Efficacy of pirfenidone for idiopathic pulmonary fibrosis: An Italian real life study.

BACKGROUND: In this retrospective Italian study, which involved all major national interstitial lung diseases centers, we evaluated the effect of pirfenidone on disease progression in patients with IPF. METHODS: We retrospectively studied 128 patients diagnosed with mild, moderate or severe IPF, and the decline in lung function monitored during the one-year treatment with pirfenidone was compared with the decline measured during the one-year pre-treatment period. RESULTS: At baseline (first pirfenidone prescription), the mean percentage forced vital capacity (FVC) was 75% (35-143%) of predicted, and the mean percentage diffuse lung capacity (DLCO) was 47% (17-120%) of predicted. Forty-eight patients (37.5%) had mild disease (GAP index stage I), 64 patients (50%) had moderate IPF (stage II), and 8 patients (6.3%) had severe disease (stage III). In the whole population, pirfenidone attenuated the decline in FVC (p = 0.065), but did not influence the decline in DLCO (p = 0.355) in comparison to the pre-treatment period. Stratification of patients into mild and severe disease groups based on %FVC level at baseline (>75% and ≤75%) revealed that attenuation of decline in FVC (p = 0.002) was more pronounced in second group of patients. Stratification of patients according to GAP index at baseline (stage I vs. II/III) also revealed that attenuation of decline in lung function was more pronounced in patients with more severe disease. CONCLUSIONS: In this national experience, pirfenidone reduced the rate of annual FVC decline (p = 0.065). Since pirfenidone provided significant treatment benefit for patients with moderate-severe disease, our results suggest that the drug may also be effective in patients with more advanced disease.

Performance of two commercial blood IFN-gamma release assays for the detection of Mycobacterium tuberculosis infection in patient candidates for anti-TNF-alpha treatment.

The reactivation of latent tuberculosis (TB) is a major complication of tumor necrosis factor (TNF)-alpha inhibitors. Screening for TB infection is recommended before anti-TNF therapy is initiated; however, the use of tuberculin skin testing (TST) is controversial, due to the high rate of false-negative results in patients receiving immunosuppressive treatment. To compare the performance of two commercial interferon (IFN)-gamma release assays (IGRA), T-SPOT.TB (TS-TB) and QuantiFERON-TB Gold "In-tube" (QFT-GIT), with TST for the detection of TB infection in patients due to start anti-TNF therapy, 69 human immunodeficiency virus (HIV)-negative Italian patients (mean age: 45.2 +/- 12.6 years; male=39) were enrolled between September 2005 to August 2006. Patients affected by rheumatoid arthritis (n = 18), psoriatic arthritis (n = 26), ulcerous rectocolitis (n = 6), and Crohn's disease (n = 19) were tested simultaneously with TST, TS-TB, and QFT-GIT. Overall, 26% of patients were positive by TST, 30.4% by TS-TB, and 31.8% by QFT-GIT. Agreement with TST was similar (kappa = 0.21, p = 0.0002 and kappa = 0.26, p < 0.001, respectively). In 11 TST-negative cases, IFN-gamma release assays were positive. In addition, in seven Mantoux-positive cases with no TB risk factors, TST result agreement was achieved with at least one blood test. Indeterminate results were detected in 5.8% and 2.8% of cases, respectively, with TS-TB and with QFT-GIT (p = not significant [ns]). In conclusion, our results suggest that IGRAs may be helpful for screening purposes in patient candidates for anti-TNF therapy to confirm positive TST results and in selected cases when false-negative results are suspected. The utility of blood tests in patients with low or no TB risk remains to be assessed.

Interleukin-6 receptor superantagonist Sant7 inhibits TGF-beta-induced proliferation of human lung fibroblasts.

