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The exacerbation of hippocampal excitotoxicity by glucocorticoids is not mediated by apoptosis.

Both endogenous and exogenous glucocorticoids (GCs) are known to cause apoptosis in a number of peripheral tissues and in some cases in the CNS. Additionally, GCs can exacerbate the neuron loss associated with such acute neurological insults as hypoxia-ischemia, excitotoxicity, and metabolic disruption. This exacerbation is accompanied by increased accumulation of glutamate in the synapse, excessive cytosolic calcium, and increased oxygen radical activity, markers usually attributed to pathways of necrotic cell death. It is also known that acute insults can involve apoptotic mediators. In this context, one outstanding question that has received little attention is whether the exacerbation of insult-mediated cell death in neurons is apoptotic in mechanism. In this study we investigate whether the GC-mediated exacerbation of hippocampal excitotoxicity in culture involves apoptosis. Specifically, we show that while the magnitude of hippocampal neuron death caused by the excitotoxin kainic acid is indeed worsened in the presence of GCs, there is no evidence of increased markers of apoptosis. Specifically, we show that neither kainic acid nor GCs alone, or in combination, cause activation of caspase 3, a critical executor of insult-induced apoptosis. Furthermore, while kainic acid causes a significant incidence of apoptotic nuclear condensation, the incidence of this morphological indicator of apoptosis is not worsened by GCs. Thus, GCs appear to augment excitotoxic death in hippocampal neurons without augmenting the occurrence of apoptosis. We suggest that this finding is to be expected, given some energetic features of GC action and the energetic demands of apoptosis.

Animals↗

Crossed and uncrossed olivocochlear pathways exacerbate temporary shifts in hearing sensitivity after narrow band sound trauma in normal ears of animals with unilateral hearing impairment.

Olivocochlear (OC) pathways have been shown to reduce the temporary threshold shifts (TTSs) caused by traumatic sounds. More recently they have been shown to exacerbate TTSs under certain conditions. One condition is the normal-hearing ear of animals with a chronic unilateral hearing loss. Testing with pure tone trauma showed that then (a) the normal-hearing ear had a lower-than-normal 'intrinsic' susceptibility to intense tones, (b) binaural trauma exacerbated TTSs in the normal-hearing ear through the activity of uncrossed OC (UOC) pathways, and (c) there was no effect on TTSs of the crossed OC (COC) pathway to the normal-hearing ear. The present study is an examination in such animals of effects with noise band trauma. The effects here confirm the previous finding that under such conditions the normal-hearing ear has a lower-than-normal susceptibility to loud sound, and binaural loud sounds exacerbate TTSs in the normal-hearing ear. They extend the previous study by demonstrating that with this traumatic sound, both COC and UOC pathways exacerbate TTSs. These effects contrast against the effects seen in animals with bilaterally normal hearing for the same noise band. Given the commonality of unilateral hearing losses in the normal human population, these data have implications for the functional effects of the OC pathways on loud sound-induced hearing damage.

Animals↗

Prognostic factors in the management of exacerbation of chronic obstructive pulmonary disease in Kuwait.

OBJECTIVE: To evaluate the clinical presentation and the factors of prognostic importance in the management of exacerbation of chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: One hundred and four patients who were hospitalized because of exacerbation of COPD between 1996 and 2000 were selected for further evaluation. Only patients who fulfilled the American Thoracic Society criteria for diagnosis of COPD were included. The factors examined included age, clinical features, duration of symptoms of exacerbation, severity of underlying disease, comorbid diseases, level of consciousness, previous hospitalization, intubation and assisted ventilation, hypercapnia, degree of acidemia and complications. RESULTS: Seventy-four of 104 (71%) hospitalized patients reviewed met the inclusion criteria for COPD. The mean age was 63.68 +/- 12.6 years. There was a male:female ratio of 3:1. Fifty-eight patients (78%) had a baseline FEV1 <50% before hospitalization and 45 (64%) had previous hospitalization. Comorbid disease was found in 50% of the cases, while 78% had acidemia and 70% hypercapnia. Fourteen (19%) died on admission. Risk factors identified included severity of disease (p < 0.05); presence of comorbid disease (p < 0.01); acidemia (p < 0.0001); hypercapnia (p < 0.0001); previous hospitalization (p < 0.01), and assisted ventilation (p < 0.001). CONCLUSION: This study revealed that the presence of comorbid disease, acidemia, previous hospitalization and assisted ventilation significantly contributed to mortality in patients with exacerbation of COPD.

