Grading Severity of Productive Cough Based on Symptoms and Airflow Obstruction

The binary approach to the diagnosis of Chronic Bronchitis (CB) is a major barrier to the study of the disease. We investigated whether severity of productive cough can be graded using symptoms and presence of fixed airflow obstruction (FAO), and whether the severity correlates with health status, exposures injurious to the lung, biomarkers of inflammation, and measures of airway wall thickening. Findings from a cross-sectional sample of 1,422 participants from the Lovelace Smokers Cohort (LSC) were validated in 4,488 participants from the COPDGene cohort (COPDGene). Health status was based on the St. George's Respiratory Questionnaire, and Medical Outcomes Study 36-Item Short Form Health Survey. Circulating CC16 levels were quantified by ELISA (LSC), and airway wall thickening was measured using computed tomography (COPDGene). FAO was defined as postbronchodilator FEV1/FVC <0.7. The presence and duration of productive cough and presence of FAO or wheeze were graded into Healthy Smokers, Productive Cough (PC), Chronic PC, PC with Signs of Airflow Obstruction, and Chronic PC with Signs of Airflow Obstruction. In both cohorts, higher grade of severity correlated with lower health status, greater frequency of injurious exposures, greater airway wall thickening, and lower circulating CC16 levels. Further, longitudinal follow-up suggested that disease resolution can occur at every grade of severity but is more common in groups of lower severity and least common once airway remodeling develops. Therefore, severity of productive cough can be graded based on symptoms and FAO and early intervention may benefit patients by changing the natural history of disease.

Propensity of pneumococcal carriage serotypes to infect the lower airways of children with chronic endobronchial infections

BACKGROUND

Chronic endobronchial infections in children are responsible for a high disease burden. Streptococcus pneumoniae is frequently isolated; however, few publications have described serotypes associated with non-invasive lower airway infection.

METHODS

Paired nasopharyngeal (NP) swabs and bronchoalveolar lavage (BAL) fluids were collected from children undergoing bronchoscopy for chronic cough. NP swabs were also collected from asymptomatic children in otitis media surveillance studies (controls). Specimens were processed and lower airway infection defined (⩾10⁴ colony forming units/mL BAL) as previously described. Serotype-specific odds ratios (ORs) were calculated (as described for invasive pneumococcal disease) to indicate propensity for infection.

RESULTS

From 2007-2015, paired specimens were processed from 435 children with protracted bacterial bronchitis (PBB), chronic suppurative lung disease (CSLD) or bronchiectasis. S. pneumoniae lower airway infection was detected in 95 children: 27% with PBB and 20% with CSLD/bronchiectasis. Most (91%) children were vaccinated with ⩾2 doses of 7-valent, 10-valent or 13-valent pneumococcal conjugate vaccine. Paired NP and BAL serotype distributions were very similar; prevalent serotypes (>10 isolates) were 19A (9%), 19F, 6C, 35B, 15B, 16F, 15A, 15C, 23A, 23F and 11A. For 21 serotypes found in both NP and BAL specimens, ORs for infection were low; range 0.46 (serotype 23B) to 2.15 (serotype 6A). In the 2008-2013 surveillance studies, NP swabs were collected from 1565 asymptomatic children; 74% were pneumococcal carriers. For 21 of 22 serotypes found in both control NP swabs and BAL specimens, ORs for infection were similarly low; range 0.33 (serotype 23B) to 3.29 (serotype 22F); none was significantly different from 1. The exception was serotype 7B with OR 8.84 (95% CI 1.46, 38.1).

CONCLUSIONS

Most NP carriage serotypes have a similar propensity to cause lower airway infection in children with suppurative lung diseases. Further development of pneumococcal vaccines is needed to prevent non-invasive disease caused by commonly carried serotypes.

Systemic signs of neutrophil mobilization during clinically stable periods and during exacerbations in smokers with obstructive pulmonary disease

BACKGROUND

It is still unclear whether signs of neutrophil mobilization in the blood of patients with chronic obstructive pulmonary disease represent true systemic events and how these relate to bacterial colonization in the airways. In this study, we evaluated these issues during clinically stable periods and during exacerbations in smokers with obstructive pulmonary disease and chronic bronchitis (OPD-CB).

METHODS

Over a period of 60 weeks for each subject, blood samples were repeatedly collected from 60 smokers with OPD-CB during clinically stable periods, as well as during and after exacerbations. Myeloperoxidase (MPO) and neutrophil elastase (NE) protein and mRNA, growth of bacteria in sputum, and clinical parameters were analyzed. Ten asymptomatic smokers and ten never-smokers were included as controls.

RESULTS

We found that, during clinically stable periods, neutrophil and NE protein concentrations were increased in smokers with OPD-CB and in the asymptomatic smokers when compared with never-smokers. During exacerbations, neutrophil and MPO protein concentrations were further increased in smokers with OPD-CB, without a detectable increase in the corresponding mRNA during exacerbations. However, MPO and NE protein and mRNA displayed positive correlations. During exacerbations, only increased neutrophil concentrations were associated with growth of bacteria in sputum. Among patients with low transcutaneous oxygen saturation during exacerbations, PaO2 (partial oxygen pressure) correlated with concentrations of MPO and NE protein and neutrophils in a negative manner.

CONCLUSION

There are signs of systemic neutrophil mobilization during clinically stable periods and even more so during exacerbations in chronic obstructive pulmonary disease. In this condition, MPO and NE may share a cellular origin, but its location remains uncertain. Factors other than local bacteria, including hypoxemia, may be important for driving systemic signs of neutrophil mobilization.

[Analysis of polymorphisms of genes associated with immune response and tissue remodeling in occupational chronic bronchitis]

The involvement of polymorphisms of genes encoding immune response-associated molecules (LTA, TNFA, ILB, ILRN, IL8, IL10, VDBP), matrix metalloproteinases (MMP1, MMP2, MMP3, MMP9, MMP12, ADAM33), and tissue and serum inhibitors of proteases (TIMP2, TIMP3, SERPINA1, SERPINA3) in the predisposition to occupational chronic bronchitis was assessed by PCR-RFLP analysis in groups of patients (n = 122) and healthy employees (n = 166). It was found that occupational chronic bronchitis was associated with polymorphisms of VDBP (P(adj) = 0.00005, OR(adj) = 2.06), MMP1 (P(adj) = 0.00002, OR(adj) = 2.57), ADAM33 (P(adj) = 0.0004, OR(adj) = 2.52), and IL8 (P(adj) = 0.0058, OR(adj) = 2.87). The most significant association was observed for the VDBP polymorphism 1296T>G. The VDBP haplotype GC*1S by the loci 1296T>G and 1307C>A was an informative susceptibility marker (P(adj) = 0.0001, OR(adj) = 2.60, 95% CI (1.62-4.19)). There was also a significant interaction between the VDBP polymorphism 1307C>A and the duration of occupational exposure to hazardous factors (P(interaction) = 0.02). Apparently, the investigated polymorphisms of VDBP, MMP1, ADAM33, and IL8 contribute to the genetic susceptibility to chronic bronchitis induced by dust and toxic agents.

