key: cord-0041338-y2rcn64y
authors: nan
title: Respiratory Infectious Diseases SIG: Poster Session
date: 2008-03-12
journal: Respirology
DOI: 10.1111/j.1440-1843.2008.01252_13.x
sha: 3889e5a21e19a7f964d4de55f41331aed539c38b
doc_id: 41338
cord_uid: y2rcn64y

nan

Increased airway smooth muscle (ASM) in asthma may be due to hyperplasia or hypertrophy of ASM cells. The contribution of extracellular matrix (ECM) within ASM bundles has not previously been accounted for when estimating ASM cell volume. Aim To estimate the mean ASM cell volume in ASM bundles in asthma. Methods Post-mortem tissues from control subjects (C n = 9); nonfatal (NFA n = 11) and fatal (FA n = 10) cases of asthma were studied. On 30 mm transverse airway sections stained with haematoxylin, the volume density (NV) of ASM cell nuclei was estimated using an optical disector (¥1000). The mean cell volume (VC = 1/NV) was calculated, correcting for the volume fraction of ASM (fASM) within the ASM bundle (corrected VC = 1/(NV ¥ fASM)). fASM was estimated on 0.5 mm thick sections of the same airway stained with Masson's trichrome. Basement membrane perimeter (Pbm) was used to indicate airway size. Results Table shows Mean Ϯ SD. (one-way ANOVA) *p < 0.05 for C v FA, NFA v FA.

Conclusion These data suggest that although ASM area is increased in asthma, mean ASM cell volume is unchanged. Therefore hyperplasia, not hypertrophy, of ASM cells is present in both mild and severe asthma. These results were similar for both large and small airways. Asthma is characterized by airway inflammation and remodelling which contribute to airway hyperresponsiveness and episodic airflow obstruction. Mast cell (MC) densities are higher on the smooth muscle (ASM) in asthma so their mediators may modulate other ASM functions as well as cause contraction. Aim To investigate the effect of MC mediators on chemokine and extracellular matrix (ECM) production by ASM cells from donors with and without asthma.

Methods MC were isolated from the resected lung samples of 6 patients, resuspended at 10 6 cells/ml in DMEM + 10% FBS and stimulated with IgE/anti-IgE. Supernatants (SN) were collected after 2 and 24 h and the MC lysed. Sub-confluent ASM cells from 6 donors with and without asthma were serum deprived for 72 h before MC SN/lysates were added in DMEM + 10%FBS for 48 h. IL-8 and eotaxin levels in all ASM SN and MC SN/lysates were measured by ELISA. Fibronectin and collagen IV deposition was measured in situ by immunoassay following ASM cell lysis.

Results In asthmatic and non-asthmatic ASM cells all MC SN and lysates reduced eotaxin release by up to 47% and 58%, whereas the 0-2 h MC SN significantly increased IL-8 release to 178 Ϯ 35.9% (p = 0.0339) and 169 Ϯ 49% (p = 0.0445) of the FBS control respectively. However, only nonasthmatic ASM cell IL-8 release was increased by the MC 2-24 h SN (216 Ϯ 85%; p = 0.0421) and cell lysates (215 Ϯ 47%; p = 0.0421). The 0-2 h MC SN also increased fibronectin deposition to 143 Ϯ 16% (p = 0.008) by asthmatic ASM cells only. MC SN and lysates had no effect on collagen IV deposition.

Conclusions Activated mast cell mediators differentially modulated chemokine and ECM secretion by ASM cells from donors with and without asthma. Thus mast cells may modulate their own recruitment to the smooth muscle and remodelling locally in the airways in asthma. Supported by NHMRC.

The technique of IgE passive sensitization reproduces IgE-related allergic responses in vitro and studies have validated this technique for investigations modelling allergic smooth muscle responses. There are no studies investigating effects of IgE sensitization on rhinovirus (RV) infection. We hypothesized that RV infection is enhanced by IgE sensitization, a consequence of diminished early innate immune responses.

Methods Beas-2B epithelial cells and primary culture airway fibroblasts were sensitized with IgE 24 h-7 d prior to infection with RV16. Samples of tissue culture supernatant and cell lysates were collected over a 12 h period after infection for analysis. Viral replication was measured by real-time RT-qPCR and viral titration and type I interferon mRNA by RT-qPCR. IgE receptor mRNA expression was examined using RT-PCR.

Results Initial studies to establish the model used human serum high in IgE (>1000 IU/ml), this yielded inconsistent results and it was found that purified IgE (1000 IU/ml) provided more reliable responses. Sensitization was established after 24 h IgE incubation and was comparable with up to 7 d. RT-PCR detected mRNA for the IgE low affinity receptor only after sensitization. Following RV16 infection, vRNA was increased after 24 h in IgE sensitized cells (p < 0.05), but this effect varied noticeably between and within cell lines. Cellular expression of IFN-b mRNA increased with viral infection but in cells sensitized with IgE lower levels of expression were noted (p < 0.05).

Conclusions IgE passive sensitization enhanced RV replication in vitro but the model is constrained by significant variability between and within cell lines. The effect of sensitization on RV replication may occur through the low affinity IgE receptor. Activated mast cells (MC) are present in higher numbers on the airway smooth muscle (ASM) in asthma compared with other inflammatory airway diseases. Matrix metallo-proteinases (MMPs) cleave chemokines and alter chemokine gradients by degrading the extracellular matrix and thus may modulate MC migration to the ASM. Aim To determine the levels of MMP-2, MMP-9 and their inhibitors, TIMP-1 and TIMP-2, secreted by ASM cells from donors with and without asthma. Method Confluent ASM cells were washed, serum-starved for 48 h and then stimulated with Th1 (IL-1, TNF and IFN) or Th2 (IL-1, IL-4 and IL-13) cytokines or left unstimulated. After 4 and 24 h,the SN were collected. The relative amount of pro and active forms of MMP-2 and MMP-9 in SN were determined by gelatine zymography. TIMP-1 and TIMP-2 levels in the SN were measured by ELISA.

Results Pro-and active MMP-9 were not detected. However, pro-MMP-2 levels were high in SN of ASM cells from donors with (195.6 Ϯ 47.2 % positive control/10 5 cells) and without (226.5 Ϯ 49.2 % positive control/10 5 cells) asthma. A trend to increased active MMP-2 production by ASM cells from donors with (7.3 Ϯ 2.7 % positive control/10 5 cells, n = 9) compared to without (2.9 Ϯ 0.7 % positive control/10 5 cells, n = 11) asthma after 24 h was not significant (p = 0.101). TIMP-1 and TIMP-2 levels respectively were high in the SN of cells from donors with (69.4 Ϯ 19.6 and 21.3 Ϯ 4.7 ng/10 5 cells, n = 5) and without (57.3 Ϯ 13.7 and 16.6 Ϯ 3.5 ng/10 5 cells, n = 5) asthma. Th1 and Th2 cytokine stimulation did not affect MMP or TIMP release. Conclusions Th1 and Th2 cytokines did not regulate ASM cell production of MMP-2, TIMP-1 and TIMP-2. Altered ASM MMP-2 activity is unlikely to play a role in MC chemotaxis to ASM cells from donors with asthma in vitro or their presence on the ASM in asthma. There has been a marked increase in the prevalence of asthma and other allergic diseases in the last few decades. One of the explanations for this is the change in our diet. One of the characteristics of the "Western diet" is a high intake of both saturated and polyunsaturated fat. This prompted us to compare the effects of high fat and low fat meals on the numbers of circulating eosinophils and other leukocytes. Methods We studied 12 volunteers who had allergic rhinitis and/or asthma and a peripheral eosinophil count at baseline of Ն200 ¥ 10 7 /L. This was a randomized, crossover trial with participants studied on two different days. On each occasion they arrived fasting and after bloods were drawn consumed a 3000 calorie meal. One of the meals was high in saturated fat and refined carbohydrate. The other meal was low in saturated fat and high in fruit and fibre. Bloods were drawn postprandially every hour for five hours.

Results Eosinophil counts were highest in the early morning and fell over the course of the day but the decrease was less with the high fat meal (p = 0.03). Over the same period of time the increase in lymphocytes (p = 0.016) was greater with the high fat meal. The high fat meal was also associated with greater increases in triglycerides (p < 0.0001) and cholesterol (0.004).

Conclusions In atopic individuals a high fat meal was associated with higher circulating numbers of eosinophils and lymphocytes than an isocaloric meal that was low in fat. Further studies of the effect of dietary fat on eosinophilic inflammation are warranted. Supported by the University of Auckland Research Committeee.

Intravenous gamma globulin therapy (IVIg), which is therapeutic in a variety of immune diseases, has been reported to be effective on patients with severe steroid-dependent asthma. Although FceR are known to play important roles in asthma, there are few reports about the role of Fcg?receptors in asthma. Fcg receptor IIB (FcgRIIB) is unique inhibitory receptor, which suppresses immune response. In this study, we evaluated the effect of IVIg in allergic airway inflammation in OVA-challenged mice and the mechanism of the inhibitory effects of IVIg and FcgRIIB. Method C57BL/6 mice (WT) and FcgRIIB deficient mice (KO) were sensitized with ovalbumin (OVA) and alum and subsequently challenged with nebulized OVA. Before OVA challenge rabbit IgG was administered intravenously. The airway inflammation and effects of IgG were assessed by histology, cell counts of BAL fluid and airway hyperresponsiveness.

Result Histology showed that IgG treatment ameliorated the inflammation around the airway and the vessels and hypertrophy of goblet cells induced by OVA challenge. The migratory activity of DCs is modulated in inflammatory diseases such as asthma. Recently, we reported that immature DCs express kinin receptors and that bradykinin (BK) significantly enhances the migration of immature DC in vitro. As kinins mediate many of the pathophysiological effects associated with asthma, we hypothesized that lys-des[Arg 9 ]-BK, which is produced during inflammation and acts via the B1 receptor (B1R), would inhibit migration of mature DCs. Methods Day 7 cultured human monocyte-derived DCs were matured with LPS, TNFa +IL-1b or CD40L in the absence or presence of lys-des[Arg 9 ]-BK. Maturation of DC was analysed by flow cytometry (FACS). B1R expression was assessed by reverse-transcriptase PCR and quantitative confocal microscopy. Migration of mature DC was assessed in transwell chambers with Lysdes [Arg 9 ]-BK and the chemokine CCL19 used as chemoattractants.

Results Maturation of DCs was found to result in down-regulation of B1R expression to varying degrees depending upon the maturation stimulus used. Mature DCs all demonstrated an ability to migrate toward Lys-des[Arg 9 ]-BK and CCL19. However pre-treatment with Lys-des[Arg 9 ]-BK decreased the migratory ability of all mature DCs to both chemoattractants. Conclusions Along with chemokines, lys-des[Arg 9 ]-BK is likely to play a crucial role in regulating the in vivo migration of mature DC during inflammation. The production of lys-des [Arg 9 ]-BK during inflammation potentially immobilizes mature DCs thereby facilitating locally-mediated immune responses within inflamed tissues. Supported by the Asthma Foundation of Western Australia.

Introduction Alternative or aberrant splicing is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms. The role of alternative splicing in asthma pathogenesis has not been previously investigated. We hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. We chose to use a new and innovative approach involving the use of the GeneChip (r) Exon array system together with real-time quantitative PCR to study asthma candidate genes in human monocyte-derived dendritic cells.

Asthmatic and non-asthmatic subjects provided 20 mL of blood from which peripheral blood mononuclear cells (PBMC) were isolated by Ficoll-Paque gradient centrifugation. Monocytes were separated from other leukocytes by adherence method, and differentiated into dendritic cells following incubation with defined concentrations of GM-CSF and IL-4. RNA was isolated and reverse transcribed for real-time semi-quantitative PCR and densitometry. Chi Squared test was used to assess associations between alternative splicing and asthma.

Results Data indicate splice variant expression in dendritic cells from asthmatic patients is influenced by asthma severity. Conclusion Exon expression array analysis has generated a number of asthma candidate genes with alternative splice variants. Further studies to validate these data in a replicate data set and establish the functional significance of our findings in asthma are underway. Alternative or aberrant splicing occurs in more than 70% of genes and is a major contributor to protein diversity, in which a single gene can generate structurally and functionally distinct protein isoforms 1 . The role of alternative splicing in asthma pathogenesis has not been previously investigated. We hypothesized that specific alternatively spliced asthma candidate genes contribute to the development of asthma. We chose to study one asthma candidate gene in human stimulated and unstimulated: (1) monocytes, (2) monocytederived dendritic cells and (3) lung smooth muscle cells.

Methods Asthmatic and non-asthmatic subjects provided 40 mL of blood from which peripheral blood mononuclear cells (PBMC) were isolated by Ficoll-Paque gradient centrifugation. Monocytes were separated from other leukocytes by adherence method. Up to 50% of the monocytes were then differentiated into dendritic cells following incubation with defined concentrations of GM-CSF and IL-4. Induction experiments used 1 mg/ml LPS and cells were stimulated for an optimal period of 24 hrs. RNA was isolated and reverse transcribed for real-time semi-quantitative PCR and densitometry. Chi Squared test was used to assess associations between alternative splicing and asthma. Results Data from stimulation experiments indicate splice variant production can be regulated by the inflammatory response and that this response is influenced by asthma status.

Conclusion Preliminary experiments have confirmed the presence of an aberrant splice variant for an asthma candidate gene in the primary cells studied. Further studies to confirm these data and establish the functional significance of our findings in asthma are underway.

Exposure to environmental factors, such as environmental tobacco smoke (ETS), plays a significant role in modulating pre-existing genetic susceptibilities to diseases including asthma. The Glutathione S-transferase enzymes (GSTs) play an important role in the detoxification of ETS. There are several GST isoforms and GSTP1 codes for the GST Pi isoform, which is the primary GST isoform expressed in human lung tissue. Two single nucleotide polymorphisms (SNPs) at positions 105 and 114 have been reported in GSTP1 and associated with asthma and atopy. The aim of this study was to examine the effect of these SNPs in combination with ETS, on asthma phenotypes in a cohort of asthmatic children. Children were recruited during an acute episode requiring presentation at an emergency department. Genotyping using PCR-RFLP was completed on 218 children and ETS exposure was determined by parental questionnaire. Urinary cotinine was measured in the children and was in agreement with questionnaire responses. Statistical analyses were performed using SPSS. There were no significant associations between the genotypes and asthma severity during acute exacerbations. Significant associations were found between the SNPs and atopy in this population with an odds ratio of 2.77 for the 105AA genotype (p = 0.029) and OR of 5.47 for the 114CC genotype (p = 0.002). However, when an interaction with ETS was included, the odds ratios increased to 9.02 for 105AA (p = 0.05) and 9.17 for 114CC (p = 0.020). These results suggest that there is a significant gene/environment interaction impacting on atopy in this cohort. The RAGE gene encodes the receptor for advanced glycation end-products (RAGE), a member of the immunoglobulin superfamily. RAGE activation by ligands, including amphoterin and S100/calgranulins, leads to prolonged NF-kB signalling and has been associated with chronic inflammation. Despite high levels of RAGE expression in lung tissue, little research has been undertaken into the role of RAGE in the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma.

Objective Determine genetic associations between functional polymorphisms in the RAGE promoter and severe and aspirin-sensitive asthma phenotypes.

Methods PCR and restriction fragment length polymorphism (RFLP) were used to genotype three RAGE promoter polymorphisms, -429T>C, -374T>A and a 63 bp deletion from -407 to -345, in a large case-control asthma population phenotyped for asthma severity, atopy and aspirin sensitivity.

Results No associations were identified between any of the polymorphisms and the occurrence of asthma. However, the -374A allele was linked with both severe asthma (P = 0.013) and aspirin-sensitive asthma (P < 0.001). Likewise, genotypes containing the -374A allele were strongly associated with both severe asthma (OR 2.10, 95% CI 1.32-3.36) and aspirin-sensitive asthma (OR 3.13, 95% CI 1.45-6.77).

Conclusions The -374A allele of the RAGE gene, previously shown to lead to a 3-fold increase in promoter activity, is associated with the chronic inflammatory asthma phenotypes of severe and aspirin-sensitive asthma. These results suggest that increased RAGE expression, with a concomitant increase in NF-kB signalling, may in part contribute to the inflammatory response seen in these conditions.

The global prevalence of allergic diseases is rising and Australia has one of the highest prevalence rates in the world. The role of early childhood infections in the development of allergic disease remains controversial.

Objective To examine the association between early childhood infections and the development of allergic diseases in later childhood, in high risk children.

Methods Data were analysed from the Melbourne Atopic Cohort Study (MACS) of 620 infants with 1 or more first-degree family members with atopic disease. Primary risk factors assessed were otitis media, bronchitis and gastroenteritis reported in the first two years of life. Outcomes were current asthma, hay fever and eczema at 6 years of age. Logistic regression was used to estimate crude and adjusted odds ratios.

Results Asthma was the most common allergic condition (25.4%, 95% CI 21.6-29.5%), followed by eczema (24.9%, 95% CI 21.1-29.0%) and hayfever (15.6%, 95% CI 12.5-19.1%). The most commonly reported infection was otitis media (58.9%, 95% CI 54.9-62.8%), then gastroenteritis (37.7%, 95% CI 33.9-41.7%) and then bronchitis (19.4%, 95% CI 16. [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] .7%). All 3 types of infection within the first 2 years of life were associated with increased risk of asthma. An increased risk of asthma at 6 years was seen with otitis media (OR = 1.14, 95% CI 1.02-1.3), bronchitis (OR = 1.34, 95% CI 1.0-1.8) and gastroenteritis (OR = 1.23, 95% CI 0.96-1.6). When the frequency of infection was examined, those who reported at least 3 episodes of gastroenteritis had a 3-4-fold increased risk and an almost 30% absolute increased risk (RD 0.34, 95% CI 0.08-0.59). Conclusion These findings appear to contradict the hygiene hypothesis. The findings for gastroenteritis are novel. Further examination of these associations and possible underlying mechanisms is warranted. Grant Support Asthma Foundation of Victoria, Nestle. Background Knowledge about incident cases of asthma in Australia is limited because they are not routinely reported. The ability to predict the number of new cases of asthma would be helpful in allocating resources for asthma education, management and care. Data on first use of medications for asthma gives an indication of the incidence of asthma. The objective of this study was to estimate the incidence rate of asthma by investigating asthma medication use in individuals. Methods Pharmaceutical Benefits Scheme (PBS) records for all prescriptions filled for inhaled corticosteroids (alone or combined formulation), cromones and leukotriene receptor antagonists from July 2002 to June 2005 were included. Using a 2-year look back window, any persons who had their first prescription for any of these drugs dispensed between July 2004 and June 2005 were assumed to be incident cases. Overall and age-specific incidence rates were calculated per 100 asthma-medication-free individuals. Results There were 352,082 individuals who had their first asthma medication dispensed between July 2004 and June 2005, which equates to an overall incidence rate for asthma of 1.89 per 100. The incidence was higher among children aged 0-14 years (2.07) and adults aged 65 years and over (2.45) .

Conclusions Our estimated incidence rates were consistent with those reported by others in the literature. While the PBS database was designed for administrative purposes, it can be used to estimate incidence rates for asthma. Support ACAM is a collaborating unit of the Australian Institute of Health and Welfare and is funded by the Department of Health and Ageing (DoHA). We acknowledge the Pharmaceutical Pricing and Estimates Section of DoHA for provision of PBS data. Keywords Asthma incidence, Pharmaceutical Benefits Scheme.

ROSARIO AMPON 1 , GUY MARKS 1 , TERESA TO 2 , LEANNE POULOS 1 , ANNE-MARIE WATERS 1 1 Australian Centre for Asthma Monitoring (ACAM), Sydney, Australia, and 2 Hospital for Sick Children, Toronto, Canada Background The ability to assess individual patterns of asthma medication use would have clinical relevance in targeting effective asthma education and management for this common condition. To describe longitudinal patterns of asthma medication use, we used a population-based prescription database to follow individuals from the first time they filled an asthma prescription. Asthma is more commonly listed on death certificates as an associated cause of death, in people whose deaths are attributed to other causes, than as an underlying cause of death. Understanding the importance of these associations would contribute towards an overall appreciation of the impact of asthma on mortality. The objective of this analysis was to estimate the prevalence of asthma as an associated cause of death when various other diseases were attributed as the underlying cause of death. Background ACAM currently recommend 24 indicators to measure population-level asthma health and outcomes. We examined correlations among several asthma indicators covering prevalence, morbidity and mortality to try and produce a condensed set of indicators which minimized redundancy. Methods Seven of the 24 indicators were included in this study: prevalence of ever having doctor diagnosed asthma, prevalence of current asthma, asthma-related general practice (GP) encounters, proportion of people with asthma with an asthma action plan (AAP), hospitalizations for asthma, hospital patient days for asthma, and deaths due to asthma. A correlation matrix was created for these indicators by age groups. Pearson correlation coefficients Ն0.7 or Յ-0.7 were considered strong. Results There were strong positive correlations between prevalence of ever asthma and current asthma (r = 1.0); GP visits and AAP possession (r = 0.74), hospitalization (r = 0.91) and patient days (r = 0.95); and hospitalization and patient days (r = 0.90) and AAP possession (r = 0.73). Recent Australian reports have shown that the prevalence of asthma and respiratory symptoms has decreased over the last 10-15 years. As part of a larger study investigating child health and air quality we have collected nationwide data from schoolchildren living in ACT, Victoria, Queensland, WA and SA. Methods Schools were selected based on proximity to air quality monitoring stations. Classes from years 3 to 6 were randomly selected and all children were invited to participate. Parents self completed a questionnaire that included questions about diagnosed asthma and respiratory symptoms. Results A total of 1989 children provided questionnaires for analysis. The response rate varied between states and territories and ranged from 30% to 42%. The sample comprised 51.9% girls and the mean age of children was 10.2 years.

