Åsa M. Wheelock

Assessing Recent Smoking Status by Measuring Exhaled Carbon Monoxide Levels

Background Cigarette smoke causes both acute and chronic changes of the immune system. Excluding recent smoking is therefore important in clinical studies with chronic inflammation as primary focus. In this context, it is common to ask the study subjects to refrain from smoking within a certain time frame prior to sampling. The duration of the smoking cessation is typically from midnight the evening before, i.e. 8 hours from sampling. As it has been shown that a proportion of current smokers underestimates or denies smoking, objective assessment of recent smoking status is of great importance. Our aim was to extend the use of exhaled carbon monoxide (CObreath), a well-established method for separating smokers from non-smokers, to assessment of recent smoking status. Methods and Findings The time course of CObreath decline was investigated by hourly measurements during one day on non-symptomatic smokers and non-smokers (6+7), as well as by measurements on three separate occasions on non-smokers (nu200a=u200a29), smokers with normal lung function (nu200a=u200a38) and smokers with chronic obstructive pulmonary disease (nu200a=u200a19) participating in a clinical study. We used regression analysis to model the decay, and receiver operator characteristics analysis for evaluation of model performance. The decline was described as a mono-exponential decay (r2u200a=u200a0.7) with a half-life of 4.5 hours. CO decline rate depends on initial CO levels, and by necessity a generic cut-off is therefore crude as initial CObreath varies a lot between individuals. However, a cut-off level of 12 ppm could classify recent smokers from smokers having refrained from smoking during the past 8 hours with a specificity of 94% and a sensitivity of 90%. Conclusions We hereby describe a method for classifying recent smokers from smokers having refrained from smoking for >8 hours that is easy to implement in a clinical setting.

Distribution of T-Cell Subsets in BAL Fluid of Patients With Mild to Moderate COPD Depends on Current Smoking Status and Not Airway Obstruction

BACKGROUNDnCOPD is characterized by chronic inflammation. CD8+ T cells and CD4+ T cells have both been implicated in the inflammatory response. We investigated whether the lymphocyte and T-cell subpopulations in BAL differ between patients with COPD who are current smokers and those who are ex-smokers.nnnMETHODSnForty never smokers, 40 smokers with normal lung function, and 38 patients with COPD, GOLD (Global Initiative for Chronic Obstructive Pulmonary Disease) stage I-II (27 smokers and 11 ex-smokers) underwent BAL. Using flow cytometry, cells were analyzed from BAL and blood for T-cell subsets, B cells, natural killer cells, and natural killer T (NKT)-like cells. The differentiation status of CD4+ T cells was also determined.nnnRESULTSnSmokers with or without COPD had higher percentages of CD8+ T cells and NKT-like cells in BAL than did never smokers and ex-smokers with COPD. Most of the NKT-like cells were CD8+. In contrast, the percentages of CD4+ T cells were lower in the smoking than in the nonsmoking groups. In blood, the frequency of CD4+ T cells was increased in the two smoking groups. Current smokers also had increased numbers of activated (CD69+) naive and effector CD4+ T cells in BAL compared with nonsmokers, particularly in patients with COPD. In male smokers with COPD, the percentage of CD8+ T cells in BAL positively correlated with the number of cigarettes per day.nnnCONCLUSIONSnCurrent smoking status has a greater impact than airway obstruction on the distribution of T-cell subsets in BAL of patients with mild to moderate COPD. This fact must be considered when the role of T cells in COPD is evaluated. Our results stress the importance of subgrouping patients with COPD in terms of smoking.

Lung density on high resolution computer tomography (HRCT) reflects degree of inflammation in smokers

BackgroundSmokers have increased cell concentration in the lower respiratory tract indicating a chronic inflammatory state, which in some individuals may lead to development of chronic obstructive pulmonary disease (COPD). Computer tomography (CT) imaging provides means of quantifying pulmonary structure and early signs of disease. We investigated whether lung density on high resolution CT differs between smokers and never-smokers and if this were associated to intensity of inflammation.MethodsForty smoking volunteers with normal pulmonary function, 40 healthy never-smokers and 40 patients with COPD of GOLD stage I-II, were included. Mean lung attenuation and percentage of pixels in the lung with attenuation between −750 and −900 HU (percentage higher density spectrum (%HDS)) were calculated on inspiratory CT-scans. Markers of systemic inflammation in blood and cell counts in bronchoalveolar lavage (BAL) fluid were recorded.ResultsLung density expressed as %HDS was increased in smokers (44.0u2009±u20095.8%) compared to both never-smokers (38.3u2009±u20095.8%) and patients with COPD (39.1u2009±u20095.8%), (pu2009<u20090.001, for both). Females had denser lungs than males, which was dependent on body height. Cell concentration in BAL were correlated to lung density in smokers (ru2009=u20090.50, pu2009<u20090.001).ConclusionsLung density on CT is associated with cell concentration in BAL in smokers and may mirror an inflammatory response in the lung. Gender difference in lung density is dependent on height. In COPD with emphysema, loss of lung tissue may counterbalance the expected increase in density due to inflammation. The findings may help to interpret high resolution CT in the context of smoking and gender and highlight the heterogeneity of structural changes in COPD.