OBJECTIVES: Both interleukin-6 (IL-6) and transforming growth factor-beta (TGF-beta) are crucially involved in fibrotic events that characterize interstitial lung diseases (ILD). Therefore, the aim of this study was to investigate in primary cultures of normal and fibrotic human lung fibroblasts (HLF), exposed to either IL-6 or TGF-beta1, the effects on phosphorylation of mitogen-activated protein kinases (MAPK) and cell growth of IL-6 signalling inhibition, performed by the IL-6 receptor superantagonist Sant7. MATERIALS AND METHODS: MAPK phosphorylation was detected by Western blotting, HLF viability and proliferation were evaluated using the trypan blue staining and the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, respectively. RESULTS: Sant7, at a concentration of 1 microg/mL, was capable of significantly inhibiting HLF proliferation and MAPK phosphorylation induced by cell exposure to IL-6 (100 ng/mL) or TGF-beta1 (10 ng/mL), whose actions were more evident in fibrotic cells. CONCLUSIONS: These findings suggest that, in HLFs derived from patients with ILDs, the proliferative mechanisms activated by TGF-beta1 are at least in part mediated by an increased release of IL-6, leading to phosphorylation-dependent MAPK activation. Such preliminary findings may thus open new therapeutic perspectives for fibrogenic ILDs, based on inhibition of signal transduction pathways stimulated by the IL-6 receptor.

Role of mycobacteria-induced monocyte/macrophage apoptosis in the pathogenesis of human tuberculosis.

Apoptosis is a physiological programmed cell death process whose dysregulation plays an important role in different human infectious diseases. An increasing number of intracellular pathogens are known to induce target cell apoptosis, while some other parasites inhibit it. Unlike necrosis, apoptosis is a silent immunological event occurring without inflammation. Infection-induced target cell apoptosis may be a successful strategy to eliminate pathogens and assure host survival. Conversely, apoptosis inhibition could represent an adaptive mechanism for pathogen survival, while it may be beneficial for the host to initiate an effective immune response. The worldwide increase in tuberculosis has stimulated more research aimed at defining the interaction between Mycobacterium tuberculosis and the immune system. M. tuberculosis possesses sophisticated strategies to circumvent its fate within target monocytic cells. Apoptosis of alveolar macrophages and monocytes has been described as a consequence of M. tuberculosis infection. Moreover, the observation that mycobacterial lipoproteins activate macrophages through Toll-like receptor (TLR) 2 suggests that innate immune receptors contribute to defence against M. tuberculosis. There is evidence that TLR-induced apoptosis modulates inflammation and immune activation during M. tuberculosis infection. Finally, the role of apoptotic-infected cells as a source of microbial antigens for cross-priming of effector T-cells is also discussed.

Carcinoembryonic antigen mRNA analysis detects micrometastatic cells in blood from lung cancer patients.

The current authors previously identified circulating cells expressing carcinoembryonic antigen (CEA) messenger ribonucleic acid (mRNA) in 80% of lung cancer patients bearing distant metastases. The current study prospectively validated the data on a novel cohort and extended the study to other mRNAs expressed by neoplastic cells. CEA, cytokeratin 19 and 20, aldolase A and epithelial glycoprotein 2 (EPG2) mRNA was analysed by reverse transcriptase-polymerase chain reaction in circulating cells from 19 healthy controls, and in biopsies and blood at diagnosis from 32 lung cancer patients monitored for 24 months. Aldolase A and cytokeratin 19 mRNA occurred in circulating cells of all controls; cytokeratin 20 was not expressed by any lung cancer biopsy. EPG2 mRNA occurred in all biopsies but not in the patients' circulating cells. CEA mRNA occurred in 29/32 (90.6%) biopsies and in 17/32 mRNA samples from circulating cells from lung cancer patients. Of these positive patients 12/17 developed metastases within 9 months of mRNA analysis. Three positive patients died, one was lost to follow-up, and one did not develop metastases within 24 months. Of the negative patients 12/15 did not develop metastases during the 24-month follow-up; one patient was lost to follow-up, one did not express CEA, and another developed metastases. Unlike in other neoplasias, cytokeratin 19 and 20, aldolase A and epithelial glycoprotein 2 messenger ribonucleic acid are not useful for the detection of circulating cancer cells in lung cancer. Carcinoembryonic antigen messenger ribonucleic acid analysis in circulating cells helps to identify lung cancer patients at a greater risk of metastases.

Monocytes/macrophages in HIV infection and tuberculosis.

