Tma Wilkinson

S67 Mortality in copd patients following community acquired pneumonia: a population database analysis of linked healthcare records

Introduction Community acquired pneumonia (CAP) is a common occurrence in patients with chronic obstructive pulmonary disease (COPD), yet controversy still remains about its affect on outcome. We therefore investigated the impact of CAP on mortality in a cohort of COPD patients identified from the Hampshire Health Record analytical database, a local NHS database containing linked, anonymised primary and secondary care records. Methods Patients were defined as having COPD if they had a diagnostic Read code in their primary care record at any time prior to the 1st January 2010 and were aged ≥40 years at the start of the study. CAP episodes occurring over a 5-year period from 1st January 2010 were identified using Read and ICD-10 codes. The outcome measure was all-cause mortality following a CAP diagnosis. Cox proportional hazard modelling was used to estimate hazard ratios (HR) and confidence intervals (CI), adjusting for age, sex, GOLD stage, smoking status and inhaled corticosteroid use (ICS)). Results The cohort comprised 14506 COPD patients. The mean age was 70.3 (±10.8) years and 53.6% were male. 1931 (13.3%) patients had at least one CAP and 2870 (19.8%) deaths occurred over the study period. 28.2% of patients diagnosed with CAP died compared to only 9.7% of those without a CAP diagnosis (p < 0.001). Logistic regression analysis, controlling for potential confounders identified CAP as an independent risk factor for future mortality (odds ratio 2.72; CI 2.37–3.12, p < 0.001). Compared to younger individuals (40–59 years) those aged 60–79 and >80 years had the highest mortality risk following CAP (HR 2.65; CI 1.61–4.34, HR 7.03; CI 4.27–11.57 respectively, both p < 0.001). Concurrent use of inhaled Fluticasone or Budesonide were associated with reduced mortality risk following CAP (HR 0.82; CI: 0.68–0.98 p = 0.029, HR 0.55; CI: 0.39–0.76 p < 0.001, respectively) (Figure 1). Conclusion CAP in COPD is associated with increased risk of mortality, especially in older individuals. Although known to increase CAP risk, ICS use appears to reduce risk of mortality following CAP. Further research to understand the mechanisms underlying CAP risk in COPD and modulating effects of ICS is key, to guide development of future, targeted preventative strategies. Abstract S67 Figure 1 Survival comparisons following CAP in COPD patients, stratified by Fluticasone (A) or Budesonide (B) use

P53 Predicting poor outcomes in COPD patients deemed ‘low risk’ by dose score

Introduction COPD continues to cause a substantial symptom, mortality and financial burden in the UK. Current treatment strategies are predominantly reactive as insufficient evidence exists to successfully target clinical resource into pre-emptive ‘early interventions’. The DOSE (dyspnoea, obstruction, smoking status and exacerbation) score has been validated as a risk predictor for mortality, hospitalisation and poorer health status. However, only a small proportion of COPD patients with poor outcomes have high DOSE scores. We sought to establish if clinical characteristics can be used to pre-emptively identify those COPD patients vulnerable to future poor health status by using an electronic database of anonymised patient records-the Hampshire Health Record Analytical Database (HHRA). Methods Within our HHRA database COPD cohort, we identified a cohort of 6890 patients who fell into the ‘low risk’ category by DOSE score (<4). Within this group, a subset met the criteria for poor COPD outcomes over the next four years, defined as; death (all cause), COPD related hospital admission, a DOSE score increase of ≥2 points or a subsequent DOSE score of ≥4 (high risk). We used logistic regression analysis to examine the association between demographic and clinical characteristics documented by Read code at baseline and those who subsequently fell into the poor outcomes subgroup. Results In our ‘low risk’ cohort of 6890 COPD patients, 5000 held sufficient data to be included in the analysis. After four years, 2211 (44.2%) of those 5000 patients fell into the poor outcomes subgroup. As shown in Table 1, poor future outcomes were significantly associated with age, high deprivation decile, low BMI, certain comorbidities, a raised eosinophil percentage (≥2%) and the prescription (in the preceding twelve months) of nebulised bronchodilators, inhaled bronchodilators and an ICS/LABA combination inhaler. A BMI of >25 and rhinosinusitis were associated with a lower risk of poor future outcomes. Conclusions Poor future clinical outcomes appear to be associated with certain clinical characteristics in a COPD database cohort deemed low risk by DOSE score. These findings warrant further validation in a clinical cohort and investigation into the effect of pre-emptive optimisation of these characteristics on health outcomes. Abstract P53 Table 1 Associations between clinical characteristics and odds of future poor clinical outcome *Variables excluded from model due to statistical insignificance: gender, IHD, hypertension, osteoporosis, GORD, diabetes, total number of comotbities. **Decile 10 represents least deprived.

