A Prediction Equation to Assess Resting Energy Expenditure in Japanese Patients with COPD

Background: Medical nutrition therapy is important in the management of chronic obstructive pulmonary disease (COPD) patients. Determination of resting energy expenditure is essential to define therapeutic goals for medical nutrition. Previous studies proposed the use of equations to predict resting energy expenditure. No prediction equation is currently available for the Japanese population. The objective of this study was to develop an equation to predict resting energy expenditure in Japanese chronic obstructive pulmonary disease patients. To this end, we investigated clinical variables that correlate with the resting energy expenditure. Methods: This study included 102 COPD patients admitted at the Matsusaka Municipal Hospital Respiratory Center. We measured resting energy expenditure by indirect calorimetry and explored the relationship of resting energy expenditure with clinical variables by univariate and stepwise linear regression analysis. Results: The resting energy expenditure by indirect calorimetry was significantly correlated with fat-free mass, body weight, body mass index, height, gender, and pulmonary function test by univariate analysis. In the stepwise linear regression analysis, the fat-free mass, body weight, and age remained significantly correlated with indirect calorimetry’s resting energy expenditure. The fat-free mass, body weight, and age explained 50.5% of the resting energy expenditure variation. Conclusion: Fat-free mass, body weight, and age were significantly correlated with resting energy expenditure by stepwise linear regression analysis, and they were used to define a predictive equation for Japanese COPD patients.

Risk factors for lung cancer in COPD - results from the Bergen COPD cohort study

BACKGROUND

COPD patients have an increased risk of developing lung cancer, but the underlying mechanisms are poorly understood. We aimed to identify risk factors for lung cancer in patients from the Bergen COPD Cohort Study.

METHODS

We compared 433 COPD patients with 279 healthy controls, all former or current smokers. All COPD patients had FEV1<80% and FEV1/FVC-ratio<0.7. Baseline predictors were sex, age, spirometry, body composition, smoking history, emphysema assessed by CT, chronic bronchitis, prior exacerbation frequency, Charlson Comorbidity Score, inhalation medication and 44 serum/plasma inflammatory biomarkers. Patients were followed up for 9 years recording incidence of lung cancer. Cox-regression models were fitted for the statistical analyses. The biomarkers were evaluated using principal component analysis.

RESULTS

28 COPD patients and 3 controls developed lung cancer, COPD patients had a significantly higher risk of developing lung cancer, (HR 5.0; 95% CI 1.5-17.1, p < 0.01, adjusted values). Among COPD patients, emphysema (HR 4.4; 1.7-10.8, p < 0.01) and obesity (HR 3.3; 1.3-8.5, p = 0.02) were associated with a higher cancer rate. Use of inhaled steroids was associated with a lower rate (HR 0.4; 0.2-0.9, p = 0.03). Smoking status, pack-years smoked or levels of systemic inflammatory markers, except for interferon gamma-induced protein 10, did not affect the lung cancer rate in patients with COPD.

CONCLUSION

Patients with COPD have a higher lung cancer rate compared to healthy controls adjusted for smoking. The presence of emphysema and obesity in COPD predicted a higher lung cancer risk in COPD patients. Systemic inflammation was not associated with increased lung cancer risk.

Identification of a Novel 33-kDa Ser/Thr Kinase that Phosphorylates the Cytoplasmic Tail of Protease-activated Receptor 1 (Thrombin Receptor) in Human Platelets

Stimulation of human platelets with thrombin or thrombin receptor agonist peptide (TRAP/ Ser-Phe-Leu-Leu-Arg-Asn) resulted in phosphorylation of the protease-activated receptor 1 (PAR1). However, protein kinase(s), capable of phosphorylating PAR1 upon activation of this receptor, has not been as yet identified in human platelets. The present study was undertaken to assess the presence of protein kinase(s) that may interact with PAR1 using a procedure based on the ability of protein kinase to undergo renaturation and phosphorylate a protein substrate fixed in a gel. We employed a fusion protein that was prepared using a glutathione S-transferase (GST) and the cytoplasmic tail of PAR1 (Pro368-Thr425)(GST-PAR1) or a reverse sequenced peptide of this domain (GST-rPAR1). The results showed that treatment of platelets with thrombin induced about 10-fold increase in the activity of the 33-kDa Ser/Thr protein kinase, which was also activated by TRAP, but not by hirudin-treated thrombin or diisopropylfluorophosphate-inactivated thrombin, suggesting that it is activated through PAR1. Furthermore, treatment of platelets with thromboxane A2 analog, STA2, led to an activation of this protein kinase and phosphorylation of PAR1. In conclusion, the present study provides evidence of homologous and heterologous activation of a novel 33-kDa Ser/Thr kinase that phosphorylates the cytoplasmic tail of PAR1.