Mycobacterium tuberculosis (MTB) and human immunodeficiency virus type 1 (HIV-1) are virulent intracellular pathogens that enter and replicate within macrophages, which represent their reservoire. Public health problems are greatly compounded when the two diseases co-exist, and this is the reason why Acquired Immunodeficiency Syndrome (AIDS) and tuberculosis (TB) have been termed "the cursed duet", given the synergistic effect they exert one each other. With the depression of immunity caused by HIV-1 infection, latent MTB infection is much more likely to progress to clinically significant disease. On the other hand, TB results in activation of T cells and macrophages that may harbor latent HIV. Here some data are reviewed that can contribute to clarify the mechanisms involved in the concurrent infection, given that MTB infection has been shown to be able to: a) enhance HIV-1 replication in macrophages, b) augment CC-CKR5 (CCR5) expression on macrophage membrane, and, c) induce apoptosis in a portion of infected macrophages.

Human macrophage gamma interferon decreases gene expression but not replication of Mycobacterium tuberculosis: analysis of the host-pathogen reciprocal influence on transcription in a comparison of strains H37Rv and CMT97.

Mycobacterium tuberculosis is an intracellular pathogen that readily survives and replicates in human macrophages (MPhi). Host cells have developed different mycobactericidal mechanisms, including the production of inflammatory cytokines. The aim of this study was to compare the MPhi response, in terms of cytokine gene expression, to infection with the M. tuberculosis laboratory strain H37Rv and the clinical M. tuberculosis isolate CMT97. Both strains induce the production of interleukin-12 (IL-12) and IL-16 at comparable levels. However, the clinical isolate induces a significantly higher and more prolonged MPhi activation, as shown by reverse transcription-PCR analysis of IL-1beta, IL-6, IL-10, transforming growth factor beta, tumor necrosis factor alpha, and gamma interferon (IFN-gamma) transcripts. Interestingly, when IFN-gamma transcription is high, the number of M. tuberculosis genes expressed decreases and vice versa, whereas no mycobactericidal effect was observed in terms of bacterial growth. Expression of 11 genes was also studied in the two M. tuberculosis strains by infecting resting or activated MPhi and compared to bacterial intracellular survival. In both cases, a peculiar inverse correlation between expression of these genes and multiplication was observed. The number and type of genes expressed by the two strains differed significantly.

Tuberculosis and lung cancer. An interesting case study.

This report describes the case of a patient with lung cancer who completely recovered when he was suffering from tuberculosis. Since bacillus Calmette-Guerin (BCG) has beneficial effects in certain types of cancer, it was hypothesized that infection with Mycobacterium tuberculosis induced an effective response against the tumour. M. tuberculosis-infected blood T-lymphocytes of the patient were cultured with two lung tumour cell lines. T-lymphocytes in vitro remained attached to tumour cells that appeared reduced in number. Moreover, M. tuberculosis isolated from the patient was a strong inducer, in infected macrophages, of the expression of the inducible form of the nitric oxide synthase, that may regulate cytotoxic activity of human macrophages.

P53 immunohistochemistry can identify bronchial dysplastic lesions proceeding to lung cancer: a prospective study.

Dysplasia is an important step in bronchial carcinogenesis and smokers present more dysplastic lesions than nonsmokers. These lesions not always lead to malignancy, so there is a need for additional, preferentially objective, diagnostic markers. To verify whether immunohistochemical overexpression of p53 protein in dysplastic areas could be a predictive marker of the development of lung cancer, we investigated p53 overexpression in 22 bronchial dysplastic lesions obtained by fibrebronchoscopy from heavy smokers who were not diagnosed as having lung cancer and were followed for a 4-yr period. Nine (41%) lesions showed p53-positivity. Seven lung cancers (78%), mostly squamous cell carcinomas, were detected within the follow-up in these patients and 3 in 13 (23%) patients with p53-negative lesions. Lung cancer occurred in all seven patients with dysplastic lesions showing >10% p53 positive nuclei. The positive predictive value of p53 immunostaining for lung cancer was 78%. The negative predictive value of p53 was 77%. p53 staining was not detected in squamous metaplasia lesions without atypia and in normal bronchial epithelium. Our findings provide evidence that p53-overexpression in bronchial dysplastic areas may be a clinically useful marker for identifying patients proceeding to, at least, squamous cell carcinoma and, in addition, may facilitate the detection of occult tumours.

