Exhaled nitric oxide levels in COPD patients who use electronic cigarettes

Emerging data from clinical studies have shown pro-inflammatory effects associated with e-cigarette use. Fractional exhaled nitric oxide (FeNO) is a biomarker of pulmonary type 2 (T2) inflammation. The effect of chronic e-cigarette use on FeNO is unclear. The aim of this study was to compare FeNO levels in COPD ex-smokers who use e-cigarettes (COPDE + e-cig) to COPDE ex-smokers (COPDE) and COPD current smokers (COPDS). FeNO levels were significantly higher in COPDE + e-cig (median 16.2 ppb) and COPDE (median 18.0 ppb) compared to COPDS (median 7.6 ppb) (p = 0.0003 and p < 0.0001 respectively). There was no difference in FeNO levels between COPDE + e-cig compared to COPDE (p > 0.9). The importance of our results is that electronic cigarette use does not alter the interpretation of FeNO results, and so does not interfere with the use of FeNO as a practical biomarker of T2 inflammation, unlike current cigarette smoking in COPD. Whilst the effect of electronic cigarette use on FeNO levels is not the same as cigarette smoke, this cannot be taken as evidence that electronic cigarettes are harmless. These differential pulmonary effects can be attributed to differences in the chemical composition of the two products.

ERS International Congress 2023: highlights from the Airway Diseases Assembly

In this review, early career and senior members of Assembly 5 (Airway Diseases, Asthma, COPD and Chronic Cough) present key recent findings pertinent to airway diseases that were presented during the European Respiratory Society International Congress 2023 in Milan, Italy, with a particular focus on asthma, COPD, chronic cough and bronchiectasis. During the congress, an increased number of symposia, workshops and abstract presentations were organised. In total, 739 abstracts were submitted for Assembly 5 and the majority of these were presented by early career members. These data highlight the increased interest in this group of respiratory diseases.

Current smoking reduces small airway eosinophil counts in COPD

Current smoking reduces small airway intraepithelial eosinophil counts in COPD patients and controls. This provides evidence of an attenuation of type-2 related inflammation in the small airways imposed by current smoking, which may affect ICS response. https://bit.ly/49YSKwG.

How inhaled corticosteroids target inflammation in COPD

Inhaled corticosteroids (ICS) are the most commonly used anti-inflammatory drugs for the treatment of COPD. COPD has been previously described as a "corticosteroid-resistant" condition, but current clinical trial evidence shows that selected COPD patients, namely those with increased exacerbation risk plus higher blood eosinophil count (BEC), can benefit from ICS treatment. This review describes the components of inflammation modulated by ICS in COPD and the reasons for the variation in response to ICS between individuals. There are corticosteroid-insensitive inflammatory pathways in COPD, such as bacteria-induced macrophage interleukin-8 production and resultant neutrophil recruitment, but also corticosteroid-sensitive pathways including the reduction of type 2 markers and mast cell numbers. The review also describes the mechanisms whereby ICS can skew the lung microbiome, with reduced diversity and increased relative abundance, towards an excess of proteobacteria. BEC is a biomarker used to enable the selective use of ICS in COPD, but the clinical outcome in an individual is decided by a complex interacting network involving the microbiome and airway inflammation.

Exhaled nitric oxide, eosinophils and current smoking in COPD patients

High FENO can occur despite low blood eosinophil counts in ex-smokers, while a minority of current smokers have elevated FENO that is not related to eosinophil counts. FENO levels may be related to noneosinophilic mechanisms in a subgroup of COPD. https://bit.ly/3PSWvM2.

The COPD Assessment Test (CAT) and Depression: A Longitudinal Analysis During the COVID-19 Pandemic

Purpose

Chronic obstructive pulmonary disease (COPD) is multifaceted, with some patients experiencing anxiety and depression. Depression in COPD has been associated with worse total scores for the COPD assessment test (CAT). Also, CAT score worsening has been observed during the COVID-19 pandemic. The relationship between the Center for Epidemiologic Studies Depression Scale (CES-D) score and CAT sub-component scores has not been evaluated. We investigated the relationship between CES-D score and CAT component scores during the COVD-19 pandemic.

