Publications by authors named "Konstantina Kontogianni"

29 Publications

  • Page 1 of 1

Fujifilm SILVAMP TB-LAM for the Diagnosis of Tuberculosis in Nigerian Adults.

J Clin Med 2021 Jun 6;10(11). Epub 2021 Jun 6.

Institut d'Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain.

There is a need for diagnostics for tuberculosis (TB) that are easy to use, able to screen non-sputum samples, and able to provide rapid results for the management of both immunocompromised and immunocompetent individuals. The Fujifilm SILVAMP TB LAM (FujiLAM) assay, a new non-sputum based point of need test for the diagnosis of TB, could potentially address most of these needs. We evaluated the performance of FujiLAM in HIV positive and HIV negative patients with presumptive TB attending three district hospitals in Nigeria. Consecutive patients were asked to provide urine samples on the spot, which were tested with FujiLAM. The results were compared against a positive culture and/or Xpert MTB/RIF as the reference standard. Forty-five patients had bacteriologically confirmed TB, and 159 had negative culture and Xpert MTB/RIF (no TB). The FujiLAM test was positive in 23 (sensitivity 65.7%, 95% CI = 48-80) HIV negative and seven (70%, 95% CI = 35-92) HIV positive patients with bacteriological confirmation of TB. FujiLAM was negative in 97 (specificity 99.0%, 95% CI = 94-100) HIV negative and 56 (93.3%, 95% CI = 83-98) HIV positive patients without TB. The FujiLAM test has good diagnostic accuracy for considering its application in both HIV positive and HIV negative patients with TB.
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http://dx.doi.org/10.3390/jcm10112514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8201264PMC
June 2021

Safety and Performance of Transbronchial Cryobiopsy for Parenchymal Lung Lesions.

Chest 2021 May 7. Epub 2021 May 7.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD. Electronic address:

Background: Despite advances in technology, the bronchoscopic diagnosis of parenchymal pulmonary lesions (PPLs) remains difficult to achieve. Transbronchial lung cryobiopsy (TLCB) offers the potential for larger samples with improved diagnostic yield; however, a paucity of data exists describing its safety and usefulness for the diagnosis of PPL.

Research Question: What is the safety profile of TLCB for PPL?

Study Design And Methods: An observational, retrospective, multicenter cohort study enrolled patients without endobronchial disease undergoing TLCB of PPL from 2015 through 2019. All procedures were performed using both rigid and flexible bronchoscopy with a flexible cryoprobe. Complication rates, including bleeding and pneumothorax rates, were collected. Bleeding was graded on a scale from 0 (trace) to 4 (requiring surgical intervention) with a grade of ≥ 3 considered clinically significant. Pneumothorax, tube thoracostomy placement, diagnostic yield, and need for subsequent interventions were recorded.

Results: One thousand twenty-four patients underwent TLCB. One hundred eighty-eight patients (18%) experienced bleeding; in 36 patients (3.5%), the bleeding was clinically significant. Sixty-eight patients (6.6%) demonstrated a pneumothorax and 64 patients (6.3%) required drainage with tube thoracostomy. All chest drains were removed within 4 days, and no cases of prolonged air leak occurred. A definitive diagnosis was achieved in 932 patients (91%). Adenocarcinoma (46%) and metastatic disease (21%) were the most common diagnoses.

Interpretation: TLCB showed an acceptable safety profile and diagnostic yield for the evaluation of PPL in this large retrospective cohort. Prospective clinical trials are underway to validate these findings further.
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http://dx.doi.org/10.1016/j.chest.2021.04.063DOI Listing
May 2021

Self-sampling of capillary blood for SARS-CoV-2 serology.

Sci Rep 2021 04 8;11(1):7754. Epub 2021 Apr 8.

Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.