Aged↗

Yield of sputum microbiological examination in patients hospitalized for exacerbations of chronic obstructive pulmonary disease with purulent sputum.

BACKGROUND: Whether sputum microbiological examination should be performed systematically in hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations remains unclear. OBJECTIVES: To assess the yield of sputum microbiological examination in COPD patients hospitalized in a medical ward for an acute exacerbation with purulent sputum. METHODS: Two hundred consecutive exacerbations in 118 patients were studied. Patients underwent sputum microbiological examination on admission and baseline lung function tests and CT scans were recorded. Factors associated with positive culture were analyzed. RESULTS: Sputum culture was positive (>or=10(7) CFU/ml) in 59% of samples, Haemophilus influenzae and Streptococcus pneumoniae being the most frequent pathogens. Factors associated with positive culture were bronchiectasis, long-term oxygen therapy and low FEV1. Pseudomonas spp. were found in 8.5% of all patients, who all had a FEV1<50% of predicted and were older. Only 25% of sputum samples satisfied all quality criteria. Sputum culture was positive in a high proportion of these samples (80.5%), but also in one half of samples with >25 leukocytes but >10 epithelial cells per field. Microbiological results induced a change in antibiotic therapy in 43.9% of cases with both quality criteria but also in 25.2% of cases with only one quality criterion. Finally, a predominant aspect after Gram stain was found in all positive samples. CONCLUSIONS: These data suggest that sputum microbiological examination with direct examination and leukocyte count should be performed routinely in patients hospitalized for COPD exacerbations with purulent sputum, especially when FEV1 is less than 50% predicted and in patients with bronchiectasis.

Aged↗

Nicotine exacerbates postischemic contractile dysfunction of 'stunned' myocardium in the canine model. Possible role of free radicals.

BACKGROUND: There is no doubt that high doses of nicotine have deleterious effects on cardiovascular function. However, the effects of lower and more clinically relevant doses of nicotine have received little attention, and the consequences of nicotine in the setting of ischemia/reperfusion are virtually unknown. The first objective of this study was to determine whether nicotine, given either before or after ischemia and at a dose mimicking that absorbed by humans during inhalation of one cigarette, exacerbated contractile dysfunction of canine myocardium "stunned" by brief transient ischemia. The second aim was to provide preliminary insight into the mechanism of action of nicotine on the stunned myocardium. METHODS AND RESULTS: Anesthetized open chest dogs underwent 15 minutes of left anterior descending coronary artery (LAD) occlusion and 3 hours of reperfusion. In protocol 1, each dog was randomized to receive nicotine at 30 minutes before LAD occlusion (80 micrograms/kg dissolved in 15 mL of saline, given i.v. over 10 minutes), nicotine at 1 hour after reperfusion (80 micrograms/kg as above), or saline. Segment shortening (assessed by sonomicrometry) in both the LAD and circumflex beds, heart rate, arterial pressure, and coronary blood flow were monitored throughout the protocol, and regional myocardial blood flow (by injection of radiolabeled microspheres) was measured during LAD occlusion and at 5 minutes after nicotine/saline infusion. All groups were equally ischemic during LAD occlusion. As expected, segment shortening in the LAD bed of control animals was depressed after reperfusion, averaging 54 +/- 6% and 50 +/- 4% of baseline at 1 and 3 hours after reflow. Nicotine given before occlusion did not alter segment shortening before LAD occlusion and did not exacerbate dyskinesis during occlusion. However, segment shortening in the LAD bed recovered to only 29 +/- 9% and 22 +/- 5% of baseline at 1 and 3 hours after reperfusion (P < .01 versus corresponding control values). Furthermore, nicotine given at 1 hour after reperfusion caused a significant deterioration in segment shortening, from 47 +/- 11% immediately before infusion (P = NS versus control at 1 hour after reflow) to 7 +/- 13% at 3 hours after reperfusion (P < .01 versus 1 hour after reperfusion; P < .01 versus control at 3 hours after reflow). This dose of nicotine did not alter heart rate, arterial pressure, or blood flow; did not cause myocyte necrosis; and did not impair contractile function in the normally perfused circumflex bed. In protocol 2, all dogs received a continuous infusion of the free radical scavenging agent N-2-mercaptopropionyl glycine (MPG; 50 mg.kg-1 x h-1) beginning 45 minutes after reperfusion and, at 1 hour after reflow, received either nicotine or saline as described in protocol 1. MPG given after reperfusion did not alter contractile function in control animals. However, MPG prevented the deterioration in postischemic function observed with nicotine in protocol 1; segment shortening averaged 54 +/- 11% and 56 +/- 9% of baseline at 1 and 3 hours after reperfusion (P = NS). CONCLUSIONS: Nicotine, given before occlusion or after reflow, significantly exacerbated contractile dysfunction of post-ischemic stunned myocardium in this canine model. This exacerbated dysfunction was not a secondary consequence of unfavorable alterations in hemodynamics or coronary blood flow and may be mediated by free radicals acting on myocytes that had been reversibly injured by the brief ischemic insult.

