riera
- Vall d'Hebron Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Critical Care Dept, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain.,Dept de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Oriol Roca
- Vall d'Hebron Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Critical Care Dept, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain.,Dept de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Maximiliano Tamae-Kakazu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Spectrum Health-Michigan State University, Grand Rapids MI, USA
| | - Antoni Torres
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Pulmonology Dept, University of Barcelona Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Richard R Watkins
- Dept of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA.,Division of Infectious Diseases, Cleveland Clinic Akron General, Akron, OH, USA
| | - Miriam Barrecheguren
- Respiratory Dept, Vall d'Hebron University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Madrid, Spain
| | - Mirko Belliato
- UOC Anestesia e Rianimazione 1, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Hassan A Chami
- Dept of Medicine, American University of Beirut, Beirut, Lebanon
| | - Rongchang Chen
- Dept of Pulmonary and Critical Care Medicine, Shenzhen Institute of Respiratory Disease, Shenzhen People's Hospital, First Affiliated Hospital of South University of Science and Technology of China, Shenzhen, China
| | | | - Charles Delacruz
- Dept of Medicine, Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven CT, USA
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Leo M A Heunks
- Dept of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Catherine L Hough
- Division of Pulmonary and Critical Care, Dept of Medicine, Oregon Health Sciences University, Portland, OR, USA
| | - Sugeet Jagpal
- Dept of Medicine, Robert Wood Johnson University Hospital, New Brunswick NJ, USA
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Takeshi Johkoh
- Dept of Radiology, Kansai Rosai Hospital, Amagaski, Japan
| | - May M Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Internal Medicine, University of Southern California, Los Angeles CA, USA
| | - Janice Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Internal Medicine, University of Southern California, Los Angeles CA, USA
| | - Gerry N McElvaney
- Department of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ari Moskowitz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA
| | | | - Iñigo Ojanguren
- Respiratory Dept, Vall d'Hebron University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Madrid, Spain
| | - Anthony O'Regan
- Dept of Respiratory Medicine, Galway University Hospitals, National University of Ireland, Galway, Ireland
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Enrico Storti
- Dept of Anesthesia and Critical Care, Ospedale Maggiore di Lodi, Lodi, Italy
| | - Charlie Strange
- Dept of Medicine, Medical University of South Carolina, Charleston SC, USA
| | - Carey C Thomson
- Division of Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Cambridge MA, Harvard Medical School, Boston MA, USA
| | - Francesca J Torriani
- Infection Prevention and Clinical Epidemiology Unit at UC San Diego Health, Division of Infectious Diseases and Global Public Health, Department of Medicine, UC San Diego, San Diego CA, USA
| | - Xun Wang
- Dept of Pulmonary and Critical Care Medicine, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Wim Wuyts
- Dept of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Tao Xu
- Dept of Pulmonary and Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Dawei Yang
- Dept of Pulmonary and Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China.,Shanghai Respiratory Research Institution, Shanghai, China
| | - Ziqiang Zhang
- Dept of Pulmonary and Critical Care Medicine, Tongji Hospital Tongji University, Shanghai, China
| | - Kevin C Wilson
- Dept of Medicine, Boston University School of Medicine, Boston, MA, USA
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157
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Singh D, Wedzicha JA, Siddiqui S, de la Hoz A, Xue W, Magnussen H, Miravitlles M, Chalmers JD, Calverley PMA. Blood eosinophils as a biomarker of future COPD exacerbation risk: pooled data from 11 clinical trials. Respir Res 2020; 21:240. [PMID: 32943047 PMCID: PMC7499955 DOI: 10.1186/s12931-020-01482-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/06/2020] [Indexed: 12/23/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow limitation and chronic inflammation. Predicting exacerbations of COPD, which contribute to disease progression, is important to guide preventative treatment and improve outcomes. Blood eosinophils are a biomarker for patient responsiveness to inhaled corticosteroids (ICS); however, their effectiveness as a predictive biomarker for COPD exacerbations is unclear. Methods This post hoc analysis pooled data from 11 Boehringer Ingelheim-sponsored Phase III and IV randomised COPD studies with similar methodologies. Exacerbation data were collected from these studies, excluding patients from the ICS withdrawal arm of the WISDOM® study. Patients were grouped according to their baseline blood eosinophil count, baseline ICS use and number of exacerbations in the year prior to each study. Results Exacerbation rate data and baseline eosinophil count were available for 22,125 patients; 45.6% presented with a baseline blood eosinophil count of ≤ 150 cells/μL, 34.3% with 150–300 cells/μL and 20.1% with > 300 cells/μL. The lowest exacerbation rates were observed in patients with ≤ 150 cells/μL, with small increases in exacerbation rate observed with increasing eosinophil count. When stratified by exacerbation history, the annual rate of exacerbations for patients with 0 exacerbations in the previous year increased in line with increasing eosinophil counts (0.38 for ≤ 150 cells/μL, 0.39 for 150–300 cells/μL and 0.44 for > 300 cells/μL respectively). A similar trend was identified for patients with one exacerbation in the previous year, 0.62, 0.66 and 0.67 respectively. For patients with ≥ 2 exacerbations, exacerbation rates fluctuated between 1.02 (≤ 150 cells/μL) to 1.10 (150–300 cells/μL) and 1.07 (> 300 cells/μL). Higher exacerbation rates were noted in patients treated with ICS at baseline (range 0.75 to 0.82 with increasing eosinophil count) compared with patients not on ICS (range 0.45 to 0.49). Conclusion We found no clinically important relationship between baseline blood eosinophil count and exacerbation rate. Hence, the current analysis does not support the use of blood eosinophils to predict exacerbation risk; however, previous exacerbation history was found to be a more reliable predictor of future exacerbations. Trial registration ClinicalTrials.gov Identifiers: NCT00168844, NCT00168831, NCT00387088, NCT00782210, NCT00782509, NCT00793624, NCT00796653, NCT01431274, NCT01431287, NCT02296138 and NCT00975195. Graphical abstract ![]()
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Jadwiga A Wedzicha
- Respiratory Division, National Heart and Lung Institute, Imperial College London, London, UK
| | - Salman Siddiqui
- NIHR Leicester Biomedical Research Centre: Respiratory Theme, and Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wenqiong Xue
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Grosshansdorf, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
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Affiliation(s)
- James D Chalmers
- Division of Molecular and Clinical Medicine University of Dundee Dundee, United Kingdom and
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine Nanyang Technological University Singapore, Singapore
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159
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Huang JTJ, Kuzmanova E, Dicker AJ, Keir HR, Finch S, Aliberti S, Fardon TC, Chalmers JD. Serum Desmosine Is Associated with Long-Term All-Cause and Cardiovascular Mortality in Bronchiectasis. Am J Respir Crit Care Med 2020; 202:897-899. [DOI: 10.1164/rccm.202002-0434le] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | | | - Stefano Aliberti
- University of MilanMilan, Italyand
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cá Granda Ospedale Maggiore PoliclinicoMilan, Italy
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160
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Chalmers JD, Lonergan M. A cuckoo COVID coincidence? Eur Respir J 2020; 56:13993003.03236-2020. [PMID: 32907889 PMCID: PMC7487271 DOI: 10.1183/13993003.03236-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Abstract
We are grateful to A.H. Morice for his reminder of the limits of observational data, and the need for caution in its interpretation. And we accept that it is unlikely to ever be proved conclusively that the dramatic restrictions imposed as countries locked down caused the dramatic changes in epidemic trajectories, even though the epidemiological changes seemed to follow the behavioural changes. However, there is also a large logical leap from observing the Swedish data to inferring that social distancing “measures can only have had a minor effect”. There are limitations to inferring causality from observational data, but lockdowns have almost certainly saved lives worldwidehttps://bit.ly/2YWAhhl
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Affiliation(s)
- James D Chalmers
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Mike Lonergan
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
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161
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Siddiqui MK, Parcell B, Allstaff S, Palmer C, Chalmers JD, Bell S. Characteristics and outcomes of health and social care workers testing positive for SARS-CoV-2 in the Tayside region of Scotland. Eur Respir J 2020; 56:2002568. [PMID: 32675210 PMCID: PMC7366178 DOI: 10.1183/13993003.02568-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 12/03/2022]
Abstract
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and reported outcomes among health and social care workers (HSCWs) is concerning [1–3]. Early in the outbreak it was recommended in the UK that HSCWs experiencing symptoms of a cough or fever remain absent from work for 7 days. In order to address this problem, National Health Service (NHS) Tayside, a health board in Scotland covering a population of 400,000, was the first in Scotland to set up a drive-through testing programme for HSCWs, other key workers and their symptomatic household contacts (including children), with results available within 24 h, allowing staff to return to work following a negative test [4]. As testing for SARS-CoV-2 was limited to hospitalised patients across much of Europe there is limited data on the self-reported clinical characteristics and outcomes of patients in the community with coronavirus disease 2019 (COVID-19). Here, we report characteristics and outcomes of HSCWs presenting to the drive-through testing centre who tested positive for SARS-CoV-2 on a combined nasal and pharyngeal swab. Anonymised record linkage was conducted between routinely collected healthcare datasets in order to ascertain clinical characteristics and outcomes of those who tested positive. All hospitalisations until 25 April and deaths until 20 May, 2020 were recorded. Approval was obtained from the local data protection officer (Caldicott Guardian). Tayside, Scotland was one of the first health boards to institute testing for all symptomatic workers. As expected, there was a high prevalence of SARS-CoV-2 among health and social care workers; however, in most cases disease was mild. https://bit.ly/38JaUmB
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Affiliation(s)
- Moneeza K Siddiqui
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Benjamin Parcell
- Dept of Medical Microbiology, Ninewells Hospital and Medical School, Dundee, UK
| | - Sarah Allstaff
- Tayside Sexual and Reproductive Health Service, Ninewells Hospital and Medical School, Dundee, UK
| | - Colin Palmer
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
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162
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Denning J, Powell P, Chalmers JD. Providing answers to respiratory patients' questions during COVID-19. Breathe (Sheff) 2020; 16:200219. [PMID: 33447282 PMCID: PMC7792813 DOI: 10.1183/20734735.0219-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The European Lung Foundation (ELF) brings patients and the public together with respiratory professionals to positively influence lung health, and regularly provides reliable information that has been co-produced by patients and professionals (from the European Respiratory Society (ERS)) and is available in multiple languages. Quickly publishing questions from people with lung conditions, answered by experts in multiple languages, provided a well-accessed source of evidence-based support for individuals across the globe during the first wave of the #COVID19 pandemichttps://bit.ly/2F5ZP4k
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163
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Gao YH, Abo Leyah H, Finch S, Lonergan M, Aliberti S, De Soyza A, Fardon TC, Tino G, Chalmers JD. Relationship between Symptoms, Exacerbations, and Treatment Response in Bronchiectasis. Am J Respir Crit Care Med 2020; 201:1499-1507. [PMID: 32097051 DOI: 10.1164/rccm.201910-1972oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Rationale: Bronchiectasis guidelines regard treatment to prevent exacerbation and treatment of daily symptoms as separate objectives.Objectives: We hypothesized that patients with greater symptoms would be at higher risk of exacerbations and therefore that a treatment aimed at reducing daily symptoms would also reduce exacerbations in highly symptomatic patients.Methods: Our study comprised an observational cohort of 333 patients from the East of Scotland (2012-2016). Either symptoms were modeled as a continuous variable or patients were classified as having high, moderate, or low symptom burden (>70, 40-70, and <40 using the St. George's Respiratory Questionnaire symptom score). The hypothesis that exacerbation reductions would only be evident in highly symptomatic patients was tested in a post hoc analysis of a randomized trial of inhaled dry powder mannitol (N = 461 patients).Measurements and Main Results: In the observational cohort, daily symptoms were a significant predictor of future exacerbations (rate ratio [RR], 1.10; 95% confidence interval [CI], 1.03-1.17; P = 0.005). Patients with higher symptom scores had higher exacerbation rates (RR, 1.74; 95% CI, 1.12-2.72; P = 0.01) over 12-month follow-up than those with lower symptoms. Inhaled mannitol treatment improved the time to first exacerbation (hazard ratio, 0.56; 95% CI, 0.40-0.77; P < 0.001), and the proportion of patients remaining exacerbation free for 12 months of treatment was higher in the mannitol group (32.7% vs. 14.6%; RR, 2.84; 95% CI, 1.40-5.76; P = 0.003), but only in highly symptomatic patients. In contrast, no benefit was evident in patients with lower symptom burden.Conclusions: Highly symptomatic patients have increased risk of exacerbations, and exacerbation benefit with inhaled mannitol was only evident in patients with high symptom burden.
