Eosinophil-guided corticosteroid therapy in patients admitted to hospital with COPD exacerbation (CORTICO-COP): a multicentre, randomised, controlled, open-label, non-inferiority trial

BACKGROUND

Treatment with systemic corticosteroids in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) is associated with debilitating adverse effects. Therefore, strategies to reduce systemic corticosteroid exposure are urgently required and might be offered by a personalised biomarker-guided approach to treatment. The aim of this study was to determine whether an algorithm based on blood eosinophil counts could safely reduce systemic corticosteroid exposure in patients admitted to hospital with acute exacerbations of COPD.

METHODS

We did a multicentre, randomised, controlled, open-label, non-inferiority trial at the respiratory departments of three different university-affiliated hospitals in Denmark. Eligible participants were patients included within 24h of admission to the participating sites, aged at least 40 years, with known airflow limitation (defined as a post-bronchodilator FEV₁/forced vital capacity [FVC] ratio ≤0·70) and a specialist-verified diagnosis of COPD, who were designated to start on systemic corticosteroids by the respiratory medicine physician on duty. We randomly assigned patients (1:1) to either eosinophil-guided therapy or standard therapy with systemic corticosteroids. Both investigators and patients were aware of the group assignment. All patients received 80 mg of intravenous methylprednisolone on the first day. The eosinophil-guided group were from the second day given 37·5 mg of prednisolone oral tablet daily (for a maximum of up to 4 days) on days when their blood eosinophil count was at least 0·3 × 10⁹ cells per L. On days when the eosinophil count was lower, prednisolone was not administered. If a patient was discharged during the treatment period, a treatment based on the last measured eosinophil count was prescribed for the remaining days within the 5-day period (last observation carried forward). The control group received 37·5 mg of prednisolone tablets daily from the second day for 4 days. The primary outcome was the number of days alive and out of hospital within 14 days after recruitment, assessed by intention to treat (ITT). Secondary outcomes included treatment failure at day 30 (ie, recurrence of acute exacerbation of COPD resulting in emergency room visits, admission to hospital, or need to intensify pharmacological treatment), number of deaths on day 30, and duration of treatment with systemic corticosteroids. The non-inferiority margin was 1·2 days (SD 3·8). This trial is registered at ClinicalTrials.gov, number NCT02857842, and was completed in January, 2019.

FINDINGS

Between Aug 3, 2016, and Sept 30, 2018, 159 patients in the eosinophil-guided group and 159 patients in the control group were included in the ITT analyses. There was no between-group difference for days alive and out of hospital within 14 days after recruitment: mean 8·9 days (95% CI 8·3-9·6) in the eosinophil-guided group versus 9·3 days (8·7-9·9) in the control group (absolute difference -0·4, 95% CI -1·3 to 0·5; p=0·34). Treatment failure at 30 days occurred in 42 (26%) of 159 patients in the eosinophil-guided group and 41 (26%) of 159 in the control group (difference 0·6%, 95% CI -9·0 to 10·3; p=0·90). At 30 days nine patients (6%) of 159 in the eosinophil-guided group and six (4%) of 159 in the control group had died (difference 1·9%, 95% CI -2·8 to 6·5; p=0·43). Median duration of systemic corticosteroid therapy was lower in the eosinophil-guided group: 2 days (IQR 1·0 to 3·0) compared with 5 days (5·0 to 5·0) in the control group, p<0·0001.

INTERPRETATION

Eosinophil-guided therapy was non-inferior compared with standard care for the number of days alive and out of hospital, and reduced the duration of systemic corticosteroid exposure, although we could not entirely exclude harm on some secondary outcome measures. Larger studies will help to determine the full safety profile of this strategy and its role in the management of COPD exacerbations.

FUNDING

The Danish Regions Medical Fund and the Danish Council for Independent Research.

Liver injury during antituberculosis treatment: an 11-year study

SETTING

Bispebjerg Hospital, Department of Pulmonary Medicine, tuberculosis referral center for the Municipality of Copenhagen.

OBJECTIVE

To evaluate routine procedure for the management of liver injury during antituberculosis treatment.