Prothrombin and Its Derivatives Stimulate Motility of Melanoma Cells

Several studies indicated that activation of the clotting system may promote the growth and the invasive behavior of tumor cells. In the present study, we evaluated the migratory response of various melanoma cell lines to several clotting factors and prothrombin derivatives (thrombin, fragment 1, fragment 2 and kringle 1 fragment). Prothrombin, thrombin and fragment 1 stimulated chemotaxis of the murine (K-1735 M2, X21) and human A375 (SM) melanoma cell lines. Prothrombin and prothrombin fragment 1 showed their maximal chemo-tactic activity at 0.5~1 μM. Chemotaxis induced by thrombin was inhibited by hirudin, but not that induced by prothrombin or fragment 1. Other clotting proteins and the fragment 2 and kringle 1 fragment of prothrombin did not elicit chemotactic activity. Checkerboard analysis indicated that motility was directional with a significant chemokinetic component. The K-1735 M2 cells also migrated in a concentration-dependent manner to substratum-bound insoluble prothrombin, thrombin or fragment 1. Ligand binding assays showed that both prothrombin and fragment 1 bound to K-1735 M2 cells with apparent Kds of 0.5 μM. This binding was inhibited by an excess concentration of unlabeled prothrombin and fragment 1 but not by similar concentrations of other prothrombin fragments. These findings suggest that prothrombin and its fragment 1 exert chemotactic activity on melanoma cells by different mechanisms and different binding sites from that induced by thrombin.

Measurement of tissue factor messenger RNA levels in leukocytes from patients in hypercoagulable state caused by several underlying diseases

In a preliminary study, we have demonstrated that tissue factor (TF) is immunohistochemically stained in monocytes from patients with disseminated intravascular coagulation (DIC) but not from healthy volunteers, and that leukocytes from DIC patients induce enhanced activated factor X (FXa) generation in the presence of a mixture of FVIIa, FX and Ca2+. Then, TF mRNA levels in leukocytes were measured to evaluate the role of TF in the pathophysiology of various diseases. TF mRNA levels in leukocytes were low in healthy volunteers but they were significantly increased in various diseases, especially in patients with infectious diseases, solid cancer, anemd hematopoietic tumors. TF mRNA levels in leukocytes were significantly higher in patients with high levels of C reactive protein (CRP) than in those with low CRP. TF mRNA levels were significantly higher in patients with DIC than in those without DIC. TF mRNA levels were well correlated with TF antigens in plasma and leukocytes. These findings suggest that the expression of TF mRNA in leukocytes is increased in various diseases and that this may play an important role in hypercoagulability or DIC.

Diagnosis of disseminated intravascular coagulation by hemostatic molecular markers

In the present study, the positive rate of thrombin-antithrombin complex (TAT), plasmin-plasmin inhibitor complex (PPIC), soluble fibrin monomer (sFM), and D-dimer for the diagnosis of disseminated intravascular coagulation (DIC) was evaluated. The study comprised 307 patients with DIC, 123 with pre-DIC, and 121 with non-DIC. Plasma levels of TAT, PPIC, sFM, and D-dimer were significantly higher in DIC and pre-DIC patients than in non-DIC patients. In DIC patients, the positive rate of sFM was high and that of D-dimer was low; the positive rate of PPIC was higher in patients with hematopoietic malignancy than in those without this disease. In pre-DIC patients, the positive rate of all markers was low (<0.16), and the positive rate of PPIC was relatively high. In non-DIC patients, the positive rate of all hemostatic markers was low (<0.16), that of sFM being the lowest. Scoring the positive rate of TAT, PPIC, and sFM disclosed the following results: 72% of DIC patients had three or more points, 17.6% of pre-DIC patients had three or more points, and almost all (96.6%) non-DIC patients had two or less points. Scoring the positive rate of TAT, PPIC, and D-dimer disclosed the following results: 52.9% of DIC patients and 27.4% of pre-DIC patients had three or more points and almost all (96.7%) non-DIC patients had 2 or less points. These data suggest that the combination of TAT, PPIC, and sFM is useful for making the diagnosis of DIC.