COPD is associated with production of autoantibodies to a broad spectrum of self-antigens, correlative with disease phenotype

The role of autoimmune pathology in development and progression of chronic obstructive pulmonary disease (COPD) is becoming increasingly appreciated. In this study, we identified serum autoantibody reactivities associated with chronic bronchitis or emphysema, as well as systemic autoimmunity and associated lung disease. Using autoantigen array analysis, we demonstrated that COPD patients produce autoantibodies reactive to a broad spectrum of self-antigens. Further, the level and reactivities of these antibodies, or autoantibody profile, correlated with disease phenotype. Patients with emphysema produced autoantibodies of higher titer and reactive to an increased number of array antigens. Strikingly, the autoantibody reactivities observed in emphysema were increased over those detected in rheumatoid arthritis patients, and included similar reactivities to those associated with lupus. These findings raise the possibility that autoantibody profiles may be used to determine COPD risk, as well as provide a diagnostic and prognostic tool. They shed light on the heterogeneity of autoantibody reactivities associated with COPD phenotype and could be of use in the personalization of medical treatment, including determining and monitoring therapeutic interventions.

Occupational nonasthmatic eosinophilic bronchitis: current concepts

BACKGROUND

Nonasthmatic eosinophilic bronchitis (NAEB) is an important cause of chronic cough, since it is present in 10-15% of patients referred for specialist investigation. The syndrome is considered a variant of occupational asthma when it develops as a consequence of occupational exposure, hence it should be considered in the spectrum of work-related airway diseases.

OBJECTIVES AND METHODS

The aim of this paper was to update and expand the previous reviews on the clinical and pathophysiological features of NAEB and analyze available data on the occupational causes of the disease. Literature on the topic between the years 1990 and 2010 was reviewed with a Med Line search.

RESULTS

The disease is probably underdiagnosed and an occupational origin was demonstrated only in isolated cases, probably due to the rarity of the disease and the lack of systematic evaluation of bronchial inflammation.

CONCLUSIONS

In view of the current knowledge on this condition and the development of techniques to evaluate bronchial inflammation, occupational NAEB cannot be neglected any more and has been rightly included in the spectrum of occupational respiratory disorders.

[Immunopathogenetic features of occupational bronchitis]

The article based on research work covers functional, bronchoscopy, microbiologic and immunologic features of chronic dust bronchitis and chronic bronchitis caused by toxic chemicals.

[Effects of mangiferin on cytokines in rats with chronic bronchitis and expression of macrophage COX-2 in mice]

OBJECTIVE

To explore the mechanism of anti-inflammatory effect of mangiferin.

METHOD

The model of chronic bronchitis in rat was established by LPS + smoke. The activity of SOD, content of MDA and NO in BALF and serum, content of TNF-alpha and IL-8 were determined. The expression of RAW264.7 macrophage COX-2 mRNA induced by LPS in mice was detected by RT-PCR.

RESULT

The activity of SOD, the content of NO in BALF and serum in rat with chronic bronchitis were significantly higher with high, medium and low-dose of lg mangiferin (400,200,100 mg x kg(-1)), while the content of MDA, and the content of TNF-alpha and IL-8 in lung tissues were lower. The expression of RAW264.7 macrophage COX-2 mRNA induced by LPS was significantly reduced by mangiferin with 200,100, 50 micromol x L(-1).

CONCLUSION

The anti-inflammatory mechanism of mangiferin is to relieve inflammation by raising the activity of SOD and content of NO and reducing the content of MDA and the expression of TNF-alpha, IL-8 and COX-2 mRNA.

[Professional eosinophilic bronchitis: considerations and new diagnostic methods in a clinical case]

Nonasthmatic eosinophilic bronchitis (NAEB) is a condition characterized by corticosteroid-responsive chronic cough, sputum eosinophilia and absence of symptoms or objective evidence of variable airflow obstruction and airway hyper-responsiveness. Like asthma, NAEB can be associated with exposure to occupational sensitizers and can be considered as being a variant of occupational asthma when it develops as a consequence of work exposure. Few case reports of NAEB caused by workplace exposure have been reported. Bakers are at high risk of developing occupational respiratory disorders and three cases of occupational NAEB have been described. We describe the first case of occupational NAEB due to storage mites in a baker in which the offending agent was identified by means of the basophil activation test (BAT), a new tool which has never been proposed in diagnostic procedures of occupational respiratory allergy. BAT's results allowed the recognition of the offending agent, that is mandatory for diagnosis.

[Colonization resistance and immunological reactivity of children's oropharyngeal mucosa in health and bronchopulmonary pathology]

The study group was comprised of 27 practically healthy children, 51 patients with acute bronchitis, 15 with chronic bronchitis and 11 with pneumonia. It was shown that changes of microbiocoenosis in back of the throat (BOT) were related to increased mucosal contamination with normal microflora and opportunistic microorganisms. The highest degree of contamination was observed in children with acute bronchitis. Normocoenosis was detected only in 13 practically healthy children. The disorders of microbiocoenosis took the form of disbiosis and acute inflammatory processes in patients with acute and chronic bronchitis and pneumonia. However, the large amount of normal flora together with the high Ig level ensured marked colonization resistance as evidenced by the values of natural colonization coefficient of nasopharyngeal epithelium (NCCNE) and balance coefficient (BC). These data suggested development of compensated secondary immunodeficiencies. In patients with acute bronchitis and pneumonia, local synthesis of Ig prevailed. It is shown that BC can be used to screen children for disorders of mucosal immunity. The presence of increased saliva IgE levels in patients with acute and chronic bronchitis supports the generally accepted concept of bronchi as a "shock organ" in allergic condition. It was demonstrated that IgE levels in saliva increase earlier than in serum and may be used as a prognostic criterion in patients with bronchopulmonary pathology.