S72 Immunomodulatory effects of carbon particulates on macrophage handling of streptococcal infections

Background and objective Airway macrophages are key to a successful immune response to pulmonary infections. Smoke exposure has been previously shown to result in particulate loading of alveolar macrophages and subsequent impaired macrophage responses to infection with Streptococcus pneumoniae.1 Rheumatic heart disease (RHD) is an autoimmune disorder that follows an airway infection with Streptococcus pyogenes in some individuals. Little is understood about the aetiological factors predisposing the development of RHD but smoke exposure from combustion of solid fuels has recently been epidemiologically linked to RHD. In the context of this epidemiological observation, we hypothesised that smoke exposure would affect macrophage handling of Streptococcus pyogenes in a similar manner to that observed in studies with Streptococcus pneumoniae. Methods Human positively-isolated CD14+ monocyte-derived macrophages (MDM), an established model for alveolar macrophages, were incubated with an optimised dose of carbon particulates. Phagocytosis of Streptococcus pneumoniae and pyogenes was assessed by bacterial culture of macrophages lysates. Autologous CD3+ T cells were co-cultured with infected MDM for 24 h. Expression of cell surface markers, T cell activation and uptake of FITC beads were assessed by flow cytometry. Results Phagocytosis of Streptococcus pneumoniae and pyogenes by carbon loaded MDM was impaired compared to non-carbon loaded MDM (18.8% reduction, p = 0.01). Phagocytosis of FITC beads was also shown to be reduced by the carbon loaded MDM (10% reduction, p = 0.03). Carbon loading decreased MDM surface expression of the phagocytic receptor CD36 (p < 0.01) and decreased the surface expression of antigen presentation molecules HLA-ABC and HLA-DR (p = 0.04 and 0.03 respectively). Addition of S. pyogenes increased expression of HLA-DR only on the cell surface of carbon loaded MDM (p = 0.02). Preliminary results suggest that autologous T cells express IFNγ in response to coculture with infected MDM and that this response is enhanced in carbon loaded MDM. Conclusion We conclude that carbon exerts immunomodulatory effects on MDM phagocytosis of Streptococcus pyogenes and subsequent antigen presentation. Further investigation of this subject in the context of both chronic lung infection and RHD is therefore warranted. Reference Rylance J, et al. Household air pollution causes dose-dependent inflammation and altered phagocytosis in human macrophages. AJRCMB 2015;52(5):584–93.

S93 Pulmonary Matrix Metalloproteinases and Small Airways Disease in COPD – The Origins of Airflow Obstruction?

