Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

First trimester antenatal depression and anxiety: prevalence and associated factors in an urban population in Soweto, South Africa

Depression and anxiety in the antenatal period are of public health concern given potential adverse effects for both mother and infant. Both are under-researched in the first trimester of pregnancy, especially in Africa. We examine the prevalence of first trimester antenatal depression and anxiety in a cohort of South African women and investigate associated risk factors. Data were collected from 946 women (2014-2016) in the Soweto First 1000 Days Cohort, a prospective pregnancy cohort in Soweto, South Africa. Antenatal depression was assessed using the Edinburgh Postnatal Depression Scale with a score of ⩾13 indicating probable depression. Anxiety was assessed using the short form of the State-Trait Anxiety Index with a score ⩾12 indicating probable anxiety. Prevalence of antenatal depression was 27% [95% confidence interval (CI) 24.2-29.8] and anxiety 15.2% (95% CI 12.9-17.5). Factors associated with antenatal depression and anxiety were predominantly relationship- and family-centred. Women who perceived that their partner made life harder for them had three-fold increased odds for depression [(odds ratio (OR) 3.33 [2.28-4.85] P<0.001], whereas those with family stressors had almost double the odds for depression (OR 1.78 [1.22-2.59] P=0.003) and anxiety (OR 1.75 [1.44-2.69] P=0.0011). Antenatal depression and anxiety are common in the first trimester of pregnancy, and partner and family relationship stressors are central. Longitudinal analysis is needed to determine if this is a phase of adjustment to pregnancy or onset of persistent symptomology. Early intervention may have secondary preventative effects and should involve the partner and family.

[Non-infectious lung diseases after hematopoietic stem cell transplantation]

Non-infectious pulmonary complications following hematopoietic stem cell transplantation are entities occuring early or late, depending on whether they occur before or after 100 days post-transplantation. They have firstly to be differentiated from infectious complications, which is not always easy, as their clinical and radiological aspects can mimic a viral or bacterial pneumonia. Corticosteroids are the most given treatment but a significant subset of patients have a fatal outcome. This article will review the clinical, radiological, functionnal features and the therapeutic options of six entities (engraftment syndrome, diffuse alveolar hemorrage, idiopathic pneumonia syndrome, organizing pneumonia, bronchiolitis obliterans, post-transplantation lympho-proliferative disease).

[Interstitial lung disease in connective tissue diseases]

Interstitial lung disease represents a major clinical aspect of the four major connective tissue diseases: rheumatoid arthritis, scleroderma, polymyositis/dermatomyositis and systemic lupus erythematosus (SLE). Early recognition in the course of the disease is essential, as interstitial lung disease will often determine the vital prognosis of these patients. Treatment is most frequently based on experts' opinion, because there are only few randomized controlled trials in this field.

[New therapeutic approaches in 2014 in pulmonary medicine: COPD, asthma and lung fibrosis]

In 2014, among new therapeutic approaches in pulmonary medicine, the role of inhaled corticosteroids has to be revaluated after the publication of the WISDOM and other studies. Their prescription should no longer be systematic even for "at risk" groups of patients, as defined by the GOLD consensus, but rather be considered on an individual basis. In the field of asthma, two major studies confirm the efficacy of mepoluzimab for the treatment of severe, eosinophilic asthma. Finally, for idiopathic pulmonary fibrosis, 2014 has taught us that treatment with N-acetylcystein is of no proven benefit, while pirfenidone and nintedanib are two new drugs that may attenuate the downhill course of the disease.

[Bronchial thermoplasty in the treatment of severe adult asthma]

Bronchial thermoplasty is a recent endoscopic technique for the treatment of severe asthma. It is an innovative treatment whose clinical efficacy and safety are beginning to be better understood. Since this is a device-based treatment, the evaluation procedure of risks and benefits is different that for pharmaceutical products; safety aspects, regulatory requirements, study design and the assessment of the magnitude of effects may all be different. The mechanism of action and optimal patient selection need to be assessed further in rigorous clinical and scientific studies. This technique is in harmony with the development of personalised medicine in the 21st century. It should be developed further in response to the numerous challenges and needs not yet met in the management of severe asthma.

[Assessment and management of chronic cough in adults]

Chronic cough is one of the most common symptoms for which outpatient care is sought. The most frequent causes are upper airway cough syndrome, asthma, and gastroesophageal reflux. It is often difficult to determine the origin of chronic cough based on the medical history and physical examination. Empirical treatment directed at the three aforementioned etiologies is thus of considerable value in the initial workup. Treatment failure is most commonly due to insufficient treatment (dosage or duration) or to the coexistence of several causes needing simultaneous use of different drugs.