Ever diagnosed asthma 27.9 Current asthma ('Does he/she still have asthma? ') 13.8 Wheeze in the past 12 months 16.1 Respiratory symptoms limiting activities 11.8 Missed school due to asthma or wheezing 8.8

Conclusions Despite the relatively low participation rate, the prevalence estimates for current asthma are similar to those reported in the National Health Survey 2004-05 [1] . There is no evidence of any recent increase in the prevalence of childhood asthma. Methods TAHS is a longitudinal population-based respiratory study of 8583 subjects which commenced in 1968 when they were 7 years of age. Since the initial study another 4 follow-ups have been conducted, including the most recent follow-up when subjects were 44 years of age. Lung function of the total sample was measured at baseline and in sub-samples in 3 subsequent followups. Asthma was categorized as persistent, frequent or episodic when participants reported asthma symptoms in at least 3 follow-ups, in 2 follow-ups or in 1 follow-up respectively. Results By age 7 years ever asthma prevalence was 16%. At age 44, 10% of those who had not reported asthma by age 7 had asthma symptoms while 75% of those who reported asthma by age 7 had no asthma symptoms. Hence over all only 25% of the asthma symptoms at age 44 were attributable to asthma developed by age 7. In contrast, 91% of the persistent and frequent asthmatics had developed their asthma by age 7. Persistent and frequent asthmatics had more symptoms and poorer lung function at age 7, 14 and 44 as well as more reversibility at age 44 (p < 0.05). Childhood asthmatics who also had a productive cough by age 7 were more likely to have persistent asthma than those without a cough (p < 0.05).

Conclusions Although the majority of middle-age asthma is related to postchildhood onset asthma, most severe middle-age asthma has its origin in persistent childhood disease. Having productive cough in childhood may identify high risk asthmatics who require especially rigorous management in early life. One third of women experience an improvement in asthma during pregnancy, and symptoms improve in most women in the late third trimester. We hypothesized that the exacerbation rate would be reduced and that symptoms during exacerbations would be less severe in the third trimester compared to the second trimester. Methods Pregnant women with asthma (n = 81) were prospectively followed from recruitment (14.8 weeks (3 SD) ) to delivery at clinic visits (18, 30, 36 weeks and during exacerbation), and fortnightly phone calls. The asthma control questionnaire (ACQ) was administered at each contact and exacerbations classified as severe (requiring medical intervention) or mild (selfmanaged). Lung function, medication use, fractional exhaled nitric oxide (FENO) and full blood counts were assessed. Paracetamol is commonly used in infants as an analgesic and antipyretic. It has been hypothesized that frequent paracetamol consumption may result in reduced lung capacity to cope with oxidative stress and increase risk of respiratory disease. To date, no study has examined exposure to paracetamol during infancy, when lungs are still developing, and risk of childhood asthma. Method A birth cohort of 620 infants with an atopic family history was recruited. Frequency of paracetamol exposure was prospectively documented up to 2 years of age. Interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. Results Paracetamol exposure in infancy was common (97% exposed by two years of age), with some infants receiving paracetamol on up to 77 days. It has been hypothesized that mucosal immune response requires a particular micro-flora milieu in the infant's gastro-intestinal tract, and that early life antibiotic exposure may disrupt this process and increase risk of allergic disease. Method A birth cohort of 620 infants with an atopic family history was recruited. Exposure to oral antibiotics was prospectively documented up to 12 months of age. Interviews were conducted at 6 and 7 years to ascertain asthma in the previous 12 months. Results By one year of age, approximately 80% of infants had received at least one course of oral antibiotics. The prevalence of current asthma in childhood was approximately 30% (148/495). Frequent use of antibiotics (more than 20 days exposure during first year of life) was associated with increased risk of childhood asthma (OR = 2.52, 95% CI = 1.40-4.54) when compared to infant who had not been exposed. Excluding infants with a diagnosis of asthma within the first two years of life, reduced this association by about 30% (OR = 1.80, 95% CI = 0.90-3.57) and adjustment for gender, parental history of asthma and number of infections in the first year of life further reduced this association (OR = 1.60, 95% CI = 0.79-3.22).

The increased risk of childhood asthma associated with antibiotic exposure in the first year of life is, at least in part, due to confounding with early life wheeze and infections. If real, the independent effect of antibiotic exposure on risk of childhood asthma is likely to be minimal in this high risk cohort. Support Dairy Australia, CRC for Asthma and Airways, VicHealth, Nestle.

The epidemiological data on asthma suggest a gender difference that varies with age. Hormonal effects have been suggested as a possible explanation for these differences. The aim of this study was to examine reproductive factors and risk of asthma among the females of the Tasmanian Longitudinal Health Study (TAHS). Methods The TAHS is a longitudinal population-based cohort study of respiratory disease which commenced in 1968 when subjects were 7 years of age. Four follow-up studies have been conducted including the current most comprehensive follow-up with subjects at 44 years of age. Information has now been collected on reproductive factors such as number of pregnancies, age at pregnancies, age at menarche and contraceptive pill use as well as on asthma status. Reproductive factors were examined as risk factors for asthma using multiple logistic regression to adjust for all likely confounders. Results A total of 2,776 women completed the most recent postal survey. Of these 355 (12.8%) had current asthma, and of these women with current asthma 73.5% (261) developed asthma after childhood. On average these women were in their mid-twenties when they developed asthma (mean Ϯ SD age = 26.6 Ϯ 12.5 yrs). We found with increasing age at first birth an approxi-mate~30% reduced risk of current asthma in women who developed their asthma post-childhood (trend p = 0.04). We did not observe any other associations between reproductive factors and risk of asthma. Conclusions Our results are consistent with the hypothesis that early pregnancy may promote asthma development by altering the immune response favouring a TH2 pathway. A delay in the age of first pregnancy reduces this risk of asthma. Grant Support NHMRC, Clifford Craig Foundation, Victorian & Tasmanian Asthma Foundations.

Introduction The association between exposure to pets in early life and subsequent development of sensitization and allergic disease remains controversial. The objective of this analysis was to examine the relationship between cat exposure before birth and development of cat sensitization over time within the Melbourne Atopic Cohort Study (MACS). Methods The MACS is a prospective longitudinal cohort study that initially recruited 620 women antenatal in Melbourne from February 1990 to November 1994. Detailed information on cat exposure was collected at recruitment and frequently until two years of age. Skin prick test (SPT) were conducted at 6, 12, 24 months and 10 years. The data were analysed by logistic regression and using Generalized Estimating Equations (GEE) for the repeated measures design.

Results Among 620 subjects, 169 (28.8%) had a cat before birth. At 6 months, 1.9% (n = 11) of subjects were sensitized to cat and by 10 years of age 18.8% (n = 68) were sensitized. Those who did not have cat before birth belong to a higher social class, and were more likely to have a father with allergic disease than those with a cat. Those who developed sensitization to cat were more likely to have a paternal family history of allergic disease and more likely to be sensitized to other allergens. We did not observe any association between exposure to cat before birth and the development of sensitization to cat at 6 months (OR = 0.7, 95% CI 0. 1-3.3) , 12 months (OR = 1.4, 0.5-3.9), 24 months (OR = 0.76, 0.2-2.5) or 10 years (OR = 0.6, 0. 2-1.4) . These crosssectional results were confirmed by the GEE analysis. Conclusion Our results fail to show an association between cat exposure before birth and development of sensitization to cat. Furthermore exposure after birth in the first 18months of life was not associated with an increased or decrease risk of sensitization to cat. Our results do not support either a benefit or risk associated with cat ownership and sensitization.

Introduction Peri-natal events influence the development of asthma and atopic diseases in childhood but the current literature is contradictory on the effect of low birth weight, small for gestational age and prematurity on asthma risk. The aim of this study was to assess the relationship between these three exposures and asthma from childhood to adulthood. Aim To assess the current prevalence of DDA, wheeze (<12 months), atopy and AHR in children and adults in Busselton. Methods An age-and sex-stratified random sample of adults, selected from the electoral roll, was invited to complete a questionnaire and attend the local study centre for assessment of atopy (allergen skin tests) and AHR (methacholine). All children from participating primary and secondary schools were also invited to attend. The prevalences of DDA, wheeze, atopy, AHR and "current asthma" (wheeze + AHR) were calculated. Background Asthma is often associated with comorbidity, however few studies have investigated comorbidities among people with this common condition. The objective of this analysis was to describe patterns of non-respiratory comorbidity among adults hospitalized with asthma in Australia. Methods Data on hospitalizations for people aged 15 years and over with a principal diagnosis of asthma (J45, J46) were obtained from the Australian Institute of Health and Welfare's (AIHW) National Hospital Morbidity Database for the period 2005-06. Patterns of comorbidity were examined by investigating additional diagnoses for non-respiratory disease according to ICD-10 diseasespecific chapters.

Results Among people aged 15 years and over hospitalized in 2005-06 with a principal diagnosis of asthma (16,566 hospitalizations; 70% female; 47% aged 35-64 years), 33% had at least one non-respiratory comorbidity. Median length of stay was higher among those with at least one comorbidity (4 days) than among those with no comorbidities (2 days). Among people aged 15-64 years, the most common comorbid condition was endocrine, nutritional and metabolic diseases (19%), while among those aged 65 years and over it was diseases of the circulatory system (32%).

Conclusions A large proportion of asthma hospitalizations in Australia are associated with non-respiratory comorbidity and a longer length of stay. Further, the pattern of non-respiratory comorbidity associated with asthma hospitalizations varies by age. Given our rapidly ageing population, the level of comorbidity associated with asthma has implications for coordinated health care and demand on health services. Support ACAM is a collaborating unit of the AIHW and is funded by the Department of Health and Ageing. Keywords Comorbidity, Hospitalization, Asthma. Background Asthma exacerbations are often triggered by viral respiratory infections, yet the influence of respiratory infections on the morbidity of acute asthma beyond the immediate period is unknown. We examined the influence of nasopharyngeal (NPA) respiratory viral, Chlamydia and Mycoplasma detection on asthma morbidity in children presenting to the Emergency Department for an acute exacerbation of asthma. Methods A subset (n = 78) of the 201 children enrolled for a randomized controlled trial (RCT) on the efficacy of 5 vs 3 days of oral prednisolone had an NPA taken at presentation. NPA were examined for Chlamydia, Mycoplasma and respiratory viruses (enteroviruses, coronaviruses, human metapneumovirus, adenovirus, parainfluenza, influenza, RSV, rhinoviruses) by PCR. Enrolled children were aged 2-16 years with recurrent wheeze and required Ն600 ?g (MDI/spacer) or Ն2.5 mg (nebulized) of salbutamol to reduce tachypnoea. Parents filled validated diary cards for cough and asthma severity, and completed asthma QOL data at enrolment and end of weeks 1 and 2.

Results PCR for various viruses was positive in 42 (53.8%) children, with no significant difference in the groups the children were randomized into. Rhinovirus PCR was positive in the NPA of 32 children, RSV in 7, hMPV in 2, adenovirus, parainfluenza, influenza A and B in one each. Specimens were negative for the other micro-organisms listed above. Children with a NPA viral positive state were significantly (p = 0.002) younger than those with a negative state. However, there was no difference in the any of the asthma outcomes of children whose NPA was positive or negative for the micro-organisms tested.

Conclusions In children with an acute asthma exacerbation presenting to emergency health facilities, a respiratory virus could be identified in >50% but the presence of a respiratory virus did not influence the morbidity of the asthma exacerbation at presentation or at the end of week-1 and week-2. The University of Sydney, NSW 2006, and 3 Royal North Shore Hospital, St Leonards, NSW 2065 Airway wall thickness measured using HRCT is reported to be increased in asthmatic compared with control subjects. However, it is unknown whether wall thickness is a fixed structural characteristic of the airways or if it responds to transient changes in bronchomotor tone or airway size. Aim To determine the effects of bronchomotor tone and lung volume on airway wall area measured by HRCT. Methods 8 patients with doctor-diagnosed asthma had partial chest HRCT scans, before and after bronchodilator (BD), at FRC, TLC and a volume midway between (MID-volume). Airway segments were identified between branch points and matched between consecutive lung volumes both before and after BD, and also at constant lung volume before and after BD. Mean lumen areas and wall areas for each airway segment at each volume were measured using automated analysis software. Paired t-tests were used to determine changes due to BD and lung inflation.

Results 44 airways were matched before and after BD at FRC. Absolute airway wall area (WA) was related to airway lumen diameter (Di Wood smoke air pollution is of concern with respect to respiratory health due to its complex chemical composition and potential to carry air toxics into the lower respiratory system. Launceston has a long history of poor winter air quality, primarily due to use of domestic wood heaters. Participants in Hobart had a similar prevalence of wood heater use, but Hobart does not experience the same wood smoke pollution (due to differences in regional geography , asthma control and anxiety and depression were completed at baseline, immediately following (6 wks), and 3 mths after the intervention period. Results Clinically and statistically (P < 0.05) significant improvements in QOL were observed in the exercise group at 6 wks compared to the control group. This difference was not maintained at 3 mths. 6MWD improved at 6 wks and 3 mths in the exercise group (p < 0.01), however the difference between groups was not significant. In the exercise group there was a trend towards improved asthma control and a reduction in anxiety and depression that was not observed in the control group. *P < 0.05, change at 6 wks vs baseline; Home asthma monitoring is important for measuring day-to-day variation in lung function and symptoms. This approach requires the availability of complete diaries for a comprehensive assessment. We assessed the completeness of written diaries collected as part of a nation wide study of air quality and child health. Methods Children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified from a cross-sectional study. These children were asked to record symptom scores and peak expiratory flows twice daily in diaries for a five week period. The diaries and peak flow devices were explained at a face-to-face meeting with parents and children. Each week diaries were mailed back and parents received a phone call to encourage completion. Completeness was defined as no missing responses to symptom questions or peak flow measurements in diaries from week two to week five. Results Data from the first 36 children (822 day records) were available for analysis. The sample included (53%) girls, mean age 10 yrs. The overall frequencies for complete records were; morning symptoms 85%, morning peak flow 85%, evening symptoms 83% and evening peak flow 82%. There was a significant trend for more complete morning peak flow records over the four weeks (Cochrane-Armitage trend test p < 0.007). Agreement between morning and evening symptom completeness and between morning and evening peak flow completeness was fairly poor (Kappa < 0.30).

Conclusions The completeness of symptom and peak flow records collected in this study was very high. The comprehensive follow-up protocol implemented is likely to have had an important impact on the completeness of asthma diaries. Daily peak expiratory flow (PEF) monitoring has been used in epidemiological studies to assess changes in lung function over time. The value of written PEF diaries has been questioned because of problems with completeness and validity. This study aimed to compare stored electronic PEF data and a written diary record of those data in a panel study in children with weekly reminders to aid adherence. Methods Children who had ever been diagnosed with asthma and had respiratory symptoms in the last year were identified in a population study. They were given electronic PEF devices with a digital readout (MiniWright Digital, MWD, Clement Clarke, UK) and written symptom and peak flow diaries and instructed in their use at a meeting with parents and children. Each child was asked to complete three PEF manoeuvres every morning and evening for five weeks and to record these in the written diary. Background Previous research suggests that comorbid anxiety is associated with lower asthma-related quality of life (AQOL) in adults with asthma. However, research is scant on the role of psychological interventions in these patients. Aim To evaluate the effectiveness of a four-session cognitive-behavioural therapy (CBT) intervention, in improving the AQOL, in participants with anxiety and asthma. Method Participants identified with comorbid anxiety and asthma were randomly assigned to the CBT intervention group (n = 10) and the asthma monitoring control group (n = 8) and evaluated on AQOL measures, at various intervals.

Results Nine participants, in the CBT group, completed the study. Seven participants showed a clinically significant improvement in asthma-related emotional functioning (EF) and six participants in total AQOL scores, at the 5-week post-intervention assessment. Additionally, six participants in the CBT group indicated clinically significant improvement in EF and five participants in total AQOL scores, at the 3-month follow-up assessment. Only three participants in the control group completed the study. None of these participants showed any improvement in AQOL scores at the 5-week or 3-month assessment.

Conclusion This pilot study suggests that a higher number of participants in the CBT group showed clinically significant improvement in EF and total AQOL scores with higher retention rates. Further research needs to confirm these findings in a larger group, identifying the elements of a successful CBT intervention and characteristics of participants who respond to the CBT intervention. Gastro-oesophageal reflux disease (GORD) is a risk factor for uncontrolled asthma. We conducted an update of a systematic review to assess whether treatment of gastro-oesophageal reflux in subjects with asthma improved asthma outcomes. Methods Randomized controlled trials (RCTs) of GORD treatment in adults or children that reported asthma health outcomes and had symptomatic GORD were included and assessed in accordance with the standard Cochrane systematic review process. Subjects received pharmacological therapies compared with conservative management. Results From 261 potentially relevant studies, 19 RCTs were included in the review. When compared to placebo, morning peak expiratory flow did not significantly improve (change from baseline WMD 10.43, 95% CI: -9.55 to 30.42) with proton pump inhibitor treatment (n = 7 trials involving 739 participants). Asthma exacerbations were not significantly less in the intervention groups compared with the control groups (odds ratio 0.66; 0.41-1.08; n = 557). Conclusions While some trials reported evidence of asthma improvement with GORD therapy, overall there appears to be no statistically significant evidence of a beneficial effect. It is clear that not all persons with GORD and asthma will gain improved control over their asthma with GORD therapy; this may be due to the heterogeneous pathophysiology of asthma. Future large-scale trials would be required to demonstrate an effect on asthma exacerbations. KEL and BRD were supported by a Cochrane Airways Group Scholarship. Background The ATS/ERS task force recommend the use of metered dose inhaler (MDI) and spacer for airflow limitation reversibility testing. Salbutamol given via MDI & spacer has been shown to be equivalent to a nebulizer in the clinical setting. This has not been well studied in respiratory laboratory setting. Aim To compare the 2 methods of reversibility testing in a laboratory setting. Methods We conducted a laboratory based crossover study in a secondary hospital. Patients with asthma or COPD were eligible. The patients firstly underwent spirometry and reversibility testing following a standard dose of nebulized salbutamol. They were asked to return for a second set of spirometry within the same week and at the same time of day when reversibility with an MDI and spacer was recorded. We used an incremental dose of salbutamol starting from 2 puffs and up to 8 puffs. Spirometry parameters were recorded 10 minutes after each intervention. The primary outcome was the percentage change in FEV1 after each intervention. Side effects were monitored for.

Results Nine patients with asthma were recruited. The mean percentage change in FEV1 was higher in the nebulizer group than after only 2 puffs via MDI & spacer (15.4 Ϯ 7.4 vs 6.2 Ϯ 8 [mean Ϯ SD], p = 0.67). However, there were no differences between the 2 arms following higher doses of bronchodilator via MDI & spacer. The mean percentage change in FEV1 after 4, 6 and 8 puffs were 12.6 Ϯ 11.3, 15.4 Ϯ 12.3, and 17.7 Ϯ 13.6 respectively (p = 0.09, 0.05 and 0.07 respectively when compared to the nebulizer group). Conclusion Using an MDI and spacer for bronchodilator reversibility is equivalent to that of a nebulizer and should be the standard method of testing. The dose of bronchodilator needs to be at least 4 puffs as recommended by the ATS/ERS; however 6 puffs correlated best with a standard nebulizer route. Further increments in bronchodilator dose provided little additional bronchodilatation. The study was limited by the small number of patients.

Asthma guidelines recommend a stepwise approach to treatment. The role of inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) combination therapy in asthma written action plans is not clear.

Objective To assess the efficacy of adjusting ICS/LABA combination therapy in a written action plan compared to fixed dosing in people with asthma requiring maintenance ICS.

Methods Cochrane systematic review of randomized controlled trials comparing ICS/LABA combination therapy in a single inhaler that is adjusted up or down according to a written action plan (WAP) to comparison 1: budesonide/ formoterol given as a fixed maintenance dose (FD) (n = 9) or comparison 2: fluticasone/salmeterol FD (n = 2).

