key: cord-0010256-teikw3km
authors: nan
title: TSANZ Oral Presentations
date: 2017-03-15
journal: Respirology
DOI: 10.1111/resp.13009
sha: a9e8f50f8f2d2f9d02821c17c3fc7e53c750941e
doc_id: 10256
cord_uid: teikw3km

nan

WILSON PETRUSHNKO MBBS 1 Two hundred and ninety-three PleurX catheters were inserted. The indication was MPE in 176 and MA in 111. Bilateral pleural PleurX were inserted in 17 patients. Pleural and peritoneal catheters were inserted simultaneously in 3 patients.

A technical success rate of 100% was achieved. Drains remained in situ for a mean of 64.0 days (range 2-392 days). Almost all (87%) of patients died with the PleurX catheter insitu. Pleurodesis was achieved in 6.1% (n=18) of patients and PleurX was removed without fluid accumulation. The remaining patients 6.9% remain alive with the PleurX insitu.

PleurX were inserted in patients MPE and MA due to NSCLC 20.5%

(n=60), breast 19.8% (n=58), gastric/esophageal 7.8%(n=23), pancreatic 7.5% (n=22), ovarian 7.5% (n=22), colorectal 6.1% (n=18), adenocarcinoma of unknown origin 4.1% (n=12), mesothelioma 3.8% (n=11), hepatocellular carcinoma 2.7% (n=8), SCLC 1.7% (n=5), melanoma 1.7% (n=5), bladder 1.7% (n=5), cholangiocarcinoma 1.4% (n=4), renal cell carcinoma 1% (n=3), angiosarcoma 0.7% (n=2), endometrial 0.7% (n=2), and alcoholic cirrhosis 1.4% (n=4), others/unknown 9.9% (n=29). Complications from drain insertion included; wound infection 2.4% (n=7), blocked catheter 1.7% (n=5), fell out/cuff exposed 1.7% (n=5), leakage from drain site 0.7% (n=2), bowel injury 0.3 % (n= 1)

The cost per patient on average for the entire duration of pleural and peritoneal PleurX was $1759 and $984 respectively (ongoing hardware cost and insertion cost). The average number of pleural drainage bottles and peritoneal drainage bags per patient was twenty-nine and twenty-two respectively.

This study demonstrates the safe use of tunnelled PleurX catheters in patients who present with MPE or MA. Once inserted, subsequent drainage of re-accumulated effusion or ascites can be managed in the comfort of the patients home. We believe the use of a PleurX catheter should be considered as a first line approach in the management of refractory MPE and MA. Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand, 2 Northern Regional Alliance, Auckland, New Zealand, 3 Oncology Services, Auckland City Hospital, Auckland, New Zealand Introduction: A new pathway for the 4 district health boards in the greater Auckland region was developed incorporating rapid access clinics (RACs) and upfront PET-CT scans for those considered potentially curable at initial assessment, in order to enable quicker lung cancer diagnosis.

Methods: In this 12-week pilot, patients graded as high suspicion of lung cancer were seen in RACs with spirometry, performance status assessment and available radiology (chest x-ray or CT scan). Those considered potentially curable by surgery or radiotherapy (FEV1 >=1 litre, ECOG score <2, no advanced disease evident on imaging, no comorbidities precluding radical treatment) received an upfront PET-CT scan; those who were not received a standard CT scan if not already done. Time through the pathway was measured and compared with historical data from the regional lung cancer database in a 6-month period the year before the pilot.

Results: 165 patients completed the pathway, of which 105 were found to have lung cancer. 41 patients had upfront PET-CT scans; 30 were confirmed as lung cancer, 7 of which subsequently had palliative treatment. 11 had non-lung cancer diagnoses (9 not cancer or nodule follow up; 1 metastasis; 1 other cancer). 17 patients had PET-CT scans later in the pathway, 4 of which subsequently had curative treatment. Median time from referral to first treatment was reduced by 16.7 days (patients with curative treatment intent 17.2 days and palliative treatment intent lar consequences, including pulmonary hypertension (PH). We aimed to compare plasma markers of oxidative stress [protein carbonyl (PC) and thiol concentrations] in two ILD cohorts who were exposed to the intervention of oxygen versus medical air. Methods: Two previously described ILD patient cohorts with either significant sleep-related hypoxia (>10% of sleep time with SpO 2 <90%), or exercise-induced desaturation (SpO 2 <88% during 6-minute walk test, 6MWT) participated in randomised, double-blinded, sham-controlled, cross-over studies. Paired plasma samples were taken following both supplemental oxygen and medical air usage during either sleep or incremental cardiopulmonary exercise testing. A sensitive enzyme-linked immunosorbent assay (ELISA) was used for pro-oxidant PC detection, and anti-oxidant thiols were quantified using the DTNB assay with the 96well plate method. life expectancy than the general population. A significant proportion of this excess mortality is due to a higher prevalence of cardiac and metabolic disease. Less is known of the prevalence of respiratory disease in this group. This cross sectional, observational study aimed to assess the prevalence of respiratory disease and symptoms in patients admitted to an inpatient mental health unit.

Methods: 82 inpatients had a structured interview and questionnaire completed. The questionnaire included self-reported diagnoses of common diseases and screening questions designed to detect respiratory disease and sleep disordered breathing. Spirometry was performed on the basis of symptoms and smoking status. Access to primary care was assessed including surrogate markers for comprehensive care such as vaccination status.

Results: Patients reported high rates of respiratory symptoms including wheeze, dyspnoea and cough. Productive cough was significantly associated with tobacco use (p<0.005). 52% of patients reported daily tobacco use and 13% used cannabis at least monthly. Ten patients (17%) had spirometry consistent with COPD of whom 6 did not have a formal diagnosis of COPD previously. Symptoms suggestive of sleep disordered breathing were common with 9 patients (11%) reporting witnessed apnoeic episodes while sleeping. Vaccination rates were low for both pneumococcal and influenza vaccine.

People with SMI have high rates of respiratory symptoms with a high prevalence of COPD on spirometry. Half of the COPD cases were not previously diagnosed suggesting a hidden burden of respiratory disease in patients with SMI. Introduction/Aim: Evidence suggests more than 75% of asthma patients fail to use their inhalers correctly resulting in frequent exacerbations. Sub-optimal education for health professionals and subsequently their patients, may be a contributing factor. Innovative technology ('augmented reality'), accessed via smartphone applications, can function as an educational tool to address these issues. Therefore the aim of this study is to obtain health professional, asthma patient and key community stakeholder perspectives on the feasibility of augmented reality technology to improve asthma inhaler technique education.

Methods: A patient information poster displaying images of the 22 asthma inhaler devices was produced based on existing evidence based recommendations and resources. Augmented reality technology was then utilised to provide a video demonstration of correct inhaler technique for each device, made accessible via a free smartphone application. Twenty-one semi-structured, one-on-one interviews with health professionals, asthma patients and key community stakeholders were conducted between August and September 2016. Data was analysed thematically using the Triandis model of interpersonal behaviour.

Interviews with asthma patients highlighted perceived competence with inhaler technique. However, health professionals and key community stakeholders identified that this perception was misguided and that poor inhaler technique is a facilitating condition for incorrect inhaler use and sub-optimal disease management.

Delivering inhaler technique education using augmented reality was favoured by all participants, particularly around ease of use with the ability to visually display various inhaler techniques for each device. However, all participants identified some barriers, particulalry for use among the elderly.

Augmented reality may be a novel means to address poor inhaler technique among certain cohorts of asthma patients and serve as a prompt for health professionals to initiate review of inhaler devices. A randomised controlled trial design is needed to evaluate efficacy of this technology for use in the clinical care setting. Introduction/Aim: People with severe refractory asthma (SRA) likely face a sizeable burden, beyond that of people with milder disease. We aimed to explore the little-known experiences of people living with SRA.

Methods: Participants identified as SRA via the Australasian Severe Asthma Network and/or specialist asthma clinics across seven Australian states were invited for telephone interview. Semi-structured interviews were conducted consecutively until no new themes emerged. Interviews were recorded, transcribed and thematically analysed.

Results: Most of the 25 participants (aged 23-81 yrs; 68% female) experienced daily symptoms. Key themes were: 'The body as a hindrance': SRA placed wide-ranging limits on life from daily chores to career, relationships and family life; 'Alone with asthma': Interviewees felt alone in understanding the experience of asthma; they suffered emotional distress including frustration, hopelessness and/or depression, but formal emotional support services were lacking; 'Striving to adapt': Participants expressed varying degrees of adjustment to their diagnosis, from denial to full acceptance; 'Concerns and experience with treatments': Most interviewees accepted the need for medicines but were concerned about oral corticosteroid side-effects and disliked reliance on treatment, which they felt took over their life; 'Day-to-day medical care': Participants reported need for more accessible, knowledgeable GPs, and better communication with GPs/specialists; 'Acute care': Exacerbations were frightening for participants/family yet they avoided emergency department presentation to avoid the disruption that hospitalisations placed on daily lives; 'Support needs': practical and emotional support varied from none at all to provision by willing/fatigued family. Participants felt compelled to 'push through' due to parenting/financial responsibility.

Conclusion: SRA imposes long-term, debilitating burdens and should be considered differently to milder asthma. There is an urgent need to improve support services and primary care for SRA patients, and assistance for their families.

Introduction/Aim: Approximately one in five patients attending general practice is a daily smoker. Information on previous quitting experiences and smoking cessation preferences of smokers attending general practice is necessary to inform effective interventions.

Methods: Current/ex-smokers (aged≥40 years, ≥10 pack years) were recruited from general practices across Melbourne for the RADICALS © studya cluster randomised controlled trial of an interdisciplinary model of care to reduce the burden of smoking and lung disease in Australian primary care. Patients completed an exhaled carbon monoxide (CO) test to confirm smoking status and a structured questionnaire during a face-toface interview.

Results: Of the 653 participants identified across 38 general practice clinics in Melbourne, 456 (70%) were current smokers; 425 (93%) of whom were daily smokers. The median exhaled CO reading was 22ppm (IQR 14-29). On a scale of 1 (low) to 10 (high), the self-reported motivation (median 6; IQR 4-8), and confidence to quit (median 5; IQR 3-7) were modest among current smokers. Of the current smokers, 237 (52%) had attempted quitting in the previous 12 months; 156 (66%) of whom reported two or more attempts in the past year. The most common pharmacological treatments used were nicotine replacement therapy (128, 54%) and varenicline (72, 30%). The most popular nonpharmacological treatment was hypnotherapy (40, 17%). Approximately 40% of smokers would use medications to aid future quit attempts. Ecigarettes have been used by 21 (9%) current smokers with at least one quit attempt in the previous year, and would be considered to help future quit attempts by 132 (29%) current smokers. smoking among Indigenous people may potentially be reduced by appropriate interventions that target prevention of tobacco smoke uptake and improved asthma management. We undertook a pilot study in two Darwin schools with a high proportion of Indigenous youth to determine the feasibility of an innovative, peer-led, school-based education program called the Asthma and Smoking Prevention Project (ASPP). A subset of children with reported persistent respiratory symptoms were also clinically evaluated to determine the lower airway inflammatory profile and optimise asthma management.

The ASPP is founded on an evidence-based program to improve asthma management and prevent the uptake of tobacco smoking. The program uses a student-centred approach in which senior students (Peer Leaders) deliver the ASPP to Grade 7 students using activities, videos and games. Students completed questionnaires related to asthma and smoking at baseline and 3-months after program delivery. Students with respiratory symptoms at 3-months were invited for a comprehensive clinical evaluation and tests including sputum induction.

The ASPP was well received. Of the 203 students involved, 56 (28%) were Indigenous and 70% completed baseline and follow-up questionnaires. Self-reported asthma was high (19%), 10% of students reported smoking and 63% reported exposure to tobacco at home. Of the 22 students who were clinically evaluated, 41% were Indigenous. Clinically important airway inflammation was high; 23% had Fractional Exhaled Nitric Oxide levels ≥35ppb, 88% had airway neutrophilia (>15%) and 29% had airway eosinophilia (>2.5%). Optimisation of medication and management was required in 59% of students.

Our study demonstrates the feasibility of implementing a school-based prevention and intervention program for at-risk groups.

The high prevalence of clinically important airway inflammation and suboptimal asthma management highlights the need for a community-based study on persistent respiratory symptoms in adolescents to reduce the burden of chronic lung disease particularly for Indigenous Australians.

Asthma and Allergy 2 TO Introduction/Aim: Rhinovirus is the most common trigger of acute exacerbations of allergic asthma. The airway epithelium is the target of rhinovirus infection, and is an important source of pro-inflammatory and anti-viral mediators. Airway epithelial cells (AECs) from patients with allergic asthma exhibit a pro-inflammatory phenotype. We aimed to characterise how the Th2 cytokine environment in allergic asthma alters the response of AECs to rhinovirus and to investigate the signalling pathways involved.

Methods: Cells of the well-differentiated human airway epithelial line, Calu-3, were cultured with or without the Th2 cytokines IL-4 and IL-13 for 48 hours, then stimulated with Poly I:C (TLR3 agonist) or imiquimod (TLR7 agonist), or infected with rhinovirus16. Quantitative real-time PCR and nCounter assays were used to characterise changes in expression of mRNA for pro-inflammatory and anti-viral mediators as well as viral pattern-recognition molecules.

In the allergic cytokine environment, enhanced expression of mRNA for the pro-inflammatory cytokines IL6 and IL8 was induced by

Poly I:C and imiquimod, while expression of anti-viral response genes IFIT1, STAT1, IRF7 and IFIH1 was induced only by Poly I:C. Following rhinovirus infection, Calu-3 cells pre-treated with Th2 cytokines exhibited significantly higher expression of IL6, IL8, CXCL10, CCL5, IL32 and CFB.

Expression of IFNB1 and IFNL2/3 was either unchanged or modestly increased in cells pre-treated with Th2 cytokines. These alterations were accompanied by increased expression of the pattern recognition receptor genes TLR3, IFIH1, DDX58, and also of ICAM1, the cell surface receptor for rhinovirus.