[Invasive pulmonary aspergillosis and chronic pulmonary aspergillosis]

Aspergillus pulmonary infection causes a spectrum of diverse diseases according to host immunity. The two major entities are invasive pulmonary aspergillosis and chronic pulmonary aspergillosis. The later can be divided into aspergilloma, then into chronic cavitary, more or less fibrosing aspergillosis, and finally into chronic necrotizing aspergillosis, or semiinvasive aspergillosis. The present article reviews this complex classification, which is necessary to reflect the diverse clinical aspect of the disease. Allergic broncho-pulmonary aspergillosis (ABPA), which is more a hypersensitivity reaction than an infectious process, will not be discussed here.

[The role of surgery in early stage small cell lung cancer: should it be re-evaluated?]

Two historical randomized controlled trials have demonstrated that chemo-radiotherapy offers the best survival advantage over surgery in small cell lung carcinoma (SCLC) and led to abandon surgery for the treatment of SCLC. Yet, widespread use of CT scanning increases the detection of early and very early stage SCLC. Therefore, the traditional 2 stages classification scheme--namely limited and extensive stage disease--is no longer sufficient for such early stage disease and must be completed by the TNM classification. Although randomized controlled trials are lacking, retrospective case series and large population databases suggest a beneficial role of surgery for the earliest SCLC stages. It is thus currently recommended to consider surgery in the multimodal treatment of stage I SCLC.

[Bronchiectasis: diagnostic workup]

Bronchiectasis is a condition defined by permanent dilation of the bronchi, either idiopathic or associated with other disease states. Diagnostic workup for bronchiectasis is essential in determining management and treatment. For diffuse bronchiectasis, we propose a workup plan that includes testing for humoral immunodeficiency by measuring serum IgG and anti-pneumococcal antibodies, looking for primary ciliary dyskinesia by exhaled nasal NO and cytologic brush biopsy of the nasal mucosa, looking for cystic fibrosis by chloride sweat testing and genotyping, evaluation for allergic bronchopulmonary aspergillosis, and testing for alpha-1-antitrypsin deficiency. Workup studies should be guided by the patient's history and clinical context.

[Cryptogenic organizing pneumonia]

Cryptogenic organizing pneumonia (COP) is a distinct clinico-pathologic entity described for the first time by Davison in 1983 and 2 years later by Epler under the name of idiopathic Bronchiolitis Obliterans Organizing Pneumonia (BOOP). It most often presents with the clinical and radiological features of an infectious pneumonia which fails to respond to antibiotic therapy. In this article, we will review the clinical and radiographic features, diagnostic assessment, and the treatment of COP.

Genome-wide association study of body mass index in 23 000 individuals with and without asthma

BACKGROUND

Both asthma and obesity are complex disorders that are influenced by environmental and genetic factors. Shared genetic factors between asthma and obesity have been proposed to partly explain epidemiological findings of co-morbidity between these conditions.

OBJECTIVE

To identify genetic variants that are associated with body mass index (BMI) in asthmatic children and adults, and to evaluate if there are differences between the genetics of BMI in asthmatics and healthy individuals.

METHODS

In total, 19 studies contributed with genome-wide analysis study (GWAS) data from more than 23 000 individuals with predominantly European descent, of whom 8165 are asthmatics.

RESULTS

We report associations between several DENND1B variants (P = 2.2 × 10(-7) for rs4915551) on chromosome 1q31 and BMI from a meta-analysis of GWAS data using 2691 asthmatic children (screening data). The top DENND1B single nucleotide polymorphisms(SNPs) were next evaluated in seven independent replication data sets comprising 2014 asthmatics, and rs4915551 was nominally replicated (P < 0.05) in two of the seven studies and of borderline significance in one (P = 0.059). However, strong evidence of effect heterogeneity was observed and overall, the association between rs4915551 and BMI was not significant in the total replication data set, P = 0.71. Using a random effects model, BMI was overall estimated to increase by 0.30 kg/m(2) (P = 0.01 for combined screening and replication data sets, N = 4705) per additional G allele of this DENND1BSNP. FTO was confirmed as an important gene for adult and childhood BMI regardless of asthma status.

CONCLUSIONS AND CLINICAL RELEVANCE

DENND1B was recently identified as an asthma susceptibility gene in a GWAS on children, and here, we find evidence that DENND1B variants may also be associated with BMI in asthmatic children. However, the association was overall not replicated in the independent data sets and the heterogeneous effect of DENND1B points to complex associations with the studied diseases that deserve further study.