Results 10 parallel randomized controlled trials describing 11 interventions met the inclusion criteria. For the trials that compared WAP to FD budesonide/ formoterol there were significant reductions for the WAP group in exacerbations, (RR (95%CI): 0.82 (0.70 to 0.97)), severe exacerbations (RR (95%CI): 0.61 (0.37 to 0.99)) and study medications (WMD (95%CI): -1.18 (-1.23 to -1.14)) with no difference in asthma control or adverse events. The results for the two trials reporting WAP budesonide/formoterol to FD fluticasone/ salmeterol were discordant and a homogenous pooled result could not be determined. Of the 318 Australians who died from asthma in 2005, over two thirds were over 50 years of age. This trend resulted in the National Asthma Council of Australia (NAC) calling for better management of asthma in the elderly. We designed an educational intervention using evidence based educational strategies to improve the content and style of general practice consultations for older people with asthma. Methods Randomized controlled trial of a multi-faceted program consisting of a group educational session, a videotaped standardized Simulated Patient Consultation, followed by an Academic Detailing session. Forty-two GPs were randomized into an active or a control group. GPs provided the names of patients who would be happy to participate in the study and the program was evaluated by patient and GP outcomes. Results GPs recruited into our program reported improvements in a range of clinical areas. One hundred and ten patients were recruited, their outcomes are under analysis. Conclusion GPs were overwhelmingly positive about participation in this trial and our intervention successfully improved the capacity and confidence of GP's to deliver care to older people with asthma. Our study also developed several tools that would enable dissemination of our findings. Supported by an Asthma Targeted In studies where direct clinical assessment is not possible, urgent health care utilization (HCU) is often used as an indirect measure of asthma control. This study aimed to identify factors predicting urgent HCU and asthma control. Methods Patients in NSW with a doctor diagnosis of asthma were recruited from community pharmacies, a research volunteer database, and databases of Asthma Foundation NSW, to complete a questionnaire about asthma. Poor asthma control was defined as Asthma Control Questionnaire (ACQ) score Ն1.5. Urgent HCU was defined as hospitalization, ED visit, or urgent doctor visit due to asthma. Multiple logistic regression was used to identify predictors of poor control and urgent HCU. Results Questionnaires were completed by 608 adults (61% female) with a doctor diagnosis of asthma (Pharmacy 260, Woolcock 299, Asthma Foundation 87). 87% used inhaled corticosteroid (ICS) Ϯ long-acting b2-agonist in the last 4 wks. Median age was 56 yrs (range 12-87), and 9% were current smokers. Mean ACQ score was 1.4 (95% CI 1.3-1.5), with 40% of participants having poor asthma control (ACQ Ն 1.5). 28% had urgent HCU for asthma in the previous year. Significant independent predictors for poor asthma control were younger age, current smoking, living in more disadvantaged areas, being retired, having only primary education, and holding a concession card. Predictors for urgent HCU were younger age, being in full-time employment, having only primary education, and being of non-English speaking background. Neither ICS use nor possession of a written asthma action plan was associated with lower risk for either poor asthma control or HCU.

Conclusions Poor asthma control is common in NSW even in patients using inhaled corticosteroids. Although urgent HCU is often used as an indirect measure of poor asthma control, it is affected by different factors, perhaps because health care utilization represents a more complex balance between need and access. Bronchial challenge tests with mannitol, to measure airway hyperresponsiveness, can take up to 30 minutes and require inhalation of up to 635 mg of mannitol. Our aim was to determine if positive mannitol challenges can be detected after half the maximal dose (315 mg) using the forced oscillation technique (FOT) to measure response.

Methods 15 non-asthmatic subjects and 52 asthmatic subjects underwent standard mannitol challenge, up to 635 mg mannitol. Respiratory system conductance (Grs) and reactance (Xrs) was measured by FOT at 6 Hz during 40 sec tidal breathing immediately after each dose of mannitol. FEV1 was measured after FOT, within 90 sec of mannitol administration. Two point dose response slope (DRS), was calculated for Grs (DRSGrs) and Xrs (DRSXrs) for standard tests, up to 635 mg, and for short tests by excluding data from doses above 315 mg. Ability to detect a positive test, defined as PD15FEV1 < 635 mg, was determined by the area under the ROC curve (AUC) and repeatability by intra-class correlation coefficient (ICC).

Results 32 asthmatic and 2 non-asthmatic subjects had positive tests, with PD15 FEV1 values from 9.2 to 622 mg. AUC (95%CI) did not differ between standard (std) and short tests for DRSGrs (p = 0.14) or DRSXrs ( Combined use of inhaled steroids (ICS) and long acting beta-agonists (LABA) have an important role in asthma management. We used data from a 2006 population sample to examine medication use in adults and children. Methods All adults (18-75 years) and children (2-17 years) from within four discrete zones in northern Sydney were eligible for an interview survey, as part of a study investigating health effects associated with traffic-related air pollution. The prevalence of use of short-acting beta-agonists (SABA), any ICS (alone or combination) and combined formulations of ICS/LABA in the previous three months was estimated for the study population and those with diagnosed asthma.

Results There were 806 children [mean (SD) age 8.7 (4.6) years and 50% female] and 2184 adults [mean (SD) age 45.6 (14.9) years and 56% female] interviewed in 1843 households, representing an overall response rate of 33%. The prevalence of ever diagnosed asthma was 16.1% in children and 17.4% in adults. Medication data were missing for 301 subjects. Background Asthma affects 1:9 adult Australians and is a leading cause of rejection for recruitment into the Australian Defence Force (ADF). Within this diagnosis there is a wide spectrum of disease activity and clinical outcomes. Also asthma assessment and management has improved so that many asthmatics are now fully active without any significant disruption or risk to their lives. Hypothesis: There is a subgroup of asthmatics who are at very low risk from significant adverse effects from asthma and who could be considered for recruitment to the ADF. Aims 1. To identify the subgroup of asthmatics who could be considered for recruitment to the ADF. 2. To develop an assessment process to identify this subgroup (screening). 3. To develop a process to evaluate the outcomes of any change to the recruitment standard for asthma (evaluation). Methods 1. A literature review of the natural history, assessment, management and response to treatment of mild episodic and mild persistent asthma. 2. A literature review of asthma in the military. 3. A clinical review of the outcomes of known asthmatics in the ADF. 4. An expert group to review the above and to develop a screening process and an evaluation of the program.

The literature review identified a subgroup of asthmatics, defined as mild episodic and mild persistent, who with appropriate management, have a low risk of significant adverse asthma outcomes. They can be identified by a combination of questionnaire, spirometry and bronchial provocation testing. A screening process has been developed which allows asthmatics to be recruited with a negative mannitol or hypertonic saline challenge on 400 mg/day or less of budesonide (or equivalent) without LABA. A methodology to evaluate the impact of these changes on the recruitment standard has also been developed. Alexithymia is a personality trait associated with difficulty identifying and communicating emotional and physical feelings. It has been associated with poor control of asthma and near fatal asthma. The primary objectives of this study were to: (1) identify alexithymia in a cohort of Australian asthma patients; (2) investigate the relationship between alexithymia and asthma control; (3) investigate the relationship between alexithymia and asthma management. Methods Cross sectional study of 25 moderate to severe asthma patients recruited from Royal Adelaide Hospital Outpatients. Participants were either mailed the questionnaire pack or completed it after a clinic appointment. Existing validated questionnaires were used. Statistical analyses were performed using SPSS.

Results 11 male (44%) and 14 female (56%) patients with moderate to severe persistent asthma (mean age 44 years, SD = 11) participated. Alexithymia scores ranged from 23.0 to 76.0 (X = 48.3, SD = 13.2). 12% (n = 3) of participants could be classified high alexithymia, 32% (n = 8) borderline alexithymia and 56% (n = 14) were low alexithymia. Alexithymia mean scores were not statistically different across sociodemographic variables. A positive correlation/association was found between alexithymia score and asthma control score (r = 0.57, p < 0.01), quality of life (r = -0.65, p < 0.01), and adherence (p = 0.03) but not satisfaction with communication (r = -0.27, p = 0.2) or number of hospitalizations (p = 0.25).

Conclusions This is the first Australian study to identify alexithymia among asthma patients and investigate relationship to control as well as management and communication. Associations between alexithymia and asthma control were confirmed. A larger sample size is needed to determine impact of alexithymia on self-management and provision of clinical care for asthma. Port Hedland is impacted by iron-containing dust particles (PM10) that may activate lung cells when inhaled. Furthermore, the effects of Port Hedland PM10 may differ from the effects of urban PM10 impacting metropolitan areas. The aim of this study was to assess the effects of Port Hedland PM10 on production and release of the inflammatory cytokines, IL-6 and IL-8, by human airway epithelial (A549) cells, and to compare these with the effects urban PM10 from metropolitan areas. Methods Human airway epithelial (A549) cells were exposed to PM10 collected at Port Hedland and at urban locations (Sydney, Perth). A549 cells were exposed to a range of PM10 concentrations (20-200 mg/ml) for 24 h. Lipopolysaccharide (LPS) and phorbol myristate acetate (PMA) were used as positive controls. Supernatants from cell cultures were assayed for IL-6 and IL-8 using specific ELISA kits. RNA was extracted and reverse transcribed to cDNA. IL-6 and IL-8 mRNA expression was quantified by duplex real-time PCR using TaqMan primer/probes. Results LPS stimulated a 2.7-fold increase in IL-8 release and PMA stimulated a 3-fold increase in IL-8 release and a 30-fold increase in IL-6 release. However, neither Port Hedland PM10 nor urban PM10 stimulated concentration dependent release of IL-6 or IL-8 by A549 cells. Expression of IL-6 or IL-8 mRNA was also not altered by Port Hedland or urban dust. CD8+ T-cells may cause airway epithelial cell apoptosis via the granzyme pathway. We have reported increased apoptosis of airway epithelial cells and increased BAL T-cell expression of granzyme b in COPD, and a positive correlation between the two. We hypothesized that the increased granzyme b would also be related to smoking history (pack years -Pk/y), age and severity of airflow obstruction (FEV1 %pred) in patients with COPD. We further hypothesized that the T-cell granzyme b expression would be higher in the airway than the peripheral blood.

Methods We investigated T-cell intracellular granzyme b expression in blood from COPD subjects (33 current and 24 ex-smokers) and 12 never-smoker controls, and bronchoalveolar lavage (BAL) and bronchial brushing (intraepithelial T-cells) from a cohort of these subjects using flow cytometry. Correlations between granzyme b and Pk/y, age or FEV1 were performed using Spearman's rank correlation. Granzyme b in T-cells from blood, BAL and bronchial brushings were compared. Results There were significant correlations between FEV1 and granzyme b expression in blood and BAL (blood: r -0.444, p = 0.002; BAL: r -0.368, p = 0.029). There was a significant correlation between Pk/y and granzyme b expression in blood (r 0.362, p = 0.002), but not in BAL. There were no significant correlations between granzyme b and age. There were no significant differences in granzyme b expression in blood, BAL or intra-epithelial compartments.

Conclusion Granzyme b is expressed at similar levels in blood, BAL and intra-epithelial compartments, supporting recent opinion that COPD is a systemic disease. T-cell granzyme b is related to severity of airflow obstruction and smoking history in patients with COPD and may be one mechanism of apoptosis leading to lung injury and airflow obstruction in COPD.

JC ALLEN 1 , T SCHLOSSER, EE RAMSAY 1 , Q GE 2 , AJ AMMIT 1

As development of remodelled airways is correlated with deterioration of lung function, we require therapies that reduce and reverse structural changes in remodelled airways. In asthma, corticosteroids can halt some, but not all, aspects of airway remodelling. Therefore, in order to aid future design of efficacious anti-remodelling agents we need a better understanding of the molecular mechanism/s underlying the development of airway remodelling and the effectiveness of corticosteroids. Hyperplasia of airway smooth muscle (ASM) is a feature of the remodelled airway in asthmatics. In this study we examined the effect of corticosteroids on a key regulator of G1 progressioncyclin D1. ASM cells from n = 8 non-asthmatics and n = 7 asthmatics were pretreated for 1 h with vehicle or dexamethasone (0.1 mM). The temporal kinetics of cyclin D1 mRNA and protein expression were measured up to 24 h after stimulation with the mitogen platelet-derived growth factor-BB (PDGF-BB). PDGF-BB induced a significant increase in cyclin D1 mRNA expression in ASM from non-asthmatics (2.6 Ϯ 0.3-fold) and asthmatics (2.9 Ϯ 0.3-fold) after 24 h stimulation. In non-asthmatics, the corticosteroid dexamethasone significantly (P < 0.05) reduced the amount of cyclin D1 mRNA expressed (to 1.6 Ϯ 0.2-fold). In contrast, cyclin D1 expression in asthmatics was relatively resistant to inhibition by dexamethasone; the amount of PDGF-BB-induced cyclin D1 expression in the absence or presence of dexamethasone was not significantly different ( Sphingosine 1-phosphate (S1P), a bioactive sphingolipid found elevated in the airways of asthmatics, modulates myriad airway smooth muscle (ASM) functions that promote inflammation and remodelling in asthma. In this study, we uncover the molecular pathway/s underlying S1P-induced secretion of IL-6, and investigate if, and how, corticosteroids inhibit IL-6 secretion. Using cultured ASM cells from non-asthmatics, we found that S1P induces IL-6 secretion from ASM cells via CRE, but not AP-1, C/EBP or NF-kB, transcriptional regulation of IL-6 gene expression. CRE-dependence was supported by S1P-induced CREB phosphorylation. Although the corticosteroid dexamethasone reduced S1P-induced IL-6 secretion in a dose-dependant manner, this inhibition appeared to occur via a pathway independent of CREB/CRE, suggesting the existence of a parallel pathway. As we recently discovered that the antiinflammatory actions of corticosteroids in ASM can be mediated via the induction of the endogenous mitogen-activated protein kinase (MAPK) inhibitor, MAPK phosphatase-1 (MKP-1), we investigated whether MAPK represents the parallel pathway targeted by corticosteroids. We found that S1P can induce activation of a variety of MAPK, however, only p38 MAPK phosphorylation was inhibited by dexamethasone; importantly, the increase in MKP-1 after corticosteroid treatment appeared to mirror the decrease in S1P-induced p38 MAPK phosphorylation. Furthermore, exogenous expression of MKP-1 inhibited S1Pinduced IL-6 secretion. Taken together, these results suggest that parallel pathways exist to induce IL-6 secretion (transcriptional via CREB/CRE and possibly post-transcriptional via p38 MAPK) and serve to underscore the importance of MKP-1 upregulation as a mechanism of action of corticocosteroids in ASM. Angiogenesis is a hallmark feature of asthma. Angiogenic promoters, such as VEGF and TGFb are reported to be increased in airways of asthmatics. Tumstatin, an endogenous angiogenic inhibitor, is the non-collagenous domain-1 (NC1) of the alpha3 chain of collagen IV. Decreased levels of collagen IV have been reported in the airways of asthmatics. We investigated the presence of tumstatin in the airway of asthmatics and its potential role as an angiogenic inhibitor. We detected the six a chain NC1domains of Col IV and the 7S domain of the a3 chain using immunohistochemistry. The level of tumstatin in serum and BAL-f was measured by dot blot. Western blots were used to identify the association with the rest of the collagen IV molecule. A tube formation assay using primary pulmonary endothelial cells (PPEC) was performed to evaluate the role of tumstatin in the airway. The effect of intranasal tumstatin on airway hyperresponsiveness and angiogenesis was studied in an ovalbumin mouse model. Tumstatin was absent in the airways of asthmatics (n = 14) while the remaining six collagen IV a chains were present. The 7S domain of the a3 chain was present in the asthmatic airway (n = 6). Tumstatin was detected in both serum and BAL-f samples from asthmatic volunteers (n = 10), however the level of expression was not significantly different from that in nonasthmatics (n = 7). In asthmatic serum tumstatin was part of the whole collagen IV a3 chain. Tumstatin was able to inhibit PPEC tube formation in a dose related manner. Tumstatin inhibited angiogenesis in the mice airways and was associated with an improvement in AHR. The fact that tumstatin is absent from asthmatic airways and inhibited airway hyperresponsiveness and angiogenesis may indicate potential for therapeutic intervention in airway remodelling. This work was supported by the CRC for Asthma and Airways and NH&MRC.

Introduction Epithelial EGFR (epidermal growth factor receptor) expression correlates with disease severity and neutrophil infiltration in asthmatic airways. Acute exacerbations of asthma and COPD are also associated with steroid refractory neutrophilic inflammation, with rhinoviruses being the most common trigger. .7 mg/L and IL-6: 5.8 vs. 3.6 ng/L). Since IL-6 stimulates the acute phase response, we correlated its levels with the other markers. Only CRP was strongly correlated with IL-6 (Spearman r = 0.58, P < 0.0001), suggesting differential regulation of SAA and IP10. SAA discriminated between Non-Pathogen (n = 10) vs. Pathogen-associated (n = 41) events (SAA: 9.4 vs. 44.1 mg/L P = 0.005), whereas no significant change was observed in the other markers (IP-10: 139.8 vs. 170.5 ng/L, CRP: 4 vs. 10 mg/L, IL-6: 4.6 vs. 7.2 ng/ L). However when AECOPD marker levels were stratified on the basis of pathogen type (Viral = 12, Bacterial = 21, Viral and Bacterial = 8), none of the markers were significantly altered.

Conclusions IP-10 is significantly elevated during an AECOPD, however only SAA differentiated non-pathogen from pathogen associated events. Background Severe persistent asthma is characterized by structural changes in the airways-airway remodelling. Airway smooth muscle (ASM) cells have the potential to play a key role in these processes through the release of growth factors, cytokines and extracellular matrix (ECM) proteins.

We have previously studied the effects of budesonide and formoterol individually however, the effect of their combination on these characteristics of ASM cells is not known. Methods ASM cells from asthmatic (n = 6) and nonasthmatic (n = 6) individuals were stimulated with transforming growth factor ß (TGFß) (1 ng/ml) with or without budesonide (10 -8 M) and formoterol (10 -10 and 10 -8 M) and fibronectin levels and interleukin-6 (IL-6) release were measured by ELISA. Bronchial rings from nonasthmatic individuals (n = 2) were incubated with TGFß with or without the drugs and ECM protein expression (fibronectin and collagen I) measured using immunohistochemistry.

Results In nonasthmatic cells, budesonide alone induced fibronectin deposition whether TGFß was present or not. Formoterol decreased fibronectin induced by TGFß and, when combined with budesonide, reversed the increase in fibronectin. A similar pattern was observed in asthmatic cells, except that budesonide did not further increase the TGFß mediated fibronectin release. As before [1] , IL-6 was induced by formoterol but inhibited by budesonide. TGFßinduced IL-6 was inhibited by both drugs and their combination in both cell types. In bronchial rings the presence of either drug did not affect TGFßinduced fibronectin or collagen I. Severe Combined Immune Deficiency (scid) spontaneous mutation specifically impairs differentiation of stem cells into mature lymphocytes. NOD-CB17prkd scid (known as NOD-scid) lacked NK cells, hence is commonly used in cell transfer experiments for transferring tissue and haematological xenografts. The aim of this study was to establish lung inflamamtory model in NOD-scid strain. Methods Balb/c and NOD-scid Balb/c mice (n = 8) were exposed to cigarette smoke for 4 days, 2 and 4 weeks (9 cigarettes/day; 5 days/week). Bronchoalveolar lavage fluid (BALF) and lung tissue were collected for inflammatory profiling and analysis for cytokines, chemokines and protease expression and/or activity.

Results NOD-scid have significant accumulation of macrophages in lung after 4 days, 2 and 4 weeks smoking as compared to no smoke control (P < 0.001) that was not different to Balb/c (P > 0.05). NOD-scid also have increased neutrophil number after 2 and 4 weeks smoking (P < 0.001). Even though myeloid cell differentiation isn't affected by scid phenotype, NOD-scid have one fold less neutrophil than Balb/c mice (P < 0.001) that is also reflected in the reduced expression of matrix metalloproteinase-9. Consistent with the known lymphopenic phenotype, NOD-scid have significant but less lymphocytes recruitment as compared to Balb/c mice after 4 weeks smoking (P < 0.001) despite the enhanced expression of inteferon inducible protein 10 (lymphocytes specific chemokine) in lung. Both mouse strains showed the same elevation of net gelatinase and serine protease activity in lung. NODscid mice also demonstrated comparable transcriptional induction of proinflammatory cytokines (TNFa, IL-6), growth factors (GM-CSF, G-CSF) and chemokines (MCP-1, MIP-2), indicating susceptibility to smoke-induced injury.

Conclusions NOD-scid mice are capable to mount smoke induced inflammatory response. This model may be useful to study localization and role of immunocytes, including adoptively transfer human cells in the pathogenesis of COPD. Supported by the NHMRC. Rhinovirus (RV) is the cause of most common colds and up to 80% of asthma attacks. In our previous studies, plasminogen activator inhibitor 2 (PAI-2) was expressed at high levels and was induced in vivo and in vitro by RV infection. PAI-2 may have antiviral properties suggested by antiviral activity in some models, high PAI-2 expression levels and further upregulation by RV infection. Methods To determine whether PAI-2 has antiviral activities following RV infection, O-Hela, PAI-2 expression-deficient cells were first transfected with PAI-2 or control genes. This was followed by infection with RV and effects on viral replication were assessed by RT-qPCR for vRNA and by viral titration for virus release. IFN expression was assessed by RT-qPCR.