Th2 cytokines appear to promote increased production of pro-inflammatory mediators following rhinovirus infection. Furthermore, any impairment of anti-viral host defence observed in allergic asthmatics is unlikely to be due to the effects of Th2 cytokines. Increased viral entry, together with enhanced signalling via TLR-3, MDA-5, and RIG-I, may gestation period = 21 days). Following hypoxic exposure, mice were returned to a normoxic environment (21% O 2 ). A second group of pregnant mice were housed under normoxic conditions throughout pregnancy (Control group). Weights of offspring were recorded until 2 weeks of age at which point responsiveness to methacholine and thoracic gas volume (TGV) were assessed.

The IUGR offspring were lighter at birth compared with Control offspring, but not at 2 weeks of age. There were no differences in snout-vent length or abdominal circumference between groups at 2 weeks of age. At 2 weeks, airway resistance after methacholine challenge was greater in male IUGR offspring compared with Controls, but not in female IUGR offspring compared with Controls. In contrast, while there was no difference in peripheral lung mechanics between male IUGR offspring and Controls, IUGR female offspring had increased tissue damping and elastance after methacholine challenge, compared with Controls. There was no difference in TGV between groups.

Maternal hypoxia induced IUGR offspring were smaller at birth but exhibited 'catch up' growth by 2 weeks of age. The physiological consequences of IUGR in the juvenile period were sex dependent: airway hyperresponsiveness in male offspring, and impaired peripheral mechanics in female offspring. Sexual dimorphism in the response to IUGR may contribute to differences in the prevalence of asthma between males and females in early childhood. 

Female > male** Inverse* Inverse** ns Positive**

Male > female** ns ns Positive* Inverse**

Male > female** ns ns ns Positive*

Cytokine production was independently associated with several variables particularly sex and pDC numbers. TNF production (but not IFNα) was linked to self-reported cold frequency. Future experiments will examine TLR7 and TLR8 genetic variants, as we predict these two X chromosome genes modify cytokine production and virus susceptibility.

Grant Support: NHMRC, Asthma Foundation of Qld, Astra Zeneca measured using a dichotomous variable or the log transformed dose response slope (logDRS), both of which lead to loss of information. Furthermore, regression of the logDRS does not consider the initial FEV 1 and the resulting estimates are difficult to interpret. In contrast, linear mixed models (LMM), a standard biostatistical tool that appears to have never been used for BHR, overcome these limitations, using all the data collected and producing more intuitive estimates. We aimed to test the utility of modelling BHR using a LMM on associations with known risk factors. Regression of the logDRS was used as a comparison. 

We demonstrate that mechanical forces similar to those induced during bronchoconstriction in vivo induce production of TGFβ 2 and impair innate anti-viral immunity in primary human airway epithelial cells. This is the first time that mechanical forces have been shown to impact on innate immunity and the data have direct relevance to human disease. Introduction/Aim: The epithelium of asthmatics is differentially dysregulated, which may allow repair but not proper regeneration after noxious stimuli (e.g. viruses and allergens) leading to further remodelling. The influenza virus H1N1 is one of the major causes of asthma exacerbations. Differentiation specific microRNAs; e.g. miR-22, may be key epigenetic factors involved in aberrant epithelial cell differentiation of asthmatics upon exposure to H1N1. We hypothesise that the impaired miR-22 expression in epithelium of asthmatics after H1N1 infection may be the link between abnormal differentiation and innate immune dysregulation in these cells. Our aims are to determine the role of miR-22 in primary bronchial epithelial cells of severe asthmatics by determining its target.

Methods: Primary bronchial epithelial cells (pBEC) from severe asthmatic and non-asthmatic subjects were cultured under air-liquid-interface (ALI) condition. Cells were incubated with H1N1 (MOI 5). miRNAs and mRNA were isolated using RNAeasy mini kit with some modifications and subjected to Taqman miR-22 and mRNA assays.

Results: pBEC from non-asthmatics and asthmatics infected with H1N1 showed the same viral titers. In cells from non-asthmatics, miR-22 expression decreased 6h after infection but then incresased and recovered to basal levels by 24h post infection. In cells from asthmatics, miR-22 expression remained unchanged during infection. Expression of the miR-22 targets, CD147 (MMP inducer) and HDAC4 (epigenetic regulator) mRNA were decreased during infection in cells from non-asthmatics. However in cells from asthmatics, CD147 expression increased during infection and HDAC4 remained unchanged.

Despite similar level of infection, miR-22 expression differs in epithelial cells from asthmatics and non-asthmatics during H1N1

infection. The reduction of CD147 and HDAC4 during H1N1 infection in cells from non-asthmatics may represent a self-defence mechanism against further cellular remodelling. COPD is linked to increased hospitalisations and morbidity. The Notch family of receptor proteins regulate airway mucus production via differentiation mechanisms that direct cells towards secretory or ciliated morphology. However little is known about Notch's role during mucus production, following differentiation.

Aim/Hypothesis: To examine the impact of inhibiting Notch signalling on mucus production in fully differentiated primary bronchial epithelial cells (pBECs) from control subjects as well as patients with asthma or COPD. We hypothesize that Notch inhibition will downregulate mucus production.

Methods: pBECs from 4-5 donors of each cohort were grown at airliquid interface (ALI) culture for 25 days to promote multicellular differentiation. At this time, cells were treated with dibenzazepine (DBZ), a potent inhibitor of Notch signalling for a further 96h during which, apical lining fluid was collected every 24h for assessment of Muc5AC release. At the completion of the experiment, samples were also collected for protein, mRNA and histological analysis.

Results: DBZ treatment significantly reduced MUC5AC expression and release in all phenotypes as assessed by qPCR, ELISA and immunofluorescence. Western blotting/qPCR revealed significant reduction of NOTCH3 intracellular domain (NICD3) and Notch3 mRNA in pBEC from all donor phenotypes. Reduced expression of NICD1 was also observed, but was restricted to cells from non-asthmatic following treatment. Finally, the goblet cell marker protein CLCA1 was unchanged across all treatments.

Conclusion: Notch inhibition reduced MUC5AC expression and secretion from differentiated pBECs, independent of goblet cell number. This reduction is NOTCH3 dependent and occurs in pBECs from control, asthmatics and patients with COPD, suggesting that Notch regulates MUC5AC production independent of secretory cell differentiation. The decrease of NICD1 in pBEC from control donors suggests additional regulation of MUC5AC production that may be compromised in cells from COPD or asthma patients. TO-043   CIGARETTE SMOKE-INDUCED INFLAMMATION IN   MACROPHAGES IS INITIATED BY NLRP3/AIM2   INFLAMMASOMES: INVOLVEMENT OF THE SPHINGOSINE-1-PHOSPHATE (S1P) SIGNALLING   HAI B TRAN 1 , RHYS HAMON 1 , TUNG T TRUONG 1 Introduction/Aim: There have been conflicting reports on the possible role of NLRP3 inflammasome activation in IL-1-driven inflammation in COPD. We hypothesized that in COPD and/or in response to cigarette smoke, there is increased activation of the NLRP3 and/or alternative AIM2 inflammasomes, regulated via sphingosine-1-phosphate (S1P) signalling.

Methods: Human primary alveolar macrophages and THP-1-derived macrophages were analysed for release of IL-1β (ELISA) and its cleavage-activation in response to cigarette smoke extract (10%, 24h). Expression and localization of IL-1β, NLRP3, AIM2, ASC (pro-caspase-1 recruiter), and cleaved caspase-1 were assessed by immunofluorescence/confocal microscopy and/or Western blot. The effects of the caspase-1 inhibitor ZYVAD-fmk or NLRP3 antagonist glyburide, and treatment with S1P or the S1P receptor regulator FTY720, with or without exposure to cigarette smoke extract were investigated.

In alveolar macrophages, cigarette smoke induced increased intracellular expression of IL-1β (~15%, p<0.05 on pooled data from 3 donors), with particulate staining for cleaved IL-1β increased both inside and outside the cell (5 fold, p<0.001 on pooled data). These particles were partially co-localized with particulate NLRP3 or AIM2 which were also increased. In THP-1 macrophages, cigarette smoke induced similar NLRP3/cleaved IL-1β complexes, which were inhibited by 20uM ZYVAD-fmk or 20uM glyburide (p<0.05). At 10nM, S1P or FTY720 significantly protected THP-1 macrophages from cigarette smoke-induced activation of IL-1β.

Conclusion: IL-1-driven inflammation in cigarette smoke-exposed macrophages is initiated by both NLRP3 and AIM2 inflammasomes, the former regulated by S1P signalling system, which suggests novel therapeutic targets in COPD. 

We hypothesise that the pro-fibrotic effects of STAT3 involve B cell-mediated immune regulation.

We have analysed immune cell composition in human lung biopsy tissue and examined the effect of B cell depletion on bleomycininduced lung fibrosis in vivo.

Results: A trend towards increased B-cell activating factor, APRIL and CXCL13 are observed in IPF patient serum versus age match controls. In addition we observed an increase in the number of mature B cells in the lungs of IPF patients. Genetic depletion of B cells in gp130 757F ;μ T −/− attenuated bleomycin-induced fibrosis. The therapeutic potential of depleting follicular B cells using anti-CD20 treatment was assessed. Mice were given two 100 μg doses of anti-CD20 antibody (provided by Genentech Inc USA), or IgG2a isotype control i.p. 7 days prior to and 7 days after bleomycin, and the extent of fibrosis measured 21 days after the last dose. FACS analysis of blood taken on days 0, 7 and 28 days post-bleomycin-treatment revealed an almost complete depletion of CD19+ and B220+ B cells. However, the extent of fibrosis, assessed using micro-CT imaging and HPLC analysis of hydroxyproline levels, was not significantly different between treatment groups.

Although antibody depletion of follicular B cells had no effect on bleomycin-induced fibrosis, residual B cells remained in the lung of these mice. Current studies are analysing B cell subsets in fibrotic lung tissue from mice and IPF patients. Methods: Primary human pulmonary fibroblasts were incubated with BSA-conjugated fatty acids for 24hr, before stimulation with TNFα for another 24hr. IL-6 and CXCL8 release was measured using ELISA. IL-6 acts as a general marker for inflammation and CXCL8 is a potent neutrophilic chemoattractant. The following fatty acids were used: arachidonic acid (AA, ω-6), eicosapentaenoic acid (EPA, ω-3), and palmitic acid (PA, saturated fatty acid) at increasing concentrations of 1, 10 and 100μM.

Results: AA induced substantial IL-6 (n=11, P<0.05) and CXCL8

(n=9, P<0.0001) release by pulmonary fibroblasts. EPA and PA did not induce CXCL8 or IL-6 release. Stimulation with the combination of AA and TNFα resulted in greater IL6 (n=9, P < 0.0001) and CXCL8 (n=8, P <0.0001) release than AA alone. The effect of the combination AA/TNFα on IL-6 release was greater than the sum of the individual effect of AA and TNFα, indicating synergy.

These findings suggest that dietary fatty acids are important modulators of inflammatory responses and that there is an interaction between arachidonic acid and TNFα, resulting in a synergetic inflammatory response in pulmonary fibroblasts. This could indicate that obese asthmatics compared to lean individuals, are more prone to airway inflammation after a high fat meal. Introduction/Aim: Innate immune responses within the lung mucosa, for instance against cigarette smoke (CS), depend on the activation of pattern recognition receptors via multiprotein complexes called inflammasomes, which facilitate the maturation and release of the proinflammatory cytokines interleukin (IL)-1β and IL-18. In recent years a plethora of data from clinical studies and mouse disease models have demonstrated that excessive inflammasome activation promotes several diseases. In that regard, emphysema a major debilitating components of COPD, has shown a link between IL-1β and IL-18 and disease. Despite these observations, a causal role for specific inflammasomes in emphysema is unknown. Therefore we aim to reveal a novel functional link between inflammasome activation and the pathogenesis of emphysema.

Methods: To identify whether inflammasomes promote emphysema,

we have utilised a genetic model ( gp130 F/F ) for spontaneous emphysema and an acute (4 days) CS-induced model, both characterised by elevated alveolar type II cell (ATIIC) apoptosis that is driven by the cytokine IL-6.

Here, we demonstrate that lung tissues from emphysema patients, as well as from spontaneous ( gp130 F/F mice) and CS-induced emphysema mouse models, are characterized by excessive productions of the gene encoding AIM2 which forms a cytoplasmic DNA-sensing inflammasome and IL-1β (but not IL-18) protein. Furthermore, genetic blockade of Aim2 in gp130 F/F mice prevents the development of emphysema by suppressing augmented ATIIC apoptosis. A positive correlation also exists between elevated IL6 and AIM2 mRNA levels, and AIM2 mRNA and IL-1β protein expression levels, in emphysema patients.

Collectively, we define for the first time that hyperactivation of the endogenous IL-6/AIM2/ IL-1β axis in the lung augments ATIIC apoptosis, which in turn causes emphysema. Finally, we believe our study also has the potential to aid future therapeutic strategies to target inflammasomes (AIM2) alone or in combination with IL-6 in human emphysema. Introduction: NKT-like cells represent a bridge between innate and adaptive immunity. We have reported increased numbers of steroid resistant cytotoxic/pro-inflammatory senescent CD28 null NKT-like cells in BAL in COPD associated with increased cytotoxicity to bronchial epithelial cells. These cells express drug efflux pump Pgp-1 and loss of glucocorticoid receptor (GCR). Recently, loss of histone deacetylase 2 (HDAC2) and heat shock protein 90 (Hsp90) have been reported from CD8+ T cells from COPD patients and we hypothesized these molecules may be decreased in CD28 null NKT-like cells (particularly the CD8+ subset).

Method: Blood was collected from a group of COPD patients and aged matched controls and expression of CD28, Pgp-1, GCR, HDAC2, Hsp90 and pro-inflammatory cytokines determined in CD8+ and CD8-NKT-like cells in the presence of AE 1μM prednisolone AE 2.5ng/mL cyclosporine A (binds to GCR-Hsp90 complex) AE 5 μg/mL theophylline following culture using flow cytometry, western blot and immunofluorescence.