DESIGN

From 1983-1993, 765 patients for whom we could trace 752 files (98%) were treated at our ward with standard Danish treatment for tuberculosis. From 1983-1986 they received a three-drug (9-month) regimen and from 1986-1993 a four-drug (6-month) regimen consisting of isoniazid, rifampicin, ethambutol + pyrazinamide. Data from a retrospective chart review.

RESULTS

An increase in aspartate aminotransferase (AST) of more than twice the upper limit of normal (ULN) was recorded in 127 patients (16%). 66 had elevated AST before treatment; most of these were men with a daily alcohol consumption in excess of 60 g. In the remaining 61 patients (8%) AST increased during antituberculosis treatment. 30 of these patients were excessive alcohol consumers, and seven had alcoholic liver cirrhosis. Despite an increase in AST of median 6 x ULN (range 2-25 x ULN), it was possible to continue treatment in 31 (15 excessive alcohol consumers) or reintroduce it fully in 14 (12 excessive alcohol consumers). Only 16 patients (2%), including 11 women with no daily alcohol consumption, needed a modified regimen. These patients were older (P < 0.05), seven were jaundiced, and one had alcoholic liver cirrhosis. Hepatotoxicity was confirmed by challenge with pyrazinamide (n = 7), isoniazid (n = 6) and combined isoniazid/rifampicin (n = 1). No deaths were caused by hepatotoxicity.

CONCLUSION

In spite of an increase in AST levels to approximately 6 x ULN during antituberculosis treatment, the drugs can be continued or reintroduced in full in most cases. Risk factors of hepatotoxicity included old age, female sex and extensive tuberculosis, and not alcohol consumption. Overall, hepatotoxicity during antituberculosis treatment can be monitored and managed easily.

Risk of hospital admission for obstructive pulmonary disease in alpha(1)-antitrypsin heterozygotes of phenotype PiMZ

Whether subjects heterozygous for alpha(1)-antitrypsin (alpha(1)-AT) deficiency are at risk for development of obstructive pulmonary disease (OPD) has been discussed for the past three decades. Both cohort and case-control studies have reached different conclusions, with the major problems being small sample sizes. A cohort of heterozygotes with the phenotype PiMZ was retrieved from the Danish Alpha(1)-Antitrypsin Deficiency Registry. Ten matched controls for each PiMZ subject were identified from the files of the Danish Central Population Registry. Cases and controls were subsequently linked to the files of the Danish Hospital Discharge Registry, and relative risk for OPD was calculated. In the cohort of 1,551 PiMZ subjects (11,678 person-years), we identified 47 subjects with a discharge diagnosis of OPD, as compared with 206 subjects with this diagnosis in the control group (109,748 person-years), yielding a relative risk (RR) of 2.2 (95% confidence interval [CI]: 1.5 to 3.0). This increased risk was present in both men and women and in all age groups; however, it was significant only in the age group from 40 to 79 yr. Of the 1,551 PiMZ subjects, 565 (36%) were first-degree relatives of PiZ index cases, and it appeared that only this group was at increased risk of hospital admission for OPD (RR: 3.4, 95% CI: 2.2 to 5.3). We conclude that alpha(1)-AT heterozygotes of phenotype PiMZ are at increased risk of hospital admission for OPD if they are first-degree relatives of PiZ index cases only, and that other, yet unknown genetic or environmental factors contribute to the development of lung disease.

Salmeterol reduces the need for inhaled corticosteroid in steroid-dependent asthmatics

