key: cord-0042044-4jgvttti
authors: nan
title: Asthma & Allergy SIG: Poster Session 3
date: 2011-03-21
journal: Respirology
DOI: 10.1111/j.1440-1843.2011.01937_3.x
sha: 31f564466fdeeb0516c61d869642275ea48d798b
doc_id: 42044
cord_uid: 4jgvttti

nan

Patients with non-eosinophilic asthma (NEA) or COPD have increased numbers of neutrophils in the airways. We have shown a similar defect in the ability of alveolar macrophages (AM) to phagocytose apoptotic cells, in sputum from patients with NEA and COPD. We have also shown that BAL-derived AM from patients with COPD have reduced expression of key macrophage phagocytic recognition molecules. The aim of this pilot study was to investigate the expression of these macrophage markers in induced sputum from patients with eosinophilic asthma (EA, n = 10), NEA (n = 13), COPD (n = 7) and controls (n = 5). Methods Participants underwent clinical assessment, skin allergy test, hypertonic saline challenge and sputum induction. Macrophage phagocytosis of apoptotic cells, expression of mannose receptor (MR), HSPR (CD91) and PCAM (CD31) was determined using fl ow cytometry. Results Phagocytosis was signifi cantly impaired in patients with NEA and COPD. Expression of MR, CD91 and CD31 were decreased in patients with NEA or COPD, but not signifi cantly changed in EA Conclusion Impaired sputum-macrophage phagocytosis of apoptotic cells in NEA is associated with reduced expression of key macrophage recognition molecules. This defect may contribute to the chronic infl ammation and persistent airway neutrophilia that characterizes this asthma subtype. The use of induced sputum as a surrogate for the more-invasive bronchoscopic sampling may provide a tool for investigating the mechanisms for the effect of therapies including azithromycin in lung disease. Supported by NHMRC. Neutrophilic asthma (NA) has been associated with increased bacterial colonization of the airways and increased expression of innate immune factors in the lung. This suggests that infection may play an important role in the pathogenesis of NA. NA is an important health issue as sufferers are resistant to steroid treatment, which is the mainstay of asthma therapy and effective therapies are urgently required. Using mouse models of Chlamydia and Haemophilus infl uenzae lung infection and ovalbumin (Ova)-induced allergic airway disease (AAD), we have shown how infection may be linked to NA. Both infections suppressed eosinophilic infl ammation and T-helper (Th) type 2 responses but increase neutrophilic infl ammation and innate and Th1 and/or Th17 responses in AAD. In the current study, the effectiveness of steroid treatment for the suppression of infection-induced neutrophilic AAD was assessed by treating infected Ovasensitized mice intranasally with dexamethasone during Ova challenge. Whilst dexamethasone treatment suppressed Th2-mediated, eosinophilic AAD in uninfected, Ova-sensitized groups, Chlamydia and Haemophilus-induced neutrophilic AAD were shown to be steroid-resistant. Our fi ndings correlate with clinical observations which show associations between infection, neutrophilic infl ammation and steroid resistance in asthmatics. These models will be utilized to examine the effectiveness of a number of novel therapies for infection-induced neutrophilic AAD and to develop improved treatment strategies for steroid-resistant asthma. Supported by NHMRC, Asthma Foundation of NSW, HMRI.

KJ BAINES 1,2 , JL SIMP S ON 1,2 , RJ SCOTT 3 , LG WOOD 1,2 , PG GIBSON 1, 2 Priority Research Centre's for 1 Asthma and Respiratory Disease, and 3 Information Based Medicine, The University of Newcastle, NSW, Australia, and 2 Respiratory & Sleep Medicine, HMRI, John Hunter Hospital, NSW, Australia Rationale Four infl ammatory phenotypes of asthma have been identifi ed including eosinophilic, neutrophilic, mixed granulocytic and paucigranulocytic asthma, based on the presence or absence of sputum granulocytes. The involvement of systemic infl ammation in the pathogenesis of infl ammatory phenotypes of asthma remains unknown. Objective This study investigates differences in the whole genome gene expression profi le of peripheral blood in infl ammatory phenotypes of asthma. Methods Induced sputum and peripheral blood were collected from participants with asthma (n = 38). Infl ammatory cell counts were performed and infl ammatory phenotype assigned based on the eosinophil and neutrophil cutoffs of 3% and 63%, respectively. RNA was extracted from whole blood, gene expression profi les were generated (Illumina Humanref-8 V2) and analysed using GeneSpring GX11. Results Participants with eosinophilic asthma had signifi cantly higher rates of atopy and levels of exhaled nitric oxide. There were 7 genes classifi ed as differentially expressed between the 4 asthma phenotypes including the α-defensins (DEFA) 1, 1B, 3 and 4, neutrophil proteases cathepsin G (CTSG) and elastase (ELA2), and the monocyte/macrophage serine esterase, carboxylesterase 1 (CES1). Expressions of DEFA1, 1B, 3, 4, CTSG and ELA2 were signifi cantly higher in neutrophilic asthma and expression of CES1 was significantly higher in mixed granulocytic asthma. Microarray results of the α-defensins and neutrophil proteases were successfully validated using realtime PCR. Conclusions There is systemic up-regulation of α-defensins and neutrophil proteases in neutrophilic asthma, and these molecules play an important role in neutrophil activation and migration. Systemic activation of neutrophils is an important feature involved in the pathogenesis of neutrophilic asthma, which is signifi cantly different to other asthma phenotypes. Supported by HMRI and Xstrata Coal; The University of Newcastle. Confl ict of Interest No. Airway mucus hypersecretion is an important cause of morbidity and mortality in asthmatic patients. Increases in goblet cell number and their secretions are likely to contribute to airfl ow obstruction in asthma. Here, we take advantage of an established sheep model of asthma to investigate the association between allergen exposure and goblet cell activity. Methods Eight allergic sheep (high House Dust Mite (HDM)-specifi c serum IgE) received 22 weekly intra-lung challenges of HDM to the right caudal lobe, and 24 weekly intra-lung challenges of HDM followed by 10 weeks without allergen exposure to the left caudal lobe, with the right medial lobe serving as an untreated internal control. A separate group of 8 sheep were also used as untreated controls. Biopsy samples of segmental bronchi tissue were collected from the different lung lobes for histological analysis at 1 and 7 days post-HDM challenge. Results The percentage of goblet cells, with respect to epithelial cells, signifi cantly increases following chronic challenge with HDM (20% HDM vs. 9% control p < 0.05). Goblet cell numbers did not decline in lung lobes after a 10-week cessation of allergen challenges. Goblet cell degranulation is significantly increased 1 day following challenge with allergen, but returns to control levels by 7 days post-allergen challenge (66% 1 day vs. 25% control p < 0.05). Furthermore, degranulation is increased in both the rested and internal control lobes 1 day following allergen challenge of the right caudal lobe. Conclusions In this sheep model of chronic asthma, repeated allergen challenges induces goblet cell hyperplasia which persists even after long-term withdrawal of allergen. Additionally, exposure to allergen in one lobe induces goblet cell degranulation in both challenged and unchallenged lobes, suggesting neural mechanisms may be operating in this model. Confl ict of Interest No.

The thickness of the airway smooth muscle (ASM) layer is related to severity but not duration of asthma or age (James 2009 ERJ; 34:1040) . It is unknown if the constituents of the ASM layer change with age. Aim To investigate the relation of mean ASM cell volume (V C ), total number of cells per mm of airway (N L ) and fractions of ASM (f ASM ) and extracellular matrix (f ECM ) within the ASM layer with age and age at onset of asthma. Methods Post-mortem tissues from control subjects (C n = 51); non-fatal (NFA n = 49) and fatal (FA n = 55) cases of asthma were used. The volume density (N V ) of ASM cell nuclei was estimated on 30 μm transverse airway sections (haematoxylin) and mean cell volume (V C = 1/N V ) was calculated, correcting for the volume fraction of ASM within the ASM layer. f ASM and f ECM were estimated on 0.5-μm thick sections of the same airway (Masson's trichrome). Effects of age on ASM cell parameters and tissue volume fractions were tested using general linear models, correcting for sex and study centre and by comparing age at onset of asthma (<16 vs. >16 years). Results Table shows Assessment of airway smooth muscle (ASM) cell size and number requires estimates of cell volume density (N V ), volume fraction of muscle (f ASM ) within the ASM layer and the volume of ASM per length of airway. Stereological techniques have now become the accepted standard for assessing ASM cell parameters, but sources of variation remain unclear. Aim To assess sources of variability in the estimation of ASM cell parameters and volume fractions within the ASM layer. Methods Large and small airways from subjects with and without asthma were examined. Transverse airway sections were cut at 0.5 μm and 4 μm (Masson's trichrome technique), and 30 μm (haematoxylin) and used to estimate ASM cell number and volume, and the volume fraction of muscle (f ASM ) within the layer of ASM. Stereological assessments of the possible sources of variation in these ASM layer parameters were assessed. Results Increased section thickness overestimated f ASM by <10% (0.5 μm), 20% (4 μm) and 25% (30 μm). Stable variation of <10% in N V occurred if 40 high-power fi elds (HPF) were used to estimate N V . Variation in the depth of muscle in thick sections of the ASM layer caused up to 10% overestimation of N V . Although the absolute area of the ASM layer varied by up to 30%, variation of f ASM was <10% around the airway circumference and along the airway length. f ASM differed signifi cantly between large and small airways. Conclusion These results suggest that partial thickness HPFs need to be excluded and that ≥40 HPF should be used to estimate ASM volume density, that a single 0.5 μm section of airway can be used to estimate f ASM and that ASM parameters should be compared separately in large and small airways. Grants NHMRC #446800. Nominations Nil. Confl ict of Interest Nil.

No signifi cant correlation was seen with age for any ASM cell parameters or tissue fractions. Results were similar for medium and small airways. Conclusion Size and number of ASM cells and the volume fractions of ASM and ECM within the layer of ASM are not related to age. Support NHMRC Australia (Grants #343601; #446800). Nomination Nil. 3.9 ± 1.2 27.4 ± 12.7 0.67 ± 0.08 0.16 ± 0.05 FA >16

3.9 ± 1.6 19.3 ± 11.0 0.67 ± 0.13 0.14 ± 0.05

Background Asthma is characterized by excessive airway narrowing to contractile stimuli, termed airway hyper-responsiveness (AHR). Changes in airway smooth muscle (ASM) protein expression or mass are possible contributing mechanisms underlying AHR and have been examined using cell culture techniques. However, how these cellular changes to ASM relate to airway narrowing at the level of the whole airway is unclear. We describe a new method to track changes in airway narrowing (responsiveness) in culture. Methods Whole airway segments (generation 12-17) from sheep lungs were studied prior to (fresh) and after 24 and 48 hours in culture in Dulbecco's Modifi ed Eagle Medium with 2% bovine serum albumin, 1% L-glutamine and antibiotics. Airway narrowing was measured from the % decrease in airway volume under a fi xed transmural pressure, using a servo-controlled syringe pump and organ bath apparatus. Cumulative acetylcholine dose-response curves (ACh, 10 −7 M − 3 × 10 −3 M) were performed to determine maximal response (E max ) and sensitivity (pD 2 , negative log of EC 50 ).

Results Fresh airway segments narrowed strongly and approached closure with an E max of 89.7% ± 9.5 (±SEM) and pD 2 of 4.4 ± 0.1. Airway narrowing responses were preserved in culture, with no signifi cant difference in maximal response or sensitivity to ACh after either 24 (E max 89.6% ± 4.7, pD 2 4.8 ± 0.3) or 48 hours in culture (E max 84.4% ± 5.1, pD 2 4.4 ± 0.3).

Conclusions The present study has validated a new method allowing changes occurring at the cellular level in culture to be related to changes in airway responsiveness at the whole airway level. Future studies will assess the effects of chronic infl ammation in disease on airway responsiveness. Background Deep inspiration (DI) produces a bronchodilator response in healthy humans, but this response is impaired in asthma. Reduced airway compliance in disease could impair the response to DI by limiting the stretch of smooth muscle. Aim To show that isolated human bronchi dilate to DI in an amplitudedependent manner and that the stretch caused by DI depends on airway compliance. Methods Bronchi were obtained following lung resection from cancer patients who had normal spirometry (n = 8). Lumen narrowing was measured using a servo-control system which set transmural pressure and simulated breathing movements. Bronchi were contracted to carbachol (CCh 3 × 10 −6 M) during tidal breathing (from 5 to 10 cmH 2 O, i.e. Δ5 cmH 2 O transmural pressure, 0.25 Hz) and infl ated to three different amplitudes of DI (Δ10, 25 or 55 cmH 2 O) applied following contraction. Results In CCh-contracted airways, all three DI amplitudes produced a transient bronchodilation. Increasing the DI amplitude caused a greater increase in luminal volume during the DI and a greater bronchodilation following the DI (p < 0.05). CCh itself cause approximately a 20% fall in specifi c compliance (p < 0.05), which was reversed by DI (p < 0.05). For each DI amplitude, the change in lumen volume during the DI was positively correlated to the specifi c compliance of the bronchi before DI (r > 0.87, p < 0.01). Conclusions Isolated human bronchi show a bronchodilation response to DI that is proportional to the expansion of the airway caused by the DI. The amount of stretch produced by a DI depends on airway wall compliance suggesting that increased airway stiffness in disease could suppress the DI response by limiting the stretch of bronchi during lung infl ation. Confl ict of Interest None.

JA DOUGLASS 1,2,3 , EA YU 1,2 , BR THOMPSON 1,2,3 , GG KING 2,4 , MJ ABRAMSON 2, 5 Introduction Increasing asthma prevalence and changes in environmental exposure suggest that there may be a relationship between asthma and dietary intake. However, to date, few studies have examined how dietary intakes of asthmatics differ from a healthy population. Aim To measure and compare the dietary intakes of adults with stable asthma and healthy controls. Methods In a cross-sectional study, dietary intakes calculated from a 186item food frequency questionnaire (FFQ) of adults with stable asthma (n = 110, age 56 years ± 15 (SD)) were compared with intakes of healthy controls (n = 65, age 47 years ± 17 (SD)) matched for age and body mass index (BMI). Spirometry, airway responsiveness to hypertonic saline, and induced sputum cell counts were also measured.

Results Subjects with severe persistent asthma (n = 59) had signifi cantly higher total fat intake than healthy controls (103 ± 49 (SEM) versus 98 ± 4 (SEM) g/day p = 0.014) and signifi cantly lower fi bre intakes (32 ± 11 (SEM) versus 37 ± 13 (SEM) g/day p = 0.018). Lower fi bre intake in asthmatic subjects (n = 124) was associated with lower %predicted FEV 1 (r = 0.41, p = 0.004), %FVC (r = 0.43, p = 0.015) and FEV 1 /FVC (r = 0.44, p = 0.048). Higher fat intake and lower fi bre intake were associated with higher absolute concentrations of sputum eosinophils (r = 0.42, p = <0.001, n = 107).

Conclusions Subjects with severe persistent asthma have an eating pattern of lower diet quality with higher intakes of fat and lower intakes of fi bre than healthy controls, which is related to lower lung function and increased airway infl ammation. Factors leading to altered dietary intake in severe asthma require further investigation. Methods A randomized, placebo-controlled, single-blinded trial of tailored asthma education including device technique and utilizing PACT to address patients' concerns versus brochure-only information for asthma patients over age 55. Measurements of lung function, asthma control (ACQ), asthma related quality of life (AQoL), medication use and adherence score (ADH) were obtained at baseline, 3 and 12 months using standard, validated questionnaires.

Results Sixty-fi ve participants (49F 16M, mean age 68 ± 8.3) were randomized to the intervention group and 58 (40F 18 M, mean age 67 ± 6.4) to the control. There were no statistically signifi cant differences between the groups' demographics or baseline measurements. A Wilcoxon Signed Ranks Test used to compare median pair ranking at baseline and 3 months post-intervention revealed a signifi cant improvement in the active, but not the brochure-only information group at 3 months in: ACQ mean ± SD = 1.5 ± 1.02 vs. 1.2 ± 0.8 (p = 0.005). AQoL mean ± SD = 1.1 ± 0.8 vs. 0.8 ± 0.6 (p = 0.003). ADH mean ± SD = 1.4 ± 1.3 vs. 0.6 ± 0.8 (p < 0.001).

Conclusion An educational intervention including device technique and addressing the concerns of older people with asthma signifi cantly improved ACQ, AQoL and ADH scores at 3 months post-intervention. 

Introduction Greater exposure to ultraviolet radiation (UV) may increase the risk of allergic disease, but this association has not been investigated using estimates of time spent outdoors by individuals. The aim of this study was to investigate the relationship between self-reported doctor-diagnosed asthma and/or hayfever, and time spent outdoors. Methods This analysis was based on cross-sectional baseline data from a subsample of the Australian 45 and Up Study, comprising 15 678 men and 20 155 women aged 45-74 years, living in New South Wales. Participants were randomly selected from the Australian universal health insurance database. Diagnoses of asthma and/or hayfever and the number of hours spent outdoors were derived by questionnaire.

In general, the odds of a diagnosis of asthma and/or hayfever decreased with increasing time spent outdoors for both women and men. For example, in women, the adjusted odds ratios for asthma with hayfever were 0.76 (95% CI: 0.52-1.13), 0.69 (0.47-0.99), 0.66 (0.45-0.97) and 0.58 (0.40-0.83) for 1-2, 2-3, 3-4 and >4 hours spent outdoors on weekends, respectively, compared with <1 hour (p trend < 0.0001). Time spent outdoors was not associated with a diagnosis of asthma alone in men. Conclusions There were statistically signifi cant inverse associations between time spent outdoors and diagnoses of asthma, hayfever or asthma with hayfever, in a large population of older Australians. Exposure to UV may protect against the development of allergic diseases, such as asthma and hayfever.

No. Background Allergic rhinitis (AR) and eczema are highly prevalent and females are more commonly affected than males in adulthood. Although there have been extensive studies on AR and eczema in females, little is known about the effect of reproductive factors and the development of late-onset AR/ eczema. We examined potential associations between reproductive factors and AR and eczema using the Tasmanian Longitudinal Health Study (TAHS) data.

Methods The TAHS is a population-based cohort study of respiratory disease. Two thousand seven hundred sixty-four (32.2%) females from the original 8583 TAHS participants were surveyed in 2004 using postal questionnaire which collected information on reproductive factors such as ever pregnancy, age at fi rst child birth, use of oral contraceptive pills (OCP) and age of starting using the OCP. Logistic regression was used to assess the predictors of AR and eczema and all analyses were mutually adjusted.

Of the 2764 participants, 45.4% (n = 1256) had late-onset AR and 35.4% (n = 978) had late-onset eczema. Maternal and paternal atopy were signifi cantly associated with AR (p < 0.0001). The risk of developing eczema was decreased signifi cantly with increasing age at fi rst menstruation (OR: 0.94, 95% CI: 0.89-1.00) and the increased age at birth of fi rst child (0.99, 0.97-1.00). A decreased risk in AR was observed with the increasing number of pregnancies (0.89, 0.81-0.98). However, the associations between age of starting using OCP and AR/eczema were not signifi cant.

Conclusion Later age at start of menses and later age at fi rst pregnancy were associated with a reduced risk of eczema which may be related to hormonal dysregulation.

TP-033 AIRWAY RESPONSIVENESS AT 6 AND 11 YEARS IS ASSOCIATED WITH ASTHMA AT 18 YEARS Introduction Asthma is the most common chronic childhood disease in Australia. Increased airway responsiveness (AR) is associated with asthma but not all individuals with increased AR have asthma. The Perth infant asthma follow-up study recruited a birth cohort of individuals who have undergone longitudinal assessments of many factors associated with childhood AR. Our previous work reported an association between increased AR in infancy and asthma at 6 and 11 years. Aim To look at the relationship of increased AR and asthma in early adulthood at different time points from birth. Methods Individuals were recruited from among expectant parents attending an antenatal clinic at a local metropolitan clinic. At ages 1, 6 and 12 months and again at 6, 11 and 18 years, participants underwent an assessment that included a respiratory questionnaire and determination of AR (as evidenced by dose-response slope (DRS) to histamine using the rapid technique).

Results 253 children were initially recruited and studied in infancy. Two hundred three, 174, 147, 103, 176 and 137 children subsequently had AR assessed at 1, 6 and 12 months, 6, 11 and 18 years, respectively. There was a signifi cant relationship between DRS at 6 and 11 years and for both asthma at 18 years (p = 0.001 and p < 0.001, respectively) and 'wheeze in the past year' at 18 years (p = 0.03 and p = 0.029, respectively). There was no significant relationship between DRS in infancy and asthma at 18. Conclusion AR at 6 and 11 years is associated with asthma at 18 years. In this study, there was no signifi cant relationship between AR in infancy and asthma at 18 years. The PCAAS has found that 87.5% of children with acute asthma presenting to the Princess Margaret Hospital for Children Emergency Department (PMH ED) had HRV, of which 69% were HRV group C. Furthermore, HRVC was associated with more severe attacks. However, the prevalence of HRVC in the community is unknown. Aim To test the hypothesis that HRVC would be found more often in children requiring emergency treatment for an ARI than sibling controls and determine the impact of days since symptoms began on the prevalence of HRV detection in children with an acute respiratory illness (ARI) and sibling controls (Sibs). Methods ARI (n = 38) had nasal samples collected on presentation to the PMH ED and Sibs with symptoms of a cold (n = 25), within 1 week of ARI recruitment. Viral RNA was extracted and reverse transcribed. A two-step PCR of the HRV 5' UTR was used for detection, followed by DNA sequencing for typing. Results ARI and Sibs were 71% and 48% male, 32% and 20% asthmatic, with mean ages of 3.4 and 4.0 years, respectively. HRV +ve ARI (n = 21, mean ± SD days of symptoms = 4.6 ± 6.1), HRV -ve ARI (n = 14, 8.2 ± 15.2), HRV +ve Sibs (n = 10, 2.8 ± 2.1) and HRV -ve Sibs (n = 15, 7.1 ± 4.7). Of the 22 and 10 HRV +ve ARI and Sibs, 76% and 70% had HRVC. Conclusions HRVC is as common in children who have HRV but do/do not require hospital treatment. Detection of HRV is more likely when the nasal sample is collected soon after the appearance of cold symptoms. Support NHMRC program grant. Nomination Nil.