Results: Loss of GCR, HDAC2 and Hsp90 (but not Pgp-1) expression was identified from CD28 null CD8+NKT-like cells compared with CD28+ counterparts. Loss of GCR, HDAC2 and Hsp90 was associated with increased production of IFNγ and TNFα and increased steroid resistance. Upregulation of GCR, HDAC2 and Hsp90 was noted in the presence of prednisolone + low dose cyclosporine A and increased HDAC2 was noted in the presence of prednisolone + theophylline.

Steroid resistance in pro-inflammatory CD28 null CD8

+NKT-like cells is associated with multiple mechanisms. Combination prednisolone, low-dose cyclosporine A and theophylline treatment therapy inhibits pro-inflammatory cytokine production from these cells and may reduce systemic inflammation in COPD. tested the effects of bronchodilators alone or with exercise training (ExT), combined with a standardised physical activity selfmanagement behaviour-modification (BM) programme, on exercise endurance time (EET) in patients with COPD.

A 12-week randomised, partially double-blind, placebo (P)controlled, parallel-group trial at 34 sites in Australia, New Zealand, USA, Canada and Europe. Interventions (all with 12-week BM): P; tiotropium (T) 5 μg; T + olodaterol (T+O) 5/5 μg; T+O 5/5 μg with 8 weeks' ExT (T+O 5/5 μg + ExT). EET (log transformed) during an endurance shuttle-walk test (ESWT) to symptom limitation was assessed after 8 weeks (primary end point) and 12 weeks.

Results: 303 patients (200 men) were randomised and treated (full analysis set n=274). Mean post-bronchodilator FEV 1 was 1.59 L (56.7% predicted). EET significantly increased with T+O 5/5 μg and T+O 5/5 μg + ExT versus P at 8 weeks ( Figure) ; 13 patients reached test termination criteria (20 minutes) without symptom limitation (P, n=0; T, n=3; T+O, n=2; T+O + ExT, n=8) at 8 weeks. No safety concerns were identified. Shorter tests such as the two-minute walk distance may offer advantages in some populations, but lack information about responsiveness to change. This study examined reliability, validity and responsiveness of the two-minute walk test in people with COPD attending pulmonary rehabilitation (PR).

Methods: At pre-PR assessment, study participants completed a two-minute walk test twice in addition to usual measures (6MWD, Chronic Respiratory Questionnaire). At post-PR assessment following a standard PR program, measures were repeated and global rating of change scores obtained (patient and therapist). Pre-post program change scores were examined for correlations with change in two-minute walk distance and used (where r>0.3) to estimate the minimal importance difference through anchor-based methods. Distribution-based estimates based on standard error of measurement were examined. Test-retest reliability (ICC, Bland Altman agreement) and validity (Pearson correlation with 6MWD) were reported.

Results: Pre-program assessment was conducted in 59 participants (68AE10 years, FEV 1 %pred=48 AE 20%). Test-retest reliability of twominute walk distance was high (ICC=0.985) with mean difference between trials of 2.4m (95%CI 0.7 to 4.0, p=0.006). Two and six-minute walk distance was highly correlated (r=0.87, p<0.01). Post-program assessment was completed in 36 patients (69 AE 8 years, FEV 1 %pred=52 AE 21%). Anchored against clinically meaningful change in 6MWD, the minimal important difference in two-minute walk distance was 3.5m (area under curve=0.82, 95%CI 0.67 to 0.97) and agreed with the distributionbased estimate of 3.4m. Two-minute walk distance and 6MWD did not significantly improve post-program in this sample, in contrast to QOL measures.

Conclusion: Improvement in two-minute walk distance of at least 3.5m following a PR program corresponded to a clinically meaningful change. Due to a learning effect between first and second trials a practice two-minute walk test is recommended. people with chronic obstructive pulmonary disease (COPD) generally target generalised anxiety and depression. This randomised controlled trial aimed to determine whether adding a cognitive behavioural therapy program for the sensation of breathlessness (CBT-BREVE) to a comprehensive pulmonary rehabilitation program (CPRP) significantly improved health outcomes beyond those achieved with a CPRP alone.

Method: Eight week CPRP cycles at the Repatriation General Hospital were block randomised to include CBT (BREVE) or social group (CPR) interventions. People with COPD and at least moderate airflow obstruction (FEV 1 < 80 % pred, FEV1 / FVC <70%, GOLD Grade ≥ 2) were eligible for inclusion. Primary (six minute walk test -6MWT, Hospital Anxiety and Depression scale -HADs) and secondary outcomes (Multidimensional Dyspnoea Profile -MDP, Chronic Respiratory Questionnaire-CRQ, sedentary and physical activity (accelerometry -Actigraph GT3X+) and symptom scores) were assessed one month before and one, six and 12 months post intervention. Participant feedback was sought after completion of the 12 month assessment. Differences between groups (intention to treat) were assessed across all four assessment points with random effects mixed models Results: 101 participants met all inclusion criteria with no significant (p<0.001) differences between subjects eligible for participation but declining (n=66 GOLD grade ≥ 2)) and those participating in the trial (n=101 mean age 70.1 AE SD 8.5, 54 males, FEV 1 % pred 47.7 AE 16.3). Preliminary analysis indicates no statistical or clinically significant differences between groups at any assessment point for 6MWT or HADs. Analysis of secondary outcomes is ongoing. Participant feedback was uniformly positive for both forms of intervention Conclusion: Despite overwhelmingly positive feedback for the CBT program, combining CPR with a CBT program specific for sensation of breathlessness did not result in greater improvements in functional exercise capacity, anxiety or depression, beyond those achieved with standard CPR. Introduction/Aim: Downhill walking (DW) enhances quadriceps contractile muscle fatigue (CMF) with less symptoms than level walking (LW) in patients with COPD. This study sought to determine the effectiveness of DW compared to LW as part of a 12-week comprehensive pulmonary rehabilitation program in patients with COPD.

Methods: 39 COPD patients (62AE9yrs; FEV 1 49AE17%pred) were randomised to PR with DW or LW. Exercise capacity (6-minute walk test, 6MWT [primary outcome]; cycle endurance test), muscle function and quality of life were assessed before and after program completion. Training responses and the proportion of patients exceeding the 30m minimally important difference (MID) for 6MWT were compared between groups via Chi 2 test.

Results: The magnitude of improvement was similar across all outcomes in both groups (Table 1) . However, a significantly greater proportion of patients in DW exceeded the 6MWT MID compared to LW (94% vs 65%, p=0.03). widely used for evaluating functional exercise capacity. The primary outcome of the 6MWT is the six minute walk distance (6MWD). Current practice recognises the use of the minimally important difference (MID) as a key index of a response to pulmonary rehabilitation (PR). However, the 6MWT also provides information on dyspnoea, heart rate (HR) and degree of desaturation (nadir S p O 2 ) achieved during the test. This information is typically not considered when evaluating patient outcome to PR. Whilst an individual may not achieve the MID, it is possible other indices from the 6MWT may reflect improvement. The aim of this study was to compare changes in peak dyspnoea, HR and nadir S p O 2 following PR in participants that did not have a clinically significant change (non-MID) in their 6MWD (−30m≤MID≤30m) with a group that did achieve the MID (>30m).

Methods: Data was retrospectively analysed from subjects that completed a 6MWT both pre and post PR over a 2 year period. The 6MWT was measured prior to and immediately following an 8 wk, twice weekly PR program. Dyspnoea (0-10 Borg scale) and HR were recorded immediately at the end of the 6MWT while nadir S p O 2 was measured during the test. lium was also processed for electron microscopy and cilia were photographed. Ciliary structure and orientation was quantified from these photographs. A Mann-Whitney U test was used to analyse the difference in ciliary orientation between patients with and without Retinitis Pigmentosa.

Results: Ciliary beat frequency of patients with Retinitis Pigmentosa was normal (mean 8Hz). Ciliary waveform was uncoordinated in video playback. Mean Ciliary Deviation of normal patients was 17 , which was in keeping with previously published normal values. Mean Ciliary Deviation of Retinitis Pigmentosa patients was 32 , which is considered almost random orientation of cilia on a cell surface.

Our data demonstrates a shared developmental link between motile and immotile cilia and may help explain the previously reported predisposition to respiratory problems in some patients with Retinitis Pigmentosa. Airway cilia movement was uncoordinated and the cilia may have been malfunctioning due to almost random ciliary orientation. Further clinical evaluation is required to characterise the respiratory history of patients with Retinitis Pigmentosa. Introduction/Aim: The audio characteristics of abnormal paediatric breath sounds are not well-defined and digital techniques to capture them have not been widely investigated. Our study aimed to define the audiological features of abnormal paediatric breath sounds objectively and compare the ability of digital stethoscopes to detect them against auscultation using standard bell-and-diaphragm stethoscopes.

Methods: Twenty children with normal breath sounds, generalized wheeze or crackles, and some with a diagnosis of cystic fibrosis were auscultated by a paediatric consultant and digitally recorded using both the Littman™ 3200 Digital Electronic Stethoscope and a Clinicloud™ Digital Stethoscope. We used spectrographic analysis and recording playback to detect abnormal breath sounds and define their audio waveform characteristics.

Results: Digital stethoscopes were more sensitive than standard auscultation in detecting wheeze in our study. Patients with clinicallydescribed wheeze had periodic waveform segments of increased intensity and frequency compared to background breath sounds, mostly spanning expiration for a period of 0.03-1.2 seconds at frequencies of 100-1050Hz, and occasionally spanning shorter inspiratory segments. Recordings of patients with crackles revealed brief (6-20 millisecond) discontinuous sounds with a distinguishing waveform identifiable within them.

Digital breath sound analysis may be more sensitive than manual auscultation in detecting breath sound abnormalities in children, with potential applications for improved diagnosis, data sharing and disease monitoring. Further research and development is needed. with aerosolised corticosteroids to reduce mouth and throat deposition produced by larger particle generating inhalers. Anecdotally, spacers are seldom used as prescribed, which has particularly been observed in the adolescent age group at Princess Margaret Hospital for Children in Perth. The recommendation to use a spacer may not be necessary with new asthma medications producing smaller particle sized aerosols. We aimed to assess the effect of particle size in pMDIs with and without a spacer.

Fourteen adolescents aged 13-17 years with mild stable asthma were randomised to use a pMDI with or without a spacer in a randomised cross-over study. Radiolabelled (Tc 99m ) corticosteroids of different mass median aerodynamic diameters (fluticasone propionate 3.5 μm (Flixotide®), and becolmethasone diproprionate 1.1μm (QVAR™)) were inhaled using correct technique, as assessed by a Clinical Nurse Specialist, and dose of drug quantified immediately after with a 2D gamma camera scan. Radiation detected was quantified per region of interest accounting for attenuation by body tissues. Drug deposition in the lungs and orogastric regions was compared in adolescents inhaling the same drug with and without a spacer using a Wilcoxon matched pairs signedrank test.

Results: Fourteen adolescents completed two visits each, with and without a spacer. We did not observe a significant difference in the QVAR group lung deposition with or without spacer (median 32.9 vs 23.0, p=0.47) or the Flixotide group lung deposition with and without spacer (median 38.3 vs 34.1, p=0.08). However, we may not have had the power to detect differences given the small sample size in the dataset.

Conclusion: Preliminary data suggests QVAR (p=0.47) may be used without a spacer in adolescents, provided inhalation technique is assessed by an appropriately trained clinical professional. We would still recommend that Flixotide be used with a spacer. Introduction/Aim: In utero smoke exposure is associated with abnormal lung function, wheeze and asthma from infancy and throughout childhood. The negative influence of in utero smoke exposure is modified by genetic polymorphisms in genes important in detoxifying tobacco byproducts, including the Glutathione S-transferase (GST) gene, a respiratory anti-oxidant. The longterm effects of in utero exposure on respiratory health into adulthood are unclear.

The Perth Infant Asthma follow up study is a longitudinal birth cohort of 253 subjects recruited antenatally from a general population with lung function carried out 1, 6,12 months, 6,11,18 and 24 years of age. Antenatal smoking history was collected from both parents at recruitment. DNA was collected at 6 and 11 years on a subgroup of 180 subjects.

Either parent smoking during the pregnancy was associated with wheeze (OR=2.5, 95% CI 1.01-6, p=0.048) and asthma (OR 2.7, 95% CI 1.2-5.9, p=0.012; n=123) in the offspring at 6 years of age, but not thereafter. Maternal smoking during the pregnancy was associated with reduced lung function in the offspring at 1 month (mean V'maxFRC of 90ml/sec (SD) versus 104ml/sec ; p=0.034; n=242) and 6 years of age (mean FEV1% predicted 99% 15 (SD) versus 105% 15, p=0.039; n=110) but not at later assessments.

Amongst those children exposed to in utero tobacco smoke (n=32), the GSTM1 homozygote null genotype was associated with significantly lower lung function at 6 years of age compared to those with GSTM1 non-null genotype (mean FEV1% predicted 93.5 15 (SD) versus 104.6; p=0.03).

In utero tobacco smoke exposure negatively impacts lung function and respiratory symptoms up to 6 years of age, but this effect does not persist into adulthood. Polymorphisms in anti-oxidant genes may contribute to worse lung function in children who were exposed to in utero tobacco smoke. Fibrosis (CF) are both inherited, progressive, incurable, respiratory conditions causing significant morbidity and mortality. In the lungs, damage is reflected as a spectrum of structural changes that can be detected on computed tomography (CT). To monitor disease progression and guide therapy, scoring systems for CT scans have been developed in CF, which quantify the extent and severity of changes seen. Most research examining structural lung changes on CT scans use scoring systems derived from a CF cohort. All studies to date describing lung damage in PCD use these CF-derived tools. This assumes lung damage in the two conditions is identical, which potentially results in a failure to identify PCD-specific changes. Our study addresses this assumption Methods: We retrospectively analysed of 58 CT scans from 40 adult and paediatric patients with PCD. The following abnormalities found in CF were scored according to presence and extent: bronchiectasis, bronchial wall thickening, atelectasis, mucous plugging, and air trapping. In addition, an experienced respiratory radiologist reviewed all scans to look for the presence of any abnormalities that differ from the above.