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Affiliation(s)
- Yong-Hua Gao
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Hani Abo Leyah
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Simon Finch
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Mike Lonergan
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Anthony De Soyza
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; and
| | - Thomas C Fardon
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Gregory Tino
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Chalmers
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
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164
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Parcell BJ, Brechin K, Allstaff S, Park M, Third W, Bean S, Hind C, Farmer R, Chandler D, Chalmers JD. Drive-through testing for SARS-CoV-2 in symptomatic health and social care workers and household members: an observational cohort study. Thorax 2020; 75:1109-1111. [PMID: 32855343 PMCID: PMC7677465 DOI: 10.1136/thoraxjnl-2020-215128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 11/24/2022]
Abstract
The requirement for health and social care workers to self-isolate when they or their household contacts develop symptoms consistent with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can lead to critical staff shortages in the context of a pandemic. In this report, we describe the implementation of a drive-through testing service in a single National Health Service region in Scotland. From 17 March 2020 to 11 April 2020, 1890 SARS-CoV-2 reverse transcription PCR assay (RT-PCR) tests were performed. 22% of tests were positive. Allowing the remaining 78% of staff to return to work within 24 hours was estimated to save over 8000 working days during the peak pandemic period.
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Affiliation(s)
- Benjamin J Parcell
- Department of Medical Microbiology, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Sarah Allstaff
- Tayside Sexual and Reproductive Health Service, Ninewells Hospital and Medical School, Dundee, UK
| | - Meg Park
- Department of Medicine and Cardiovascular, Ninewells Hospital and Medical School, Dundee, UK
| | - Wendy Third
- Dundee Health and Social Care Partnership, Dundee, UK
| | - Susan Bean
- Department of Medicine and Cardiovascular, Ninewells Hospital and Medical School, Dundee, UK
| | - Chris Hind
- Department of Medical Microbiology, Ninewells Hospital and Medical School, Dundee, UK
| | - Rajiv Farmer
- Virology Department, Ninewells Hospital and Medical School, Dundee, UK
| | | | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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165
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Loebinger MR, Polverino E, Chalmers JD, Tiddens HA, Goossens H, Tunney M, Ringshausen FC, Hill AT, Pathan R, Angyalosi G, Blasi F, Elborn SJ, Haworth CS. Efficacy and safety of TOBI Podhaler in Pseudomonas aeruginosa-infected bronchiectasis patients: iBEST study. Eur Respir J 2020; 57:13993003.01451-2020. [DOI: 10.1183/13993003.01451-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/18/2020] [Indexed: 12/24/2022]
Abstract
The study aimed to determine the efficacy of a safe and well-tolerated dose and regimen of tobramycin inhalation powder (TIP) on Pseudomonas aeruginosa sputum density in patients with bronchiectasis.This is a phase II, double-blind, randomised study in bronchiectasis patients aged ≥18 years with chronic P. aeruginosa infection. Patients were randomised 1:1:1 to either cohort A: three capsules of TIP once daily (84 mg); cohort B: five capsules once daily (140 mg) or cohort C: four capsules twice daily (224 mg). Within each cohort, patients were further randomised 2:2:1 either to TIP continuously, TIP cyclically (alternating 28 days of TIP and placebo) or placebo for 16 weeks, respectively and were followed up for 8 weeks.Overall, 107 patients were randomised to cohorts A (n=34), B (n=36) and C (n=37). All three TIP doses significantly reduced the P. aeruginosa sputum density from baseline to day 29 versus placebo in a dose-dependent manner (p≤0.0001, each). A smaller proportion of patients in the continuous-TIP (34.1%) and cyclical-TIP (35.7%) groups experienced pulmonary exacerbations versus placebo (47.6%) and also required fewer anti-pseudomonal antibiotics (38.6% on continuous TIP and 42.9% on cyclical TIP) versus placebo (57.1%) although not statistically significant. Pulmonary exacerbation of bronchiectasis was the most frequent (37.4%) adverse event. Overall, TIP was well tolerated, however, 23.4% of the patients discontinued the study drug due to adverse events.Continuous- and cyclical-TIP regimens with all three doses were safe and effective in reducing the P. aeruginosa sputum density in patients with bronchiectasis and chronic P. aeruginosa infection.
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166
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Pletz MW, Blasi F, Chalmers JD, Dela Cruz CS, Feldman C, Luna CM, Ramirez JA, Shindo Y, Stolz D, Torres A, Webb B, Welte T, Wunderink R, Aliberti S. International Perspective on the New 2019 American Thoracic Society/Infectious Diseases Society of America Community-Acquired Pneumonia Guideline: A Critical Appraisal by a Global Expert Panel. Chest 2020; 158:1912-1918. [PMID: 32858009 PMCID: PMC7445464 DOI: 10.1016/j.chest.2020.07.089] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/29/2020] [Accepted: 07/22/2020] [Indexed: 01/22/2023] Open
Abstract
In 2019, the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) issued a substantial revision of the 2007 guideline on community-acquired pneumonia (CAP). Despite the fact that generalization of infectious disease guidelines is limited because of substantial geographic differences in microbiologic etiology and antimicrobial resistance, the ATS/IDSA guideline is frequently applied outside the United States. Therefore, this project aimed to give a perspective on the ATS/IDSA CAP recommendations related to the management of CAP outside the United States. For this, an expert panel composed of 14 international key opinion leaders in the field of CAP from 10 countries across five continents, who were not involved in producing the 2019 guideline, was asked to subjectively name the five most useful changes, the recommendation viewed most critically, and the recommendation that cannot be applied to their respective region. There was no formal consensus process, and the article reflects different opinions. Recommendations welcomed by most of the international pneumonia experts included the abandonment of the concept of “health-care-associated pneumonia,” the more restrictive indication for empiric macrolide treatment in outpatients, the increased emphasis on microbiologic diagnostics, and addressing the use of corticosteroids. Main criticisms included the somewhat arbitrary choice of a 25% resistance threshold for outpatient macrolide monotherapy. Experts from areas with elevated mycobacterial prevalence particularly opposed the recommendation of fluoroquinolones, even as an alternative.
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Affiliation(s)
- Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany (member of the CAPNETZ Foundation).
| | - Francesco Blasi
- Respiratory Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Charles S Dela Cruz
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University School of Medicine, New Haven, CT
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carlos M Luna
- Pulmonary Diseases Division, Department of Medicine, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Julio A Ramirez
- Division of Infectious Diseases, Department of Medicine, University of Louisville Health Sciences Center, Louisville, KY
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daiana Stolz
- Pneumology and Pulmonary Cell Research, Departments of Respiratory Medicine and Biomedicine, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Institució Catalana de Recerca i Estudis Avançats (ICREA) Academia, Barcelona, Spain
| | - Brandon Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School (member of the German Center of Lung Research and the CAPNETZ Foundation), Hannover, Germany
| | - Richard Wunderink
- Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Stefano Aliberti
- Respiratory Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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167
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Flume PA, Griffith DE, Chalmers JD, Daley CL, Olivier K, O'Donnell A, Aksamit T, Kasperbauer S, Leitman A, Winthrop KL. Development of Drugs for Nontuberculous Mycobacterial Disease: Clinicians' Interpretation of a US Food and Drug Administration Workshop. Chest 2020; 159:537-543. [PMID: 32853648 DOI: 10.1016/j.chest.2020.08.2055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/09/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022] Open
Abstract
The US Food and Drug Administration convened a workshop to discuss clinical trial design challenges and considerations related to the treatment of nontuberculous mycobacterial pulmonary disease, to include topics such as clinical trial end points, duration, and populations. The clinicians participating in the meeting provide here their interpretation of the discussion, which included US Food and Drug Administration and industry representatives. The treatment of nontuberculous mycobacterial pulmonary disease typically includes multiple antibiotics for a prolonged period and can be difficult to tolerate; there is a great need for new treatment options. Most individuals have a microbiologic response to therapy, but data correlating decreasing bacillary load with patient-reported outcomes or measured functional improvement are lacking. Accordingly, trial designs for new therapeutic agents should incorporate both microbiologic and clinical outcome measures and select appropriate study candidates with capacity for measurable change of such outcome measures. The need for shorter study designs, early primary end points, and placebo control arms was highlighted during the workshop.