Introduction Upper airway dysfunction may make asthma more diffi cult to control and should be suspected in asthmatics refractory to prescribed medical therapy. Aim A novel imaging technique, dynamic 320-slice computerized tomography (CT), was used to examine laryngeal behaviour in healthy and asthmatic individuals. Method Vocal cord movement was imaged using 320-slice CT larynx. Healthy volunteers were studied to develop and validate an analysis algorithm for quantifi cation of normal vocal cord function. Further studies were then conducted in 46 patients with diffi cult-to-treat asthma. In eight severe asthmatics with abnormal vocal cord movement, asthma outcomes were measured after speech therapy. Results Vocal cord movement was quantifi ed over the breathing cycle by CT using the ratio of vocal cord diameter to tracheal diameter. Normal limits were calculated, validated and applied to evaluate diffi cult-to-treat asthma. Vocal cord movement was abnormal with excessive narrowing in 23 of 46 (50%) asthmatics and severe in nine (19%) patients (abnormal >50% of inspiration or expiration time). After speech therapy in a small subgroup, asthma symptoms and morbidity improved. Conclusion Non-invasive CT larynx quantifi cation of vocal cord movement was achieved. This new approach has identifi ed frequent upper airway dysfunction in asthma with potential implications for disease control and treatment. Aim To investigate the characteristics and mechanisms of chronic cough (CC) following acute respiratory illness from laboratory-confi rmed H1N1 2009 infl uenza. Methods 136 subjects who had current symptoms and had been tested for H1N1 2009 infl uenza by PCR assay participated in this study. Twenty-one of those continued onto clinical testing. Investigations to assess cough included symptom questionnaires, hypertonic saline challenge and cough monitoring. Results Of the 136 participants, 43% tested positive for H1N1 and 57% tested negative for H1N1. H1N1-infected participants were younger and predominantly female. The prevalence of post-H1N1 CC was 9.4%, and for non-H1N1 infection, 4.9%. Objectively measured cough frequency was 3 times greater; there was a 5-fold increase in cough refl ex sensitivity, and greater quality-of-life impairment in the participants with chronic post-infectious cough than the non-cough participants. Conclusions CC was found to be relatively common, mild in severity and tending to resolution with time. The characteristics of post-H1N1 CC were similar to other post-infectious cough and were associated with cough refl ex hypersensitivity. Aim Upper airway dysfunction may accompany acute severe asthma, but this has not been investigated. A novel imaging technique, dynamic 320-slice computerized tomography (CT), was used to examine laryngeal behaviour in acute asthma exacerbation. Methods Patients were studied in the emergency department or as acute inpatients following admission for an acute exacerbation of asthma. Vocal cord movement was imaged by 320-slice CT larynx and compared to normal vocal cord movement in a healthy cohort. Results Vocal cord movement was abnormal with excessive narrowing during either inspiration, expiration or both in 11 of 16 cases (68.7%) with acute severe asthma. Imaging again revealed that laryngeal dysfunction characterized the movement abnormality, rather than isolated vocal cord dysfunction. Radiation exposure was low and generally <2 milli-Sievert. Conclusion Non-invasive CT larynx quantifi cation of vocal cord movement was effectively achieved in acute severe asthma. We identifi ed frequent upper airway dysfunction in acute severe asthma suggesting that treatment of upper airway obstruction (e.g. using BiPAP) may be merited during asthma exacerbation. Aim To determine whether eicosanoids could alter the deposition of extracellular matrix (ECM) proteins and cytokine release from human airway cells. Methods Airway smooth muscle cells (ASM), fi broblasts and epithelial cells were stimulated with leukotrienes B 4 , C 4 , D 4 , E 4 and the prostaglandins E 2 , D 2 , F 2α and the PGI 2 analogue MRE-269. After 72 hours, culture medium was collected and IL-6 and IL-8 production and cell deposited ECM proteins tenascin C, fi bronectin and perlecan were assessed by ELISA. To determine whether eicosanoids infl uenced cell proliferation, manual counting of cells in the experiments were carried out before and after stimulation. Results Neither leukotrienes or prostanoids altered cell proliferation after 3 days of stimulation (n > 5). Leukotrienes had no effect on ECM protein deposition or cytokine release from ASM or fi broblasts (n > 5). Leukotrienes did not alter either parameters in epithelial cells except leukotriene D4, which increased tenascin C deposition (n = 7, p < 0.05). Prostanoids induced IL-6 and IL-8 and other various changes in ASM and fi broblasts (n > 5, p < 0.05) (see below).

Introduction The function of asthmatic airway epithelium is disrupted facilitating immune and infl ammatory responses resulting in epithelial damage. Human rhinovirus (HRV) causes asthma exacerbations in children; however, paucity exists on how it affects barrier function. This study assessed how HRV infection affects epithelial barrier function and integrity in healthy and asthmatic epithelium. Methods Adult BALB/c mice were intranasally infected with HRV-1B and followed for 21 days. Tight junction (TJ) expression was assessed using immunohistochemistry (IHC) and Western blot analysis. Primary airway epithelial cells from healthy and asthmatic children were assessed for TJ gene and protein expression by qPCR and IHC, respectively. Results Occludin and zonal occludin-1 (ZO-1) expression was lost and sustained in mice infected with HRV-1B however was not observed in shaminjected mice. Asthmatic airway epithelial cells were found to exhibit elevated basal gene expression levels of TJs (ZO-1, occludin and plakophilin-3 (PKP-3)) but markedly lower corresponding protein levels. Conclusion HRV-1B compromises barrier function in vivo through sustained loss of TJ proteins. The marked decreased expression of TJ proteins in paediatric asthmatic epithelium may contribute towards increased susceptibility to viral infections. Disparity between gene and protein TJ expression could indicate either post-transcriptional regulation or compensatory effects by other TJ proteins and requires further study. Supported by Asthma Foundation WA; NHMRC. Confl ict of Interest None. Conclusion Leukotrienes alone did not affect the ECM proteins and cytokines assessed in this study. Prostanoids decreased ECM protein deposition whilst increasing cytokine release without affecting cell proliferation. This study shows that prostanoids may have a more pronounced role on direct ECM remodelling than leukotrienes in airway cells. Supported by Merck. Background Toll-like receptor (TLR)2 is an innate immune receptor involved in the initial detection of pathogen-associated molecular patterns. The effect of ageing and chronic obstructive pulmonary disease (COPD) on TLR2 responses and the impact of these innate immune responses in COPD pathogenesis remain unclear. Hypothesis Expression and activity of TLR2 on peripheral blood mononuclear cells (PBMCs) is increased with healthy ageing and further increased in COPD.

Methods PBMCs from healthy controls <55 years and >55 years; and participants with COPD (n = 8 per group) were cultured with or without Pam3C YS K4 (TLR2 agonist). Cells and supernatants were collected at 24 hours and protein (cytometric bead array or fl ow cytometry) and gene (real time PCR) expression was examined. Results TLR2 activation led to increased release of interleukin (IL)-8, 6, 1β, and tumor necrosis factor (TNF)-α. TLR2 gene expression was increased with stimulation; however, cell surface receptor levels were unchanged. There was no difference in the level of TLR2 between the 3 groups. In older people, TLR2 activation resulted in less IL-1β and TNF-α release, but similar release of IL-8 and IL-6. Similar results were seen in COPD. At baseline in COPD, there was up-regulation of TNF-α gene expression compared to the older healthy group; however, the TLR2 cytokine response did not differ between the groups. Conclusion Healthy ageing is characterized by an impaired systemic proinfl ammatory cytokine response to TLR2-mediated innate immune activation. This effect persists in COPD and is selective in the cytokine pathways involved. These altered infl ammatory mechanisms may affect responses to infection and injury impacting disease pathogenesis and warrant further evaluation. 

Aim To investigate whether the inhibition of matrix metalloproteinase-2 (MMP-2) by a non-selective MMP inhibitor (doxycycline) and the specifi c MMP-2 inhibitor I (olic acid) can regulate cellular migration of TSC2-null mouse embryonic fi broblasts (MEFs), which act as a model for lymphangioleiomyomatosis (LAM) cells, as compared to wild-type MEFs.

Methods Wild-type (TSC2-positive) and TSC2-null MEFs were treated with diluent, doxycycline (0.1 pg/mL-100 μg/mL) or olic acid (0.3-30 μM) for 24 hours. MMP-2 levels were assessed by zymography and ELISA. Cell migration for 4 hours was measured using a transwell migration assay. Results Under basal conditions, MMP-2 release and cellular migration was 2.3-fold and 2.9-fold higher, respectively, in TSC2-null MEFs compared to TSC2-positive MEFs (MMP-2 release, TSC2-null (n = 6) and TSC2-positive (n = 6), p < 0.05; cell migration, TSC2-null (n = 10) and TSC2-positive (n = 10), p < 0.05). MMP-2 release was reduced in TSC2-null MEFs after 24-hour treatment with doxycycline (30 and 100 μg/mL, n = 6, p < 0.05) and with olic acid (1-30 μM, n = 3, p < 0.05). Treatment with doxycycline (10 pg/mL-100 μg/mL, n = 5, p < 0.05) or olic acid (1-30 μM, n = 3, p < 0.05) also signifi cantly reduced cell migration of TSC2-null MEFs. COPD is a leading cause of death worldwide. Treatments are limited and restricted to symptomatic care. There is an urgent need for new treatment options targeting the infl ammation. Tissue damage in COPD is thought to result from an inability of the normal repair processes with accumulation of apoptotic material and impaired clearance of this material by macrophages in the airways. Lung infl ammation and macrophage function involves the bioactive sphingolipid sphingosine 1-phosphate (S1P). Multiple studies have showed the involvement of these components in infl ammation. Methods We investigated lung tissue samples from 55 patients (COPD or non COPD controls) undergoing curative lobectomy for lung cancer. We analysed the mRNA expression profi le, the sphingosine-kinase (SphK) protein activity and the localization and expression of individual proteins.

Results We show in this study for the fi rst time a comprehensive expression profi le of all synthesizing enzymes, receptors and degrading enzymes in the human lung. Correlations between receptor subtypes, degrading enzymes and between S1P receptor subtype 1 were detected. Multivariance ANOVA showed that in COPD, the relative mRNA expression of S1P receptor subtype 5 was reduced. Conclusion The correlations between receptors and enzymes involved in the sphingosine kinase signalling system in the lung suggest common regulatory mechanisms. S1PR5 is expressed on dendritic and NK cells which are reduced under conditions of COPD. Therefore, our fi ndings of reduced S1PR5 in COPD may provide a novel target for pharmacotherapy. Lung cancer is responsible for more cancer-related deaths than colon, breast and prostate cancers combined. In patients with COPD and/or lung cancer, we have shown a reduction in lung and airway macrophage function, evident by a reduced ability to phagocytose apoptotic airway epithelial cells and neutrophils. The potential for lung cancer cells to directly inhibit this function (a potential immune evasion mechanism) has not been investigated. 

Background Kinins have been implicated in airway lung diseases such as asthma and lung cancer by regulating infl ammation, cell proliferation and migration. The effect of kinins is mediated through the binding of two receptors, kinin B 1 and B 2 receptors (B 1 R and B 2 R). A novel B 1 R splice variant (SV) resulting in a shorter 5' untranslated region (UTR) was identifi ed in cultured airway epithelial and fi broblasts as well as in lung carcinoma tissue and leukocytes. This study aims to characterize the functional role of the novel B 1 R SV in mRNA stability, translation effi ciency and receptor expression in cultured airway epithelial cells. Methods Stability of B 1 R SV was determined by measuring B 1 R mRNA levels over time in H2126 cells after actinomycin D treatment. Translational effi ciency of WT and SV 5'UTR was determined by measuring luciferase activity in transfected H2126 cells. Expression of WT and SV transcripts through Q-RTPCR were compared in cells treated with a B 1 R-specifi c agonist DAKD. Cell-surface receptor expression post-agonist stimulation was quantifi ed using FACS.

Results mRNA stability studies indicated that B 1 R SV was ≈35% less stable than the WT transcript in H2126 cells suggesting a stabilizing element 5'UTR. Translation effi ciency of SV was no different to WT B 1 R. DAKD stimulation increased both WT and SV transcripts early in the time course, although the peak expression of WT and SV differed at 3 hours and 6 hours, respectively. DAKD stimulated cells showed two phases of receptor expression, (1) decrease of cell surface receptor up to 4.5 hours post-stimulation; (2) increase in cell surface B 1 R after 4.5 hours.

Conclusion This study has identifi ed a novel regulatory mechanism of B 1 R expression through the production of a SV that alters the 5'UTR. The translation effi ciency of B 1 R is not affected, but the SV was less stable than the WT in H2126 cells and may play a role in allowing quicker changes in transcription. Agonist-induced up-regulation of transcripts in a time-dependent manner may be important in maintaining a chronic response during infl ammation. Circulating lymphocytes are increasingly used as a surrogate cell type to refl ect changes in ADRβ2 density elsewhere in the body, particularly the respiratory system. However, ADRβ2 density is non-uniform among lymphocyte subsets and it is unclear if, and the degree to which, ADRβ2 density varies between individuals. Aim To assess the extent of variability in ADRβ2 density on human peripheral blood mononuclear cells (PBMC) including lymphocytes and monocytes. Method PBMC were isolated from blood of 10 healthy subjects by density gradient centrifugation with Ficoll-Paque. Cell surface and total ADRβ2 of intact and permeabilized lymphocytes (CD14+) and monocytes (CD3+) were measured using anti-ADRβ2 via FACS. Geometric mean fl uorescence (GMF) was used as the indices for ADRβ2 density per cell. Result Surface ADRβ2 -GMF increased by 3.54-and 4.62-folds over negative controls for lymphocytes and monocytes, respectively. Magnitude of foldchange was not signifi cantly different between these cells (p = 0.16), but the distribution of GMF intensity between samples suggests greater variability in ADRβ2 density in lymphocytes versus monocytes (p = 0.06). Proportion of cells-stained ADRβ2-positive was signifi cantly higher in monocytes versus lymphocytes (71.9 ± 3.6% vs. 36.7 ± 8.5%, p = 0.02). Total ADRβ2 -GMF increased by 12.4 ± 5.8 and 9.61 ± 3.8-folds for lymphocytes and monocytes, respectively (p > 0.05). Proportion of ADRβ2-positively stained cells were similar between samples (lymphocytes 80%, monocytes 86%, p = 0.47), but greater variability was observed for lymphocytes (range 27-99%) versus monocytes (66-100%). Conclusions Despite similarities in surface and total ADRβ2 density, lymphocytes display greater inter-subject variability compared with monocytes. This will have implication in experimental designs and interpretation of changes in ADRβ2 density in studies using human PBMC as an alternative to primary cells from the organ of interest. Confl ict of Interest No. PGE2 plays a protective role in asthma by inhibiting airway infl ammation. It is predominantly produced by epithelial cells in response to pro-infl ammatory stimuli and acts as an autocrine and paracrine mediator. On the contrary, IL-1β is a highly potent cytokine that induces many pro-infl ammatory effects in the human airway including activation of the human lung epithelium which promotes production of pro-infl ammatory cytokines and chemokines. Airway epithelial cells express all four known PGE2 (E Prostanoid (EP) receptors, but mechanisms underlying the regulation of expression of EP receptors in human lung epithelial cells have remained elusive. Therefore, we investigated whether PGE2, an endogenous protective mechanism of the airways, can modulate IL-1β infl uence on EP receptor expression in human epithelial cells. Methods EP receptor mRNA and protein expression was quantifi ed in 16-HBE cells at basal levels and following stimulation with IL-1β or PGE2 alone, or simultaneously, using Real Time RT PCR and FACS analysis, respectively. Results PGE2 up-regulates all four EP receptors at mRNA level, while IL-1β up-regulates EP1, EP2 and EP4 and does not infl uence expression of EP3. At protein level, preliminary results show transient increase of EP1 receptors in the presence of PGE2, while IL-1β down-regulates this receptor. EP2 and EP4 are up-regulated following stimulation with both stimuli. Importantly, antiinfl ammatory EP3 receptor is up-regulated only in the presence of PGE2. Conclusion We show for the fi rst time that PGE2 may infl uence expression of its own receptors and oppose the effect of IL-1β in human lung epithelial cells. This may in turn alter PGE2 production and autocrine activation with potential implication on the function of epithelial cells, which is important in modulation of immune response in asthma and lung infl ammatory diseases. Nomination Nil. Confl ict of Interest No. The Burden of Obstructive Lung Disease (BOLD) Study is an international study designed to measure the prevalence, risk factors and burden of COPD. Data collection using the BOLD protocol has been undertaken at eight sites with inclusion of urban, rural, coastal and inland regions of Australia. Methods A random sample of adults aged ≥40 years was identifi ed. Information on respiratory symptoms and diagnosed COPD were collected by questionnaire. Post-bronchodilator FEV 1 and FVC were used to defi ne GOLD stage. The (un-weighted) prevalence rates are presented by age groups and sex. Results

S TIMMINS 1, 2, 3, 4 , G KING 1,2,3,4 , C SALOME 1,3,4 , R SCHOEFFEL 1,2,3 , C WALSH 1, 3, 4 

The extent of emphysema could increase ventilation heterogeneity independently of its effects on airway narrowing. The aim of this study was to examine the relationship between emphysema extent on computed tomography scans (CT), and airway narrowing and ventilation distribution in COPD. Methods 27 subjects with COPD underwent CT scanning, spirometry, DLCO and nitrogen washout by single and multiple breath techniques. Closing capacity (CC/TLC%), slope of phase III (Δphase III ) and indices of ventilation distribution conductive (Scond) and diffusion-dependent airways (Sacin) were derived from washouts. Helical CT scans were performed at TLC. Emphysema extent was measured as low attenuation areas < −910HU using Osirix program, expressed as % of CT total lung volume. Results Subjects were of mean (range) age 70 years (55-85), BMI 27.3 (17.5-42.7), FEV 1 of 57 (34-92%) %predicted and DLCO of 50 (29-78) %predicted. Emphysema extent was 22.7% (0.1-54.1). Geometric mean (CI) Δphase III was 8.1 (6.8-9.6), Sacin was increased at 0.553 L −1 (0.477-0.641) and CC/TLC% was 46% (44-48). Emphysema extent correlated with FEV 1 / FVC (r = −0.56, p = 0.002), DLCO (r = −0.63, p < 0.001), BMI (r = 0.49, p = 0.009), Δphase III (r = 0.46, p = 0.017), and Sacin (r = 0.56 p = 0.003). In multiple regression analysis, emphysema extent was predicted by FEV 1 /FVC and Δphase III (model r 2 = 0.46, p = 0.0005). Conclusions The extent of emphysema increases the heterogeneity of ventilation independently of any effects on overall airway narrowing. Supported by Australian Lung Foundation Webster Memorial Award, CRCAA.

Conclusions Self-reported wheeze in the last 12 months is very common in adults over 40 years. In the younger age group (40-54 years), many people with wheeze did not have airfl ow obstruction or reversible spirometry at the time of test. Aim To determine whether there is any association between change in FEV 1 among COPD patients and ambient ultrafi ne particle number concentrations in Melbourne.

Methods Participants with mild to moderate COPD were asked to measure their FEV 1 using a portable electronic spirometer (PiKO) two times a day (morning and evening) for consecutive 7 days. The same procedure was repeated on average 9 months later. Ambient ultrafi ne (diameter <0.1 μm) particle number concentrations were measured for the same period using an ultrafi ne condensation particle counter and Micro-Orifi ce Uniform Deposit Impactor.

Results 108 Aim To examine the implementation of, and barriers and enablers to, six high-evidence recommendations for COPD management, in COPD hospital inpatients.

Method Observational, mixed methods study in consecutive COPD patients admitted to a tertiary hospital. Demographic, disease and admission characteristics are recorded. Implementation (or not) of smoking cessation, pulmonary rehabilitation, long-term oxygen use if hypoxaemic, medication use, vaccinations and plans for future exacerbations are determined from medical records and patient interviews. Interviews with medical offi cers examine their perspectives on recommendation implementation.

Of pilot data in 10 COPD patients (mean (SD) age 76(10) years, length of stay 7(6) days), 2 were current smokers and 4 had severe COPD (6 moderate). Highest levels of implementation were fl u vaccination (completed by GPs, n = 10), medication (but not spacer) use, and oxygen use if hypoxaemic (investigated and implemented in all suitable, n = 4). Pulmonary rehabilitation was discussed with half of the patients, but only 2 severe patients with long length of stay accepted further rehabilitation. Exacerbation plans were in place for 1 patient, and newly initiated in 2 patients. Doctor interviews (n = 8) confi rmed pulmonary rehabilitation was considered mostly for severely unwell patients, and use of exacerbation plans was inconsistent.

Conclusion Pilot data suggest pulmonary rehabilitation is offered and accepted by a small subset of COPD patients. Findings from this pilot will inform planned larger observational studies, and in turn, experimental studies to improve COPD care. High-and extreme high-risk interventions were found by panel (0-3.33% extreme and 3.57-13.33% high-risk interventions) and patients' respiratory physicians (3% extreme and 27% high-risk interventions). Additionally, clinical pharmacist involvement was associated with many benefi ts such as: improvement in medication compliance, high level of patient satisfaction and identifi cation of patients with issues in medication knowledge.

