A Double-Blind Randomized Placebo-Controlled Phase 3 Trial of Tobramycin Inhalation Solution in Adults With Bronchiectasis With Pseudomonas aeruginosa Infection.

BACKGROUND: Few large-scale studies have demonstrated the efficacy of tobramycin nebulization in bronchiectasis. We evaluated the efficacy and safety of nebulized tobramycin inhalation solution (TIS) in adults with bronchiectasis with Pseudomonas aeruginosa infection. RESEARCH QUESTION: Can TIS effectively reduce sputum P aeruginosa density and improve the bronchiectasis-specific quality of life in patients with bronchiectasis with P aeruginosa infection? STUDY DESIGN AND METHODS: This was a phase 3, 16-week, multicenter, randomized, double-blind, placebo-controlled trial. Eligible adults with bronchiectasis were recruited from October 2018 to July 2021. On the basis of usual care, patients nebulized TIS (300 mg/5 mL twice daily) or normal saline (5 mL twice daily) via vibrating-mesh nebulizer. Treatment consisted of two cycles, each consisting of 28 days on-treatment and 28 days off-treatment. The coprimary end points included changes from baseline in P aeruginosa density and Quality-of-Life Bronchiectasis Respiratory Symptoms score on day 29. RESULTS: The modified intention-to-treat population consisted of 167 patients in the tobramycin group and 172 patients in the placebo group. Compared with placebo, TIS resulted in a significantly greater reduction in P aeruginosa density (adjusted mean difference, 1.74 log10 colony-forming units/g; 95% CI, 1.12-2.35; P < .001) and greater improvement in Quality-of-Life Bronchiectasis Respiratory Symptoms score (adjusted mean difference, 7.91; 95% CI, 5.72-10.11; P < .001) on day 29. Similar findings were observed on day 85. TIS resulted in a significant reduction in 24-h sputum volume and sputum purulence score on days 29, 57, and 85. More patients became culture negative for P aeruginosa in the tobramycin group than in the placebo group on day 29 (29.3% vs 10.6%). The incidence of adverse events and serious adverse events were comparable between the two groups. INTERPRETATION: TIS is an effective treatment option and has an acceptable safety profile in patients with bronchiectasis with P aeruginosa infection. TRIAL REGISTRATION: ClinicalTrials.gov; No. NCT03715322; URL: www. CLINICALTRIALS: gov.

Effect of CPAP therapy on C-reactive protein and cognitive impairment in patients with obstructive sleep apnea hypopnea syndrome.

PURPOSE: Obstructive sleep apnea hypopnea syndrome (OSAHS) is associated with neurocognitive impairment. We examined the role of the systemic inflammatory response, measured by high-sensitivity C-reactive protein (hsCRP) assay, and the effect of CPAP treatment on hsCRP and cognitive impairment in patients with OSAHS. METHODS: Eligible subjects (n = 178) were categorized into two groups: absent or mild OSAHS, and moderate to severe OSAHS. First, the Montreal Cognitive Assessment (MoCA) and serum hsCRP concentration were measured. Then, the moderate to severe OSAHS group was further divided into a conservative treatment subgroup (n = 68) and a CPAP subgroup (n = 68). After 6 months of treatment, MoCA scores and hsCRP concentrations were re-measured in the moderate to severe group. RESULTS: Compared with the absent or mild OSAHS group, hsCRP concentration was higher (1.00 ± 1.28 mg/L versus 2.71 ± 1.8, p < 0.001) and MoCA scores were significantly lower (27.4 ± 1.4 versus 26.3 ± 2.0, p < 0.001) in the moderate to severe group. After adjustment for age, education, body mass index, and neck circumference, hsCRP and MoCA scores correlated with parameters of overnight hypoxia. hsCRP and the proportion of time spent with blood oxygen saturation < 90 % (T90) predicted MoCA score. hsCRP and MoCA score improved, and the subdomains of the MoCA were partially improved, in the CPAP treatment subgroup. In conservatively managed patients, hsCRP concentration increased, and there was no improvement in neurocognitive dysfunction, with the memory subdomain significantly worse. CONCLUSIONS: hsCRP may play a role in neurocognitive dysfunction in OSAHS. Long-term CPAP treatment could normalize the serum hsCRP concentration and partially reverse cognitive dysfunction in OSAHS.

Clinical aspects and cytokine response in adults with seasonal influenza infection.