Diagnosis and management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

[Pulmonary medicine 2012: news for the general practitioner]

This review reports on papers published in 2012 that will most likely impact on daily medical practice in four different areas of pulmonary medicine. How should treatment of asthma with inhaled corticosteroids be adjusted on the long run? Should idiopathic pulmonary fibrosis receive treatment with immunosuppressive drugs? Is a long-term treatment with azithromycine for bronchiectasis supported by evidence, apart from patients with cystic fibrosis? And finally, can treatment of obstructive sleep apnea with continuous positive pressure (CPAP) prevent the occurrence of new, systemic hypertension?

[What is the role of outdoor air pollution in asthma?]

Strong scientific evidence has shown that ordinary peaks of outdoor air pollution worsen the symptoms and control of asthma. As for chronic exposure, elevated mean level of local, near-road air pollution may cause increased incidence of asthma among children, and probably also among adults. By contrast, while there is no doubt that air pollution worsens allergic inflammatory processes, it is not clearly established that it may increase allergic sensitization among the general population. In this regard, more research is needed, particularly on the effects of outdoor air pollution in the early periods of life.

Acute respiratory health effects of urban air pollutants in adults with different patterns of underlying respiratory disease

OBJECTIVE

Whether underlying chronic respiratory diseases are susceptible factors for symptomatic episodes, which lead to primary-level care, in association with air pollutant exposures is unknown. We evaluated and compared association lag structures between daily ambient levels of nitrogen dioxide (NO(2)) and total suspended particulates (TSP) and respiratory symptom-related doctor visits in adults with different patterns of underlying chronic respiratory disease.

METHODS

In a time-stratified case-crossover analysis nested within a diary panel study, 459 Swiss adult participants with asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD) and healthy participants recorded occurrence of respiratory-symptom related doctor visits (n = 1,048) in one to six four-week intervals over two years. For each disease subgroup, odds ratios (ORs) for doctor visit were estimated as a function of NO(2) or TSP concentrations (per 10 micrograms per cubic meter [µg/m(3)]) lagged between 0-13 days in a polynomial distributed lag model.

RESULTS

Higher ORs for NO(2) in participants with COPD (OR: 1.17, 95%CI: 1.02-1.35) and asthma (OR: 1.15, 95%CI: 1.02-1.30) occurred at exposure lags of two and five days, respectively. Doctor visits increased by 9.1% (95%CI: 3.2-15.4%) and 4.2% (95%CI: 1.2-7.2%) over the first week following a 10 µg/m(3) increase in NO(2) concentration in the COPD and chronic bronchitis subgroups, respectively. The percent increase in the COPD subgroup was significantly greater (p <0.05) when compared with the healthy subgroup. Observed findings were similar for TSP.

CONCLUSIONS

Respiratory problems leading to a doctor visit, associated with an increase in exposure to NO(2) and TSP, may have a faster dynamic in individuals with COPD.

[Management of acute asthma in the emergency room]

Acute asthma is a frequent occurrence in the emergency room. Early care includes gradation of severity and rapid administration of systemic corticosteroid and bronchodilators. After initial treatment, if the patient has no longer criteria for severe asthma, and no poor outcome risk factor, continuation of treatment at home is a possible option. It requires to schedule a close appointment for medical follow-up, establishment of an asthma treatment plan, prescription of a short course of oral corticosteroids together with a combination of inhaled corticosteroid and long acting beta-2-agonist for longer duration of treatment.

Effect modification of immunoglobulin E-mediated atopy and rhinitis by glutathione S-transferase genotypes in passive smokers

BACKGROUND

Experimental studies suggest that glutathione S-transferase (GST) genotypes modify nasal allergen responses induced by secondhand smoke (SHS) exposure.

OBJECTIVE

We aimed to investigate whether GSTs affected systemic IgE and allergic rhinitis (AR) in SHS-exposed individuals from a population-based cohort.

METHODS

Analyses comprised 2309 never-smokers from the Swiss study on air pollution and health in adults cohort, reporting SHS status at baseline and 11 years later. Outcomes were defined by total serum IgE≥100 kU/L, specific serum IgE determined by Phadiatop® ≥0.35 kU/L and self-reported AR. GSTP1 Ile105Val, GSTM1 and GSTT1 gene deletion genotypes were identified at the follow-up survey.

RESULTS

After adjustment for relevant covariates, the homozygous GSTP1 105-Val genotype was negatively associated with high total IgE and high-specific IgE by Phadiatop®, notably in subjects persistently exposed to SHS (OR: 0.20, 95% CI 0.05-0.75; P=0.02, for high total IgE and OR: 0.29, 95% CI 0.10-0.89; P=0.03, for high specific IgE by Phadiatop®). Carrying at least one copy of the GSTM1 gene (non-null) showed a similar association for high specific IgE by Phadiatop® (OR: 0.41, 95% CI 0.22-0.76; P=0.004). No significant associations were found between GSTs and rhinitis.