Conclusion Clinical pharmacist interventions were estimated to prevent extreme and high risks that might happen due to drug-related problems. Clinical pharmacy consultation was associated with positive impact on other important measured outcomes. Aerobic exercise training in the form of supervised 20-minute walks (20MW) reduces exertional dyspnoea in patients with COPD. 20MW goal (20MWG) distances, aiming for a training effect, are generated from a baseline submaximal test (6-minute walk (6MWD), where 20WG = 0.8 × 6MWD/6 × 20. Aim To compare 20MWG with actual initial 20MW achieved and to examine the predictors of 20MWG achievers (GA). Methods Retrospective review of 404 patients, 58% male, age 68 ± 9 years (mean ± SD), FEV 1 42 ± 17%predicted, who completed pulmonary rehabilitation (PR). Patients were assessed at baseline and post-completion of PR. Initial 20MWG was calculated from the best of two 6MWD at initial assessment and GA were defi ned as patients who achieved their 20MWG at their fi rst visit to PR. Results For the group, there was a statistically signifi cant but not clinically signifi cant difference between 20MWG and actual 20MW achieved (1025 ± 320 m vs. 1086 ± 398 m, p < 0.05, paired t-test). The 264 patients (65%) who achieved their 20MWG exceeded the goal by 182 ± 141 m, whereas the 140 patients who did not achieve their 20MWG fell short by 173 ± 168 m. There was no signifi cant difference between GA and non-GA in age or lung function, but GA had a higher initial 6MWD, with fewer rests, lower dyspnoea score and lower HR at start and fi nish (p < 0.05, unpaired t-test). GA were also more likely to have a clinically signifi cant response to PR, measured by 6MWD, compared with non-GA (mean change 63 m vs. 37 m, p < 0.05, chi-square). Conclusion 20MW goals as currently calculated either signifi cantly underestimate or overestimate actual 20MW achieved. It may be that in non-GA, the 6MWD is functioning as a true maximal test and these are a group of patients who are truly ventilatory-limited, rather than deconditioned. The receptor for advanced glycation end products (RAGE) is a key candidate for promoting a self-perpetuating cycle of infl ammation and thereby is a major contributor to numerous chronic disease states. The potential of RAGE to function as a switch converting a transient infl ammatory response such as one generated by cigarette smoke to sustained cellular dysfunction allows it to act as a mediator for ongoing infl ammation in chronic obstructive pulmonary disease (COPD). Although the molecular mechanisms regulating RAGE expression have not been fully elucidated, altered RAGE activity arises from polymorphisms within the RAGE gene and its promoter. Three polymorphisms in the RAGE promoter (−374T/A, −429T/C and a 63 bp deletion from −407 to −345) increase transcriptional activity and RAGE expression. The RAGE G82S allele results in an increased ligand-binding affi nity and activation of the infl ammatory mediators with subsequent up-regulation of infl ammatory response. The aim of this pilot cross-sectional study was to investigate the relationship between three known RAGE polymorphisms (−374T/A, 63 bp deletion, G82S) and COPD and disease severity. Methods Genomic DNA was isolated from peripheral blood lymphocytes. PCR and TaqMan assays were used to genotype the three RAGE polymorphisms in 67 COPD patients, 70 healthy non-smokers and 70 healthy smokers. FEV 1 was measured in all subjects. Disease severity was defi ned using GOLD guidelines.

Results There was no statistically signifi cant association between 63 bp deletion and COPD (p = 0.61), −374T > A and COPD (p = 0.58), G82S and COPD (p = 0.42).

Conclusion No association was found between the −374T > A, 63 bp deletion and G82S polymorphisms and COPD, disease severity or FEV 1 Introduction The receptor for advanced glycation end products (RAGE) mediates neutrophil traffi cking and is implicated in the pathogenesis of chronic airways disease. We determined whether changes in airway and systemic levels of soluble RAGE (which acts as a receptor decoy to limit RAGE activation) and RAGE ligands are related to neutrophilic infl ammation in asthma and COPD.

Methods Bronchial lavage (BL) fl uid from subjects with moderate-severe persistent asthma or COPD, and healthy controls were analysed for neutrophils, total sRAGE (cleaved and secreted), secreted sRAGE (esRAGE) and the RAGE ligands HMGB1 and serum amyloid A (SAA). Systemic levels sRAGE and esRAGE were also determined in asthmatic and COPD subjects. Aims Increased numbers of neutrophils are found in the lungs of COPD patients, which contribute to airway infl ammation. While cigarette smoke exposure is the major risk factor for COPD, it is unclear how cigarette smoke modifi es neutrophil function and activity. This study aimed to assess the effect of cigarette smoke extract (CSE) on neutrophils in an in vitro model. Methods Neutrophils were isolated from peripheral blood donated by volunteers using Percoll density gradient centrifugation. Neutrophils were seeded in 24 well plates (10 6 cells/well), exposed to different concentrations of CSE (10%, 1%) and monitored at 2, 4 and 18 hours. At each time point, viability of neutrophils was measured by trypan blue exclusion and supernatant was collected for measurement of CXCL8 release by ELISA (R&D Systems Conclusions In neutrophils exposed to CSE, viability is maintained and CXCL8 release increases with increasing dose of CSE. We conclude that cigarette smoke stimulates an infl ammatory response by neutrophils, which would contribute to the infl ammatory burden in the airways in COPD. Introduction Factor VIII (F8) and collagen IV (C4) antibodies are used for quantifying vessels in tissue sections. We compared these two antibodies for vessels staining in bronchial biopsies (BB) in COPD.

Methods BB from 7 healthy non-smokers (H-N) and 28 COPD subjects were stained for both antibodies. Number, area and mean vascular size (MVS) (surface area/vessel number) of vessels in the lamina propria (LP) to the depth of 150 μm were measured and compared between the two antibodies and are reported as median (range). Results Number of vessels was not signifi cantly different between the two methods of staining. In COPD and H-N, vascular area (μm 2 /μm 2 of LP × 100) stained with F8 was less than that with C4 (4.1 (1.8-8) vs. 6 (2-10.3), p < 0.01 and 3.9 (2.6-8.7) vs. 6.8 (3.7-8.9), p < 0.05 

Introduction Previous studies have shown that C-reactive protein levels increase at the onset of some COPD exacerbations; however, there is limited data on the normal fl uctuation in CRP levels in stable patients. Aim To investigate within patient variation in CRP levels to determine the magnitude of normal day-to-day fl uctuations in stable patients and the correlation with patients' perception of symptom severity. Methods Early morning CRP levels were measured on days 1, 3 5 and 6 from 22 patients from the Melbourne COPD Cohort (GOLD Category II-IV) who identifi ed themselves as stable. Patients recorded daily symptom scores including: Borg dyspnoea scale at rest, severity of wheeze, cough, dyspnoea, change in sputum colour or volume, night-time waking and the presence of viral symptoms. CRP levels were measured by the clinical pathology service and using a point-of care device. Variation in CRP levels in stable COPD and correlation between change in CRP levels and symptoms were analysed. 

Aim Patient-completed diaries monitoring changes in key symptoms in COPD are often used to recognize acute exacerbations (AE) both to prompt additional treatment and monitor treatment effi cacy. We assessed diary compliance and the predictive value of major symptoms of AEs which required hospital attendance. Methods Inpatients recruited during an AE of COPD completed daily paper or web-based diaries for 12 months, recording changes from their stable state for: breathlessness, cough, sputum, subjective 'wellness', physical activity and use of reliever (7-point scale, mid-pt = no change). The predictive value of current and lagged symptom scores was compared for each and between symptoms. Diagnostic accuracy was assessed by area under the curve (AUC) and at specifi c cut-points.

In 55 participants (18M, 37F) with mean age 67 ± 10 and mean FEV 1 % predicted 35 ± 14, there were 116 such AEs involving 32 patients. Duration of diary keeping was shorter with lower education attainment (p = 0.05), but compliance did not vary for other demographic or clinical factors. Daily compliance while diaries were being kept was 85%. Excluding the current day, the best predictor was the distributed lag score over 6 days, sputum changes giving the strongest signal; relative risk 1.65 (95% CI 1.21 to 2.23) with most of the signal in the 2 days prior to the AE. Little was gained by combining symptoms. The predictive value was moderate AUC = 0.67.

Conclusions Compliance with symptom diaries in severe COPD is surprisingly good. However, with only a weak signal for an impending AE requiring hospital attendance up to 48 hours before and for lagged symptom scores over 6 days before, with low positive predictive values, the utility of keeping daily symptom diaries for raising alerts for impending severe AEs in COPD is questionable. Results Seven studies with 288 inpatient participants were identifi ed; 3 published as abstracts for which data were not available did not contribute to meta-analyses. No study specifi ed diagnostic criteria for COPD and only one specifi ed AE criteria. Short course treatment varied between 3-7 days and longer duration 10-15 days; 5 studies used oral prednisolone (dose 30 mg, 4 studies, 1 tapered dose) and 2 studies used intravenous SCS treatment. Mean ages of participants ranged from 64 to 73 years. Primary outcomes: likelihood of treatment failure did not differ by duration of treatment (odds ratio 0.82; 95% CI 0.24 to 2.79) (3 studies, n = 146). FEV 1 did not differ signifi cantly when measured up to 7 days (Mean difference (MD) −0.07 L; 95% CI −0.19 to 0.05) or after 7 days (MD −0.02 L; 95% CI −0.10 to 0.06) (4 studies, n = 197). Secondary outcomes: limited data (1 study) precluded meta-analysis for readmission or mortality. The likelihood of an adverse event (4 studies, n = 102) was not signifi cantly lower for shorter SCS (OR 0.58; 95% CI 0.14 to 2.40).

Conclusions We found no signifi cant differences between short (≤7 days) and longer (>7 days) corticosteroid therapy for AE of COPD. This has implications for clinical practice and may reduce adverse effects for patients, shorten hospital admissions and reduce costs, but more studies are needed to confi rm these fi ndings. Aim To explore factors which infl uence the self-management of exacerbations in patients with COPD. Methods A pilot cross-sectional study was undertaken to assess patients' compliance with their action plan and their action taken prior to an admission. Patients were interviewed during an admission to hospital for exacerbation of COPD. The effect of pulmonary rehabilitation on patients' knowledge of COPD was also assessed. Results 70% of patients were provided with a written action plan, and 25% with a verbal action plan. In response to an exacerbation, more than 70% of the patients stated that they used their action plan. However, where action plans were not adequately utilized, patients delayed seeking medical attention and failed to initiate oral prednisolone and antibiotics during an exacerbation despite being prescribed an emergency supply of these medications. Pulmonary rehabilitation had a positive outcome towards enhancing the patients' knowledge of COPD. Clinical pharmacists have limited involvement in terms of COPD and smoking cessation education. Conclusion The need to offer a thorough self-management program along with providing a more comprehensive written action plan will encourage patients to start early treatment and follow their action plans. Encouraging collaboration between the HCP and patients encourages self-management through discussing and agreeing on goals of treatment and developing a personalized written action plan. Context Dyspnoea is a common symptom in COPD and increases during exacerbations. When respiratory failure supervenes, and assisted ventilation is required, non-invasive ventilation (NIV) is the treatment of choice.

Objective To determine if NIV relieves dyspnoea in inpatients with acute respiratory failure due to exacerbations of COPD. Data Sources English language randomized controlled trials (RCTs) published prior to August 2010 were identifi ed using Medline, Embase, CINAHL, PsychINFO and PubMed. Additional studies were identifi ed by reviewing the reference list of included studies. Search terms included NIV, NIPPV, NPPV, Bilevel CPAP, BiPAP, artifi cial ventilation, COPD and randomized controlled trial. Study selection RCTs comparing usual medical care (UMC) to UMC plus NIV and measuring dyspnoea at relevant time points were included. Abstracts for potentially relevant articles were extracted by one author. These were assessed by a second author to ensure inclusion criteria were met. Articles were reviewed to determine if dyspnoea was measured and appropriate statistical analysis reported.

The search yielded 327 individual articles. Four articles met the review criteria. Three articles fi nd that NIV relieved dyspnoea to a statistically signifi cant level and two suggested that the relief of dyspnoea is clinically signifi cant. Discussion In spite of the common use of NIV to relieve dyspnoea, little work has analysed effi cacy in terms of this patient-reported outcome. While our results may suggest NIV relieves dyspnoea, reporting or methodological fl aws in several articles limit the strength of the conclusions that may be drawn. These limitations make the conclusion that NIV relieves dyspnoea contentious. Conclusion Despite over two decades of studies investigating NIV, the therapeutic impact on breathlessness is poorly described. Understanding the impact of NIV on patient-reported outcomes is of critical importance in clinical care. Confl ict of Interest None. Introduction In mice, the most direct lung dosing method delivers the agents directly into the trachea. For our cystic fi brosis gene-therapy studies, we deliver fl uids -an airway pretreatment followed by a lentiviral vector -directly into the mouse trachea to target conducting airways. Despite using standardized delivery techniques, we see substantial variability in the amount and location of gene transfer. Aim The aim of this experiment was to use synchrotron X-ray imaging to track the dynamics of fl uid doses delivered into the live mouse trachea. Methods Four nembutal anaesthetized C57Bl/6 mice were imaged on the BL20B2 beamline at the SPring-8 synchrotron. Mice were intubated and ventilated at 80 br/min with 1 image captured per breath. After 1 minute of baseline, a 15-μL sample of iodine-based contrast fl uid (a surrogate for our airway pretreatment or gene-vector) was delivered over 30 seconds. Following 20 minutes of data collection, an additional 15 μL bolus was delivered over 3.6 seconds. Image capture continued for a further 10 minutes. Frame differencing was used to reveal fl uid motion.

Results Substantial dose losses may occur upon delivery into mouse trachea via immediate retrograde fl uid motion. The speed of bolus delivery into lung may also infl uence the relative targeting of conducting airways and deep lung. 

Introduction Use of effi cient nebulizers can enhance the quality of life of CF patients by reducing the treatment time and improving drug delivery effi ciency. The aim of this study was to determine which commonly recommended nebulizer was optimal for delivery of the most commonly used therapies to CF. Methods Seventeen children with CF (8-17 years) were recruited. Delivery of three commonly used CF therapies (7% hypertonic saline (4 mL, 0.07 g/ mL), Tobramycin (4 mL, 20 mg/mL) and Pulmozyme (2.5 mL, 1 mg/mL)) by two vibrating membrane nebulizers, the eFlow rapid and the Aeroneb Go, and a jet nebulizer LC Sprint Junior with PariBoy SX (5.1 L/min) were tested. For each drug-nebulizer combination (in random order), each child was asked to inhale through an inspiratory fi lter, and drug delivery to the fi lter was measured. Pulmozyme was quantifi ed using an enzymatic activity assay, tobramycin was measured using HPLC and hypertonic saline was measured using conductivity. Total nebulization time was recorded.

The results showed that there was no difference in the amount of drug delivered to patients when the 3 nebulizers were compared for all three therapies (p > 0.05). However, the nebulization time for the eFlow rapid was signifi cantly shorter than that for the Aeroneb Go and LC Sprint Junior. Similarly, the nebulization time for Aeroneb Go was shorter than that for the LC Sprint Junior (p > 0.01) for all therapies). Conclusion Overall, there were no signifi cant differences between nebulizers in delivered dose for three forms of CF therapy, due to inter-patient variability. Despite this, both vibrating membrane nebulizers had shorter nebulization times than the LC Sprint Junior, with the eFlow rapid delivering drug in the shortest time.

Confl ict of Interest Nil. Introduction As the life expectancy of patients with cystic fi brosis (CF) increases, treatment-related morbidity is increasingly recognized. Totally implantable venous access devices (TIVADs) offer reliable long-term central venous access but are associated with recognized complications including venous thrombosis. Superior vena cava syndrome (SVCS) however has been rarely reported in this setting. We report a single CF Centre's experience of SVCS associated with TIVADs. Methods Retrospective review of episodes of SVCS in patients with CF and a TIVAD attending the adult CF Centre, Prince Charles Hospital, Queensland. Results Between February 2008 and December 2009, fi ve episodes of SVCS occurred in 60 patients with TIVADs from a clinic population of 251 patients. All of the affected patients were female, with moderately severe lung disease (Mean FEV 1 predicted 45.8%). No patients had a recognized thrombophilia. Four TIVADs were inserted at a centre different to our own, three were on oestrogen-based contraception, and two suffered with dehydration at presentation. SVCS treatment consisted of anticoagulation (5), line removal (4), angioplasty (2), thrombolysis (1) Noninvasive bioluminescence imaging has allowed for rapid in vivo quantifi cation of long-lasting gene transfer in experimental animals. We are testing the longevity of a single nasal delivery of our lentiviral (LV) gene transfer system in mouse airways. Methods Normal (C57Bl/6) and cystic fi brosis (CF) mice received a nasal bolus of lysophosphatidylcholine (LPC) or a control (PBS) pretreatment 1 hour prior to delivery of a LV vector containing the reporter-gene luciferase (LV-Luc). Another control group received LPC 1 hour prior to an empty vector (LV-MT). Bioluminescence was measured at 1 week, 1, 3, 6, 9, 12, 15, 18, 21 and 24 months post-LV dosing to assess gene transfer. Results Normal mice: Mice that received LPC/LV-Luc treatment had significantly greater gene transfer compared to the two control groups at all time points (p < 0.05, RM ANOVA). No luminescence was detected in mice treated with LPC/LV-MT. Unexpectedly, luciferase activity was also detected in the lung. There was no difference in lung luminescence between the LPC and PBS pretreated mice that received LV-Luc. CF mice: A statistically signifi cant increase in nasal luminescence persisted for up to 6 months following LPC/ LV-Luc (p < 0.05, RM ANOVA). Similar to normal mice, there was no statistical difference in lung luminescence between mice that received LPC and PBS LV-Luc. Conclusions Lentiviral luciferase gene expression was signifi cantly improved in mouse nasal airways using LPC pretreatment in both strains. However, the longevity of transduction was reduced in CF mice, which may, in part, be due to reduced animal numbers at the later time points tested. Supported by NH&MRC. Background The Nintendo-Wii® facilitates exercise-based programs that may be considered novel, fun and potentially motivating. Objective exercise outcomes using the Wii have yet to be reported in the cystic fi brosis (CF) adult population. Aim To investigate Nintendo-Wii® exercise training compared with standard exercise in adult CF patients whilst hospitalized for treatment of a pulmonary exacerbation. Methods A within-subjects, randomized cross-over study. Adult CF participants received two 15-minute exercise treatment sessions within a 48-hour period, at least 1 day apart, during the last days of hospitalization. Wii exercise consisted interval training with games such as boxing, dancing and track exercises. Standard exercise consisted of interval training on treadmill or cycle ergometer at 60-80% of heart rate maximum. Results 19 participants completed the study (mean (SD) age 27 (7) years, 47% females), with a mean FEV 1 % of 51 (21)%. During exercise, no difference was found between groups in average heart rate (p = 0.98), oxygen desaturation (p = 0.46), Borg Rate of Perceived Exertion (p = 0.39) or Modifi ed Borg for dyspnoea (p = 0.61). On VAS (0-10), participants reported the Wii program to be more enjoyable (p < 0.01) and less fatiguing (p = 0.05). Participants rated both exercise sessions as equally effective (p = 0.25). Conclusions This study suggests that a Nintendo-Wii® exercise session provides an equivalent cardiovascular demand to a standard exercise session in an inpatient adult CF population. Greater enjoyment levels and lower fatigue levels reported during Nintendo-Wii® training may have a positive infl uence on adherence to exercise. Further study into the long-term effects of Nintendo-Wii® training needs to be undertaken. Confl ict of Interest Nil. Introduction Ion transport is important to maintain the airway epithelial surface, as shown by the disease cystic fi brosis (CF) which is characterized by decreased Clsecretion and increased Na + absorption. We have previously shown that the CF airway can develop Clresponses when the surface is nominally calcium free (Middleton et al. AJRCCM 2003; 168: 1223 -1226 . Aim To determine the effects of citrate on the nasal potential difference (NPD) with and without amiloride pretreatment, and to compare these effects with other clinically relevant calcium chelators and dicarboxylic acids. Methods NPD was measured using standard techniques (ERJ 1994; 7: 2050) in CF and non-CF subjects. The nasal PD response to citrate, oxalate, malate, succinate and fumarate (all 10 mM) was compared with the calcium chelators EDTA and EGTA. Results Citrate decreased the basal NPD by ∼2 mV, but in the presence of amiloride, citrate increased the PD by ∼2 mV. With amiloride/low Clpretreatment, citrate increased NPD by 5-6 mV, which suggests that citrate increased Clsecretion. In contrast, the other dicarboxylic acids and calcium chelators exhibited little response. Conclusion The combination of these responses suggests that citrate exerts complex effects on airway ion transport, most likely dual effects of decreased Na + absorption and increased Clsecretion. Aim To assess the validity of the International Physical Activity Questionnaire (IPAQ) in CF adults by comparing energy expenditure measured by the IPAQ versus the accelerometer. Methods With ethics approval, suitable successive adult patients with CF attending the Alfred CF Outpatient Clinic were recruited. All participants wore an accelerometer (Actigraph GT1M) around the waist for 7 days of awake time, at the end of which, they completed the IPAQ. Criterion validity of the IPAQ was assessed by comparing the IPAQ weekly energy expenditure (EE) in kilocalories (kCal) with weekly EE (kCal) from the accelerometer using spearman correlations and Bland-Altman procedures. Results Thirty participants (53% females) completed the assessment: mean (SD); age = 29 (7) years, FEV 1 %predicted = 61 (25)