Cytokine responses play an important role in the pathogenesis of influenza infection. Previous studies found that cytokine expressions in patients infected with the novel A (H1N1) influenza virus (nvA (H1N1)) could reflect the severity of the disease. But the patterns of cytokine response in patients infected with seasonal influenza virus and the correlations between cytokine responses and clinical data are still unknown. Seventy-two outpatients for laboratory-confirmed seasonal influenza infection were studied: twenty-four seasonal influenza A patients and forty-eight seasonal influenza B patients. Thirty healthy volunteers were enrolled as a control group. Serum samples from influenza patients obtained on the admission day and 6 days later were measured for eight cytokines using enzyme-linked immunosorbent assay (ELISA). The clinical variables were recorded prospectively. The levels of interleukin (IL)-6, IL-33 and tumor necrosis factor (TNF)-α were significantly higher in influenza A patients than those in the control group while IL-6, IL-17A, IL-29, interferon (IFN)-γ and interferon gamma-induced protein (IP)-10 were significantly higher in influenza B patients than those in the control group. Furthermore, IL-17A, IL-29 and IP-10 were increased in seasonal influenza B patients when comparing with those in the seasonal influenza A patients. A positive correlation of IL-29 levels with fever (Spearman's rho, P-values < 0.05) and a negative correlation of IFN-γ and IP-10 levels with lymphocyte count (Spearman's rho, P-values < 0.05) were found in seasonal influenza infection. While a hyperactivated proinflammatory cytokine responses were found in seasonal influenza infection, a higher elevation of cytokines (IL-17A, IL-29 and IP-10) were found in seasonal influenza B infection versus influenza A. IL-29, IFN-γ and IP-10 were important hallmarks in seasonal influenza infection, which can help clinicians make timely treatment decision for severe patients.

[The negative enrichment by immunomagnetic beads for tumor cells from malignant pleural effusions].

OBJECTIVE: To establish a method (negative enrichment by immunomagnetic beads) for detection of tumor cells in pleural effusions and to evaluate the sensitivity and specificity of the method for clinical application. METHODS: Five, 10, 20, 50 and 100 A549 (lung adenocarcinoma) cells were labeled with DAPI and added into 20 ml pleural effusions [containing (1 - 10)×10(6)cells] from heart failure patients, followed by immunomagnetic negative enrichment method. Recovered cancer cells were enumerated using a fluorescent microscope. Tumor cells were enriched from pleural effusion samples by means of density gradient centrifugation and negative enrichment by immunomagnetic beads method, followed by identification with cytology analysis (Wright's Giemsa's staining), immunofluorescence staining (IF) and fluorescence in situ hybridization (FISH) using centromere DNA probes of chromosome 7 and 8. Cytology, IF and FISH evaluations were performed in 53 pleural effusion samples, including 36 cases of malignant disease (25 male and 11 female patients aging 40 to 78 years, mean age (63 ± 9) and 17 cases of benign disease (8 male and 9 female patients aging 25 to 81 years, mean age (53 ± 18). RESULTS: After DAPI staining and mixing with pleural effusions from heart failure patients, the cell recovery rates of A549 cells evaluated under fluorescence microscope were 75%, 78%, 82%, 85%, 88%, and the average recovery rate was 81.6%. Using negative enrichment method and density gradient centrifugation combined with cytology analysis, the positive rates of tumor cells in 36 malignant pleural effusion samples were 81% (29/36) and 61% (22/36), respectively (χ(2) = 4.00, P = 0.039). Using negative enrichment method combined with IF, the positive rate of CK18(+), DAPI(+), CD(45)(-) cells was 100%. Moreover, using negative enrichment method combined with FISH analysis, the positive rate of tumor cells was 86% (31/36), much higher than that using density gradient centrifugation combined with cytology analysis (χ(2) = 5.818, P = 0.012). In 17 cases of benign pleural effusions, using negative enrichment method combined with IF, the positive rate was 100%. But other methods didn't find cancer cells from benign pleural effusions. CONCLUSIONS: It was applicable to enrich tumor cells from pleural effusions using negative enrichment method by immunomagnetic beads. This method combined with cytology analysis or FISH significantly enhanced the sensitivity and specificity of tumor cell detection in pleural effusions. But it was difficult to distinguish cancer cells from mesothelial cells using immunofluorescence staining with CK18, DAPI and CD(45) label. More specific markers were needed to recognize tumor cells from pleural effusions.

[ γδ T lymphocyte function and the polymorphism of T cell receptor V δ chain in lungs of asthmatic patients].