Results IFN-a and -b mRNA expression were induced in response to RV infection and to PAI-2 expression in cells. PAI-2 expression followed by RV infection elicited a synergistic response and PAI-2 over-expression reduced vRNA by >5 fold and viral titre by >3 log (p < 0.05). However, this effect was not specific to PAI-2, as transfection of cells with control genes/plasmids reduced viral titre to a comparableextent. One of the pathological findings in idiopathic pulmonary fibrosis (IPF) is the presence on fibroblastic foci comprising cells which exhibit mesenchymal phenotypic features such as myofibroblast-like morphology, increased aSMA expression and collagen deposition. Currently steroid treatment in IPF has shown limited efficacy. The cellular origins of these mesenchymal cells remain unclear, but evidence from other studies suggests that epithelial cells may undergo a transition to a mesenchymal cell phenotype (EMT). Transforming growth factor ß has been implicated in promoting this EMT. In this study we have induced a morphological change in A549 cells using TGF-ß1 and assessed the influence of glucocorticoids, and the changes to the extracellular environment of the cells, on EMT.

Methods A549 cells were grown on uncoated plastic cultures plates or those coated with monomeric or fibrillar collagen and treated with 200-500 pM TGF-ß1. The influence of the glucocorticoid, dexamethasone (Dex, 1-1000 nM), or collagen type, on EMT was assessed by microscopy, RT-PCR and Western blotting for markers of myofibroblast phenotype. Results TGF-ß1 induced an increase in mRNA expression of aSMA (1.5 fold), collagen (7.0 fold) and fibronectin (2.0 fold). Dex (100 nM) partially inhibited the expression of collagen, but had no effect on aSMA levels. However, Dex (100 nM) reduced aSMA and CTGF protein levels. Dex (100 nM) also prevented the TGF-ß1-induced morphological changes, regardless of ECM matrix.

Conclusion Glucocorticoids appear to control some of the EMT phenotype changes induced by TGF-ß1. However, the inability to fully inhibit these changes may contribute to the resistance of IPF to glucocorticoids. The extracellular environment may also play a role in the development of fibroblastic foci and their pharmacological responses. Defective alveolar macrophage (AM) phagocytic function in the airway may perpetuate inflammation via secondary necrosis of uncleared apoptotic cells in COPD. We have previously reported that low-dose azithromycin improved macrophage function in vitro, although the mechanisms for this effect were not identified. We explored the possible role of the collectin pathway in the azithromycin-mediated improvement in phagocytosis as well as possible defects in this pathway in COPD subjects. Methods (1) Mannose binding lectin (MBL), mannose receptor (MR), surfactant protein D (SP-D) were measured in COPD subjects and controls. (2) The in vitro effects of addition of rhMBL, and blocking MR with a specific antibody, on AM phagocytic ability were assessed. In vitro effects of azithromycin on AM expression of MR were also investigated. (3) Azithromycin (250 mg orally 2¥ weekly/12 weeks) was administered to 11 COPD subjects. Bronchoscopies were performed prior to and 12 weeks following therapy. Ex vivo assessments included AM phagocytic ability, levels of MBL, SP-D and MR and apoptosis of bronchial epithelial cells.

Results AM MR expression and levels of MBL and SP-D were significantly reduced in COPD subjects vs controls. Azithomycin (500 ng/ml) increased MR expression by 31% in vitro. rhMBL induced a dose-dependent increase in AM phagocytic ability (up to 148%). Blocking MR significantly decreased AM phagocytic ability by 60%. In COPD patients following azithromycin therapy, we observed improved AM phagcocytic ability, increased levels of MR and reduced levels of bronchial epithelial cell apoptosis. Conclusions These findings strongly implicate the MR in both the defective phagocytic function of AM in COPD and as a target for the azithromycinmediated improvement in phagocytic ability. Obstructive sleep apnea (OSA) is associated with hypoxia and increased cardiovascular morbidity. T cells and monocytes play a significant role in atherogenesis via cytokine production. There have been reports of benefits of continuous positive airway pressure (CPAP) therapy in OSA. The purpose of this study was to characterize leucocyte inflammatory cytokine/chemokine production by T cells and monocytes in a group of OSA patients and to investigate the therapeutic effects of CPAP therapy. Methods A comprehensive range of intracellular T-cell and monocyte proand anti-inflammatory cytokines/chemokines was investigated in peripheral blood from 5 OSA patients and 5 aged-matched control subjects (with no evidence of sleep problems) using multiparameter flow cytometry. OSA patients were again studied following 7 days of CPAP therapy. Results In OSA patients there was an increase in intracellular T-cell IFNg and TNFa production but no change in IL-2, IL-4 or TGFb compared with control.

There was an increase in intracellular monocyte IL-1a, IL-8, TNFa, MCP-1 and MCP-3 in OSA patients but no change in IL-10 or IL-12. Following CPAP therapy, T-cell IFNg and TNFa production returned to 'normal' levels. However, although intracellular monocyte cytokine/chemokine production was decreased following CPAP, levels were significantly elevated compared with control.

Conclusions OSA is associated with increased intracellular proinflammatory cytokine/chemokines, many of which are increased in atherosclerotic plaques. Although one week of CPAP therapy resulted in amelioration of T-cell pro-inflammatory cytokines, longer CPAP use or alternative therapy may be required to reduce monocyte pro-inflammatory mediators associated with atherosclerosis in patients with OSA. Gp130 has been associated with the progression of fibrosis especially in patients with idiopathic pulmonary fibrosis (IPF). Gp130 is the common subunit of the receptor complexes for the IL-6 family of cytokines including IL-11 and oncostatin M (OSM), where gp130-mediated signalling leads to activation of the ERK or STAT pathways. We have previously demonstrated exaggerated gp130-STAT signalling to be fundamental to the development of pulmonary fibrosis in a murine model of bleomycin-induced lung fibrosis. The aim of this study was to elucidate the role of the IL-6 cytokine family in the development of pulmonary fibrosis by identifying which IL-6 family cytokines regulate fibrosis in bleomycin treated mice, and determine the effects of these cytokines on cell function. Bleomycin (0.05 U/mouse) or control saline was administered intranasally to wildtype mice (wt), genetically engineered mice containing point mutations to prevent gp130 ERK signalling (gp130 757F ) or gp130 STAT signalling (gp130 DSTAT ), and duel IL-6 and IL-11 a-receptor knockout mice (IL-6 -/-;IL-11aR -/-). The effect of bleomycin on collagen production was examined in lung tissue 30 days post treatment by HPLC. There was a significant increase in collagen levels in bleomycin treated wt lungs which was further increased in gp130 757F lungs. The lungs of gp130 DSTAT and IL-6 -/-;IL-11aR -/mice were protected from fibrosis suggesting that gp130-STAT signalling is important in inducing lung fibrosis which may be mediated through IL-6 and/or IL-11. Cell proliferation was examined in lung fibroblasts isolated from wt, gp130 DSTAT and gp130 757F mice. IL-6, IL-11 and OSM were significantly mitogenic for gp130 DSTAT cells but not for wt or gp130 757F cells, reflecting different responses to the different signalling pathways. Changes in cytokine profiles are currently being examined in lung tissue and serum of control and bleomycin treated mice 0-30 days after treatment. In conclusion, IL-6 and IL-11 are likely to play a role in bleomycin-induced fibrosis via the gp130-STAT-mediated pathway, however this may not be due to regulation of proliferation induced by these cytokines. Supported by the NHMRC. Mimicking viral infection by application of various toll-like receptor ligands has shown clinical promise in the treatment of persistent viral infections and more recently with malignant tumours. Commercially available toll-like receptor 7 ligands (TLR7L), such as those of the Imidazoquinoline family have been applied clinically for the treatment of a number of conditions including basal cell carcinoma and HPV-induced genital warts. These compounds are known to retard tumour growth indirectly by promoting activation and migration of DCs, leading to a strong Th1 cellular response, and directly via release of proinflammatory cytokines and promotion of tumour cell apoptosis. Malignant mesothelioma (MM), an aggressive tumour with a mean survival of 9 months, is highly resistant to chemotherapy, radiotherapy and surgery and is therefore an interesting candidate for immunotherapy in the form of TLR7 ligand treatment. Whilst TLR7 is known to be selectively expressed in immune cells and its relative expression low amongst other cell and tissue types in mammals, its expression on tumour cells and the consequences of such expression on tumour growth are unknown. Here we describe the presence of TLR7 (mRNA and protein) directly in a range of different tumours, including several murine and human MM cell lines. Reactive oxygen species (ROS) produced during the innate immune response are important agents of anti-pathogen defense but may also cause oxidative lung damage. Glutathione peroxidase-1 (gpx-1) is a detoxifying enzyme that may protect lungs from such damage. Methods Wild-type (WT) or mice deficient in glutathione peroxidase-1 (gpx-1 -/-) were placed in a perspex chamber and exposed to cigarette (cig) smoke generated from 9 cigs per day for 4 days. On the fifth day, mice were killed, the lungs lavaged with PBS and then harvested for proteomic and genomic analysis.

Results WT mice exposed to cig smoke for 4 days had significantly more macrophages (3.1 Ϯ 0.1(SEM) ¥ 10 5 ) and neutrophils (4.9 Ϯ 0.4 ¥ 10 5 ) than sham-exposed mice (2.2 Ϯ 0.2 ¥ 10 5 and 0, respectively) (n = 6, p < 0.05). However, gpx-1mice exposed to cig smoke had significantly greater macrophages (5.4 Ϯ 0.3 ¥ 10 5 ) and neutrophils (1.2 Ϯ 0.1 ¥ 10 6 ) than smokeexposed WT mice (n = 6, p < 0.001). Macrophage and neutrophil numbers in sham-exposed gpx-1 -/mice (1.7 Ϯ 0.3 ¥ 10 5 and 0.5 Ϯ 0.4 ¥ 10 3 ) were similar to those of sham-exposed WT mice (2.2 Ϯ 0.2 ¥ 10 5 and 0). In addition, we found that BALF of gpx1 -/mice exposed to cig smoke had an increased proteolytic burden compared with smoke-exposed WT mice as assessed by zymography and net gelatinase activity assay.

Conclusions These data suggest that gpx-1 protects the lung from cigarette smoke-induced inflammation and that targeting gpx-1 may have therapeutic utility in inflammatory lung diseases where cigarette smoke plays a role. Funded by NHMRC. The BECs from subjects with chronic obstructive pulmonary disease (COPD) are exposed to frequent infectious and inflammatory stimuli. Infection with RV is known to trigger acute exacerbations and subjects with COPD are particularly susceptible. We hypothesized that exposure of COPD BECs to these stimuli would alter their response to RV infection. Methods BEC were obtained by endobronchial brushing from subjects with GOLD stage 3 COPD (n = 4, all ex-smokers), subjects with mild persistent asthma (n = 4) and healthy controls (HC, n = 4). BECs were cultured and then treated with Tumour Necrosis Factor (TNF)a 10 ng/ml or LPS 100 mg/ml for 24 hrs and then infected with RV-43, RV-1B. Response was measured by release of IL-8, IL-6 and IP-10 mRNA and by ELISA. Virus replication measured by cell titration assay.

Results Infection with both RV strains led to increased release of IL-8 and IP-10 in all groups. Exposure of HC and asthma BECs to both LPS and TNF led to increased release of IL-8. In these BECs there was no increase in release of IL-8 exposed to LPS and TNF and then infected with either RV. BECs from subjects with COPD released significantly less IL-8 in response to all conditions and RV infection compared to HCs and asthma. No differences were seen in RV replication. The aim of this study was to determine opinions and attitudes to exercise from chronic obstructive pulmonary disease (COPD) subjects after completion of a 12-month maintenance exercise program. Methods Following completion of a 12-month exercise study, which included a supervised program (Intervention, n = 18) and control group (Control, n = 17), COPD subjects [mean age (SD): 66 (8); mean FEV1 (% predicted) = 56% (19)] were asked to complete a questionnaire. The questionnaire included closedended questions using visual analogue scales (100 mm). In COPD the 6 minute walk distance (6MWD) is known to increase with test repetition (familiarization) and in response to exercise training. It is unknown whether the magnitudes of these increases are related to the degree of disability of the individual patient. Methods 6MWD was measured twice before and once after an 8 week out-patient exercise program in 121 patients (82 males) aged 67Ϯ8.6 yrs, FEV1 37Ϯ15% predicted (meanϮSD) with stable COPD. The changes in 6MWD following a familiarization test and following training were compared between patients grouped according to their degree of disability (defined as the pre-training 6MWD [best of 2 tests] expressed as %predicted 6MWD). *p < 0.05 Gp 3 vs Gp 1. Conclusions Before training, 6MWD increases following a familiarization test irrespective of the level of disability. The magnitude of this increase is similar in all groups when normalized for their pre-training 6MWD. Following training, the increase in 6MWD is greatest in patients with the greatest disability (lowest pre-training 6MWD). In less disabled patients, the relatively smaller increase in 6MWD following training may reflect an inability to further increase stride length, thereby reducing the responsiveness of the 6MWT in this group. Supported by NHMRC. Endotoxin is a stimulant of the innate immune system and is a major component of cigarette smoke. Smokers have evidence of increased airway neutrophils and inflammation. We hypothesized that endotoxin levels would be higher in the bronchial lavage (BL) of subjects who were former smokers and subjects with chronic obstructive pulmonary disease (COPD).

Methods Subjects were all ex-smokers for at least 5 years (n = 10, 5 COPD, 5 healthy controls) or never smokers (n = 12, 6 asthma, 6 healthy controls). BL was collected and analysed for cell count and differential, culture for microbiology. The supernatant was analysed for IL-8 by ELISA and endotoxin by quantitative kinetic LAL assay.

Results Median endotoxin levels were significantly higher in ex-smokers 101 compared to never smokers 6.3 U/ml (p < 0.001). There were no differences between subjects with COPD and HS. Subjects with COPD had higher median endotoxin levels (80 U/ml), compared to asthma (5.2 U/ml) and HC (6.3 U/ml, p = 0.03). There was no correlation between endotoxin levels and BL total cell count, neutrophils (%) or FEV1 % predicted. There was a strong correlation with previous packet years smoked and endotoxin levels (r = 0.72, p < 0.01).

Conclusions BL endotoxin levels are higher in ex-smokers, including subjects with COPD. Despite this there is no relationship to increased neutrophilic inflammation. COPD is associated with inflammation associated with ineffective repair of the injured epithelium and loss of structural integrity. We have shown that these changes may result from dysregulated 'efferocytosis' (increased apoptosis of bronchial epithelial cells and defective clearance of these cells by alveolar macrophages (AM)). We have also reported that azithromycin, at subbactericidal dose, improved AM phagocytic function ex vivo. Methods We administered azithromycin at low dose (250 mg/ twice weekly for 12 weeks) to 10 COPD subjects (7 male, age: 62 Ϯ 8 yr, 5 current/ 5 ex-smokers, FEV1: 63 Ϯ 9% pred, FEV1/FVC: 48 Ϯ 9%).

The study was openlabel, uncontrolled and primarily focused on objective biological responses obtained from the bronchoscopy samples taken. Phagocytic ability of AM (from BAL), apoptosis of bronchial epithelial cells (from bronchial brushing), markers of inflammation in blood, BAL and breath condensate (CRP, WCC and inflammatory cytokines), health status (St. George's respiratory questionnaire), ECG and lung function were assessed pre and post-administration of azithromycin. Results Azithromycin significantly improved phagocytic ability of AM (by 37%) and reduced bronchial epithelial cell apoptosis (by 34%). Antiinflammatory effects of azithromycin included significantly reduced blood WCC and CRP. There were non-significant reductions in levels of pro-inflammatory cytokines IL-8, IL-6 and TNF-a in blood, BAL and breath condensate, and a trend for improved health status. Conclusions Our findings indicate a novel approach to supplement existing therapies in COPD that may improve clearance of accumulated apoptotic material and reduce the risk of secondary necrosis and release of toxic cell contents that perpetuate inflammation. Background The prevalence of gastro-oesophageal reflux disease (GORD) across the disease spectrum in COPD and bronchiectasis is not well described. The aim of this study was to determine the prevalence of symptomatic and silent GORD in COPD and bronchiectasis and its effect on lung function and quality of life (QOL 4] ) and 18 healthy controls were recruited. The prevalence of GORD in bronchiectasis was 33%; 37% in COPD; 17% in controls. In COPD and bronchiectasis, total NRE and RI were increased in those with distal and proximal GORD compared to those without GORD (all p < 0.05). There was no difference in extent or severity of bronchiectasis in patients with or without GORD (all p > 0.05). In COPD, the relationship between proximal GORD and FEV1 was small to moderate (r = 0.383). SGRQ symptom scores were higher in patients with bronchiectasis with increased RI (p = 0.02). Increased proximal NRE was associated with reduced physical (p = 0.03) and mental health (p = 0.02) in the SF-36 in COPD.

Conclusions GORD is a co-morbidity in patients with COPD and bronchiectasis. The impact of GORD on disease severity requires further evaluation.

Funding source NHMRC, The University of Melbourne, Monash University, Physiotherapy Research Foundation.

Chronic obstructive pulmonary disease (COPD) is prevalent among older people, however little is known about the influence of ageing on airway inflammation. The aim of this study was to compare airway inflammation in older people with obstructive airway disease to groups of older and younger healthy controls.

Methods Participants (>55 years of age) with stable airway disease and incomplete reversibility (FEV1% predicted <80% and FEV1/FVC < 70%; COPD n = 71) and healthy controls (n = 45, 35 older >55 years and 10 younger <55 years) were recruited from the Respiratory Ambulatory Care Clinic or by advertisement. Participants underwent a clinical assessment, skin allergy test, hypertonic saline challenge, sputum induction and gas diffusion studies. Results Participants with COPD had moderate airflow obstruction (mean (SD) FEV1% predicted 56 (19)) and 45 (63%) were current or ex-smokers with a median (IQR) pack year history of 36 (20-54) pack years. Ageing was associated with an increase in airway neutrophils (p = 0.0001). Compared to older controls, participants with COPD had increased airway eosinophils and lymphopenia (p = 0.004, p = 0.003 respectively), but no difference in airway neutrophils.

Conclusion Airway neutrophilia is a feature of ageing and is not further increased in the presence of COPD. COPD is associated increased numbers of airway eosinophils with reduced lymphocytes which may impact on the ability of the immune system to combat infection. Supported by NHMRC, The University of Newcastle. Chronic Obstructive Pulmonary disease (COPD) is third leading cause of death and fourth leading cause of disease burden in Australia. Mechanisms involved in emphysema severity have not been fully understood. MicroRNAs are noncoding RNAs that regulate gene expression. We hypothesize that microRNA expression differs between emphysema severity in COPD patients. Methods miRNA profiling was performed using 15K Agilent Human Oligo miRNA microarrays on total RNA extracted from non-tumour lung tissue from 30 COPD patients undergoing resection for lung cancer. The miRNAs were quantile normalized and ANOVA was used to find differentially expressed genes.

Results Demographic characteristics of the COPD patients (mean (SD)) were age 69 (6) years, FEV1 72 (17) % predicted and FEV1/FVC ratio (<70%). ANOVA identified 31 miRNAs that were differentially expressed when stratified into two classes according to KCO % predicted > or <75% (t-test, P < 0.05). Discussion This miRNA analysis has identified miRNAs that may be important in emphysema severity in COPD patients. Further validation will be performed using qRT-PCR and miRNA assays on the training set and an independent set, and target prediction and validation. 

T-helper type 1 (TH1) and type 2 (TH2) lymphocyte responses have been well recognized as being important pathways in inflammation. Recently another form of inflammatory lymphocyte response has been described, the TH17 pathway. TH17 cells produce cytokines such as IL-17A to clear extra-cellular bacteria and fungi and have been implicated in autoimmune and chronic inflammatory diseases. The TH17 response in COPD is unknown. Methods Subjects were patients with COPD (ex-smokers, FEV1 < 70% predicted who had not had an exacerbation for at least 1 month) and control subjects (ex-smokers and normal spirometry). Serum samples were obtained for measurement of C reactive protein (CRP) and IL-17A, the latter measured using enzyme-linked immunosorbent assay (ELISA). Production of IL-17A by T-cell subsets was also identified by intra-cellular cytokine staining and measured by flow cytometry.

The mean FEV1 of COPD subjects was 42 % predicted (6.1 SEM, n = 6) and mean FEV1 of controls was 112 % predicted (3.0 SEM, n = 4). The COPD group had a higher mean level of CRP 9.5 mg/l (3.9 SEM) compared to the control group mean level of 4.6 mg/l (0.6 SEM). The mean level of the IL-17 in the COPD group as measured by ELISA was 22.3 pg/ml (16.9 SEM, range 0-87) whilst no IL-17 was measured in any of the control subjects.