The median (range) EE: IPAQ = 3695 (113,19573) kCal, GT1M = 1669 (355,5443) kCal. Spearman correlations of FEV 1 %predicted with EE were GT1M EE r = 0.68, p < 0.001; IPAQ EE r = 0.28, p > 0.05. Correlation of the IPAQ EE with accelerometer EE was moderate (r = 0.46, p = 0.010). There was a trend towards higher EE measured by the IPAQ than measured by the accelerometer (Wilcoxon signed ranks test: z = −3.4, p = 0.001). Conclusion The IPAQ underestimates physical activity for patients with lower energy expenditure activities and overestimates for those with higher energy expenditure activities in adults with CF. The IPAQ would be a useful screening tool for exercise prescription and monitoring of physical activity longitudinally, but more quantifi able methods for assessment such as the accelerometer should be used in research. Confl ict of Interest None. Infectious endometritis associated with Pseudomonas aeruginosa (Pa) is an important equine disease resulting in reduced fertility and decreased foal drop. Previous typing studies of equine Pa report clonal heterogeneity, suggestive of sporadic acquisition, and small clusters of indistinguishable strains. Aim We performed molecular typing of a large sample of genital Pa isolates from horses in S-E Qld. Methods Thoroughbred genital tract Pa isolates submitted to UQ Vet Diagnostic Lab during 2005-2009 (screening or infection suspected) were studied. ERIC-PCR fi ngerprint analysis was performed. Isolates producing indistinguishable fi ngerprints were allocated to the same ERIC-PCR type. MLST was performed on a subset of 24 isolates. Results Overall, 2700 genital (clitoral or uterine) swabs from 2040 mares and 45 urethral fossa swabs from 18 stallions located on 16 stud farms were processed. Pa was identifi ed in genital cultures from 93 of the 2040 (4.6%) mares but from none of the 18 stallions. Six clusters involving ≥2 mares were detected. Cluster-A was observed amongst isolates collected from 42 (45%) mares from 13 studs and each year. Cluster-B isolates were present in 5 mares from 2 studs during 2005-2007. Clusters C-to-F each contained isolates from 2 mares from 1 or 2 studs. Conclusions Overall, 57% of mares harbouring Pa had clonally related strains. However, we found no evidence of horizontal transmission between stallions. These data raise the possibility of transmission via environmental or other sources. Alternatively, specifi c strains may have trophism for the reproductive tract of horses. The fi nding of a dominant strain amongst thoroughbred mares in a geographic region has interesting parallels with recent evidence of the spread of highly prevalent clonal strains in cystic fi brosis clinics. Aim To investigate the prevalence and impact of incontinence in adult men with cystic fi brosis (CF) as compared with age-and sex matched control subjects. Methods Men with CF were recruited through outpatient clinics and control subjects through advertisements to complete standardized questionnaires relating to respiratory symptoms, bladder and bowel function, mood and physical activity levels. Demographic data were collected from medical records for the CF group. Results Seventy-four men with CF participated (mean (SD) age 29.9 (7.4) years). Forty-nine men volunteered as controls (33.5 (9) years), and were well matched in terms of physical activity levels. 11/74 (15%) in the CF group and 4/49 (8%) in the control group had reported episodes of urine leakage. In the men with CF, there was no difference in lung function between men with episodes of leak and those with no history of leak (FEV 1 % predicted 62 (26)% vs. 63 (24)%, p = 0.943). Anxiety levels were higher in men from both groups with episodes of leak compared to those with no history of leak (Hospital Anxiety and Depression anxiety score 9.3 (4.1) vs. 4.6 (3.8), p < 0.001). Depression scores were also higher in men with episodes of leak compared to those with no history of leak (6.4 (4.4) vs. 2.1 (2.9), p < 0.001). Conclusions Urinary incontinence in men with CF is not associated with disease severity, as measured by lung function. Anxiety and depression levels were higher in men with leakage of urine. Confl ict of Interest No. Aim To investigate the bone mineral status of children and adolescents with CF and to explore the relationship between bone mineral density (BMD) and anthropometric and clinical parameters including height, body mass index (BMI), lung function tests and vitamin D levels (25-hydroxyvitamin D) in the CF centre at Starship Children's Hospital, New Zealand. Methods BMD of the lumbar spine was assessed by dual X-ray absortiometry between January 2007 and December 2009. The results of 35 subjects with CF (21 males) with a mean age of 14.6 years (range 10-18.8 years) were collected. Anthropometric data (height, BMI), forced expiratory volume in 1 second as percent predicted (%FEV 1 ) and vitamin levels were assessed and related to BMD. Results BMD in our subjects was low in 25.7% and very low in 8.6% when adjusted for age, sex and height (difference in BMD g/cm 2 in the lumbar spine L1-L4). There was a strong positive relationship between the lumbar areal BMD (aBMD) and BMI Z scores (p < 0.0001), aBMD and % FEV 1 Z scores (p < 0.003), and aBMD Z scores and vitamin D levels (p < 0.03). Conclusions BMD was normal in the younger and well-nourished subjects with normal or mild reduction of FEV 1 . Low BMD appeared to evolve during adolescence with decreasing BMI and reduction in lung function. This will lead to ongoing bone disease in early adulthood. It is a further indication to maintain optimal nutritional status and maximize lung health. Malnutrition in CF is associated with poorer pulmonary function and is an independent risk factor of survival. Aim To compare the nutritional status of the adults attending an Adult CF Centre in 2009 with 1999. Method Retrospective audit of 260 patients (48 excluded, incomplete data) including demographics, nutritional status, pancreatic enzyme replacement therapy (PERT) usage, glucose tolerance and dietetic review. Results The mean age of the clinic population increased from 26.8 to 29.8 years. Mean (SD) BMI increased from 1999 (21.1 ± 3.0 kg/m 2 ) to 2009 (22.5 ± 3.8) (p = 0.0017). In 2009, 89% of the clinic population was taking PERT with a mean dose of 4315 ± 2782 IU lipase/kg/day. The proportion of patients with abnormal glucose tolerance has increased from 12% to 26% (p = 0.004). Oral supplement use has increased from 26% to 45%, yet enteral feeding remained stable (12% −1999, 8% −2009). This occurred during period of increased annual dietetic review of the patients attending the clinic from 73% in 1999 to 90% in 2009 (p = 0.0001). Discussion Over a 10-year period, an improvement in mean BMI refl ects improvement in nutritional status. Prevalence of abnormal glucose tolerance has increased; this is likely due to commencing a screening program (2000). Use of oral supplements has increased and is higher than identifi ed in the recent DAA survey of nutrition practices of CF Dietitians (18%). Annual review by the CF Dietitian has increased despite a twofold increase in the CF population may be attributable to a stable and experienced workforce. Current service provision of 1. 

A ABBOTT 1 , E CHEUNG 2 , L MORGAN 1

Aim To characterize the microbial colonization of a group of stable adults with non-CF bronchiectasis using an extended culture protocol. Methods Sputum was collected over an 18-month period from clinically stable patients. Standard semi-quantitative bacterial culture was extended to 7 days with the addition of fungal and mycobacterial culture as routine.

Results 61 specimens of spontaneously expectorated sputum were collected from 28 patients; mean age 62 years (21-87 years); mean (SD) FEV 1 / FVC ratio 63% (22%); 21/28 never smokers; 19/28 on inhaled or oral corticosteroids. The bacteria identifi ed were P. aeruginosa (21% of specimens), H. infl uenzae (18%), H. parainfl uenzae (5%), Acinetobacter baumanii (2%), Enterobacteriaceae (6%). Commensals only were identifi ed in 43% of specimens. Fungi included Candida species (20%), Aspergillus fumigatus (5%) and Penicillium species (2%). Non-tuberculous mycobacteria (NTMB) were grown in 11% of specimens: M. gordonae (7%), M. intracellulare (2%) and M. lentifl avum (2%). The NTM identifi ed were all considered non-pathogenic. Only the mycobacteria were identifi ed after day 2. Conclusion Microorganisms with potential pathogenicity are frequently identifi ed in adult patients with non-cystic fi brosis bronchiectasis who are not experiencing an acute exacerbation. All these organisms were identifi ed using a standard short culture protocol. The extended regimen, which was costly, did not identify any unusual or unexpected pathogens. It was rare for patients to be colonized with fungi. This study suggests there is limited value in requesting extended culture for bacterial pathogens, including looking for fungi or NMTB in this stable patient group as this adds little to the empiric antibiotic choice for infective exacerbations. Confl ict of Interest None.

S STELZER-BRAID 1,2 , H ALSUBIE 3 , A NEILSEN 3 , H JOHAL 1 , A STELLER 1 , ER TOVEY 4 , K MCKAY 3 , P VAN ASPEREN 3 , WD RAWLINSON 1, 2 Introduction Respiratory infections are of fundamental importance in determining the morbidity and mortality associated with cystic fi brosis (CF) as such infections can lead to progressive and fatal obstructive lung disease. Using polymerase chain reaction (PCR) to detect such infections has advantages over previous studies that used relatively insensitive traditional detection methods and could have underestimated viral prevalence. Methods Viral and bacterial multiplex PCRs were developed for detection of respiratory pathogens important for children with CF. Nasal brush samples were collected from CF patients who were symptomatic or asymptomatic for acute respiratory illness (n = 56). Sputum and exhaled bioaerosols via a novel mask sampler were collected from a subset (n = 16). Results As expected, almost all (81%) sputum samples were positive for bacteria. Detection of bacteria in the upper respiratory tract was lower (12.5%). Data from nasal samples indicated strong association of viral pathogen presence, particularly rhinovirus, with exacerbation of disease. Results also showed good evidence for rhinovirus infection in the lower respiratory tract. The novel mask sampler is promising as a non-invasive sampling tool. Conclusions Our results demonstrate the importance of pathogens in exacerbations. Early detection and understanding the development of bacterial and viral infections in CF patients is important in clinical decision-making as more and better antiviral and antibiotic agents become available. Aim To determine the factors affecting microbiological yield from bronchoalveolar lavage (BAL) in patients with suspected pulmonary infection and haematological malignancy or following stem cell transplantation at a tertiary bone marrow transplant centre. Methods A retrospective 12-month audit of patients with pulmonary infi ltrates or febrile neutropenia with haematological malignancy or post-stem cell transplant who underwent BAL for microbiological diagnosis. Data were obtained on microbiological yield, radiographic appearances, current antimicrobial therapy, the presence and duration of neutropenia and complication rate.

Of the 48 BAL procedures performed, a clinically signifi cant microbiological result was obtained in 33% of cases (16/48). Of these positive results, 31% (5/16) were exclusively viral pathogens, 19% (3/16) were fungal, 25% (4/16) were bacterial and polymicrobial infection was observed in 25% (4/16) of cases. A high proportion of patients had commenced anti-microbial treatment empirically, with 88% (42/28) receiving broad spectrum antibacterial treatment and 56% (27/48) receiving treatment doses of antifungal agents prior to bronchoscopy. In 23% (11/48), the results of the BAL changed the patients therapy. The presence and duration of neutropenia or radiological appearances were not reliable discriminators of specifi c infective aetiologies. Complication rates were low and included fevers in 25% (12/48), hypoxia 8% (4/48), small volume haemoptysis in 2% (1/48), atrial fi brillation in 2% (1/48) and pneumothorax in 2% (1/48). Conclusion Whilst BAL remains a safe and important tool in establishing a microbiological diagnosis in immunosuppressed patients with pulmonary infi ltrates, a clinically signifi cant yield and changes to patient treatment occur in the minority of cases. Clinicians should have a high degree of suspicion of viral infective aetiology when treating this population of patients. Aim To examine the outcomes and complications of intercostal catheter (ICC) treatment of pneumothoraces (primary (PP) and secondary (SP)) and effusions (malignant (ME) and parapneumonic (PE)). Methods Retrospective review of all ICCs in admitted patients in a respiratory unit over 15 months. Data collected included type of pneumothorax or effusion, ICC type, insertion details, complications (major and minor) and outcome (success defi ned as resolution of pneumothorax or effusion with single tube insertion). Results 88 patients required ICC treatment. Forty-six ICCs were used in 38 patients with pneumothorax: PP 18; SP 14; iatrogenic 5; hydropneumothorax 1. Complication rate was 45% (12% major) and was signifi cantly less in PP (35%) compared with SP (60%), p < 0.05, chi-square. Success rate for pneumothorax ICC drainage was 44% (signifi cantly higher for PP (72%) compared with SP (20%), p < 0.05). Fifty-eight ICCs were used in 50 patients with pleural effusions: ME 35, PE 11, other 4. Complication rate was 57% (13% major) and was signifi cantly higher in ME (67%) compared with PE (36%), p < 0.05. Success rate for effusion ICC drainage was 58% (signifi cantly less in ME (49%) compared with PE (81%), p < 0.05). Small bore ICCs (gauge <16Fr) were used for 91% of pneumothoraces and 66% of effusions. Tube size did not signifi cantly infl uence complication or success rate for either pneumothoraces or effusions. Conclusions Compared with PP, ICC treatment of SP was less successful and more likely to be associated with complications. Similarly, compared with PE, intervention for ME with ICC was less successful and had a higher complication rate. We conclude that ICC intervention is most successful for PP and PE, and speculate that SP and ME should have early surgical intervention. Introduction Spontaneous pneumothorax is a common condition. Current management guidelines recommend large pneumothoraces are managed by primary intercostal catheter insertion. We report a single centre's experience in the management of large spontaneous pneumothorax. Methods Retrospective audit of cases of spontaneous pneumothoraces managed at the Prince Charles Hospital between 1 January and 31 December 2009. Patient demographics, co-morbidities, presenting symptoms, examination fi ndings, radiology, management and complications were reviewed. Results Forty-two patients (36 male, 6 female) experienced 61 episodes of spontaneous pneumothorax. Chest pain and dyspnoea were the most commonly reported symptoms (50) 82%. There were forty-two (69%) episodes of large pneumothorax (≥20% of hemithorax). Management of large pneumothoraces consisted of: observation, (15) Seldinger ICC (17) and Large bore ICC (10). Complications occurred in three patients with Seldinger ICC (2 vasovagal, 1 hydro-pneumothorax) compared to none with large bore ICC. Outcomes were similar for patients managed by observation compared to ICC insertion. All recurrent cases (26%) were referred for consideration of surgical pleurodesis. Conclusion Patients with large pneumothorax managed by observation recovered similarly to those treated with ICC, suggesting a higher threshold for ICC insertion should be considered in the future. Grant Support Nil. Aim A pilot study of an instrument of pleural ultrasound training in thoracic physicians after a pleural ultrasound course. The instrument was tested for inter-observer agreement and also its ability to be used in a patient compared to a dedicated manikin. Methods All chest physicians (4) were novices in ultrasound and underwent a dedicated 3-day training course in pleural ultrasound at The Australian Institute of Ultrasound. They were assessed 3 months later by 2 radiologists and one senior ultrasonographer using a specially designed pleural ultrasound training assessment tool (USGT-SAT) on both a subject with pleural effusion and a dedicated ultrasound manikin.

The mean scores, out of a maximum of 100, obtained by the each of the 4 participants for the manikin were 95.0, 87.7, 89.3 and 84.3, respectively, while the scores for the patient was 87.3, 85.0, 94.0 and 86.7, respectively. The mean scores of the participants as a group for manikin were 89 ± 7.2 and for the patient as 88.3 ± 8.11. There was general agreement between the 3 examiners with mean combined participant scores of 91.5, 88.8 and 87.0 in the manikin, respectively, and mean score of 95.8, 81.3 and 87.8 in the patient. Conclusions This pilot study shows ranges of scores for design of future validation studies of the USGT-SAT. Test performance by the chest physicians after a short course in pleural ultrasound was generally good and results for the use of the manikin as an alternative to patients in pleural ultrasound training are encouraging. Further studies with larger sample size are required. Supported by Nil. Nomination Nil. Confl ict of Interest No.

Since the fi rst commercial availability in 1968, fl exible bronchoscopy has evolved from a simple 'look see' procedure to a more complex multifaceted one. Today, fl exible bronchoscopy is a tool used for diagnostic procedures, surveillance, delivery of therapy and clinical trials. Increasingly, it involves utilizing expensive purpose built equipment in complex diagnostic procedures. This evolution requires a specifi c knowledge base and skill set to safely perform the procedure and care for the equipment. This now mandates additional training by nursing and medical staff to develop and maintain the required skills. Medical staff now rely on their nurses to assist in the full range of procedures. Thus, the nurses must keep abreast of modern trends and techniques. The modern bronchoscopy suites team is an integrated one, with specifi c roles, defi ned to each member. The procedures performed will refl ect local needs and expertise. Just as bronchoscopy has evolved into the speciality of interventional pulmonology, so must bronchoscopy suite nursing be accepted as a specialized area of nursing with a credentialed 'Special Interest Group' to promote, educate and develop the subject as more therapeutic and diagnostic procedures evolve. This will allow nurses involved in bronchoscopy to be respected, recognized and accepted for their unique knowledge and abilities. Confl ict of Interest Nil. Background Transthoracic pneumostomy (TP) is a novel treatment for patients with severe emphysema that aims to defl ate the lung and improve function. Aim To assess the effect of unilateral TP on the volume of each lung and mechanical properties of the lungs. Methods Subjects were recruited for a multicentre trial of TP (see ACTRN 12608000408381). In parallel with the main protocol, we measured (1) 

In the six subjects recruited, compared to plethysmography, lung volume was overestimated by CXR (mean difference +3.4%, range −16.6 to +17.3) and underestimated but more closely correlated by CT (mean difference −5.5%, range −14.9 to −1.9). Based on CT, the volume of the treated lung decreased in all patients after TP (mean −17.6%, range −6.3 to −28.1) whilst that of the untreated lung did not change (mean −1.4%, range −6.3 to +5.1).

In 5 patients with available data, TP reduced dynamic hyperinfl ation during exercise (mean −180 mL, −8.4% of IC, range +0.7% to −17.9%). Lung mechanics were performed in 4 patients. Low lung elastic recoil prior to TP and an increase in elastic recoil after TP were associated with greater reductions in lung volume and greater improvements in exercise tolerance. Conclusions Supine chest CT provided reasonably accurate estimates of plethysmographic lung volume. Unilateral TP defl ated the lung and there was no evidence of signifi cant compensatory hyperinfl ation of the contralateral lung. TP also reduced dynamic hyperinfl ation. Measurement of lung elastic recoil may help select patients who are likely to benefi t from TP. Support and Confl ict of Interest Nil. Methods We performed a retrospective chart review of all adult patients who had an ICC over a 24-month period within a tertiary hospital respiratory service. We noted patient demographics, details surrounding chest drain insertion including image guidance and subsequent inpatient events. Results Over a 24-month period, there were 102 small-bore ICC insertions, of which 28 were image-guided. Mean patient age was 58 years, males comprised 69/102. Forty drains were inserted for pneumothoraces, 25 for malignant effusions, 18 for parapneumonic effusions, 6 for transudates and 13 for undiagnosed exudative effusions. Mean duration of drainage was 4.8 days. There were no life-threatening complications. Three of the chest drains fell out and 7 became blocked. Six pneumothoraces were noted, all following insertion without direct image guidance; none required further intervention. Local infection occurred in 1 patient. Insertion details were not documented in 9 patients. Conclusion Insertion of small-bore ICCs via the Seldinger technique appears to be a safe method of draining pneumothoraces and pleural effusions. Image guidance may reduce complication rate of this procedure. Documentation of drain insertions could be improved. Confl ict of Interest Nil. Rationale Pleural effusions are frequently encountered in clinical practice, and often require aspiration for diagnostic and/or therapeutic purposes. Use of radiological guidance varies, despite current guidelines recommending routine use of ultrasound. Furthermore, concerns exist regarding the downskilling of thoracic medicine trainees due to the increased use of interventional radiology. As a precursor to developing a procedural pleural ultrasound service, we performed a retrospective case review of our current practice. Methods Patients who had pleural fl uid sent to pathology between January 2008 and December 2009 were identifi ed on an existing database. Patient records were reviewed and details regarding the drainage procedure and outcomes were recorded. Information on patient location, method of procedure and performing clinician were also collected. Results To date, 22 pleural fl uid aspirations in 21 patients have been identifi ed. Overall, 68% of aspirations were carried out on the ward and 18% in the radiology department. Two procedures occurred in the endoscopy suite on outpatients, and one in the emergency department. Fifty percent of procedures were performed using an intravenous cannula for drainage and 45% utilized a pigtail catheter. All procedures occurring in the radiology department were performed under ultrasound guidance by a radiologist or radiology registrar. Of the remaining procedures, 56% were performed by medical registrars and 61% were performed with ultrasound marking. Six complications occurred following 5 procedures: 4 pneumothoraces, 1 vasovagal and 1 tube blockage. There were signifi cantly more pneumothoraces in patients who did not have an ultrasound marking (3 of 7 without marking, 1 of 15 with marking, p = 0.03). None of the complications required further intervention. Conclusion These preliminary data suggest ultrasound marking signifi cantly reduces pneumothorax incidence, supporting the establishment of a pleural ultrasound service. This is likely to have the added benefi t of improved training for thoracic medicine trainees. Aim To investigate differences between semi-recumbent and supine posture in terms of cough rate, degree of oxygen desaturation, oxygen supplementation, increase in pulse rate and sedative use during the initial phase of bronchoscopy. Methods Consecutive patients (n = 69) undergoing diagnostic bronchoscopy at an endoscopy unit were recruited for this observational cohort study. The posture was determined by the bronchoscopist's usual practice. Patient age, gender, % predicted FEV 1 and FVC, indication, pulse and oxygen saturation were recorded. The initial phase was defi ned as the time from bronchoscopy insertion to visualization plus lignocaine instillation of both distal main bronchi. Cough rate, peak pulse, nadir oxygen saturation (SpO2), range of oxygen supplementation and sedation use during the initial phase were recorded. A post-procedure questionnaire was administered to the patient and the attending nurse. Results 36 patients had bronchoscopy in the semi-recumbent posture and 33 in the supine posture. Three of 5 bronchoscopists performed in both postures. There were no signifi cant differences in age, gender, smoking status and spirometry between the two groups. The semi-recumbent postures resulted in signifi cantly less cough rate (mean (SD) 3.6 (2.3) vs. 6.3 (4.8) coughs/min, p = 0.004) and less fentanyl use (60 (16) vs. 76 (22) mcg, p = 0.001) in the initial phase. There were no signifi cant differences in the nadir SpO2, fall in SpO2, oxygen supplementation or increase in pulse rate between the two groups. Nurse perception of patient discomfort was lower in the semirecumbent position (23 (21) vs. 39 (28) mm on 100 mm visual analogue scale, p = 0.01), and there was a trend towards less patient-perceived cough during the procedure in the semi-recumbent group (28 (25) Introduction Pulmonary infi ltrates in immunocompromised patients with haematological malignancy have a diverse aetiology and are a major source of morbidity. A specifi c diagnosis and targeted therapy may optimize outcomes and reduce the cost of treatment. The diagnostic value of fi breoptic bronchoscopy (FOB) and the infl uence of timing of the procedure are unclear. Aim To determine the yield of FOB, its impact on antibiotic therapy and the infl uence of early vs late timing in this patient population. Methods We conducted a retrospective review of immunosuppressed patients with underlying haematological malignancy and new pulmonary infi ltrates who underwent FOB over a 30-month period. The outcomes of early (EB, ≤2 days from initial respiratory consultation) and late (LB, ≥3 days) FOB were compared using Fisher's exact test. Results Thirty-eight FOBs, including 6 bronchial or transbronchial biopsies, were performed in 33 patients (males 21). There were 19 patients who received EB and 19 who received LB. A specifi c diagnosis was obtained from 13 procedures (34%), including 11 infections (6 in EB vs. 5 in LB, p = 1.0) and 4 non-infective diagnoses (1 EB vs. 3 LB, p = 0.6) based on histology. FOB fi ndings from 17 procedures (45%) (11 EB vs. 6 LB, p = 0.2) resulted in modifi cation of antibiotic therapy. There were no procedure-related severe complications. Conclusions FOB is a useful diagnostic procedure which infl uences diagnostic and therapeutic decisions in this patient group. Although early procedures tended to be more likely to change antibiotic therapy than late procedures, the difference was not signifi cant. Confl ict of Interest None.

