Co-morbid manifestations in COPD

Effects of extracellular Hsp70, lipopolysaccharide and lipoteichoic acid on human monocyte-derived macrophages and differentiated THP-1 cells

Extracellular Hsp70 (eHsp70) is elevated in blood of patients with inflammatory diseases (e.g. chronic obstructive pulmonary disease), prone to bacterial infections. It stimulates pro-inflammatory effects in cells via TLR2 and TLR4. The main hypothesis was that eHsp70 induces inflammation and alters inflammatory responses to lipopolysaccharide (LPS) and lipoteichoic acid (LTA). We assessed pro-inflammatory cytokines concentrations, TLR2, TLR4 and Hsp70 mRNA expressions, NF-κB and MAPKs activation, and viability after treatment of monocyte-derived macrophages (MDMs) and THP-1 cells with recombinant human (rh) Hsp70, LPS and LTA. rhHsp70, LPS, LTA and their combinations induced IL-6, IL-8 and TNF-α from MDMs. LPS, LTA, and combinations with rhHsp70 increased TLR2 and decreased TLR4 in both cells. rhHsp70 increased TLR2 and TLR4 in THP-1 cells, and TLR2 in MDMs. rhHsp70, LPS and their combinations up-regulated Hsp70 in MDMs, while down-regulated it in THP-1. LPS and its combinations with rhHsp70 lowered cell viability in THP-1 cells and activated caspases-8 and -9. Involvement of NF-κB and MAPKs in inflammatory and survival mechanisms stimulated by rhHsp70 was demonstrated. eHsp70 alone and in combination with bacterial components could provoke inflammation and affect viability of MDMs and THP-1 cells leading to disturbed inflammatory responses in diseases accompanied with bacterial colonisations or infections.

Extracellular Hsp70 induces inflammation and modulates LPS/LTA-stimulated inflammatory response in THP-1 cells

Extracellular Hsp70 (eHsp70) can act as damage-associated molecular pattern (DAMP) via Toll-like receptors TLR2 and TLR4, and stimulate immune and inflammatory responses leading to sterile inflammation and propagation of already existing inflammation. It was found elevated in the blood of patients with chronic obstructive pulmonary disease (COPD), who might suffer occasional bacterial colonizations and infections. We used a monocytic THP-1 cell line as a cellular model of systemic compartment of COPD to assess inflammatory effects of eHsp70 when present alone or together with bacterial products lypopolysaccharide (LPS) and lypoteichoic acid (LTA). THP-1 cells were differentiated into macrophage-like cells and treated with various concentrations of recombinant human Hsp70 protein (rhHsp70), LPS (TLR4 agonist), LTA (TLR2 agonist), and their combinations for 4, 12, 24, and 48 h. Concentrations of IL-1α, IL-6, IL-8, and TNF-α were determined by ELISA. Cell viability was assessed by MTS assay, and mode of cell death by luminometric measurements of caspases-3/7, -8, and -9 activities. rhHsp70 showed cell protecting effect by suppressing caspases-3/7 activation, while LPS provoked cytotoxicity through caspases-8 and -3/7 pathway. Regarding inflammatory processes, rhHsp70 alone induced secretion of IL-1α and IL-8, but had modulatory effects on release of all four cytokines when applied together with LPS or LTA. Combined effect with LPS was mainly synergistic, and with LTA mainly antagonistic, although it was cytokine- and time-dependent. Our results confirmed pro-inflammatory function of extracellular Hsp70, and suggest its possible implication in COPD exacerbations caused by bacterial infection through desensitization or inappropriate activation of TLR2 and TLR4 receptors.

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation

BACKGROUND

Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

PURPOSE

The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

METHODS

A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

RESULTS

An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

CONCLUSIONS

The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Risk factors for osteoporosis in Caucasian patients with moderate chronic obstructive pulmonary disease: a case control study