Conclusions The findings of this pilot study suggest that IL-17 may be elevated in association with CRP in stable COPD. Airway obstruction is defined as a FEV1/FVC ratio below the lower limit of normal. Airway obstruction may prolong the forced expiratory time (FET). Method Spirometry results from 467 patients were categorized as obstructive, restrictive or normal. The mean, range and coefficient of variation were determined for FET in each diagnostic group. Receiver operator characteristic (ROC) curves were used to determine if FET could predict a low FEV1/FVC. The number of patients with airway obstruction in five FET groups: <9; 9; 10-12; 13-14; and >14 seconds were determined. Results The coefficient of variation was high for all groups. Pair-wise comparisons showed a difference in mean FET between patients with normal lung function versus those with airway obstruction (p < 0.001). The best cut-point in the ROC analysis of 9.895 seconds had a sensitivity of 0.66, specificity 0.77 and area under the curve of 0.743 for predicting obstruction. The technique of skeletal muscle microbiopsy has previously been validated [1] and shown to be minimally invasive and well tolerated in participants with stable COPD. Aim A study was undertaken to determine the feasibility and tolerability of obtaining microbiopsy muscle samples from the patient admitted for acute exacerbation of COPD patient. Methods Written informed consent was obtained to collect the muscle, blood and sputum samples for research purposes. Local anaesthetic was injected prior to the insertion of a 16 gauge Bard Max Core Disposable Biopsy Instrument through the associated guide needle. Multiple passes (up to 6) were obtained. The patient was asked to evaluate the experience by rating it on the modified Borg scale 0-10. Results To date 5 patients and 3 controls have participated in this study. The GOLD severity ranged from 2-4 and ATS exacerbation severity 2-3. The mean age 75 years (range 68-83 years), BMI mean 23.6 kg m -2 (range 17.2-27.1 kg m -2 ) and fat free mass was determined using single frequency bioimpedance. The sample mass obtained ranged from 27.2-104.1 mg, with an increasing yield occurring with increased experience of the operator. The procedure has been well tolerated, the Borg scale rating ranged from 1-2/10. All patients were ambulant post procedure; no haematoma or bruising was observed in any of the subjects. Conclusion The microbiopsy technique allows the collection of muscle tissue with minimal discomfort to the participant. Small tissue masses such as these are sufficient to obtain measures of local markers of wasting and may prove to be a useful adjunct to the collection of sputum and blood for the measure of biomarkers in COPD research. Introduction Older people (OP) with obstructive airways disease (OAD) experience multiple problems that may impact on their quality of life (QOL) and disease management. These problems may relate to pathophysiology, symptoms, self management skills, psychological issues, lifestyle or other problems identified as important by the patient.

Aim The aim of this study was to determine the frequency of clinical problems associated with OAD and to determine if a problem based assessment (PBA) could adequately identify these problems. Methods A multidimensional assessment tool was developed and the content compared to Clinical Practice Guidelines. Participants over 55 years with diagnosed OAD underwent this assessment. Results Sixty-one consecutive patients, aged 59-87 years, with mean (SD) FEV1 of 51.4 (17.85) % predicted were assessed. The assessment tool identified a mean (SD) of 3.03 (2.13) current and significant co morbidities with an additional 11 (3.37) clinical problems per patient. QOL was increasingly impaired with an increasing number of problems (p < 0.0001). Regression modelling identified that the number of identified clinical problems accounted for 55% of the QOL impairment. The model demonstrated that every additional patient problem was associated with a clinically significant change in QOL impairment (4.22 units) .

Conclusions OP with OAD experience multiple clinical problems and co morbidities that adversely impact their QOL. A PBA of OP with OAD identifies significant problems that may not be addressed in a diagnosis centred approach. There is a need to identify and effectively manage this array of problems in clinical practice.

Discussion In this diverse group of COPD patients, there was a positive correlation between DLco and FEV1, but not Kco and FEV1. The FEV1/ Kco plot identifies substantial numbers of patients with the potential AD and E phenotypes defined above. We intend to study inflammatory biomarkers in these groups. Fat free mass index (FFMI) is a marker of morbidity and mortality in COPD. Measurement of FFM in the out-patient population is commonly undertaken using Single Frequency Bioelectrical Impedance Analysis (BIA). However the formulae to convert measured values to FFM are population dependent. Schols et al (Am J Clin Nutr, 1991) suggested that formula used for the general population may be inappropriate for patients with COPD, and derived a specific formula from total body water (TBW) as measured by deuterium dilution. We compare this method of measuring FFM with 5 others, along with TBW and FFM hydration.

Methods TBW was measured in 31 outpatients with COPD by BIA and a Difference Method (weight-(protein+bone mineral+fat+non-bone mineral+ glycogen)) and FFM hydration was calculated. FFMI was measured by skin fold anthropometry (SFA), BIA (3 separate formulae), Dual Energy X-ray Absorptiometry (DEXA) and Total Body Potassium by g-counter (TBK). Comparison between methods for TBW and FFMI was made by Bland-Altman analysis and between methods of calculation of FFM hydration by paired t-test.

The two methods of assessment of TBW showed little difference (bias -0.04, 95% limits of agreement -5.40 to 5.31). However there was a significant difference in calculation of hydration of FFM (p = 0.0001). SFA, BIA (Lukaski), BIA (Tanita) and TBK underestimated FFMI when compared to BIA (Schols), with bias of -1.24, -3.87, -1.06 and -2.76 respectively. DEXA however had a bias of only 0.05 and 95% LOA of -3.09 to 3.21. Conclusions There are differences between methods of assessment of TBW and FFMI and comparing values between methods must be done with caution. This has implications for assessment of morbidity and mortality in COPD.

Chronic obstructive pulmonary disease (COPD) has been identified as a major health problem in Australia. Recent studies have suggested that respiratory viral infections are the major cause of a worsening of COPD; however this has not been studied in Australia. Aim To characterize PEF changes and identify viruses during COPD exacerbations.

Methods A pilot prospective longitudinal cohort study was done. Patients had confirmed COPD with FEV1 <70% predicted and reversibility <10% and/or 200 ml. Patients recorded daily peak expiratory flow (PEF) measurements and daily chest and cold scores over a period of 2 years. Sputum samples and nasal aspirates were taken at 6-month review (control visit) and whenever they had symptoms of an exacerbation (worsening of COPD symptoms -Seemungal et. al. Am J Resp Crit Care Med, 2001). Nasal aspirates and sputum samples were obtained and analysed by RT-PCR for rhinovirus (RV). Result Five patients have finished 2 years of study. A total of 12 exacerbations were reported based on patient symptoms. Only 3 exacerbations were associated with significant reductions in PEF and only one was linked to increases in nasal cold scores. All samples taken at control visits and nasal aspirates and sputum samples during exacerbations were negative for RV by RT-PCR. Positive controls confirmed the accuracy of the assay. Conclusion Our data suggest that a symptom-based definition of COPD exacerbation is not always accompanied by significant reductions in lung function parameters. These 'exacerbations' are also not associated with the commonest reported viral cause. Our findings suggest that variability of COPD may mimic. 

Bronchiectasis is characterized by hypersecretion of mucus and impaired clearance that results in mucus accumulation, chronic cough, sputum production and recurrent infections. Inhaled mannitol (400 mg) improves clearance of mucus by increasing the airway hydration and by reducing the viscoelastic and surface properties of mucus. However, the effect of other doses of mannitol on the clearance of mucus in patients with bronchiectasis is unknown. Methods Fourteen patients, age: 63.3 Ϯ 5.7 yr, were studied on 5 visits. Clearance of mucus was measured using 99m Tc-sulphur colloid and imaging with a gamma camera at baseline and with mannitol ( Weight loss and skeletal muscle atrophy are major determinants of morbidity in Chronic Obstructive Pulmonary disease (COPD), which are independent of lung function impairment. Thus, we examined if a high-fat diet (HFD) protected against the wasting associated with prolonged cigarette smoke exposure (SE) in mice.

Methods Male BALB/c mice were exposed to the smoke of 4 cigarettes/day, 6 days/week for 7 weeks. Sham mice were handled identically without smoke exposure. Mice consumed either standard laboratory chow (3.5 kcal/g, consisting of 12 % fat) or a HFD (4.3 kcal/g, 32% consisting of fat). We examined the effect of SE and HFD on hind limb skeletal muscles, lung (tissue & bronchoalveolar lavage (BALF)) and systemic inflammation in the 4 groups of mice (n = 8/ group). Results After 7 weeks of HFD, sham and SE mice were 12 and 13% heavier (respectively, P < 0.05) than chow fed animals. Conversely, SE significantly decreased body weight of chow and HFD fed mice by 16 and 15%, respectively, compared to sham animals (P < 0.05). The HFD did not protect against the decrease in soleus, tibialis anterior and gastrocnemius skeletal muscle weights induced by SE (P < 0.05). SE altered the mRNA expression of a number of genes associated with the regulation of skeletal muscle mass including insulin-like growth factor-I (IGF-I), atrogin-1 and interleukin (IL)-6. The mRNA expression of pro-inflammatory cytokines and chemokines was significantly increased by SE in the lung, as were the number of inflammatory cells in BALF (P < 0.05). On the other hand, although obesity has been linked to systemic inflammation, the HFD exerted little direct effect on the skeletal muscle and lung parameters measured. SE and HFD had no effect on two markers of systemic inflammation, IL-6 and serum amyloid A, whereas SE tended to reduce circulating IGF-I, an anabolic hormone. Conclusions The HFD was not protective against the weight loss and skeletal muscle wasting associated with cigarette smoke exposure. Supported by the NHMRC and CRC for Chronic Inflammatory Diseases. Background Patients with COPD and bronchiectasis undertake airway clearance therapy (ACT) and exercise as part of physiotherapy management but it is unknown whether these treatments provoke gastro-oesophageal reflux (GOR). This study aimed to determine the impact of positive expiratory pressure (PEP) therapy and exercise on gastro-oesophageal function. P. aeruginosa is a significant opportunistic lung pathogen in individuals with cystic fibrosis (CF) and is associated with increased lung disease and morbidity. Early intervention is beneficial for the effective clearance of P. aeruginosa and better long-term health outcomes. Currently, lung flora of CF patients is monitored by regular culturing of sputum, however, children unable to expectorate are limited to annual bronchoalveolar lavages (BAL), which is invasive and requires general anaesthesia. Saliva is useful for clinical assays as collection is simple, non-invasive. We are developing a standardized enzymelinked immunosorbent assay (ELISA) to detect respiratory infection of P. aeruginosa in CF children who cannot expectorate.

Methods 18 children (7-18 years) with CF and recent P. aeruginosa lung infection history and 16 non CF children (1-6 years) with no previous P. aeruginosa infection history provided saliva as positive, negative controls respectively. Saliva was obtained by spitting, or absorbed using cellulose swabs and later extracted. These cell-free supernatant samples were used in an ELISA anti-P. aeruginosa IgA using commercial antigen. All results were standardized to account for flow using total IgA expression. Results Median value was increased 9 fold in the recent P. aeruginosa lung infection group (Mann-Whitney test, n = 34, p Յ 0.001). There was no significance between mucoid and non mucoid samples, and detection was independent of cfu/ml. Discussion Early findings support that P. aeruginosa respiratory infection can be detected through specific analysis of salivary IgA expression. Larger population sampling (30 positive, 90 negative) will aid selection of cut-off values for specificity and sensitivity testing in the future to objectively determine the utility of this assay as a means of monitoring for P. aeruginosa and for determining effectiveness of treatment. Medical thoracoscopy is utilized widely throughout Europe and Northern America by thoracic physicians for the management of pleural disease, including the undiagnosed pleural effusion, malignant effusions and less commonly pneumothorax (PTX). Australia has limited experience in this modality. We report the success of medical thoracoscopy in both primary and secondary PTX requiring intervention. Methods Data were collected from 2001 to 2007 in patients treated with medical thoracoscopy for the treatment of PTX.

Results 11 patients, 7 male, 4 female. Average age 48 (range 19-86). 1 first episode primary spontaneous (PS) PTX, 2 third episodes of PS, 5 first secondary spontaneous (SS), 1 second SSPTX, 2 third SSPTX. Underlying pulmonary disease in secondary PTX included: 4 chronic obstructive pulmonary disease, 1 lymphangioleiomyomatosis, 1 mesothelioma, 1 metastatic angiosarcoma and 1 was secondary to a motor vehicle accident. 7 had a history of smoking, 5 were former smokers and 2 were current smokers, with a mean 24 pack year history (range 5-45). 7 PTX were large, 4 moderate. 5 patients had an intercostal catheter (ICC) inserted prior to thoracoscopy, 1 had failed pleural aspirate. There was evidence of bronchopleural fistula in 7 patients prior to the procedure. There was a median of 9 days from PTX to thoracoscopy. Light sedation was used for the procedure in 10 patients, 1 required a general anaesthesia with a double lumen endotracheal tube due to anxiety. Single port entry, dry Talc poudrage and a 16 gauge French ICC was used for all procedures. ICC was removed a mean of 2 days following thoracoscopy and patients discharged on day 4. Pain was the most common complication, requiring narcotic analgesia. One patient died on day 7, secondary to metastatic angiosarcoma. There has been no recurrence of PTX in any patient. Conclusion Medical thoracoscopy, performed by thoracic physicians is an effective procedure for the treatment of pneumothorax requiring intervention, including selected patients with evidence of bronchopleural fistula. Funding Nil.

Conflict of Interest Nil. Nomination for young investigator award No.

Background Lung cancer incidence and mortality are high in Tasmania.

Australia (AIHW 2003) 85/100 000 72/100 000 Tasmania (Cancer Registry 2003) 102/100 000 89/100 000 Aims and Objectives (a) to determine patient demographics in Southern Tasmania, (b) to determine compliance to identified measures of best practice and (c) assess referral rates, clinical utility and potential delay to Positron Emission Tomography (PET) in a regional setting.

Methods A prospective database collected information on local clinical practice. Cases presented at a multidisciplinary lung cancer meeting over a 12 month period (March 2006 -April 2007 were analysed. Data were available for n = 121/161 (75%). Results are shown as mean Ϯ SD.

Results 113 primary lung cancer cases were identified. The mean age was 71 Ϯ 11 years. 58% of patients were male and 95% were current or ex-smokers. 81% were non-small cell lung cancers (NSCLC).

Tissue diagnosis 93% Time from diagnosis to surgery (27 Ϯ 15 days) 82% < 42 days Macroscopically complete surgical resection (9/11) 82% PET for Stage IIIb before radical chemoradiotherapy 75%

62% of patients presenting with early or locally advanced disease underwent further staging with PET (n = 34/55). Management was changed in 50% of cases (17/34). The average time from PET referral to scan was 11 Ϯ 5 days. Conclusion A disproportionate number of lung cancers occurred in women.

Although surgery was performed within recognized timeframes, 2 of 11 patients had incomplete resections. PET influenced management decisions and was performed in a timely fashion.

HP CHAN 1,2 , V TRAN 1,2 , C LEWIS 1,3 , P THOMAS Exhaled breath condensate (EBC) is a simple, safe and non-invasive method of sampling breath and has the potential to investigate lung cancer and the associated neoplastic process in the lungs. Increased oxidative stress has been implicated in the pathogenesis of lung cancer, and is characterized by elevated hydrogen ions, and hydrogen peroxide (H2O2), which is formed from the conversion of superoxide anions by superoxide dismutase. Airway pH has already been shown to be decreased in EBC of patients with other respiratory conditions, but not in lung cancer. Therefore the concentration of H2O2 and hydrogen ions in the EBC of lung cancer subjects was compared with matched controls. Methods Six subjects with newly diagnosed lung cancer were recruited and matched with control subjects: non-smokers, ex-smokers and smokers. EBC was collected and H2O2 was then measured by an assay method based on oxidation of 3,3',5,5'-tetramethybenzidine by horseradish peroxidase and H2O2 while pH was measured using a pH meter. Results There was a significant difference (p = 0.033, ANOVA) in H2O2 concentration between the 4 groups with the lung cancer group having elevated mean H2O2 concentration of 23.68 mM (9.15 (SEM) compared to the controls: non-smokers, 17.59 mM (6.53 (SEM); ex-smokers, 14.35 mM (3.79 (SEM); and smokers, 5.21mM (0.69 (SEM). pH did not differ significantly (p = 0.659, Kruskal-Wallis test) between the groups. Conclusion These preliminary data suggest that there is significant difference in H2O2 concentration between the groups. The demonstration of an elevated H2O2 level in those with lung cancer indicates an increase in oxidative stress which implies that this may be part of the pathogenesis or response to neoplasia. Supported by None. Conflict of Interest None.

Pro-inflammatory Th1 cytokines produced by T cells and monocytes play an important role in the immune response to malignant cells. However, tumours may escape immune surveillance by inhibiting Th1 response and promoting chronic inflammation at the tumour site.

Methods To investigate the effect of soluble factors released by lung cancer cells on T cell and monocyte pro-and anti-inflammatory cytokines, culture supernatants from several lung cancer cell lines and a normal epithelial cell line (16HBE) were cultured with whole blood for 24 hours, then for a further 16 hrs with and without stimuli. Intracellular cytokine / chemokine production was determined using multiparameter flow cytometry.

Results In stimulated cultures, there was a significant decrease in T cell Th1 pro-inflammatory cytokines IFNg, TNFa and IL-2 and a decrease in monocyte IL-1a, IL-8, IL-12, TNFa, MCP-1 and MCP-3 but an increase in antiinflammatory cytokine IL-10 compared with 16HBE and control media. In non-stimulated blood cultures there was an increase in all monocyte inflammatory cytokines / chemokines in the presence of lung cancer supernatants. Conclusions Lung cancers secrete soluble factors that inhibit the antitumour pro-inflammatory Th1 response by T cells and monocytes and upregulate monocyte anti-inflammatory cytokine IL-10 following "antigenic challenge". Lung cancer cells may also escape immune surveillance by secreting soluble factors that cause newly recruited monocytes to release inflammatory cytokines promoting chronic inflammation at the tumour site. Cytotoxic T-cells (CTL's) are important barriers against tumour cells. CTL's induce apoptosis of target cells by mechanisms that include the release of pore-forming perforin and granule associated enzymes, such as granzyme B and granulysin. Proteinase inhibitor-9 (PI-9) is the only known granzyme B inhibitor and its expression has been observed in some cancers. We hypothesized that PI-9 would be differentially expressed in lung cancer cells and may inhibit granzyme B-induced apoptosis in these cells.

Methods We investigated PI-9, granulysin and granzyme B expression in various lung cancer cell lines (1299 ( , 1466 ( , 2009 and normal epithelial cells obtained from bronchial brushing using flow cytometry. Peripheral bloodderived T-cells were then incubated with lung cancer cell line supernatants and levels of PI-9, granzyme B and T-cell reactive oxygen species (ROS) were assessed. Results PI-9 expression was detected in all lung cancer cell lines, (1299 (54.2%), 1466 (90.2%), 2009 (85%), SBC-1 (81%)), at much higher levels than in normal bronchial epithelial cells (8.5%). Granzyme B and granulysin levels were undetectable or low in cancer cells (0-9.2%). Increased expression of PI-9 and reduced levels of granzyme B were observed in CD8+ T-cells in the presence of all cancer cell supernatants tested (p < 0.05). Interestingly, T-cell ROS levels were significantly increased in CD8+ T-cells after incubation with cancer cell supernatants (p < 0.05).

Conclusions High PI-9 expression in lung cancer cells combined with a reduction in T-cell granzyme B expression and enhanced intracellular T-cell ROS levels may be a mechanism of immune evasion of lung cancer cells to granzyme B-induced cytotoxicity.

Immunotherapy for lung malignancies such as lung cancer and mesothelioma is most likely to be successful it it can be combined with conventional tumour debulking approaches such as chemotherapy and surgery. But they scientific basis of such combinations is yet to be determined.

To study this we evaluated (1) the capacity of different lung chemotherapy drugs to alter tumour antigen cross-presentation and immunogencity, (2) duration of antigen presentation and responsiveness to immunotherapy after debulking surgery with/without lymphadenectomy, and (3) the pattern of TLR agonism which best synergized with chemotherapy and surgery. We used the AB1-HA murine model of lung malignancy in BALB/c mice.

Results (1) The antimetabolite drugs gemcitabine and pemetrexed were most immunogenic compared to the cytotoxic antibiotics doxorubicin and mitomycin C and the alkylating agent cisplatin. Gemcitabine delived large amounts of tumour antigen into the cross-presentation pathway. (2) Tumour antigen cross-presentation persisted for only 10 days following resection. The optimal window for immunotherapy following cancer surgery is 1 week for effector CTL stimulation and 2-4 weeks for memory CTL stimulation. (3) The viral-like TLR agonists TLR 3, 7 and 9 were the most effective adjuvant TLR molecules, with TLR 7 agonists generating the strongest systemic anti-tumour responses. Conclusion These results help explain previous lung immunotherapy failures and will inform new clinical trials. Background Mesothelioma is a highly aggressive tumour with an increasing world wide incidence. The serum biomarker mesothelin is elevated in some individuals prior to development of clinical symptoms of the disease and may be useful for screening. We therefore studied the sensitivity and specificity of urinary versus serum levels of mesothelin for mesothelioma patients and evaluated the influence if renal function on the biomarker level. Materials and Methods Concurrent sera and urine samples collected from patients with and control populations. Mesothelin concentrations were determined by double-determinant ELISA using the MESOMARK TM assay (FDI, PA). Their estimated glomerular filtration rate (eGFR) was also calculated. Results Mesothelin levels correlated between serum and urine samples (Pearson's correlation 0.791; p < 0.0001). Mesothelin levels were significantly higher in patients with mesothelioma compared to those with asbestosis and/or pleural plaques in serum (4 Ϯ 0.9 versus 0.9 Ϯ 0.05 nM; p < 0.0001, respectively), in urine (1.9 Ϯ 0.5 versus 0.3 Ϯ 0.03; p < 0.0001) and in urine following normalization using creatine levels (0.2 Ϯ 0.05 versus 0.04 Ϯ 0.01). Age and eGFR were significantly associated with mesothelin levels.