Patients and Methods

Sixty-five patients were recruited. Pre-pandemic (baseline) was defined as 23rd March 2019-23rd March 2020, CAT scores and information related to exacerbations were collected via telephone at 8-week intervals between 23rd March 2020-23rd March 2021.

Results

There were no differences in CAT scores pre- compared to during the pandemic (ANOVA p = 0.97). Total CAT scores were higher in patients with symptoms of depression compared to those without both pre- (p < 0.001) and during-pandemic (eg, at 12 months 21.2 versus 12.9, mean difference = 8.3 (95% CI = 2.3-14.2), p = 0.02). Individual CAT component scores showed significantly higher chest tightness, breathlessness, activity limitation, confidence, sleep and energy scores in patients with symptoms of depression at most time points (p < 0.05). Significantly fewer exacerbations were observed during- compared to pre-pandemic (p = 0.04). We observed that COPD patients with symptoms of depression had higher CAT scores both pre- and during the COVID-19 pandemic.

Conclusion

Presence of depressive symptoms was selectively associated with individual component scores. Symptoms of depression may potentially influence total CAT scores.

ERS International Congress 2022: highlights from the Airway Diseases Assembly

The European Respiratory Society (ERS) celebrated the return of an in-person meeting in Barcelona, Spain, after 2 years of virtual congresses. The ERS Congress 2022 programme was replete with symposia, skills workshops and abstract presentations from all 14 assemblies, encompassing over 3000 abstracts presented in the form of thematic poster discussion and oral presentations. In this article, highlights from the ERS Congress 2022 (including from thematic poster sessions, oral presentations and symposia from keynote speakers), presented by Assembly 5 (Airway diseases, asthma, COPD and chronic cough), are reviewed by Early Career Members and experts in the field, with the aim of presenting key recent findings in the field.

Sputum neutrophil counts in healthy subjects: relationship with age

A threshold of approximately 60% has commonly been used in asthma and COPD studies to define the presence of neutrophilic airway inflammation. This threshold is based on relatively young healthy subject data sets. However, age-related increases in sputum neutrophils have been observed previously. We used a healthy cohort, with a comparatively wider age range, to re-evaluate the age-related increase in sputum neutrophils, analysing changes by decade. We also studied the long-term repeatability of sputum neutrophil counts.

Differential sputum cell count data for healthy subjects (n=121) was retrospectively analysed. Subjects with a repeated count (mean interval 4.8 years) were included in longitudinal analysis.

There was a significant positive association between age and sputum neutrophil % (rho=0.24, p<0.01), with 51.2% of subjects having a sputum neutrophil count >60%. Sputum neutrophil counts increased with each decade until approximately 60 years where a plateau was observed. The baseline sputum neutrophil % increased significantly at repeated sampling (p=0.02), with excellent long-term repeatability (intraclass correlation coefficient=0.80).

We confirm previous reports of an age-related increase in sputum neutrophil % in healthy individuals, and identified a plateau which occurs at approximately age 60 years. There was an increase in sputum neutrophil percentage during longitudinal follow up, indicating that age related neutrophilia is a progressive phenomenon. These findings question the use of an unadjusted threshold, in relation to age, to identify the presence of neutrophilic airway inflammation.

Validation of Sputum Biomarker Immunoassays and Cytokine Expression Profiles in COPD