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Affiliation(s)
- Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC.
| | | | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, Scotland
| | - Charles L Daley
- Department of Medicine, National Jewish Health and the University of Colorado, Denver, CO
| | - Kenneth Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung and Blood Institute/National Institutes of Health, Bethesda, MD
| | - Anne O'Donnell
- Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Medical Center, Washington, DC
| | - Timothy Aksamit
- Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Shannon Kasperbauer
- Department of Medicine, National Jewish Health and the University of Colorado, Denver, CO
| | | | - Kevin L Winthrop
- Division of Infectious Disease, Oregon Health and Science University Schools of Public Health and Medicine, Portland, OR
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168
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Wilkinson T, Dixon R, Page C, Carroll M, Griffiths G, Ho LP, De Soyza A, Felton T, Lewis KE, Phekoo K, Chalmers JD, Gordon A, McGarvey L, Doherty J, Read RC, Shankar-Hari M, Martinez-Alier N, O’Kelly M, Duncan G, Walles R, Sykes J, Summers C, Singh D. ACCORD: A Multicentre, Seamless, Phase 2 Adaptive Randomisation Platform Study to Assess the Efficacy and Safety of Multiple Candidate Agents for the Treatment of COVID-19 in Hospitalised Patients: A structured summary of a study protocol for a randomised controlled trial. Trials 2020; 21:691. [PMID: 32736596 PMCID: PMC7393340 DOI: 10.1186/s13063-020-04584-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Stage 1: To evaluate the safety and efficacy of candidate agents as add-on therapies to standard of care (SoC) in patients hospitalised with COVID-19 in a screening stage. Stage 2: To confirm the efficacy of candidate agents selected on the basis of evidence from Stage 1 in patients hospitalised with COVID-19 in an expansion stage. TRIAL DESIGN ACCORD is a seamless, Phase 2, adaptive, randomised controlled platform study, designed to rapidly test candidate agents in the treatment of COVID-19. Designed as a master protocol with each candidate agent being included via its own sub-protocol, initially randomising equally between each candidate and a single contemporaneous SoC arm (which can adapt into 2:1). Candidate agents currently include bemcentinib, MEDI3506, acalabrutinib, zilucoplan and nebulised heparin. For each candidate a total of 60 patients will be recruited in Stage 1. If Stage 1 provides evidence of efficacy and acceptable safety the candidate will enter Stage 2 where a total of approximately 126 patients will be recruited into each study arm sub-protocol. Enrollees and outcomes will not be shared across the Stages; the endpoint, analysis and sample size for Stage 2 may be adjusted based on evidence from Stage 1. Additional arms may be added as new potential candidate agents are identified via candidate agent specific sub-protocols. PARTICIPANTS The study will include hospitalised adult patients (≥18 years) with confirmed SARS-CoV-2 infection, the virus that causes COVID-19, that clinically meet Grades 3 (hospitalised - mild disease, no oxygen therapy), Grades 4 (hospitalised, oxygen by mask or nasal prongs) and 5 (hospitalised, non-invasive ventilation or high flow oxygen) of the WHO Working Group on the Clinical Characteristics of COVID-19 9-point category ordinal scale. Participants will be recruited from England, Northern Ireland, Wales and Scotland. INTERVENTION AND COMPARATOR Comparator is current standard of care (SoC) for the treatment of COVID-19. Current candidate experimental arms include bemcentinib, MEDI3506, acalabrutinib, zilucoplan and nebulised heparin with others to be added over time. Bemcentinib could potentially reduce viral infection and blocks SARS-CoV-2 spike protein; MEDI3506 is a clinic-ready anti-IL-33 monoclonal antibody with the potential to treat respiratory failure caused by COVID; acalabrutinib is a BTK inhibitor which is anti-viral and anti-inflammatory; zilucoplan is a complement C5 inhibitor which may block the severe inflammatory response in COVID-19 and; nebulised heparin has been shown to bind with the spike protein. ACCORD is linked with the UK national COVID therapeutics task force to help prioritise candidate agents. MAIN OUTCOMES Time to sustained clinical improvement of at least 2 points (from randomisation) on the WHO 9-point category ordinal scale, live discharge from the hospital, or considered fit for discharge (a score of 0, 1, or 2 on the ordinal scale), whichever comes first, by Day 29 (this will also define the "responder" for the response rate analyses). RANDOMISATION An electronic randomization will be performed by Cenduit using Interactive Response Technology (IRT). Randomisation will be stratified by baseline severity grade. Randomisation will proceed with an equal allocation to each arm and a contemporaneous SoC arm (e.g. 1:1 if control and 1 experimental arm; 1:1:1 if two experimental candidate arms etc) but will be reviewed as the trial progresses and may be changed to 2:1 in favour of the candidate agents. BLINDING (MASKING) The trial is open label and no blinding is currently planned in the study. NUMBERS TO BE RANDOMISED (SAMPLE SIZE) This will be in the order of 60 patients per candidate agent for Stage 1, and 126 patients for Stage 2. However, sample size re-estimation may be considered after Stage 1. It is estimated that up to 1800 patients will participate in the overall study. TRIAL STATUS Master protocol version ACCORD-2-001 - Master Protocol (Amendment 1) 22nd April 2020, the trial has full regulatory approval and recruitment is ongoing in the bemcentinib (first patient recruited 6/5/2020), MEDI3506 (first patient recruited 19/5/2020), acalabrutinib (first patient recruited 20/5/2020) and zilucoplan (first patient recruited 19/5/2020) candidates (and SoC). The recruitment dates of each arm will vary between candidate agents as they are added or dropped from the trial, but will have recruited and reported within a year. TRIAL REGISTRATION EudraCT 2020-001736-95 , registered 28th April 2020. FULL PROTOCOL The full protocol (Master Protocol with each of the candidate sub-protocols) is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
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Affiliation(s)
- Tom Wilkinson
- University of Southampton, Southampton, Hampshire UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
| | | | | | | | | | - Ling-Pei Ho
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Anthony De Soyza
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Timothy Felton
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | | | - Karen Phekoo
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | | | - Jillian Doherty
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert C. Read
- University of Southampton, Southampton, Hampshire UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
| | | | - Nuria Martinez-Alier
- IQVIA, Reading, UK
- Evelina London Children’s Hospital Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Dave Singh
- University of Manchester, Manchester, UK
| | - on behalf of the ACCORD Collaborators
- University of Southampton, Southampton, Hampshire UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
- IQVIA, Reading, UK
- King’s College London, London, UK
- Public Health England, London, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
- Swansea University, Swansea, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Dundee, Dundee, UK
- Imperial College London, London, UK
- Queen’s University Belfast, Belfast, UK
- Evelina London Children’s Hospital Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
- IQVIA, Dublin, Ireland
- IQVIA, Edinburgh, UK
- University of Cambridge, Cambridge, UK
- University of Manchester, Manchester, UK
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Lonergan M, Chalmers JD. Estimates of the ongoing need for social distancing and control measures post-"lockdown" from trajectories of COVID-19 cases and mortality. Eur Respir J 2020; 56:13993003.01483-2020. [PMID: 32482785 PMCID: PMC7263071 DOI: 10.1183/13993003.01483-2020] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 01/09/2023]
Abstract
By 21 May 2020, severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) had caused more than 5 million cases of coronavirus 2019 (COVID-19) across more than 200 countries. Most countries with significant outbreaks have introduced social distancing or “lockdown” measures to reduce viral transmission. So the key question now is when, how and to what extent these measures can be lifted. Publicly available data on daily numbers of newly confirmed cases and mortality were used to fit regression models estimating trajectories, doubling times and the reproduction number (R0) of the disease, before and under the control measures. These data ran up to 21 May 2020, and were sufficient for analysis in 89 countries. The estimates of R0 before lockdown based on these data were broadly consistent with those previously published: between 2.0 and 3.7 in the countries with the largest number of cases available for analysis (USA, Italy, Spain, France and UK). There was little evidence to suggest that the restrictions had reduced R far below 1 in many places, with France having the most rapid reductions: R0 0.76 (95% CI 0.72–0.82) based on cases, and 0.77 (95% CI 0.73–0.80) based on mortality. Intermittent lockdown has been proposed as a means of controlling the outbreak while allowing periods of increased freedom and economic activity. These data suggest that few countries could have even 1 week per month unrestricted without seeing resurgence of the epidemic. Similarly, restoring 20% of the activity that has been prevented by the lockdowns looks difficult to reconcile with preventing the resurgence of the disease in most countries. Data from multiple countries show that current restrictions on behaviour barely contain the spread of COVID-19. Resuming 20% of the currently excluded contact between individuals looks sufficient to restart the epidemic's progression in many countries.https://bit.ly/2B4dIOw
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Affiliation(s)
- Mike Lonergan
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
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170
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Crichton ML, Lonergan M, Barker AF, Sibila O, Goeminne P, Shoemark A, Chalmers JD. Inhaled aztreonam improves symptoms of cough and sputum production in patients with bronchiectasis: a post hoc analysis of the AIR-BX studies. Eur Respir J 2020; 56:13993003.00608-2020. [PMID: 32265309 DOI: 10.1183/13993003.00608-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/31/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Inhaled antibiotics may improve symptom scores, but it is not known which specific symptoms improve with therapy. Item-level analysis of questionnaire data may allow us to identify which specific symptoms respond best to treatment. METHODS Post hoc analysis of the AIR-BX1 studies and two trials of inhaled aztreonam versus placebo in bronchiectasis. Individual items from the quality of life bronchiectasis (QOL-B) respiratory symptom scale, were extracted as representing severity of nine distinct symptoms. Generalised linear models were used to evaluate changes in symptoms with treatment versus placebo from baseline to end of first on-treatment cycle and mixed models were used to evaluate changes across the full 16-week trial. RESULTS Aztreonam improved cough (difference 0.22, 95% CI 0.08-0.37; p=0.002), sputum production (0.30, 95% CI 0.15-0.44; p<0.0001) and sputum colour (0.29, 95% CI 0.15-0.43; p<0.0001) versus placebo equating to a 20% improvement in cough and 25% improvement in sputum production and colour. Similar results were observed for cough, sputum production and sputum purulence across the trial duration (all p<0.05). Patients with higher sputum production and sputum colour scores had a greater response on the overall QOL-B (difference 4.82, 95% CI 1.12-8.53; p=0.011 for sputum production and 5.02, 95% CI 1.19-8.86; p=0.01 for sputum colour). In contrast, treating patients who had lower levels of bronchitic symptoms resulted in shorter time to next exacerbation (hazard ratio 1.83, 95% CI 1.02-3.28; p=0.042). CONCLUSION Baseline bronchitic symptoms predict response to inhaled aztreonam in bronchiectasis. More sensitive tools to measure bronchitic symptoms may be useful to better identify inhaled antibiotic responders and to evaluate patient response to treatment.