Previous results have demonstrated addition of long-acting beta2-adrenergic agonists to be beneficial in asthma patients already receiving inhaled corticosteroid. The purpose of this study was to determine, qualitatively as well as quantitatively, the steroid-sparing properties of salmeterol in stable asthma patients receiving maintenance inhaled corticosteroids (800-1600 microg day(-1)). In these patients, the daily dose of beclomethasone dipropionate was reduced by 200 microg each week until asthma deteriorated, with the minimal acceptable dose (MAD) being defined as the dose one step above deterioration (sensitivity period). Following this, patients received three times the MAD for 2 weeks. Patients were randomized to receive either salmeterol 50 microg twice daily or placebo and the MAD was again determined (treatment period). Forced expiratory volume in 1 sec (FEV1) was measured each week. Morning and evening peak expiratory flow (PEF), symptom score and use of bronchodilator were recorded each day. Fifteen patients received salmeterol and 19 placebo. The MAD was significantly lower in the salmeterol group compared with placebo during the treatment period (P<0.01). A 50% reduction of the MAD was achieved by more patients treated with salmeterol than placebo (P = 0.001). Salmeterol caused a significantly greater reduction in daytime symptom score and use of as-needed beta2-agoinist therapy between sensitivity and treatment periods compared with placebo (P<0.05 for both). The results demonstrate, that the addition of salmeterol to corticosteroid treatment offers a clinically relevant potential for reduction of inhaled corticosteroid dose in steroid sensitive asthmatics.

Clinical evaluation of MPT-64 and MPT-59, two proteins secreted from Mycobacterium tuberculosis, for skin test reagents

SETTING

Department of Pulmonary Medicine P, Bispebjerg Hospital, Copenhagen, Denmark.

OBJECTIVE

To study the ability of two proteins secreted from Mycobacterium tuberculosis, MPT-64 and MPT-59 to induce delayed type hypersensitivity (DTH) reactions following intradermal administration.

DESIGN

In a small scale clinical investigation, skin reactions to these antigens were compared to reactions to tuberculin PPD RT23 in 1) patients with active tuberculosis, 2) BCG vaccinated healthy subjects with close contact with tuberculous patients, and 3) BCG vaccinated healthy subjects without contact with tuberculous patients. Tests for in vitro reactivity to these antigens were carried out in similar groups.

RESULTS

All subjects gave positive reaction to tuberculin PPD RT23, whereas approximately half of the subjects in each of the three groups reacted to MPT-59. Two subjects (one patient with tuberculosis and one healthy bacille Calmette-Guérin vaccinated subject without patient contact) reacted to MPT-64. The studies of cell proliferation and induction of interferon-gamma (IFN-gamma) following stimulation with tuberculin PPD and MPT-64 supported this profile of reactivity.

CONCLUSION

None of the experimental skin test antigens had properties superior to tuberculin PPD RT23 in humans. The failure of MPT-64 to induce delayed type hypersensitivity reactions in the majority of tuberculosis patients is discussed, in view of the potent reactivity to MPT-64 in tuberculous guinea pigs.

Transmitting genetic risk information in families: attitudes about disclosing the identity of relatives

Attitudes about disclosing the identities of family members to a physician to ensure diffusion of genetic risk information within affected families were examined in a questionnaire study of Danish patients with alpha1-antitrypsin deficiency (A1AD), their relatives, and a control group of Danish citizens. The questionnaires were returned by 1,761 (82%) of 2,146 recipients; 1,609 (75%) agreed to participate and completed the questionnaire. Only 2.8% objected to disclosing the identity of children, 9.1% objected to disclosing the identity of parents, and 6.7% objected to disclosing the identity of siblings. When genetic tests are offered to a sister, 75.4% of screened individuals with severe A1AD (phenotype "piZ") and 66.8% of piZ probands thought that the physician should say who is ill. Important reasons for informing a sister at risk were, for 58%, the opportunity to prevent disease and, for 41% of piZ-probands, the opportunity to maintain openness in the family and to avoid uncertainty. Stepwise logistic regression of background variables showed that relatives were those for whom most respondents approved the disclosure of the parents' and siblings' identities to enable the physician to examine them for the presence of A1AD. Women were less prone to disclose the identity of siblings. The results indicate that the genetic counselor should inquire about relatives' identities, to ensure that they are properly informed about the known risk of severe genetic disorder, such as A1AD, for which disability can be prevented by a change of lifestyle or by careful management. Disease prevention is essential, but openness and avoidance of uncertainty in affected families are also important. Our findings imply that fully informing all relatives about the disorder and about who is actually ill should be the principal rule.

Early pulmonary rehabilitation after acute exacerbation of COPD: a randomised controlled trial

Objectives

The aim of this study was to establish whether early pulmonary rehabilitation after severe exacerbation of chronic obstructive pulmonary disease (COPD) reduces mortality and hospital admissions, and increases physical performance and quality of life compared to rehabilitation initiated later in the stable phase of COPD.