Conclusion The sensitivity and specificity of mesothelin in urine and in serum were comparable. Urine mesothelin may prove to be a useful alternative to serum mesothelin for mass screening of asbestos-exposed individuals. Patients undergoing CT Coronary Angiogram (CTA) are often former or current smokers with a high incidence of asymptomatic lung disease. Overseas reports show a rate of lung abnormalities ranging from 6.7% to 19%. There are no studies from Australia and local factors such as the higher incidence of atypical Mycobacteria may influence the rate of benign findings. We are therefore performing a prospective observational study to identify the prevalence and characteristics of incidental lung findings in people undergoing routine CTA. Methods Population: 100 patients undergoing routine CTA after informed consent. Intervention: Radiologist evaluation of lung windows on diagnostic standard workstations. Comparator: Uncontrolled observational study of consecutive patients. Outcomes: Primary: Prevalence and characteristics of abnormal findings, final diagnosis (clinical judgment, biopsy or long term followup). Secondary: Number of downstream investigations and costs.

Results 25 CTAs have been studied to date. In 8/25 (32%), abnormalities were noted on lung windows. In 2/25 (8%), there were lung nodules, in 2/25 (8%) there were hilar lymph node abnormalities, in 1/25 (4%), there was hemidiaphragm elevation and in 3/25 (12%) there were pleural plaques (data collection ongoing with study closure expected in February 2008).

Conclusions Preliminary data indicate a substantial number of incidental pulmonary findings from CTA; full results will be presented. Further analysis is required to determine the impact (benefits, costs and harms) that may result from the concurrent examination of lung windows at routine CTA. Aim Increased levels of nitrogen oxides (NOx) and inflammatory markers have been found in bronchoalveolar fluid of lung cancer (LC) patients, but have not been investigated in exhaled breath condensate (EBC).The aim of this study was to compare NOx and total protein levels in EBC of LC patients with control subjects. Methods EBC was collected during tidal breathing through a glass collection device cooled to 4°C. EBC NOx concentrations were measured by a fluorescent modification of the Greiss method. Total protein in EBC was determined employing the bicinchoninic acid (BCA) assay. EBC NOx data were log transformed. All data were analysed using ANOVA and expressed as mean Ϯ SEM. Results A total of 88 control subjects and 54 patients with primary LC were recruited. NOx and protein concentrations are shown in Table 1 . There was no significant difference in EBC NOx levels (p > 0.05), but in total protein there was a significant difference between lung cancer patients and all control groups (p = 0.04).

Conclusion Significantly increased EBC total protein levels were found in patients with lung cancer. These data suggest that protein mediator secretion or vascular leak may be present in those with lung cancer. Future studies will focus upon the identification of these proteins. Methods In this two stage case-control study 446 lung cancer cases and 484 healthy smoker controls were recruited. 180 genetic markers (SNPs) implicated in lung cancer were screened in our test cohort of 439 smokers and ex-smokers. 30 SNPs whose genotypes (co-dominant or recessive model) were associated with either the healthy smokers (protective) or lung cancer (susceptibility) phenotype were identified. After genotyping this 30 SNP panel in a second cohort of 491 subjects 19 SNPs were chosen and assigned a simple composite genetic score that was combined with scores for age, history of COPD and family history of lung cancer, weighted according to our multivariate regression analysis (n = 930 total subjects).

The lung cancer risk score was linearly related to the likelihood of lung cancer with odds ratios (referenced against the lowest score quintile) ranging from 1 to 29 in the highest quintile. On receiver operator curve analyses, the AUC was 0.78 and the frequency distribution showed bimodal separation between healthy smokers and lung cancer cases. Utility of the score was not affected by effects of age, smoking history or lung function.

We suggest that genetic data may be combined with other risk variables to define smokers or ex-smokers at risk of lung cancer for targeted interventions such as smoking cessation and early detection of lung cancer. Supported by Health Research Council, NZ. Conflict of Interest Yes.

TP 144

V AIYAPPAN 1 , A GRAHAM 2 1 Department of Medicine, Maroondah Hospital, Melbourne, Australia, and 2

The new disease-modifying anti-rheumatic drug (DMARD) leflunomide is being used increasingly to treat inflammatory arthritis. Its association with interstitial lung disease needs to be considered before combining it with methotrexate. Case Report A 73-year-old male who was known to have Rheumatoid arthritis and was on methotrexate was admitted with progressive dyspnoea and malaise. He had been recently started on leflunomide. Investigations revealed interstitial lung disease and acute renal failure. He improved on conservative treatment (stoppage of disease modifying drugs (DMARD), IV fluids and steroids).

Review of Literature An epidemiological study by Suissa et al has suggested that there is increased risk of ILD associated with leflunomide in patients with a history of ILD or methotrexate use but they attributed this to channelling bias. There has also been a report of leflunomide associated with IgA glomerulonephritis.By this presentation we aim to increase the awareness of this entity. We also suggest that any patient who is started on combination DMARD (i.e. methotrexate and leflunomide) should have a baseline Chest X-ray and be monitored for development of interstitial lung disease. Conclusion We are reporting the first ever case of Interstitial lung disease and Glomerulonephritis (in the same patient), due to usage of leflunomide. This entity needs to be thought about in any patient on combination DMARDs.

Background Bone Morphogenic Protein Receptor II (BMPR-II) mutations are associated with pulmonary artery hypertension. Failure of the growth inhibitory effects of BMP may contribute to vascular obliteration and remodelling leading to pulmonary artery hypertension (PAH) [1] . PAH has been observed following venous thrombembolic disease (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT) [2] . Local markers of the pulmonary vascular endothelium rather than traditional markers of thromobophilia are thought to be involved [3] . Methods Plasma was collected from age and gender matched participants within 24 hours of diagnosis of VTE and prior to commencement of Warfarin therapy. Plasma samples were hybridized to individual human cytokine antibody arrays, to detect protein levels of BMP2, BMP4 and BMPR-II. Results BMP2 and BMP4 levels were higher in patients with DVT than PE. No difference in the BMP level was observed between patients with PE and controls. Soluble BMPR-II receptor was lower in patients with PE than in controls or patients with DVT. Conclusion In patients with pulmonary artery stress during the time of a PE the BMPR-II receptor is reduced, which may predispose patients to vascular remodelling and obliteration. The BMP 2 and 4 levels are reduced at the same time, suggesting a possible overriding regulatory mechanism. The physiological role of BMP's and BMP receptors in patients with VTE warrants further investigation. Historically, cyclophosphamide has had a variable role in interstitial lung disease (ILD), the rationale for its use based on the benefit seen in vasculitis and scleroderma, its rapid effect and low toxicity profile. In patients with severe progressive ILD a rapidly effective, well-tolerated agent is desirable. For this reason a treatment protocol for the use of intravenous (IV) cyclophosphamide was implemented at our hospital. Aim To review the indications, duration, tolerability and effect of intravenous cyclophosphamide in ILD patients following the introduction of a treatment protocol.

Methods Records of 92 patients [DLco was 40 Ϯ 15% and FVC 61 Ϯ 20%] completing a course of IV cyclophosphamide during 2005-6 were reviewed (excluding patients with systemic sclerosis). Data covering 18 months prior to and following treatment were collected. Comparative analysis of paired pulmonary function data 6 months before and after treatment was performed. 61% had underlying autoimmune disease.

Results Primary treatment indications included progressive disease(n = 67); severe disease (n = 16); suspected vasculopathy (n = 11); bridging therapy to transplantation (n = 10); and accelerated decline (n = 5). Patients received 600 mg/m 2 [mean dose 1152 Ϯ 165 mg, median number of pulses 6 (1-12)]. Patients with paired pulmonary function data had a difference in median change in DLco% predicted from -15.6% (-95.4 to 29.9%) before treatment to +4.25% (-17.3 to 73.9%) following treatment (p < 0.0001). This remained significant with exclusion of vasculitis, or any autoimmune disease, and independent of prior immunosuppression. Therapy was well tolerated (4 withdrew from treatment, 5 deaths within 1yr, none directly related to treatment). Conclusion IV cyclophosphamide is well tolerated, and associated with functional stability or improvement in the majority of patients. It remains a viable treatment alternative for consideration.

Pulmonary hypertension is common in interstitial lung disease (ILD) and associated with a poor prognosis. As the gold-standard test, right-heart catheterization (RHC) is invasive, and resource-limited, reliable non-invasive measures of PH are needed. Methods All ILD patients referred for RHC during 1997-2007 were included (n = 95; 54 male; age 56.5 Ϯ 12 yrs). All patients had concurrent echocardiography (TTE) and pulmonary function. The relationship of RHC mean pulmonary artery pressure (mPAP) to TTE variables, pulmonary function, exercise capacity, as measured by six minute walk testing (6MWT, n = 58) and brain natriuretic peptide (BNP, n = 36), was examined. 

Case A 65 year old male, non-smoker for 25 years, retired professor of anatomy (had chronic exposure to embalming fluids, formaldehyde, phenol, antifungal and other solvents, for 20 years) presented with chronic cough and phlegm production. These symptoms were worse at night (waking him several times) and early morning. His pulmonary tests were stopped due to persistent cough. A chest X-ray revealed features of longstanding interstitial lung disease. The HRCT revealed widespread subpleural interlobular thickening, worse at bases, in keeping with idiopathic pulmonary fibrosis (IPF). There was minimal fibrosis and honeycombing, but no groundglass opacification, large bullae, pleural calcification or pleural plaques. However, there was associated bronchiectasis at the lung bases considered to be due to traction. The BA lavage showed 50% macrophages, 7% neutrophils, 3% Lymphocytes, and 40%, eosinophils and no infection. The patient declined to have a lung biopsy. As per his past X-rays, the duration of his IPF is a little over one year. He maintains that his symptoms started only after starting irbesartan (IRB). Introduction Transbronchial lung biopsy (TBB) has a variable and unpredictable diagnostic yield in sarcoidosis. We hypothesized that the extent and pattern of parenchymal disease on CT would predict the likelihood of a positive TBB.

Methods Data relating to ethnicity, symptoms, pulmonary function and site and results of TBB and bronchoalveolar lavage (BAL) from 70 sarcoidosis patients were recorded. All had a CT scan within 6 weeks prior to the TBB procedure. CXR stage was determined from radiology report. CT scans were scored quantitatively for patterns of parenchymal disease (nodular, reticular, consolidation, ground glass and mosaic attenuation) on a lobar basis. Results 50% patients had a positive TBB (total 67% of cohort had histological confirmation). Symptoms, ethnicity, treatment, lung function and CXR stage were not predictors of a positive biopsy. Positive biopsy was associated with higher BAL lymphocyte count (p < 0.05) and female gender (p < 0.01). A reticular pattern (p < 0.05) and higher total lung score (excluding DA) (p < 0.05) on CT scan predicted a positive biopsy. In those patients with TBB from right lower lobe (53/70) the total RLL score on CT was predictive of positive biopsy (p < 0.05). On multivariate analysis gender, BAL lymphocytosis and total lung score were independent predictors of a positive TBB (area under ROC 0.82). Pulmonary arterial hypertension has two histological variants; 'arterial-only pulmonary arterial hypertension' (artPAH) and 'pulmonary veno-occlusive disease' (PVOD). Bosentan, a dual endothelin receptor antagonist, has been found to improve haemodynamics, functional capacity and survival in artPAH. However, the response to Bosentan in clinically diagnosed artPAH is often variable. It was hypothesized that a lack of response to Bosentan therapy in clinically diagnosed artPAH can be explained by misdiagnosed PVOD. Aims included to: (1) perform morphometric and qualitative pulmonary vessel analysis on normal controls and cases clinically diagnosed with artPAH who had failed Bosentan therapy; (2) ascertain if PVOD is present within the case group;

(3) correlate clinical variables and vessel microanatomy to identify the pathologies driving pulmonary pressure elevation. This study reviewed 14 cases of clinically diagnosed artPAH (idiopathic n = 12, associated with scleroderma n = 2), who had failed Bosentan therapy and had available lung tissue. Controls (n = 6) were obtained from explanted lungs for other causes and a prior transthoracic echocardiogram excluded pulmonary hypertension. Vessel morphometry and qualitative analysis was performed with a novel technique of smooth muscle actin immunohistochemistry counterstained with Verhoeff's elastin. Baseline clinical data were retrieved. We found 86% of cases had pathology confirmed PVOD. Only 14% of cases had artPAH, the original clinical diagnosis. In PVOD, significant pathology was present in all vessel types. All vessels had significant smooth muscle hypertrophy. The obstructive, collagenous, pauci-cellular intimal fibrosis of the venules (p < 0.0001) and arterioles (p < 0.0001) was considerably different to the concentric laminar proliferation of smooth muscle observed in the muscular arteries (p < 0.0001) and arterioles (p = 0.001) in artPAH. artPAH also had muscular artery smooth muscle hypertrophy (p = 0.007). The median time to Bosentan failure was shorter in PVOD than artPAH (290 vs. 657 days). In conclusion, PVOD is an under-diagnosed cause of pulmonary hypertension, is commonly clinically misdiagnosed as artPAH and may present with a poor Bosentan therapy response. Finally, PVOD is a vaso-occlusive, not a veno-occlusive disease, and is an independent type of pulmonary hypertension, not a subtype of pulmonary arterial hypertension. Cutaneous T cell Lymphomas (CTCL) are a heterogenous group of lymphoproliferative disorders. They show various clinical manifestations and diverse morphological, histological and immunological characteristics of the malignant cells. They are caused by clonally derived, skin invasive T cells. Peripheral T cell Lymphomas (PTCL) are generally more aggressive and have one of the lowest overall and failure-free survival rates. Because of the rarity of these disorders, diagnosis and treatment remain challenging. This case report describes a 69-year-old woman presenting with progressive dyspnoea and cough, together with a distressing generalized pruritic rash. She was initially treated as left ventricular failure with the rash ascribed to a drug reaction as suggested by initial skin biopsies. The diagnosis was made on a third skin biopsy and flow cytometry of lymphocytes obtained by broncho-alveolar lavage 6 months after presentation. Despite an initial response to chemotherapy she succumbed to the disease 20 months after diagnosis. Clinical pathways to guide the investigation of suspected pulmonary embolism (PE) have been increasingly adopted by emergency departments (ED) worldwide. Compliance with these diagnostic algorithms is critical in ensuring good patient outcomes. This study evaluated the compliance to the clinical pathway used in our ED that combines risk assessment (Wells scoring system) with D-dimer test, VQ scan or CTPA. The main objectives of this study were to identify those factors which contributed to compliance and to assess patient outcomes.

Methods A prospective observational study of 239 consecutive patients who underwent investigation for PE in our ED. Patient demographics, pathway parameters and patient outcomes at 3-month follow-up were collected. Case We report the case of a 37 year old woman who presented to the Emergency Department with a three day history of dry cough and dyspnoea. The patient was in her third pregnancy at 30 weeks gestation. She had no fever, chest pain or coryzal symptoms. The patient had presented with a right sided spontaneous pneumothorax seven months prior to the current presentation. Her past medical history included placental abruption, complicating her previous two pregnancies. Her second pregnancy was complicated by placental abruption at 27 weeks and the foetus had not survived. Her first pregnancy was complicated by placental abruption at 36 weeks with successful delivery of the foetus. At presentation, significant findings included tachycardia, hypoxemia, tachypnoea and reduced breath sounds over the right side of the chest. Chest x-ray demonstrated a large right pneumothorax. A right intercostal catheter was inserted resulting in right lung re-expansion. The catheter was removed three days later. The patient returned to hospital twenty four hours after catheter removal with a recurrent right sided pneumothorax. The patient agreed to surgical intervention involving video-assisted thoracotomy and talc pleurodesis. The patient had no further complications with the pregnancy. She delivered a healthy baby at 38 weeks gestation. Discussion Spontaneous pneumothorax in pregnancy is rare and there is little evidence to provide guidelines for the management of recurrent pneumothorax in high risk pregnancy. Our case illustrates a successful outcome for mother and foetus with surgical intervention at 32 weeks gestation. FOLFOX is currently the standard adjuvant treatment for locally advanced (stage III) colon cancer and increases disease free survival. Its toxicity is well tolerated with common adverse effects being paraesthesia, bone marrow suppression and gastrointestinal disturbance. Pulmonary toxicity has rarely been reported. Three clinical cases of acute dyspnoea following FOLFOX therapy (2005) (2006) (2007) for stage III colon cancer are reported. All had an anterior resection followed by 11-12 cycles of FOLFOX. Each developed rapidly progressive dyspnoea requiring hospital admission within one week of their last cycle. One patient required invasive ventilation in ICU. High resolution computed tomography (HRCT) showed bilateral widespread honeycomb pattern with associated ground glass opacification consistent with pulmonary fibrosis. They had reduced lung volumes and gas transfer. Transbronchial biopsy and bronchoalveolar lavage in one patient showed an acute eosinophilic pneumonitis. Other causes of interstitial lung disease were carefully excluded. All three patients received high dose corticosteroids with one receiving additional cyclophosphamide. The first patient showed complete recovery following an eight week course of corticosteroids, with resolution of the HRCT changes and improvement in lung function. The second had symptomatic improvement of dyspnoea, but a persistent moderate reduction in gas transfer. The final patient had persisting radiographic changes and a reduced gas transfer. He remained dependant on ambulatory oxygen 6 months after his initial presentation. These patients' interstitial lung disease appears due to FOLFOX with oxaliplatin being the most likely causative agent. The use of oxaliplatin chemotherapy has increased markedly over the last 3 years and although rare, physicians should be aware of its potential for lung toxicity. Lung function testing at baseline, during and towards the end of oxaliplatin treatment should be undertaken and may allow early detection and intervention in cases of pulmonary toxicity. The forced oscillation technique (FOT) with broadband signals has been employed relatively rarely in the studies on respiratory mechanics. Recent work from our laboratory [1] indicated that the cheek support and the neck angle have minor influence on the impedance spectra around the first antiresonance (far,1), which makes the use of the broadband FOT especially attractive in young children.

Methods We studied 7 healthy children (C; female: 4) and 8 children with bronchopulmonary dysplasia (BPD; female: 3), using multiple-frequency FOT between 8 and 256 Hz superimposed on spontaneous breathing. Results Groups C and BPD did not differ in age ( Lung function impairment is common in children with cardiac defects associated with increases in pulmonary blood flow/pressure. To investigate the development of bronchial hyperreactivity (BHR), an aorto-caval shunt was created in a model of precapillary pulmonary hypertension. Surgical shunt repair was performed to assess the reversibility of BHR.

Methods 26 rats were divided into 3 groups: Group C (n = 10) with sham surgery, group S (n = 8) where an aorto-caval shunt was created (follow-up 4 wks), group R (n = 8) with aorto-caval shunt but surgical correction of the shunt at 4 wks (follow-up 8 wks). In all animals, respiratory input impedance (Zrs) was measured at baseline and following increasing doses of methacholine (Mch 2, 4, 8, 12 mcg/kg). Airway resistance (Raw), inertance, tissue damping (G) and elastance were estimated from the Zrs spectra by model fitting. Measurements were repeated in all animals at 4 wks and at 8 wks for groups R and C. Results There was a significant increase in Raw and G in group S and Rat 4 wks at baseline and following Mch ( Fig.) which was reversed after surgery. To characterize the factors contributing to lung function impairment following cardiopulmonary bypass (CPB), functional residual capacity (FRC), lung clearance index (LCI) and respiratory mechanics were measured in children with pulmonary hypoperfusion (Tetralogy of Fallot, TOF n = 12) and hyperperfusion (ventricular septal defect, VSD n = 12) undergoing surgical repair of congenital heart disease. Methods FRC and LCI were measured using a SF6 washout technique and respiratory mechanics using a low frequency oscillation technique in the perioperative period. Results While chest opening led to a significant improvement of lung volumes and respiratory mechanics in all patients (p < 0.001), a reduction in pulmonary blood flow during CPB decreased lung volumes and airway resistance in parallel but significantly more in children with TOF compared with those with VSD. Re-establishing pulmonary blood flow during CPB improved respiratory function particularly in children with TOF ( Figure) .