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Affiliation(s)
- Megan L Crichton
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Mike Lonergan
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alan F Barker
- Division of Pulmonology and Critical Care, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Oriol Sibila
- Dept of Respiratory Medicine, Hospital Clinic, Barcelona, Spain
| | - Pieter Goeminne
- Dept of Respiratory Medicine, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Amelia Shoemark
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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171
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Affiliation(s)
- James D Chalmers
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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172
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Lonergan M, Dicker AJ, Crichton ML, Keir HR, Van Dyke MK, Mullerova H, Miller BE, Tal-Singer R, Chalmers JD. Blood neutrophil counts are associated with exacerbation frequency and mortality in COPD. Respir Res 2020; 21:166. [PMID: 32611352 PMCID: PMC7329438 DOI: 10.1186/s12931-020-01436-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/25/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Identifying patients with COPD at increased risk of poor outcomes is challenging due to disease heterogeneity. Potential biomarkers need to be readily available in real-life clinical practice. Blood eosinophil counts are widely studied but few studies have examined the prognostic value of blood neutrophil counts (BNC). METHODS In a large population-based COPD registry in the East of Scotland (TARDIS: Tayside Allergic and Respiratory Disease Information System), BNC were compared to measures of disease severity and mortality for up to 15 years follow-up. Potential mechanisms of disease modification by BNC were explored in a nested microbiome substudy. RESULTS 178,120 neutrophil counts were obtained from 7220 people (mean follow up 9 years) during stable disease periods. Median BNC was 5200cells/μL (IQR 4000-7000cells/μL). Mortality rates among the 34% of patients with elevated BNCs (defined as 6000-15000cells/μL) at the study start were 80% higher (14.0/100 person years v 7.8/100py, P < 0.001) than those with BNC in the normal range (2000-6000cells/μL). People with elevated BNC were more likely to be classified as GOLD D (46% v 33% P < 0.001), have more exacerbations (mean 2.3 v 1.3/year, P < 0.001), and were more likely to have severe exacerbations (13% vs. 5%, P < 0.001) in the following year. Eosinophil counts were much less predictive of these outcomes. In a sub-cohort (N = 276), patients with elevated BNC had increased relative abundance of Proteobacteria and reduced microbiome diversity. CONCLUSION High BNC may provide a useful indicator of risk of exacerbations and mortality in COPD patients.
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Affiliation(s)
- Mike Lonergan
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Alison J Dicker
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Megan L Crichton
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Holly R Keir
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Melissa K Van Dyke
- Epidemiology, Value Evidence and Outcomes, GSK R&D, Collegeville, PA, USA
| | - Hana Mullerova
- Epidemiology, Value Evidence and Outcomes, GSK R&D, Uxbridge, UK
| | - Bruce E Miller
- Medical Innovation, Value Evidence and Outcomes, GSK R&D, Collegeville, PA, USA
| | - Ruth Tal-Singer
- Medical Innovation, Value Evidence and Outcomes, GSK R&D, Collegeville, PA, USA
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
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173
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Affiliation(s)
- Yong-Hua Gao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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174
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Gramegna A, Aliberti S, Sibila O, Di Francesco C, Sotgiu G, Perea L, Terranova L, Oriano M, Pilocane T, Saderi L, Chalmers JD, Marchisio P, Blasi F. Sputum neutrophil elastase in bronchiectasis: a Southern European cohort study. Eur Respir J 2020; 56:2001702. [PMID: 32586875 DOI: 10.1183/13993003.01702-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/03/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Andrea Gramegna
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Disease and Adult Cystic Fibrosis Center, Milan, Italy
| | - Stefano Aliberti
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Disease and Adult Cystic Fibrosis Center, Milan, Italy
| | - Oriol Sibila
- Respiratory Department, Hospital Clinic, IDIBAPS, CIBERES, Barcelona, Spain
| | - Carlotta Di Francesco
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Lidia Perea
- Inflammatory Diseases, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Leonardo Terranova
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Disease and Adult Cystic Fibrosis Center, Milan, Italy
| | - Martina Oriano
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Disease and Adult Cystic Fibrosis Center, Milan, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Tommaso Pilocane
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Disease and Adult Cystic Fibrosis Center, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Paola Marchisio
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Paediatric Highly Intensive Care Unit, Milan, Italy
| | - Francesco Blasi
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Disease and Adult Cystic Fibrosis Center, Milan, Italy
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175
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Davies KA, Fitzgibbon C, Young SN, Garnish SE, Yeung W, Coursier D, Birkinshaw RW, Sandow JJ, Lehmann WIL, Liang LY, Lucet IS, Chalmers JD, Patrick WM, Kannan N, Petrie EJ, Czabotar PE, Murphy JM. Distinct pseudokinase domain conformations underlie divergent activation mechanisms among vertebrate MLKL orthologues. Nat Commun 2020; 11:3060. [PMID: 32561735 PMCID: PMC7305131 DOI: 10.1038/s41467-020-16823-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022] Open
Abstract
The MLKL pseudokinase is the terminal effector in the necroptosis cell death pathway. Phosphorylation by its upstream regulator, RIPK3, triggers MLKL's conversion from a dormant cytoplasmic protein into oligomers that translocate to, and permeabilize, the plasma membrane to kill cells. The precise mechanisms underlying these processes are incompletely understood, and were proposed to differ between mouse and human cells. Here, we examine the divergence of activation mechanisms among nine vertebrate MLKL orthologues, revealing remarkable specificity of mouse and human RIPK3 for MLKL orthologues. Pig MLKL can restore necroptotic signaling in human cells; while horse and pig, but not rat, MLKL can reconstitute the mouse pathway. This selectivity can be rationalized from the distinct conformations observed in the crystal structures of horse and rat MLKL pseudokinase domains. These studies identify important differences in necroptotic signaling between species, and suggest that, more broadly, divergent regulatory mechanisms may exist among orthologous pseudoenzymes.
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Affiliation(s)
- Katherine A Davies
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Cheree Fitzgibbon
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Samuel N Young
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Sarah E Garnish
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Wayland Yeung
- Institute of Bioinformatics, University of Georgia, Athens, GA, 30602, USA
| | - Diane Coursier
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Richard W Birkinshaw
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Jarrod J Sandow
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Wil I L Lehmann
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Lung-Yu Liang
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Isabelle S Lucet
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - James D Chalmers
- Department of Biochemistry, University of Otago, Dunedin, 9054, New Zealand
| | - Wayne M Patrick
- School of Biological Sciences, Victoria University of Wellington, Wellington, 6140, New Zealand
| | - Natarajan Kannan
- Institute of Bioinformatics, University of Georgia, Athens, GA, 30602, USA
| | - Emma J Petrie
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Peter E Czabotar
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - James M Murphy
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia.
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176
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Affiliation(s)
- James D Chalmers
- Division of Molecular and Clinical Medicine.,University of DundeeDundee, United Kingdomand
| | - Oriol Sibila
- Servei de PneumologiaHospital Sant PauBarcelona, Spain
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177
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Harrison T, Pavord ID, Chalmers JD, Whelan G, Fagerås M, Rutgersson A, Belton L, Siddiqui S, Gustafson P. Variability in airway inflammation, symptoms, lung function and reliever use in asthma: anti-inflammatory reliever hypothesis and STIFLE study design. ERJ Open Res 2020; 6:00333-2019. [PMID: 32550224 PMCID: PMC7276524 DOI: 10.1183/23120541.00333-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/24/2020] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory airway disease. Increase in airway inflammation is hypothesised to contribute to worsening of asthma symptoms and deterioration in lung function, resulting in the use of reliever medication. Short-acting β2-agonists only treat the symptoms, whereas an anti-inflammatory reliever is believed to treat both symptoms and the underlying inflammation, thereby arresting the progression to an exacerbation. As-needed budesonide/formoterol as an anti-inflammatory reliever reduces the risk of severe exacerbations. However, supporting mechanistic evidence has not yet been described, specifically the temporal dynamics of parameters including airway inflammation, over time and during asthma worsening. The STIFLE study aims to characterise daily variability in airway inflammation, symptoms, lung function and reliever use in people with asthma. This phase IV, open-label, parallel-group, multicentre, exploratory study will enrol 60-80 adult patients with asthma receiving low- or medium-dose inhaled corticosteroids/long-acting β2-agonists (EudraCT identifier number 2018-003467-64). Participants will be randomised 1:1 to either as-needed budesonide/formoterol dry-powder inhaler or salbutamol reliever for 24 weeks, in addition to their maintenance therapy. Daily data will be captured for fractional exhaled nitric oxide, spirometry, asthma symptoms and medication use using devices connected to a smartphone via the STIFLE application. STIFLE will thereby enable not only characterisation of the variability of airway inflammation and clinical outcomes in relation to asthma worsening, but also elucidate the effect of as-needed budesonide/formoterol on airway inflammation against a background of daily maintenance therapy.
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Affiliation(s)
- Tim Harrison
- Nottingham NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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178
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Chalmers JD, Laska IF, Franssen FME, Janssens W, Pavord I, Rigau D, McDonnell MJ, Roche N, Sin DD, Stolz D, Suissa S, Wedzicha J, Miravitlles M. Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline. Eur Respir J 2020; 55:13993003.00351-2020. [PMID: 32366483 DOI: 10.1183/13993003.00351-2020] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL-1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.
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Affiliation(s)
- James D Chalmers
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
| | - Irena F Laska
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,These three authors contributed equally to the development of this guideline
| | - Frits M E Franssen
- Dept of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Dept of Research and Education, CIRO, Horn, The Netherlands
| | - Wim Janssens
- Clinical Dept of Respiratory Diseases, UZ Leuven and Breathe, Dept CHROMETA, KU Leuven, Leuven, Belgium
| | - Ian Pavord
- Oxford NIHR Respiratory BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | | | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, AP-HP Centre University of Paris, Cochin Institute (UMR1016), Paris, France
| | - Don D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital and Respiratory Division, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital, Basel, Switzerland
| | - Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital and Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Jadwiga Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain .,Task Force co-chairs.,These three authors contributed equally to the development of this guideline
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179
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Dicker AJ, Huang JTJ, Lonergan M, Keir HR, Fong CJ, Tan B, Cassidy AJ, Finch S, Mullerova H, Miller BE, Tal-Singer R, Chalmers JD. The sputum microbiome, airway inflammation, and mortality in chronic obstructive pulmonary disease. J Allergy Clin Immunol 2020; 147:158-167. [PMID: 32353489 DOI: 10.1016/j.jaci.2020.02.040] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The sputum microbiome has a potential role in disease phenotyping and risk stratification in chronic obstructive pulmonary disease (COPD), but few large longitudinal cohort studies exist. OBJECTIVE Our aim was to investigate the COPD sputum microbiome and its association with inflammatory phenotypes and mortality. METHODS 16S ribosomal RNA gene sequencing was performed on sputum from 253 clinically stable COPD patients (4-year median follow-up). Samples were classified as Proteobacteria or Firmicutes (phylum level) and Haemophilus or Streptococcus (genus level) dominant. Alpha diversity was measured by using Shannon-Wiener diversity and Berger-Parker dominance indices. Survival was modeled by using Cox proportional hazards regression. A subset of 78 patients had label-free liquid chromatography with tandem mass spectrometry performed, with partial least square discriminant analysis integrating clinical, microbiome, and proteomics data. RESULTS Proteobacteria dominance and lower diversity was associated with more severe COPD according to the Global Initiative for Chronic Obstructive Lung Disease classification system (P = .0015), more frequent exacerbations (P = .0042), blood eosinophil level less than or equal to 100 cells/μL (P < .0001), and lower FEV1 (P = .026). Blood eosinophil counts showed a positive relationship with percent of Firmicutes and Streptococcus and a negative association with percent Proteobacteria and Haemophilus. Proteobacteria dominance was associated with increased mortality compared with Firmicutes-dominated or balanced microbiome profiles (hazard ratio = 2.58; 95% CI = 1.43-4.66; P = .0017 and hazard ratio = 7.47; 95% CI = 1.02-54.86; P = .048, respectively). Integrated omics analysis showed significant associations between Proteobacteria dominance and the neutrophil activation pathway in sputum. CONCLUSION The sputum microbiome is associated with clinical and inflammatory phenotypes in COPD. Reduced microbiome diversity, associated with Proteobacteria (predominantly Haemophilus) dominance, is associated with neutrophil-associated protein profiles and an increased risk of mortality.