OBJECTIVE: To observe the function of gamma delta T lymphocytes and the polymorphism of T cell receptor V delta chain in the lungs of asthmatic patients and explore the role of gamma delta T cells in airway inflammation. METHODS: Bronchoalveolar lavage fluid BALF was obtained from 7 asthmatic patients and 7 healthy control individuals. The percentage of gamma delta T cell in BALF was measured by flow cytometry. The gamma delta T cell in BALF was purified by magnetic labeled beads. Proliferous activity was examined by MTT assay. Cytokines secreted by gamma delta T cells in medium was assessed by enzyme-linked immunosorbent assay. Polymorphism of T cell receptor V delta chain was detected by RT-PCR and gene scan analysis. RESULTS: The proportion of gamma delta T cell in the BALF of asthmatic patients [(6.39+/-0.71)%] was significantly higher than that in control subjects [(2.62+/-0.37)%] (P<0.01). The proportion of macrophage in the BALF of asthmatic patients [(81+/-4)] was significantly lower than that in control subjects [(86+/-2)] (P<0.05). The proliferation rate of asthmatic patients [(284.2+/-43.6)%] was significantly higher than that of control subjects [(217.5+/-59.5)%] (P<0.05). Interleukin-4 secreted by gamma delta T cells of asthmatic patients [(18.9+/-3.1) pg/ml)] significantly increased when compared with the control subjects [(14.1+/-3.0) pg/ml] (P<0.05). The polymorphism of T cell receptor V delta chain was not significantly different between these two groups. CONCLUSIONS: The increase of gamma delta T cells in the lung of asthmatic patients further exacerbates Th1/Th2 disturbance and airway inflammation. Antigen recognition by gamma delta T cells is non-specific.

[Effect of IL-4 on ABCG2 expression in human lung adenocarcinoma cell lines].

AIM: To investigate the effect of IL-4 on the expression of ABCG2 in lung adencarcinoma cell lines. METHODS: The ABCG2 mRNA and protein expression was determined by semi-quantitative RT-PCR and Western blot respectively. RESULTS: The ABCG2 mRNA and protein was detectable in lung adencarcinoma cell lines A549 and SPC-A-1. But IL-4 stimulation did not significantly affect the ABCG2 mRNA and protein expression in lung adencarcinoma cell lines. CONCLUSION: IL-4 does not regulate ABCG2 expression in human lung adencarcinoma cell lines.

Effect of IFN-gamma and dexamethasone on TGF-beta1-induced human fetal lung fibroblast-myofibroblast differentiation.

AIM: To study whether Smads signaling pathway was involved in human fetal lung fibroblast-myofibroblast differentiation induced by transforming growth factor (TGF)-beta1 and the role of interferon (IFN)-gamma, dexamethasone (DEX) in the fibroblast-myofibroblast differentiation. METHODS: Alpha-smooth muscle actin (alpha-SMA), Smad2/3, and Smad7 protein were assessed by Western blot. Collagen protein was analyzed by measuring hydroxyproline. Alpha-SMA and collagen III mRNA were assessed by RT-PCR. Myofibroblasts morphology and Smad2/3 nuclear translocation were assessed by immunohistochemistry. The overexpression of Smad7, a negative mediator of Smads signaling pathway, was acquired by transfection of Smad7 vector. RESULTS: During fibroblast-myofibroblast differentiation induced by TGF-beta1, IFN-gamma 200 microg/L markedly blocked TGF-beta1-induced alpha-SMA protein expression (P<0.01), collagen protein (P<0.01) and mRNA (P<0.05) expression, and myofibroblasts morphological transformation, but DEX 10 micromol/L augmented TGF-beta1-induced alpha-SMA expression (P<0.01). For myofibroblasts, both IFN-gamma 200 microg/L and DEX 10 micromol/L did not inhibit alpha-SMA expression (P>0.05) and collagen protein (P>0.05) and mRNA expression (P>0.05) and did not change myofibroblasts morphology. Transient transfection of Smad7 vector resulted in significant inhibition of TGF-beta1-induced alpha-SMA expression (P<0.01). IFN-gamma 200 microg/L did not block TGF-beta1-stimulated Smad2/3 phosphorylation and their nuclear translocation. CONCLUSION: TGF-beta1 induced fibroblast-myofibroblast differentiation in a Smad proteins-dependent manner. IFN-gamma could block this process but it was not mediated by interrupting smad2/3 phosphorylation and their nuclear translocation and DEX played a synergism with TGF-beta1. Differentiated myofibroblasts, however, were resistant to both IFN-gamma and DEX.

[Influence of N-acetylcysteine on the cytokines and matrix metalloproteinases in chronic obstructive pulmonary disease rat models].