Conclusions Sternotomy had a great impact on lung function with parallel improvement in alveolar recruitment, ventilation inhomogeneity and airway resistance. In contrast, onset of CPB led to lung function impairment with a significant drop in FRC especially in children with pre-existing hypoperfused lungs. This suggest that pulmonary blood flow enhances alveolar stability through a tethering effect on the alveolar walls. Children with advanced lung disease being considered for lung transplantation are likely to spend disproportionately longer periods on transplant waiting lists before appropriately sized donor organs become available. These longer waiting times reflect the lower organ donation rates seen in children; rates that are significantly lower than those reported in the adult population. We describe two children with advanced lung disease who deteriorated whilst on the waiting list for lung transplantation, and in the absence of appropriately sized donor lungs, underwent lobar lung transplantation. Methods We describe the clinical course of two children, aged 9 and 13 years old, with advanced lung disease secondary to post-mycoplasma obliterative bronchiolitis and cystic fibrosis-associated bronchiectasis, respectively. Results Both children received a "cutdown" bilateral lobar transplant from two oversized adult brain-dead organ donors. In both cases the transplant operation involved implantation of the right middle and upper lobes, and of the left upper lobe from the donor. Conclusion Given the low organ donation rates in children, and in the absence of appropriately sized donor lungs, novel strategies such as lobar transplantation must be considered, particularly when children continue to clinically deteriorate whilst on the lung transplant waiting list. Data from the West Australian adult outcomes of extreme preterm birth study suggest that adult survivors of bronchopulmonary dysplasia (BPD) may be left with functional and structural pulmonary abnormalities, most notably emphysema. Animal data suggest that the antenatal administration of corticosteroids may adversely affect lung development. We therefore sought to determine if maternal variables, including administration of corticosteroid, could predict emphysema severity in adulthood. Methods BPD subjects (birthweight < 1500 g and oxygen dependence at 36 weeks post-menstrual age) born prior to 1988 were identified and recruited prospectively via the statewide neonatal follow up program as previously described. Pulmonary function tests and thin selective inspiratory and expiratory computerised (CT) images were acquired and scored for emphysema severity (voxel index (%)). The obstetric history was obtained from retrospective review of case notes. Results 21 adults (12 females, aged 18-34) were studied, 2 declined CT. All subjects had abnormal CT findings. Fifteen (79%) had areas of emphysema. Emphysema score and FEV1 were not influenced by the administration of antenatal corticosteroids, indication for delivery, maternal age or presence or absence of chorioamnionitis. Conclusion Maternal factors, including the administration of antenatal corticosteroids, do not predict the long term respiratory outcome of BPD. The factors determining the severity of emphysema in this group remain unknown. The prevalence of childhood asthma is high in the Torres Strait. Children have generally more severe asthma and asthma knowledge is poor. However, there is no culturally appropriate asthma education program for these children. We are conducting a randomized controlled trial to examine the additional benefits of an education intervention by Indigenous Health Care Workers (HCW) on asthma outcomes. We describe the study's objectives, design and baseline measurements. Methods Children with wheeze were reviewed by two paediatric respiratory physicians using a standardized protocol; children with asthma were eligible. After obtaining informed consent children were randomly allocated to: (1) three additional asthma education sessions with a HCW; or (2) no additional education from a HCW. Trained HCWs carried out the education sessions using culturally appropriate tools. Primary outcome was the number of unscheduled hospital/doctor visits due to asthma exacerbation. All children were re-assessed at 12 months. Results We enrolled 113 children aged 1 to 17 years, 81% were Torres Strait Islanders and 12% Aboriginal and Torres Strait Islanders. The clinical spectrum of asthma was: 51% infrequent episodic asthma, 22% frequent episodic asthma and 27% chronic asthma. Eighteen percent of the children knew what a written Asthma Action Plan was; 8.5% had one. Carers' assessment of knowledge of medications showed that 52% could not name any asthma medication used by their child, 40% could not explain dosage, and 67% could not explain how beta2 agonists worked. Conclusions Asthma knowledge and possession of asthma action plans in this cohort is poor at baseline. There is substantial room for improvement and additional asthma education by HCWs potentially has significant benefits. Impulse Oscillometry System (IOS) measures respiratory function during normal breathing by transmitting mixed frequency rectangular pressure impulses down the airways and measuring reflected pressure. Computer analysis calculates respiratory impedance and its components, airways resistance and reactance, at a range of frequencies from 0.1 Hz to 150 Hz. No previous Australian normative data exists. The IOS software generates predictive normal values for each of the parameters measured including total airway resistance (R5), the proximal airway resistance (R20) as well as peripheral capacitive reactance (X5). However, they are based on German data. Methods Cross-sectional study of 100 community dwelling adults, with 10 males and females per 10-year cohort. Inclusion criteria: age range 25-74 years, apparently good respiratory health. Exclusion criteria: smokers, asthmatics and others with acute or chronic respiratory disease. Both IOS and spirometry were conducted on all participants. Results Australian predictive normal equations have been generated and compared to the current published equations. The IOS parameters have been correlated with the spirometric data. Results have been analysed by gender, age, height and weight and compared with the predictive normal values for each parameter provided by the German manufacturer of the IOS instrument. Analysis includes calculation of mean range, and lower limit of normal. Conclusions A preliminary set of Australian predictive equations have now been produced for the IOS. These have been compared with international equations. IOS has potential application in a range of respiratory disease states and in population screening for occupational health (e.g. mining, & high dust load environments). Supported by PHC RED. Rationale Although clinical practice guidelines for both asthma and COPD recommend spirometry for diagnosis and monitoring, beneficial effects on the management of chronic respiratory diseases in general practice have not been established. We hypothesized that spirometry would improve health outcomes compared to usual care. Methods We are conducting a single masked RCT with 3 arms: Group A receive 3 monthly spirometry and followup, Group B receive spirometry before and after the trial and Group C usual care. 45 general practices were recruited though Divisions of General Practice in Melbourne. Invitations were mailed by 31 of these practices to patients who had been prescribed inhaled medications during the previous 6 months. Participants returned respiratory and generic quality of life questionnaires and an asthma score card. Groups A and B were tested on a MicroMedical turbine spirometer following ATS/ERS guidelines. Results 351 eligible patients (275 adults, 50 children aged 8-13 and 26 youths aged 14-17 years) entered the trial. 122 were randomized to Group A, 134 to Group B and 95 to Group C. The mean (SD) age of adult participants was 54.3 (12.7), children 10.3 (1.7) and youths 15 (1.1) years. There were 130 males and 221 females. The adults were highly symptomatic in the previous 12 months: 82% reporting wheeze, 50% chest tightness on waking, 74% shortness of breath on exertion, 61% nocturnal cough, 46% morning cough and 75% sputum. Symptoms of chronic bronchitis were reported by 39% of adults and a diagnosis of COPD by 19%. Asthma was reported by 84%, confirmed by a doctor in 96% and 55% had experienced an attack in the last 12 months. Only 35% had a written asthma action plan. 37% of adults had ever visited a hospital ED and 28% had been admitted. Conclusion It is possible to recruit asthma and COPD patients from general practice and to randomize them to spirometry or usual care. Whether spirometry is associated with fewer symptoms, changes in medication, uptake of action plans or improvement in lung function or quality of life requires further followup. Supported by NHMRC.

S SHAH 1 , JK ROYDHOUSE 1 , B TOELLE 2 , S SAWYER 3 , C JENKINS 2 for the PACE Australia Management Committee 1 University of Sydney, 2 Woolcock Institute of Medical Research, Sydney, NSW 2006, and 3 Royal Children's Hospital, Melbourne, VIC 3052 It is widely held that recruitment of general practitioners for research can be challenging. In this paper, we discuss the recruitment experience from a current study evaluating the impact of an educational asthma intervention on patient outcomes. Our aim is to describe the two different strategies utilized to date: (1) in-house through an academic department of GP and (2) outsourced to a private GP organization. Methods Initial interest was generated through faxes, presentations at GP Divisional meetings and newsletter advertisements. GPs who expressed interest were visited by project staff to discuss the study further. A major difference was recruiting one GP per practice in the first strategy versus multiple GPs per practice in the second strategy. To assess the strategies, we examined participant characteristics, number of GPs recruited and number retained. Results Participant characteristics: Under both strategies, 30% of recruits had trained in Asia and 54% were women. The first strategy recruited more GPs who spoke at least two languages at home (85% vs 42%) and the second strategy recruited more recently graduated GPs (58% vs 50%). Recruitment: The first strategy recruited 35 GPs over 6 months and the second recruited 34 GPs over 3 months. Retention: 19 GPs (54%) from the first strategy stayed in, compared to 29 (85%) from the second. Conclusions Whilst absolute numbers of GPs recruited were similar, retention was much higher under the second strategy. Recruitment in primary care is difficult and requires a range of approaches which need to be re-evaluated and adapted as necessary during the course of the study. Supported by the Australian Government Department of Health and Ageing. Bronchiectasis is a heterogeneous condition with a large number of causative factors and range of symptoms. The classification of this condition is often confusing and hard to remember. The aim of this study was to classify non-CF bronchiectasis into different clinical phenotypes. Methods 178 consecutive patients with non-CF bronchiectasis confirmed on high resolution CT scanning had a detailed clinical, spirometric and laboratory assessment performed by a respiratory physician (PK/MF/PW) and were then followed up for an average of 9 Ϯ 4 years (mean and SD) for a total of over 2000 reviews. Results 160 of the 178 patients (90%) could be classified as belonging to 3 phenotypic groups; 1) bronchiectasis arising in childhood, 2) bronchiectasis occurring in smokers and 3) bronchiectasis occurring in the elderly. Each group had different features which are listed in the There are few data on the long term outcomes of treatment for tuberculosis (TB) by directly observed therapy (DOT) in low-incidence settings. The aim of this study was to assess the incidence of recurrent TB in NSW. Methods Data linkage was performed within the NSW Department of Health TB notifications database to identify cases that had more than one TB notification between 1994 and 2006. Recurrent tuberculosis was defined to include all patients with two or more culture positive episodes at least 6 months apart, where patients had received at least six months treatment for the initial episode. In cases where data contained within the notification details was not sufficient to allow us to distinguish between true cases of recurrent disease, duplication notification for the same episode or persistent disease after incomplete treatment, additional information was obtained from the Area TB coordinator. Results There were 5723 TB notifications between 1994 and 2006 with 3731 being culture positive. 15 cases of recurrent culture positive disease after completed treatment for the first episode were identified (recurrence rate: 0.4%).

Conclusions In a population with a low TB incidence, treatment of active tuberculosis with DOT results in a very low rate of disease recurrence over a long period of follow-up. Support NHMRC CCRE in Respiratory and Sleep Medicine.

Introduction Rhinoviruses (RVs) are the major cause of viral-induced exacerbation of asthma. To date, the molecular mechanisms of RV pathogenesis are not understood. Recent findings suggest that RV pathology may involve host cell nucleocytoplasmic trafficking, inhibiting key cell functions such as transcription and translation. The study aims to investigate the mechanism of RV 3C protease nuclear trafficking. Methods HeLa cells were infected with RV or transfected with plasmids and cellular localization of 3C analysed at various times thereafter using immunofluorescent confocal microscopy and Western blotting with specific antibodies. Results 3C protease was predominantly present in nuclei of RV infected cells up to 6 hours after infection, becoming increasingly cytoplasmic thereafter. The nuclear membrane of infected cells became progressively indistinct with time.

Using a specific inhibitor we also found that 3C utilizes the CRM-1 nuclear export pathway. 3C was predominantly in the form of 3CD in both cytoplasm and nucleus of infected cells; mature 3C protease was also detected from 6 hours after infection. Deletion analysis indicats that the nuclear localization domain and a nuclear export signal are most likely to be present within the N terminal 64 amino acids. The nuclear export signal is inhibited in the full length protein, via an unknown mechanism. Conclusion Our data suggest that 3C and 3CD proteins localize to the nucleus in infected cells where they may play a key role in RV pathogenesis by disrupting cellular transcription and the nuclear transport machinery. Chronic necrotizing pulmonary aspergillosis (CNPA) is a relatively uncommon, sub-acute, locally destructive process due to Aspergillus invasion of the lung. The incidence and prognosis of CNPA are poorly described. Case report We present a case of CNPA in a patient on intermittent low dose steroid therapy and recurrent refractory exacerbations of chronic obstructive pulmonary disease (COPD).The patient presented with worsening shortness of breath and productive cough requiring recurrent inpatient admissions. Human influenza virus is found to bind preferentially to SAa2,6GAL receptors found in the upper respiratory tract, while avian viruses bind to SAa2,3GAL receptors expressed in lower airways. This is thought to affect the ability of transmission to humans. Our aim was to study the ability of avian and human influenza strains to infect bronchial epithelial cells and relate this to levels of the sialic acid receptor expression. Methods Calu-3 cells were used as a proximal airway cell and A549 were used as distal airway cell. Human primary bronchial epithelial cells (pBECs) were obtained from healthy, asthmatic, and COPD volunteers by endobronchial brushing. Epithelial cells were stained with Sambucus nigra lectin that binds SAa2,6Gal receptor, and maackia amurensis lectin II that binds to SAa2,3Gal. The cells was analysed by flow cytometry. Human influenza A/H3N2/Wellington strain and low pathogenic avian influenza A/H11N9/Sandpiper were chosen and were used at an MOI of 0.005 to infect cells. The supernatants were harvested at 48 hr post infection, of which was then analysed by plaque assay for virus replication.

Results The Calu-3 showed greater expression of SAa2,6Gal linkage than SAa2,3Gal linkage, and A549 displayed slightly higher expression of both receptors compared to pBECs. Despite this human and avian influenza virus replicated to similar titre at 15,000 pfu/ml in both cell lines, but showed low replication in pBECs. Background Treatment of community-acquired pneumonia remains based on 'best guess' empiric algorithms because of the poor utility of current pathogen tests. Furthermore our ability to stratify patients into risk groups is crude at best, relying on scores such as the pneumonia severity index or the CURB-65 have major limitations. We have been slowly improving real-time PCR assays for pneumococcus as a clinical tool in patients with pneumonia. Methods Building on previous research we assesed two targets in the autolysin (lytA) gene and the pneumolysin (ply) gene of S.pneumoniae using the LightCycler instrument and Fluorescence Resonance Energy Transfer (FRET) probes. All common S. pneumoniae serotypes were detected while other bacteria and viruses were not. The lytA target had the best sensitivity with a detection range between 21 ng to 21 fg. Both assays were then applied to whole blood samples from 400 adult patients with community-acquired pneumonia, all of whom had blood cultures prior to antibiotic administration and urinary antigen testing for S.pneumoniae.

The lytA PCR had the best performance characteristics with a sensitivity more than twice that of blood cultures in the clinical samples. Most PCR+ve/culture -ve patients had positive urinary antigen tests. There was clinical evidence that urinary antigen +ve/ PCR -ve patients were false +ves.

Most significantly there was a strong correlation between quantitative bacterial count and clinical outcome. Conclusions Real-time quantitative PCR for pneumococcus has significant potential as both a diagnostic and therapeutic tool in patients with pneumonia.

The Pitjantjatjara Lands are situated in the north-western corner of South Australia, occupying an area of over 120 000 square kilometres with a population of approximately 3000. The population lives in small communities or homelands, and there is a high level of mobility between this region and other Aboriginal communities in South Australia and the Northern Territory. Nganampa Health Council provides all health care services to the region. Specialized support for TB control comes from both the South Australia TB service based at Royal Adelaide Hospital as well as a Centre for Disease Control in Alice Springs. The prevalence of tuberculosis (TB) in this predominantly indigenous community is thought to be significantly higher than the national rate. There are considerable challenges in detecting and managing tuberculosis, relating to the community's geographical remoteness, migration of populations and access to health services. The aims of this study are to quantify the prevalence of tuberculosis in the Pitjantjatjara Lands, and describe the significant barriers to TB diagnosis and treatment.

Methods A retrospective study of all diagnoses of tuberculosis within the Pitjantjatjara lands in the period 1995-2006. Outcomes include measures of tuberculosis diagnosis, the rates of completed TB treatment and rates of tuberculosis drug resistance. The study will draw conclusions about the reasons for high levels of TB prevalence in this community and identify barriers to effective tuberculosis treatment.

Conflict of Interest NO.

Patients admitted to hospital with a diagnosis of community-acquired pneumonia (CAP) are usually treated with intravenous (iv) antibiotics irrespective of pneumonia severity. Available guidelines vary in recommended timing and indications for switching to oral antibiotics. Aim To examine the patterns of antibiotic choice and delivery method (iv, oral and time to switch) in patients admitted with CAP. Methods A retrospective chart review of admissions to the Respiratory Unit over a 12-month period with a Diagnostic-Related Group (DRG) coding of pneumonia. 41 charts were reviewed. Data collected included patient demographics, clinical features at presentation (temperature, pulse rate, respiratory rate, BP, oxygenation), initial investigations, initial antibiotic regime, time to change (iv to oral), subsequent antibiotic regime and duration, time to defervescence, length of stay and outcome. Pneumonia severity was calculated using the revised British Thoracic Society system (CURB-65), score Ն 2 = severe. Results 3 patients were excluded due to incorrect coding. Of the 38 patients, age was 50 Ϯ 21 (mean Ϯ SD) yrs and 25 (66%) were male. 28 patients (74%) were febrile at presentation and the median CURB-65 score was 1 (range 0-4). 37 patients (97%) received iv antibiotics. The CURB-65 score was 0 or 1 (non-severe) in 25 patients and 22 of these patients received a combination of iv ceftriaxone and a macrolide. Time to defervescence was 2.9 Ϯ 2.3 days. Time from defervescence to switching to oral therapy was 3.4 Ϯ 2.8 days. In non-febrile patients, time to switch was 4.7Ϯ4.3 days. Length of stay was 8.7Ϯ13.0 days. Conclusions The time between defervescence and switch to an oral regime was relatively long, possibly contributing to an increased length of stay. Many patients received ceftriaxone even with a CURB-65 severity rating of 0 or 1. Implementing local guideline-based treatment protocols may reduce length of stay. 

Ultrasonic flow sensors can determine flow, volume and molar mass (MM) of the gas flow simultaneously. During tidal breathing the expired molar mass curve can be used to compute CO2 over expired volume and a Capnography Index (CPI) can be computed. The relationship between CPI and COPD classification according to GOLD was investigated. Methods Prospective, controlled trial. Consecutive patients who underwent routine lung function were enrolled to participate in a tidal breathing test using an ultrasonic flow sensor. Each test consisted of three tidal breathing recordings of 60 sec. Flow, volume and molar mass were measured at 200 Hz and data were acquired using prototype WBreath data acquisition software. Mean expirograms (MM over volume) were computed and the measurements were analyzed to determine the slope of exhaled phase II (S2), the slope of phase III (S3) and the relationship between S2 and S3 (CPI = S3/S2). GOLD stages were determined from the lung function results and the ERS predicted values.

Results 53 volunteers participated in the study with a mean age of 62 (SD 14), 23 were male, mean BMI 26 (SD 5), 17 had never smoked. The mean pack/year smoking history was 38. There was a clear relationship between GOLD stage and CPI: GOLD stage 'normal' had a mean CPI of 5.5 (SD 3.7, n = 21), stage 'severe' had a mean CPI of 13.7(SD = 3.9, n = 7). Conclusion Computation of CPI based on tidal breathing analysis using an ultrasonic flow and MM sensor correlates well with GOLD stages. It may therefore be possible to use a simple tidal breathing test to determine the severity of airways disease. Background OSA is common in tetraplegia and appears within weeks of injury. Although CPAP treatment is efficacious in able-bodied subjects, case series suggest that CPAP is poorly tolerated in tetraplegia. No prospective study has examined CPAP efficacy or adherence in tetraplegia. Aim To determine the feasibility of CPAP use to treat OSA following acute tetraplegia. Methods All acute admissions who consented and fulfilled the inclusion and exclusion criteria underwent full, portable polysomnography. Those found to have an apnoea hypopnoea index of >10 events per hour (OSA) were offered CPAP, delivered via an auto-titrating device. Results To date, 25 patients have been admitted (11 excluded, 3 refused consent). No significant, adverse events have been observed. Two patients did not have OSA. Of the nine with OSA, four are mid-study, two had incomplete follow-up (1 returned to UK and 1 refused 3 month assessment), two adhered with CPAP and one did not due to severe, pre-existing nasal obstruction. Preliminary analyses suggest that those who adhered to CPAP had a marked reduction (80% compared with 10-40%) in sleepiness and a greater reduction in the functional outcomes of sleepiness compared to either those without OSA or who were unable to use CPAP. Patient accrual, recruitment and completion rates are consistent with our initial estimates. Study recruitment will be completed by end-October 2007.

Conclusion Initial data suggest that auto-titrating CPAP is a feasible treatment for OSA in acute tetraplegia. These data will be used to finalize planning for a multi-national, multi-centre randomized controlled of therapy. This research was supported by the Transport Accident Commission. Visual recognition of cyanosis is an important clinical activity. Cyanosis recognition is affected by lighting colour and there is anecdotal evidence that people with significant colour vision deficiencies (CVDs) have particular difficulty. Studies to date have centred on the colour change with oxygenation of isolated blood but it is not clear how this extrapolates to cyanotic patients in vivo. Methods Ten patients known to be chronically hypoxaemic and showing signs of cyanosis were recruited from the chronic respiratory program. Ten normal subjects were recruited as controls. The spectral reflectances of their lips, nail beds and palm creases were measured using a Topcon SR-3 telespectroradiometer. The patients were measured at rest and after exercise to lower their saturation by 5-10%. The chromaticities were calculated and plotted.