Animals↗

Subcutaneous administration of hyaluronan reduces the number of infectious exacerbations in patients with chronic bronchitis.

Hyaluronan (HA) is a high molecular weight glycosaminoglycan found in large amounts in the skin, joints, and other organs. Previous studies have shown that HA stimulates neutrophil functions both in vitro and in vivo. The object of this study was to test the hypothesis that HA administration subcutaneously might reduce the number of bacterial infections in humans with an increased susceptibility to such infections. For this purpose we have studied 29 patients with chronic bronchitis and recurrent acute exacerbations of their disease. The patients were randomly separated into two groups. One group had HA for 6 mo followed by 6 mo of placebo, and the other group started with placebo treatment followed by HA. The treatment periods occurred during two consecutive winter periods. HA-treated patients had significantly fewer acute exacerbations (p = 0.01) than did placebo-treated patients. Likewise the consumption of antibiotics and other signs of bacterial infections were reduced. In the crossover study the placebo-treated patients again had much higher numbers of acute exacerbations than did the HA-treated patients (p < 0.0001). It is concluded that HA reduces the number of infectious exacerbations in patients with chronic bronchitis, possibly by enhancing cellular host defense mechanisms. HA is a new endogenous substance that can be used to stimulate host defense reactions and reduce the need of antibiotics. Before being recommended for clinical use, however, our results should be confirmed by further studies.

Aged↗

Controlled trial of oral prednisone in outpatients with acute COPD exacerbation.

Corticosteroids are often used in the outpatient treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD). To date, there are few data documenting the benefit of this practice. The objective of this randomized, double-blind, placebo-controlled trial was to assess the efficacy of corticosteroids in the outpatient treatment of COPD exacerbations. Twenty-seven patients presenting with acute COPD exacerbation were studied. In addition to continuing their previous medications and increasing their use of beta-agonists, patients were randomized to receive a 9-d tapering dose of either oral prednisone or placebo. Treatment with prednisone rather than placebo resulted in a more rapid improvement in arterial PO2 (PaO2) (1.12 mm Hg/d versus -0.03 mm Hg/day; p = 0.002), alveolar-arterial oxygen gradient (A-aDO2) (-1.16 mm Hg/d versus -0.03 mm Hg/day; p = 0.04), FEV1 (0.05 L/d versus 0.00 L/d; p = 0.006), and peak expiratory flow (PEF) (0.15 L/s/d versus 0.04 L/s/d; p = 0.009). Prednisone also resulted in fewer treatment failures (p = 0.002) and in a trend toward more rapid improvement in dyspnea scale scores. Outpatient treatment of acute COPD exacerbation with prednisone accelerates recovery of PaO2, A-aDO2, FEV1, and PEF, reduces the treatment failure rate, and improves subjective dyspnea.

Administration, Oral↗

Evidence for excessive bronchial inflammation during an acute exacerbation of chronic obstructive pulmonary disease in patients with alpha(1)-antitrypsin deficiency (PiZ).