Serological testing is emerging as a powerful tool to progress our understanding of COVID-19 exposure, transmission and immune response. Large-scale testing is limited by the need for in-person blood collection by staff trained in venepuncture, and the limited sensitivity of lateral flow tests. Capillary blood self-sampling and postage to laboratories for analysis could provide a reliable alternative. Two-hundred and nine matched venous and capillary blood samples were obtained from thirty nine participants and analysed using a COVID-19 IgG ELISA to detect antibodies against SARS-CoV-2. Thirty eight out of thirty nine participants were able to self-collect an adequate sample of capillary blood (≥ 50 µl). Using plasma from venous blood collected in lithium heparin as the reference standard, matched capillary blood samples, collected in lithium heparin-treated tubes and on filter paper as dried blood spots, achieved a Cohen's kappa coefficient of > 0.88 (near-perfect agreement, 95% CI 0.738-1.000). Storage of capillary blood at room temperature for up to 7 days post sampling did not affect concordance. Our results indicate that capillary blood self-sampling is a reliable and feasible alternative to venepuncture for serological assessment in COVID-19.
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http://dx.doi.org/10.1038/s41598-021-86008-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032656PMC
April 2021

Systematic Review of Pooling Sputum as an Efficient Method for Xpert MTB/RIF Tuberculosis Testing during the COVID-19 Pandemic.

Emerg Infect Dis 2021 03;27(3):719-727

GeneXpert-based testing with Xpert MTB/RIF or Ultra assays is essential for tuberculosis diagnosis. However, testing may be affected by cartridge and staff shortages. More efficient testing strategies could help, especially during the coronavirus disease pandemic. We searched the literature to systematically review whether GeneXpert-based testing of pooled sputum samples achieves sensitivity and specificity similar to testing individual samples; this method could potentially save time and preserve the limited supply of cartridges. From 6 publications, we found 2-sample pools using Xpert MTB/RIF had 87.5% and 96.0% sensitivity (average sensitivity 94%; 95% CI 89.0%-98.0%) (2 studies). Four-sample pools averaged 91% sensitivity with Xpert MTB/RIF (2 studies) and 98% with Ultra (2 studies); combining >4 samples resulted in lower sensitivity. Two studies reported that pooling achieved 99%-100% specificity and 27%-31% in cartridge savings. Our results show that pooling may improve efficiency of GeneXpert-based testing.
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http://dx.doi.org/10.3201/eid2703.204090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920689PMC
March 2021

Characterization of DNA methylation in Malawian clinical isolates.

PeerJ 2020 16;8:e10432. Epub 2020 Dec 16.

University of Liverpool, Liverpool, United Kingdom.

Background: Although strains exhibit genomic homology of >99%, there is considerable variation in the phenotype. The underlying mechanisms of phenotypic heterogeneity in are not well understood but epigenetic variation is thought to contribute. At present the methylome of has not been completely characterized.

Methods: We completed methylomes of 18 () clinical isolates from Malawi representing the largest number of genomes to be completed in a single study using Single Molecule Real Time (SMRT) sequencing to date.

Results: We replicate and confirm four methylation disrupting mutations in 4 lineages of . For the first time we report complete loss of methylation courtesy of C758T (S253L) mutation in the gene of Indo-oceanic lineage of . Additionally, we report a novel missense mutation G454A (G152S) in the gene of the Euro-American lineage which could potentially be attributed to total disruption of methylation in the CCCG motif but partial loss in a partner motif. Through a genomic and methylome comparative analysis with a global sample of sixteen, we report previously unknown mutations affecting the locus in L6 isolates. We confirm that methylation in is lineage specific although some unresolved issues still remain.
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http://dx.doi.org/10.7717/peerj.10432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749660PMC
December 2020

Endobronchial Ultrasound Elastography for Differentiating Benign and Malignant Lymph Nodes.

Respiration 2020;99(9):779-783. Epub 2020 Oct 7.

Pneumology and Critical Care medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Endobronchial ultrasound elastography that provides information on tissue stiffness may help distinguish malignant from benign mediastinal and hilar lymph nodes.

Objectives: In this prospective trial, we assessed the diagnostic value of elastographic images and the interobserver agreement in its evaluation.