Immunoassays are commonly used to assess airway inflammation in sputum samples from chronic obstructive pulmonary disease (COPD) patients. However, assay performance and validation in this complex matrix is inconsistently reported. The aim of this study was to assess the suitability of various immunoassays for use with sputum samples, followed by use of validated immunoassays to evaluate biomarker levels in COPD patients. Assays were assessed for recombinant reference standard suitability, optimal sample dilution, standard recovery in the biological matrix and reproducibility. Validated assays were used to assess sputum supernatants in Cohort A (n = 30 COPD, n = 10 smokers, n = 10 healthy) and Cohort B (n = 81 COPD, n = 15 smokers, n = 26 healthy). Paired baseline and exacerbation samples from 14 COPD patients were assessed in cohort A, and associations with sputum cell counts and bacterial colonisation investigated in cohort B. 25/32 assays passed validation; the primary reason for validation failure was recombinant reference standard suitability and sample dilution effects. Interleukin (IL-)6 and IL-8 were significantly increased in COPD patients compared to healthy subjects and smokers for both cohorts. Tumour necrosis factor (TNF)α and IL-1β were higher in COPD compared to smokers using one immunoassay but not another, partly explained by different absolute recovery rates. IL-1β, IL-2, IL-4, IL-8, IL-17A, Granulocyte colony stimulating factor (G-CSF), Interferon (IFN-)γ, Interferon gamma induced protein (IP-)10, Macrophage inflammatory protein (MIP)-1α, MIP-1β and TNF-α levels correlated with sputum neutrophil percentage in COPD patients. IL-1β, IL-4, IL-8, G-CSF and IFN-γ levels were associated with Haemophilus influenzae colonisation in COPD patients. Current smokers had lower levels of IL-1β, IL-4, IL-8, G-CSF, IFN-γ, IP-10, Monocyte chemoattractant protein (MCP)-1, MIP-1α, MIP-1β and TNF-α. Validated immunoassays applied to sputum supernatants demonstrated differences between COPD patients and controls, the effects of current smoking and associations between Haemophilus influenzae colonisation and higher levels of selected cytokines. Immunoassay validation enabled inflammatory mediators associated with different COPD characteristics to be determined.

Differential responses of COPD macrophages to respiratory bacterial pathogens

COPD patients have increased susceptibility to airway bacterial colonisation. Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae are three of the most common respiratory bacterial species in COPD. H. influenzae colonisation, but not other bacteria, in COPD patients is associated with higher sputum neutrophil counts. Alveolar macrophages are key in clearance of bacteria as well as releasing mediators to recruit and activate other immune cells in response to infection. The aim was to characterise differences in COPD macrophage responses to H. influenzae, M. catarrhalisand S. pneumoniae, focusing on release of inflammatory and chemotactic mediators, and apoptosis regulation.

 Lung macrophages and monocyte-derived macrophages from COPD patients and control subjects were exposed to H. influenzae, M. catarrhalisor S. pneumoniae. Cytokine secretion (tumour necrosis factor-α, interleukin (IL)-6, CXCL8, CCL5 and IL-1β) were measured by ELISA and quantitative reverse transcriptase PCR (RT-qPCR), and apoptosis genes MCL-1, BCL-2, BAX and BAK1 by RT-qPCR. Apoptosis and reactive oxygen species (ROS) release were also measured.

 Macrophages responded differentially to the bacterial species, with increased, prolonged production of the neutrophil chemoattractant CXCL8 in response to H. influenzae and M. catarrhalis but not S. pneumoniae. S. pneumoniae initiated macrophage apoptosis and ROS release, H. influenzae and M. catarrhalis did not and increased anti-apoptosis gene expression (BCL-2 5.5-fold and MCL-1 2.4-fold, respectively).

 Differential cytokine responses of macrophages to these bacterial species can explain neutrophilic airway inflammation associated with H. influenzae, but not S. pneumoniae in COPD. Furthermore, delayed macrophage apoptosis is a potential mechanism contributing to inability to clear H. influenzae.

Differential cytokine responses of macrophages to Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae can explain neutrophilic airway inflammation associated with H. influenzae but not S. pneumoniae in COPDhttps://bit.ly/3950HVZ

Expiratory flow limitation in a cohort of highly symptomatic COPD patients

The question addressed by the study

Small airway collapse during expiration, known as expiratory flow limitation (EFL), can be detected using oscillometry and is associated with worse clinical outcomes in COPD. This study investigated the prevalence of EFL in a cohort of highly symptomatic patients, evaluated clinical and lung function characteristics of patients with EFL and studied the repeatability of EFL over 6 months.