Patients with homozygous (PiZ) alpha(1)-antitrypsin (AAT) deficiency have not only low baseline serum AAT levels (approximately 10 to 15% normal) but also an attenuated acute phase response. They are susceptible to the development of premature emphysema but may also be particularly susceptible to lung damage during bacterial exacerbations when there will be a significant neutrophil influx. The purposes of the present study were to assess the inflammatory nature of acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD) in subjects with AAT deficiency, to compare this with COPD patients without deficiency, and to monitor the inflammatory process and its resolution following appropriate antibacterial therapy. At the start of the exacerbation, patients with AAT deficiency had lower sputum AAT (p < 0.001) and secretory leukoprotease inhibitor (SLPI; p = 0.02) with higher elastase activity (p = 0.02) compared with COPD patients without deficiency. Both groups had a comparable acute phase response as assessed by C-reactive protein (CRP) but the AAT-deficient patients had a minimal rise in serum AAT (to < 6 microM). After treatment with antibiotics, in patients with AAT deficiency, there were significant changes in many sputum proteins including a rise in SLPI levels, and a reduction in myeloperoxidase (MPO) and elastase activity (p < 0. 005 for all measures); the sputum chemoattractants interleukin-8 (IL-8) and leukotriene B(4) (LTB(4)) fell (p < 0.01), and protein leak (sputum/serum albumin ratio) became lower (p < 0.01). The changes were rapid and within 3 d of the commencement of antibiotic therapy the biochemical markers had decreased significantly, but took a variable time thereafter to return to baseline values. In conclusion, patients with AAT deficiency had evidence of increased elastase activity at the start of the exacerbation when compared with nondeficient COPD patients which probably reflects a deficient antiproteinase screen (lower sputum AAT and SLPI). The increased bronchial inflammation at presentation resolved rapidly with 14 d of antibiotic therapy.

Acute Disease↗

Elevated soluble ST2 protein levels in sera of patients with asthma with an acute exacerbation.

Previous studies have reported that ST2 is preferentially expressed on Th2 cells and plays a critical part in controlling airway inflammation in murine models of asthma. However, the clinical role of ST2 in patients with bronchial asthma remains unclear. In our study, we examined 56 patients with atopic asthma in a nonattack phase and 200 nonatopic normal volunteers for healthy control, and analyzed the relationship of their serum ST2 levels to asthma severity, pulmonary function, and laboratory data. Of the 56 patients with atopic asthma, 30 exhibited asthmatic exacerbation, and their serum ST2 levels were also analyzed. The serum ST2 levels were low, but a statistical difference was found between patients with nonattack asthma and the healthy control group (p < 0.05). We also found a differential rise of serum ST2 level that correlates well with the severity of asthma exacerbation. Furthermore, the serum ST2 levels during asthma exacerbation statistically correlated with the percentage of predicted peak expiratory flow (r = -0.634, p = 0.004) and Pa(CO(2)) (r = 0.516, p = 0.003). These results suggest that soluble human ST2 protein in sera may be related to Th2-mediated allergic inflammation inducing acute exacerbation in patients with atopic asthma.

Acute Disease↗

Aldehydes and glutathione in exhaled breath condensate of children with asthma exacerbation.

Oxidative stress is implicated in the pathogenesis of asthma, and clinical studies show an imbalance in the level of oxidants to the level of antioxidants in subjects with asthma. Aldehydes and glutathione are examples of biomarkers of oxidant-induced damage and antioxidant status in asthma, respectively. In the study, we applied analytical techniques based on liquid chromatography for the assessment of aldehydes and glutathione in the exhaled breath condensate of children with asthma and in control subjects without asthma. Twelve subjects with asthma were evaluated at exacerbation and after 5 days of therapy with prednisone. At exacerbation, malondialdehyde levels were higher in patients with asthma (30.2 +/- 2.4 nM) than in control subjects (19.4 +/- 1.9 nM, p = 0.002) and were reduced after steroid therapy (18.5 +/- 1.6 nM, p = 0.001). At exacerbation, glutathione levels were lower in subjects with asthma (5.96 +/- 0.6 nM) than in control subjects (14.1 +/- 0.8 nM, p < 0.0001) and were increased after the therapy (8.44 +/- 1.2 nM, p = 0.04). Malondialdehyde and glutathione both in subjects with asthma and control subjects were negatively correlated (r = -0.5, p = 0.001). The study shows that aldehydes and glutathione are detectable in the exhaled breath condensate of children with asthma and healthy children and that their levels are modified during asthma exacerbation and after a 5-day course of therapy with oral prednisone.