Methods

In a randomised controlled trial of 150 patients hospitalised with an exacerbation of COPD, participants were allocated to pulmonary rehabilitation either within 2 weeks after discharge or the same rehabilitation programme but initiated 2 months after discharge.

Results

Early pulmonary rehabilitation did not prolong time to first hospital admission or time to death (hazard ratio 0.79, 95% CI 0.47–1.23, p=0.33) compared to rehabilitation in stable phase. However, 2 months after inclusion, pulmonary rehabilitation resulted in a significantly better improvement in the incremental shuttle walk test (33.9 m, 95% CI 4.18–63.7, p=0.02) compared to that in the stable phase. The difference in the endurance shuttle walk test was of borderline significance (140 s, 95% CI −2.03–282.76, p=0.05), but there was no significant difference concerning the COPD assessment test (−1.43 points, 95% CI −3.44–0.59, p=0.17).

Conclusion

Early pulmonary rehabilitation after acute exacerbation of COPD led to a faster improvement in physical performance compared to rehabilitation initiated later in the stable phase, but did not improve survival or prolong time to hospital readmission.

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Radiographic spectrum of adult pulmonary tuberculosis in a developed country

SETTING

Bispebjerg Hospital, Department of Pulmonary Medicine P. The referral centre of adult tuberculosis in the municipality of Copenhagen, Denmark.

OBJECTIVE

To evaluate the radiographic spectrum of pulmonary tuberculosis (TB) in adults in a low-prevalence country and to correlate radiographic appearances with bacteriological results, clinical and demographic data.

DESIGN

Retrospective review of medical files on 548 cases with pulmonary TB according to the criteria of WHO.

RESULTS

Usual radiographic pattern of reactivating TB, with upper lobe involvement, was found in 92% (n = 504), eight percent (n = 44) showed unusual X-ray patterns for adults, such as isolated lower lobe infiltrations (n = 19), hilar adenopathy (n = 10), miliary TB (n = 7), tuberculoma (n = 2), pleural effusion (n = 1) and normal chest X-ray (n = 3). Eight-nine percent of cases with cavitary lesions were positive by microscopy.

CONCLUSION

The risk of missing a diagnosis of pulmonary TB may be high if patients present with an X-ray unusual for TB, but this is fortunately seen only in 8% of cases of pulmonary tuberculosis. Unusual X-ray is more commonly found in patients with concomitant disease, such as diabetes and cancer. If chest X-ray shows cavities, but the smear is negative for Mycobacterium, TB is unlikely and further diagnostic procedures should be performed without waiting for culture results.

Toxicity and toxicokinetics of carbaryl in chickens and rats: a comparative study

Carbaryl, a carbamate insecticide, exerts its toxic effect in animals by inhibiting the activity of neural acetylcholinesterase. Differences in sensitivity of this enzyme to inhibition were studied after intraperitoneal administration to chickens and rats. A dose of 900 mg/kg to chickens and 70 mg/kg to rats caused equivalent inhibition of brain cholinesterase activities (57% +/- 6 and 47% +/- 4, respectively) 60 min after administration, which was the time of maximal cholinergic signs. Signs of toxicity (salivation, respiratory distress, muscle tremors and weakness) were more pronounced in rats than in chickens when brain acetylcholinesterase was inhibited to the same extent in both species. Carboxylesterase activities in brain, liver, and plasma were also inhibited 60 min after administration of carbaryl to chickens and rats. Activities of enzymes associated with hepatic microsomes were unaffected. Specific activities of brain esterases, including acetylcholinesterase, carboxylesterase and neurotoxic esterase, were higher in untreated chickens than in untreated rats. Specific activities of liver esterases (carboxylesterase, A-esterase) were, however, 4- and 10-fold lower in untreated chickens than in untreated rats. Total clearance of carbaryl in the chicken, determined after intravenous administration of 5 mg/kg, was 0.26 +/- 0.02 l/kg/min. This value is 5.7 times higher than that reported for the rat, indicating that the relatively lower activities of esterases in the liver of chickens did not affect the clearance of this chemical in the avian species.