Materials/patients and methods

70 patients were recruited. Clinical characteristics and lung function metrics were collected at baseline and 6 months. Impulse oscillometry was used to detect the presence of EFL. Patients were defined as EFL^High (change in reactance measured at 5 Hz (ΔX₅) ≥0.28 kPa·L⁻¹·s⁻¹); EFL^Intermediate (ΔX₅ 0.1–0.27 kPa·L⁻¹·s⁻¹) and EFL^None (ΔX₅ <0.1 kPa·L⁻¹·s⁻¹).

Results

EFL^High was present in 47.8% of patients at baseline. ΔX₅ showed excellent repeatability over 6 months (ρ=0.78, p<0.0001, intraclass correlation coefficient (ICC) 0.88), with the best repeatability observed in EFL^None and EFL^High patients (ICC 0.77 and 0.65, respectively). Compared to EFL^None patients, EFL^High had a higher body mass index, worse health-related quality of life and increased peripheral airway resistance. EFL^Intermediate was more variable over time with less severe physiological impairment.

Answer to the question

Overall, these data indicate that EFL^High is a common, and relatively stable, component of disease pathophysiology in highly symptomatic COPD patients. EFL^High was also associated with worse quality of life and obesity.

EFL, defined by oscillometry, is a common and relatively stable component of disease pathophysiology in highly symptomatic COPD patients. EFL is associated with worse airflow obstruction, small airway resistance, worse quality of life and obesity.https://bit.ly/3AMRjjL

Airway Bacteria Quantification Using Polymerase Chain Reaction Combined with Neutrophil and Eosinophil Counts Identifies Distinct COPD Endotypes

BACKGROUND

Chronic obstructive pulmonary disease (COPD) inflammatory endotypes are associated with different airway microbiomes. We used quantitative polymerase chain reaction (qPCR) analysis of sputum samples to establish the bacterial load upper limit in healthy controls; these values determined the bacterial colonisation prevalence in a longitudinal COPD cohort. Bacteriology combined with sputum inflammatory cells counts were used to investigate COPD endotypes.

METHODS

Sixty COPD patients and 15 healthy non-smoking controls were recruited. Sputum was analysed by qPCR (for Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae and Psuedomonas aeruginosa) and sputum differential cell counts at baseline and 6 months.

RESULTS

At baseline and 6 months, 23.1% and 25.6% of COPD patients were colonised with H. influenzae, while colonisation with other bacterial species was less common, e.g., S. pneumoniae-1.9% and 5.1%, respectively. H. influenzae + ve patients had higher neutrophil counts at baseline (90.1% vs. 67.3%, p < 0.01), with similar results at 6 months. COPD patients with sputum eosinophil counts ≥3% at ≥1 visit rarely showed bacterial colonisation.

CONCLUSIONS

The prevalence of H. influenzae colonisation was approximately 25%, with low colonisation for other bacterial species. H. influenzae colonisation was associated with sputum neutrophilia, while eosinophilic inflammation and H. influenzae colonisation rarely coexisted.

Eosinophil-derived neurotoxin: A biologically and analytically attractive asthma biomarker

There is a growing body of evidence for the utility of eosinophil-derived neurotoxin (EDN) as a biomarker in asthma, including association with eosinophilic airway inflammation, assessment of disease severity and potential for predicting pathogenic risks, including exacerbations. However, to interpret any biomarker data with confidence, it is first important to understand the preanalytical factors and biological variation that may affect its reliable measurement and results interpretation. In this study we defined the healthy serum EDN reference range for men and women as 1.98 to 26.10 ng/mL, with no significant gender differences. Smoking did not impact the mean EDN levels and no circadian rhythm was identified for EDN, unlike blood eosinophils (EOS) where levels peaked at 00:00h. EDN expression in different cell types was investigated and shown to occur primarily in eosinophils, indicating they are likely to be the main cellular repository for EDN. We also confirm that the quantification of serum EDN is not influenced by the type of storage tube used, and it is stable at ambient temperature or when refrigerated for at least 7 days and for up to one year when frozen at -20°C or -80°C. In summary, EDN is a stable biomarker that may prove useful in precision medicine approaches by enabling the identification of a subpopulation of asthma patients with activated eosinophils and a more severe form of the disease.