Results: Bronchial wall thickening was the most common abnormality, and air trapping the least common. All abnormalities were present significantly more often in the middle and lower lobes compared to the upper lobes, with all p values <0.001. When present, all abnormalities were significantly more extensive in the middle and lower lobes compared to the upper lobes. Bronchiectasis, mucus plugging, atelectasis (p<0.001) and air trapping (p=0.005) were all present significantly more often in the PCD cohort than the respective CF cohorts. The PCD-unique changes identified were dextrocardia, extensive tree-in-bud patterns, whole lobe atelectasis, and interlobar and interlobular septal thickening.

Conclusion: Significant structural changes were seen on CT scans in patients with PCD, which were not consistent with those previously described in patients with CF. Our findings illustrate the need for development of a PCD-specific scoring system, which can function as a tool for the objective assessment of disease status, progression and efficacy of therapy. Methods: All patients undergoing annual surveillance CT and bronchoalveolar lavage (BAL) were included. To assess structural lung disease extent, the PRAGMA-CF method was developed: a grid was overlaid on CT slices and annotated hierarchically for the presence of bronchiectasis, bronchial wall thickening, and mucous plugging (inspiratory scan) or trapped air (expiratory scan). Overall disease (%Dis) and trapped air (%TA) were expressed as the proportions of cells with disease and trapped air (respectively) compared to healthy.

Thirty scans were randomly selected for rescoring to assess repeatability (intraclass correlation coefficient, ICC). Linear mixed model analysis was used to compare CT outcomes to the presence of neutrophil elastase (NE) and infection from BAL.

Results: 683 scans from 256 patients were included in the final analysis. ICCs to assess repeatability were above 0.8 (grade of excellent). CT outcomes were associated with both the presence and history of NE and infection. Sample size calculations showed that multicentre clinical trials of intervention can be performed with around 100 patients.

Discussion: PRAGMA-CF is a sensitive tool to monitor structural lung disease in CF. It is highly repeatable, biologically plausible (associated with clinical markers of lung disease), and is suitable for use as an outcome measure in multicentre clinical trials. This study provides both a rationale and a means to test interventions aimed at preventing structural lung disease in young children with CF. Introduction/Aim: microRNA expression profiles are of interest as a biomarker of tuberculosis (TB). The effect of anti-TB therapy on miRNA profiles in pulmonary TB patients is unknown and was examined in this study.

Methods: Plasma miRNA levels for 175 miRNAs were compared in 20 TB patients and matched healthy controls from China. 87 miRNAs were differentially regulated between the two groups. Ten of these were analysed in a test cohort of 100 pulmonary TB patients sampled prior to the commencement of antibiotic therapy and at one, two and six months during treatment.

Results: Six miRNA were differentially expressed in the test group of TB patients. miRs -29a and -99b were up-regulated, whilst miRs −21, 26a, −146a and −652 were down-regulated. A combination of 4 miRNA distinguished pulmonary TB from healthy controls with a sensitivity of 90% and a specificity of 84%, with an AUC of 0.941. Within one month of treatment, significant modulation of miRs -29a, −99b,-26a and 146a was seen in successfully treated patients, although not all miRNAs had returned to baseline at completion of treatment.

Six miRNA were differentially expressed in the test group of TB patients. miRs -29a and -99b were up-regulated, whilst miRs −21, 26a, −146a and −652 were down-regulated. A combination of Introduction/Aims: Recent advances have implicated the airway epithelium as a key driver in asthma pathogenesis, partly due to its dysregulated response to damage. Novel therapies focusing on protecting and repairing vulnerable airways, particularly in early life, could transform asthma treatment by preventing disease development/progression. (1)To analyse primary airway epithelial cells (pAEC) migration patterns postwounding in-vitro. (2)To identify mechanisms and potential therapeutic targets enhancing wound repair processes.

Methods: pAEC were obtained from non-asthmatic and asthmatic paediatric airways. Scratch wounds were performed on pAEC monolayers to assess repair and imaged every 30 minutes (IncuCyte ZOOM®,Essen Bioscience). Migration trajectories of leading-edge pAEC were analysed using ImageJ. Integrin gene and protein expression were investigated by qPCR and In-Cell™ Western,respectively. Total RNA was sequenced(Illumina Hi-Seq2500) and differential gene-expression analysis was performed(DESeq2 and Ingenuity Systems(QIAGEN)).

Results: Response to wounding in asthmatic children was deficient and lacked specificity with significantly lower mean migration distance(non-asthma and asthma; 256.9AE7.1 and 152.3AE8.6μm(mean-AESEM)), velocity(0.42AE0.02 and 0.22AE0.01μm/min), directionality (91.3AE0.1 and 61.1AE0.1%) and forward migration index(95.3AE0.1 and 64.6AE0.1%). A major regulator of cell migration, i.e. integrin α5β1, was investigated in pAEC. Lower gene(α5, 5.9-fold, p<0.0001; β1,1.5-fold, p<0.05). and protein(α5, 2.8-fold, p<0.05; β1, 3.1-fold, p<0.05) levels in pAEC from asthmatic children(n≥11) compared to control(n≥23). RNAseq analysis identified 1,153 differentially expressed genes in asthmatic children(n=6) relative to control(n=4) with overrepresented gene ontologies related to integrins and extracellular matrix. Drug database screening identified several clinically safe drugs that are now being examined for drug repurposing potential to restore integrin expression and aid wound repair.

These novel experiments demonstrate abnormal migration behaviour of asthmatic airway epithelium post-wounding. Some mechanisms controlling this disease phenomenon were identified like decreased integrin α5β1, and multiple transcriptional mechanisms were dysregulated in asthmatics, some of which are targetable by existing drugs. Supporting airway epithelial repair and barrier integrity may be a novel therapeutic avenue for asthma. 

To simulate the synergistic effects of virus infection and allergen exposure on asthma susceptibility, mice were exposed to low dose pneumonia virus of mouse (PVM; 1pfu) and low dose (1μg) cockroach antigen (CRE) in early life and again in later life. Four weeks after the final CRE exposure, mice were inoculated with rhinovirus (RV-1B, TCID50 5x106). Anti-IL-33 or dexamethasone was administered intraperitoneally twice/week between the CRE and RV challenge, then daily until euthanasia.

were necessary for disease onset and progression. IL-33 levels were elevated immediately following the final CRE exposure and persisted in the airways until the time of RV-1B challenge. Mice co-exposed to PVM/CRE, but not CRE or PVM alone, presented with eosinophilic inflammation, increased numbers of type 2 innate lymphoid cells, mucous hypersecretion and elevated IL-13 levels following RV infection. Treatment with anti-IL-33 or dexamethasone attenuated the RV-1B-induced type 2 inflammation but had no effect on mucous production. Critically, anti-IL-33, but not dexamethasone, promoted the expression of antiviral cytokines, accelerating RV-1B viral clearance. Obstructive Pulmonary Disease (COPD) is known to complicate prognostication, potentially preventing timely transition to palliative care, thus the primary responsibility for care provision remains with the family of the person with COPD. We aimed to explore the experiences of older people living with Stage IV COPD in a rural community, and how COPD influenced their relationships and identity.

Methods: Eleven older people with Stage IV COPD living in regional NSW undertook narrative interviews, discussing their 'COPD journey'. The interviews were transcribed, then analysed and interpreted in accordance with a hermeneutic phenomenological methodology.

Results: Spousal care was generally well accepted and expected by married participants as an extension of the marital role. However, when adult children were involved in care or decision making, participants expressed guilt and frustration about perceived and actual burden placed on them. This self-perceived burden, grounded in their own experiences caring for loved ones, had flow on effects to their uptake of coping and treatment strategies, and Advance Care Planning (ACP) as well as creating communication barriers between each of the parties. Parents aimed to protect their adult children from distress or impacting on their lives, by prioritising the children's wishes above their own, whilst simultaneously under-communicating need and disease specific information. Paradoxically, many participants went on to design their ACP to refuse treatment rather than extend any impact on their children's lives, contrary to their children's ACP requests of them.

With the protection of adult children being a primary determinant of end of life decision making, it is critical to establish more formal and effective communication pathways between family and health professionals to facilitate a 'good death' within the family group. Conclusion: This analysis is among the first to examine a combination of biomarkers to assess response to omalizumab in SAA patients.

They suggest that subgroups with a combination of increased IgE and EOS may experience a greater clinical benefit. However, caution must be used in interpreting these results given their post-hoc nature. Conclusion: VCD was present in a third of our patients with difficult asthma. VCD was associated with female sex and poorer asthma outcomes despite better lung function. Improved lung function and poorer quality of life were both independent predictors of VCD. Our findings highlight the importance of identifying and addressing VCD in this challenging patient group. and SERPINB2) genotype has been shown to predict response to inhaled steroids in mild asthma and a 6 genes signature (6GS) in sputum cells (CLC, CPA3, DNASEI1L3, IL1B, ALPL, and CXCR2) distinguishes between asthma inflammatory phenotypes. The aim was to determine gene expression of both signatures in endobronchial biopsies from adults with asthma and related to asthma severity and airway inflammatory phenotypes.

Methods: Non-smoking adults with asthma had current respiratory symptoms, and evidence of variable airflow obstruction. Asthma severity was defined according to GINA. Inflammatory phenotypes using BAL cell count. The 9 genes were analyzed by qPCR using extracted RNA.

Results: Biopsies were evaluated from; severe asthma (n=40), mild/ moderate asthma (n=32), with no differences in age, sex, atopy or smoking history between the groups. Gene expression of SERPINB2 was significantly increased in severe compared with mild/moderate asthma (p=0.022) and inversely associated with FEV 1 % predicted in participants with asthma (r=−0.337,p=0.005). Gene expression CLC and SERPINB2 were significantly increased in eosinophilic asthma (n=20) compared with paucigranulocytic asthma (n=21, p=0.003 and P=0.0009 respectively), while ALPL was increased in eosinophilic compared with mixed-granulocytic asthma (n=13, p=0.0056). Only gene expression for CLC was associated with asthma BAL eosinophils % r=0.325 p=0.006. Gene expression for IL-1β was increased in neutrophilic (n=18) compared with paucigranulocytic asthma (p=0.006) and was significantly associated with BAL neutrophils % r=0.234, p=0.0496. Results: RSV infection of OVA-sensitised/challenged BALB/c mice resulted in significantly increased AHR and macrophage and neutrophil lung infiltration. Exacerbation was accompanied by increased levels of inflammatory cytokines (including TNFα, MCP-1, and KC) compared to uninfected OVA-treated mice or OVA-treated mice exposed to UVinactivated RSV. Dexamethasone treatment completely inhibited all features of allergic disease including AHR and eosinophil infiltration in uninfected OVA-sensitised/challenged mice. Conversely, dexamethasone treatment following RSV-induced exacerbation only partially suppressed AHR, and failed to dampen macrophage and neutrophil infiltration or inflammatory cytokine production (TNFα, MCP-1, and KC). This mimics clinical observations in patients with exacerbations, which is associated with increased neutrophils and often poorly responds to corticosteroid therapy. Interestingly, we also observed increased TNFα levels in sputum samples from neutrophilic asthmatic patients. While RSV-induced exacerbation was resistant to steroid treatment, inhibition of TNFα and MCP-1 function or depletion of macrophages suppressed features of disease including AHR, macrophage and neutrophil infiltration.

Our findings highlight critical roles for macrophages and inflammatory cytokines (including TNFα and MCP-1) in viral-induced exacerbation of asthma and suggest examination of these pathways as novel therapeutic approaches for disease management. unchanged. Interleukin-6 levels were significantly increased in the IB-3 CFTR mutant compared to C38 AEC supernatants at baseline and both AEC lines demonstrated a significant increase in IL-6 production following FAC challenge. Preliminary pathway analyses from the proteomic data reveal significant differential expression of proteins involved in oxidative stress and mitochondrial stress responses in the IB3-1 compared to C38 AEC.

The airway epithelium in CF demonstrates abnormalities of iron regulation, exhibits a pro-inflammatory phenotype and activation of cell pathways involve in oxidative stress. Results: 681 spirometry measurements were available (mean age 9.3AE2.1) years). Total CF-CT score at 5-6 years (n=171) that was greater than the median was significantly associated with shortened time before Results: Seventeen infants with CF (median age 2.6 months (interquartile range (IQR) 1.6-4.9 months); male 59%; P.Phe508del homozygous 71%) and nine control infants (median age 5.0 months (IQR 2.9-8.2 months); male 78%) contributed BAL samples. Diversity was reduced in CF compared with control BAL samples (median shannon diversity index 1.3 (IQR 0.9-2.0) and 2.0 (IQR 1.4-2.3) respectively). Firmicutes was the most prevalent phylum in both groups, accouting for 76.9% and 49% of total reads respectively, however Staphylococcus was predominant in CF samples only (39.8% total reads). The next most prevalent genera in the CF samples were Streptococcus (15.0%), Haemophilus (9.9%), Granulicatella (9.2%) and Gemella (6.7%). In contrast, the five most abundant genera in the control samples were Streptococcus (30.0%), Fusobacterium (12.8%), Neisseria (12.4%), Gemella (6.3%) and

Introduction/Aim: The six minute walk test (6MWT) is an objective tool used to assess functional exercise capacity in cystic fibrosis (CF). However, the relationship between 6MWT outcomes and need for hospitalisation for treatment of pulmonary exacerbation (PE) has not been studied. Therefore, the primary aim was to determine the relationship between six minute walk distance (6MWD), subjective breathlessness (Modified Borg score) and oxygen saturation (S p O 2 ) during the 6MWT, and frequency and duration of hospitalisation in adults with CF. Theodora Ahilas will present on the rights to compensation for workers with occupational lung diseases.

Theodora will discuss legal entitlements that flow from the diagnosis of an occupational lung disease. The different legal and statutory entitlements that follow in the different States together with the complexity of assessing these claims particularly in the presence of co-morbidities. Introduction/Aim: Little is known about how many Australians have been exposed to potentially hazardous agents in workplaces during their lifetime. Assessment of exposure status using only current job data can miss earlier exposures with potential long-term effects, and does not account for changes to occupational exposures over time.