Capsule endoscopy is increasingly performed in gastroenterology to investigate possible small intestinal bleeding. The capsule endoscope is swallowed and then takes photographs every 4 seconds for 8 hours during its transit through the gastrointestinal tract. The images are downloaded by a radio link and the capsule is then passed normally and disposed of. In the present case, the capsule endoscope was inhaled and lodged in the bronchus intermedius. This was only recognized when the images from the capsule download were examined. Removal of the capsule was effected with a fi breoptic bronchoscope using an ERCP balloon and Roth basket. This is believed the only capsule bronchoscopy so far reported. Capsule endoscopes are large (23 mm × 11 mm diameter) and smooth. This case report shows the images from the capsule endoscope and describes the methods necessary to remove this unusual foreign body from the lung. Support Nil. Background Bronchoscopy with endobronchial biopsy (EB) is now an integral component of the research evaluation of airway diseases. There are no published safety data for EB in adult non-CF bronchiectasis. Methods A subgroup of subjects enrolled in the Bronchiectasis and Low Dose Erythromycin Study (BLESS) a randomized controlled trial of long-term prophylactic erythromycin (ANZCTRN12608000460303) underwent bronchoscopy with bronchoalveolar lavage (BAL) and EB performed by a single operator. Results Ninety-nine bronchoscopies were performed (BAL alone in 10) in 41 subjects. Of 89 procedures with EB, 4 (4.5%) were associated with very signifi cant bleeding (>100 mL either at time of EB or several days post-procedure) and a further 3 (3.4%) with immediate moderate bleeding (25-50 mL). One subject had a history of prior signifi cant haemoptysis. In the four subjects with very signifi cant bleeding, immediate bleeding of >150 mL occurred in 2 subjects, 40 mL in one subject and 25 mL in one. Immediate bleeding was controlled uneventfully. Three of the 4 subjects subsequently developed signifi cant haemoptysis (>100 mL) 4 to 6 days post-bronchoscopy without intervening haemoptysis, with one subject developing massive haemoptysis (>300 mL) on day 4 post-bronchoscopy. Further research EBs were ceased. In one of the 3 subjects with 'delayed rebleeding', repeat bronchoscopy confi rmed the biopsied lobe as the bleeding site. Haemoptysis settled in all 3 subjects within 36 hours with simple conservative measures. Conclusions In contrast to the experience in asthma and COPD, research EB in adults with non-CF bronchiectasis is associated with a signifi cant risk of bleeding, of potentially life-threatening magnitude in 4.5% of cases. Of particular concern was the observation of sudden onset delayed rebleeding developing up to 6 days post-EB in spite of early local control. Histopathological evaluation will clarify the potential contributions of airway wall vascularity and infl ammation to these events. Malignant mesothelioma (MM) is an aggressive cancer which is often associated with exposure to asbestos and SV40. This disease has a high latency period and a low survival rate. Therefore, new strategies for therapeutic intervention must be developed. Recent studies have shown that developmental pathways including the Hedgehog (HH) pathway are associated with various types of cancers. The aberrant activation of key Hedgehog pathway proteins has been shown to contribute to cancer progression. However, the role of this pathway in MM has yet to be explored. We hypothesize that aberrant activation of the HH pathway is a contributing factor for the development of MM. The mRNA expression of HH pathway genes; Sonic Hedgehog (SHH), Patched -1 (PTCH-1), Smoothened (SMO) and GLI-1 were examined in MM cell lines and tumour tissues by RT-PCR and qRT-PCR. HH pathway proteins and mRNA expression and distribution were then observed in the tumours by immunochistochemistry and in situ hybridization. We used real-time superarrays to examine the change in expression of a panel of key HH pathway genes by activating and inhibiting the pathway. We showed that the key HH pathway genes are expressed in both the cell lines and tissue samples. Upon stimulation with the ligand SHH, there was an increase in expression of Indian Hedgehog (IHH) and SHH in most of the mouse and human cell lines that we looked at. Interestingly, for the transcription factor GLI-2, there was a significant decrease in both mouse and human cell lines. Inhibiting this pathway increased the expression of PTCH in the mouse and human cell lines. The expression and up-regulation of key HH pathway components in MM at baseline and following stimulation suggests a role for the pathway in MM. Methods Incident cases were obtained from the Australian and WA Mesothelioma and Cancer Registries and Death Registries. Exposure was calculated using measures of dustiness in the industry and the town for the period of employment or residence of each case. Latency (time from fi rst exposure to diagnosis) by sex, age, smoking status, exposure variables and worker or resident status was estimated. Multivariate linear regression modelling examined the determinants of latency. Results The mean latency periods of 32.4 (SD = 11.4) years for LC and 36.8 (SD = 9.2) years for MM have increased linearly. Increased duration of exposure was associated with reduced latency for MM after adjustment for age at fi rst exposure and age at diagnosis but not signifi cantly for LC. Age at diagnosis was strongly associated with latency length for both LC and MM (p < 0.001). Smoking, sex, cumulative exposure (log f/mL-year) and status at Wittenoom were not related to latency. Latency for LC with increasing age at fi rst exposure declined faster than for MM. Conclusions Age at diagnosis is associated with reduced shorter latency of MM and LC. Duration of exposure is associated with shorter latency of MM. Supported by NHMRC Australia. Confl ict of Interest No.

Aim To assess overall survival of patients following resection for Stage 1 NSCLC at a centre that has substantially greater resection rates than the NSW average. Methods A retrospective audit of those patients who underwent lung resection for Stage 1 NSCLC at Nepean Hospital between January 2005 and February 2008. Results 57 patients (33M:24F), mean age 68 (range 51-85) underwent resection. There were 2 pneumonectomies, 2 bilobectomies and 9 segmentectomies, one involving chest wall resection. The remaining procedures were lobectomies. There was one perioperative death from respiratory failure. Actuarial overall survival at 12 months was 84%, at 24 months, 76% and at 5 years 47%. Survival was not infl uenced by histology or age. Conclusion In our institution, we have an agreed aggressive approach to resection of Stage 1 NSCLC and our resection rate is 87%. This pro-surgical policy is associated with good perioperative and long-term overall survival. Confl ict of Interest No.

Introduction Malignant pleural effusions (MPEs) are common, although their management varies widely. Providing ambulatory care to minimize hospitalization is a key goal for patients with MPEs. Indwelling pleural catheters (IPCs) are a new treatment strategy that allows outpatient fl uid drainage. We hypothesized that MPE patients managed with IPCs require fewer hospital admissions. Methods A prospective, multicentre, non-randomized study involving all three major respiratory centres in Western Australia. Patients diagnosed to have MPEs were prospectively followed, and admissions were recorded. In the absence of accepted guidelines for IPC use, the choice of treatments (thoracentesis, IPC, pleurodesis) was decided by clinicians in-charge. All complications were recorded. Bacterial cultures of pleural fl uid were performed monthly for patients with IPCs. 

HM GALLAGHER 1 , EE DUHIG 2 , IA YANG 1 , RV BOWMAN 1 , BE CLARK 2 , HM MARSHALL 1 , KM FONG 1

Aim To determine the concordance of histological subtyping of NSCLC in diagnostic samples to the gold-standard lung resection specimens. Methods We have so far evaluated 301 consecutive subjects who underwent curative surgery for primary NSCLC at The Prince Charles Hospital between the years 2006 and 2010. Many of these had workup at other institutions. One hundred forty-seven had Queensland health electronic record of positive preoperative diagnostic sampling. We correlated the fi nal NSCLC WHO histological subtype with the subtypes diagnosed by samples prior to surgery including sputum, fi beroptic bronchoscopy (FOB) and trans-thoracic needle aspiration (TTNA). The resection subtype was set as the reference standard, and concordance was compared. Results Of the 301 cases of resected NSCLC, 147 had malignancy on diagnostic sampling pre-resection, as shown in the Results 159 patients were included: median age 71 years (range 45-91); 93% male; 65% living in major cities versus 35% in regional areas; 62% rightsided MPM; 60% epithelial subtype. Median time from asbestos exposure to diagnosis was 51 years (range 11-72). Median time from fi rst symptoms or investigations to diagnosis was 6 weeks (range 0-140). All patients had at least one chest X-ray and CT scan and 18% had PET scan. A variety of procedures led to the diagnosis: 75% thoracoscopy, 15% thoracotomy, 4% radiology-guided, 2% chest wall biopsy and 2% medical pleuroscopy, with 4% having had cytology alone. Median number of diagnostic immunohistochemical stains used was 7 (range 0-18), with calretinin (94%) the most commonly used mesothelial marker and carcinoembryonic antigen (CEA; 72%) the most common carcinoma marker. Median OS for the cohort was 11.7 months (95% CI: 9.1-14.2), with no statistical difference in OS between major city and regional patients (11 vs. 12.5 months, respectively, p = 0.35).

Conclusions MPM appeared to affect mainly the elderly, and thoracoscopy was the most common diagnostic procedure. OS did not differ between Australian major city and regional patients and was comparable to the largest phase III trial in MPM.

AW MUSK 1,2 , P ABOAGYE-SCARFO 1 , A REID 1, 4 

A MILLER, S RUWANPURA, L MCLEOD, P BARDIN, N WATKINS, BJ JENKINS

Rationale Lung cancer is the leading cause of cancer death worldwide. It is well established that cigarette smoking is linked to emphysema and lung cancer, and smokers with emphysema are at an increased risk of developing lung cancer. Notably, recent epidemiological studies have indicated that emphysema can predispose to lung cancer irrespective of pack-year smoking history. Although infl ammation has been proposed as a common mechanism linking these two diametrically opposed diseases, the conceptual inter-relationship between infl ammation, emphysema and lung cancer has been poorly investigated because existing experimentally induced and genetically modifi ed animal models for lung cancer occur in the absence of emphysema. Method We have utilized a newly identifi ed mouse model (gp130 F/F ) of spontaneous lung infl ammation and emphysema in two well-established lung cancer models. The gp130 F/F mouse is characterized by deregulated cytokine signalling via gp130, the critical co-receptor for the interleukin (IL)-6 cytokine family, leading to hyper-activation of STAT3, a potent pro-infl ammatory and oncogenic latent transcription factor. In 2 separate studies, we exposed gp130 F/F mice to a cigarette-derived carcinogen (NNK), and crossed them with the genetically susceptible KRas(G12D) strain of mice.

Results In both NNK-and KRas(G12D)-induced lung cancer models, the lungs of gp130 F/F mice were highly predisposed to hyperplasia and tumour formation. Increased levels of cellular proliferation were observed in hyperplastic and tumour lesions, as well as surrounding areas, of these mice. These observations were verifi ed at the molecular level by gene expression profi ling of tumour-bearing lung tissue. Conclusions These studies provide unique insights into the importance of interactions between the gp130 signalling axis and factors that predispose to lung tumourigenesis in emphysema. Support NHMRC. 

Aim To assess the preparedness of hospitals with respect to protecting health-care workers (HCWs) during a pandemic. Methods A self-administered questionnaire was performed between November 2009 and January 2010, and a scoring system was developed to provide a quantifi able measure of preparedness. Results A total of 12 hospitals in NSW, Australia, were approached -six regional hospitals (RHs) and six tertiary referral centres (TRCs). The study was extended to assess three hospitals in England, allowing a limited comparison between the hospitals in Australia that had faced the initial wave of the H1N1 ('swine fl u') pandemic and the hospitals in the UK that had more time to prepare for the outbreak. Response rates were 66% from the TRCs, 33% from the RHs and 100% from the English hospitals. The overall preparedness scores were relatively high, with a median total score (adjusted) of 50.75 out of 70. The demographic that scored the highest Total was tertiary referral centres in Sydney. All English hospitals scored below the median. However, the range of scores across hospitals was quite narrow (45.1-57.1 adjusted). Scores were generally high for the areas of Preparedness, Infection control, Education and Training. Scores for Vaccination were more variable. The category that consistently demonstrated the lowest scores was that of Psychosocial Welfare and Assistance, despite this found in previous research to be an integral part of that which HCWs have identifi ed as important.

Conclusions Given their integral role in pandemic response, protecting HCWs must be a priority as part of any pandemic preparedness plan. This goes beyond protection from infection, extending into aspects of physical and psychological wellbeing. Identifying these issues and addressing them is the key to maximizing staff support and morale, and minimizing staff absenteeism at such a crucial time. 

Aim To describe the relationship of respiratory and refl ux symptoms within the general population and relate this to the possible confounding factors of body mass index (BMI) and obstructive sleep apnoea (OSA). Methods Data from a cross-sectional health survey, performed in Bussleton, West Australia in 2005-2007, were used to examine the relative effects of BMI and OSA on the relationship between respiratory and refl ux symptoms. Questionnaire data included information on asthma, cough, wheeze, dyspnoea and GORD symptoms. GORD symptoms were categorized as never, monthly or less often and weekly or more often. BMI, risk of OSA defi ned according to the Berlin questionnaire, spirometry and airway hyperresponsiveness to methacholine were also recorded. Logistic regression models obtained odds ratios for the associations between each GORD symptoms, various respiratory symptoms, BMI and OSA. Results Average age was 55 years and recent wheeze was reported in 23% and cough and phlegm in 23%. Twelve percent were current smokers. AHR was present in 12% and OSA in 23%. GORD symptoms occured in 50% and frequent symptoms (weekly or more often) were present in 5-10%. There were strong positive associations between GORD symptoms and cough/phlegm, breathlessness, chest tightness and wheeze in the last 12 months. Odds ratios increased with increasing frequency of refl ux p ≤ 0.001. There was no effect of obesity or OSA on the relationship between respiratory and GORD. Conclusion Cough and phlegm, breathlessness, chest tightness and wheeze (ever or recent) are all strongly associated with symptoms of GORD. This relationship is amplifi ed with increasing frequency of GORD symptoms indicating a dose-response relationship between refl ux and respiratory symptoms. Obesity and OSA do not affect the association between GORD and respiratory symptoms. Introduction Diesel exhaust particles (DEP) make up the bulk of particulate matter in urban areas. High ambient levels of particulate matter are associated with increased hospitalization due to respiratory disease. We aimed to determine if exposure to DEP exacerbates responses to acute viral infection. Methods Adult female BALB/c mice were inoculated with 100 μg DEP or control 3.75 days after infection with 10 4.5 plaque forming units (pfu) of infl uenza A/Mem71 (or control). Six hours after DEP inoculation, lung volume (TGV) and lung mechanics were measured by plethysmography and the forced oscillation technique, respectively. Bronchoalveolar lavage fl uid was collected to assess cellular infl ammation and cytokine levels.

Results Viral titre was signifi cantly higher in infl uenza-infected mice exposed to DEP compared to those exposed to infl uenza alone (p = 0.04). Both DEP (p = 0.03) and infl uenza infection (p < 0.001) alone signifi cantly increased cellular infl ammation; however, there was no difference between mice exposed to both DEP and infl uenza compared to those exposed to infl uenza alone (p = 0.42). A similar pattern was found in levels of cytokines in the bronchoalveolar lavage (TNF-α, MCP-1, IL-6, IFN-γ). Specifi c airway resistance, specifi c tissue damping, specifi c tissue elastance and hysteresivity were signifi cantly increased in infl uenza infected mice (p < 0.001 in all cases). None of these parameters were infl uenced by DEP exposure alone (p > 0.33 in all cases) and there was no additive effect of DEP on lung function (p > 0.22 in all cases) in infl uenza-infected mice. Conclusions DEP increases viral titre but is not suffi cient to physiologically exacerbate pre-existing respiratory disease caused by infl uenza infection in mice. Supported by NHMRC. Confl ict of Interest No. 

Introduction Lack of treatments for post-transplant obliterative bronchiolitis (OB) is mainly due to the poor understanding of its pathogenesis and lack of small airway models. Epithelial-mesenchymal transition (EMT) may play a central role and could be crucial to developing treatment drugs. We hypothesize that EMT induction may be prevented by pharmacologically available compounds.

Methods Primary cultures of small and large airway epithelial cells (SAEC and LAEC) were established and EMT induced by adding TGFβ1 (50 ng/mL) (n = 6). Azithromycin (1-100 μM), mycophenolate (0.05-5 mg/L) and RAD001 (0.01-1 ng/L) were then added and expression of epithelial (ZO-1, Ck-19) and mesenchymal markers (Eda-Fn, Vim) measured via Western blot as well as MMP 2 and 9 activity via zymography.

Results Signifi cantly lower increase in mesenchymal markers and lower decrease in epithelial markers, compared to controls was noted for azithromycin and mycophenolate indicating suppression of EMT. MMP 2 and 9 activity increase was also signifi cantly suppressed. Azithromycin suppressed EMT to a greater extent compared to mycophenolate, but was equally effective in both small and large airway epithelia. RAD001 appeared to have no effect.

Conclusions Azithromycin and mycophenolate are both effective in preventing EMT and thus have potential for the clinical treatment of OB. Supported by ABN Foundation. Confl ict of Interest None.

Journal Compilation © 2011 Asian Pacifi c Society of Respirology TP-120

G HODGE 1,2 , S HODGE 1,2 , C-L LIEW 1, 2, 3 T-cell pro-infl ammatory cytokines are associated with acute lung transplant rejection. We have previously shown compartmentalization of production of these cytokines in bronchial intraepithelial T cells (IET) obtained by bronchial brushings from stable lung transplant patients. During acute rejection episodes, no signifi cant differences in IET cytokines were observed between stable and rejecting patients due to broad cytokine variability between patient groups. To overcome this limitation, we hypothesized that there would be increased graft pro-infl ammatory IET cytokines compared with native lung or trachea during acute rejection. Methods Cell cultures from stable patients, patients with evidence of acute rejection and BOS and healthy controls were stimulated and intracellular cytokines determined using multiparameter fl ow cytometry. Results There was a signifi cant increase in graft IET-cell IFNγ and TNFα in the lungs of patients with acute rejection compared with IET cells obtained from the native lung or trachea, but no changes were noted between other patient groups. There was a signifi cant correlation between increased graft IET-cell TNFα compared with trachea and lungs and acute rejection grade. Conclusions Differential expression of pro-infl ammatory cytokines by IET cells from graft, trachea or native lung distinguishes severity of acute rejection. Improved monitoring response using this assay or therapeutic targeting of these pro-infl ammatory cytokines may reduce acute lung transplant rejection. Supported by NHMRC.

Aim To determine the prevalence of reduced carbon monoxide transfer factor (DLCO ≤70% predicted) in subjects undergoing pulmonary function testing (PFTs) and to determine whether a cause has been identifi ed. Methods A clinical audit of all subjects undergoing PFTs at Royal Melbourne Hospital from 1 August 2007 to 31 August 2009 who have a DLCO ≤70% in the setting of normal spirometry. Medical records and investigations including transthoracic echocardiogram (TTE), high-resolution commuted tomography (HRCT), ventilation/perfusion (V/Q) scans were reviewed to determine whether a cause for the reduced DLCO was established. Where a cause was not clear, subjects were invited to participate in a telephone interview to evaluate symptoms and to undergo repeat PFTs. Subjects with a persistently reduced DLCO were invited to undergo further investigation with TTE, HRCT and V/Q scan. Preliminary Results PFT results from 2412 subjects were reviewed. Subjects with FEV 1 /FVC < 70, FEV 1 < 80% predicted and FVC < 80% predicted were excluded. Three hundred seventy subjects (15%) had an isolated reduction in DLCO. 149/370 (40%) of these subjects underwent TTE with 34/149 (23%) demonstrating an elevated right ventricular systolic pressure (RVSP). In all cases where there was an elevated RVSP an identifi able cause was found. 8/34 (24%) of these subjects subsequently identifi ed as having Pulmonary Arterial Hypertension (PAH) and commenced appropriate therapy and 7/34 (21%) identifi ed as having PAH where treatment was not commenced. There were 221/370 (60%) of subjects who appeared not to have undergone a TTE. Further evaluation of medical records of subjects who had not undergone TTE and those with normal TTE is continuing. Review of subjects HRCT, V/Q scans and right heart catheterizations is currently proceeding. Conclusions Preliminary results suggest that a signifi cant proportion of subjects with isolated reduction of DLCO on PFTs do not undergo TTE which is an important investigation in determining the cause for the reduced DLCO. When a TTE is performed and demonstrates an elevated RVSP, a cause for the elevated RVSP is identifi ed. Sponsor Actelion Pharmaceuticals Australia Pty Ltd.

G HODGE 1,2 , S HODGE 1,2 , C-L LIEW 1,2,3 , PN REYNOLDS 1,2 , M HOLMES 1,2,3

Background T-cell pro-infl ammatory mediators are associated with acute lung transplant rejection. We have previously shown that BOS was associated with lack of immunosuppression of T-cell pro-infl ammatory cytokines and increased T-cell granzyme B in peripheral blood. Recently, we also showed that NKT-like cells are a major source of pro-infl ammatory cytokines and granzymes in the blood of stable lung transplant patients. We hypothesized that BOS may be associated with lack of immunosuppression of these proinfl ammatory mediators in blood NK and NKT-like cells. Method Granzyme/perforin profi les from stable patients, patients with evidence of BOS and healthy controls were determined and blood cultures stimulated and intracellular cytokines determined using multiparameter fl ow cytometry. Results There was a signifi cant increase in the percentage of NK cells expressing granzymes and perforin in BOS patients compared with stable patients and controls. There was an increase in the percentage of T, NK and NKT-like cells producing IFNγ and TNFα in BOS compared with stable patients. There was a signifi cant correlation between increased NK IFNγ and TNFα and FEV 1 . Conclusions BOS is associated with increased peripheral blood NKT-like and NK cell granzymes, perforin and Th1 pro-infl ammatory cytokines. Therapeutic targeting of these pro-infl ammatory mediators and monitoring response using this assay may reduce BOS. Supported by NHMRC. Confl ict of Interest Nil.

Rationale Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world. Consequently accurate diagnosis of PE is critical. This must be tempered by the potential radiation risk of investigations to the mother and foetus. We performed a retrospective case review to determine the incidence of PE in pregnant patients investigated for this condition. Demographic information, the diagnostic algorithm utilized and the diagnostic yield of investigations were obtained. Method Pregnant women who underwent Ventilation Perfusion (VQ) scanning or Computed Tomography Pulmonary Angiogram (CTPA) at our institution between January 2005 and January 2010 were identifi ed by an internal database audit. In addition to demographic data, information about the diagnostic pathway and fi nal diagnosis were collected. In cases where PE was not diagnosed, the medical records were reviewed for any subsequent events up until the date of delivery. Results During the fi ve-year period, 28 VQ scans and 20 CTPAs were performed on 46 pregnant women. The average gestation at investigation was 26 weeks. Only one patient had a previous history of venous thrombo-embolism. 50% underwent Doppler ultrasound of the lower limbs prior to VQ or CTPA. Overall the incidence of PE was 2%, diagnosed by VQ scan. Otherwise the VQ scans were normal in 46%, low probability in 42% and non-diagnostic in 8% cases. CTPA was non-diagnostic in 2% of cases. All other CTPA studies demonstrated no emboli. Almost 50% of scans were done after hours (50% VQ and 40% CTPA). No patients without PE were felt to have had the PE missed up to the time of delivery. Conclusions The overall incidence of PE in patients being investigated was extremely low at 2%. During this study period slightly more VQ studies were performed than CTPAs, with each test having similar diagnostic rates. Only 50% of patients had undergone venous Doppler prior to undergoing radiationexposing investigations. Nomination Nil.