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Affiliation(s)
- Alison J Dicker
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Jeffrey T J Huang
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Mike Lonergan
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Holly R Keir
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Christopher J Fong
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Brandon Tan
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Andrew J Cassidy
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | - Simon Finch
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom
| | | | | | | | - James D Chalmers
- the Scottish Centre for Respiratory Research, University of Dundee, Dundee, United Kingdom.
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180
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Carreto L, Morrison M, Donovan J, Finch S, Tan GL, Fardon T, Wilson R, Furrie E, Loebinger M, Chalmers JD. Utility of routine screening for alpha-1 antitrypsin deficiency in patients with bronchiectasis. Thorax 2020; 75:592-593. [PMID: 32303623 PMCID: PMC7361016 DOI: 10.1136/thoraxjnl-2019-214195] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/15/2020] [Accepted: 03/18/2020] [Indexed: 11/13/2022]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a cause of bronchiectasis. Guidelines for bronchiectasis from the British Thoracic Society do not recommend to routinely test patients for AATD. In contrast, guidelines for AATD recommend routine screening. This contradiction, in part, results from the lack of data from large studies performing comprehensive screening. We screened 1600 patients with bronchiectasis at two centres in the UK from 2012 to 2016. In total, only eight individuals with AATD were identified representing 0.5% of the overall population. We conclude that routine screening for AATD in bronchiectasis in the UK has a low rate of detection. Further studies are required in different geographical regions, which may have a higher prevalence of AATD.
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Affiliation(s)
- Luis Carreto
- Respiratory Medicine, Hospital Professor Fernando Fonseca (HFF), Lisbon, Portugal
| | | | - Jackie Donovan
- Biochemistry, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Simon Finch
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Gan Liang Tan
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Tom Fardon
- Respiratory Medicine, University of Dundee, Dundee, UK.,Respiratory Medicine, NHS Tayside, Dundee, UK
| | - Robert Wilson
- Host Defence Unit, Division of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Elisabeth Furrie
- Department of Immunology, Department of Medicine, Ninewells Hospital, Dundee, UK
| | - Michael Loebinger
- Host Defence Unit, Division of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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181
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Abstract
The definition of a disease requires that distinguishing signs and symptoms are present that are common, and that the constellation of signs and symptoms differentiate the condition from other causes. In bronchiectasis, anatomical changes, airways inflammation and airway infection are the distinguishing features that are common to this disease. However, bronchiectasis is a heterogenous disease: signs and symptoms are shared with other airway diseases, there are multiple aetiologies and certain phenotypes of bronchiectasis have distinct clinical and laboratory features that are not common to all people with bronchiectasis. Furthermore, response to therapeutic interventions in clinical trials is not uniform. The concept of bronchiectasis as a treatable trait has been suggested, but this may be too restrictive in view of the heterogeneity of bronchiectasis. It is our opinion that bronchiectasis should be defined as a disease in its own right, but one that shares several pathophysiological features and "treatable traits" with other airway diseases. These traits define the large heterogeneity in the pathogenesis and clinical features and suggest a more targeted approach to therapy.
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Affiliation(s)
- Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel .,Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Patrick A Flume
- Dept of Medicine and Dept of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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182
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Finch S, Shoemark A, Dicker AJ, Keir HR, Smith A, Ong S, Tan B, Choi JY, Fardon TC, Cassidy D, Huang JTJ, Chalmers JD. Pregnancy Zone Protein Is Associated with Airway Infection, Neutrophil Extracellular Trap Formation, and Disease Severity in Bronchiectasis. Am J Respir Crit Care Med 2020; 200:992-1001. [PMID: 31264895 PMCID: PMC6794104 DOI: 10.1164/rccm.201812-2351oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Rationale: PZP (pregnancy zone protein) is a broad-spectrum immunosuppressive protein believed to suppress T-cell function during pregnancy to prevent fetal rejection. It has not previously been reported in the airway. Objectives: To characterize PZP in the bronchiectasis airway, including its relationship with disease severity. Methods: Label-free liquid chromatography/mass spectrometry was performed for sputum protein profiling of patients with bronchiectasis confirmed by high-resolution computed tomography. Results for patients with and without Pseudomonas aeruginosa infection were compared. Sputum and serum PZP was measured by validated ELISA. Airway infection status was established by culture and 16S ribosomal RNA sequencing. Immunofluorescence, ELISA, and electron microscopy were used to identify the cellular source of PZP in neutrophils treated with multiple stimuli. Measurements and Main Results: Elevated PZP was identified by label-free liquid chromatography/mass spectrometry as being associated with P. aeruginosa infection. In a validation study of 124 patients, sputum but not serum concentrations of PZP were significantly associated with the Bronchiectasis Severity Index, the frequency of exacerbations, and symptoms. Airway infection with Proteobacteria such as P. aeruginosa was associated with higher concentrations of PZP. PZP in sputum was directly related to airway bacterial load. Neutrophils induced to form neutrophil extracellular traps (NETs) with phorbol myristate acetate released high concentrations of PZP in vitro, and fluorescence microscopy confirmed the presence of PZP in NETs, whereas fluorescence and electron microscopy localized PZP to the cytoplasm and nuclei of neutrophils. Effective antibiotic therapy reduced sputum PZP. Conclusions: PZP is released into NETs. We report a novel link between airway infection, NET formation, and disease severity in bronchiectasis during chronic airway inflammation.
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Affiliation(s)
- Simon Finch
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Amelia Shoemark
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Alison J Dicker
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Holly R Keir
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | | | - Samantha Ong
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Brandon Tan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Jean-Yu Choi
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Thomas C Fardon
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Diane Cassidy
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - Jeffrey T J Huang
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
| | - James D Chalmers
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom; and
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183
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Poh TY, Tiew PY, Lim AYH, Thng KX, Binte Mohamed Ali NA, Narayana JK, Mac Aogáin M, Tien Z, Chew WM, Wai Chan AK, Keir HR, Dicker AJ, Hassan TM, Xu H, Tee AKH, Ong TH, Koh MS, Abisheganaden JA, Chalmers JD, Chotirmall SH. Increased Chitotriosidase Is Associated With Aspergillus and Frequent Exacerbations in South-East Asian Patients With Bronchiectasis. Chest 2020; 158:512-522. [PMID: 32184111 DOI: 10.1016/j.chest.2020.02.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Chitinase activity is an important innate immune defence mechanism against infection that includes fungi. The 2 human chitinases: chitotriosidase (CHIT1) and acidic mammalian chitinase are associated to allergy, asthma, and COPD; however, their role in bronchiectasis and bronchiectasis-COPD overlap (BCO) is unknown. RESEARCH QUESTION What is the association between chitinase activity, airway fungi and clinical outcomes in bronchiectasis and bronchiectasis-COPD overlap? STUDY DESIGN AND METHODS A prospective cohort of 463 individuals were recruited across five hospital sites in three countries (Singapore, Malaysia, and Scotland) including individuals who were not diseased (n = 35) and who had severe asthma (n = 54), COPD (n = 90), bronchiectasis (n = 241) and BCO (n = 43). Systemic chitinase levels were assessed for bronchiectasis and BCO and related to clinical outcomes, airway Aspergillus status, and underlying pulmonary mycobiome profiles. RESULTS Systemic chitinase activity is elevated significantly in bronchiectasis and BCO and exceed the activity in other airway diseases. CHIT1 activity strongly predicts bronchiectasis exacerbations and is associated with the presence of at least one Aspergillus species in the airway and frequent exacerbations (≥3 exacerbations/y). Subgroup analysis reveals an association between CHIT1 activity and the "frequent exacerbator" phenotype in South-East Asian patients whose airway mycobiome profiles indicate the presence of novel fungal taxa that include Macroventuria, Curvularia and Sarocladium. These taxa, enriched in frequently exacerbating South-East Asian patients with high CHIT1 may have potential roles in bronchiectasis exacerbations. INTERPRETATION Systemic CHIT1 activity may represent a useful clinical tool for the identification of fungal-driven "frequent exacerbators" with bronchiectasis in South-East Asian populations.
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Affiliation(s)
- Tuang Yeow Poh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Pei Yee Tiew
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Albert Yick Hou Lim
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Kai Xian Thng
- School of Biological Sciences, Nanyang Technological University, Singapore
| | | | | | - Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Zhijun Tien
- School of Biological Sciences, Nanyang Technological University, Singapore
| | - Wui Mei Chew
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Adrian Kwok Wai Chan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Holly R Keir
- Ninewells Hospital and Medical School, University of Dundee, Scotland
| | - Alison J Dicker
- Ninewells Hospital and Medical School, University of Dundee, Scotland
| | | | - Huiying Xu
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Augustine K H Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Mariko Siyue Koh
- Duke-NUS Medical School, Singapore; Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | | | - James D Chalmers
- Ninewells Hospital and Medical School, University of Dundee, Scotland
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
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184
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Sibila O, Laserna E, Shoemark A, Keir HR, Finch S, Rodrigo-Troyano A, Perea L, Lonergan M, Goeminne PC, Chalmers JD. Airway Bacterial Load and Inhaled Antibiotic Response in Bronchiectasis. Am J Respir Crit Care Med 2020; 200:33-41. [PMID: 31109172 DOI: 10.1164/rccm.201809-1651oc] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Rationale: The principal underlying inhaled antibiotic treatment in bronchiectasis is that airway bacterial load drives inflammation, and therefore antibiotic treatment will reduce symptoms. Objectives: To determine the relationship between bacterial load and clinical outcomes, assess the stability of bacterial load over time, and test the hypothesis that response to inhaled antibiotics would be predicted by baseline bacterial load. Methods: We performed three studies. Studies 1 and 2 were prospective studies including adults with bronchiectasis. Study 3 was a post hoc analysis of a randomized trial of inhaled aztreonam. A priori patients were divided into low (<105 cfu/g), moderate (105-106 cfu/g), and high bacterial load (≥107 cfu/g) using quantitative sputum culture. Measurements and Main Results: Bacterial load was a stable trait associated with worse quality of life and more airway inflammation in studies 1, 2, and 3. In study 3, patients with high bacterial load showed an improvement in the primary endpoint (Quality of Life-Bronchiectasis-Respiratory Symptoms Score at Week 4) in favor of aztreonam (mean difference of 9.7 points; 95% confidence interval, 3.4-16.0; P = 0.003). The proportion of patients who achieved an increase above the minimum clinically important difference was higher in the aztreonam group at Week 4 (63% vs. 37%; P = 0.01) and at Week 12 (62% vs. 38%; P = 0.01) only in high bacterial load patients. Conclusions: Improvement of quality of life with inhaled aztreonam was only evident in patients with high bacterial load. Bacterial load may be a useful biomarker of severity of disease and treatment response.