The effect of inhaled glucocorticosteroids in emphysema due to alpha1-antitrypsin deficiency

Despite the success of inhaled steroids in controlling asthma, the benefit in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Five subjects with moderate to severe emphysema due to alpha 1-antitrypsin deficiency (phenotype PiZ) were followed with daily home spirometry in a 2 x 8 weeks, randomized double-blind, placebo-controlled, crossover study of inhaled budesonide 0.8 mg b.i.d. In three of the five patients, there was a statistically significant increase in the mean forced expiratory volume in 1 s (FEV1), and in two of these patients, there was also a statistically significant increase in the mean forced vital capacity (FVC) during budesonide treatment. A significant diurnal variation in FEV1 and FVC was found in three and two patients, respectively, but did not change significantly during treatment. These findings emphasize the need for renewed evaluation of inhaled steroids in the treatment of patients with emphysema, and indicate that individual patients may have significant clinical improvement.

An expert system for information on pharmacology and drug interactions

Pharmacological information has been organized and encoded in rules and frames for systematic retrieval. This includes: delineation, definition, and hierarchical subdivision of mechanisms responsible for drug interactions; division of pharmacological agents into a hierarchy of subclasses to allow for defining interacting drugs by classes as well as by specific agents; correlation of drug classes and specific drugs with mechanisms by which they may be involved in drug interactions. This information, accessible through a natural language-like and menu driven interface, allows clinicians to know what may happen when two drugs are used together, why, what can be done to alleviate detrimental interactions, and what related drugs may also be involved in similar interactions.

Effect of cyclic phenyl saligenin phosphate and paraoxon treatment on vascular response to adrenergic and cholinergic agents in hens

The response of peripheral blood vessels to adrenergic and cholinergic agonists was examined 1, 3, 7, and 21 d after hens were treated with a single intramuscular injection of 2.5 mg/kg cyclic phenyl saligenin phosphate (PSP) or 0.10 mg/kg paraoxon (PXN). These two organophosphates (OPs) cause different clinical effects in exposed animals, as PSP causes organophosphate-induced delayed neuropathy (OPIDN) and PXN causes acute poisoning through inhibition of acetylcholinesterase. For these studies, the ischiadic artery was cannulated both prograde and retrograde and the blood was shunted through a pump to maintain a constant flow. Alterations in pressure measured at the pump outflow were used to indicate changes in limb vascular resistance. Dose-response curves were generated for the response to intravenous administration of acetylcholine (ACh), phenylephrine (PE), or salbutamol (SAL) (10(-8) to 10(-4) mol/kg). Acetylcholine at 10(-8) to 10(-7) mol/kg caused an increase in vascular resistance, whereas concentrations of 10(-5) to 10(-4) mol/kg caused a decrease in vascular resistance in hens given PSP 1 and 3 d previously. The response of PXN-treated hens to ACh was not significantly altered from that of vehicle-treated hens. The resistance generated in response to PE, an alpha 1-adrenergic agonist, in PSP-treated hens was greater than levels in vehicle-treated hens on d 1 and 3 and greater than the response seen in hens treated with PXN. Salbutamol, a beta 2-adrenergic agonist, at concentrations of 10(-7) to 10(-4) mol/kg caused an increase in resistance 1 and 3 d after PSP and a decrease on d 7. The responses to SAL were different in PXN-treated hens, as these hens demonstrated a lesser increase in resistance at concentrations of 10(-8) to 10(-7) mol/kg and a decrease in resistance at 10(-5) to 10(-4) mol/kg 1 d after administration of PXN. These observations indicate that response to vasoactive agents is altered in OP-treated hens and that responses differ between a compound capable of causing OPIDN (PSP) and a compound that only causes acute effects (PXN).