[Immunity in chronic bronchitis patients with significant residual changes after prior pulmonary tuberculosis]

To study the immunological features in chronic bronchitis (CB) patients with great residual changes (GRC) after prior pulmonary tuberculosis, the authors examined two groups: 1) 40 CB patients with GRC after prior pulmonary tuberculosis (a study group) and 2) 30 CB patients without a history of pulmonary tuberculosis. The examination revealed that CB patients with GRC after prior pulmonary tuberculosis were found to have higher T lymphocytes, lower B lymphocytes on an exacerbation of the disease. The phagocytic properties of neutrophils were altered as their high phagocytic activity, decreased oxygen-dependent microbicidal activity of phagocytes with their stimulation. The humoral response remained to be slightly pronounced in CB bronchitis with GRC. The low serum levels of TBC active products may suggest the low activity of lipid peroxidation processes in the study group patients. After prior pulmonary tuberculosis, antioxidative activity preserves to be high in CB patients with GRC.

[Immune mechanisms of broncho-pulmonary diseases in aluminium production workers]

Complex clinical examination of aluminium production workers having broncho-pulmonary diseases revealed immunologic criteria of toxic dust bronchitis, diffuse pneumosclerosis and secondary infection-dependent bronchial asthma, caused by combination of occupational hazards. Contribution of allergic environmental factors was shown as they deplete immune reserves in the workers. The authors proved efficiency of contemporary immune modulator polyoxydonium, when included into the complex therapy.

[Characteristics of the immune system in workers of heavy industry with chronic bronchitis]

Chronic bronchitis is a disease at the base of it we see inflammation process, when under the influence of factors of environment the immune system changes. The author has studied the influence of adverse factors on the state of the immune system of workers of engineering plants with chronic bronchitis. 15 workers of engineering plants with chronic bronchitis have been observed. 8 workers with chronic bronchitis had unhealthy conditions of work (main group) and other 7 workers with chronic bronchitis had not had unhealthy conditions of work (control group). The author revealed workers of engineering plants with chronic bronchitis to have changes of the immune system characterized by the increase in immunoglobulin M by 0.64 +/- 0.3 g/l in comparison with the control group (P < 0.05) and the increase in immunoglobulin G by 5.02 +/- 1.65 g/l (P < 0.05). Immunoglobulin A has decreased by 1.60 +/- 0.45 g/l (p < 0.05) in comparison with the control group. Then, CD3+ was 66.0 +/- 2.9% in the main group and in the control group it was by 4.35 +/- 3.1% greater. It was seen decrease in the activity of T-suppressors of patients with chronic bronchitis who were exposed to unhealthy conditions of work. CD4+ and CD20+ were also different in the main and control groups. It is worthy to note that patients with chronic bronchitis working in unhealthy conditions (main group) had reduced activity of neutrophilic granulocytes while this activity is increased in the workers of the control group. So these data certify that changes in the immune system of workers of engineering plants with chronic bronchitis significantly correlate with the presence of unhealthy conditions in work.

Increased serum inflammatory markers as predictors of airway obstruction

Recruitment and activation of both neutrophils and eosinophils seem to be a characteristic of chronic bronchitis. The purpose of this study was to evaluate whether eosinophil cationic protein and/or myeloperoxidase (ECP/MPO) serum levels differ between patients with chronic obstructive and nonobstructive bronchitis during an exacerbation-free period and if they represent clinical gravity indicators of disease. To identify a correlation between ECP/MPO values in serum and bronco-obstruction, a statistical analysis by logistic regression was used. Study results show that there is a relationship between increased serum levels of ECP and log MPO and an increased risk for forced expiratory volume in 1 second (FEV1) pathologic values associated with obstructive chronic bronchitis, with an ECP odds ratio = 1.04 and logMPO = 4.45.

Chronic obstructive pulmonary disease: clinical signs and infections

Chronic obstructive pulmonary disease (COPD) is a pathological condition that involves excessive production of mucus, chronic cough and inflammatory changes leading to airway limitation. The most common cause of COPD is cigarette smoking. COPD can be categorized into either chronic bronchitis or emphysema; both conditions can be differentiated by age and the production of copious, tenacious sputum. Patients with COPD are susceptible to pulmonary infections of bacterial or viral origin. Nurses should be aware of the subtle differences in conditions and the usefulness of antibiotics in the treatment of acute bacterial exacerbations of chronic bronchitis.

High seroprevalence of Helicobacter pylori in chronic bronchitis among Chinese population

An increased seroprevalence of Helicobacter pylori (H. pylori), especially high virulent cytotoxin-associated gene-A (CagA) positive strains, has been found in many extragastrointestinal disorders. Moreover, it has been reported that the risk of chronic bronchitis may be increased in H. pylori infected patients. However, until now there are no data regarding the relationship between H. pylori infection and chronic bronchitis among Chinese population. Therefore the aim of the present study was to assess the seroprevalence of H. pylori and in particular of CagA positive virulent strains in patients with chronic bronchitis among Chinese population. We evaluated 46 patients with chronic bronchitis, 48 age- and sex-matched patients with peptic ulcer and 48 healthy control subjects. All enrolled subjects underwent a serologic test for H. pylori IgG and CagA by enzyme linked-immunosorbent assay (ELISA). There was no significant difference in the seropositivity for these parameters between chronic bronchitis and peptic ulcer groups (86.9% vs 89.6% for anti-H. pylori IgG and 67.4% vs 72.9% for anti-H. pylori-CagA IgG). However, these serological parameters were significantly higher in the patients with chronic bronchitis or peptic ulcer than those in control group, who showed 60.4% for anti-H. pylori IgG seropositivity and 20.8% for anti-H. pylori-CagA IgG seropositivity. Among the patients with chronic bronchitis, no significant difference was found in these serological parameters between the current cigarette smokers and never smokers. This is the first report of a high seroprevalence of H. pylori infection in chronic bronchitis among Chinese population.