Method: Elastographic images from 77 lymph nodes in 65 patients were reviewed by 3 pneumologists. The elastographic image was classified based on the predominant colour: predominantly green, intermediary, and predominantly blue. With 2 or 3 interobserver matches, the corresponding elastographic image was correlated with the pathological result obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and/or other invasive procedures.

Results: All 3 reviewers had agreement in classifying elastographic images in 45% (35/77). Overall, the interobserver agreement among the 3 readers for classifying elastographic pattern was found to be moderate (Fleiss Kappa index = 0.519; 95% CI = [0.427; 0.611]). On cytological/histological evaluation, 55 lymph nodes were malignant and 22 were benign. In classifying "green" as benign and "blue" as malignant, the sensitivity and specificity were 71% (95% CI = [54%; 85%]) and 67% (95%-CI = [35%; 90%]), respectively.

Conclusions: Elastography will not replace invasive EBUS-TBNA due to a moderate interobserver agreement and insufficient sensitivity and specificity. However, elastography will, maybe, present an additional feature to identify malignant lymph nodes in the context of clinical, radiological, and cytological results.
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http://dx.doi.org/10.1159/000509297DOI Listing
October 2020

Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure.

Ann Thorac Surg 2021 06 28;111(6):1858-1865. Epub 2020 Sep 28.

Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany.

Background: Bronchoscopic valve placement constitutes an effective endoscopic lung volume reduction (ELVR) therapy in patients with severe emphysema and low collateral ventilation. After the most destroyed lobe is occluded with valves, significant target lobe volume reduction leads to improvements in lung function, exercise capacity, and quality of life. The effects are not consistent in some patients, leading to long-term therapy failure. We hypothesized that surgical lung volume reduction (LVRS) would reestablish ELVR short-term clinical improvements after ELVR long-term failure.

Methods: This retrospective single-center analysis included all patients who underwent consolidating LVRS by lobectomy after long-term failure of valve therapy between 2010 and 2015. Changes in forced expiratory volume in 1 second, residual volume, 6-minute walking distance, and Modified Medical Research Council dyspnea score 90 days after ELVR and LVRS were analyzed, and the outcomes of both procedures were compared.

Results: LVRS was performed in 20 patients after ELVR failure. A lower lobectomy was performed in 90%. The 30-day mortality of the cohort was 0% and 90-day mortality was 5% (1 of 20). The remaining 19 patients showed a significant increase in forced expiratory volume in 1 second (+27.5% ± 19.4%) and a reduction in residual volume (-21.0% ± 17.4%) and total lung capacity (-11.1% ± 11.1%). This resulted in significant improvements in exercise tolerance (6-minute walking distance: +56 ± 60 m) and relief of dyspnea (ΔModified Medical Research Council: -1.8 ± 1.4 points.).

Conclusions: Consolidating LVRS by lobectomy after failure of a previously successful ELVR is feasible and results in significant symptom relief and improvement of lung function.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.148DOI Listing
June 2021

Saliva Alternative to Upper Respiratory Swabs for SARS-CoV-2 Diagnosis.

Emerg Infect Dis 2020 11 11;26(11):2770-2771. Epub 2020 Sep 11.

PCR of upper respiratory specimens is the diagnostic standard for severe acute respiratory syndrome coronavirus 2 infection. However, saliva sampling is an easy alternative to nasal and throat swabbing. We found similar viral loads in saliva samples and in nasal and throat swab samples from 110 patients with coronavirus disease.
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http://dx.doi.org/10.3201/eid2611.203283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588522PMC
November 2020

Efficacy and Safety of the 9-mm Intrabronchial Valve in Patients with Advanced Emphysema.

Respiration 2020;99(4):333-343. Epub 2020 Apr 20.

Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Endoscopic valve therapy aims at lung volume reduction that is associated with improved lung function, exercise tolerance and quality of life in emphysema patients. The size of intrabronchial valves of the Spiration® Valve System (SVS) selected to achieve lobar occlusion may have an influence on treatment outcomes.