Halitosis as a product of hepatic disease

OBJECTIVES

This study evaluated halitosis in patients suffering from hepatic disease.

MATERIAL AND METHODS

Twenty-five patients (12 males and 13 females) aged between 16 and 73 years who had undergone treatment for liver disease were included in this study. Three halimeter recordings were performed to measure methyl mercarptan and hydrogen sulphite. Mean values were calculated and compared with normal values (75-120 ppb). The level of significance was set at P < .05. Results: Thirteen of the 25 subjects (52%) had normal Volatile Sulphur Compound (VSC) values (75-120 ppb). Twelve subjects (48%) recorded values ranging from 132 to 1112 ppb. There was no correlation between hepatic pathology and halitosis. Fifty-two percent of all subjects had poor oral hygiene, strongly correlated with high VSC values (P<0.05) whereas the remaining 48% with good hygiene had normal levels of VSC.

CONCLUSIONS

Within the limitations of this study, high values of VSC were not associated with the presence of hepatic disease.

A Prospective Randomised Controlled Trial of VNUS Closure versus Surgery for the Treatment of Recurrent Long Saphenous Varicose Veins

OBJECTIVE

This study aimed to assess the outcome of endoluminal thermal ablation (VNUS) and traditional redo groin surgery (RGS) and long saphenous vein (LSV) stripping in patients with bilateral recurrent long saphenous varicose veins.

METHODS

This was a randomised patient controlled double blind study. Sample size calculations required 16 patients. Their median age was 54 and 11 were women. The median CEAP class was 3. At operation one leg, chosen at random, was treated with VNUS and avulsions using intra-operative duplex control. The other leg was treated with traditional RGS, exposure of the femoral vein, stripping of the LSV and multiple avulsions. Post-operatively patients completed 10 cm visual analogue scales for pain and bruising. Digital Image analysis was used to objectively assess bruising. Statistical analysis was done using Wilcoxon signed rank test for paired data. Results are expressed as median values (inter-quartile ranges).

RESULTS

Time to perform VNUS was 25.5 (20.5-31.3) min compared with 40 (34.5-45.5) min it took for RGS (p=0.02). Pain score for VNUS was 1.7 (0.2-4), significantly lower than that for RGS 3.8 (0.6-6.3) (p=0.02). Bruise score for VNUS was 1.7 (0.4-4.4), and that for RGS was 5.2 (2.6-7) (p=0.03). All LSVs were sealed by VNUS at duplex follow up. Three legs in the RGS group and two in the VNUS group had a minor complication.

CONCLUSIONS

VNUS caused less pain and bruising and was performed more quickly than RGS. VNUS should be considered the treatment of choice for recurrent long saphenous varicose veins.

Developing a one-stop clinic for leg ulcer patients

Leg ulceration may be caused by a variety of different factors and specialist assessment is required. Patients with complex leg ulcers in Nottingham are assessed at a one-stop dermatology/vascular clinic. Nurses undertake assessments, provide education and support and liaise with the community nursing services.

An exploration of child sexual abusers' sexual fantasies before and after treatment

Although there is a substantial literature looking at the relationship between deviant sexual fantasies and child sexual abuse, there is scant previous work that focuses upon the actual content of such fantasies. The present study looks at child sexual abusers' deviant fantasies both pre- and postintervention. Using both qualitative and quantitative methodologies, a description of the frequency and content of, and triggers for, child sexual abusers' deviant fantasies is reported both pre- and postintervention. The implications of this information for subsequent intervention programs is explored.