Should patients with acute exacerbation of chronic bronchitis be treated with antibiotics? Advantages of the use of fluoroquinolones

The pathological changes in chronic bronchitis (CB) produce airflow obstruction, reduce the effectiveness of the mucocilliary drainage system and lead to bacterial colonisation of bronchial secretion. The presence of bacteria induces an inflammatory response mediated by leukocytes. There is a direct relationship between the degree of impairment of the mucocilliary drainage system, the density of bacteria in mucus and the number of leukocytes in the sputum. Purulent sputum is a good marker of a high bacterial load. Eventually, if the number of leukocytes is high, their normal activity could decrease the effectiveness of the drainage system, increase the bronchial obstruction and probably damage the lung parenchyma. Whenever the density of bacteria in the bronchial lumen is >or=10(6) CFU/mL, there is a high probability that the degree of inflammatory response will lead to a vicious cycle which in turn tends to sustain the process. This situation can arise during the clinical course of any acute exacerbation of CB, independently of its aetiology, provided the episode is sufficiently severe and/or prolonged. Fluoroquinolones of the third and fourth generation are bactericidal against most microorganisms usually related to acute exacerbations of CB. Their diffusion to bronchial mucus is adequate. When used in short (5-day) treatment they reduce the bacterial load in a higher proportion than is achieved by beta-lactam or macrolide antibiotics given orally. Although the clinical cure rate is similar to that obtained with other antibiotics, the time between exacerbations could be increased.

The -308G/A polymorphism of TNF-alpha influences immunological parameters in old subjects affected by infectious diseases

Abnormal increments of pro-inflammatory cytokines (IL-6 and TNF-alpha) characterize the outbreak of infectious diseases, which are the major cause of death in the elderly. A counterbalance to the inflammation is exerted by IL-10 with an inhibitory role on TNF-alpha production. As is well known, some cytokine gene polymorphisms influence the cytokine production, playing a role as susceptibility or resistance factors against immune-mediated and infectious disease. Genetic variations in the -308A/G locus for TNF-alpha seems to affect the clinical outcome of some infectious diseases. In fact, the -308A allele is associated with severe septic shock and death. On this basis, we have screened healthy old subjects, nonagenarians and old patients affected by the acute phase of chronic obstructive bronchitis and bronchopneumonia of bacteria origin for the -308G/A locus (PCR-RFLP). Subjects are grouped in A+ (AG, AA genotypes) and A- (GG genotype) and data on IL-6, TNF-alpha, IL-10, NK cell cytotoxicity, zinc and metallothioneins (MTs) gene expression (RT-PCR) were stratified according to different TNF-alpha genotypes. The frequency of the A allele was increased in infected patients in comparison with healthy old controls. No differences existed between A+ and A- young adult, old and nonagenarian controls in tested parameters. Conversely, A+-infected patients displayed elevated IL-6, TNF-alpha and MTmRNA, low IL-10 coupled with impaired NK cell cytotoxicity and lower zinc ion than A- patients. However, the data reported are gender independent. Therefore, the -308A polymorphism at the locus of TNF-alpha may be one of the susceptibility factor for infectious diseases in old persons, particularly considering its association to the increased release of pro-inflammatory cytokines and to the reduction of zinc release and MTs synthesis involved in the control of the inflammatory response. These data strongly suggest that the genetic screening of the -308G/A polymorphism may be a valid tool for identification of subjects needing a more appropriate therapy when affected by acute and/or recurrent infectious diseases.

[IFN-gamma in non atopic children with recurrent obstructive bronchitis]

Recurrent respiratory infection cause an imbalance of Th1/Th2 immune response with decreased level of IFN-gamma. Result of several studies have provided evidence linking Mycoplasma infection with recurrent wheezing in atopic children. The aim of the present study was to investigate the influence of Mycoplasma infection on IFN-gamma level in non-atopic children with recurrent obstructive bronchitis. Serum IFN-gamma was measured in two groups: the study group included 30 non-atopic children 1-4 years of age with recurrent obstructive bronchitis caused by Mycoplasma pneumoniae, the control group included 15 children with the same disease with negative Mycoplasma pneumoniae result. There were no differences in age, sex and family history of atopy. This result shows reduced Th 1 immune response that causes reduced antiviral activity and high morbidity in non-atopic wheezy children.

Tumor necrosis factor-alpha hyper-responsiveness to endotoxin in whole blood is associated with chronic bronchitis in farmers

Many farmers experience chronic bronchitis, airflow obstruction, and asthma. It is thought that these respiratory problems may be related to workplace inhalation of organic dust containing endotoxin. The purpose of this study was to determine whether whole blood cytokine responsiveness to endotoxin is associated with airflow disorders (i.e., airflow obstruction, chronic bronchitis, and doctor-diagnosed asthma). Farmers (N = 95) were recruited from a rural cohort study and completed a respiratory symptom and history questionnaire, spirometry, and blood sampling. Blood was incubated 24 hours in the presence and absence of endotoxin and supernatants were analyzed for TNF-alpha, IL-1beta, IL-6, and IL-8. Hypo- or hyper-responsiveness to endotoxin was based on whether cytokine values were in the lower or upper 10% of the group range, respectively. A significant association existed between TNF-alpha hyper-responsiveness and chronic bronchitis. These results indicate that the whole blood cytokine assay may be useful to identify individual responsiveness to endotoxin, and may provide an additional diagnostic tool to evaluate persons potentially at risk for developing chronic bronchitis following exposure to organic dust in the workplace.

[Effects of budesonide on chronic airway inflammation in guinea pigs sensitized with repeated exposure to allergen]

OBJECTIVE

Inhaled glucocorticosteroids (ICS) remains the first line controller medication for chronic airway inflammation in asthma till now. If the impact of allergen could not be eliminated, how would the improvement of airway inflammation be achieved with inhaled glucocorticosteroids therapy? What was its effect on airway remodeling? In this study, an animal model of asthma was established and the effects of budesonide on airway allergic inflammation and extracellular matrix (ECM) deposition in sensitized guinea pigs with repeated exposure to allergen were investigated.

METHODS

Thirty-two male Hartley guinea pigs were randomly divided into four groups with 8 in each group: (A) Group of repeated exposure to ovalbumin (OVA), (B) Group of repeated exposure to OVA plus budesonide (BUD) intervention, (C) Group of stopping repeated exposure to OVA plus stopping BUD intervention, (D) Control group. At 24 h after the last OVA challenge (8 weeks after the first OVA challenge), bronchoalveolar lavage fluid (BALF) was collected from each animal. Total and differential leukocyte counts in BALF was performed on cell suspension smear stained with May-Grünwald-Giemsa (MGG) method. The upper lobe of right lung was removed and regularly fixed, then paraffin embedded lung tissues sections were prepared. The count of eosinophils infiltrated in the airway wall was performed on H&E stained lung tissue sections with LEICA Q500IW computerized image analysis system. Fibronectin and collagen type III (Col-III) deposited in the airway wall were detected by immunohistochemical staining on the paraffin embedded lung tissues sections. The intensity of positive reaction of fibronectin or Col-III deposited in the airway wall was analyzed with LEICA Q500IW computerized image analysis system.