Increased intraepithelial (CD103+) CD8+ T cells in the airways of smokers with and without chronic obstructive pulmonary disease

T cells are accumulated in the lungs of chronic obstructive pulmonary disease (COPD) patients. Intraepithelial T cells, expressing the integrin αE (CD103) β7, and regulatory T cells have been implicated in pathogenesis of the disease. We asked whether COPD patients and smokers have altered frequencies of these T cells and if their phenotypes differ. A total of 40 never-smokers, 40 smokers with normal lung function and 38 COPD patients (GOLD I and II), of which 11 were ex-smokers, were included. T cells in bronchoalveolar lavage (BAL) fluid and peripheral blood were analysed for the expression of CD103, FOXP3 and markers of activation and differentiation using multi-colour flow cytometry. Smokers, regardless of airway obstruction, had significantly more CD8+CD103+ cells in their BAL fluid compared to never-smokers but less of those cells were CD27+CD69-. Smokers, in particular those with chronic bronchitis, had a higher percentage of CD4+FOXP3+ T-regulatory BAL cells compared to never-smokers and COPD ex-smokers. Chronic cigarette smoking leads to an accumulation of CD8+ T cells with an altered phenotype in the airway epithelium. The increased frequency of regulatory T cells may influence the ability to regulate smoke-induced inflammation which could be decisive for disease development. Our results further indicate a reversibility of smoke-induced changes.

Increased pulmonary Wnt (wingless/integrated)- signaling in patients with sarcoidosis

BACKGROUNDnSarcoidosis is an inflammatory multisystemic granulomatous disease of unknown aetiology commonly affecting the lungs, and pulmonary fibrosis often develops in chronic sarcoidosis. It has been suggested that Wnt (Wingless/integrated)-signaling has a role in inflammatory and fibrotic processes in the lungs, but its role in sarcoidosis has not been investigated. We hypothesised that Wnts secreted from T cells or other inflammatory cells have a role in the pathogenesis of sarcoidosis.nnnMETHODSnBrush biopsies and bronchoalveolar lavage (BAL) were obtained through bronchoscopy from healthy controls (n = 18) and patients with sarcoidosis (n = 48). Semi-quantitative RT-PCR, electrophoretic mobility shift assay (EMSA) and immunocytochemistry were performed to analyse Wnt expression and activation of the Wnt-signal transducer β-catenin.nnnRESULTSnAltered expression of Wnt5A, Wnt7A and Wnt7B mRNA in BAL cells was observed, as well as an increased activation of β-catenin, measured by EMSA and confirmed with immunocytochemistry, in resident lung cells from patients with sarcoidosis. More pronounced changes in Wnt expression were seen with advancing disease stage. Thus, by three independent methods, we have found evidence of increased pulmonary Wnt-activation in sarcoidosis.nnnCONCLUSIONSnIn the lungs of patients with sarcoidosis there is a previously unappreciated increased Wnt-signal activation that could contribute to the inflammatory processes.

Approach for Identifying Human Leukocyte Antigen (HLA)-DR Bound Peptides from Scarce Clinical Samples

Immune-mediated diseases strongly associating with human leukocyte antigen (HLA) alleles are likely linked to specific antigens. These antigens are presented to T cells in the form of peptides bound to HLA molecules on antigen presenting cells, e.g. dendritic cells, macrophages or B cells. The identification of HLA-DR-bound peptides presents a valuable tool to investigate the human immunopeptidome. The lung is likely a key player in the activation of potentially auto-aggressive T cells prior to entering target tissues and inducing autoimmune disease. This makes the lung of exceptional interest and presents an ideal paradigm to study the human immunopeptidome and to identify antigenic peptides. Our previous investigation of HLA-DR peptide presentation in the lung required high numbers of cells (800 × 106 bronchoalveolar lavage (BAL) cells). Because BAL from healthy nonsmokers typically contains 10–15 × 106 cells, there is a need for a highly sensitive approach to study immunopeptides in the lungs of individual patients and controls. In this work, we analyzed the HLA-DR immunopeptidome in the lung by an optimized methodology to identify HLA-DR-bound peptides from low cell numbers. We used an Epstein-Barr Virus (EBV) immortalized B cell line and bronchoalveolar lavage (BAL) cells obtained from patients with sarcoidosis, an inflammatory T cell driven disease mainly occurring in the lung. Specifically, membrane complexes were isolated prior to immunoprecipitation, eluted peptides were identified by nanoLC-MS/MS and processed using the in-house developed ClusterMHCII software. With the optimized procedure we were able to identify peptides from 10 × 106 cells, which on average correspond to 10.9 peptides/million cells in EBV-B cells and 9.4 peptides/million cells in BAL cells. This work presents an optimized approach designed to identify HLA-DR-bound peptides from low numbers of cells, enabling the investigation of the BAL immunopeptidome from individual patients and healthy controls in order to identify disease-associated peptides.

Differences in regional air trapping in current smokers with normal spirometry

We investigated regional air trapping on computed tomography in current smokers with normal spirometry. It was hypothesised that presence of regional air trapping may indicate a specific manifestation of smoking-related changes. 40 current smokers, 40 patients with chronic obstructive pulmonary disease (COPD), and 40 healthy never- smokers underwent computed tomography scans. Regional air trapping was assessed on end-expiratory scans and emphysema, micronodules and bronchial wall thickening on inspiratory scans. The ratio of expiratory and inspiratory mean lung attenuation (E/I) was calculated as a measure of static (fixed) air trapping. Regional air trapping was present in 63% of current smokers, in 45% of never smokers and in 8% of COPD patients (p<0.001). Current smokers with and without regional air trapping had E/I ratio of 0.81 and 0.91, respectively (p<0.001). Forced expiratory volume in 1u2005s (FEV1) was significantly higher and emphysema less frequent in current smokers with regional air trapping. Current smokers with regional air trapping had higher FEV1 and less emphysema on computed tomography. In contrast, current smokers without regional air trapping resembled COPD. Our results highlight heterogeneity among smokers with normal spirometry and may contribute to early detection of smoking related structural changes in the lungs. Smokers with regional air trapping on expiratory CT scan are less obstructive/have less emphysema than those without http://ow.ly/96lV305tgtZ