Introduction and objectives Matrix-metalloproteinases (MMPs) are proteolytic enzymes that can degrade the extra-cellular matrix (ECM) and drive tissue remodelling, key processes in the pathogenesis of COPD. The development of small airway disease and emphysema have been identified as critical mechanisms in the development of airflow obstruction but the contribution of MMPs in human disease is poorly characterised. We investigated the role of MMPs in the lung by quantifying levels and determining relationships with the key pathological components of COPD, measured by CT, in patients and healthy controls. Methods 24 mild and moderate COPD and 8 control subjects were enrolled onto the study and underwent bronchoalveolar lavage (BAL) and high resolution CT. We analysed levels of MMPs in BAL using a Luminex immunoassay. Image analysis, performed using VIDA Apollo software, quantitatively assessed emphysema, bronchial wall thickening and small airways disease. Results Multiple MMPs (MMP-1, -2, -3, -8, -9 and -10) were significantly elevated in the lungs of COPD subjects. MMP -3, -7, -8, -9, -10, and -12 concentrations were closely associated with CT markers of small airways disease (Table 1). Emphysema severity was also associated with MMP-3, -7, -8 and -10. However there were no strong relationships between MMPs and bronchial wall thickness of the larger airways.Abstract S93 Table 1 Linear regression analysis between MMPs and CT measures of disease MMP-1# MMP-2# MMP-3# MMP-7# MMP-8# MMP-9# MMP-10# MMP-12# MMP-13# Emphysema% (LAA%) 0.01 0.02 0.25** 0.23** 0.15* 0.11 0.34** 0.01 0.01 Small airways Disease (E/I MLD) 0.14 0.14 0.53*** 0.29* 0.56*** 0.36** 0.50*** 0.24* 0.00 Bronchial wall area (Pi10) 0.03 0.00 0.00 0.01 0.04 0.01 0.00 0.17* 0.00 R2 values given. #These values were logged to improve normality of residuals. LAA% (n = 31), Pi10 (n = 31) and E/I MLD (n = 22). *p < 0.05 **p < 0.01 ***p < 0.001. Stepwise linear regression analysis identified MMP-10 to be the only significant predictor of emphysema (R2 0.34, p 0.001) that was independent of each of the other MMPs while MMP-8 was the only significant predictor of small airways disease (R2 0.56, p < 0.001) independent of each of the other MMPs. Conclusion Pulmonary MMP concentrations are directly associated with the extent of gas trapping and small airways disease identified on CT scan. This suggests that MMPs may play a significant role in the pathogenesis of COPD by causing breakdown of the pulmonary ECM leading to abnormal remodelling in both the small airways and lung parenchyma. Whilst most previous work has focused on MMPs and emphysema, this study shows the strongest associations were with small airways disease.

S121 Co-morbidity and Pneumonia Risk in COPD Patients: A Population Database Analysis of Primary Care Patients

Background Co-morbidities are common in COPD and have been associated with poorer clinical outcomes. Furthermore, patients with COPD are at an increased risk of developing Community acquired pneumonia (CAP). We investigated the impact of concurrent co-morbidity on the risk of developing CAP, in a cohort of COPD patients identified from the Hampshire Health Record analytical database, a local NHS database containing anonymised primary and secondary care records. Methods Patients defined as having COPD, had a diagnostic Read code (classification of clinical terms for electronic information coding) in their primary care record at any time prior to 1st January 2010 and were aged ≥40 years at the start of the study period. Using clinician-coded diagnoses, CAP episodes which occurred over a 1-year period from the 1st January 2010 were identified using Read and ICD-10 code lists and were defined as taking up to 70 days to resolve. Listed co-morbidities were based on coded entries at any time prior to 1st January 2010. Results Included were 6707 patients with a complete history in 2010 and valid data for all variables considered in the analysis. 55% of patients were men and 36% were current smokers, the mean age was 70 years. 189 patients (2.8%) had at least one CAP episode during 2010. Compared to patients without CAP, patients with CAP were more likely to have ischaemic heart disease (IHD p = 0.005), congestive heart failure (CHF p = 0.021), hypertension (p = 0.017), cerebrovascular disease (CVD p < 0.001), dementia (p < 0.001), and bronchiectasis (p = 0.001). Using logistic regression and controlling for potential confounders, CVD and dementia were independent risk factors for CAP (p = 0.009 and 0.007, respectively), while bronchiectasis trended towards significance (p = 0.073) (Table 1).Abstract S121 Table 1 Co-morbidities associated with CAP occurrence in COPD Conclusion In this large population database analysis, CVD and dementia were identified as being independently associated with an increased risk of CAP. Oro-pharyngeal dysfunction in CVD and use of sedative medications in dementia, may contribute to these findings. Further analysis of the complete cohort, over the full 5-year observation period will allow the formulation of robust conclusions about the important factors of CAP risk in COPD, including the impact of pharmacotherapy, blood markers and functional parameters.