RESULTS

The count of eosinophils in BALF (x 10(5)/ml) of group A and B were higher than that of group C and D (35.70 +/- 25.22, 11.49 +/- 5.51 vs. 1.00 +/- 0.90, 1.02 +/- 0.78, P < 0.01), the difference between group A and B, group B and C was significant. The count of eosinophils infiltrated at each level of airway wall in group A and B were higher than that of group C and D (large airway: 6.95 +/- 2.28, 1.54 +/- 1.09 vs. 0.76 +/- 0.45, 0.88 +/- 0.25; medial airway: 9.22 +/- 3.89, 3.99 +/- 2.3 vs. 1.25 +/- 1.20, 0.64 +/- 0.36; small airway: 11.56 +/- 4.02, 2.67 +/- 1.15 vs. 1.32 +/- 0.83, 0.43 +/- 0.24, P < 0.01), the difference between group A and B, group B and C was significant. The gray values of fibronectin deposited in medial and small airway of group A and B were lower than those of group C and D (medial airway 122 +/- 22, 174 +/- 23 vs. 219 +/- 34, 229 +/- 20; small airway 135 +/- 29, 165 +/- 41 vs. 236 +/- 20, 220 +/- 16, P < 0.05), the difference between group A and B, group B and C was significant. The gray values of Col-III deposited in medial and small airway of group A and B were lower than those of group C and D (medial airway 153 +/- 21, 174 +/- 22 vs. 189 +/- 14, 200 +/- 18; small airway 133 +/- 23, 176 +/- 20 vs. 191 +/- 14, 198 +/- 20, P < 0.05), the difference between group A and B was significant.

CONCLUSION

Inhaled budesonide could partially inhibit allergic inflammation and ECM deposition in airway wall in guinea pig chronic asthma model with repeated exposure to allergen. Early inhaled budesonide combined with avoidance of OVA exposure could completely inhibit allergic inflammation and ECM deposition. These results suggest that the inhibitory effect on airway allergic inflammation and airway remodeling of inhaled glucocorticosteroids would be limited when the allergen factor could not be avoided.

[Effect of the treatment of relapsing bronchitis in children with combined interferon preparations applicated by different methods]

The clinico-immunological effect and significance of the rectal and inhalation methods of the application of recombinant IFN-alpha2 with complex immunoglobulin preparation (CIP) in the treatment of relapsing bronchitis in children have been determined. The determination of the levels of interferon activity in buccal secretions and in venous blood permits the objective evaluation of the immune responsiveness of the body and the treatment effect. The immunocorrecting action of the combined immunobiological preparation (recombinant IFN-alpha2 and CIP) is manifested by an increased level of endogenic interferon and the stimulation of phagocytic activity.

Immunopathogenic role of IgG antibody and RANTES in house dust mite-induced chronic bronchitis

Based on immunological and clinical examinations, 21 patients were diagnosed as having house dust mite (HDM)-induced chronic bronchitis and classified into three groups according to the clinical presentation of the disease: stable bronchitis, exacerbated bronchitis and asthma on top of bronchitis. Using ELISA, the levels of serum anti-Dermatophagoides farinae and anti-D. pteronyssinus IgG antibodies and plasma RANTES (regulated upon activation, normal T-cell-expressed and secreted; a chemokine with attractive and activator role for eosinophils) were measured in correlation to serum eosinophil cationic protein (ECP, a marker of eosinophil activation and degranulation measured by chemiluminescent immunometric technique). Using immunoblotting, IgG binding components of D. farinae and D. pteronyssinus were determined providing a clue for diagnosis of HDM-induced chronic bronchitis. Significant higher levels of anti-D. farinae and anti-D. pteronyssinus IgG antibodies and RANTES were found in asthmatic group followed by exacerbated chronic bronchitis in comparison to stable bronchitis and control groups. ECP level correlated significantly with IgG and RANTES levels in exacerbated bronchitis and asthmatic groups. The results provided evidence that over expression of IgG and RANTES plays a crucial role, as mediator in immunopathogenesis of HDM-induced chronic bronchitis and as marker of the immunological changes likely responsible for progression of bronchitis to asthma in HDM-sensitive patients yet, RANTES seemed to be an early indicator. Definition of the immunopathogenic role of IgG and RANTES in HDM-induced bronchitis should enable the manipulation of the critical immune response in the hope of establishing new therapies. D. farinae and D. pteronyssinu antigenic bands at > 205 and 205 KDa, respectively, considered together showed 71.4% sensitivity in diagnosis of HDM induced chronic bronchitis and 100% specificity by immuno-blotting.

[Experience of ribomunyl application in patients with chronic bronchitis]

The authors performed clinical and immunological evaluation of efficacy of treatment of patients with occupational chronic bronchitis (CB) working in contact with pneumotropic pollutants, including airway irritants and dusts. The complex therapy included an immune-correcting agent of bacterial origin, ribomunyl. The indicators to the drug administration were remission or moderate manifestations of the disease with disturbances of mucosal immunity, both isolated (imbalance of IgA, IgG and salivary lysozyme) or combined with systemic immunity disorder (decrease of neutrophilic phagocyte activity, serum IgM and IgG, and the number of T-lymphocytes). The course lasted 3 weeks; the regimen was standard: 3 tablets in the morning before meals 4 days a week. During the whole period of immune correction the patients were under clinical observation; respiratoryfunctions (RF), bronchial hyperactivity, and immune status were evaluated prior to and after the treatment. After the treatment with ribomunyl most patients displayed improvement of the symptoms and FF parameters. The study found significant improvement of a range of immunological parameters: reduction of the imbalance of salivary protective factors, elevation of the phagocyte activity of peripheral blood neutrophils, and a tendency towards increase of IgG and blood T-lymphocyte levels. The results show that clinical, functional and immune parameters normalized simultaneously, with the most evident matching in salivary immunity. The authors conclude that ribomunyl is efficient in treatment of occupational CB when administered with taking individual disturbances of mucosal and systemic immunity into account.