Asthma↗

Osteoclastogenesis during infective exacerbations in patients with cystic fibrosis.

RATIONALE: Adults with cystic fibrosis (CF) are at increased risk of developing osteoporosis. During infective exacerbations, increased production of proinflammatory cytokines and markers of bone resorption have been reported. OBJECTIVE: The aim of this study is to investigate the growth and proliferation of potential osteoclast precursor cells before, during, and after intravenous antibiotic treatment of infective exacerbations in patients with CF. METHODS: Hematopoietic precursor cell growth was examined using colony formation assays using Methocult culture medium. Circulating potential osteoclast precursors were identified using four-color flow cytometry by CD14, CD33, CD34, and CD45 expression. RESULTS: At the start of an infective exacerbation increases in hematopoietic precursor colony formation (15.42 colonies/10(5) cells plated, p = 0.025), proliferation (28.5%, p < 0.001), and the numbers of circulating potential osteoclast precursors (6.5%, p < 0.001) were seen in comparison with baseline levels. These increases declined after treatment with intravenous antibiotics to a level close to baseline. CONCLUSIONS: The results demonstrate an increase in the production of potential osteoclast precursors in the peripheral blood during CF infective exacerbations. This may result in increased bone resorption and contribute to bone loss in patients with CF.

Anti-Bacterial Agents↗

Mortality in patients hospitalized for asthma exacerbations in the United States.

RATIONALE: Hospitalizations for asthma exacerbations are common in the United States, but there are no national estimates of outcomes in this population. It is also not known if race disparities in asthma deaths exist among hospitalized patients. OBJECTIVES: To estimate outcomes of patients hospitalized for asthma in the United States and to determine if the risk of death in this population is higher among black patients compared with white patients. METHODS: We used the Nationwide Inpatient Sample for 2000. Admissions for asthma exacerbations among patients > 5 yr of age were included. Mortality was the primary outcome; secondary outcomes were length of stay and total hospital charges. MEASUREMENTS AND MAIN RESULTS: In-hospital asthma mortality was 0.5% (99% confidence interval [CI], 0.4-0.6), with mean hospital stay of 2.7 d (99% CI, 2.6-2.8 d) and 9,078 dollars (99% CI, 8,300-9,855 dollars) in hospital charges. Deaths in this population accounted for about one-third of all asthma deaths reported in the United States. Black patients hospitalized for asthma exacerbations were less likely to die when compared with white patients (0.3 vs. 0.6%; p < 0.001). However, in multivariable analyses, there were no significant race differences in hospital deaths. CONCLUSIONS: Mortality among patients hospitalized for asthma exacerbations accounts for one-third of all deaths from asthma. The higher overall risk of death from asthma in black patients compared with white patients in the United States is not explained by race differences in hospital deaths and therefore is attributable to factors preceding hospitalization.

Adolescent↗

Multi-trait polygenic scores for COPD and COPD exacerbations implicate druggable proteins.

BACKGROUNDWe constructed multi-trait polygenic risk scores (PRSs) predicting chronic obstructive pulmonary disease (COPD) and exacerbations, validated their performance in diverse cohorts, and identified PRS-related proteins for potential therapeutic targeting.METHODSPRSmix+, a multi-trait PRS framework, is used to train a composite PRS (PRSmulti) in COPDGene non-Hispanic White participants (n = 6,647). Associations of PRSmulti with COPD status (GOLD 2-4 vs. GOLD 0 or ICD) and exacerbation frequency were tested in COPDGene African American (n = 2,466), ECLIPSE (n = 1,858), Mass General Brigham Biobank (n = 15,152), and All of Us (n = 118,566). Protein prediction models were applied to GWAS summary statistics from traits contributing to PRSmulti and were validated with proteomic data in COPDGene (n = 5,173) and UK Biobank (n = 5,012).RESULTSPRSmix+ selected 7 traits for PRSmulti. In multivariable models, PRSmulti was associated with COPD status (meta-analysis random effects [RE] OR 1.58 [95% CI: 1.28-1.94]) and exacerbation frequency (meta-analysis RE &#x3b2; 0.21 [95% CI: 0.11-0.31]), with higher effect sizes observed in smoking-enriched cohorts. PRSmulti outperformed traditional single-trait PRS in all tested cohorts. Using protein prediction models, we identified 73 proteins associated with the PRSs that were also validated with measured protein levels in COPDGene and UK Biobank. Of these proteins, 25 were linked to approved or investigational drugs. Notable targets include RAGE/sRAGE, IL1RL1, and SCARF2, all implicated in COPD pathogenesis and exacerbations.CONCLUSIONSMulti-trait PRS improves prediction of COPD and exacerbation risk. Integration with proteomic data identifies druggable protein targets, offering a promising avenue for precision medicine in COPD management.TRIAL REGISTRATIONCOPDGene: ClinicalTrials.gov NCT00608764; ECLIPSE: ClinicalTrials.gov NCT00292552.