CONCLUSION AND CLINICAL RELEVANCE

In this large cohort, homozygosity for GSTP1 105-Val or carrying the GSTM1 non-null genotype decreased the risk of high total IgE or high specific IgE using Phadiatop® by nearly half in subjects exposed to SHS, as compared with subjects carrying opposite alleles. These findings underline the value of genetic susceptibility when evaluating the effects of environmental exposure on allergic illness. The potential long-term effects of persistent SHS exposure in genetically vulnerable individuals may be of public health relevance.

[Critical pathway for community-acquired pneumonia]

A clinical pathway is a methodological tool for standardizing medical practice, improving the quality and efficiency of care delivery, and enhancing the diffusion of evidence-based medicine. Despite the fact that a majority of trials have shown that the use of clinical pathways improves certain specific outcomes such as length of stay or complications, the overall impact of these pathways in the clinical setting has yet to be documented. In the setting of community-acquired pneumonia, a few observational and one large randomized trial have shown positive effects on various outcomes. We describe in this article the clinical pathway for community-acquired pneumonia developed at our institution.

Upper and lower respiratory tract viral infections and acute graft rejection in lung transplant recipients

BACKGROUND

Lung transplant recipients are frequently exposed to respiratory viruses and are particularly at risk for severe complications. The aim of this study was to assess the association among the presence of a respiratory virus detected by molecular assays in bronchoalveolar lavage (BAL) fluid, respiratory symptoms, and acute rejection in adult lung transplant recipients.

METHODS

Upper (nasopharyngeal swab) and lower (BAL) respiratory tract specimens from 77 lung transplant recipients enrolled in a cohort study and undergoing bronchoscopy with BAL and transbronchial biopsies were screened using 17 different polymerase chain reaction-based assays.

RESULTS

BAL fluid and biopsy specimens from 343 bronchoscopic procedures performed in 77 patients were analyzed. We also compared paired nasopharyngeal and BAL fluid specimens collected in a subgroup of 283 cases. The overall viral positivity rate was 29.3% in the upper respiratory tract specimens and 17.2% in the BAL samples (P < .001). We observed a significant association between the presence of respiratory symptoms and positive viral detection in the lower respiratory tract (P = .012). Conversely, acute rejection was not associated with the presence of viral infection (odds ratio, 0.41; 95% confidence interval, 0.20-0.88). The recovery of lung function was significantly slower when acute rejection and viral infection were both present.

CONCLUSIONS

A temporal relationship exists between acute respiratory symptoms and positive viral nucleic acid detection in BAL fluid from lung transplant recipients. We provide evidence suggesting that respiratory viruses are not associated with acute graft rejection during the acute phase of infection.

HMOX1 and GST variants modify attenuation of FEF25-75% decline due to PM10 reduction

Reduced exposure to particulate matter with a 50% cut-off aerodynamic diameter of 10 microm (PM(10)) attenuated age-related lung function decline in our cohort, particularly in the small airways. We hypothesised that polymorphisms in glutathione S-transferase (GST) and haem oxygenase-1 (HMOX1) genes, important for oxidative stress defence, modify these beneficial effects. A population-based sample of 4,365 adults was followed up after 11 yrs, including questionnaire, spirometry and DNA blood sampling. PM(10) exposure was estimated by dispersion modelling and temporal interpolation. The main effects on annual decline in forced expiratory flow at 25-75% of forced vital capacity (FEF(25-75%)) and interactions with PM(10) reduction were investigated for polymorphisms HMOX1 rs2071746 (T/A), rs735266 (T/A) and rs5995098 (G/C), HMOX1 (GT)(n) promoter repeat, GSTM1 and GSTT1 deletions, and GSTP1 p.Ile105Val, using mixed linear regression models. HMOX1 rs5995098, HMOX1 haplotype TTG and GSTP1 showed significant genetic main effects. Interactions with PM(10) reduction were detected: a 10 microg.m(-3) reduction significantly attenuated annual FEF(25-75%) decline by 15.3 mL.s(-1) only in the absence of HMOX1 haplotype ATC. Similarly, carriers of long (GT)(n) promoter repeat alleles or the GSTP1 Val/Val genotype profited significantly more from a 10 microg.m(-3) reduction (26.5 mL.s(-1) and 27.3 mL.s(-1) respectively) than non-carriers. Benefits of a reduction in PM(10) exposure are not equally distributed across the population but are modified by the individual genetic make-up determining oxidative stress defence.