Introduction Anti-Ro-52 antibodies have been associated with idiopathic interstitial pneumonia (IIP) in one small series (n = 4). We hypothesize that Ro-52 antibodies, just like myositis antibodies, can serve as a marker of undifferentiated connective tissue disease (CTD) with interstitial pneumonia as the primary phenotypic manifestation. The aim of this study was to examine the characteristics of patients with Ro-52 and IIP. Methods Retrospective study identifying patients with IIP and Ro-52 positivity, but negative for CTD and/or myositis antibodies, presenting between June 2005 and June 2010. Data relating to demographics, diagnosis, pulmonary function tests, length of follow-up and outcome were obtained. All HRCT images were reviewed by an independent expert radiologist (DM). Results 10/17 Ro-52 positive subjects fulfi lled criteria (7 male, median age 64 (39-83), 8 European, 5 never smoked). 8/10 had Ro-52 titers above 40 and 2 in the intermediate (30-40) range. Three patients had Raynauds phenomenon; there were no other CTD features. 7/10 patients had HRCT diagnosis of NSIP and 3/10 organizing pneumonia; 7/10 had extensive fi brosis. Mean (SD) % predicted baseline FVC 66 (20), DLCO 46(16). Median length of follow-up was 29 months. All patients were treated and 8 were considered overall stable at last follow-up, one had declined and one died of respiratory failure. Conclusion This study confi rms an association between Ro-52 positivity and interstitial pneumonia in the absence of defi ned connective tissue disease, suggesting an autoimmune basis for the interstitial lung disease in this group of patients. A larger cohort is required to determine the true signifi cance of this observation.

Background Community acquired respiratory viral (CARV) infections are believed to contribute to morbidity and mortality after lung transplantation, but previous studies have not conclusively established the evidence base in this area. Patients and Methods A prospective cohort study was performed at a single centre from August 1998 to March 2010 (n = 201 lung transplant recipients). CARV infection (human metapneumovirus (hMPV), respiratory syncytial virus (RSV), infl uenza A (Flu A), infl uenza B (Flu B), adenovirus and parainfl uenza virus (PIV)) was confi rmed using polymerase chain reaction (PCR) of upper (nasopharangeal swab) and/or lower (bronchoalveolar lavage) respiratory tract secretions. CARV infection and BOS were included as segmented time-dependent covariates in a Cox proportional hazards model with death as the outcome variable.

Results 87 patients (43% of the total cohort) had a total of 147 separate CARV episodes: 42 PIV, 26 hMPV, 37 RSV, 26 Flu A, 10 Flu B, and 6 adenovirus. Infection with either RSV or hMPV was associated with an increased risk of death (p < 0.001 HR 3.6, 95% confi dence interval, 1.86-6.98), and the effect persisted after multivariate analysis. BOS was also a risk factor for acquiring hMPV or RSV infection (p = 0.023 OR 2.13, 95% confi dence interval, 1.11-4.11 ). Conclusions Infections with hMPV and RSV, but not other CARVs, are associated with an increased likelihood of death. The presence of BOS is a risk factor for symptomatic infection with hMPV and RSV.

NS HARUN 1 , K SANDERS 2 , A STUART 2 , CL STEINFORT 1 1 Department of Respiratory Medicine, Barwon Health, Vic., Australia, and 2 Department of Clinical and Biomedical Sciences, Barwon Health, Vic., Australia Aims Nebulized colistin is used to treat recurrent exacerbations of bronchiectasis due to Pseudomonas aeruginosa, a major pathogen regarded as diffi cult to eradicate. This case-control study aimed to establish if long-term colistin use could clear P. aeruginosa from the sputum of adults with non-cystic fi brosis bronchiectasis, and if so, whether colistin could be ceased in these patients. Secondary outcomes included effects of colistin on quality of life (QoL), symptom control, admission rates, lung function and tolerability. Methods (1) Sputum was collected in 42 bronchiectasis patients with P. aeruginosa. Clearance rates in those on colistin were compared with a control group not on colistin. (2) Colistin patients cleared of P. aeruginosa ceased treatment. Sputum was re-cultured at day 7 and 28 to detect recurrence. (3) A questionnaire assessing QoL, symptom control, and admission rates was performed on 32 patients. Outcomes were compared before and after colistin use. Long-term colistin side-effects and lung function were also assessed. Results (1) 58% (n = 14/24) of colistin patients cleared P. aeruginosa from sputum compared with 44% (n = 8/18) in the controls (p = 0.372). (2) 38% (n = 3/8) of patients ceasing colistin remained free of P. aeruginosa at day 28.

(3) There was no difference in frequency of breathlessness, sputum production or QoL scores between the groups (p > 0.05). The colistin group had lower FVC (1.46 vs. 2.26L, p = 0.023) and higher admission rates (42% vs. 12%, p = 0.049). On colistin, 69% of patients reported reduction in sputum frequency, breathlessness and improvement in QoL. Fifty percent reported decreased admission rates. There were no colistin side effects. Conclusions Clearance of P. aeruginosa in sputum is possible. Clearance rates were similar in those with more severe bronchiectasis treated with colistin compared with stable patients not on colistin, and may suggest suppression of P. aeruginosa by colistin in this severe group. There are benefi ts of colistin on QoL, symptom control and admission rates. Continued sputum clearance after colistin cessation is achievable in some patients. Nebulized colistin use is well tolerated. Nomination Janet Elder Travel Award. Confl ict of Interest No. However, use of such agents is suboptimal in hospital patients. This study aims to determine whether a dedicated multidisciplinary education and reinforcement program improves the use of appropriate VTE prophylaxis. Methods Prior to the education programme, we audited a 30 bed general thoracic medical ward including patients with general medical conditions, lung cancer, chronic obstructive pulmonary disease, lung transplant and Cystic Fibrosis. Our multidisciplinary research team developed and implemented an education program over 3 months, using posters, leafl ets and oral presentations to increase awareness and promote adherence to VTE prophylaxis guidelines for health care staff involved in direct patient management. Following completion of the program, we reaudited the same 30 bed ward. Results Prior to the education program, a total of 21 patients (mean age 60 ± 10) were identifi ed as appropriate for VTE prophylaxis. Of these 14 (66%) were on appropriate VTE prophylaxis. The post education audit showed 22 out of 23 (96%) patients were on appropriate VTE prophylaxis. (p = 0.013). Conclusion An effective multi-faceted educational program can improve delivery of appropriate VTE prophylaxis, leading to improved outcomes in hospitalized patients. Supported by Sanofi Aventis. Confl ict of Interest Nil.

The anti-rheumatic anti-infl ammatory biological agents in clinical use are abatacept, anakinra, adalimumab, etanercept, infl iximab and rituximab. A variety of pulmonary side-effects have recently been reported for these agents and the purpose of this review is to compile the various reported pulmonary toxicities and their prevalence Methods We performed a search of databases OVID MEDLINE® and EMBASE of the English literature up to August 2010 using the MESH terms of abatacept, anakinra, rituximab, adalimumab, etanercept, infl iximab and respiratory tract disease with limits to include only human studies or case reports. In addition case reports of respiratory adverse effects reported to the Australian Drug Reaction Advisory Committee (ADRAC) were obtained in order to identify the most common pulmonary reactions reported with each individual agent. Results Using the search criteria defi ned above 110 and 237 articles were identifi ed in the OVID MEDLINE and EMBASE database respectively. The majority of ADRAC reports were associated with rituximab (n = 108) and infliximab (n = 107), followed by adalimumab (n = 43) and etanercept (n = 43). Various pulmonary side-effects including interstitial lung disease associated with anti-infl ammatory agents were identifi ed. Discussion From the articles reviewed, details about the duration between onset of treatment and incidence of pulmonary side effects, diagnosis, treatment options and outcome of patients were extracted and are presented here. Conclusion This comprehensive systematic review hopes to improve the awareness about the serious and potentially life-threatening pulmonary sideeffects of this group of agents. Confl ict of Interest No.

SJ SIMPSON 1 , PD SLY 1 , P FRANKLIN 2 , E LOMBARDI 3 , C CALOGERO 3 , M PALUMBO 4 , GL HALL 1, 5 Introduction The forced oscillation technique (FOT) is effort independent and thus ideal for young children. The area under the reactance curve (AX) has been proposed to amplify clinically relevant signal by taking advantage of any shape change in the reactance (Xrs) curve below the resonant frequency. This study aimed to develop reference values for resistance (Rrs), Xrs and AX in a large healthy population of children, and determine if AX conferred any additional clinical benefi t when examining disease in children born preterm. Methods Impedance spectra were obtained in 760 healthy children (335 male), aged less than 13 years and with height less than 160 cm using a commercial device (I2M, Chess Medical, Belgium). AX was calculated in 647 of these children between 6 Hz and the resonant frequency. Backwards stepwise linear regressions identifi ed the best predictors of AX, and Xrs and Rrs at 8 Hz (Xrs 8 , Rrs 8 ), and Z scores were generated. Z scores were calculated for 156 children born preterm, of which 87 received a neonatal diagnosis of bronchopulmonary dysplasia (BPD). Chi squared tests examined the difference in proportion of children born preterm (with and without BPD) with abnormal Z scores for each FOT variable. Results All FOT variables were predicted by height (p < 0.001) and sex. Mean (SD) Z scores for preterm children with and without BPD for Rrs 8 (0.59 (0.88); 0.58 (1.03)), Xrs 8 (1.05 (0.68); 0.61 (0.82)) and AX (0.84 (0.70); 0.51 (0.98)) were all signifi cantly different (p < 0.001) from the healthy population. The number of children born preterm with abnormal Z scores was not significantly different when comparing AX, Rrs 8 and Xrs 8 . Conclusions While AX is able to detect respiratory disease in preterm children with and without BPD, it is no more sensitive than Xrs or Rrs. Supported by PMH Foundation, NHMRC, Asthma Foundation WA, CaRiVit, NGO 'Solidarietà e Servizio' Viterbo. Confl ict of Interest No.

Introduction Survivors of preterm birth born with bronchopulmonary dysplasia (BPD) in the pre-surfactant era of neonatal care (classical BPD) have a reduced pulmonary gas transfer capacity. There is, however, little data to describe gas transfer in preterm infants with BPD in the post-surfactant era (new BPD). Objective Assess gas transfer using carbon monoxide diffusing capacity (DL CO ) and its components, pulmonary capillary blood volume (Vc) and pulmonary membrane diffusion (D M ), in contemporary survivors of preterm birth. Method Gas transfer was assessed using single-breath DL CO in children aged 9 to 11 years and born <32 weeks gestation with BPD (PB, n = 15) and without BPD (PT, n = 20), and in term born controls (TC, n = 27). DL CO Z scores were calculated. D M and Vc were determined in 12 PB, 12 PT and 25 TC children.

The mean (SD) DL CO Z score for the PB group was −0.58 (0.89) differing signifi cantly from 0 (p = 0.03) while the PT and TC groups (0.01 (1.02) and −0.12 (0.94), respectively) did not (p > 0.05). D M was lower in the PB group than the PT and TC groups, with no difference between PT and TC groups. Differences in D M were not signifi cant after adjusting for lung size. There were no differences in Vc between groups. Conclusion Gas transfer is reduced in survivors of preterm birth with new BPD. The tendency for reduced D M and not Vc in children with new BPD suggests that impaired gas transfer may be a result of alterations in the alveolar membrane rather than pulmonary vascular function. Background Bronchiectasis is common in indigenous populations such as Alaska Natives, Australian Aboriginal, and New Zealand Maori and Pacifi ca. As part of an international collaborative interventional study, we sought the participation of Maori and Pacifi ca families -groups diffi cult to engage in research in the past. Aim To engage, enrol and retain children from Maori and Pacifi ca families from Auckland in a 2-year research study. Methods A randomized controlled trial to determine whether azithromycin is superior to placebo in reducing exacerbations seeking to enrol children aged 12 months to 8 years with bronchiectasis. The enrolment procedure was modifi ed to a process deemed more appropriate to these cultures: (1) Request to defer the decision of enrolment until the process had been completed. (2) A minimum of 3 meetings; initial invitation, discussion in the home with the extended family, invitation to the extended family to participate in the day of enrolment. (3) Appointment of a 'whanau worker' (family worker) to sit with the family and empower them to get all the information they seek prior to enrolment. Results Of 39 families approached, 38 (97%) children (median age 5.4 years, range 0.8-8.9 years) enrolled with 26% Samoan, 23% Tongan, 16% Maori and 35% mixed Maori/Pacifi ca heritage. After 1-year retention was 34 (89%) with 1 exiting the study after 1 month with new non-pulmonary disease, and 3 exiting after 1 year, 2 moving outside study area. Conclusions These are high enrolment and retention fi gures reported in this population. We believe that following a prolonged procedure for enrolment, involving the extended family and appointing a worker to sit 'alongside' the family will improve their understanding of a research project and allow them to feel more comfortable about participating.

Aim Bronchiolitis is the most common reason for hospital admission for infants globally (1) . The use of macrolides for treating bronchiolitis in nonaffl uent settings remains controversial but potentially benefi cial. In our region readmission with lower respiratory illness in young children (particularly indigenous children) remains high. This RCT aims to determine if a single dose of azithromycin reduces the morbidity of young children with bronchiolitis. Methods Double blinded RCT. Young children ≤18 months admitted to Royal Darwin Hospital (RDH) diagnosed with bronchiolitis are eligible. Children are given a single dose (30 mg/kg) of either azithromycin/placebo. Primary outcome is length of stay for respiratory disease. Secondary outcomes are duration of oxygen use and readmission for respiratory illness in 6-month period. Respiratory viral infections often lead to exacerbations of chronic respiratory diseases such as asthma and COPD though there is no similar data in noncystic fi brosis (CF) bronchiectasis. The objectives of our study were to (1) determine the point prevalence and identify viruses associated with exacerbations and (2) evaluate clinical and investigational differences between viral infection positive and negative exacerbations in children with non-CF bronchiectasis. Methods A cohort of 69 children (median age 7 years; 33 boys) with non-CF bronchiectasis was prospectively followed for 900 child-months. Polymerase chain reaction for 16 respiratory viruses was performed on nasopharyngeal aspirates collected during 77 paediatric pulmonologist defi ned exacerbations. Data on clinical, parent cough-specifi c quality of life (PC-QOL), systemic markers (CRP, IL6, procalcitonin, amyloid-A, fi brinogen) and lung function parameters were also collected. Results Respiratory viruses were detected during 37(48%) exacerbations: picornavirus in 24 episodes [Human-rhinovirus (HRV) in 20, enterovirus in 4]; Human Bocavirus in 4; adenovirus, Human meta-pneumovirus, infl uenza A, respiratory syncytial virus, parainfl uenza 3 and 4 in two each; coronavirus and parainfl uenza 1 and 2 in one each. Viral co-detections occurred in 6(8%) exacerbations. Among 14 genotyped HRV's, more HRV-A's (n = 9) were identifi ed than HRV-C's (n = 2). Children with proven viral infections were more likely to have fever (OR 3.8, 95% CI 1.1-13.3), wheeze and/or crackles (OR 3.4, 95% CI 1.3-8.7) and raised CRP (OR 4.8, 95% CI 1.8-12.9) when compared with virus negative exacerbations. There were no other statistically signifi cant differences. Conclusions Respiratory viruses are commonly found during pulmonary exacerbations in children with non-CF bronchiectasis. HRV-A is the most frequently detected virus. Time sequenced cohort studies during stable state, exacerbations and recovery periods are needed to determine the importance of viral infections and their possible interaction with bacteria. Supported by ANZ Trustees scholarship. Confl ict of Interest None. Nominations None.

To date 58 children enrolled, 34% RSV+ve. Median age 5.7 months. Fifty percent have had at least one co-morbidity. Readmission rate = 18%. Conclusion Co-morbidities are high in this population. Antibiotics have the potential to help reduce the impact of additional respiratory burden.

Foundation. Introduction Foreign body inhalation is a relatively common presentation in young children, especially less than 3 years of age. Early recognition remains a critical factor in the treatment of foreign body inhalation in children. Inhaled foreign bodies in children are most often organic material, with seeds and peanuts being the most common items. On review of the literature, there are very few case reports of inhaled metal screws. We report two unusual cases of inhaled metal screws that presented to our service. Case Presentation Both cases presented to our emergency department with wheeze, respiratory distress and fever. Foreign body inhalation was not considered as a cause for their symptoms until the object was identifi ed on chest x-ray. Both foreign bodies were removed successfully but one child required invasive ventilation in our intensive care unit post removal. Both children made a full recovery. Interestingly, both metal screws came from fl at pack furniture purchased from a well known international home products store. Conclusion Foreign body inhalation must always be considered as a cause of respiratory distress in a child. With the increase in the number of fl at pack furniture in Australian home's, we believe parents must be warned of the potential danger of loose metal screws to young children. Supported by None.

Cough in children is a common symptom. Data on causes of chronic cough in young children have previously been published by our units. However, differences in underlying diagnosis by age at presentation have not been assessed. We present the 'time to cessation' of cough in our multicentre RCT using a standardized management algorithm in newly referred children with chronic cough (>4 weeks) from 7 Australian centres. Methods Parents completed validated cough diary and cough specifi c QOL (PC-QOL) at recruitment and at cessation of cough. The diagnosis made by the treating physician was based on 2006 TSANZ Position Statement.

Results The median (range) age of the 226 children recruited was 3.3 years (0.2-14.2); 131 (58%) were boys. Median (IQR) PC-QOL post treatment of 6.5 (5.1, 6.9) improved signifi cantly (p = 0.0001) from 3.8 (2.8, 5 .0) at enrolment. The median (IQR) duration of cough at recruitment was 16 weeks (8.0, 48.5) and 'time to cessation' of cough after application of the management algorithm was 3 weeks (1.0, 7.0). There was no signifi cant difference (p = 0.615) in median (IQR) 'time to cessation' of cough among the three age cohorts: <2 years (n = 74, 32.7%) was 2.5 weeks (0.8, 7.0); 2-6 years (n = 93, 41.2%) was 3 weeks (1.0, 7.0); and >6 years (n = 59, 26.1%) was 3 weeks (3.0, 7.0). There was also no signifi cant difference in the fi nal primary diagnosis among the three age cohorts (p = 0.09). The most common diagnoses were protracted bacterial bronchitis (n = 95, 42%), asthma/reactive airways disease (n = 38, 16.8%), tracheobronchomalacia (n = 17, 7.5%) and bronchiectasis (n = 16, 7.1%). 76 children (33.6%) had more than one diagnosis. Conclusions The aetiology and 'time to cessation' of chronic cough in children managed in accordance to a standardized pathway were similar among the three age groups. It is likely that our previous fi ndings in very young children are also applicable to older children. Supported by NHMRC grant number 490321. Confl ict of Interest None.

Aim To determine the role of fl exible bronchoscopy with bronchial alveolar lavage (BAL) in the management of patients with febrile neutropenia. Methods A retrospective analysis was made of the number of patients admitted with febrile neutropenia at a single institution who underwent bronchoscopy plus BAL from years 2004 to 2010. Computer database plus patient case notes were reviewed to establish clinical symptoms and signs, radiological fi ndings, antimicrobial treatment and mean duration to bronchoscopy following admission.

Results A total of 668 episodes of febrile neutropenia were recorded years 2004 to 2010. Seven patients (3 males and 4 females) were referred for bronchoscopy plus BAL. The mean age was 10.1 years (age range 4-14 years) and all had been diagnosed with acute lymphoblastic leukemia. All patients had at least cough as a clinical symptom along with radiological fi ndings. All patients had been on broad spectrum antibiotics at the time of bronchoscopy. The mean duration from admission to time of bronchoscopy was 216 hours (9 days) with a standard deviation of 139 hours. Of the seven patients one patient yielded a positive result on BAL. This did not result in a change in management as the patient improved clinically before the result of the BAL was confi rmed. Conclusion In this retrospective case series the diagnostic yield of fl exible bronchoscopy plus BAL in children with febrile neutropenia was low. Prospective studies plus early timing towards bronchoscopy and BAL should be conducted to further defi ne its role in the management of febrile neutropenic patients. Confl ict of Interest Nil. Methods Prospective cohort study involving monthly follow-up with caregivers. Two years post enrolment, children undergo clinical and lung function assessment (FOT). Presence of bronchiectasis is determined by physician review and radiological confi rmation (when indicated). The frequency of PBB episodes is recorded over the study period.

Of 166 children recruited to the cohort study to date, 64% (107/166) were male. The median age at recruitment was 23 months (IQR 12, 55). 80% of children had recurrent PBB. Of the 20 children who have had 2-year clinical follow-up, 9 were able to perform FOT and 22% (2/9) showed abnormalities (reactance above normal range.) 20% (4/20) with PBB have had subsequent physician diagnosis of bronchiectasis or CSLD. Conclusion The burden of cough in children with PBB 2 years after diagnosis remains high. Ongoing clinical follow-up of this cohort of children with PBB should provide further insight into the likelihood of progression from PBB to CSLD and bronchiectasis. Support Financial Markets Foundation for Children (for project), Allen & Hanburys and QCMRI (for DW), NHMRC (for JU and AC).

Introduction National Streptococcus pneumoniae (SP) serotype surveillance reports only culture positive cases from sterile sites but the yield from culture is low. Polymerase chain reaction (PCR) is more sensitive in detecting SP in culture negative samples. Aim To determine whether enhanced molecular surveillance in childhood empyema provides additional SP serotype information compared to national surveillance methods. Methods Pleural fl uid from children with empyema underwent culture and PCR to identify SP-targeting autolysin (lytA) and multiplex PCR to identify SP serotypes. National surveillance data were obtained from the National Notifiable Diseases Surveillance System (NNDSS) for the same time period and age groups.