Vascular surgical society of great britain and ireland: randomized controlled trial of heparin plus graduated compression stocking for the prophylaxis of deep venous thrombosis in general surgical patients

BACKGROUND: A randomized controlled study was undertaken to compare heparin with heparin plus graduated compression stockings (Brevet Tx, Seton Healthcare) in the prophylaxis of deep vein thrombosis (DVT) following abdominal surgery. METHODS: Sixty high-risk patients were recruited if they met at least two of the following criteria identified as predisposing to DVT: age greater than 39 years, malignancy, varicose veins, cardiac disease or hypertension, diabetes mellitus, obesity or previous thromboembolic episode. All patients received subcutaneous heparin and were randomized to receive Brevet Tx to either the right or left leg before surgery. The stocking was worn for 2 weeks after surgery. The patients underwent duplex imaging before surgery, and at 3, 6 and 14 days after operation. All scans were performed by one sonographer. The policy was to perform a venogram where a positive result was indicated by duplex scanning. RESULTS: Fifty-six patients completed the study. Six patients (11 per cent) suffered a DVT in the non-stockinged leg, but none in the stockinged leg (P = 0.016, McNemar's test). The DVTs occurred on days 3, 6, 7, 8, 9 and 12 following surgery. CONCLUSION: Brevet Tx in addition to low-dose subcutaneous heparin significantly reduced the incidence of DVT in high-risk patients undergoing abdominal surgery.

Individual differences in cognitive processes: towards an explanation of schizophrenic symptomatology

A study is reported that examined the relationship between a measure of schizophrenic-like characteristics (schizotypy) in normal subjects and cognitive inhibition. Both repetitive and semantic measures of priming were used. It was found that low schizotypes showed negative priming (i.e. longer reaction times to the re-presentation of initially ignored stimuli) while high schizotypes did not; high schizotypes exhibited semantic facilitation (i.e. shorter reaction times to previously ignored stimuli) but low schizotypes did not. A model is suggested, including both inhibitory and facilitatory processes, which can account for these findings. Theorizing about these processes is of interest as it may shed some light on the mechanisms involved in the specifically cognitive symptoms of schizophrenia.

Evidence of reduced 'cognitive inhibition' in schizophrenia

An experiment is described which investigated cognitive inhibition in schizophrenia. It is noted that both the abnormal and cognitive literatures use the concept of inhibition. Frith (1979) suggests that the more cognitive symptoms of schizophrenia may be due to the failure to limit the current contents of consciousness due to a failure adequately to inhibit the output of preconscious processes. Current thinking in cognitive psychology suggests that in the process of selective attention there is active inhibition of distractor information. A technique used to investigate this is termed negative priming (Tipper, 1985). The general nature of this paradigm is as follows: if a distractor, which has been previously ignored, is response, due to inhibition of the information when it was originally a distractor. It was found that inhibition of such distracting information was reduced in schizophrenics. This finding is seen as providing some support for Frith's (1979) theory that the cognitive symptoms of schizophrenia are due to awareness of processes that normally occur preconsciously.

Individual differences in schizotypy as reflected in measures of cognitive inhibition

Three experiments are reported using the 'negative priming' paradigm to investigate cognitive differences in normal schizotypal subjects. Lists of Stroop colour words were presented at different display times in a number of priming and non-priming conditions, in one of which the ignored colour name predicted the colour of the next target item. The increased RT latencies to the target normally found in this condition were reduced, or even reversed, in high schizotypal subjects selected on the basis of a new schizotypy scale (STA). This effect was confined to a very short presentation time (100 ms), suggesting that schizotypy is associated with weakened inhibition operating in the early (automatic) stages of information processing. The familiar Stroop (interference) effect was related overall to negative priming, but was not responsible for the schizotypy differences.

Individual differences in negative priming: relations with schizotypal personality traits

A study is reported of normal subjects, selected for degree of schizotypal personality traits, on a cognitive task designed to measure, in a negative priming paradigm, the extent to which they differed in interference and presumed inhibitory effects on performance. The main individual differences measure used--a new scale of schizotypy--showed, as predicted, a significant correlation with negative priming. The correlation with a measure of 'interference' was non-significant but in the expected direction. The results are judged relevant to research implicating a weakening of inhibitory selective mechanisms in schizophrenia and to models in abnormal psychology proposing a continuum between normal and abnormal cognitive function. As such, they suggest a soundly based theoretical approach to the analysis of the individual variations in information processing commonly observed in general cognitive psychology.