Determinants of change in airway reactivity over 11 years in the SAPALDIA population study

We investigated determinants of change in bronchial reactivity in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA), a population-based cohort with wide age range (29-72 yrs at follow-up). The role of sex, age, atopic status, smoking and body mass index (BMI) on percentage change in bronchial reactivity slope from the baseline value was analysed in 3,005 participants with methacholine tests in 1991 and 2002, and complete covariate data. Slope was defined as percentage decline in forced expiratory volume in 1 s from its maximal value per micromole of methacholine. Bronchial hyperreactivity prevalence fell from 14.3 to 12.5% during follow-up. Baseline age was nonlinearly associated with change in reactivity slope: participants aged <50 yrs experienced a decline and those above an increase during follow-up. Atopy was not associated with change, but accentuated the age pattern (p-value for interaction = 0.038). Smoking significantly increased slope by 21.2%, as did weight gain (2.7% increase per BMI unit). Compared with persistent smokers, those who ceased smoking before baseline or during follow-up experienced a significant decrease in slope (-27.7 and -23.9%, respectively). Differing, but not statistically different, age relationships and effect sizes for smoking and BMI between sexes were found. Mean bronchial reactivity increases after 50 yrs of age, possibly due to airway remodelling or ventilation-perfusion disturbances related to cumulative lifetime exposures.

Prevalence of airflow obstruction in smokers and never-smokers in Switzerland

The aim of the present study was to measure age-specific prevalence of airflow obstruction in Switzerland in smokers and never-smokers using pulmonary function tests and respiratory symptoms from 6,126 subjects participating in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults. The lower limit of normal of the forced expiratory volume in 1 s/forced vital capacity ratio was used to define airflow obstruction. Severity of airflow obstruction was graded according to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Prevalence of airflow obstruction ranged from 2.5% in subjects aged 30-39 yrs to 8.0% in those aged ≥ 70 yrs. In multivariate analysis, age (OR 2.8, ≥ 70 yrs versus 30-39 yrs), smoking (OR 1.8) and asthma (OR 6.7) were associated with airflow obstruction. Never-smokers constituted 29.3% of subjects with airflow obstruction. Never-smokers with airflow obstruction were younger, more likely to be male and reported asthma more frequently than obstructive smokers. Obstructive smokers and never-smokers had similar level of symptoms and quality of life impairment. The prevalence of airflow obstruction in Switzerland is similar to other developed countries. Never-smokers account for a third of the prevalence, which is higher proportion than elsewhere. Airflow obstruction in never-smokers deserves attention because of its frequency and its similar health impact to that in smokers.

Longitudinal change of prebronchodilator spirometric obstruction and health outcomes: results from the SAPALDIA cohort

BACKGROUND

Understanding the prognostic meaning of early stages of chronic obstructive pulmonary disease (COPD) in the general population is relevant for discussions about underdiagnosis. To date, COPD prevalence and incidence have often been estimated using prebrochodilation spirometry instead of postbronchodilation spirometry. In the SAPALDIA (Swiss Study on Air Pollution and Lung Disease in Adults) cohort, time course, clinical relevance and determinants of severity stages of obstruction were investigated using prebronchodilator spirometry.

METHODS

Incident obstruction was defined as an FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio >or=0.70 at baseline and <0.70 at follow-up, and non-persistence was defined inversely. Determinants were assessed in 5490 adults with spirometry and respiratory symptom data in 1991 and 2002 using Poisson regression controlling for self-declared asthma and wheezing. Change in obstruction severity (defined analogously to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification) over 11 years was related to shortness of breath and health service utilisation for respiratory problems by logistic models.

RESULTS

The incidence rate of obstruction was 14.2 cases/1000 person years. 20.9% of obstructive cases (n = 113/540) were non-persistent. Age, smoking, chronic bronchitis and non-current asthma were determinants of incidence. After adjustment for asthma, only progressive stage I or persistent stage II obstruction was associated with shortness of breath (OR 1.71, 95% CI 0.83 to 3.54; OR 3.11, 95% CI 1.50 to 6.42, respectively) and health service utilisation for respiratory problems (OR 2.49, 95% CI 1.02 to 6.10; OR 4.17 95% CI 1.91 to 9.13, respectively) at follow-up.

CONCLUSIONS

The observed non-persistence of obstruction suggests that prebronchodilation spirometry, as used in epidemiological studies, might misclassify COPD. Future epidemiological studies should consider both prebronchodilation and postbronchodilation measurements and take specific clinical factors related to asthma and COPD into consideration for estimation of disease burden and prediction of health outcomes.