Results Empyema: 89 children, 48 male, median age 3.5 (range 0.6-15.5) were recruited from 1 April 08 for 12 months. SP was cultured in 9/74 (12.2%) in blood and 5/84 (9.5%) in pleural fl uid. SP was identifi ed by PCR in 43/79 (54.4%). Serotypes: 1, n = 4 (8.9%); 3, n = 9 (22.2%); 19A, n = 12 (26.7%); 7F7A, n = 1 (2.2%); 9V/9A, n = 1 (2.2%); 22F/22A, n = 2 (4.4%); non-typeable, n = 4 (8.9%). One subject had 2 serotypes and in11 a serotype could not be established. NNDSS: 361 SP culture positive cases were reported. Serotypes: 1, n = 8 (2.2%); 3, n = 13 (3.6%); 19A, n = 131 (36.3%); 7F7A, n = 8 (2.2%); 9V/9A, n = 3 (0.8%); 22F/22A, n = 17 (4.7%); non-typeable, n = 30 (8.3%).

Other serotypes were reported in 151 SP positive cases. Signifi cant differences between empyema and NSDSS data were identifi ed for serotypes 1 (p < 0.05) and 3 (p < 0.005).

Conclusions The proportion of serotypes 1 and 3 were signifi cantly higher in empyema fl uid using PCR. This disease model provides additional serotype information to national surveillance data. This has important implications in monitoring replacement serotypes following the introduction of new vaccines. Funded by GlaxoSmithKline, Belgium.

H GIDDINGS 1 , L SECCOMBE 1 , P ROGERS 1 , A CORBETT 2 , E VEITCH 1

Recent theories on the pathophysiology of Parkinson's disease (PD) emphasize early brainstem involvement. Furthermore various respiratory function abnormalities have been reported without consistent pattern. We sought to study the effects of idiopathic PD on respiratory function and ventilatory response to hypercapnoea and hypoxia.

Methods Patients with a diagnosis of PD but no known respiratory disease were recruited. Subjects underwent lung function testing including respiratory muscle strength, ventilatory response to hypercapnoea (with central respiratory drive (P 100 )) and a hypoxic simulation (FIO 2 15% Cough is the most common symptom presenting to doctors. Paediatric cough is associated with signifi cant morbidity for both children and their parents. The symptom of cough is associated with airway hyper-reactivity and is a dominant symptom of airway infl ammation. Inhaled corticosteroids (ICS) can reduce airway infl ammation and hyper-reactivity. The objective of this review was to evaluate evidence for the effi cacy of ICS in reducing the severity of cough in children with sub-acute cough (defi ned as cough duration of 2-4 weeks). Methods Search was conducted by the Cochrane Airways Group using Cochrane methodology. All randomized controlled trials (RCTs) comparing ICS with a control group for treatment of sub-acute cough in children were considered for inclusion. Search results were analysed using pre-determined criteria for inclusion. Results Two studies were eligible for inclusion in the review, however there were limitations in that the participants of both these studies were infants, post acute bronchiolitis illness, and cough duration at start of study treatment was ill-defi ned. 98 children were included in the meta-analysis. There was no signifi cant difference between groups in proportion of children 'not cured' (primary outcome measure), with a pooled OR of 0.61 (95% CI 0.24, 1.55) (using intention to treat analysis). Conclusions There is currently no evidence to support the use of ICS in sub-acute cough in children. However, this systematic review is limited by the small number of studies available for analysis and the quality and design of these studies. Further well-designed RCTs are required to support or refute the effi cacy of treatment with ICS in children with sub-acute cough. Once obstructive sleep apnoea (OSA) is diagnosed, a CPAP implementation sleep study is traditionally performed to determine the pressure required to control the upper airway. However, since modern CPAP machines store sophisticated control data we reasoned it may equally be possible to commence CPAP via a 'best guess' iterative approach without compromising OSA control or compliance. Aim To compare the outcomes at 3 months of patients commencing CPAP after best guess with those commencing CPAP after a CPAP implementation sleep study. Methods We retrospectively reviewed the records of all patients referred by respiratory physicians to our CPAP clinic between March 2008 and March 2010, and the two methods of starting CPAP were compared. Data collected included age, sex, BMI, respiratory disturbance index (RDI), CPAP pressure commenced, fi nal pressure at 3 months, CPAP usage data and CPAP clinic contacts.

Results 287 patients were identifi ed, aged 59 ± 13 years, 66%male, BMI 36.4 ± 8.1, with severe OSA, RDI 44 ± 25. 183 commenced CPAP via best guess and 107 after a CPAP sleep study. The starting pressures in both groups were similar, 9.6 ± 3.0 versus 8.8 ± 1.1 cmH2O. In those patients continuing to use CPAP at 3 months, there were no differences between the groups for fi nal pressure, numbers of patients changing pressure, control of OSA with CPAP, and hours CPAP used per day. In the best guess group however, signifi cantly more patients were continuing to use CPAP at 3 months, 87% versus 71% (p = 0.004). Conclusion This study demonstrates that it may no longer be necessary to perform CPAP implementation sleep studies routinely and this will save hospital bed days. Confl ict of Interest Nil. Six required intubation and the rest were managed with non-invasive ventilation in ICU. The average length of stay in ICU was 9.28 days. Polysomnographic data will be described.

Conclusions Obesity hypoventilation as a cause of respiratory failure is likely to increase in frequency as the incidence of obesity increases. Increased awareness by the lay public, as well as clinical suspicion and recognition of the condition by all clinicians at an earlier stage, is likely to prevent progression to the point of needing intensive care. It is hoped that this case series may provide a springboard for further study into why these patients presented at such a late stage of their disease process. Supported by None. Confl ict of Interest None. Although SA and sleepiness often co-exist, the commonest cause of sleepiness in a general community is depression, with SA being the 7th most common cause. In order to assist recognition of depression in a snoring population attending a sleep clinic, we introduced a simple two question 'Beyond Blue Questionnaire(BBQ)' into our routine assessment. Aims To (1) Background Indices of ventilation distribution in diffusion (S acin ) and convection (S cond ) dependent airways derived from multiple breath nitrogen washout (MBNW) may vary between interpreters because of differences in calculation of phase III slopes (Δphase III ). Aims To compare S cond and S acin results of 3 interpreters from a single MBNW in 10 COPD subjects.

Methods 10 subjects with COPD underwent MBNW. Three washouts were analysed independently by 1 experienced and 2 novice interpreters using custom software for automated breath identifi cation. Δphase III was fi tted automatically by least squares fi t between 2 predetermined points, and then adjusted manually. S cond was the linear slope of Δphase III plotted against lung turnover (cumulative expired volume/FRC), between turnovers 1.5-6. S acin was the Δphase III of the fi rst breath minus the S cond component. Differences expressed as ICC and COV, were examined by repeated measures ANOVA. Results Mean ± SD age was 71 ± 10 years. FEV 1 was 62 ± 15% predicted. S cond was greater while S acin was lower from the experienced Introduction β-blockers may cause bronchoconstriction and mask the effect of β 2 -adrenergic agonists. This has implications for the interpretation of routine diagnostic spirometry and bronchodilator response. This study examined this issue in a routine lung function laboratory, and whether it applied to both cardio-selective (C) and non-selective (NC) preparations. Method All patients attending the Lung Function Laboratory, Royal Adelaide Hospital over a 2-month period were asked whether they were currently taking a β-blocker and to identify the drug. Spirometry results were analysed to assess airfl ow obstruction and reversibility.

Results 407 patients completed the survey and 60 patients (14%) were taking β 2 -blockers. The table shows the results of the 352 patients who could be assessed for reversibility in spirometry. Of the 48 patients in this group 40 patients (83%) were taking (C) and 8 (17%) (NC) agents. Fifty-three patients were unsure whether they were taking a β 2 -blocker. No signifi cant differences were found in the percentage of patients with airfl ow obstruction or reversibility between the groups. Aim To examine patterns of adult lung function in terms of airfl ow obstruction, hyperinfl ation and/or reduced diffusing capacity (D L CO). This can then be related to the life-time history of risk factors such as smoking, asthma and infections.

Methods Using the population-based Tasmanian Longitudinal Health Study (TAHS) cohort followed since 1968, an asthma-enriched sub-sample was selected consisting of 50% ever with asthma, of whom half reported current asthma. Measurement of spirometry, D L CO (uncorrected for haemoglobin) and lung volumes was performed, then lung function data were analysed using the mean predicted values. Airfl ow obstruction was defi ned as post-bronchodilator FEV 1 /FVC (post-b.d. FER) <0.7, hyperinfl ation as total lung capacity (TLC) >120% predicted, and reduced D L CO as <80% predicted. Aim To examine the gender-specifi c differences in adult spirometry, D L CO and lung volumes, with a view to relating them to life-time respiratory risk factors. Methods Using the population-based Tasmanian Longitudinal Health Study (TAHS) followed since 1968, an asthma-enriched sub-sample was selected consisting of 50% ever with asthma, of whom half reported current asthma. Measurement of spirometry, D L CO (corrected for haemoglobin) and lung volumes were performed. Data were analysed using the statistical upper and lower limits of normal of reference equations by NHANES III, Roca et al and Quanjer et al.

Of the 1365 Caucasian adults (665 females), 80% completed all tests.

Mean age 44.8 years (range 43-47). Elevated rates of airfl ow obstruction and hyperinfl ation were seen. Signifi cantly higher proportions of females than males had reduced D L CO and D L CO/V A (p < 0.05). Only 3.2% (n = 18) of females had a low D L CO with low FEV 1 /FVC ratio, and 1.7% (n = 23) had a reduced TLC overall. There were no signifi cant gender differences in V A , TLC, or ever and current active smoking. Males and females averaged over 15 kg more than the Mediterranean adults described by Roca et al., however weight is not relevant to D L CO in males. Conclusion A higher percentage of middle aged females have a reduced D L CO and/or D L CO /V A, compared to males, with an increased rate overall. Grant Support NHMRC, Australian Postgraduate Association.

D CHAPMAN 1, 2, 3 , J KERMODE 1, 2, 3 , N BROWN 1, 2, 3 , N BEREND 1, 2, 3 , G KING 1, 2, 3, 4 Background During bronchoconstriction, a deep inspiration (DI) dilates the airways, which then re-narrow once tidal breathing is resumed. Re-narrowing occurs faster in asthmatic subjects and may be due reduced airway distensibility. Aim To determine the association between baseline airway distensibility and the rate of re-narrowing after DI. Methods Eleven asthmatic and fi ve non-asthmatic subjects had baseline airway distensibility measured by forced oscillation technique (FOT). After methacholine challenge, respiratory system resistance (Rrs) was measured during 1 min of tidal breathing, followed by DI to total lung capacity (TLC) and passive return to normal tidal breathing. Dilatation was measured as the decrease in Rrs between end tidal inspiration and TLC, and re-narrowing as end-expiratory Rrs immediately after DI, as per cent Rrs at end-tidal expiration before the DI. Distensibility is presented as geometric mean ± 95%CI and re-narrowing as mean ± 95% CI. Results Airway distensibility was reduced in asthmatic compared to healthy subjects (0.17 s −1 .cmH 2 O −1 (0.11-0.23) vs. 0.35 s −1 .cmH 2 O −1 (0.18-0.66), p = 0.04). Dilatation did not differ between groups (p = 0.79) but re-narrowing was increased in asthmatic compared to healthy subjects (129 ± 38% vs. 53 ± 13%, p = 0.02). Airway distensibility did not correlate with airway re-narrowing (r s = -0.07, p = 0.80). Conclusion The increased re-narrowing after DI in asthmatic subjects is not due to reduced baseline airway distensibility and may be due to increased shortening velocity of airway smooth muscle or reduced elastic recoil. Supported by The NHMRC and the CRC for Asthma and Airways. Nomination Nil. Confl ict of Interest No.

C NG 1,2,3 , S JENKINS 1, 2, 3 , N CECINS 2,3 , P EASTWOOD 1, 4, 5 Aim To evaluate the measurement properties of two accelerometers: the ActivPAL and the StepWatch Activity Monitor (SAM) in people with COPD. Methods The ActivPAL and SAM were attached to the anterior right midthigh and the right ankle, respectively (as per device recommendations). Each participant performed 4 walking tasks; 2 at a self-selected slow speed and 2 at a self-selected normal speed. At each speed, one walk was performed with a 4-wheeled walker (WW) and the other without. Results 20 participants aged 73 (9) years (FEV 1 = 35 (13) % pred; 8 males) completed the study. The slow and normal speeds were 34 (7) m·min −1 and 46 (10) m·min −1 , respectively. Agreement between steps recorded by the SAM with steps counted during observation did not differ with speed or WW use (p = 0.63). The mean difference was 2 steps·min −1 and the limit of agreement (LOA) was 6 steps·min −1 . Agreement between steps recorded by the ActivPAL with steps counted was worse at slow speeds (mean difference 7 steps·min −1 with LOA of 10 steps·min −1 ) compared with normal speeds (mean difference 4 steps·min −1 with LOA of 5 steps·min -1 ) (p = 0.03), but was not affected by WW use. Both accelerometers detected the small difference in walk speed irrespective of WW use (p < 0.001). Conclusions Neither the accuracy nor responsiveness of either accelerometer was affected by WW use. In contrast to the ActivPAL, SAM was accurate at both speeds and therefore can be used to detect steps in people who walk very slowly during daily life. Breathing and Sleep, Heidelberg Vic., 4 Eastern Health, Melbourne Vic., 5 Northern Health, Epping Vic., and 6 Monash University, Clayton Vic.

Aim To document the care and pathways patients with COPD travel at three metropolitan health services. Methods Data were extracted from data sets for patients attending the emergency department of the three hospitals with a diagnosis of COPD over 1 year. The three hospitals included a city-based tertiary/quaternary hospital and two smaller community hospitals. Analysis was completed on similarities and differences in admission and referral rates, average length of stay, and discharge destination, standardized by age, sex and mode of transport to the emergency department. Results There were 2441 inpatient separations and 1182 emergency department presentations for patients with COPD. Discharge patterns related to the designated role of the hospital, with the community hospitals discharging 75 to 82% of patients directly home and the more specialized city hospital discharging 24% to other hospitals and 64% home. There were signifi cant differences in the admission rates for category 3 and 4 patients among the hospitals. We found unexplained variation in the acute average lengths of stay of 5.4, 6.9 and 7.2 days. Conclusions The analysis confi rmed some expected patterns based on the type of hospital, but also identifi ed unexplained variation that suggests that factors other than patient characteristics may be contributing to the variation in care pathways. Aims To: (1) determine which tests of exercise capacity relate to average daily energy expenditure (DEE) and; (2) quantify the intensity at which activities of daily living (ADL) are undertaken in people with chronic obstructive pulmonary disease (COPD). Methods A study was undertaken in 26 subjects with stable COPD (mean, SD) aged 66 (7) years with an FEV 1 of 50 (16) % predicted (16 males). Measures were collected of distance walked during the six-minute walk test (6MWD) and incremental shuttle walk test (ISWD) and peak rate of oxygen uptake during a cycle ergometry test (VO 2peak ). The Sensewear ArmBand® was worn during the waking hours for 4.4 (1.1) days to measure DEE. The intensity at which activities of daily living were undertaken was expressed as a percentage of VO 2peak . Results DEE was associated with 6MWD (r = 0.40; p = 0.046), ISWD (r = 0.52; p = 0.007) but not VO 2peak (r = 0.07; p = 0.74). Stronger associations were observed between DEE and the body weight-walking product for 6MWD (r = 0.73; p < 0.001) and ISWD (r = 0.75; p < 0.001). The average intensity of ADL was equal to 58 (12%) of VO 2peak (range 39 to 90%). Conclusions 6MWD and ISWD, but not VO 2peak were related to DEE. As ADL were performed at a high percentage of VO 2peak it may be more realistic to increase DEE by increasing the frequency or duration, rather than the intensity of physical activity. In patients with COPD, two 6MWTs are recommended prior to commencing a pulmonary rehabilitation program (PRP) to allow for a learning effect. Aim To determine the characteristics of patients with COPD in whom 6-minute walk distance (6MWD) did not increase on a second test. Methods 245 patients (162 males) with stable COPD (aged 68, 37 to 86 years) naïve to the 6MWT performed two tests (30 minutes apart) prior to commencing a PRP. Patients were categorized according to their change in 6MWD with test repetition. Results 6MWD was the same or decreased on the second test in 31 patients (13%) (Table) . In the remaining 214 patients (87%), 6MWD increased by 44 m (13%) (95% CI 40 to 48 m, 12 to 15%). Logistic regression analysis identifi ed FEV 1 (L) as the only signifi cant variable (p < 0.01) that predicted the absence of a learning effect in 6MWD with test repetition. Conclusions Some patients with severe COPD may not require a practice 6MWT to achieve their maximum performance at a PRP baseline assessment. (7) years, with stable IPF were evaluated in this study. Demographic data and measures of pulmonary function (spirometry, diffusing capacity for carbon monoxide, (DL CO )), dyspnoea (Baseline Dyspnoea Index, BDI), peripheral muscle force (isometric quadriceps force (QF) and handgrip force (HF)), functional exercise capacity (6-minute walk distance, 6MWD), limitation in daily activities (Activities of Daily Living (ADL) score), and health status (SF-36) were assessed. Relationships between 6MWD and MRC Grade, pulmonary function, QF, BDI and ADL score were examined. Results The number of subjects in MRC Grades 2, 3, 4 and 5 was 16 (25%), 17 (26%), 17 (26%) and 15 (23%), respectively. Pulmonary function, BDI, QF, HF, 6MWD, ADL score, and SF-36 decreased signifi cantly with increasing MRC Grade (all p < 0.05). Moderate to strong correlations were found between 6MWD and MRC Grade (r = −0.89), DL CO (r = 0.67), QF (r = 0.66), BDI (r = 0.87) and ADL score (r = 0.85) (all p < 0.005). Conclusions These fi ndings suggest that the MRC Dyspnoea Scale can be used to discriminate and classify subjects with IPF according to the severity of impairment and disability. (16) year (mean, SD) completed two assessment sessions on separate days. On one day, they exercised twice to symptom limitation (Tlim) on a treadmill. On the other day, they exercised twice to Tlim on a cycle ergometer. The order of exercise modality was randomized between days. On both days, the only difference between the exercise tests was that BiPAP, titrated to patient comfort, was used during the second test. Measures were made of; 1) Tlim and, (2) the difference in dyspnoea, using Borg scores, at Tlim during the fi rst test and the equivalent exercise time during the second test (i.e. iso-time). Results BiPAP increased Tlim on the treadmill (175 (97) seconds; p = 0.016) but not the bike (69 (169) seconds; p = 0.411). The reduction in dyspnoea at iso-time on the treadmill and bike was similar being, 4 (3) and 2 (1), respectively (p = 0.29). Conclusions BiPAP may confer greater benefi t in exercise tolerance exercising on a treadmill compared with a cycle ergometer in patients awaiting lung or heart-lung transplant. Infection with rhinovirus (RV) is known to trigger acute exacerbations in subjects with asthma and these subjects also have increased susceptibility to the effects of RV. The mechanisms remain poorly understood, but appear to involve a host innate immune defect in the airway epithelium. Aim We sought to determine in bronchial epithelial cells (BECs) if oxidative stress in the form of exposure to cigarette smoke extract (CSE), hydrogen peroxide (H 2 O 2 ) and eosinophil peroxidise (EPO) results in impaired mitochondrial function and if this directly impairs signalling of RV infection through MDA5 and alters the release of type I and type III interferons (IFNs). Methods pBECs were grown to confl uence. Cells were then exposed to CSE (1%, no fi lter) or H 2 O 2 (0.2mM) or EPO. Cells were then infected with RV1-B (MOI = 20). Virus replication was measured by cell titration assay. Following infection, IL-6, CXCL-8, CXCL-10 was measured using cytometric bead array and fl ow cytometry. Supernatants and whole cell lysates were collected for IFN-β, BAX and MDA5 detection by western blot. IFN-λ and cytochrome-c was measured using conventional ELISA. Cell viability was assessed by Annexin V-PE staining and fl ow cytometry. Results RV infection alone induced CXCL-8, IL-6, CXCL-10 and IFN-λ. pBECs treated with each of the oxidative stressors had increased cytochromec release and increased apoptosis. This mitochondrial dysfunction led to degradation of MDA5 expression and resulted in specifi c suppression of CXCL-10 and IFN-λ. Conclusions Exposure of BECs to an oxidative stress results in mitochondrial dysfunction in airway epithelial cells. This leads to defective antiviral signalling in the airway epithelium after infection with RV. Introduction Pleural infection is associated with high morbidity. Prompt drainage is key, but pus is often loculated and thick making drainage diffi cult. Based on promising animal studies, we hypothesize that intrapleural therapy with t-PA and DNase, which lyse adhesions and reduce fl uid viscosity respectively, can signifi cantly improve pus evacuation in pleural infection. Methods Consecutive patients with pleural infection were treated with standard antibiotics and intercostal chest tube (ICT) drainage. Additionally, t-PA 10mg and DNase 5 mg (each in 50 mL of 0.9% NaCl) were instilled intrapleurally via an ICT twice daily for up to six doses. The ICT was clamped for 45 minutes after each instillation. Patients were followed clinically and with serial CXR. Opacity from pleural effusion was quantifi ed on chest radiographs.

Results Eleven patients (8 male; mean age 51) were treated. Nine effusions were associated with community acquired pneumonia, of these, eight were visibly purulent, fi ve were culture positive and the mean fl uid pH was 7.0 (range 6.45-7.50). Ten patients (91%) were successfully managed conservatively and one patient required surgery. Median hospital stay from fi rst intrapleural treatment dose to discharge was 7 days (range 4-20). The median amount of fl uid drained in the 24 hours preceding t-PA/DNase treatment was 180 mL (range 0-1365), and improved signifi cantly to 1475 mL (range 200-4150) following two doses of treatment. This was paralleled by a signifi cant reduction in radiographic opacity by a mean value of 26% of the hemithorax (range 10-48%). Four patients showed an initial rise in CRP following t-PA/DNase, but all patients had resolution of sepsis and signifi cant reduction in CRP. There were no major complications. Pleuritic chest pain requiring opioid analgesia developed in three patients. Methods Clinical data were collected using a standardized form for Aboriginal children aged 29 days -<60 months hospitalized with ALRI and enrolled in a RCT of Vitamin A/Zinc supplementation were matched with data collected during a population-based study of WHO-defi ned primary endpoint pneumonia (WHO-P). Sensitivities, specifi cities, positive and negative predictive values (PPV, NPV) for these signs were compared between WHO-P cases and lobar pneumonia assigned by a respiratory paediatrician.