Results Both groups showed a spread of colours but they fell into two distinct ranges. The colour difference between the groups lies very close to the colour confusions made by congenital CVDs. Within the cyanosed group, the colour shift was not tightly related to decreasing oxygen saturation. This is most likely due to interpersonal factors such as pigmentation and vascular perfusion that affect colour and the difficulties in measuring the colour of heterogeneous anatomical features.

Conclusions These results quantify the anecdotal difficulties in detecting cyanosis and suggest that observers with CVD would have problems recognizing the condition. The photographs obtained from this study will be used to compare the ability of subjects with and without CVD to detect cyanosis. Supported by the NSW Ambulance Service. Baroreflex sensitivity is depressed in OSA patients during sleep but effects during wakefulness are less clear. We have now examined relationships between awake BRS and severity of sleep disordered breathing (SDB).

Methods Immediately prior to overnight polysomnography, continuous (5 min) beat-to-beat arterial blood pressure was measured via finger plethysmography (Portapres) and heart rate via ECG in 20, supine, normotensive, untreated OSA patients (17 males; age: 49 Ϯ 15 years (mean Ϯ SD); BMI: 26 Ϯ 11 kg/m 2 ). Spontaneous baroreflex sensitivity (BRS) was calculated using the sequence technique. SDB was characterized as apnoea hyponoea index (events/hour) and arousal index (AI). Data were analysed via mathematical modelling and unpaired t test.

Results BRS fell with increasing AHI. Patients with AHI > 30 events/hour (n = 9) had a significantly lower BRS (8.1 Ϯ 1.5 ms/mmHg) than those with AHI < 30 events/hour (19.8 Ϯ 8.7 ms/mmHg, p < 0.001). BRS was negatively related to both AHI and AI via fitted exponential functions (r 2 = 0.45 and 0.70, respectively). It is hypothesized that the analysis of morphology of the ECG waveform in combination with the heart rate patterns could lead to the possibility of detection of the start and duration of apnoea/hypopnoea events and consequently estimation of the apnoea-hypopnoea index (AHI). To the authors' knowledge the published ECG based algorithms for detecting sleep disordered breathing are only capable of minute by minute analysis rather than detection of individual respiratory events. Methods Changes to ECG parameters were investigated during respiratory events with no distinction made between apnoea and hypopnoea events. 632 isolated respiratory events and 1264 controls of identical duration were obtained from 7 polysomnographic studies, using a randomized procedure. Features such as the R wave amplitude, T wave amplitude, QRS area and the R-R interval were extracted from the 2 lead ECG. A number of physiological predictors based on these features were generated. A logistic regression model was used to investigate the association between the predictors and true events, using the statistical software, Stata. Results Univariate and multivariate analyses were performed. Three multivariate models were developed; heart parameters only, ECG waveform morphology parameters only and the combinations of the two. The area under the receiver operator characteristic curves (AUC) for these models were compared. The best results were obtained with the combination of morphology and heart rate parameters (AUC = 0.8858 (0.0078 (SD))) compared to the morphology (AUC = 0.8169 (0.0121 (SD))) and heart rate (AUC = 0.7195 (0.0103 (SD))) models.

The multivariate analysis has shown encouraging results indicating that an algorithm using a combination of heart rate and ECG morphological parameters could potentially be constructed that would enable the determination of individual respiratory events and subsequently an AHI. Supported by the ARC.

Introduction Sacin and Scond are measures of ventilation heterogeneity in acinar and conducting airways, derived from analysis of MBNW. Maintaining tidal volumes of 1 L at 9-11 breaths/minute (bpm) is impossible for some. Our aim was to examine the effect of different tidal volumes on Sacin and Scond in normals and asthmatics.

Methods 10 normals (23-41 yrs) and 12 asthmatics (21-63 yrs) underwent MBNW at tidal volumes of 500 ml at 20-23 bpm, 1 L at 9-11 bpm, and 2 L at 5-7 bpm. Scond and Sacin, were determined from the normalized phase III slopes of breaths between turnovers (cumulative ventilation/FRC) 1.5 & 6.

Results The mean Ϯ SD %predicted FEV1 was 97.3 Ϯ 17% in normals and 88 Ϯ 11% in asthmatics. In normals, Sacin at TV of 0.5, 1 and 2 L were 0.195 Ϯ 0.105 L -1 , 0.095 Ϯ 0.036 L -1 and 0.058 Ϯ 0.031 L -1 , respectively (p = 0.0003, ANOVA), while Scond were 0.098 Ϯ 0.047 L -1 , 0.042 Ϯ 0.021 L -1 and 0.029 Ϯ 0.014 L -1 (p = 0.0002), respectively. In asthmatics, Sacin were 0.440 Ϯ 0.195 L -1 , 0.181 Ϯ 0.087 L -1 and 0.100 Ϯ 0.047 L -1 , respectively (p < 0.01), while Scond were 0.204 Ϯ 0.111 L -1 , 0.068 Ϯ 0.037 L -1 and 0.031 Ϯ 0.013 L -1 , respectively (p < 0.0001). Conclusion Increasing tidal volume while maintaining the same minute ventilation during MBNW led to large decreases in Scond and Sacin in both asthmatics and normals. This may be due to reduced inter-regional differences in specific ventilation with greater TV. The log-log relationship between Sacin and TV allows an adjustment to be made for variations in tidal volume. Funding CRC for Asthma and Airways and NHMRC Project Grant #547346.

DJ SMITH 1 , K BOWDEN 2 , T LLOYD 2 , J COUCHER 2 , L GARSKE 1 1 Respiratory Medicine, and 2 Radiology, Princess Alexandra Hospital, Brisbane, Australia

Introduction We have shown diaphragmatic flattening and decreased diaphragmatic excursion qualitatively assessed on ultrasound is strongly predictive of dyspnea severity and lower lung inflation in patients with pleural effusion. We sought to quantitatively measure diaphragm length and movement and determine how closely these are related to dyspnea severity and lung inflation.

Methods patients with unilateral pleural effusions had CT imaging of their diaphragm during a measured inspiratory capacity manoeuvre. Maximal sagittal length was measured at TLC, and FRC. Patients had a Baseline Dyspnea Index (BDI: 0-12) and respiratory function measured. Results 4 patients with unilateral effusion (all right side; 3 malignant mesothelioma, 1 inflammatory) had a mean (SD) BDI of 5.5 (2.89), and TLC of 74% (3.91) predicted. The right diaphragm on the side of the effusion tended to be shorter than the left at FRC (P = 0.08), and had a trend to reduced shortening with inspiration (P = 0.08). Conclusions the right diaphragm is known to be longer than the left in health.

The strong trend to a shorter and less mobile right diaphragm associated with effusion suggests this is a potential mechanism for dyspnea. Further recruitment will enable correlation between BDI, TLC and diaphragm length and mobility. 4) ) that was slightly worse than an able bodied, control population (17.9 (3.1)), but better than an able-bodied population with untreated OSA (14.5 (3.6)). The MAPI predicted that 14% of the sample were likely to have OSA. These data will be complimented by full sleep studies to be performed at the participants' homes in late 2007, early 2008. Conclusion Our interim data suggest that the rate of subjective sleep complaints are not substantially different in the population with tetraplegia compared with the able-bodied. This research was supported by the Victorian Neurotrauma Initiative. It has long been assumed that the ventilation heterogeneity associated with lung disease could in itself affect the measurement of carbon monoxide transfer factor. The aim of this study was to investigate the potential estimation errors of carbon monoxide diffusing capacity (TLco) measurement that are specifically due to conductive ventilation heterogeneity. We induced conductive airway ventilation heterogeneity in 35 never-smoker normal subjects by histamine provocation, and related the resulting changes in ventilation heterogeneity (derived from the multiple breath washout test) to corresponding changes in diffusing capacity, alveolar volume and inspired vital capacity (derived from the single breath TLco method). Average conductive ventilation heterogeneity doubled (p < 0.001), while TLco decreased by 6% (p < 0.001), with no correlation between individual data (p > 0.1). When dividing diffusing capacity by alveolar volume, the resulting transfer coefficient was not significantly different pre versus post histamine (p = 0.074). These findings can be brought in agreement with recent modelling work, where specific ventilation heterogeneity resulting from different distributions of either inspired volume or end-expiratory lung volume have been shown to affect TLco estimation errors in opposite ways. The combination of these errors appears to largely cancel out in our experimental situation of induced ventilation heterogeneity comparable to that observed in lung disease. We conclude that conductive ventilation heterogeneity per se has a negligible effect on diffusing capacity measurement. An important determinant of airway function in humans is vagal-mediated cholinergic tone in airway smooth muscle (ASM). This airway tone may be altered in disease states. The use of mouse models for the study of airway diseases, including asthma, pulmonary fibrosis and COPD is well established. However, it is not known whether mice actually possess basal ASM tone or, if it does exist, how this tone changes in disease models. This study was undertaken to determine whether mice have detectable ASM tone in vivo.

Methods Respiratory system impedance (Zrs) was measured in female adult BALB/c mice using a wave-tube modification of the forced oscillation technique. Zrs was measured during slow (~35 s) inflation-deflation manoeuvres between the transrespiratory pressures of 0 and 20 cmH2O. Baseline lung mechanics and thoracic lung volumes (TGV) were measured before and after each mouse was allocated to one of four treatment groups: 'saline' mice received an i.p injection of saline, 'atropine' mice received i.p. atropine sulphate, 'vagotomy' mice had their left and right cervical vagus nerves isolated by blunt dissection and cut, and 'sham' mice had the area of the vagus nerves exposed but the nerves were not cut. Results There were no post-treatment changes in TGV, airway resistance, tissue damping, tissue elastance, inertance or tissue hysteresivity in any of the four groups.

Conclusions The lack of change in lung mechanics post-atropine or postvagotomy in BALB/c mice suggests that, unlike humans and many other species, the airways of mice have no baseline ASM tone. Supported by NHMRC grant#11488. Nomination None.

Conflict of Interest None.

Both male gender and increased mandibular enclosure volume predict more severe sleep disordered breathing in obstructive sleep apnoea patients. We now examine gender/body size/mandibular enclosure volume relationships for normal subjects

Stepwise multiple linear regression analysis was used to model body size/enclosure volume interactions. Results For the whole group, MV was 261.1 Ϯ 6.0 ml (mean Ϯ SE) while RMV was 205.1 Ϯ 4.9 ml. Head circumference (positive) and forehead height (negative) were both independent predictors for MV and RMV (both p < 0.02), while hip circumference was an additional positive predictive factor for RMV (p < 0.04). After adjusting for these parameters, male MV and RMV were larger than for females

Conclusion These findings suggest that mandibular enclosure volumes are relatively larger in males, even after adjusting for body size/cranial dimension. Differing body size/mandibular enclosure volume interactions may contribute to gender influences on the severity of sleep disordered breathing. Supported by NHMRC of Australia Nomination John Read Prize for Sleep and Physiological Research

TP 027

AUDIT OF CTPA IN A REGIONAL HOSPITAL Y RAJE, S VINCENT, G SIMPSON Department of Thoracic Medicine, Cairns Base Hospital, Cairns, QLD 4870 Since the introduction of computerized tomographic pulmonary angiograms (CTPA) at our institution the number of requests for this investigation at our institution has grown at an alarming rate. The purpose of this study was to evaluate the clinical assessment of suspected pulmonary embolism (PE). Methods 50 CTPA were reviewed. Results 31 female, 19 male. Mean age 50 yrs (range 21-87). 26 CTPA requests came from Department of Medicine, 21 from Emergency Department, 2 from surgical teams and 1 from oncology outpatients. 36 patients presented with chest pain (pleuritic in 20 cases), 25 had dyspnea, 7 presented with collapse. 4 patients had haemoptysis. Hypoxaemia was recorded in 7. None were clinically shocked and only one had a recorded tachycardia. D-dimer requested in 10 patients and was elevated in 9. Arterial blood gases performed in only 10 patients (20%). 47 patients had prior chest X-ray which was normal in 24 (48%). 8 patients had consolidation on chest X-ray, 2 pleural effusions, 2 atelectasis and 1 fractured ribs. Recorded risk factors included 4 patients with previous DVT or PE, 4 patients with malignancy and 6 patients were immediately post-operative. Only 6 CTPAs (12%) demonstrated evidence of PE. Of these 2 had recent DVT and 2 were post-operative. 1 had a history of bowel cancer. There was no formal record of pre-test clinical probability of PE (eg Wells' score) for any of the 50 cases. Retrospective calculation of the cases of PE, 4 had a Wells' score of 4.5 and 1 of 4 with the remaining patient with Wells' score of under 2. Only 3 patients (one with clinically probable PE) had received fractionated heparin prior to the CTPA. Conclusion (1) CTPAs performed at our institution have a low yield (12%).(2) Pre-investigation clinical assessment was poor and there was poor adherence to published guidelines, (3) This results in many unnecessary CTPA examinations generating increased work and expense for the Medical Imaging Department and exposes many patients to unnecessary and potentially harmful radiation exposure. The evaluation and management of Hereditary Hemorrhagic Telangiectasia involves a multidisciplinary approach according to international guidelines. The aim of this audit was to compare the assessment process in one centre with that of the international recommendations. Methods Retrospective comparison was made by medical chart review of all patients with a diagnosis of HHT between the years 1994 to 2006. Demographic along with clinical data with diagnostic investigations, complications, treatment and genetic evaluation, including family screening was collected. The proportion of patients evaluated and managed as per the international recommendations was determined. Results The audit identified 26 patients with the diagnosis of HHT, with the mean age 58 years. Diagnostic criteria were met in 77% of the cohort. Of the known clinical features, 54% had a family history, and 81% epistaxis. Cutaneous telangiectasia was present in 85% and visceral involvement in 92%. Pulmonary arterio-venous malformations (PAVM) were seen in 16 patients, cerebral AVM in 4, gastrointestinal telangiectasia was documented in 8. One patient had a spinal (cervical) AVM, and another had pulmonary hypertension in association with this condition. Only 8 patients underwent diagnostic or screening investigations in accordance with the international recommendations. Furthermore, one patient was referred for a genetic evaluation. Conclusions This clinical audit found that 31% of patients referred to this centre were evaluated in accordance with the international recommendations. Genetic assessment was lacking. The study supports the need for a coordinated, multidisciplinary approach to the evaluation and management of HHT in this centre.

LM YOUNG 1 , N GOOD 1 , D MILNE 2 , W FERGUSSON 1 , I ZENG 1 , J KOLBE 1 , ML WILSHER 1

Background While airflow limitation is the most common physiological impairment in sarcoidosis, there are limited data on airway hyperresponsiveness (AHR). Understanding the role of AHR in sarcoidosis, if any, may help to identify individuals who might benefit from inhaled therapies. Aims (1) To determine the prevalence of AHR in sarcoidosis. (2) To determine the correlation between responses to direct (using histamine) and indirect (using hypertonic saline) bronchial challenge. (3) To determine the clinical, physiological and radiological predictors of AHR. Methods Subjects with a diagnosis of sarcoidosis based on typical clinical presentation and compatible HRCT features and/or tissue biopsy and with a baseline FEV1>35% predicted were recruited. Subjects underwent standard hypertonic (15% fall in FEV1) and histamine (20% fall in FEV1) challenge (>1 day but <7 days apart), lung function testing and high resolution computed tomography (HRCT) of the chest. Results The 52 subjects (48 Ϯ 11 years, 35% female, 92% European, 35% Stage I, 25% Stage II, 40% Stage III, 0% Stage IV) had well preserved lung function overall (FEV1 = 2.8L Ϯ 0.7.87% predicted). AHR was detected in 5/47 (11%) to hypertonic saline and 19/43 (44%) to histamine challenge. On univariate analysis, response to histamine challenge was predicted by conglomerate fibrosis (p = 0.002) and reticular pattern (p = 0.05) on HRCT. The baseline % predicted FEV1 was significantly associated with AHR on univariate (p = 0.004), and multivariate analysis (p = 0.01) when adjusted by HRCT patterns. Conclusions There is a high prevalence of AHR using histamine challenge in this study of sarcoidosis subjects. AHR most strongly associates with baseline % predicted FEV1 but also conglomerate fibrosis and reticular pattern on HRCT. These findings may reflect the consequence of airway remodelling following inflammation. Further studies are warranted to confirm these findings. Background Upper airway shunt represents a significant source of measurement artefact in the use of the forced oscillation technique (FOT), with increasing importance in young children. Changes in respiratory system admittance, Ars (or Zrs -1 ), are theoretically independent of the upper airway shunt. This study examines the possible clinical benefit of Ars in preschool children by assessing any increased ability to differentiate responses to bronchial challenges in the routine clinical setting. We hypothesized the use of Ars would provide improved sensitivity to clinically relevant obstruction, bronchodilator responsiveness (BDR) and airway hyper-responsiveness (AHR) in young children with respiratory disease. Method Previous FOT measurements were re-analysed and Ars calculated to derive: (1) Ars reference equations in healthy young children (n = 158); (2) BDR in Ars, respiratory system resistance (Rrs) and reactance (Xrs) in healthy children (n = 78), children with cystic fibrosis (n = 39), neonatal chronic lung disease (n = 49), asthma (n = 56) and wheeze (n = 66); (3) AHR to inhaled adenosine-5′-monosphate (AMP) in 19 children. Fisher's exact tests were used to assess changes in diagnostic outcomes between Ars and conventional FOT outcomes (Rrs and Xrs). Results Ars was no more sensitive to bronchodilator induced changes than conventional FOT outcomes. AMP challenges resulted in equivalent responses measured by relative changes in Rrs and Ars while absolute changes in Ars were the least sensitive variable. Conclusion This study does not support a clinical advantage in using Ars in measuring responses to either inhaled bronchodilator or AMP. C HOLLIER 1,2 , C MENADUE 1,2 , D FLUNT 1,2 , AJ PIPER 1,2 1 Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, NSW 2050, and 2 Woolcock Institute of Medical Research, NSW 2050 Serial measurement of arterial carbon dioxide (PaCO2), pH and bicarbonate (HCO3 -) is essential in the management of patients with hypercapnic respiratory failure (HRF). This information is usually obtained from a sample of arterial blood (ABG). The procedure can be painful and distressing for patients, and is sometimes technically difficult due to obesity or contractures. Our aim was to determine the validity and feasibility of arterialized venous blood (AV) sampling as an alternative to ABGs in measuring PaCO2, pH and HCO3levels in patients with chronic HRF. Method Eighteen patients completed the study. Venous blood was arterialized by heating forearm skin to a temperature of 42-45°C with an electric heating pad. An AV sample was taken from a cannula positioned in a vein of the heated forearm simultaneously with an ABG. In addition, the reliability of AV sampling within the recommended temperature range (42-45°C) was investigated in ten healthy volunteers placed on volume cycled ventilation in order to maintain constant ventilation. AV samples were taken at 0.5°C temperature intervals from 42.5-45°C Results The table below summarizes results for validation of AV sampling: Based on the evidence that cardiovascular dynamics are altered due to obstructive sleep apnea, this study aims to identify the onset and termination of each apnea event using power spectral density (PSD) and morphological features of single lead ECG signal over 5 second period. Methods ECGs from 4 patients overnight sleep studies were examined for location of the pre-scored apnea events. Onset (n = 1995), maximum (n = 6751) and termination (n = 1996) of each apnea event and normal events (n = 11219) were annotated on 5 second windows. Features extracted were PSD, amplitudes of R and T wave of 5 second ECGs. Receiver operating Characteristics (ROC) analysis was used to gauge the event recognition ability of all features. Weight loss causes an improvement in the severity of OSA, however substantial weight loss is very difficult for obese patients. The Very Low Caloric Diet (VLCD) has been shown to be successful in causing significant weight loss in obese patients. This is a pilot study on the use of a formal screening protocol to identify OSA patients who are potentially eligible for the supervised VLCD program offered by the Endocrinology Department at Auckland City Hospital. Method 344 consecutive patients who attended the sleep laboratory at ACH between June to December 2006 were screened using the protocol. Patients who are eligible to be considered for the VLCD program are identified as having a combination of obesity (BMI > 30), OSA (AHI > 5 on sleep study) and being residents within the Auckland District Healthboard region.

Results 243/ 344 patients screened did not fulfil the inclusion criteria: 171 lived outside the ADHB region; 71 had BMI < 30; 7 patients did not have OSA (AHI < 5). 101 patients fulfilled the inclusion criteria. 54/101 patients (54%) were excluded due to medical or psychiatric contraindications to VLCD.47 patients (47%) who did not have contraindications to VLCD were contacted. 33 patients were contacted successfully. 14 patients were either unavailable to phone contacts on 3 separate days or were disconnected. 12/101 patients consented to being referred (12%). 21/101 patients declined referral (21%). Conclusion This pilot study is the first study using a formal comprehensive screening protocol in the recruitment of obese OSA patients into a medically supervised VLCD program. Only a small proportion (12%) of patients proceeded to being referred to the VLCD program.