Ineffective interferon treatment of chronic hepatitis C-associated porphyria cutanea tarda, but with a transient decrease in HCV RNA levels

Many patients with porphyria cutanea tarda (PCT) have been reported to be hepatitis C virus (HCV) carriers, suggesting that HCV infection plays a role in the pathogenesis of this type of porphyria. In this study, we report a patient with chronic hepatitis C-associated PCT. Therapy with interferon (IFN) transiently decreased HCV RNA levels, but levels of urinary porphyrins and serum transaminases and ferritin remained unchanged. Serum ferritin and urinary porphyrin levels improved after phlebotomy, but this therapy was not effective in improving serum transaminase levels. Although a physiopathological association between HCV infection and PCT has been suggested previously, IFN was not effective in this patient. The transient decrease in HCV RNA levels was a factor independent of porphyrin metabolism.

Case report: Alanine aminotransferase deficiency detected in a patient with chronic hepatitis C

We report a case of alanine aminotransferase (ALT) deficiency in a 68-year-old Japanese female with chronic hepatitis C. The serum was positive for antibody to hepatitis C virus (HCV) and HCV-RNA. Liver biopsy showed histological evidence of chronic active hepatitis. The level of serum aspartate aminotransferase (sAST) was elevated, but sALT was extremely low. The patient was followed up for her serum aminotransferase levels for 1.5 years under the treatment with ursodeoxycholic acid. The low sALT level persisted during all the follow-up period. The ALT activity in liver tissue was also decreased. Based on these findings, ALT deficiency was suspected. sALT activity was also found to be low in her two sons. This latter finding suggests the hereditary character of this abnormality.

Collagen markers during anticancer therapy for lung cancer

Recently, many studies have reported that collagen metabolism markers, such as the aminoterminal propeptide of type IIE collagen (PIIIP) and the 7-S domain of type TV collagen (7-S collagen), increased in malignancy and that, they correlate with the clinical behavior of the disease. The objective of the present study was to assess the serum concentration of these collagen markers in relation to the clinical progression of the disease and during chemotherapy in lung cancer patients. This study comprised 48 lung cancer patients. Sixteen patients underwent cisplatin-based chemotherapy. Samples taken from controls were available for comparison. Serum concentrations of PIIIP and 7S-collagen were significantly higher as compared to the control group. While the collagen markes tended to decrease in the responder patients, they increased significantly after chemotherapy in the non-responder group. Collagen markers are suggested to be potentially useful for the early evaluation of the tumor response to chemotherapy in lung cancer.

Correlation between increased granulocyte elastase release and activation of blood coagulation in patients with lung cancer

BACKGROUND

Coagulopathies often are associated with malignant tumors. The pathogenesis of these complications in cancer is not clear. Host inflammatory (monocyte/macrophage) cell-mediated triggering of clotting activation has been suggested.

METHODS

The objective of this study was to evaluate the role of neutrophil-derived elastase in the activation of blood coagulation and fibrinolysis in lung cancer. The study population was 42 consecutive patients with lung cancer (34 men and 8 women). Thirteen patients had small cell lung cancer (SCLC), 13 had squamous cell lung cancer, and 16 had adenocarcinoma. Hemostatic function was assessed by measuring D-dimer (DD), thrombin-antithrombin III complex (TAT), plasmin-alpha 2-antiplasmin complex (PAP), fibrin degradation product (FDP), fibrinogen, prothrombin time (PT) and activated partial thromboplastin time (APTT). Elastase-alpha 1-protease inhibitor (EPI) complex was measured as a marker of neutrophil activation.

RESULTS

Significant elevation of the elastase plasma levels and coagulation-fibrinolysis parameters was found in patients with cancer compared with control subjects. Among all patients, the plasma concentration of EPI was significantly correlated with APTT, DD, TAT, PAP, and fibrinogen. Although in patients with non-small cell lung cancer (non-SCLC), DD, TAT, PAP, APTT, and fibrinogen were significantly correlated with EPI, such a correlation was not found in patients with SCLC. Patients with non-SCLC had stronger correlation of EPI with TAT, PAP, and PT than did patients with advanced stages of disease.

CONCLUSION

The activation of coagulation-fibrinolysis system in lung cancer may be triggered, at least in part, by an increased release of neutrophil elastase. This mechanism is stage related and seems to operate predominantly in non-SCLC.