Mycobacterium tuberculosis and HIV co-infection in the lung: synergic immune dysregulation leading to disease progression.

There is evidence that Mycobacterium tuberculosis (Mtb) impacts on human immunodeficiency virus (HIV) infection and that HIV promotes mycobacterial diseases. Epidemiological and clinical studies demonstrate the detrimental effect of tuberculosis (TB) on the progression of HIV infection, that is an increased risk of death among Mtb-HIV co-infected patients. Pulmonary TB may occur very early during HIV infection, whereas extrapulmonary or atypical manifestations are associated with more profound immunodeficiency, showing features like mycobacteraemia and multi-drug resistance, much more severe than in immunocompetent hosts. During the last decade, many efforts have been focused on the immunological aspects of Mtb-HIV co-infection. The host protective response to TB is mediated by cell immunity, which, mainly supported by interleukin (IL)-12 and interferon (IFN)-gamma production, leads to granuloma formation. Perturbations in the cytokine expression, that is a reduced type-1-like response, have been suggested in HIV-infected patients to contribute to their susceptibility to TB. Indeed, an impaired balance between pro-inflammatory and anti-inflammatory cytokines and apoptosis-induced depletion of immune effector cells account for the dissemination of both the pathogens and for a poor granulomatous reaction in Mtb-HIV co-infected patients. However, the recently elucidated role of chemokines and their receptors in immune regulation opens new questions on the pathogenesis of Mtb-HIV co-infection.

Lung cancer metastatic cells detected in blood by reverse transcriptase-polymerase chain reaction and dot-blot analysis.

PURPOSE: We analyzed the blood of patients with lung cancer at different stages of presentation for the presence of carcinoembryonic antigen (CEA) mRNA detected by reverse transcriptase-polymerase chain reaction (RT-PCR) combined with the dot-blot procedure as an indicator of micrometastatic malignant cells. PATIENTS AND METHODS: We studied 24 lung cancer patients (10 with distant metastases and 14 with no evidence of distant metastases), eight age- and sex-matched patients affected by nonneoplastic respiratory diseases (four smokers), and eight healthy subjects. We used immunohistochemistry and RT-PCR dot-blot analysis to evaluate CEA expression in the neoplastic tissue, and the RT-PCR dot-blot procedure to analyze CEA mRNA in circulating cells. RESULTS: The RT-PCR dot-blot procedure was highly sensitive aspecific: it detected CEA mRNA in samples of RNA from lung cancer diluted 10(6)-fold with RNA extracted from normal blood cells, and sequence analysis confirmed that the amplified product was CEA. CEA mRNA was found in circulating cells from eight of 10 lung cancer patients with distant metastases (diagnostic sensitivity, 80%) and in four of 14 patients with no evidence of distant metastases. Two of the latter had distant metastases within 6 months of analysis. Thus, the diagnostic specificity of the analysis toward lung cancer without distant metastases was 86%. The analysis was negative in the eight nonneoplastic patients and in the eight healthy controls. CONCLUSION: The RT-PCR dot-blot analysis of CEA mRNA in blood cells seems to be a promising tool for the early detection of micrometastatic circulating cells in patients with lung cancer.

Apoptosis of human monocytes/macrophages in Mycobacterium tuberculosis infection.

Tuberculosis (TB) is still a major health problem, both as a single disease entity and as a cofactor in AIDS. The interaction between macrophage and Mycobacterium tuberculosis (MTB) is a critical step in the establishment of an early chronic infection. This study analyses the capacity of MTB to induce apoptosis in cells obtained by broncho-alveolar lavage (BAL) from patients with reactive pulmonary tuberculosis and from AIDS patients with disseminated pulmonary tuberculosis. Apoptosis was increased three-fold in BAL cells obtained from patients with pulmonary tuberculosis and even more markedly in alveolar macrophages of MTB-infected AIDS patients, compared with controls. Apoptosis was analysed and characterized by propidium iodide (PI) incorporation, terminal deoxy transferase (TDT)-mediated dUTP-biotin nick end labelling (TUNEL), and tissue transglutaminase (tTG) expression. The MTB-macrophage interaction was also investigated in vitro by infecting monocyte-derived macrophages (MDM) with MTB (virulent strain H37Rv). The induction of apoptosis by MTB required viable bacteria, was dose-dependent, and was restricted to H37Rv. Infection with either Mycobacterium avium complex (MAC) or HIV-1 and treatment with heat-killed MTB failed to induce apoptosis.