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Affiliation(s)
- Oriol Sibila
- 1 Respiratory Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,2 Biomedical Research Institute Sant Pau, Barcelona, Spain
| | - Elena Laserna
- 3 Hospital Comarcal de Mollet, Mollet del Vallés, Spain
| | - Amelia Shoemark
- 4 Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Holly R Keir
- 4 Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Simon Finch
- 4 Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Ana Rodrigo-Troyano
- 1 Respiratory Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,2 Biomedical Research Institute Sant Pau, Barcelona, Spain
| | - Lidia Perea
- 2 Biomedical Research Institute Sant Pau, Barcelona, Spain
| | - Mike Lonergan
- 4 Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
| | - Pieter C Goeminne
- 5 Department of Respiratory Medicine, AZ Nikolaas, Sint-Niklaas, Belgium; and.,6 Department of Respiratory Medicine, UZ Leuven, Leuven, Belgium
| | - James D Chalmers
- 4 Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, United Kingdom
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185
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Chalmers JD, Reeves EL, Bullen NJ, Kolb M. The evolution of the European Respiratory Journal: ready for the new decade! Eur Respir J 2020; 55:55/1/1902503. [PMID: 31974124 DOI: 10.1183/13993003.02503-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 11/05/2022]
Affiliation(s)
- James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Elin L Reeves
- European Respiratory Society, Publications Office, Sheffield, UK
| | - Neil J Bullen
- European Respiratory Society, Publications Office, Sheffield, UK
| | - Martin Kolb
- Dept of Respiratory Medicine, Pathology and Molecular Medicine, McMaster University and St Joseph's Healthcare, Hamilton, ON, Canada
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186
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Mac Aogáin M, Tiew PY, Lim AYH, Low TB, Tan GL, Hassan T, Ong TH, Pang SL, Lee ZY, Gwee XW, Martinus C, Sio YY, Matta SA, Ong TC, Tiong YS, Wong KN, Narayanan S, Au VB, Marlier D, Keir HR, Tee A, Abisheganaden JA, Koh MS, Wang DY, Connolly JE, Chew FT, Chalmers JD, Chotirmall SH. Distinct "Immunoallertypes" of Disease and High Frequencies of Sensitization in Non-Cystic Fibrosis Bronchiectasis. Am J Respir Crit Care Med 2020; 199:842-853. [PMID: 30265843 DOI: 10.1164/rccm.201807-1355oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Allergic sensitization is associated with poor clinical outcomes in asthma, chronic obstructive pulmonary disease, and cystic fibrosis; however, its presence, frequency, and clinical significance in non-cystic fibrosis bronchiectasis remain unclear. OBJECTIVES To determine the frequency and geographic variability that exists in a sensitization pattern to common and specific allergens, including house dust mite and fungi, and to correlate such patterns to airway immune-inflammatory status and clinical outcomes in bronchiectasis. METHODS Patients with bronchiectasis were recruited in Asia (Singapore and Malaysia) and the United Kingdom (Scotland) (n = 238), forming the Cohort of Asian and Matched European Bronchiectasis, which matched recruited patients on age, sex, and bronchiectasis severity. Specific IgE response against a range of common allergens was determined, combined with airway immune-inflammatory status and correlated to clinical outcomes. Clinically relevant patient clusters, based on sensitization pattern and airway immune profiles ("immunoallertypes"), were determined. MEASUREMENTS AND MAIN RESULTS A high frequency of sensitization to multiple allergens was detected in bronchiectasis, exceeding that in a comparator cohort with allergic rhinitis (n = 149). Sensitization was associated with poor clinical outcomes, including decreased pulmonary function and more severe disease. "Sensitized bronchiectasis" was classified into two immunoallertypes: one fungal driven and proinflammatory, the other house dust mite driven and chemokine dominant, with the former demonstrating poorer clinical outcome. CONCLUSIONS Allergic sensitization occurs at high frequency in patients with bronchiectasis recruited from different global centers. Improving endophenotyping of sensitized bronchiectasis, a clinically significant state, and a "treatable trait" permits therapeutic intervention in appropriate patients, and may allow improved stratification in future bronchiectasis research and clinical trials.
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Affiliation(s)
- Micheál Mac Aogáin
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Pei Yee Tiew
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Albert Yick Hou Lim
- 3 Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Teck Boon Low
- 4 Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Gan Liang Tan
- 2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Tidi Hassan
- 5 Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Thun How Ong
- 2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Sze Lei Pang
- 6 Department of Biological Sciences, National University of Singapore, Singapore.,7 Institute of Systems Biology, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Zi Yang Lee
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Xiao Wei Gwee
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Christopher Martinus
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Yang Yie Sio
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Sri Anusha Matta
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Tan Ching Ong
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Yuen Seng Tiong
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Kang Ning Wong
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | | | | | - Damien Marlier
- 8 Institute of Molecular and Cell Biology, A*STAR, Singapore
| | - Holly R Keir
- 9 University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland; and
| | - Augustine Tee
- 4 Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | - Mariko Siyue Koh
- 2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - De Yun Wang
- 10 Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - John E Connolly
- 8 Institute of Molecular and Cell Biology, A*STAR, Singapore
| | - Fook Tim Chew
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - James D Chalmers
- 9 University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland; and
| | - Sanjay H Chotirmall
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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187
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Artaraz A, Crichton ML, Finch S, Abo-Leyah H, Goeminne P, Aliberti S, Fardon T, Chalmers JD. Development and initial validation of the bronchiectasis exacerbation and symptom tool (BEST). Respir Res 2020; 21:18. [PMID: 31931782 PMCID: PMC6958700 DOI: 10.1186/s12931-019-1272-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/29/2019] [Indexed: 12/25/2022] Open
Abstract
Background Recurrent bronchiectasis exacerbations are related to deterioration of lung function, progression of the disease, impairment of quality of life, and to an increased mortality. Improved detection of exacerbations has been accomplished in chronic obstructive pulmonary disease through the use of patient completed diaries. These tools may enhance exacerbation reporting and identification. The aim of this study was to develop a novel symptom diary for bronchiectasis symptom burden and detection of exacerbations, named the BEST diary. Methods Prospective observational study of patients with bronchiectasis conducted at Ninewells Hospital, Dundee. We included patients with confirmed bronchiectasis by computed tomography, who were symptomatic and had at least 1 documented exacerbation of bronchiectasis in the previous 12 months to participate. Symptoms were recorded daily in a diary incorporating cough, sputum volume, sputum colour, dyspnoea, fatigue and systemic disturbance scored from 0 to 26. Results Twenty-one patients were included in the study. We identified 29 reported (treated exacerbations) and 23 unreported (untreated) exacerbations over 6-month follow-up. The BEST diary score showed a good correlation with the established and validated questionnaires and measures of health status (COPD Assessment Test, r = 0.61, p = 0.0037, Leicester Cough Questionnaire, r = − 0.52,p = 0.0015, St Georges Respiratory Questionnaire, r = 0.61,p < 0.0001 and 6 min walk test, r = − 0.46,p = 0.037). The mean BEST score at baseline was 7.1 points (SD 2.2). The peak symptom score during exacerbation was a mean of 16.4 (3.1), and the change from baseline to exacerbation was a mean of 9.1 points (SD 2.5). Mean duration of exacerbations based on time for a return to baseline symptoms was 15.3 days (SD 5.7). A minimum clinically important difference of 4 points is proposed. Conclusions The BEST symptom diary has shown concurrent validity with current health questionnaires and is responsive at onset and recovery from exacerbation. The BEST diary may be useful to detect and characterise exacerbations in bronchiectasis clinical trials.
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Affiliation(s)
- Amaia Artaraz
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Megan L Crichton
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Division of Molecular and Clinical Medicine, University of Dundee, DD1 9SY, Dundee, Scotland
| | - Simon Finch
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Division of Molecular and Clinical Medicine, University of Dundee, DD1 9SY, Dundee, Scotland
| | - Hani Abo-Leyah
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Division of Molecular and Clinical Medicine, University of Dundee, DD1 9SY, Dundee, Scotland
| | | | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Thomas Fardon
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Division of Molecular and Clinical Medicine, University of Dundee, DD1 9SY, Dundee, Scotland
| | - James D Chalmers
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, Division of Molecular and Clinical Medicine, University of Dundee, DD1 9SY, Dundee, Scotland.
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188
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Chalmers JD. Cystic fibrosis lung disease and bronchiectasis. The Lancet Respiratory Medicine 2020; 8:12-14. [DOI: 10.1016/s2213-2600(19)30335-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
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189
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Dunkley EJ, Chalmers JD, Cho S, Finn TJ, Patrick WM. Assessment of Phenotype Microarray plates for rapid and high-throughput analysis of collateral sensitivity networks. PLoS One 2019; 14:e0219879. [PMID: 31851668 PMCID: PMC6919586 DOI: 10.1371/journal.pone.0219879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/23/2019] [Indexed: 11/29/2022] Open
Abstract
The crisis of antimicrobial resistance is driving research into the phenomenon of collateral sensitivity. Sometimes, when a bacterium evolves resistance to one antimicrobial, it becomes sensitive to others. In this study, we have investigated the utility of Phenotype Microarray (PM) plates for identifying collateral sensitivities with unprecedented throughput. We assessed the relative resistance/sensitivity phenotypes of nine strains of Staphylococcus aureus (two laboratory strains and seven clinical isolates) towards the 72 antimicrobials contained in three PM plates. In general, the PM plates reported on resistance and sensitivity with a high degree of reproducibility. However, a rigorous comparison of PM growth phenotypes with minimum inhibitory concentration (MIC) measurements revealed a trade-off between throughput and accuracy. Small differences in PM growth phenotype did not necessarily correlate with changes in MIC. Thus, we conclude that PM plates are useful for the rapid and high-throughput assessment of large changes in collateral sensitivity phenotypes during the evolution of antimicrobial resistance, but more subtle examples of cross-resistance or collateral sensitivity cannot be identified reliably using this approach.