Functional characterization of equine neutrophils in response to calcium ionophore A23187 and phorbol myristate acetate ex vivo

Equine neutrophils (PMN) play a critical role in inflammatory processes in horses. The objective of this study was to characterize equine PMN function ex vivo following stimulation with calcium ionophore A23187 (A23187) and phorbol myristate acetate (PMA). These stimulants trigger different branches of the PMN activation process that occurs in vivo. Equine PMN were isolated from the whole blood of six clinically normal geldings using a one-step discontinuous Percoll gradient technique. Neutrophil aggregation, degranulation, and superoxide anion production were evaluated in assay systems which had previously been established to quantitate PMN function. Dose-response curves for A23187 and PMA were derived for the three functions. Results indicate that equine PMN aggregation and superoxide anion production are more responsive to activation by PMA as the maximum change in percent transmittance and maximum nanomoles of superoxide anion produced following PMA stimulation (60.8% and 10.4 nmol per 10(6) cells, respectively) were greater than those values stimulated by A23187 (41.5% and 5.2 nmol per 10(6) cells, respectively). However, degranulation was found to be more responsive to A23187 stimulation (maximum percent degranulation: 56.1%) than to PMA stimulation (maximum percent degranulation: 30.7%). Dose-response curves following A23187 and PMA stimulation revealed that superoxide anion production had the lowest threshold concentration among the three functions. Degranulation had the highest threshold concentration among the three functions for both stimulants. Results indicate that equine PMN functions differ in their dependence on second messengers in the activation pathway. These functions also occur in a dose-dependent manner and differ in the threshold concentrations required for their stimulation.

Diagnostic strategy for pulmonary tuberculosis in a low-incidence country: results of chest X-ray and sputum cultured for Mycobacterium tuberculosis

The referral centre of tuberculosis in the municipality of Copenhagen, Denmark was the setting for this study, which aimed to assess the diagnostic strategy (chest X-ray and clinical mycobacteriology) in pulmonary tuberculosis. Patient records and chest X-rays were examined for all patients who had sputum or gastric lavage examined for Mycobacterium tuberculosis (Mtb) from 1 January 1992 to 30 April 1994. All chest X-rays were re-evaluated by a trained lung specialist, who did not know the results of sputum culture. Evaluation was referred to one of seven X-ray categories, and compared to the results of culture. Culture of sputum or gastric lavage were positive for Mtb in 54 (14%) of 392 patients; in 61% of 59 patients with X-ray changes thought to be due to tuberculosis (TB); in 20% of 51 patients with X-ray changes compatible with TB; in 14% of 35 patients with previous TB and radiographically active TB; in 2% of 103 patients with previous TB, but not radiographically active TB; in 1% of 112 patients with X-ray changes thought to be due to other disease; and none out of 32 patients with normal X-ray. Even in this highly selected material, it is relatively expensive to find the very few cases of active TB in patients with chest X-ray changes not suspected to be due to TB. It is recommended that: (1) examination of sputum for Mtb should always be preceded by X-ray of the chest in a low-prevalence country; (2) routine culture of sputum for Mtb is restricted to patients with X-ray changes typical or compatible with active TB; and (3) exceptions to this general rule should be made on the basis of the individual's clinical history.

Effect of salmeterol is independent of previously inhaled salbutamol: a clinical controlled study

The objective of this study was to examine the bronchodilating effect of an inhaled long acting beta2-agonist (salmeterol) after a high dose of an inhaled short acting beta2-agonist (salbutamol) in asthma patients. We used a randomized double-blind, placebo-controlled, crossover design, studying seven subjects with moderate asthma, treated with inhaled steroids and highly reversible to salbutamol and salmeterol. 1.5 h after salmeterol inhalation, the mean difference in FEV1 between salbutamol and placebo pretreatment days was 6.31% and ranged from 0.02 to 1.05%, 2.5-10.5 h after salmeterol inhalation. We concluded that the effect measured as the duration of bronchodilation of salmeterol is not decreased by previously inhaled salbutamol. We only found a trend toward an additive effect of combining salbutamol and salmeterol, probably because the high dose of salbutamol did not give room for further improvement in FEV1. In accordance with other clinical studies we were unable to demonstrate any clinical implications of the salmeterol partial beta2-antagonism known from animal and in vitro studies.