[Clinical characteristics of pulmonary tuberculosis in the compromised host]

The incidence of pulmonary tuberculosis in Japan has decreased remarkably. However, high frequency of tuberculosis can still be noticed in those subjects with underlying diseases, the so-called compromised host. This study aimed at to clarify the clinical characteristics of pulmonary tuberculosis in the compromised host. To achieve our objective we compare the clinical and radiological findings in patients with and without underlying disease. This study comprised 44 pulmonary tuberculosis patients. Among these, 24 cases (55%) of tuberculosis occurred in those with a pre-existing disease. Most patients of the compromised host group were seen because of pulmonary symptomatology. There were 3 cases (15%) with cavitated pulmonary infiltration in the normal host group, whereas in the compromised host group 7 cases (29%) presented cavitary lesions. From these results, it was confirmed the high frequency of pulmonary tuberculosis in patients with an underlying disease. In addition, this work suggests that the presence of an atypical radiological findings should orient the clinician to start an early work-up for the diagnosis of pulmonary tuberculosis in those high risk group of patients.

[Usefulness of DLco for the early diagnosis of pulmonary involvement in collagen diseases]

Collagen disease are chronic multisystemic disorders affecting many organs. Pulmonary involvement is frequently associated with these collagen diseases. The usefulness of the diffusion capacity of the lung for the early detection of pulmonary involvement was assessed in 182 collagen vascular disease patients. In addition, the clinical characteristics of those patients with pulmonary lesions were also evaluated. Among these, there were 69 cases of chronic rheumatoid arthritis (RA), 39 progressive systemic sclerosis (PSS), 24 systemic lupus erythematosus (SLE), 12 dermatomyositis-polymyositis (DM-PM), 12 mixed connective tissue disease (MCTD), 11 Sjögren syndrome (SS), 9 Behçet's disease (BD) and 6 unclassified connective tissue disease (UCTD). Patients with normal chest X-ray but with pulmonary dysfunction were recognized in 56% of RA, 59% of PSS, 50% of SLE, 50% of DM-PM, 71% of MCTD, 33% of SS, and 50% of BD cases. Moreover, a higher degree of immunological abnormalities was observed in those with pulmonary complications. From these results, we conclude that diffusion lung capacity is a useful index for the early diagnosis of pulmonary involvement in collagen vascular disorders.

[Obstructive pneumonitis in lung cancer patients--a retrospective study]

We evaluated the frequency and the backgrounds of lung cancer patients with obstructive pneumonitis. Among 84 cases of lung cancer, 35 presented with bronchial obstruction at bronchoscopy or on radiological studies. Of these 35 cases, 8 had infectious obstructive pneumonitis. This complication was observed more commonly in patients with squamous cell carcinoma. A comparative analysis of the immunological and nutritional states before the occurrence of bacterial complication was performed on patients with infectious obstructive pneumonitis and those with non-infectious obstructive pneumonitis. The serum concentration of total protein, albumin and total cholesterol was significantly lower in patients who subsequently developed bronchial obstruction and bacterial infection, compared to concentrations in patients with non-infectious obstructive pneumonitis. Similarly, there was significant decrease in the number of peripheral lymphocytes, and neutrophils as well as a significant reduction of the serum concentration of IgM in the group of patients with infectious complications. These results suggest that nutritional and immunological deficiencies, in association with local airway obstruction, may be determining factors in the occurrence of infectious obstructive pneumonitis in patients with lung cancer.

[A case of symmetrical and bilateral tuberculoma of both lung apices]

A 28-year-old man with solitary nodular shadows in both lungs was admitted. The erythrocyte sedimentation rate was accelerated, with elevation of the serum IAP values, and the tuberculin reaction was strongly positive. The X-Ray film of the chest revealed symmetrical and bilateral nodular shadow in both lung apices. Both nodular lesions revealed a tendency to grow, pleural indentation and spiculated margins. Moreover, the tomogram film showed convergence of the pulmonary vein branch in the central part of the left apex nodule. Since it was extremely difficult to distinguish these lesions from malignant nodules based on just radiographic findings, an exploratory thoracotomy was carried out. The histologic diagnosis of both nodules was tuberculoma. Currently, the radiologic criteria used to distinguish between benign and malignant lesions are assessment of size, contour, absence or presence of tumor growing tendency by serial radiographs, calcification as well as the relation between the lesion with the pulmonary vasculature. It was concluded that, as was shown by this case, the radiographic criteria appear to be insufficient to categorize the nature of a lesion into benign or malignant. Consequently, more reliable non-invasive techniques would be desirable for the accurate diagnosis of tuberculosis.