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Affiliation(s)
- Elsie J Dunkley
- Centre for Biodiscovery, School of Biological Sciences, Victoria University, Wellington, New Zealand
| | - James D Chalmers
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Stephanie Cho
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Thomas J Finn
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Wayne M Patrick
- Centre for Biodiscovery, School of Biological Sciences, Victoria University, Wellington, New Zealand.,Department of Biochemistry, University of Otago, Dunedin, New Zealand
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190
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Contarini M, Shoemark A, Rademacher J, Finch S, Gramegna A, Gaffuri M, Roncoroni L, Seia M, Ringshausen FC, Welte T, Blasi F, Aliberti S, Chalmers JD. Why, when and how to investigate primary ciliary dyskinesia in adult patients with bronchiectasis. Multidiscip Respir Med 2019. [DOI: 10.4081/mrm.2018.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Bronchiectasis represents the final pathway of several infectious, genetic, immunologic or allergic disorders. Accurate and prompt identification of the underlying cause is a key recommendation of several international guidelines, in order to tailor treatment appropriately. Primary ciliary dyskinesia (PCD) is a genetic cause of bronchiectasis in which failure of motile cilia leads to poor mucociliary clearance. Due to poor ciliary function in other organs, individuals can suffer from chronic rhinosinusitis, otitis media and infertility. This paper explores the current literature describing why, when and how to investigate PCD in adult patients with bronchiectasis. We describe the main PCD diagnostic tests and compare the two international PCD diagnostic guidelines. The expensive multi-test diagnostic approach requiring a high level of expertise and specialist equipment, make the multifaceted PCD diagnostic pathway complex. Therefore, the risk of late or missed diagnosis is high and has clinical and research implications. Defining the number of patients with bronchiectasis due to PCD is complex. To date, few studies outlining the aetiology of adult patients with bronchiectasis conduct screening tests for PCD, but they do differ in their diagnostic approach. Comparison of these studies reveals an estimated PCD prevalence of 1–13% in adults with bronchiectasis and describe patients as younger than their counterparts with moderate impairment of lung function and higher rates of chronic infection with Pseudomonas aeruginosa. Diagnosing PCD has clinical, socioeconomic and psychological implications, which affect patients’ life, including the possibility to have a specific and multidisciplinary team approach in a PCD referral centre, as well as a genetic and fertility counselling and special legal aspects in some countries. To date no specific treatments for PCD have been approved, standardized diagnostic protocols for PCD and recent diagnostic guidelines will be helpful to accurately define a population on which planning RCT studies to evaluate efficacy, safety and accuracy of PCD specific treatments.
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191
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Aliberti S, Chalmers JD. Get together to increase awareness in bronchiectasis: a report of the 2nd World Bronchiectasis Conference. Multidiscip Respir Med 2019. [DOI: 10.4081/mrm.2018.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Bronchiectasis is a chronic respiratory disease character- ized by a permanent dilation of the bronchi associated with cough, daily sputum production and recurrent episodes of respiratory infections. Bronchiectasis pathophysiology starts with a structural airway damage leading to an impaired mucociliary clearance, subsequent chronic bacterial infection and neutrophilic inflammation, which perpetuates this vicious cycle. For a long period of time, bronchiectasis has been recognized as an isolated radiological finding, while now we understand it as chronic and debilitating disease which requires specific management to improve patients’ outcomes.
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192
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Aliberti S, Ruffo Codecasa L, Gori A, Sotgiu G, Spotti M, Di Biagio A, Calcagno A, Nardini S, Assael BM, Tortoli E, Besozzi G, Ferrarese M, Matteelli A, Girardi E, De Lorenzo S, Seia M, Gramegna A, Del Prato B, Terranova L, Oriano M, Sverzellati N, Mirsaeidi M, Chalmers JD, Haworth CS, Loebinger MR, Aksamit T, Winthrop K, Ringshausen FC, Previdi G, Blasi F. The Italian registry of pulmonary nontuberculous mycobacteria - IRENE: the study protocol. Multidiscip Respir Med 2019. [DOI: 10.4081/mrm.2018.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: A substantial increase in pulmonary and extra-pulmonary diseases due to non-tuberculous mycobacteria (NTM) has been documented worldwide, especially among subjects suffering from chronic respiratory diseases and immunocompromised patients. Many questions remain regarding the epidemiology of pulmonary disease due to NTM (NTM-PD) mainly because reporting of NTM-PD to health authorities is not mandated in several countries, including Italy. This manuscript describes the protocol of the first Italian registry of adult patients with respiratory infections caused by NTM (IRENE). Methods: IRENE is an observational, multicenter, prospective, cohort study enrolling consecutive adult patients with either a NTM respiratory isolate or those with NTM-PD. A total of 41 centers, including mainly pulmonary and infectious disease departments, joined the registry so far. Adult patients with all of the following are included in the registry: 1) at least one positive culture for any NTM species from any respiratory sample; 2) at least one positive culture for NTM isolated in the year prior the enrolment and/or prescribed NTM treatment in the year prior the enrolment; 3) given consent to inclusion in the study. No exclusion criteria are applied to the study. Patients are managed according to standard operating procedures implemented in each IRENE clinical center. An online case report form has been developed to collect patients’ demographics, comorbidities, microbiological, laboratory, functional, radiological, clinical, treatment and outcome data at baseline and on an annual basis. An IRENE biobank has also been developed within the network and linked to the clinical data of the registry. Conclusions: IRENE has been developed to inform the clinical and scientific community on the current management of adult patients with NTM respiratory infections in Italy and acts as a national network to increase the disease’s awareness. Trial registration: Clinicaltrial.gov: NCT03339063.
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193
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Finch S, Laska IF, Abo-Leyah H, Fardon TC, Chalmers JD. Validation of the COPD Assessment Test (CAT) as an Outcome Measure in Bronchiectasis. Chest 2019; 157:815-823. [PMID: 31730832 DOI: 10.1016/j.chest.2019.10.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Objective assessment of symptoms in bronchiectasis is important for research and in clinical practice. The COPD Assessment Test (CAT) is a short, simple assessment tool widely used in COPD. The items included in the CAT are not specific to COPD and also reflect the dominant symptoms of bronchiectasis. We therefore performed a study to validate the CAT as an outcome measure in bronchiectasis. METHODS The CAT was administered to two cohorts of bronchiectasis patients along with other quality of life questionnaires. Patients underwent comprehensive clinical assessment. One cohort had repeated questionnaires collected before-and-after treatment of acute exacerbations. We analyzed convergent validity, repeatability, and responsiveness of the score and calculated the minimum clinically important difference (MCID) using a combination of distribution and anchor-based methods. RESULTS In both cohorts there were positive correlations between the CAT and the St. George's Respiratory Questionnaire (r = 0.90, P < .0001 and r = 0.87, P < .0001). There was an inverse relationship between CAT and Quality of Life - Bronchiectasis Respiratory Symptoms Scale (r = -0.75, P < .0001) and Leicester Cough Questionnaire score (r = -0.77, P < .0001). Patients with more severe disease, based on the bronchiectasis severity index, had significantly higher CAT scores. CAT also correlated with FEV1 % predicted and 6-min walk distance (6MWD). CAT increased significantly at exacerbation and fell at recovery. The intraclass correlation coefficient for two measurements four-weeks apart while clinically stable was 0.88 (95% CI, 0.73-0.95, P < .0001). An MCID of 4 was most consistent. CONCLUSIONS CAT is a valid, responsive symptom assessment tool in bronchiectasis. The MCID is estimated as 4 points.
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Affiliation(s)
- Simon Finch
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Irena F Laska
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Hani Abo-Leyah
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Thomas C Fardon
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland.
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194
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Shteinberg M, Crossley B, Lavie T, Nadler S, Boyd J, Ringshausen FC, Aksamit T, Chalmers JD, Goeminne P. Recommendations for travelling with bronchiectasis: a joint ELF/EMBARC/ERN-Lung collaboration. ERJ Open Res 2019; 5:00113-2019. [PMID: 31687371 PMCID: PMC6819988 DOI: 10.1183/23120541.00113-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/03/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction People with bronchiectasis frequently request specialist advice to prepare for travelling, but there are few publications providing advice on safe travel with bronchiectasis. There is a need for recommendations on adapting everyday treatment to the requirements during travelling. Methods A panel of 13 patient volunteers formulated questions regarding different aspects of travelling, including safety of travel, maintaining regular treatment during travel, and dealing with deterioration while away. Patient input was used to derive a questionnaire and circulated among a panel of bronchiectasis experts. Where 80% or more experts agreed on a response, a recommendation was made. Results A total of 26 bronchiectasis experts answered the questionnaire. Recommendations were made on safety of travel, choice of destinations and activities, choice of travel insurance, carrying medications and devices, maintaining regular treatments in transport, documentation to be provided and oxygen requirements. Some statements did not reach an 80% agreement; in many cases these statements may be valid for some, but not all bronchiectasis patients. Conclusions The general agreement was that it is considered safe for most people with bronchiectasis to travel. Careful planning and preparation with robust communication between patients and their healthcare provider prior to travel for different scenarios is fundamental to a successful journey. It is safe for most people with bronchiectasis to travel. Careful planning and preparation for different scenarios are fundamental to a successful journey.http://bit.ly/2yWEowA
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Affiliation(s)
- Michal Shteinberg
- Pulmonology Institute and CF Center - Carmel Medical Center, the Technion - Israel Institute of Technology, Haifa, Israel
| | | | - Tal Lavie
- Clinical Pharmacology Unit, Carmel Medical Center, Haifa, Israel
| | - Sima Nadler
- European Lung Foundation Bronchiectasis Patient Advisory Group
| | | | - Felix C Ringshausen
- Dept of Respiratory Medicine, Hannover Medical School, Member of the German Centre for Lung Research, Hannover, Germany
| | | | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Pieter Goeminne
- Dept of Respiratory Medicine, AZ Nikolaas, Sint-Niklaas, Belgium
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195
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Oriano M, Terranova L, Sotgiu G, Saderi L, Bellofiore A, Retucci M, Marotta C, Gramegna A, Miglietta D, Carnini C, Marchisio P, Chalmers JD, Aliberti S, Blasi F. Evaluation of active neutrophil elastase in sputum of bronchiectasis and cystic fibrosis patients: A comparison among different techniques. Pulm Pharmacol Ther 2019; 59:101856. [PMID: 31626976 DOI: 10.1016/j.pupt.2019.101856] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/10/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Neutrophil elastase (NE) is a crucial marker of neutrophilic inflammation. We aimed to compare different techniques to detect active NE in sputum samples of 50 Bronchiectasis (BE) and 50 Cystic Fibrosis (CF) patients. Three methods including a ProteaseTag® Active NE Immunoassay (ELISA) and two enzymatic digestion assays (chromogenic -CS- and fluorogenic -FS- substrate) were compared. Results of active NE were also correlated with clinical data. The three methods provided statistically different values for NE activity in the same sputum samples in both cohorts. In the BE cohort, the highest correlations between NE activity and Bronchiectasis Severity Index (rho = 0.40, P < 0.0001), sputum purulence (AUC = 0.79), and chronic infections due to any pathogen (AUC = 0.76) and P. aeruginosa (AUC = 0.80) were found when NE was measured through the activity-based immunoassay. In the CF cohort, the highest correlations between NE activity and sputum quantity (rho = 0.71) and FEV1% (rho = 0.42, P = 0.03) were observed when the FS method was used, while similar correlations with chronic P. aeruginosa infection were identified with the FS and ELISA methods. NE activity in sputum correlates with clinical variables in both diseases. However, different methods to evaluate active NE in sputum lead to significantly different results, also in terms of correlation with clinical data.