Humans↗

Strategy aimed at reduction of sputum eosinophils decreases exacerbation rate in patients with asthma.

Under Global Initiative for Asthma guidelines, the clinical control of disease activity and the adjustment of treatment in patients with asthma are based on symptoms, use of rescue medication, lung function and peak expiratory flow measurement (standard strategy). We investigated whether a strategy to reduce the number of sputum eosinophils (EOS strategy) gives better clinical control and a lower exacerbation rate compared with the standard strategy. Fifty-five patients with moderate to severe asthma entered this open, randomized, parallel-group study and visited the out-patient department every 3 months for 18 months. The dose of corticosteroids was adjusted according to the standard strategy or the percentage of sputum eosinophils (EOS strategy). During the study period, the EOS strategy led to a significantly lower incidence of asthma exacerbations compared with the standard strategy group (0.22 and 0.78 exacerbations per year per patient, respectively). There were significant differences between the strategies in time to first exacerbation.

Adrenal Cortex Hormones↗

Plasma TARC concentration may be a useful marker for asthmatic exacerbation in children.

Recent studies suggested the T-helper cells type-2 lymphocytes-specific thymus and activation-regulated chemokine (TARC) and monocyte-derived chemokine (MDC) are useful inflammatory markers for chronic asthma. However, their roles in assessing the severity of acute asthma are unknown. This study aims to evaluate the serial changes of plasma TARC and MDC concentrations in children with asthmatic exacerbation. All patients with acute asthma were treated with systemic corticosteroid for 5 days. The severity of asthmatic exacerbation was classified according to the Global Initiative for Asthma guidelines. Plasma TARC and MDC concentrations were measured by sandwich enzyme immunoassays. Sixteen children, with a median (interquartile range) age of 9.3 (7.2-10.6) yrs and asthmatic exacerbation, were recruited. Plasma TARC concentration showed inverse correlation with peak expiratory flow rate at presentation. The median plasma TARC concentration was highest during the acute attacks (46 pg x mL(-1)) as compared to those levels at 1 (31 pg x mL(-1)) and 5 weeks (32 pg x mL(-1)) following treatment. The median plasma MDC level similarly decreased from 698 pg x mL(-1) at baseline to 261 pg x mL(-1) 1 week later, but increased back to 574 pg x mL(-1) at 5 weeks. These results suggest that plasma T-helper cells type-2 lymphocytes-specific thymus and activation-regulated chemokine but not monocyte-derived chemokine concentration may be a useful inflammatory marker in assessing asthmatic exacerbation in children.

Acute Disease↗

Acute exacerbations in patients with COPD: predictors of need for mechanical ventilation.

Predictive factors in mechanically-ventilated patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) have been extensively studied but not in spontaneously breathing patients. The aim of this retrospective study was to evaluate the contribution of parameters of respiratory mechanics, clinical and nutritional status in predicting the need for mechanical ventilation (MV) in COPD patients treated with medical therapy for an acute exacerbation. Anthropometric data, Acute Physiology and Chronic Health Evaluation (APACHE) II score, bedside spirometry, breathing pattern, respiratory mechanics and blood gases were measured in 39 COPD patients upon hospital admission for exacerbation of their disease. Fourteen patients in whom MV was necessary were compared with 25 patients in whom medical therapy was enough for a good outcome. The discriminant analysis showed, with decreasing order of power, that nutritional prognostic index (NPI), APACHE II score, forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, vital capacity (VC) (% predicted) and FVC (% pred) provided a significant distinction between the two groups. The discriminant equation considering NPI, and FVC (% pred) could correctly predict the success in 76% of the patients. A multiparametric stepwise regression analysis showed that APACHE II score was significantly correlated with NPI, VC (% pred), pressure time index (PTI) and duty cycle, i.e. fraction of inspiration to duration of total breathing cycle (tl/ttot). In conclusion, underlying general conditions as assessed by malnutrition and APACHE II score were shown to be unfavourable indices of outcome for chronic obstructive pulmonary disease patients who experienced an exacerbation of their disease and were treated with medical therapy. Flow limitation data as assessed by the forced expiratory manoeuvre may provide additional information.