This analysis determines proportions of a national population-based sample of Australian adults ever-exposed to potentially hazardous agents during their working life.

Methods: Individuals were recruited by telephone to participate in a study as controls to a national sample of Idiopathic Pulmonary Fibrosis (IPF) cases in Australia; individually matched 2:1 for age, sex and State. Consenting participants completed a telephone interview collecting data including demographics, self-reported environmental exposures and detailed occupational history. Each reported job was coded to the Finnish Job Exposure Matrix (FinJEM) to assign associated exposures during the relevant time period. Participants were considered exposed to an agent in a job if the probability of exposure was >25%. Data from each job in participants' occupational history were collated to assess lifetime exposure status. Descriptive statistics were conducted to assess the proportions ever-exposed. Respirable dust 36.5%; Animal dust 13.6%; Iron 13.0%; Plant dust 13.0%; Asbestos 12.5%; Environmental tobacco smoke 11.0%; Moulds 10.3%; Quartz dust (Silica) 9.9%. Analysis of self-reported occupational exposure data yielded higher proportions: Dusty environment 50.6%; Gases/fumes/chemicals 47.0%; Asbestos 33.7%; Silica 19.5%. As expected, significantly more males were exposed than females for all agents (p<0.05).

A considerable number of older Australians have been exposed to potentially harmful agents within their working life. Data about these lifetime occupational exposures are required to examine potential occupational risk factors for diseases such as IPF. Aim: We aimed to determine the impact of community-sampled geogenic dust PM 10 (particulate matter <10μm diameter) on immortalized human airway epithelial cells (NuLi-1). In particular, we aimed to determine its effects on non-typeable Haemophilus influenzae (NTHi) infection.

Geogenic dust was collected from remote towns in Western Australia and PM 10 was extracted. NuLi-1 cells were exposed to PM 10 (10μg/mL in PBS) in vitro for 24h before the addition of live NTHi-86 (MOI 10:1) for 3h. Trypan blue staining was used to determine cell viability, and bacterial infection (attachment and invasion) was determined using a gentamicin survival assay. Epithelial release of IL-6 and IL-8 was assessed using a bead based immunoassay.

Results: Pre-treatment of NuLi-1 cells with dust PM 10 significantly increased the ability of NTHi to attach to and invade cells (p<0.001 and p=0.013, respectively). After dust exposure, the IL-6 response was increased (p=0.043) and the IL-8 response was suppressed (p=0.041).

human airway cells and may contribute to more common and severe respiratory infections. This has important implications for lung health in individuals living in arid environments, such as those in remote Australia, who are exposed to high loads of geogenic dust. Introduction/Aim: Australian Aboriginal children have a much higher incidence of infectious diseases than their non-Aboriginal counterparts. Many Aboriginal communities are exposed to high levels of ambient dust from a geogenic (earth-derived) origin. We have previously reported an association between self-reported dust exposure and poor health in remote Aboriginal communities. The aim of this study was to examine the association between self-reported dust exposure and infectious diseases in Aboriginal children.

Child Health Survey (WAACHS) were linked to the EHNS. Odds ratios for the association between the health outcomes and exposure were calculated using multivariate logistic regression models within a multi-level framework to take into account the hierarchical structure of the data. Results: Preliminary results highlight the difficulties in diagnosis of coal worker's pneumoconiosis. Although data collection is ongoing, the radiological grade in the majority of cases to date has been low grade (ILO 1). In addition, this case series highlights that in the early stages coal workers presents with soft or ground glass nodules that are low density and therefore extremely difficult to detect on plain radiograph. There has been no case of progressive massive fibrosis from coal exposure alone. Clinical and occupational history is predictive of diagnosis with most patients having a symptomatic cough and a strong occupational history of dust exposure.

Queensland has been in workers with occupational histories of heavy dust exposure who are usually symptomatic. Radiographic changes are often subtle, particularly on plain radiograph. Introduction/Aims: Assessing the community health impacts of short-term particle exposure events (e.g. fires) can be difficult. One approach involves collecting particle samples from the roof-space of exposed dwellings as a proxy for particles that were generated during the exposure event. In follow up studies from a 2014 fire, we collected particles from ceilings of houses at different distances from the particle source. Using a mouse model, we aimed to determine whether in utero exposure to these particles alters post-natal lung function.

Methods: C57BL/6 mouse dams were intranasally exposed to ceiling particles (100μg in 50μL saline), carbon black particles (control) or saline alone at gestation day (E)13.5, E15.5 and E17.5. At two weeks of age, lung volume (TGV) and lung mechanics (airway resistance; Raw; tissue damping, G; tissue elastance, H) were measured in anaesthetised and tracheostomised mice using plethysmography and the forced oscillation technique (FOT) respectively.

There was no effect of in utero exposure to ceiling dust or carbon particles on TGV in 2-week-old mice (female, P = 0.59; male, P = 0.73). Similarly, there was no effect of exposure to particles on Raw (female, P = 0.18; male, P = 0.88) or G (female, P = 0.46; male, P = 0.10). However, while there was no effect in females (P = 0.35), male mice exposed to ceiling dust (P = 0.04), but not carbon (P = 0.22) had higher H. The magnitude of the response was not associated with distance from the particle source.

In utero exposure to particles of ceiling dust increased lung stiffness, but only in male mice. These data suggest that exposure to ceiling dust may impact on lung growth in a sex specific manner. These responses appeared to be unrelated to the relative contamination of the ceiling dust with particles from a combustion source. 

Introduction/Aim: Steroid-resistant asthma is the major unmet need in asthma management. Effective treatments are urgently required, however, their development is hampered by a lack of understanding of the pathogenic mechanisms involved. An increasing body of evidence shows that a high fat diet (HFD) and/or obesity are associated with steroidresistant asthma, however, the precise mechanisms involved remain unclear. Studies show that HFD-induced obesity causes increased airway hyper-responsiveness (AHR) in mice and that these responses are driven by NLRP3 inflammasome-mediated IL-1β responses. However, whether HFD/obesity affects steroid responsiveness and whether therapeutically inhibiting the NLRP3 inflammasome is effective for the treatment of HFD/obesity-induced experimental asthma is unknown.

We have developed a novel mouse model of HFD/obesity and combined it with an established model of ovalbumin-induced steroid sensitive, allergic airway disease (AAD). The effects of steroid treatment and the roles and potential for targeting of NLRP3-inflammasome responses in the lung in HFD/obesity-induced AAD were examined using therapeutic treatment with dexamethasone and a potent, highly selective NLRP3 inhibitor, MCC950.

We show HFD results in significant increases in adiposity and weight gain. Significantly, HFD/obesity induces increased eosinophil numbers in the lung and steroid-resistant AHR in both the absence and presence of AAD. We also show that HFD results in an increase in NLRP3 staining in the airway epithelium as well as significant increases in active caspase-1 in whole lung tissue. Significantly, treatment with MCC950 suppressed HFD/obesity-induced steroid-resistant AHR in both the absence and presence of AAD.

We have developed a novel murine model of HFDinduced obesity that induces steroid-resistant AAD. We have also identified a previously unrecognised role for HFD/obesity-induced, NLRP3

inflammasome-mediated responses in the lung the development of steroid-resistant AAD. Thus, HFD/obesity induces increased NLRP3 inflammasome responses in the lung that may be therapeutically targeted in for the treatment of steroid-resistant asthma. 

We show that respiratory infections suppress the induction of Slc26a4 in the airway epithelium in AAD. This is associated with increased levels of free H + ions in bronchoalveolar lavage. Treatment with NaHCO 3 during infection-induced SSIAAD suppressed steroid-resistant AHR. In a complementary gain-of-function study, administration of acetazolamide (a carbonic anhydrase inhibitor) in steroid-sensitive AAD, to mimic the effect of decreased Slc26a4 responses, induced steroid resistance of AHR.

Slc26a4 in promoting RA and SSRAAD. Introduction/Aim: Electronic cigarettes ("e-cigarettes") heat and aerosolise a liquid producing an inhalable aerosol often containing nicotine and flavourings. Very little is known about their potential to impact healthhowever some research indicates they increase airway resistance in healthy and asthmatic individuals and may facilitate asthma attacks. We aimed to assess the effects of e-cigarette use on lung function (early and late phase asthmatic responses; EPR and LPR respectively) in mice with and without existing ovalbumin-induced allergic airways disease.

We assessed volume and lung function using plethysmography and the forced-oscillation technique in naïve and asthmatic adult female BALB/c mice each minute for 30 minutes after an acute e-cigarette aerosol exposure. We also measured airway hyper-responsiveness (AHR) in a second group of mice 6 hours after 30 minutes of aerosol exposure. Four types of e-cigarette were tested.

For EPR studies, acute e-cigarette exposure had little effect on lung function, except for mice exposed to vegetable-glycerin vapours, which exhibited immediate, temporary impairments in lung function. There was little difference between asthmatic and non-asthmatic mice. For LPR studies, previous e-cigarette exposure did not exacerbate functional asthmatic responses, and there was a protective effect of nicotine free ecigarette vapour on inflammation. For both studies, sensitisation and challenge with ovalbumin increased AHR and cellular inflammation, and there was exacerbation of eosinophilia and neutrophilia e-cigarette exposed asthmatic mice.

This study showed that acute e-cigarette aerosol exposure has limited effects on respiratory health in a mouse model of allergic airways disease. E-cigarette aerosol exposure had both negative and protective effects on respiratory health, apparently dependent on the type of e-cigarette excipient. Until more information is available, caution should be exercised when advocating e-cigarettes as a safe alternative to tobacco smoking, especially in asthmatics. Introduction/Aim: Idiopathic pulmonary fibrosis (IPF), a fatal lung disease of unknown etiology, occurs predominantly in the elderly. The mechanisms that link aging with the persistent accumulation of lung fibroblasts (LFs) in IPF, remain incompletely understood. Fibroblast senescence, characterized by growth arrest, apoptosis resistance and a senescence-associated secretory phenotype (SASP), occurs in aging and may contribute to IPF. The aim of this study was to characterize senescence in human LFs in vitro, and to ascertain the role of mitochondrial dysfunction in the acquisition and/or reinforcement of the senescent phenotype.

Methods: IPF-LF lines established from lung tissue of IPF patients were compared with LFs of age-matched controls (Ctrl-LFs). Cell proliferation, telomere length, SASP cytokine production, senescent-associated β-galactosidase (SA-β-Gal) activity and levels of p16 and p21 were assessed by cell counting, PCR, ELISA, cytochemistry and immunoblotting respectively. Increased levels of mitochondrial DNA and superoxide, features of mitochondrial dysfunction, were evaluated by PCR and the MitoSox fluorogenic dye respectively. Rotenone was used to disrupt mitochondrial activity.

Results: IPF-LFs displayed slower growth accompanied by decreased levels of cellular protein and telomere length when compared with Ctrl-LFs (p<0.05). Conversely, IPF-LFs were more resistant to H 2 O 2induced cytoxicity than Ctrl-LFs (p<0.05). IPF-LFs also exhibited increased SA-β-Gal activity, SASP cytokine production and levels of p16 and p21 (p<0.05). Furthermore, IPF-LFs had lower levels of the mitochondria-driven proteins Bcl-2 and Bax, but higher levels of mitochondrial DNA and superoxide production than Ctrl-LFs. Rotenone (0.6 μM) increased mitochondrial superoxide in Ctrl-LFs, preceding increases in markers of senescence.

Our study suggests that IPF-LFs exhibit senescent like features, including replicative arrest, resistance to oxidative stressinduced cytoxicity and induction of a SASP. Mitochondrial dysfunction is tightly linked with senescence and is likely to contribute to the healing/ repairing malfunction of LFs in IPF. Introduction/Aim: We reported defective efferocytosis associated with cigarette smoking and/or airways inflammation in chronic lung diseases including chronic obstructive pulmonary disease and severe asthma. We also showed defects in phagocytosis of non-typeable H. influenzae (NTHi), a common colonizer of the lower airway in COPD. These defects could be substantially overcome with low-dose Azithromycin; however, chronic usage may induce bacterial resistance. We investigated two novel macrolides, GS-459755 (2'-desoxy-9-(S)-erythromycylamine) and GS-560660 (Azithromycin-based 2'-desoxy molecule) with significantly diminished antibiotic activity against S. aureus, S. pneumonia, M. catarrhalis, and H. influenzae.

NTHi (flow cytometry), secreted and cleaved intracellular IL-1β (CBA, immunofluorescence/ confocal microscopy) and NLRP3, were tested on primary alveolar macrophages and THP-1 macrophages AE 10% cigarette smoke extract. p=.043; GS-560660 23.5% and 22% p=.043, respectively). Macrophage viability remained >85% following 24h exposure to either macrolide at concentrations up to 20μg/mL. Secreted and intracellular cleaved IL-1β were decreased with both macrolides with no significant changes in recognition molecules MerTk, SRA1, TLR2/4 or CD36. Particulate cytoplasmic immunofluorescence of NLRP3 inflammasome was also significantly reduced.

We conclude that GS-459755 and GS-560660 may be useful for reducing airway inflammation in chronic lung diseases without inducing bacterial resistance. There was no effect of H or VC on expression of surfactant proteins or number of surfactant producing cells present in lung tissue.

Here we show effects of chronic fetal hypoxemia on molecular programming of oxidative stress and airway remodelling in the lung in early adulthood and that maternal antenatal antioxidant treatment is protective, offering insight into mechanism and possible treatment to improve offspring respiratory outcomes. Introduction: Iron is essential for many biological processes. Too much or too little iron can result a wide variety of pathologies. Altered iron levels and/or dysregulated iron homeostasis have been associated with a number of lung diseases, including chronic obstructive pulmonary disease, lung cancer and cystic fibrosis, however, the mechanisms that underpin these associations and whether iron plays a role in the pathogenesis of lung disease are yet to be fully elucidated.