Surfactant function in children with chronic airway inflammation

Pulmonary surfactant is necessary to keep the terminal conducting airways patent. It is unknown whether mild to moderate airway inflammation may influence surfactant function and thus contribute to the pathogenesis of chronic airway inflammation in children. To answer this question, 21 children with chronic obstructive bronchitis and 19 asymptomatic children with long-term tracheostomy and increased numbers of neutrophils in their airways were compared with 15 healthy controls. Bronchoalveolar lavage fluid was separated into large surfactant aggregates (LA) and a supernatant containing inhibitory constituents. Surfactant function of LA, recombinations of LA and supernatant, and recombinations of a defined bovine surfactant and supernatant was assessed in a capillary surfactometer. Compared with controls, the function of the LA surfactant was reduced and there was no difference between children with tracheostomy and chronic obstructive bronchitis. The function of LA-supernatant recombinations was poor in all subjects. This may be explained by the well-known protein influx during the lavage procedure. The activity of bovine surfactant-supernatant reconstitutions was impaired in children with tracheostomy. In all surfactant mixtures assessed, surfactant function was inversely correlated to the number of neutrophils in the lavage fluid. Chronic lower airway inflammation with mild or no clinical symptoms is associated with impaired surfactant function. The dysfunction may contribute to airflow restrictions frequently observed in these children.

[Possibilities of immunomodulation in patients with chronic bronchitis during physiotherapeutic impacts on the thymic area]

Immune effects of galvanic current (GC) and ultrasound (US) applied on the thymic area were studied in 66 patients with chronic bronchitis (CB) on rehabilitation treatment. 64 control CB patients either receive an immunomodulating drug thymalin or were treated without immunomodulation. It was found that GC and US are effective in disorders of cellular immunity and result in closer interaction between separate components of immune system. The immunomodulating effect of GC and US was comparable with that of thymalin.

Pneumocystis jiroveci isolates with dihydropteroate synthase mutations in patients with chronic bronchitis

Since mutations in the dihydropteroate synthase (DHPS) gene possibly associated with sulfonamide resistance have been reported in patients with Pneumocystis jiroveci (previously carinii) pneumonia, and since P. jiroveci colonization has been recently demonstrated in patients with chronic pulmonary diseases, the present study aimed to investigate the possible occurrence of P. jiroveci DHPS mutations in patients with chronic bronchitis. P. jiroveci colonization was detected in 15 of 37 non-selected patients with chronic bronchitis by amplifying the large subunit of the mitochondrial gene of the ribosomal RNA using nested PCR. DHPS mutations were demonstrated using touchdown PCR and restriction enzyme analysis in two of eight patients with chronic bronchitis and in two of six patients from the same region who had AIDS-associated Pneumocystis pneumonia. In all cases, mutations were observed in subjects with no prior exposure to sulfonamides. These data could have important implications for public health, since (i) P. jiroveci colonization could speed the progression of chronic bronchitis, and (ii) these patients, who are customary sputum producers, could represent a reservoir for sulfonamide-resistant strains with the potential ability to transmit them to immunocompromised hosts susceptible to Pneumocystis pneumonia.

[Effect of jiawei yupingfeng powder on T-lymphocyte subsets in patients with senile chronic bronchitis in acute onset stage]

OBJECTIVE

To explore the effect of Jiawei Yupingfeng Powder (JYP) on T-lymphocyte subsets in patients with senile chronic bronchitis in acute onset stage (SCB-AOS).

METHODS

Patients were divided, according to the randomized controlled principle, into two groups, the 44 patients in the treated group and the 40 in the control group. The conventional western medicinal therapy was given to both groups, but to the treated group, JYP was administered additionally. The therapeutic course to them was 14 days. Changes of CD3, CD4, CD8 and the ratio of them were observed.

RESULTS

Increase of CD3, CD4 and CD4/CD8 (P < 0.05) and decrease of CD8 (P < 0.01) were significantly shown in the treated group after treatment, but no change in the control group. Besides, comparison of the total effective rate in the two groups also showed significant difference (P < 0.05).

CONCLUSION

Cellular immune function disturbance exists in patients with SCB-AOS, JYP could enhance the efficacy by way of modulating cellular immune function.

[Metabolism of proinflammatory cytokine (interleukin-1 beta) and oxidant activity of neutrophils in various forms of chronic bronchitis]

AIM

To study content of interleukin-1 beta (IL-1 beta) and free radical oxidation in neutrophils of blood, saliva and bronchoalveolar lavage (BAL) in chronic bronchitis for prediction of obstructive defects.

MATERIAL AND METHODS

Enzyme immunoassay was used to measure IL-1 beta in the blood, saliva, BAL of 49 males with chronic bronchitis aged 39-72 years. Functional ability of the neutrophils to generate free oxygen radicals was assessed by luminol-dependent chemiluminescence.

RESULTS

Patients with chronic obstructive bronchitis exhibited excessive accumulation of IL-1 beta in the blood and BAL, enhanced activity of hematosalivary barrier for IL-1 beta and production of active oxygen radicals by systemic and tissue neutrophils.

CONCLUSION

Elevated concentration of systemic and tissue IL-1 beta, activation of free radical oxidation by blood neutrophils and BAL, enhancement of hematosalivary barrier for IL-1 beta can be considered as prognostically unfavourable factors of bronchial obstruction in patients with chronic bronchitis.

[Changes of the immune status of children with relapsing herpetic stomatitis, suffering from allergic diseases, during licopide treatment]

The efficiency of licopide in combination with traditional treatment was evaluated in 59 children aged 1-14 years suffering from allergic diseases and relapsing herpetic stomatitis. Immunological studies were carried out before and after a course of therapy: local oral immunity, cellular immunity (in the blast transformation test with phytohemagglutinin), lymphocyte populations and subpopulations, humoral immunity values (IgA, IgM, IgG, and IgE), and C3 complement component were evaluated. The results indicate that licopide in complex with traditional methods normalized the immunological values, had a favorable impact on the course of relapsing herpetic stomatitis, and led to a stable remission of allergic diseases (p<0.001).