Attitudes toward an unsolicited approach in relation to status of genetic disease: exemplified by alpha(1)-antitrypsin deficiency

Knowledge of a genetic disease in an individual raises the questions of whether and how this information should be communicated to his or her family. The aim of the present study was to provide factual information about attitudes towards an unsolicited approach from a physician regarding genetic counseling within affected families. We performed a questionnaire study among patients with alpha(1)-antitrypsin deficiency, their examined and unexamined relatives, and a control group of Danish citizens. Of 2,146 subjects, the questionnaires were returned by 1,761 (82%), and 1,609 (75%) wanted to participate. Stepwise logistic regression showed that phenotype/subgroup, having descendants, and being female were significantly related to the approval of an unsolicited approach and the informing of relatives. Provided it was difficult for the index case to inform relatives about their risk and about his/her disease, then a total of 75.8% would not proscribe an unsolicited approach by the physician. Most of those for proscribing an unsolicited approach found that relatives should be informed in advance by the index case. The control group of randomly chosen Danes was the most skeptical towards an unsolicited approach. Most individuals found that genetic risk information should be shared with relatives at-risk. A flexible information policy by the health care system based on active approach towards relatives is acceptable to 75 to 95% of individuals in order to ensure diffusion of genetic risk information within families segregating for a genetic disease with a modifiable outcome.

Elevated Levels of Interleukin-1β and Interleukin-10 Are Associated With Faster Lung Function Decline in People With Well-Treated Human Immunodeficiency Virus

BACKGROUND

People with human immunodeficiency virus (PWH) have an increased risk of chronic lung diseases and chronic inflammation. We aimed to investigate if inflammatory markers and monocyte activation are associated with faster lung function decline in PWH.

METHODS

We included 655 PWH from the Copenhagen Comorbidity in HIV Infection (COCOMO) Study. Eligible participants were aged ≥25 years and had 2 spirometries separated by >2 years. Inflammatory markers (interleukin [IL]-1β, IL-2, IL-6, IL-10, tumor necrosis factor-α, and interferon-γ) were measured at baseline by Luminex, and soluble CD14 and soluble CD163 by enzyme-linked immunosorbent assay. Using linear mixed models, we investigated whether elevated cytokine levels were associated with faster lung function decline.

RESULTS

The majority of PWH were males (85.2%) with undetectable viral replication (95.3%). We found a faster decline in forced expiratory volume in 1 second (FEV1) in PWH with elevated IL-1β and IL-10, with an additional decline of 10.3 mL/year (95% confidence interval [CI], 2.1-18.6; P = .014) and 10.0 mL/year (95% CI, 1.8-18.2; P = .017), respectively. We found no interaction between smoking and IL-1β or IL-10 on FEV1 decline.

CONCLUSIONS

Elevated IL-1β and IL-10 were independently associated with faster lung function decline in PWH, suggesting that dysregulated systemic inflammation may play a role in the pathogenesis of chronic lung diseases.

Tuberculosis in a cohort of Vietnamese refugees after arrival in Denmark 1979-1982

SETTING

Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.

OBJECTIVE

To study the occurrence of tuberculosis (TB) in a cohort of immigrants from a high incidence country during the years following arrival in a low incidence country.

DESIGN

Follow-up analysis in a cohort of 1983 Vietnamese refugees who arrived in Denmark during the period 1979-1982. The civil registration number could be identified for 1936 (98%) individuals from the original cohort. Date of possible death, emigration and the development of tuberculosis were determined by checking the refugees' civil registration number in the National Civil Register and the National Infectious Disease Registry for Tuberculosis.

RESULTS

Tuberculosis notification for the 1936 individuals fell from 1.14% for the first 12 months to a mean of 0.08% per year during the following 5-year period. During the 16 years of follow up, 36 of the refugees developed tuberculosis, of whom 14 (39%) had had abnormal chest X-ray on arrival and 14 (39%) (including one with normal chest X-ray) had been identified as having active tuberculosis through screening on arrival.

CONCLUSION

Decline in tuberculosis incidence for immigrants is very rapid if the tuberculosis infection rate is low following arrival. With a very limited TB screening programme (chest X-ray on arrival) and a passive diagnosis policy without preventive chemotherapy, it is possible to control tuberculosis among high prevalence immigrants in a low incidence country.