The prevalence of osteoporosis is high in chronic obstructive pulmonary disease (COPD) patients. The gold standard for the diagnosis of osteoporosis is bone mineral density (BMD) measurements as assessed by dual energy absorptiometry (DXA) scanning as well as vertebral fractures as assessed by instant vertebral assessment (IVA). The aim of this study was to compare COPD GOLD II patients (that is, patients with moderate COPD, stage II, according to the GOLD classification) with osteoporosis (cases) to COPD GOLD II patients without osteoporosis (controls) to identify risk factors for osteoporosis. The diagnosis of osteoporosis was based on BMD and vertebral fractures. Cases (n=49) were matched for gender, age and forced expiratory volume in the first second to controls (n=49). We assessed pulmonary function, body composition, vitamin D, emphysema score (by high-resolution computer tomography), medical history and medication use in all patients. Variables that were significantly different between the cases and controls were included in a logistic regression analysis. COPD patients with osteoporosis had a significantly lower body mass index (BMI) and higher residual volume as the percentage of total lung capacity (RV%TLC) compared to COPD patients without osteoporosis. Decreasing BMI and increasing RV%TLC increased the odds ratio for osteoporosis. Overweight and obese BMI values were protective for osteoporosis. Screening for osteoporosis should be performed even in moderate COPD patients, especially in those with a low BMI and/or a high RV%TLC.

Advance care planning for patients with COPD: past, present and future

OBJECTIVE

To discuss the importance, current status and directions for improvement of advance care planning and communication about end-of-life care for patients with Chronic Obstructive Pulmonary Disease (COPD).

METHODS

Narrative review of the currently available literature regarding advance care planning and communication about end-of-life care in COPD.

RESULTS

Advance care planning, including patient-clinician communication about end-of-life care, can improve outcomes for patients and their families and may be particularly important for patients with COPD. Patient-clinician communication is needed to inform and prepare patients about their diagnosis, treatment, prognosis, and what dying might be like. It is necessary to help patients and their clinicians understand patient preferences for life-sustaining treatments. Despite these advantages, advance care planning and conversations about end-of-life care in current practice are limited and their quality is often poor.

CONCLUSION

Advance care planning can improve outcomes for patients and their relatives. Recent studies provide directions for how to facilitate advance care planning for patients with COPD.

PRACTICE IMPLICATIONS

Advance care planning ought to be part of care for patients with advanced COPD. Future studies should focus on interventions to facilitate advance care planning in patients with COPD with the goal of improving the quality of end-of-life care.

Effect of inhaled glucocorticoids and beta(2) agonists on vertebral fracture risk in COPD patients: the EOLO study

Although inhaled glucocorticoids (GCs) and beta(2) agonists are being more frequently prescribed in the management of chronic obstructive pulmonary disease (COPD), their role in the impairment of bone status and in fracture risk remains controversial. This study aimed to evaluate whether the dose of inhaled GCs and beta(2) agonists may independently influence bone status and vertebral fracture risk in COPD patients aged 50 years or over. COPD severity, presence of vertebral fractures on lateral chest X-ray, and bone status by quantitative ultrasound (QUS) at the calcaneus were evaluated. The risk of vertebral fractures was significantly increased in patients taking the highest daily dose (>1,500 microg) of inhaled GCs (OR = 1.4, CI 1.04-1.89). The highest dose of inhaled GCs was significantly associated with low values of stiffness index (OR = 1.74, CI 1.03-2.94). Inhaled beta(2) agonists were not associated either with increased risk of vertebral fracture or with reduced values of stiffness. Moreover, the risk of fractures was markedly increased in patients with very severe or severe COPD (OR = 2.05, CI 1.28-3.28, and OR = 1.40, CI 1.06-1.82, respectively). In conclusion, in COPD patients high doses of inhaled GCs, but not beta(2) agonists, are associated with an increased risk of vertebral fractures and a reduction of QUS at the calcaneus.

Osteoporosis risk in patients with chronic obstructive pulmonary disease: the EOLO study

Chronic obstructive pulmonary disease (COPD) appears to be associated with osteoporosis. The aim of the study was to evaluate the prevalence of osteoporosis risk (OP risk) in a sample of patients with COPD. In 3030 patients (1768 men and 1262 women) aged >50 yr, we evaluated COPD severity with spirometry and OP risk by using a quantitative ultrasound device. We analyzed several risk factors for osteoporosis, such as age, gender, body mass index (BMI), fracture history, smoking status, glucocorticoid (GC) treatment in univariate and in multinomial logistic regressions. The risk of osteoporosis was higher in women and in older participants, among those with more severe COPD, treated with GC. In multivariate analysis, we found interactions between fracture history and smoking and between age and gender. Significant associations were found with BMI and GC treatment, whereas only a tendency, not statistically significant, was found for very severe COPD being associated to high risk of osteoporosis. In COPD patients the risk of osteoporosis is high, in particular at severe stages of the disease, but seems to be due to traditional risk factors, such as older age, female gender, low BMI, history of smoking and fractures, GC treatment.