APACHE↗

Classification of severe asthma exacerbations: a proposal.

The intensity of asthma exacerbations may vary from mild to severe. Many studies have demonstrated that the speed at which severe asthma exacerbation (SAE) develops varies among patients. In some asthmatics, the exacerbation comes on very quickly, whereas in others there is a progressive deterioration of clinical, functional and blood gas parameters. Sudden SAE are characterised by their explosive presentation and quick recovery. This evolution contrasts with that of patients with a slow onset SAE, who often need prolonged hospitalization. Absence of secretions suctioned from the airways during mechanical ventilation has been reported in sudden SAE, whereas large amounts of viscid mucus are found in patients with the slow onset SAE. The lungs of patients who died during a sudden onset SAE often show empty airways and a predominant neutrophilic infiltration in the bronchial epithelium, in contrast to the presence of abundant eosinophils in patients who died during a slow onset SAE. Sudden onset SAE may occur as sporadic cases or in outbreaks. Sporadic cases may result from the ingestion of nonsteroidal anti-inflammatory drugs (NSAID) in patients with intolerance to these products, massive exposure to common allergens and ingestion of foods containing sulphites. Asthma outbreaks have been described in many cities. In contrast to sudden onset SAE, slow onset SAE is characterized by a progressive deterioration, accompanied by an increase in the use of bronchodilators. Lack of appropriate monitoring of function by peak expiratory flow (PEF) recording, failure of patients to recognize worsening symptoms and underusage of inhaled and oral steroid treatment have been repeatedly identified as factors which are likely to be associated with slow onset SAE. The contribution of psychosocial problems, depression, denial of asthma severity and nonadherence with the treatment should not be overlooked in patients with slow onset SAE. Classification of severe asthma exacerbations into two types (sudden onset and slow onset) could help to reveal the aetiology of the attack and may also be relevant to the management of the patient.

Administration, Inhalation↗

Cytokine expression in bronchial biopsies of cystic fibrosis patients with and without acute exacerbation.

In patients with cystic fibrosis (CF), the progression of pulmonary disease differs considerably, even in identical cystic fibrosis transmembrane conductance regulator-genotypes which could reflect an additional influence of the host's immune response. This study therefore measured cytokine expression patterns in CF patients with different clinical presentation. Expression of interleukin (IL)-8, interferon gamma (IFN-gamma), IL-4, IL-10, and transforming growth factor (TGF)beta(I) was assessed in bronchial mucosal biopsies of eight CF patients with acute exacerbation (age 6.0-14.2 yrs), eight CF patients with chronic stable disease (age 7.3-17.4 yrs), and in five normal control subjects by semiquantitative and quantitative reverse transcriptase polymerase chain reaction combined with histopathological assessment and immunohistochemical staining. All CF patients expressed IL-8. In acute exacerbation, expression of TGF-beta1 and IFN-gamma was either absent or extremely low. In contrast, all patients with stable disease strongly expressed TGF-beta1. The highest expression of TGF-beta1 and IFN-gamma was found in CF patients with mild disease and a history of infrequent exacerbations. No correlation was found between the expression of IL-4 and IL-10 and patient history. In normal control subjects, only a weak expression of TGF-beta1 was observed. These results show a remarkable correlation between cytokine pattern and the clinical course of cystic fibrosis. High expression of transforming growth factor-beta1 and interferon gamma was associated with mild disease, whereas no or very weak expression of these cytokines was typical for patients with acute disease and frequent exacerbations suggesting a contribution of the immune response to the progression of pulmonary disease in cystic fibrosis.

Biopsy↗