P252 PD-1 Expression on Human Lung T Cells in Health and COPD

Introduction and Objectives Patient s with chronic obstructive pulmonary disease (COPD) are susceptible to the effects of recurrent respiratory infections despite increased numbers of CD8+ T cells in the lungs. We hypothesised that the inability of CD8+ T cells to successfully combat respiratory pathogens in COPD may be due to T cell “exhaustion” - a phenomenon described in chronic infections. Exhausted CD8+ T cells have significantly reduced cytotoxicity and inflammatory cytokine release. Exhaustion is thought to be initiated by the binding of PD-1 on T cells to its ligand (PD-L1) which is expressed on epithelial cells and macrophages. PD-1 expression is upregulated in murine models of acute and chronic viral infection, but this has yet to be elucidated in human cells. We aimed to identify and quantify PD-1+ CD4+ and CD8+ T cells and cells expressing PD-L1 in the lungs of COPD patients and non-COPD controls. Methods Lung tissue from patients undergoing surgery was digested using collagenase to form single-cell suspensions. Lung T cells were identified as populations of CD45+CD3+ cells which were either CD4+CD8- or CD4-CD8+. T cells expressing PD-1 were quantified by multi-colour flow cytometry. Patients with a FEV1/FVC ratio <70% were defined as having COPD. Results The proportion of CD8+ T cells in the COPD lung (mean expression=40.87%, SD=14.67) was significantly higher (p=0.013, students t-test) than in non-COPD (mean expression=26.74%, SD=11.12), reflecting previous findings. PD-1 expression in CD4+ T cells appeared to be lower in COPD (mean expression=39.91%, SD=13.02) than non-COPD (mean expression=50.53%, sd=13.05) but this was not significant. PD-1 expressing CD4+ cells (mean expression=2.17%, SD=1.4) and CD8+ cells (mean expression=6.02%, sd=5.73) were detected in tissue, but not in the blood of the same patients. PD-L1 was undetectable on lung epithelial cells but was expressed on macrophages (mean expression = 2.85%, SD=1.91). Conclusion Elements of the exhaustion pathway are expressed in the human lung in stable COPD. Further work is needed to clarify if there is an upregulation of this pathway in COPD that may explain the susceptibility of these patients to viral exacerbation. Exhaustion of cells recognising respiratory pathogens may have a significant role in COPD outcomes and requires further elucidation.

S106 Influenza Infection of Human Lung Macrophages Increases PDL1 Expression

Background & Objective Influenza infection has recently been shown to cause rapid functional impairment of CD8+ T cell responses in a murine infection model via the PD1/PDL1 pathway.1 In this mouse model, it was the induction of PDL1 that was required for this impairment of CD8+ function. A previous study suggested that the anti-inflammatory cytokine, IL-10, was the principal driver of human macrophage PDL1 expression in response to HIV infection.2 The aim of this study was to investigate how human lung macrophages regulate their PDL1 expression in response to influenza infection. Methods Alveolar macrophages washed from resected human lung tissue and purified by plate adherence or human positively-isolated CD14+ monocyte-derived macrophages (MDMs) were cultured with H3N2 X31 influenza virus or a UV-irradiated aliquot of virus (UVX31) for 2 h, after which the cultures were washed and media replaced and incubation continued for a further 22 h. Virally infected cells and expression of cell surface markers were identified using flow cytometry. Gene expression was measured using RT-PCR. Results No increase in MDM infection was seen using the UVX31 but incubation with X31 resulted in an average infection rate of 9.1%. Infection with X31 significantly increased cell surface expression of HLA-DR and PDL1 (p<0.05), but not of PDL2 by MDMs as measured by flow cytometry. Using RT-PCR, we observed an increase of PDL1 mRNA after X31 infection suggesting that the expression of this protein is transcriptionally regulated. In addition, we saw an increase in type I interferon expression by MDMs in response to X31 infection, but no expression of IFNγ. In contrast we observed a trend towards decreased expression of IL-10 mRNA. In further experiments, infection of alveolar macrophages with X31 also caused significant increases in HLA-DR and PDL1 cell surface expression. Conclusions These data indicate that, in contrast to HIV infection of macrophages2 influenza-induced expression of PDL1 may not be regulated by IL-10 in human macrophages. Erickson et al (2012) J Clin Invest doi: 10.1172/JCI62860. Rodriguez-Garcia, et al. (2011) J Leukoc Biol 89(4):507–15.