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Affiliation(s)
- Martina Oriano
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Leonardo Terranova
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Angela Bellofiore
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Mariangela Retucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Cinzia Marotta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | - Andrea Gramegna
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
| | | | | | - Paola Marchisio
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Paediatric Highly Intensive Care Unit, Milan, Italy
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Stefano Aliberti
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy.
| | - Francesco Blasi
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Milan, Italy
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196
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Smith AH, Chalmers JD. The microbiome in bronchiectasis: Cutting a lung story short. Respirology 2019; 25:43-44. [DOI: 10.1111/resp.13697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 01/09/2023]
Affiliation(s)
| | - James D. Chalmers
- Scottish Centre for Respiratory ResearchUniversity of Dundee, Ninewells Hospital and Medical School Dundee UK
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197
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Loebinger MR, Polverino E, Blasi F, Elborn SJ, Chalmers JD, Tiddens HA, Goossens H, Tunney M, Zhou W, Angyalosi G, Hill AT, Haworth CS. Efficacy and safety of tobramycin inhalation powder in bronchiectasis patients with P. aeruginosa infection: Design of a dose-finding study (iBEST-1). Pulm Pharmacol Ther 2019; 58:101834. [PMID: 31433997 DOI: 10.1016/j.pupt.2019.101834] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/17/2019] [Indexed: 01/26/2023]
Abstract
In patients with bronchiectasis (BE), infection with Pseudomonas aeruginosa (Pa) results in disease progression, frequent pulmonary exacerbations and lung function decline. However, at present, no inhaled antibiotics have been approved for the treatment of these patients. Tobramycin inhalation powder (TIP), approved for treatment of Pa infection in cystic fibrosis, could be a promising candidate. We aimed to assess effective and well-tolerated doses and regimens of TIP in BE patients with Pa infection. In this phase II, double-blind, placebo-controlled, randomised study, three different daily doses of TIP are administered either as continuous or cyclical regimens. The study protocol comprises 7-28 days of screening, 112 days of double-blind treatment and 56 days of follow-up. The plan was to enrol 180 patients (aged ≥18 years) with BE, documented Pa infection and a history of exacerbations. The primary outcome is change in sputum Pa density from baseline. Key secondary outcomes include number of pulmonary exacerbations, use of antipseudomonal antibiotics, serum and sputum tobramycin concentrations, quality of life and safety. Exploratory endpoints include lung clearance index, sputum inflammatory markers and microbiome analysis. As of October 2018, 107/180 patients were enrolled at 34 sites (six countries) following which recruitment was closed for administrative reasons unrelated to safety findings. Despite a reduced sample size from initially planned enrolment, the unique design may inform the benefit-risk profile of TIP in BE patients with chronic Pa infection. Moreover, several novel and exploratory endpoints (lung clearance index, inflammatory biomarkers, lung microbiome), will contribute to the advancement of research in this area.
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Affiliation(s)
- Michael R Loebinger
- Host Defence Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; Imperial College London, London, United Kingdom.
| | - Eva Polverino
- Respiratory Disease Department, Vall d' Hebron University Hospital - VHIR, CIBER, Barcelona, Spain
| | - Francesco Blasi
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Stuart J Elborn
- Halo Research Group, Centre for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom; Imperial College and Royal Brompton Hospital and Harefield NHS Foundation Trust, London, United Kingdom
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, United Kingdom
| | - Harm Awm Tiddens
- Department of Paediatric Pulmonology and Allergology, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Herman Goossens
- Department of Clinical Microbiology, University Hospital Antwerp, Antwerp, Belgium
| | - Michael Tunney
- Halo Research Group, School of Pharmacy, Queen's University Belfast, Belfast, United Kingdom
| | | | | | - Adam T Hill
- Respiratory Medicine, Royal Infirmary of Edinburgh, and University of Edinburgh, Edinburgh, United Kingdom
| | - Charles S Haworth
- Cambridge Centre for Lung Infection, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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Spinou A, Chalmers JD. Respiratory physiotherapy in the bronchiectasis guidelines: is there a loud voice we are yet to hear? Eur Respir J 2019; 54:54/3/1901610. [PMID: 31563873 DOI: 10.1183/13993003.01610-2019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Arietta Spinou
- Population Health Sciences, Life Sciences and Medicine, King's College London, London, UK
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Richardson H, Dicker AJ, Barclay H, Chalmers JD. The microbiome in bronchiectasis. Eur Respir Rev 2019; 28:28/153/190048. [DOI: 10.1183/16000617.0048-2019] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/01/2019] [Indexed: 12/17/2022] Open
Abstract
Bronchiectasis is increasing in prevalence worldwide, yet current treatments available are limited to those alleviating symptoms and reducing exacerbations. The pathogenesis of the disease and the inflammatory, infective and molecular drivers of disease progression are not fully understood, making the development of novel treatments challenging. Understanding the role bacteria play in disease progression has been enhanced by the use of next-generation sequencing techniques such as 16S rRNA sequencing. The microbiome has not been extensively studied in bronchiectasis, but existing data show lung bacterial communities dominated by Pseudomonas, Haemophilus and Streptococcus, while exhibiting intraindividual stability and large interindividual variability. Pseudomonas- and Haemophilus-dominated microbiomes have been shown to be linked to severe disease and frequent exacerbations. Studies completed to date are limited in size and do not fully represent all clinically observed disease subtypes. Further research is required to understand the microbiomes role in bronchiectasis disease progression. This review discusses recent developments and future perspectives on the lung microbiome in bronchiectasis.
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200
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Laska IF, Crichton ML, Shoemark A, Chalmers JD. The efficacy and safety of inhaled antibiotics for the treatment of bronchiectasis in adults: a systematic review and meta-analysis. Lancet Respir Med 2019; 7:855-869. [PMID: 31405826 DOI: 10.1016/s2213-2600(19)30185-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although use of inhaled antibiotics is the standard of care in cystic fibrosis, there is insufficient evidence to support use of inhaled antibiotics in patients with bronchiectasis not due to cystic fibrosis. We aimed to assess the efficacy and safety of inhaled antibiotics for the long-term treatment of adults with bronchiectasis and chronic respiratory tract infections. METHODS We did a systematic review and meta-analysis of all randomised controlled trials of inhaled-antibiotic use in adult patients with bronchiectasis and chronic respiratory tract infections. Eligible publications were identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov. Randomised controlled trials of inhaled antibiotics were included if the patients were adults with stable bronchiectasis diagnosed by CT or bronchography, the trials had treatment a duration of at least 4 weeks, and their outcomes met at least one of the endpoints of interest. Studies in cystic fibrosis were excluded. Efficacy endpoints assessed were bacterial load, bacterial eradication from sputum, frequency of exacerbations, time to first exacerbation, proportion of patients with at least one exacerbation, frequency of severe exacerbations, quality of life, change in FEV1, 6-min walk distance, mortality, adherence to treatment, and sputum volume; safety endpoints were adverse events and bacterial resistance in sputum. Each study was independently reviewed for methodological quality using the Cochrane risk of bias tool. Random-effects meta-analysis was used to pool individual studies. Heterogeneity was assessed using I2. The review is registered on PROSPERO, number CRD42019122892. FINDINGS 16 trials (n=2597 patients) were included for analysis. The mean reduction of colony forming units per g of sputum with inhaled antibiotics was -2·32 log units (95% CI -3·20 to -1·45; p<0·0001). Bacterial eradication was increased with inhaled antibiotic therapy (odds ratio [OR] 3·36, 1·63 to 6·91; p=0·0010). Inhaled antibiotics significantly reduced exacerbation frequency (rate ratio 0·81, 0·67 to 0·97; p=0·020). Time to first exacerbation was significantly prolonged with inhaled antibiotics (hazard ratio 0·83, 0·69 to 0·99; p=0·028). The proportion of patients with at least one exacerbation decreased (risk ratio 0·85, 0·74 to 0·97; p=0·015). There was a significant reduction in the frequency of severe exacerbations (rate ratio 0·43, 0·24 to 0·78; p=0·0050). The scores for neither the Quality of Life Bronchiectasis questionnaire nor St George's Respiratory Questionnaire improved above the minimal clinically important difference. The relative change in FEV1 was a deterioration of 0·87% predicted value (-2·00 to 0·26%; p=0·13). Other efficacy endpoints were reported in only few studies or had few events. There was no difference in treatment-emergent adverse effects (OR 0·97, 0·67 to 1·40; p=0·85) or bronchospasm (0·99, 0·66 to 1·48; p=0·95). Emergence of bacterial resistance was evident at the end of the treatment period (risk ratio 1·91, 1·46 to 2·49; p<0·0001). INTERPRETATION Inhaled antibiotics are well tolerated, reduce bacterial load, and achieve a small but statistically significant reduction in exacerbation frequency without clinically significant improvements in quality of life in patients with bronchiectasis and chronic respiratory tract infections. FUNDING British Lung Foundation through the GSK/British Lung Foundation Chair of Respiratory Research and European Respiratory Society through the EMBARC2 consortium. EMBARC2 is supported by project partners Chiesi, Grifols, Insmed, Novartis, and Zambon.
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Affiliation(s)
- Irena F Laska
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - Megan L Crichton
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - Amelia Shoemark
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Medicine, University of Dundee, Dundee, UK; Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
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