OBJECTIVE: To investigate the changes of interferon-gamma (IFNgamma), interleukin (IL)-4, matrix metalloproteinase (MMP)-9, MMP-12 and tissue inhibitor of matrix metalloproteinase (TIMP)-1 in smoke-induced chronic obstructive pulmonary disease (COPD) rat models and the therapeutic effect of N-acetylcysteine (NAC). METHODS: Male Wistar rats were exposed to cigarette smoke for 3.5 months. NAC was given in the last month. Lung function was measured at the end of the study. The levels of IL-4 and IFNgamma in broncho-alveolar lavage fluid (BALF) and lung tissues were determined by ELISA. The expression of MMP-9, MMP-12 and TIMP-1 mRNA in lung tissues were determined by RT-PCR. RESULTS: (1) In comparison with the control group, smoke exposed group presented a significant decrease in forced expiratory volume in 0.3 second (FEV(0.3))/forced vital capacity (FVC), dynamic lung compliance (Cdyn), mean alveolar numbers (MAN) and a significant increase in expiratory resistance (Re), pulmonary mean linear intercept (Lm) (P < 0.05). After treatment with NAC, FEV(0.3)/FVC, Re and Cdyn were improved significantly (P < 0.05). No significant changes were found in Lm and MAN (P > 0.05). (2) In the lung tissues of smoke exposed group, IL-4 level was 10.00 pg/ml, IFNgamma level was 19.37 pg/ml, and the IL-4/IFNgamma ratio was 0.49. In the lung tissues of the control group, they were 4.38 pg/ml, 54.94 pg/ml and 0.10, respectively. There were significant differences in these indexes between the smoke exposed group and the control group (P < 0.05). IL-4 level in the NAC group was 7.99 pg/ml which was similar to that in the smoke exposed group (P > 0.05). IFNgamma and IL-4/IFNgamma ratio were 43.40 pg/ml and 0.15, the former being significantly higher and the latter being significantly lower than those in the smoke exposed group (P < 0.05). (3) The expression of MMP-12 mRNA and MMP-12/TIMP-1 ratio in the smoke exposed group (0.36, 1.21) were significantly higher than those in the control group (0.24, 0.88) (P < 0.05). There was no difference in TIMP-1 (P > 0.05). The expression of MMP-12, TIMP-1 mRNA and the MMP-12/TIMP-1 ratio in NAC group were similar to those in the smoke exposed group (P > 0.05). CONCLUSIONS: (1) Cigarette smoke exposure increased IL-4 and decreased IFNgamma. This may contribute to smoke-induced changes in lung function. NAC had no effect on IL-4, but increased IFNgamma, and the IL-4/IFNgamma ratio returned to normal. This might be one of the mechanisms of NAC in improving lung function. (2) Cigarette smoke promoted MMP-12 gene expression and increased the MMP-12/TIMP-1 ratio. This may play a role in smoke-induced emphysema. NAC did not alter MMP-12/TIMP-1 ratio when given in the late phase of smoke exposure. This result could explain the emphysematous changes in the NAC group.

[Different cytokine profiles in usual interstitial pneumonia and nonspecific interstitial pneumonia].

OBJECTIVE: To study the distribution, the expression and the significance of TGF-beta(1), b-FGF, IL-8, IL-13 and IFN-gamma in different lung tissue compartments in usual interstitial pneumonia/idiopathic pulmonary fibrosis (UIP/IPF) and nonspecific interstitial pneumonia (NSIP). METHODS: Specimens were obtained by open or video-assisted thoracoscopic lung biopsy from patients with UIP (n = 5) and NSIP (n = 8). Control specimens were obtained by surgical lobectomy from patients with primary lung cancer (n = 5). The distribution of these cytokines in lung tissues was observed by semi-quantitative method using immunohistochemical staining. RESULTS: TGF-beta(1), IL-8 and b-FGF were localized in alveolar epithelial cells, alveolar macrophages, and the bronchial epithelium. Overall intensity of TGF-beta(1), IL-8 and b-FGF expression in UIP was stronger in comparison with NSIP. IL-13 was distributed in alveolar epithelial cells, alveolar macrophages and interstitial mononuclear cells. Its expression in UIP was similar to that in NSIP. IFN-gamma was expressed mainly in interstitial mononuclear cells. Its expression in NSIP was stronger than that in UIP. The ratio of IL-13 to IFN-gamma in UIP (2.18 +/- 0.76) was significantly higher than that in NSIP (0.95 +/- 0.28) or that in the control (0.91 +/- 0.16) (P < 0.05, UIP versus NSIP or control), whereas the ratio of IL-13 to IFN-gamma in NSIP was similar to that in the control. In normal lungs, only alveolar macrophages expressed these cytokines. CONCLUSION: The different expression of TGF-beta(1), IL-8 and b-FGF in UIP and NSIP and the balance of IL-13/IFN-gamma may be involved in the different pathogenesis in these two diseases.