To determine the effects of systemic iron overloading on iron levels in the lung and to assess the effects of increased iron on lung structure and function.

and function were assessed in transferrin receptor (TFR)2 mutant mice and wild-type (WT) BALB/c mice fed a 2% carbonyl iron diet compared to WT and normal diet controls, respectively. The effects of increased iron loading on murine models of bleomycin-induced fibrosis and house dust mite (HDM)-induced allergic airway disease (AAD) were also assessed.

the genetic and diet-induced models of iron overloading. Increased iron levels in the lung were associated with emphysema-like alveolar enlargement, small airways collagen deposition, alterations in baseline lung function and increased airways hyper-responsiveness (AHR). Whilst iron overloading in the absence of bleomycin administration results in the generation of fibrosis in the small airways and AHR to similar levels observed with bleomycin-induced fibrosis, iron overloading had minimal additional effects when combined with bleomycin. Iron overloading also resulted in increased eosinophilic inflammation and severe AHR in HDMinduced AAD.

Conclusion: These data show that increased iron levels in the lung results in emphysema and airways fibrosis that corresponds with reduced lung function. These models will be used to better understand the role of iron in the pathogenesis of lung disease.

fibrosing interstitial pneumonia of unknown cause and has a median survival of only 3 years. We have previously shown that dysregulated activation of the transcription factor STAT3 characterizes functionally different subsets of fibroblasts, the presence of which correlates with IPF progression. The question of what drives these phenotypically divergent cells and prolongs their lifespan remains unanswered. Our hypothesis is that activated STAT3, a transcription factor that is increased in fibrotic lung tissue of IPF patients, contributes to senescence via its roles in cytokine expression and mitochondrial dysfunction. The aim of this work is to evaluate whether STAT3 has a role in senescence of lung fibroblasts (LFs) in IPF.

Method: Primary cultures of LFs were established from lung tissue of IPF patients (IPF-LF) and control donors (Ct-LF). Senescence was induced by exposing cells to hydrogen peroxide (H 2 0 2 , 150 μM) for 2 hr. STAT3 activation was assessed at different passages or following H 2 0 2 by immunoblotting. Senescence was evaluated by measuring senescentassociated-β-galactosidase (SA-β-Gal) activity, IL-6 production and expression of cell-cycle arrest protein p21. Mitochondrial superoxide production was assessed using the mitosox flourogenic assay. STAT3 was inhibited with pharmacological inhibitors or by transfection with siRNA. Methods: Electrocardiograms were assessed for tachycardia, atrial fibrillation, right and left ventricular hypertrophy, and ischaemic changes in 389 patients. Chest radiographs were assessed for signs of heart failure in 350 patients. All assessments were done by two independent examiners blinded to cardiac biomarker status. Associations between abnormalities with at least moderate inter-rater agreement and high cardiac biomarkers (NT-proBNP >220pmol/L and troponin T >0.03ug/L or high-sensitivity >50ng/L) were analysed.

Results: High NT-proBNP values were associated with atrial fibrillation (22% vs. 6%), right ventricular hypertrophy (24% vs. 15%), left ventricular hypertrophy (15% vs. 4%), ischaemia (59% vs. 33%) on electrocardiogram and cardiomegaly (42% vs. 20%) on chest radiographs. High troponin T values were associated with tachycardia (65% vs. 41%), right ventricular hypertrophy (26% vs. 15%) and ischaemic changes (60% vs. 36%) on electrocardiogram. None of these tests were very sensitive or specific for biochemical indicators of cardiac dysfunction: the best-performing indicator for NT-proBNP was ischaemic change (sensitivity 59% and specificity 67%). For troponin T the best indicators were tachycardia and ischaemic change (sensitivity 65% and 60%, specificity 59% and 64% respectively).

are associated with abnormal cardiac biomarkers and may indicate cardiac disease in patients with exacerbations of COPD. However, electrocardiograms and chest radiographs have poor sensitivity and specificity for diagnosing acute cardiac dysfunction in this setting. Cardiac biomarkers provide additional information about acute cardiac dysfunction in patients with exacerbations of COPD.

Research Fund and the Heart Foundation New Zealand is the 3 rd leading cause of chronic morbidity and death worldwide. Cigarette smoking is the major cause of COPD in developed countries. Current therapies have limited efficacy, fail to halt disease progression, and can cause adverse side effects. Effective treatments are urgently required, however, their development is hampered by a lack of understanding of the mechanisms that promote the pathogenesis of disease. The functions of microRNAs (miRs) in health and disease are firmly established and their aberrant expression has been associated with several lung diseases, including COPD. This study aimed to identify miRs that promote the development of COPD and assess the therapeutic potential of targeting the miRs that we identify.

We performed miR microarray analyses of the lungs of mice exposed to our highly representative, cigarette smoke (CS)-induced model of experimental COPD. We identified miR-21 as one of the highest upregulated miRs. The roles and potential for targeting of CS-induced miR-21 in the lung were examined using treatment with a specific miR-21 inhibitor (antagomir, Ant-21).

Results: Lung miR-21 expression was increased throughout CS exposure in experimental COPD. Reduced lung function in human COPD patients correlated with lung miR-21 expression. Treatment with Ant-21 inhibited CS-induced lung miR-21 expression and suppressed airway inflammation and small airway fibrosis, and improved lung function, in experimental COPD. In silico analyses identified a potential miR-21/ SATB1/S100A9/NF-κB axis. SATB1 is a putative miR-21 target that negatively regulates S100A9, a known inducer of NF-κB activity. Significantly, CS exposure decreased lung SATB1 in our model, and Ant-21 treatment restored SATB1 levels and decreased S100A9 expression and NF-κB activity.

We have identified a previously unrecognised pathogenic role for a miR-21/SATB1/S100A9/NF-κB axis in experimental COPD. Our data highlights miR-21 as a novel therapeutic target for the treatment of COPD. (TLCO) is a feature of both emphysema and pulmonary hypertension. CT can quantify emphysema via the emphysema index (EI). In addition, pulmonary artery distensibility (PAD) is known to correlate with mean pulmonary artery pressure measured at right heart catheterisation and can be measured simultaneously using ECG-gated CT. The impact of pulmonary artery distensibility on the relationship of FEV 1 and Emphysema Index (EI) with TLCO has never been examined. The aim of this study is to determine the effect of PAD, FEV 1 (%) and EI on TLCO, with the hypothesis that the addition of PAD data would help account for variability in TLCO unexplained by the other two parameters.

Methods: Patients were analysed from the 4C cohort, a prospective group of patients who were recruited over a 1 year period during acute exacerbations of COPD and had subsequent ECG gated CT and pulmonary function tests performed during stable periods. After excluding patients with missing data, significant motion artefact on CT and those unable to perform TLCO, 34 patients were entered into a multiple linear regression model.

: TLCO corrected for haemoglobin was entered as the dependent variable and in order FEV1(%), EI and PAD were entered into the regression model as independent variables. Overall, the model was able to explain 62.5% of the variation in TLCO (Corrected R 2 0.625). Both FEV1(%) and EI were significantly correlated with TLCO after controlling for the other variables (FEV1(%) r = 0.512 and P<0.001, EI r = −0.431 and p = 0.003) However, after controlling for FEV1pp and EI, PAD was not significantly correlated with TLCO (r = −0.055, p = 0.637).

Emphysema Index was significantly negatively correlated with TLCO after controlling for the other variable. The addition of PAD data did not appear to add to the analysis. Introduction/Aim: The prevalence of Chronic Obstructive Pulmonary Disease (COPD) using spirometry cirteria has been extensively studied, however little evidence exists for the usefulness of Transfer Factor for carbon monoxide (TLCO) in the diagnosis and classification of COPD. The guidelines for the Global Initiative for Chronic Obstructive Lung Disease (GOLD) currently utilise spirometry predominately to aid a physician-diagnosis of COPD. Since only a relatively small proportion of smokers develop COPD, we aim to assess how TLCO can serve as a useful early biomarker for the detection of lung disease in younger smokers with normal spirometry.

We performed a cross-sectional analysis of subjects who have had both spirometry and TLCO measured at the Respiratory Laboratory at Monash Lung & Sleep, Monash Health. Subjects included male and females aged 40 to 60 years with normal spirometry and at least 10 pack-years smoking history.

One hundred and six subjects aged between 40 and 60 with normal spirometry and significant smoking histories were identified. Of this cohort, 77 subjects (73% of the group) had a TLCO below their lower limit of normal (using ATS criteria). The cohort was equally divided into 53 males (of whom 33 had a low TLCO) and 53 females (of whom 43 had a low TLCO) and fibrinogen combined with Thrombin) is a fibrin sealant indicated for use as an adjunct to haemostasis in patients undergoing surgery when control of bleeding by conventional surgical techniques is ineffective or impractical. It is widely used in general surgical procedures but remains a non-standard approach in the management of haemoptysis.

There have been recent case reports describing its effective usage in massive haemoptysis where other techniques such as bronchial embolisation, bronchoscopic suctioning or surgical resection have failed or may be ineffective. However, when TISSEEL is used independently endoscopially, migration, dislodgment or even expectoration of the fibrin clot is a common complication that leads to recurrence of haemoptysis.

We present the first ever reported case of successful endobronchial use of TISSEEL in controlling active distal bronchial bleeding. A 67 year old lady suffering from ongoing haemoptysis secondary to recurrent non small cell lung cancer involving lateral segment of left lower lobe (LB9) underwent therapeutic bronchoscopy utilising a therapeutic video scope (Olympus T180) introduced via a rigid bronchoscope which provided secure airway access. After identifying the source of bleeding, 1ml of TIS-SEEL was injected into distal LB9. A size 6 Spiration IBV was then inserted to add stability and prevent expectoration of the fibrin clot. A further 1 mL of TISSEEL was then injected proximally on top of the valve. There was excellent seal after the procedure with resolution of bleeding. Methods: Patients were selected from established criteria by a multidisciplinary team.10 patients underwent EBV insertion in the first 18 months of this program. One patient who did not have complete post procedure lung function was excluded. The change in residual volume (RV), total lung capacity (TLC) and relative change in FEV1 was calculated for each patient from testing done prior to EBV insertion compared to three month post procedure follow up. Minimally clinically important differences (MCID) were used to assess for objective response. Patients also underwent clinical review to ascertain for any subjective change in wellbeing.

There was a relative increase in mean FEV1 by 16.2% (p<0.05), a decrease in mean residual volume by 600mls (p<0.05) and a decrease in mean TLC by 540 mls (p<0.05) following EBV insertion. With regards to minimally clinically important differences, 55.6% of the patient cohort had a greater than 430mls volume reduction in their RV whereas 66.7% of the patient cohort had a relative increase in their FEV1 by more than 10%. One patient had a pneumothorax following valve insertion and one of nine patients had valve migration that required repositioning. All of the patients had a subjective response in their first clinical review post valve insertion with one patient no longer requiring home oxygen.

Our audit demonstrated both a subjective and objective benefit of EBV insertion for carefully selected patients with symptomatic emphysema on best current management. Such a program can be successful in a public hospital setting with local support. 

Of the 27 cases of NSCLC NOS, 23 patients underwent a PET scan, all of which were reported to be consistent with a primary lung lesion with nodal metastasis. All malignancy cases were discussed at a multidisciplinary case conference.

In patients who have a peripheral lung nodule and hilar or mediastinal lymph node enlargement, EBUS TBNA is an effective method of providing both diagnosis and staging, avoiding additional procedures. The use of combination pathology and PET gives convincing evidence between the nodal disease and peripheral lung lesion. lesions identified on radial endobronchial ultrasound (EBUS) images can characterise benign versus malignant aetiologies 1 . Previously reported analyses with expert defined region-of-interest (ROI) correctly classified 76.8% of lesions with a positive predictive value (PPV) of 75% 1 . However, the main limitation of that study was the restricted ROI to a maximum 32x32 pixels. The aim of this study was to assess whether unconstrained ROI selection, resulting in a larger portion of the lesion being analysed, would improve results.

Nguyen et al's study were utilised. Using custom written image analysis software, an expert physician identified an unconstrained, polygonal ROI. From this the following grey-scale features were calculated: mean, maximum, minimum, maximum -minimum, standard deviation, entropy, contrast, correlation, energy, and homogeneity. Mann-Whitney U tests were used to compare features. Receiver-operating characteristic (ROC) curves were generated and optimal cut-off points determined for malignant versus benign differentiation. The sensitivity, specificity, accuracy, and PPV were calculated.

Results: There were 46 malignant and 38 benign cases. Five greyscale texture features (maximum, maximum -minimum, mean, standard deviation, entropy) were significantly different between malignant and benign groups. Maximum, maximum -minimum, and standard deviation had area-under ROC curves of 0.85, 0.8, and 0.74, respectively. At optimal cut-off values: maximum pixel value had 78% sensitivity, 87% specificity and 88% PPV for malignancy; maximum -minimum pixel value had 67% sensitivity, 84% specificity and 84% PPV and standard deviation had 84% sensitivity, 74% specificity and 76% PPV. Maximum grey-scale pixel value had the highest diagnostic accuracy (82%). 

We performed an single-centre audit of all patients with known NSCLC who had a PET scan and also underwent EBUS-TBNA for the explicitly stated purpose of pulmonary lymph node staging from 2005-2015. A combination of bronchoscopy reports, pathology reports, imaging reports and chart reviews were used to identify patient information.

Results: Overall, 40 cases were identified; 4 were excluded due to incomplete collection of date. Of these, PET demonstrated 12 cases of low to intermediate grade bilateral lymph node uptake, 22 cases of unilateral lymph node uptake and two cases of no PET uptake. Of cases with bilateral uptake, there were no cases in which EBUS-TBNA sampling was positive for malignancy. Two cases (9%) were subsequently upstaged to positive nodal involvement when they underwent surgery. Of cases with unilateral nodal involvement on PET scan, the frequency of biobsies positive for malignancy on both EBUS-TBNA, and on those who subsequently underwent surgery was 50%. Dust inhalation was seen on biopsy specimens of 41.7% of patients with bilateral PET uptake and 13.6% of patients with unilateral PET uptake.