Epidemiology of lower respiratory tract infections.

The aim of this review is to focus on the epidemiology of lower respiratory tract infections, the etiology, prognosis and risk factors, dividing these problems into the following issues: global impact of these afflictions, community-acquired pneumonia, hospital acquired pneumonia, respiratory infections in surgery, acute bronchitis and exacerbations of chronic bronchitis. Every year about 5 million people die of acute respiratory infections. Among these, pneumonia represents the most frequent cause of mortality, hospitalization and medical consultation. Several factors (age, underlying disease, environment) influence mortality, morbidity and also microbial etiology. The authors also refer to recent data on the most frequently identified antibiotic resistance of respiratory pathogens. The knowledge of such different clinico-epidemiological situations is essential to physicians for an effective approach to treatment of pneumonia and bronchitis.

[The role of bronchoalveolar lavage (BAL) in assessing pulmonary compromise in AIDS]. / Ruolo del lavaggio bronco-alveolare (BAL) nella valutazione della compromissione polmonare in corso di AIDS.

The severe immunologic alterations caused by HIV infection is at the base of respiratory tract infections, neoplasms and inflammatory complications which represent the most frequent cause of death in AIDS patients. The etiological diagnosis is difficult and often needs invasive procedures. Among those, BAL is surely the most useful method because of its lesser invasiveness and better tolerability and more for its sensibility and easier repeatability. Besides the etiological evaluation of lung infections, BAL allows to obtain and analyze immunologic and inflammatory cells from alveolar spaces consenting the acquisition of data regarding immunopathogenetic mechanisms related to pulmonary complications during AIDS. We report data about cytoimmunologic study of BAL fluid in 10 patients of ours.

Human basophil/mast cell releasability. V. Functional comparisons of cells obtained from peripheral blood, lung parenchyma, and bronchoalveolar lavage in asthmatics.

Releasability of human basophils and mast cells is an important parameter in allergic disorders. We compared IgE- and non-IgE-mediated releasability of human peripheral blood basophils with that of mast cells obtained from lung parenchyma (isolated by mechanical or enzymatic dissociation) and from bronchoalveolar lavage of normal and asthmatic donors. In a first study, the response to anti-IgE, Staph A, Con A, f-met peptide, and Ca2+ ionophore A23187 of basophils obtained from 52 donors was compared with that of mast cells isolated enzymatically (PMCE) or mechanically (PMCM) from lung parenchyma obtained during surgery. The histamine content of basophils (1.1 +/- 0.1 pg/cell) was significantly lower than that of PMCE (4.1 +/- 0.3 pg/cell; p less than 0.001) and PMCM (3.7 +/- 0.3; p less than 0.001). The maximal percent anti-IgE-induced histamine secretion in basophils (41.3 +/- 3.6) was higher than in PMCE (17.5 +/- 1.8) and in PMCM (13.8 +/- 1.5). Similarly, the response to Staph A and Con A was higher in basophils (29 +/- 3.9 and 31.6 +/- 4.9, respectively) than in PMCE (3.5 +/- 0.6 and 3.3 +/- 0.8, respectively) and PMCM (5.1 +/- 1.3 and 8.8 +/- 2.2, respectively). A positive correlation between the maximal percent of histamine release induced by anti-IgE and Staph A was found in basophils (rs = 0.61; p less than 0.001), whereas there was a negative correlation between the reactivity of PMCE (rs = 0.67; p less than 0.001) and PMCM (rs = -0.40; p less than 0.001) to anti-IgE and their reactivity to Staph A.(ABSTRACT TRUNCATED AT 250 WORDS)