In 147 episodes of hospitalized ALRI, WHO-P was diagnosed in 40 (27.2%); the respiratory paediatrician classifi ed 70 (47.6%) as lobar pneumonia. The sensitivities of clinical signs ranged from a high of 45% for tachypnoea to 5% for fever + tachypnoea + chest-indrawing; the PPV range was 40% to 20%, respectively. Higher PPVs were observed against the paediatric respiratory physicians diagnosis compared to WHO-P.

Conclusions Clinical signs on admission are not useful in predicting WHO-P in this population, presenting challenges for future pneumonia research in this population. WHO-P may underestimate alveolar consolidation in a clinical context and its use in clinical practice or in research designed to inform clinical management in this population should be avoided. The incidence of TB in the non-Indigenous Australian population is uncommon at 0.9 cases per 100 000 population 1 . In this paper, we report three cases of pulmonary tuberculosis in young Australian born, non-indigenous adults in the Hunter New England area where marijuana possibly was a signifi cant risk factor in transmission and severity of disease. All three cases had severe cavitating disease at time of presentation. Contact tracing from the fi rst case, a regular heavy marijuana user, identifi ed 26 Mantoux positive contacts, one of whom developed active pulmonary tuberculosis. All contacts, mainly young adult males, denied sharing marijuana with the index case. Contact tracing from the second case identifi ed 5 Mantoux positive contacts, 4 of whom use marijuana regularly and shared bongs (water pipes) with the index case. There were 3 positive Mantoux contacts of the third case, one of whom shared bongs with the index case. Health professionals need to remain aware of the possibility of tuberculosis in groups with historically low incidence rates. Marijuana bong smoking is possibly associated with transmission and severity of tuberculosis 2 . Introduction In 2007, these previously well women survived and made a good recovery from severe pneumonia and acute lung injury after retrieval on ECMO. Streptococcus pyogenes is an unusual cause of pneumonia in adults. Case 1 A 22-year-old veterinarian with a history of mild asthma presented with 4 days of fever and respiratory symptoms. The diagnosis was confi rmed by a fourfold rise in the anti-streptococcal antibody. This was complicated by respiratory failure, septic shock, acute renal failure, severe pulmonary hypertension and bilateral parapneumonic effusions. Despite maximal interventions she deteriorated. Femoral venous-venous ECMO was initiated on day 5 at the Calvary Mater Hospital in Newcastle by a retrieval team from Royal Prince Alfred Hospital (RPA), Sydney. She was transferred 158 kms on ECMO in a large multipurpose ambulance. She developed lung abscesses and recurrent pneumothoraces and she required a pleurodesis. She required 40 days of ventilation and 15 days of ECMO. Three months later she was asymptomatic, with mildly restrictive spirometry and minor CXR change. Case 2 A 47-year-old offi ce worker with S pyogenes bacteraemia made a similar presentation to our institution. She was ventilated for 24 days, ECMO was initiated by the retrieval team and continued for 7 days. Three months later she was asymptomatic with a normal CXR and pulmonary function tests. Introduction The urinary pneumococcal antigen (UPA) test has been shown to have superior sensitivity to other investigations in determining the aetiology of community-acquired pneumonia (CAP), but there is very limited data on its performance in local populations. The aims of this study are to establish the prevalence of positive UPA testing in patients admitted to hospital with CAP, and determine its utility. Secondary aims are to identify associations with positive testing, as well as to determine if a positive test infl uences clinical outcomes. Methods The study is a prospective, single-centre study that is still recruiting. Adult patients are included upon admission to hospital if they have the diagnosis of CAP, as defi ned by new infi ltrates on chest radiograph along with consistent clinical features. Clinical data including CURB-65 score of severity, current and prior antibiotics, co-morbidities, mortality and length of hospital stay are recorded. Results Preliminary results show a positive test prevalence of 9/124 (7.3%, 95% CI 3.6-13.7%) amongst patients admitted with CAP. Overall prevalence of pneumococcal pneumonia is 12/124 (9.7%, CI 5.3-16.7%). Patients with a positive UPA result have a higher mean CURB-65 score of 2.7 compared with 1.5 in those with a negative result (p = 0.02). 44.4% of patients with a positive result were admitted to the intensive care unit, compared with 13.0% those with a negative result (p = 0.04). Conclusions The overall prevalence of positive UPA testing in patients admitted to hospital with CAP is low. Preliminary data suggests that patients with positive results are more likely to have greater severity pneumonia and to require intensive care support. Comparative data on length of stay, mortality, previous antibiotic use and specifi c co-morbidities has not revealed any statistically signifi cant differences between positive and negative groups. Confl ict of Interests No.

S HERATH 1 , C LEWIS 2 , M NISBET 1,2 1 Respiratory Department, Auckland City Hospital, Auckland, New Zealand, and 2 Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand Rhodococcus equi (R. equi), previously known as Corynebacterium equi is a Gram positive bacillus that is found in soil and causes infection in grazing livestock. It is infrequently isolated from clinical specimens. It is usually associated with human disease in immunocompromised patients and is an uncommon cause of infection in immunocompetent patients. Infection is usually acquired by the airborne route with pneumonia being the most common manifestation but it can also be acquired orally or by direct inoculation. We present a case of pneumonia caused by R. equi infection in a 55 year old male builder who presented with cough, dyspnoea and night sweats. R. equi was cultured from a transbronchial aspirate from a subcarinal lymph node. Despite extensive investigation, no contributing host immune defect was identifi ed. The patient recovered after three months of antibiotic treatment, initially with intravenous vancomycin and meropenem followed by oral clarithromycin and rifampicin. Although infections due to R. equi have been increasingly reported in immunocompromised patients, since 1989 there have only been 24 cases described in patients where no associated host immune defect was reported. In this cohort, the median age at presentation was 53 years (range 16-83) and 18 (72%) patients were male. Ten (42%) of these cases had pulmonary infection. Two (8%) patients died and the remainder were successfully treated with prolonged antibiotics. R. equi is an uncommon cause of infection in humans and rarely occurs in patients where a host immune defect cannot be identifi ed.

Introduction Recognition of pulmonary involvement in Extra Pulmonary Tuberculosis (EP-TB) may be an important public health issue, as it has been estimated that patients with smear negative Pulmonary TB (PTB) are responsible for 17% of new infections. Usually, all patients with EP-TB have a chest x-ray but sputum cultures are requested only if there is an abnormality. Methods In this retrospective clinical audit, we aimed to evaluate the percentage of EP-TB patients with PTB despite a normal Chest X Ray (CXR), and to explore any clinical characteristics of this group. Clinical notes, microbiology and CXR reports were reviewed from consecutive patients presenting with EP-TB between 2007 and 2010. Results Of 103 patients with EP-TB, 47% were male and the mean age was 41 (range 16 to 98). Most patients were of Asian ethnicity (n = 70, 68%). The commonest presentation of EP-TB was lymphadenopathy (n = 51, 50%), followed by pleural (n = 24 23%) and bone (n = 6, 5.8%) disease. EP-TB was diagnosed by biopsy/excision of the EP site in the majority (n = 77, 74.8%), and by sputum testing alone in 26 (25.2%). Sputum cultures were performed in n = 67, (88%) overall, with n = 46 (67%) being positive. There was higher infl ammatory markers in the sputum culture positive group (ESR 64.2 vs. 37.7, p = 0.0088 and CRP 50.8 vs. 28.2, p = 0.0203). The majority had CXR abnormalities (n = 76, 74%). In the group with normal CXR (n = 27), 15 (55%) had sputum cultures performed. Of these, 5 were culture positive and 2 of these also 1+ smear positive (1 on immunosuppression, 1 with cough). Conclusion A small number of patients with EP-TB and normal CXR had pulmonary TB, of whom 2 were smear positive. Thus, induced sputum testing should be considered in patients with EP-TB even if CXR is normal. This may aid diagnosis and determine infectivity. NTM are normal inhabitants of environmental reservoirs including water. Disease due to NTM has been increasing in QLD. 1 Aim To document the presence of NTM in potable water in Brisbane, to compare the species isolated during summer and winter and to relate this to the geographic distribution of patients with NTM. Methods Water samples (1L) were collected from 196 routine collection sites in winter 2007 and 190 sites in summer 2008. Samples were processed in triplicate as previously described. 2 7H11 subcultures were taken from positive specimens, DNA extracted, followed by 16s rRNA sequencing. Patient addresses were obtained from the QLD TB control centre database. Aim To gauge the full impact of pandemic H1N1 infl uenza across demographic groups in the Northern Territory, particularly Indigenous and remoteliving individuals. Methods We performed two cross-sectional serological surveys on specimens from residents of the Northern Territory, with 445 specimens obtained from January to May 2009 (pre-pandemic) and 1689 specimens from September 2009 (post-pandemic). Specimens were selected from among serum tubes collected from ambulatory outpatients. Antibody titres were measured by haemagglutination inhibition against the A/California/7/2009 reference virus. All specimens had available data for gender, age, and address, with Indigenous status determined in 94.1% of cases. Results Protective antibody levels, defi ned as a titre of 40 or greater, were present in 7.6% of pre-pandemic specimens and 19.5% of post-pandemic specimens. The pre-pandemic proportion immune was greater with increasing age, but did not differ by other demographic characteristics. The post-pandemic proportion immune was greater among Aboriginal and Torres Strait Islanders and in younger age groups, but did not differ by gender or Socio-Economic Index For Area. However, the proportion immune was geographically heterogeneous, particularly among remote-living and Indigenous groups. The Northern Territory-wide attack rate adjusted to 2009 age, region and Indigenous status was 14.9%. Conclusions Pandemic infl uenza disproportionately affected children and Indigenous Australians in the Northern Territory in 2009. The proportion of specimens demonstrating post-pandemic immunity was particularly variable among Indigenous and remote-living individuals. The KORMP found asymptomatic Aboriginal children (AC) had more HRV than asymptomatic non-Aboriginal children (non-AC) in a longitudinal communitybased cohort study where infants had nasopharyngeal aspirates (NPA) collected regularly from birth to 2 years of age. Aim To compare the frequency of HRV groups in asymptomatic AC and non-AC in the KORMP. Methods NPA positive for HRV (n = 191) from the 1011 NPA previously tested for respiratory viruses, had viral RNA extracted and reverse transcribed. HRV was detected and typed using a two-step PCR of the HRV 5' UTR, followed by DNA sequencing for typing. Chi-square analyses were used. Results HRV was detected and typed in 164 NPA (from 106 children; 55 AC and 51 non-AC), 16 could not be typed and 11 were not positive for HRV. AC had more HRV in summer and autumn than non-AC and were more likely to be co-infected with at least 1/3 bacterial species identifi ed. HRVA, B & C were found in 51.8, 15.9 and 32.3% of HRV detected. HRVB & C were increased in infants exposed than not exposed to tobacco smoke in utero (HRVB; 4.3 vs. 2.0%, p = 0.04 and HRVC; 7.4 vs. 4.3%, p = 0.046). Of the 1011 NPA, HRV-A was detected more often in NPA from AC than non-AC (11.1 vs. 6.1%, p = 0.006), particularly at 3-4 months of age (p = 0.008) and during summer (p < 0.05). HRVB was detected more often in NPA from AC than non-AC in autumn (p < 0.05). HRVC was detected as often in AC as non-AC in each season except summer. 

Aim To determine whether interferon-gamma release assay (IGRA) can be effectively used for diagnosis of latent tuberculosis infection in a remote location. Methods Subjects were enrolled from the Darwin Centre for Disease Control Tuberculosis clinic and were eligible if a tuberculin skin test (TST) of 10mm or greater had been recorded for any indication. IGRAs were performed using Quantiferon®-TB Gold Whole Blood In-Tube assay according to manufacturer's instructions. Specimens were incubated and centrifuged at the local laboratory before refrigeration for transport. Interferon assay was performed at the reference laboratory, over 3000 km away. Results 62 IGRAs were performed, with 42 patients (68%) recording negative results, 19 (31%) positive and only one result (2%) indeterminate. Negative, and therefore discordant, test results were more common in BCG vaccinated individuals. This effect was not limited to those with TST results of 10-14mm, but was seen primarily in those with results of 15 mm and above. Conclusions These results are broadly comparable to fi ndings for IGRA use in less remote settings. In particular, our low rate of indeterminate results suggests that IGRA testing is feasible at a remote site after local processing. This approach could be considered for use in the Northern Territory Tuberculosis Control Program. Inhaled medications form the mainstay of drug treatment for patients with airways disease. Effectiveness of therapy is dependent on the appropriate selection and prescription of drug and device, correct supply and adherence to therapy with an effective technique. Patients frequently admit to acute medical wards both with acute exacerbations and for other co-morbidities eg heart failure or pneumonia. Inpatient episodes provide an opportunity to review inhaled therapy however anecdotally add to patient confusion and introduce complexity (rational or ad hoc changes to inhaled drug, device, strength, dose or frequency). Aim Identify prescribing accuracy and effectiveness of patients' inhaler technique. Describe any discrepancies between inhaled therapy: (1) used prior to admission, (2) prescribed for inpatient use, (3) available at the bedside and (4) administered, prior to and after implementation of an inhaler prescribing and administration guide. Methods A single day audit of all inpatients on 2 general medical wards was conducted October 2010 (review of medication charts and inhalers in patients' bedside lockers, brief questioning and direct observation of patients' inhaler technique. Results compared to post implement of the 'Prescribing and Administering Inhalers' tool (audit in December 2010). Results 19 from 58 (33%) patients had inhalers prescribed, (mean: 2.4 prescriptions per patient). 95% of prescriptions were accurate (88% patient had no errors). Discrepancies between used prior to admission and inpatient prescriptions were found in 7 (41%) patients while those between inpatient prescriptions and available at the bedside were found in 29%. Self-administration ('S') was noted on medication charts of 79 (53%) patients, 3 of whom had an ineffective inhaler technique. 2/17 patients has a spacer at the bedside with a further r 5 prescribed metered aerosol inhalers. Post-intervention differences in prescribing, supply, administration and technique errors will be discussed. Conclusions A combination of errors and prescription discrepancies reduce the effectiveness of inhaled therapy for inpatients. Confl ict of Interest No.

Males (n (%) 95% CI) Females (n (%) 95% CI)

Adm and bed days

BMI, body mass index

HRQoL, health related quality of life

Chronic Respiratory Disease Questionnaire; adm, admissions, Mean (SD)

uberculosis notifi cations in Australia

A cluster of tuberculosis associated with use of a marijuana water pipe

The Prince Charles Hospital Foundation

CC DOBLER 1,2 , GB MARKS 1,2 1 Woolcock Institute of Medical Research, The University of Sydney, NSW, and 2 Department of Respiratory Medicine, Liverpool Hospital, Sydney, NSW Aim To determine the incidence rate and nature of adverse events in patients taking treatment for latent tuberculosis infection (LTBI). Methods Records of all patients who received treatment for LTBI at the Chest Clinic of a large tertiary hospital between 01/2000 and 04/2008 were reviewed. An adverse event was defi ned as any change in health status or side effect that led to treatment interruption or cessation. Liver function tests were not performed routinely during follow-up, except when the patient was considered to be at an increased risk of developing hepatitis. Results Of 201 patients in whom treatment for LTBI was initiated 143 (71%) received isoniazid for 6 months, 32 (15%) received a combination of isoniazid and rifampicin for 6 months, and the remainder were treated with different regimens. Their mean (SD) age was 21 (17) years and 44% were male. Nineteen patients (9.5%) experienced an adverse event. Seven patients developed a rash, four had lethargy and/or mood disorders, three had subclinical hepatitis, four experienced severe nausea, vomiting and/or other gastrointestinal symptoms and three had features of peripheral neuropathy. In eight patients who experienced an adverse event medication was temporarily ceased and then re-started without change; in four the treatment regimen was changed; and in seven the treatment was ceased completely. The risk of adverse events was not signifi cantly related to age, sex, drug regimen (single drug versus combination therapy) or baseline transaminase levels. Conclusions In this cohort almost 1 in 10 patients on treatment for LTBI experienced an adverse event. Although the adverse events were generally mild to moderate, this risk has to be taken into account when deciding whether to advise treatment for LTBI. Introduction Human rhinovirus (HRV) is the commonest cause of asthma exacerbations in children. Pernasal aspirate (PNA) is the gold standard for microbiological sampling but is invasive and distressing for children. Studies have showed that less invasive swabs may be just as effi cacious. Aim To test the hypothesis that HRV detection is as effi cient using nasal fl ocked swabs or washes and more comfortable, compared with PNA in children with respiratory illnesses. Methods Children were recruited on presentation to the emergency department with respiratory symptoms. PNA was collected from one nostril of all children recruited and nasal fl ocked swab (n = 21) or wash (n = 12) collected from the other nostril alternately. Subjects rated the comfort of each sampling method 1 to 10 (least to most). Viral RNA was extracted and reverse transcribed. A two-step PCR of the HRV 5' UTR was used for detection, followed by sequencing for typing. Results To date, 33 children (56% male, mean age of 3.32 years) had paired samples taken. Of these children, 67% (n = 22) presented with a diagnosis of viral induced wheeze and 73% (n = 24) had a HRV positive sample. Compared with PNAs, nasal fl ocked swabs were 85% (11 of 13 PNA positive) effective in detecting HRV, whilst nasal washes showed 100% (11 of 11 PNA positive) effi cacy. Of the 25 successfully typed samples, 3 had HRVA and 22 had HRVC. Nasal washes had a better comfort rating (mean 9.09, n = 11) than fl ocked swabs (mean 6.15, n = 13) and PNAs (mean 3.21, n = 24). Conclusion Our fi ndings suggest that whilst nasal fl ocked swabs are an effective sampling method for HRV detection, nasal washes were more effective, being as effective as PNAs and were the most comfortable. Support NHMRC, PMH Foundation. Nomination Nil.

Aim To describe the inpatients treated by a dedicated NIV service. Methods A retrospective audit of inpatients treated by the Alfred NIV service between 1 January 2009 and 30 June 2009. The defi nition of NIV included patients treated with CPAP and bilevel positive pressure ventilation. Results 150 patients (age: 58 ± 17 years (mean ± SD), gender: 60% male) were treated with NIV on 172 occasions (repeat admissions 11 patients). Commonest indications for NIV were OSA (n = 49, 28%), acute exacerbations (AE) of COPD (n = 33, 19%), acute cardiogenic pulmonary oedema (ACPO) (n = 18, 10%) and post-lung transplantation (n = 16, 9%). Treatment was delivered primarily in the respiratory ward (n = 37, 21%), cardiac ward (n = 19, 11%), ICU (n = 16, 9%) and general medical ward (n = 15, 9%). 65episodes of CPAP (mean pressure 10 ± 3 cmH2O), OSA and ACPO made up 76% of those treated. Seventy-two episodes of bilevel PAP (mean IPAP 13 ± 3 cmH2O and EPAP 6 ± 1 cmH2O), AECOPD and weaning post-mechanical ventilation made up 43% of those treated. Outcome data was available in a subgroup of patients with ACPO (n = 17) andAECOPD (n = 33). In the ACPO group, 9 patients (53%) improved and NIV was ceased. Three patients (18%) deteriorated and were intubated and 4 patients (23%) were palliated. In the AECOPD group, 23 patients (70%) improved andNIV was ceased or they were discharged on therapy. 10 patients either deteriorated on NIV or could not tolerate therapy, of these 7 (21%) continued ward management and 3 (9%) were palliated. Conclusion The Alfred NIV service model has managed a large number of referrals across a range of diseases in a variety of wards. This is likely to have reduced demand on ICU, HDU and respiratory ward beds. Compared to the published literature, theoutcomes for ACPO are worse than expected but comparable for AECOPD. This may be explained by local referral patterns for ACPO. We believe that our service model provides a viable means of administering NIV to an ever expanding referral base. Transitional & Community Service, 2 The University of South Australia, Adelaide, SA 5000, 3 The University of Adelaide, Adelaide, SA, 5005, 4 The Mary Potter Hospice, North Adelaide, SA, 5006, 5 Thoracic Medicine, The Royal Adelaide Hospital, Adelaide, SA, 5000, 6 The Royal District Nursing Service, Wayville, SA 5034, and 7 The Palliative Care Council of SA Eastwood, SA 5063 Introduction: The Adelaide Health Service is in the process of developing a new and innovative model of COPD community based care. A number of initiatives have informed this development including a recent research project examining the experiences of 15 participants with end stage COPD and their carers. A growing body of evidence indicates the importance of a palliative approach, however this often takes the form of referral to a palliative care service rather than a broader application of palliative principles in both specialist and primary care. Methods: Fifteen participants were interviewed twice at 6 monthly intervals to explore their needs and the services they accessed. A series of focus groups with key service providers in SA was also undertaken. Data were analysed to identify how hospital, specialist palliative care units and primary care services currently interface to meet identifi ed patient and carer needs. Results: The current service model is episodic and reactive with services activated through the acute care system. Our research has shown that, as COPD advances, current models of care do not address the importance of supporting quality of life (including a focus on ADLs) and carers in their ongoing role. Also emphasised was the lack of co-ordination of care, collaboration between service providers and communication -the basics of chronic disease management.

Conclusions The outcomes of this study will inform the development of a proactive, multidisciplinary model of care which is no longer reliant on tertiary care, but places primary care at the centre of the model. Greater collaboration between respiratory, palliative and primary care services will provide an integrated approach, focusing on the needs of the patient and carer. Aim Long term conditions are prevalent in South Auckland and impact on the individual, the community and the health system. As nurses living within this community, and employed by Counties Manakau District Health Board, our aim was to explore funding opportunities available through the Pacifi c Health Team. LotuMoui was established to improve health outcomes/behaviours for Pacifi c populations. The Church we attend has wide cultural diversity and had no knowledge of the programme and the support provided to make healthy changes within our community. Methods Firstly a Health Committee was formed within the Church, having 'sold' our vision to the Parish Council. We launched the group by undertaking free Blood Pressure checks, followed by a 'Walk the Talk' project for the 40 days leading into Easter. Baseline observations were taken and pedometers issued. Results The parishioners who attend regular exercise sessions are reporting improved quality of life, exercise tolerance and reducing waist lines. BP parameters are also reducing. Conclusions A dedicated Health Committee within a Parish Community, supported by the District Health Board can impact on changes in lifestyle by simple interventions. The investment by the Pacifi c Team will reap benefi ts for the individual and the health sector. Confl ict of Interest No.