This case series also adds to the growing body of evidence of dust inhalation associated with PET positivity. Although symmetrical uptake on PET scanning technically represents N3 disease, both EBUS-TBNA and surgery demonstrate a low rate of positive lymph node metastases. This highlights the role of EBUS-TBNA to rule patients in for surge, rather than be excluded by PET findings alone. life-saving strategy for acute respiratory distress syndrome (ARDS), can lead to ventilator-induced lung injury (VILI) which can increase morbidity and mortality. Despite decades of research, progress in designing ventilation strategies to prevent VILI has been limited. This is in part due to our inability to assess regional responses to mechanical ventilation. The aim of this study was to use a novel non-invasive X-ray imaging approach to quantify regional responses to mechanical ventilation and explore the impact of tidal volume on regional heterogeneity in VILI. The mice were imaged using a laboratory X-ray source and acquisition was synchronised with the ventilator to obtain 4DCT images. The images were post-processed using 3D X-ray velocimetry combined with quantitative CT to obtain regional volume data (tidal volume and FRC) in situ.

Results: Qualitatively, the tissue expansion contours in the imaging data show substantial regional variation in tidal stretch in both groups in response to mechanical ventilation. Globally, after 2 hours of ventilation, for mice on the protective strategy, there was no significant change in tidal volume (−3 AE13% (SD); n = 8, p = 0.589) or FRC (−5 AE7% (SD); n = 8, p = 0.071). In contrast, mice on the injurious strategy had a decrease in tidal volume (−14 AE7% (SD); n = 6, p = 0.003), and a decrease in FRC (−25 AE5% (SD); n = 6, p < 0.001).

Preliminary results are promising and show a clear regional variation in distension for both ventilation groups. Quantitative data is possible on a regional (lobar or sub-lobar) basis with this imaging technology and is the focus of ongoing work. The results of this investigation will lead to a better understanding of VILI, resulting in improved outcomes for critically ill patients requiring mechanical ventilation. severe asthma. However, their response to treatment with high-dose, high-fine particle fraction inhaled corticosteroid/long acting beta agonist (ICS/LABA) combination has yet to be established. We aimed to measure the effect of fluticasone/eformoterol on ventilation heterogeneity measured by multiple breath nitrogen washout and on clinical outcomes. In addition we aimed to determine predictors of improvements in conductive (Scond) and acinar (Sacin) ventilation heterogeneity. We hypothesised that changing to high-dose fluticasone/eformoterol would improve Scond and Sacin, along with clinical improvement in asthma control.

Methods: 21 patients (7 males) with a doctor diagnosis of asthma, were uncontrolled (5 component asthma control questionnaire score (ACQ5)>1.5) and were currently on ICS or ICS/LABA (maximum of 500μg/day fluticasone equivalent) were enrolled. Baseline Scond, Sacin, ACQ5, exhaled nitric oxide (FeNO), airway hyperresponsiveness (AHR) to methacholine (log 10 dose response slope (log 10 DRS)) , and spirometry were measured. Patients took 250/10μg ii bd of fluticasone/eformoterol via a spacer for 8 weeks before repeat testing. The relationship between changes in Scond and Sacin, and baseline ACQ5, AHR, spirometry and FeNO were examined.

Results which is associated with ventilation heterogeneity. AHR is slow to resolve with anti-inflammatory treatment and the mechanism is poorly understood. The aim of this study was to determine if anti-inflammatory treatment reduces heterogenous bronchoconstriction by measuring low ventilation areas on VSPECT/CT and investigating the role of peripheral airway heterogeneity in this mechanism.

Methods: Twenty-one asthmatic subjects (13 female Mean AE SD Age: 31 AE 13 yrs, FEV1: 83 AE 16% Pred) had baseline and methacholine challenge VSPECT/CT scans, before and after 8 weeks of combined ICS/LABA treatment. Low ventilation was measured by changes in ventilated volume at two thresholds on VSPECT(80/50 ratio). Dose response slope (DRS) was calculated to measure AHR and is reported as logDRS.

Multiple breath nitrogen washout was performed at baseline and after treatment to determine peripheral ventilation heterogeneity (Sacin).

Results were analysed using paired t-test and linear regression. Conclusion: Anti-inflammatory treatment reduces heterogeneous bronchoconstriction measured on functional lung imaging. The reduction in the development of low ventilation areas (after challenge) with treatment is predicted by pre-treatment airway hyperresponsiveness. Peripheral heterogeneity improved with treatment but did not relate to imaging. Bronchoconstriction patterns on imaging are difficult to quantify but potentially could give valuable mechanistic insight for future treatment improvements. and an increase in the ventilatory drive. This hyperventilatory response is characterised by a worsening breathing efficiency (increased V E /VCO 2 ) and a lower end tidal CO 2 (P ET CO 2 ) both at rest and during exercise.

Whilst the time-course changes in the hyperventilatory response are wellcharacteristed in acclimated climbers, to date there has been little or no examination of the response during ascent and on return from altitude in a large group of non-acclimated climbers. The aim of the current study was to examine the changes in gas exchange measures in a group of non-acclimated climbers during the ascent of Mt Kilimanjaro and immediately on return from altitude.

Kilimanjaro during an 11-day climb. Exercise testing (4-minute step test with gas-exchange) was completed on four occasions at the following altitudes: (1) basecamp, 1 850m (P B =690 mmHg); (2) 3500m (PB=505 mmHg); (3) 4840m (PB=428 mmHg) and on return to base camp (4) 2 850m (P B =690 mmHg).

Results: During the ascent subjects became increasingly hypoxic and there was a decrease in the nadir S p O 2 during exercise (nadir S p O 2 (%): 1 850m: 96AE2; 3500m: 82AE3; 4840m: 73AE4). During exercise breathing efficiency worsened (V E /VCO 2 : 1 850m: 28.5AE2.9; 3500m: 35.8AE4.6; 4840m: 50.7AE5.8) and P ET CO 2 fell (P ET CO 2 mmHg: 1 850m: 37.1AE3.6; 3500m: 28.5AE2.6; 4840m: 20.8AE1.9) as subjects ascended.

On return from altitude ( 2 850m) S p O 2 normalised (S P O 2 (%)=97AE3 ), however there was persistent evidence of hyperventilation with both breathing efficiency and P ET CO 2 remaining abnormal during exercise (V E /VCO 2 : 32.8 +3.2, P ET CO 2 ,mmHg: 31.2+3.0; p<0.01 vs 1 850m) and at rest.

With high altitude exposure there is an increased ventilatory drive. Following high altitude exposure and once S p O 2 normalises, gas exchange remains altered. We hypothesise that this altered gas exchange may be due to a sustained alkalosis with the central chemoreceptors remaining reset to defend a lower PCO 2 established during high altitude exposure. • Patients who had a pneumothorax following TTNB who were either admitted for observation vs requiring a chest drain were recorded, including duration of hospital admission. Patients requiring a chest drain were defined as having "poor tolerance" to pneumothorax.

• Chi square and t tests were used to determine associations between age, preexisting COPD, smoking history, comorbidities, reduced lung function (FEV1 <50% or DLCO <50%) and "poor tolerance" to pneumothorax.

Results: A total of 154 TTNB procedures were carried out. 65 of the procedures (42.2%) were complicated with a pneumothorax and 13 patients (8.4%) required aspiration or chest drain. Mean length of stay (LOS) in days were 4.17 +/−8.73 for all procedures.

Of those who had poor tolerance to pneumothorax, the average FEV1 % predicted was 66.5 +/− SD 30.6 and average DLCO % predicted was 63.5 +/− SD 19.8. Ie both were moderately reduced. 7 patients (58.3%) out of the 13 patients who requred a chest drain had COPD. Chi Square testing did not show any statistically significant association between COPD and poor tolerance to pneumothorax (p=0.599).

There was no statistically significant association between older patients >70 years and poor tolerance of pneumothorax (p=0.934) or between reduced lung function and poor tolerance to pneumothorax (p=0.091).

presence of COPD/having reduced lung function/older age and "poor tolerance" to pneumothorax. This is a negative study however it was limited by its small numbers. Larger studies looking at these risk factors will be crucial to prevent unneccessary lengthy hospital stays and chest drain insertions caused by a routine TTNB procedure.

Nil declaration of interest Introduction/Aim: Endobronchial Ultrasound Guide Sheath (EBUS-GS) is used to locate and biopsy peripheral lung lesions with sensitivity and specificity of 73% and 100% respectively. (1) There is minimal data regarding a combined conventional transbronchial lung biopsy (cTBLB) plus EBUS-GS biopsy approach in the same patient. We aimed to assess the utility of this approach, and assess complication rates. Results: 73 patients were eligible with mean(SD) age 71(7) years.

43 were male. Mean(SD) lesion size was 26(3.5)mm. Of the 73 patients, lesions were successfully localised using EBUS-GS in 59(80%). Of these 59 lesions, 44 were concentric, 12 were eccentric and data was missing for the remaining 3. EBUS-GS biopsies were positive in 29 patients (49%) and definitive atypical pattern was seen in 6 patients (10%) giving a cumulative sensitivity of 60%. Brushings via guide sheath were positive in 20 patients (33%). cTBLB were definitively positive in 28 patients (38%) and an atypical cytology pattern was seen in 3 patients giving a cumulative sensitivity of 42% using non GS guided procedures. Standard brushing were positive in 15 patients (21%).

Four patients (7%) were diagnosed based on cTBLB alone, where EBUS-GS guided investigations were negative. Combining cTBLB and EBUS-GS at the same procedure increased sensitivity from 60% to 68%.

There was one small pneumothorax managed conservatively and one episode of bleeding requiring local adrenaline therapy.

: EBUS GS provides a higher success rate for diagnosis of peripheral lung lesions than cTBLB, however when EBUS-GS is combined with cTBLB, it may further increase the diagnostic yield. (LUSWE) is a novel technique to assess surface lung tissue elastic properties by measuring surface wave propagation speed using an ultrasound detector system. The surface wave propagation on lung is noninvasively generated by a local and small mechanical actuation on the skin of the chest wall.Since many interstitial diseases predominantly affect the lung periphery, these may be especially suitable for this type of assessment, non-invasively and without radiation exposure.

Methods: 7 healthy controls and 7 patients who had CT chest identified peripherally distributed pulmonary fibrosis were studied. LUSWE was performed by generating small 0.1 second harmonic vibrations at 100 Hz by indenting a 3 mm area in an intercostal space with a handheld shaker and measuring the surface wave propagation on the lung with a ultrasound probe placed 5 mm away in the same intercostal space. Three measurements, at full inspiration, were made in each of 3 locations over each lung.

Results: All measurements below were made at 100 Hz and and are in m/secAESD. Conclusion: These results suggest that LUSWE can identify a difference in wave speed between control and abnormal, peripherally fibrotic, lungs. Its reproducibility, specificity and sensitivity, and ability to detect longitudinal change are yet to be defined but it has the promising advantage of being both non-invasive and radiation-free.

Grant Support: NIH R01HL125234 from the National Heart, Lung, and Blood Institute. Conclusion: Chinese individuals with OSA have a unique sleep phenotype, compared to Caucasians, characterised by a high arousal threshold, and an increased cycling period and chemoreflex delay which is reflected in a propensity for longer respiratory events. These data suggest: (1) the mechanisms that cause OSA are influenced by ethnicity, and (2) the use of sedatives to raise the arousal threshold may be less effective in treating OSA in Chinese populations. there is a lack of understanding of host immunity and disease mechanisms during respiratory infection with CoVs. In this study, we characterised the innate immune responses of differentiated primary bronchial epithelial cells (pBECs) to infection with related less virulent OC43-CoV and 229E-CoV.

Methods: Human pBECs were obtained from subjects by brushing during bronchoscopy. Cells were grown at the air liquid interface (ALI) until differentiation with cilia beat and mucus production was observed (25-30 days). Cells were infected at a multiplicity of infection (MOI) 0.1or 1 with OC43-CoV or 229E-CoV for 6, 24, 48, 72, 96 hours and 7 days. Supernatants, total cell protein extracts and RNA were collected at each time point to measure expression of pro-inflammatory-and anti-viral-cytokines, and virus replication.

Results: OC43-CoV and 229E-CoV demonstrated different viral replication kinetics. 229E-CoV replicated earlier and more efficiently, peaking between 48 and 72 hours. This was associated with an activation of the innate host response, with induction of type I interferon (IFN-β), and IFN stimulated genes, CXCL-10 and viperin. In contrast, replication of OC43-CoV peaked later between 96 hours and 7 days. This virus demonstrated attenuated levels of IFN-β, CXCL10 and viperin. We have begun to investigate virulence factors that control epithelial responses to CoV. Sequence analysis of viral proteins (EMBO Needle) revealed only 49.2% identical matches between OC43 and 229E highlighting the potential for variation in host (epithelial)-virus interaction.

This study demonstrated that both OC43 and 229E-CoVs replicated in differentiated pBECs, but they induce a divergent innate immune response potentially linked to their different replication kinetics. Understanding the host-virus interaction for these less virulent coronaviruses will give insight into pathogenic mechanisms underpinning SARS-CoV and MERS-CoV-induced respiratory disease. of mortality and morbidity. Literature suggests that bacterial co-infections complicate 20-33% of influenza cases and contribute to a more severe and prolonged course of illness. The challenge in clinical practice remains in the identification of patients who will benefit from empirical antibiotics.

Methods: This is a retrospective audit of patients with influenza infection diagnosed on viral nasopharyngeal swab in the GCHHS between July and September 2015. Demographics, clinical and microbiological data, complications and outcomes were collected. Data on antibiotic prescription was also collected. Patients with and without bacterial coinfection were compared.

Results: 481 patients were diagnosed with Influenza infection on viral nasopharyngeal swab. Bacterial co-infection was present in 52 (11%) patients. The most common co-infecting bacterial pathogen is Staphylococcus aureus (n=13, 22%), Streptococcus pneumoniae (n=11, 18%) and Pseudomonas aeruginosa (10, 17%). Chronic lung disease and COPD were associated with a significantly higher risk of bacterial coinfection (p<0.05). Other co-morbidities examined including active smoking, active malignancy, chronic cardiovascular disease, end-stage renal failure, diabetes mellitus and immunosuppressed or immunocompromised states did not achieve statistical significance. 218 (51%) patients who did not have microbiological findings of bacterial co-infection received antibiotics. Prescription of antibiotics in this group of patients resulted in no significant difference in in-hospital mortality (p=0.22). In-hospital mortality, length-of-stay and ICU admission were significantly higher in patients with bacterial co-infection compared with those without, although 30-day mortality was similar between the two groups.