Clinical observation in 31 cases of chronic bronchitis at remission stage treated with bufei keli

To observe the therapeutic effects of a Chinese drug Bufei Keli ([symbol: see text] granules for invigorating the lung) in the treatment of chronic bronchitis at remission stage, 62 cases were randomly divided into a treatment group (treated with Bufei Keli) and a control group (treated with Yupingfeng Keli [symbol: see text]). The results turned out to be that the short-term clinically controlled and markedly effective rate was 77.42% and the long-term relapse-resisting markedly effective rate was 74.2% in the treatment group, which were obviously higher than 45.16% and 38.71% respectively in the control group (P < 0.05). And the increase in contents of SOD and CD3 and the decrease in LPO content in the treatment group were also bigger than that in the control group (P < 0.01). It is therefore concluded that Bufei Keli can improve qi deficiency syndrome and raise the immunity of patients with chronic bronchitis, hence its effect of resisting relapse of chronic bronchitis.

Variation of CD8+ T-lymphocytes around the bronchial internal perimeter in chronic bronchitis

The variation of CD8+ cells has been determined around the internal perimeter of intrapulmonary bronchi in smokers with chronic bronchitis (CB), and the amount of tissue required to confidently estimate the true mean has been calculated. Lung specimens were obtained from 10 smokers with CB. Paraffin sections of intrapulmonary bronchi were immunostained and CD8+ cells counted in the epithelium and subepithelium in up to 10 sequential 1-mm segments around the internal perimeter of each airway. The percentage of counts falling between +/-20% of the final mean was 43.0% for epithelium and 40.9% for subepithelium. In 90% of subjects, the cumulative mean was stable after examination of subepithelial tissue associated with 5 mm of reticular basement membrane. There is considerable variation in the counts of CD8+ cells between adjacent 1-mm airway mucosal segments in chronic bronchitis. In order to achieve a representative count and to maximise statistical power to detect differences between study populations, subepithelial tissue including a minimum of 5 mm of reticular basement membrane length should be examined.

Chronic bronchitis in immunocompromised patients: association with a novel Mycoplasma species

Patients with primary antibody deficiency are prone to recurrent bronchitis, often caused by nonencapsulated Haemophilus influenzae and streptococcal infection. Productive cough often persists even after elimination of these organisms with antibiotics. During an investigation into the cause of unexplained chronic bronchitis in these patients, a novel Mycoplasma species (designated A39) was first isolated from the sputum of a man with X-linked agammaglobulinaemia. Screening of sputa from a further 45 patients with primary antibody deficiency showed that 10 were positive for a similar organism using culture and/or a polymerase chain reaction based on sequences within the 16S ribosomal RNA gene. A comparison of the sequence data showed that the organism was distinct from but similar to Mycoplasma pneumoniae and other closely related mycoplasmas found in humans and animals. Electron microscopy showed some unique morphological characteristics. Although respiratory symptoms improved after elimination of A39 from the sputum of the patient with X-linked agammaglobulinaemia, further work is needed to establish the organism as a pathogen.

[Cytological and biochemical indices of induced sputum in patients with bronchial asthma and chronic obstructive bronchitis]

The aim of our research was to study the apoptotic index and the representativeness of CD95-receptor in the effector cells, in addition to estimation of the content of tumor necrosis factor-alpha in the induced sputum supernatant observed in patients with bronchial asthma and chronic obstructive bronchitis. These indices were evaluated in the disease dynamics and involves various treatment programs. The object of our research was induced sputum. The analysis has proven that apoptotic index of effector cell nuclei, representativeness of CD95-receptor and the content of tumor necrosis factor-alpha in the induced sputum differed, respectively, in patients with bronchial asthma and chronical obstructive bronchitis, and depended on the period of disease and employed treatment. The induced sputum analysis results can be used for the airway inflammation activity monitoring, with regard to these diseases and to treatment efficiency monitoring.

[Correction of immune disorders with neoselenium in patients with chronic bronchitis]

The examination covered 55 patients with chronic bronchitis (mean age 58 +/- 4.2 years, mean duration of the disease 11.2 +/- 5.2 years). All the patients were in remission and received broncholytics. In 32 of them, basic treatment was combined with a course of immunorehabilitation with neoselenium. The effect of the latter was assessed at immunological examination of the patients before and after the treatment with indirect immunofluorescence with monoclonal antibodies. Neoselenium appeared to have an immunomodulating action on all immunity links, it enhanced functional activity and bactericidity of antigen-presenting cells and cytotoxic activity of natural killers, diminished the tension in the function of endogenic antioxidant systems.

[Content of the antigenic determinants CD16, CD25, CD95, and HLA-DR in induced sputum of patients with bronchial asthma and chronic obstructive bronchitis]

AIM

To examine the content of CD16, CD25, CD95, and HLA-DR antigenic determinants in induced sputum (IS) of patients with bronchial asthma (BA) and chronic obstructive bronchitis (COB).

MATERIALS AND METHODS

The study enrolled 36 patients with BA and 15 with COB whose age was 21 to 58 years. The cellular precipitate of IS served as a material for the study. The studied receptors were determined by immunofluorescence using the "Clonospectrum" monoclonal antibodies.

RESULTS

There was an increase in the content of CD16, CD25, HLA-DR, CD95 whose expression was decreased when glucocorticosteroids were used. At remission of asthma, the level of these receptors approximated that in the control group. On an exacerbation of COB, the content of these markers was significantly less than that in the controls and the use of antibacterial agents and methylxanthines led to its rise. At remission of COB, CD16 and CD25 cells were not recorded.

CONCLUSION

The levels of membrane markers in IM of patients with BA and COB depend on the period of the disease and used therapy.

[Bronchial inflammation during chronic bronchitis, importance of fenspiride]

PATHOPHYSIOLOGY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD): Chronic inflammation of the upper airways, pulmonary parenchyma and pulmonary vasculature is the characteristic feature of COPD. Two mechanisms besides inflammation are also involved: oxidative stress and imbalance between proteinases and antiproteinases. Cellular infiltration of the upper airways involved neutrophils, macrophages, T lymphocytes and eosinophils. Inflammatory mediators appear to play a crucial role in the interaction between inflammation and obstruction. PROPERTIES OF FENSPIRIDE: A nonsteroidal drug, fenspiride, exhibits interesting properties documented in vitro: anti-bronchoconstriction activity, anti-secretory activity, and anti-inflammatory activity (reduction in the activity of phospholipase A2 and release of proinflammatory leukotriens). Two french clinical trials have studied the efficacy of fenspiride in patients with acute excerbation or stable COPD and have demonstrated an improvement in the group treated with fenspiride compared with the placebo group.