The incidence of bacterial co-infection in our cohort of patients is lower than anticipated. Our findings suggest a probable overuse of antibiotics. A group of patients who may benefit from empirical treatment with antibiotics is those with chronic lung disease and COPD. A prospective study to develop a scoring system could help identify patients who would benefit from empirical antibiotics.

Conclusion: This is the first study to develop lung function trajectories from childhood to middle age in a general population. We identified three trajectories for increased risk of COPD: (1) only accelerated lung decline in adulthood, (2) low initial lung function in childhood with normal growth and normal decline, and (3) low initial lung function in childhood with reduced growth and accelerated decline. Important modifiable childhood risk factors for these three trajectories included exposure to maternal smoking in childhood and a lack of exclusive breast feeding in very early life. Strategies to maximize lung function growth from early life as well as preventing accelerated decline are important for COPD prevention. 

The RFTC introduction was bi-phasic, initially patients had their CT scan on their first specialist assessment (FSA) (phase 2). After two months biopsy was incorporated (bronchoscopy, CT-guided biopsy, ultrasound-guided biopsy) into the RFTC (phase 3). Patients with suspected lung cancer were identified between December 2015 and May 2016 prior to the RFTC (phase 1) and the time for the diagnostic pathway was measured and compared to those in phases 2 (May to July 2016) and 3 (July to October 2016). Median times were used for statistical analysis as some patients underwent long waits for personal or clinical reasons thereby distorting the data.

Results: 212 were investigated for suspected lung cancer. Prevalence by age was normally distributed peaking 61-70, with preference for lower socio-economic deciles, equal gender and proportional ethnic distributions. Endobronchial ultrasound (EBUS) was the most utilised biopsy method, followed by bronchoscopy.

Time from GP referral to FSA between phase 1-3 improved significantly (p = 0.005). Similarly, time from FSA to diagnosis and treatment improved significantly, median times reducing from 15 to 0 (p = <0.001) and from 37 to 24 days (p = 0.004) respectively between phases 1-3. (Table 1 ) Appointment = first consultation with hospital specialist GP referral = date of the referral to specialist from general practitioner Diagnosis = date of diagnosis (biopsy report date or CT report date if no biopsy taken) Treatment = day of treatment (chemotherapy, radiotherapy, surgery or best supportive care) Discussion: The RTFC significantly shortened time to diagnosis and treatment in our population. To the best of our knowledge, this is the first study demonstrating a reduction in time to treatment for lung cancer patients in NZ in a fast track clinic. A previous study (1), using EBUS as the initial investigation resulted in faster treatment and seemed to improve survival. EBUS could easily be incorporated into the RFTC model and this may confer a survival advantage. Methods: In a prospective study of 63 consecutive patients with lung malignancy (m/f ratio 1.2, mean 66.6 AE 9.5 years), EBUS-TBNA was performed using 2-5 (median 3) aspirates with an Olympus needle (NA-201SX-4021). Smear and cell block tumour cell abundance were assessed by experienced cytopathologists on a scale from 0 (absent) to 4 (abundant). Genomic DNA was isolated from both smears and blocks, quantified then sequenced using the TruSeq Amplicon Cancer Panel (Illumina, San Diego, CA) on a MiSeq platform. Diff quik slides were digitally scanned before being used for DNA exraction.

Results: Unexpectedly, the overall cellularity was higher in the cytology slides than the cell blocks: 35/63 cases had 3-4 scores for tumour cell abundance compared with 22/64 cell blocks ( p < 0.05, Chi-squared test).39 cases provided adequate DNA for amplicon sequencing (>50 ng). The highest DNA yields from cell blocks and cytology slides were 4.80 μg and 15.96 μg respectively, with mean (standard deviation; SD) DNA yields from cell blocks (439 ng (858 ng)) and cytology slides (1745 ng (3173 ng)) differing significantly (p < 0.001, paired t-test). Extracted DNA was of good quality exhibiting DNA fragment sizes of up to 10Kb on a 1% agarose gel.

Conclusion: DiffQuik stained cytology slides present numerous advantages over FFPE cell blocks as a source of DNA for molecular pathology including increased DNA yield, and an immediate visual confirmation of adequate malignant cell sampling.

Influenza Control Guideline for Public Health Units

Influenza -Minimising Transmission of Influenza in Healthcare Facilities: 2010 Influenza Season

APA (UWA), Centre for Cell

Introduction: Airway stenting is a therapeutic intervention for the management of complex malignant and benign central airway obstruction. Our institution commenced an airway stenting program 5 years ago. We present an audit of the patient case-mix and outcomes from this service since inception.Methods: Chart review of stent insertion cases performed at Liverpool Hospital between Dec 2010 to July 2016. Indications, stent selection, peri-procedure and stent-related complications, survival and impact of stent on symptoms were reviewed.Results: 37 stents (14 silicon; 20 self-expanding metallic, 3 Dynamic Y) were inserted in 32 patients. Stent numbers increased over the first 4 years then stabilised. The case-mix consisted of emergent malignant airway obstruction and outpatients with both benign and malignant pathology. 20 patients were from the Local Health District and 12 were referred from other Health Districts. 11 patients had stents inserted for nonmalignant indications. In these patients, post-operative complications included mucous retention, stent migration, obstructing granulation tissue and mucosal flap tissue. Repeat bronchoscopies to address these complications averaged 4 procedures per patient (range 1-12). 21 patients had stents inserted for malignant indications primarily for palliative indications. 17 patients were able to be either transferred back to their referral centre to complete further therapy or were discharged from their acute hospital admission. There were 2 peri-procedural stent related deaths, 1 due to post insertion hospital acquired pneumonia and another due to central airway laceration resulting in massive surgical and mediastinal emphysema.

Stenting offers symptomatic palliation from central airway obstruction but stent related complications are common, particularly in benign conditions. For malignant airway obstruction, the short term palliative benefits allow the majority of patients to be discharged from acute hospital admission offering scope for further treatments. Further study is required to look at physiologic and QOL improvements.Deaths -TBM massive emphysema lady, GOershal (pneumonia), patients with respiratory failure, has been shown to contribute to mortality by inducing inflammation, which leads to multisystem organ failure through systemic effects. Different regions of the lung have been shown to heterogeneously respond to mechanical ventilation, which suggests that ventilator-induced lung injury may vary regionally. However, the impact of mechanical ventilation on regional lung inflammation is unknown. The aim of this study was to assess regional gene expression in response to mechanical ventilation in the healthy lung.

We ventilated two groups of BALB/c mice (n = 8 per group) for 2 h using protective [low tidal volume with moderate positive end expiration (PEEP)] or injurious [high tidal volume with zero PEEP] ventilation strategy. mRNA levels of 19 genes of interest in ten different regions of each mouse lung were quantified using qPCR array and compared between the two groups and a free-breathing control group (n=8).

The mRNA levels of ten genes were not differentially expressed between groups (P>0.05). Five genes had significantly different mRNA levels depending on the ventilation strategy (TFN-α, Cxcl-2, fos, IL-6, and Nfe2I2; P≤0.01 for all comparisons). Five genes were differentially expressed between lung regions (TFN-α, Cxcl-2, IL-1β, Vim, and Ccl-2; P<0.05 for all comparisons), while two genes had differential regional expression that depended on the ventilation strategy (IL-6, P=0.02 and Ccl-2, P<0.01).

To our knowledge, this is the first demonstration of regional variation in gene expression in response to mechanical ventilation. Our results provide critical insight into the relationship between regional lung response to mechanical ventilation and regional injury. Future studies should be aimed at understanding the link between local tissue stretch and the expression of these injury related genes. Debate continues over use of blood eosinophils (EOS) to predict ICS response, with some suggesting a cut-off of ≥2%. 1 In the WISDOM study (NCT00975195), this response was driven by patients with higher EOS levels (≥4% or ≥300 cells/μL). 2 We analysed WISDOM data stratified by prior exacerbations and EOS levels to determine if the ICS responder group could be better specified.

Post hoc analysis of the rate of moderate/severe exacerbations after complete ICS withdrawal using a negative binomial regression model to estimate exacerbations rate according to number of prior exacerbations (<2 and ≥2, estimated based on the number of courses of antibiotics or steroids in the past year) and EOS subgroups.Results: High EOS counts (≥400 cells/μL) were associated with increased exacerbations rate after complete ICS withdrawal only in patients with ≥2 prior exacerbations. Intermune. EFMW reported serving on advisory committees of Nycomed and as a speaker for AstraZeneca, GlaxoSmithKline, and Novartis; he has received research support from AstraZeneca and GlaxoSmithKline. HW has received consultancy fees and travel support from Takeda; has received consultancy fees from Almirall, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis; has received research support from AstraZeneca and GlaxoSmithKline; has received lecture fees from Astra-Zeneca, Almirall, Boehringer Ingelheim, BerlinChemie, GlaxoSmithKline, Merck, and Novartis; has received payment for development of educational presentations from Boehringer Ingelheim and BerlinChemie; and has received travel support from AstraZeneca, GlaxoSmithKline, and Novartis. Conclusion: Dynamic MDCT permits simultaneous evaluation of emphysema, PA pressure and right ventricular performance. Increased severity of emphysema appears associated with reduced PA distensibility. Impaired PA distensibility appears associated with decreased RVEF. Dynamic MDCT provides a valuable tool for assessment of heart-lung interaction in COPD. Antimicrobials were prescribed to 201 (91%) patients (Table 1) . Antibiotic number and duration of use were similar in all three groups. 57 (59%) Group 2 patients received ceftriaxone and 34 (35%) received azithromycin first line, which are recommended treatments for pneumonia but not 

Introduction/Aim: The gold standard for measuring changes in arterial CO2 in response to therapy is arterial (PaCO2) or capillary (PcapCO2) blood gas measurement. However these measurements are painful and do not allow real-time monitoring. Transcutaneous carbon dioxide (PtCO2) monitoring is painless and allows continuous monitoring of CO2 and oxygen levels and. The limits of agreement for PtCO2 compared with PaCO2 are too wide for PtCO2 to be used to diagnose hypercapnia, but the limits of agreement for change in CO2 over time are not well described. We hypothesised that the PtCO2 trend may show more precise agreement and be sufficiently accurate to guide treatment.Methods: Paired PtCO2 (SenTec AG, Switzerland) and PcapCO2 data were available from 80 adults with an exacerbation of COPD who took part in a study investigating the effect of oxygen driven versus air driven nebulisers. Repeat measurements were taken after 35 minutes. A limits of agreement analysis was performed, with estimation of the bias by paired t-test for the differences in the two measurements.

were approximately plus or minus 4mmHg for each individual measurement obtained (n=160). The mean change in PtCO2 was 1.7mmHg (SD 2.2, range −2.5 to 8.0) and the mean change in PcapCO2 was 1.7mmHg (SD 2.3, range −3.0 to 9.0), revealing an estimate of bias for change in CO2 of 0.03mmHg (95% CI −0.44 to 0.38) p=0.89.

Despite reasonably large limits of agreement between the two methods for individual measurements, there was no significant difference in the mean change in PCO2 over time measured by the two methods. Transcutaneous devices can be used to monitor the effect of change in PaCO2 over time without any significant bias, in this population. Result: The best fit model showed six distinct trajectories (Figure 1 ).Based on initial lung function at 7 years, lung function growth and decline rates, the trajectories were labelled as "early low, reduced growth, accelerated decline" (7.4%; n = 159), "early normal/high, normal growth, accelerated decline" (5%; n = 107), "early low, normal growth, normal decline" (28.7%; n = 615), "early low, accelerated growth, normal decline" (4.2%, n = 90), "persistently high" (14%; n = 300) and "normal" (40.7%; n = 871). The first three trajectories had increased risk of COPD (post-bronchodilator FEV 1 / FVC < LLN) at age 53 years compared with the "normal" group. Childhood asthma, bronchitis, pneumonia/pleurisy, maternal asthma and maternal smoking were positively associated with these three trajectories while negative associations were observed for breast feeding and childhood overweight. guided versus symptom-guided asthma management during pregnancy on the prevalence of childhood-onset asthma.

The Growing Into Asthma (GIA) study is a prospective longitudinal birth cohort following up the offspring of asthmatic women involved in a double-blind RCT comparing a treatment algorithm using FeNO in combination with asthma symptoms ascertained with the asthma control questionnaire [ACQ] (FeNO Group) against a treatment algorithm using ACQ only (clinical group) which found a 50% reduction in asthma exacerbations during pregnancy in the FeNO group. 140/179 (78%) consenting children completed the follow-up at 4-6 years of age. Four asthma-associated 17q21 single-nucleotide polymorphisms (SNPs) rs7216389, rs8076131, rs9303277 and rs2290400 were genotyped.

We found that FeNO-guided asthma management during pregnancy significantly reduced the odds ratio for childhood-onset asthma in the offspring (OR 0.45, 95% confidence interval [CI] 0.21-0.95, p = 0.04). Furthermore frequent wheeze in the past 12 months (OR 0.26; CI 0.08-0.81, p = 0.02), wheeze ever (OR 0.49; CI 0.25-0.98, p = 0.04) and recurrent bronchiolitis (OR 0.20; CI 0.06-0.62, p = 0.005), were less common in the FeNO group. Asthma was significantly associated with all four variants at 17q21 (p0.01) only in children with a past history of bronchiolitis and this interaction was significant for the majority of SNPs (p = 0.008 to 0.03). Asthma was also associated with ORMDL3 mRNA levels in PBMCs (p = 0.02) only in children with a past history of bronchiolitis and this interaction was significant (p = 0.04). Notably, no interaction between 17q21 variants and the FeNO intervention for the risk of asthma was observed.Conclusion: FeNO-guided asthma management during pregnancy significantly reduced asthma prevalence in childhood. 17q21 variants interact with bronchiolitis in early life to increase the asthma risk (geneenvironment interaction), but there is no evidence of an interaction with FeNO guided asthma mangement. Thus the prevention strategy may benefit children with and without variants at 17q21.