[Effect of Chinese bushen huatan drugs on pituitary-sex gland-immune axis in smoking induced chronic bronchitis mice]

OBJECTIVE

To study the effect of Chinese Bushen Huatan Drugs (BSHT, Chinese drugs for Kidney tonifying and phlegm resolving) on pituitary-sex gland-immune axis in smoking induced mice model of chronic bronchitis.

METHODS

Model mice were induced by smoking and divided into the model control group, the large dosage of BSHT group, the small dosage of BSHT group and the positive control group (treated by Guilong Kechuanning, a proved effective Chinese patent drug). A blank group of normal mice was also set for control. Serum levels of testosterone (T), luteotropic hormone (LH), interleukin-2 (IL-2), interleukin-8 (IL-8), visceral indexes of testis, epididymis and thymus were measured and microstructure of testis tissue was also observed.

RESULTS

As compared with those in the blank group, serum T, LH and IL-2 levels, and testis, epididymis and thymus indexes were all lower, and IL-8 level was higher in the model control group, moreover, atrophic change of testis was present in the model mice. These abnormal changes were all improved in the BSHT groups.

CONCLUSION

Smoking induced mice model of chronic bronchitis, which may cause reproductive endocrine disturbance and immunosuppression. BSHT could modulate the pituitary-sex gland-immune axis through adjusting the disturbed sex hormone, improve the pathological change of testis and enhance the immunity of organism.

Eotaxin and CCR3 are up-regulated in exacerbations of chronic bronchitis

BACKGROUND

Eosinophils and T lymphocytes represent constant features in the airways of subjects with exacerbated chronic bronchitis. Eotaxin is the most potent and selective eosinophil chemoattractant which can also attracts lymphocytes. The aim of the study was to evaluate the expression of eotaxin and its receptor, CCR3, in bronchial airways during exacerbation of chronic bronchitis.

METHODS

By immunohistochemistry we studied eotaxin and CCR3 expression in the lamina propria of 14 subjects with acute exacerbation of chronic bronchitis. 20 asthmatics, and 8 healthy subjects. We determined the cell types expressing the CCR3 receptor by colocalization experiments. We finally studied the relationship between eotaxin and CCR3 and eosinophils and T lymphocytes.

RESULTS

The number of eotaxin+ and CCR3+ cells was significantly higher in exacerbated chronic bronchitis (P<0.003 and P<0.002) and asthma (P<0.002 and P<0.0001) when compared to healthy subjects. CCR3 was mainly expressed by eosinophils and to a lesser extent by CD4+ and CD8+ lymphocytes. In exacerbated chronic bronchitis the number of CCR3+ cells was strongly correlated to the number of eosinophils (P<0.0002. r=0.85) and to the number of CD4+ lymphocytes (P<0.05, r=0.57).

CONCLUSION

Our study suggests that eotaxin and CCR3 are up-regulated and could be involved in the eosinophil and CD4+ lymphocyte recruitment into the airways which occur during acute exacerbations of chronic bronchitis.

[Clinical study on treatment of chronic bronchitis by tracheitis plaster]

OBJECTIVE

To study the clinical effect and mechanism of Tracheitis Plaster (TP) in treating chronic bronchitis.

METHODS

TP is consisted of ephedra, almond, pinellia tuber, earthworm and white mustard seed. Patients were randomly divided into two groups, 59 patients in the treated group were treated with TP sticking on acupoints Dingchuan, Dashu, Fengmen, Feishu and Xinshu at back along both sides of thoracic vertebrae 1-6 and the 25 patients in the control group were treated with intramuscular injection of Siqikang. The times of treatment for both groups were 20. Clinical symptoms, X-ray chest film, level of immunoglobulin and T-lymphocyte subsets were recorded before and after treatment, and follow-up were carried out 0.5-1 year later.

RESULTS

The clinical total effective rate was 93.2% and the X-ray improvement rate was 40.7% in the treated group, while in the control group, 80.0% and 20.0% respectively. Half and 1 year follow-up studies showed the total effective rate in the treated group was 91.5% and 89.8% respectively, which was significantly higher than that in the control group (80.0% and 76.0%) respectively (P < 0.05). The improvement in levels of IgG and CD8 in the treated group was also superior to those in the control group (P < 0.05).

CONCLUSION

TP is a highly effective transcutaneous absorbent with promising long-term effect, it could regulate the immune function.

[Autoantibodies in children with chronic inflammatory lung diseases]

124 sera of children with chronic bronchitis, chronic pneumonia, bronchial asthma, exogenic allergic alveolitis, congenital developmental defects of the lungs and the syndrome of the situs inversus of organs were examined with a view to study the state of humoral immunity to tissues. The study was carried out by means of the enzyme-linked immunosorbent assay with the use of collagen, elastin, DNA (native and denaturated), membrane antigens of the lung, the liver, the small intestine and the large intestine. Among all groups of patients autoimmune disturbances, manifested by a rise in the level of autoantibodies of different specificity, were registered. The degree of manifestation of autoimmune disturbances depended on the kind of pathology. After treatment a decrease in the level of autoantibodies was registered in the examinees.

FAB-MS characterization of sialyl Lewis x determinants on polylactosamine chains of human airway mucins secreted by patients suffering from cystic fibrosis or chronic bronchitis

Although a large body of structural data exists for bronchial mucins from cystic fibrosis (CF) and chronic bronchitis (CB) patients, little is known about terminal structures carried on poly-N-acetyllactosamine antennae. Such structures are of interest because they are potential ligands for bacterial adhesins and other lectins. In this study, we have used fast atom bombardment mass spectrometry (FAB-MS) to examine terminal sequences released by endo-beta-galactosidase from O-glycans obtained by reductive elimination of bronchial mucins purified from the sputum of 8 CF and 8 CB patients. Our data show that, although the polylactosamine antennae of CF and CB mucins have several terminal sequences in common, they differ significantly in their sialyl Lewis(x) (NeuAcalpha2-3Galbeta1-4[Fucalpha1-3]GlcNAcbeta1-) content. Thus all examined mucins from CF patients carry sialyl Lewis(x) on their polylactosamine antennae, whereas this type of epitope is present on only three out of the eight CB mucins examined, notably in the airways of one CB patient which were heavily infected by Pseudomonas aeruginosa as are the airways of all the CF patients. This suggests that, in airway mucins, the expression of sialyl Lewis(x) on polylactosamine antennae is probably more related to inflammation and infection than to a direct effect of the CF defect.