Methods: 49 severe emphysema patients (M/F: 24/25, age: 64 ± 7 years), with complete interlobar fissures on the side intended to be treated, underwent treatment with at least one 9-mm intrabronchial valve implantation at 3 centers and were followed up at 30, 90 and 180 days after intervention. Changes in pulmonary function tests (PFT), 6-min walk test (6MWT), modified Medical Research Council (mMRC) dyspnea scale and chronic obstructive pulmonary disease assessment test scores as well as possible complications were recorded.

Results: Forced expiratory volume in 1 s (FEV1) improved significantly over the 6-month period of the study, and the proportion of patients achieving a minimal clinically important difference (MCID) for FEV1 was 46.4% at 6 months. Regarding the remaining PFT values, the changes were not statistically significant at 6 months, but when looking at the MCIDs, 44.4% of the patients achieved the MCID decrease for residual volume. The 6MWT distance also improved statistically significantly, and an MCID increase of ≥26 m was reached by 41.7% of the patients. Furthermore, there was a statistically significant improvement in the mMRC score. The incidence of pneumothoraxes requiring drainage was 26.5% while a valve dislocation rate of 24% was observed but only in the lower lobes.

Conclusions: Endoscopic lung volume reduction with the 9-mm SVS valves was associated with statistically significant but modest improvement of FEV1, mMRC and 6MWT up to 6 months after intervention. These results were accompanied by an anticipated and acceptable risk profile. The relative increased incidence of device dislocation observed needs to be further elucidated.
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http://dx.doi.org/10.1159/000506521DOI Listing
April 2021

PrimeStore MTM and OMNIgene Sputum for the Preservation of Sputum for Xpert MTB/RIF Testing in Nigeria.

J Clin Med 2019 Dec 4;8(12). Epub 2019 Dec 4.

Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.

Background: Xpert MTB/RIF (GX) for tuberculosis (TB) diagnosis is often located in reference laboratories, and sputum needs to be transported using a cold chain. Transport media to preserve sputum are available, but performance data under programmatic conditions are limited.

Methods: Sputum samples were collected from patients with presumptive TB in Nigeria. One sputum was transported in a cold chain, tested immediately with GX and cultured. One sputum was swabbed and stored in PrimeStore-Molecular-Transport-Medium (Primestore), and the remainder was stored in OMNIGene-sputum (Omnigene), kept for seven days and tested with GX.

Results: Of 248 patients, 63 were fresh-sputum culture-positive and 56 GX-positive (sensitivity 88.9%, 95% CI: 78.4-95.4%). Four of 185 culture-negative patients were GX-positive (specificity 97.8%, 94.6-99.4%). Omnigene GX and Primestore GX were positive in 56/62 (90.3%, 80.1-96.4%) and 49/62 (79.0%, 66.8-88.3%) culture-positive, respectively, and 1/185 (99.5%, 97.0-100.0%) and 3/185 (98.4%, 95.3-99.7%) were culture-negative patients. 14 Human Immunodeficiency Virus (HIV)-infected and 44 HIV-uninfected patients were culture-positive. Omnigene and Primestore detected 12/14 (85.7%, 57.2-98.2%) and 5/14 (35.7%, 12.8-64.9%) HIV-infected and 41/44 (93.2%, 81.3-98.6%) HIV-uninfected culture-positive patients. Interpretation Omnigene stored and fresh sputum samples had similar GX results. The GX results of Primestore-stored samples were similar to those found in the fresh sputum of non-HIV infected patients, but GX-positivity was lower in HIV-infected patients. This was likely due to the lower amount of bacilli collected by the swab and transferred to PrimeStore.
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http://dx.doi.org/10.3390/jcm8122146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947270PMC
December 2019

Genetic diversity of clinical isolates in Blantyre, Malawi.

Heliyon 2019 Oct 10;5(10):e02638. Epub 2019 Oct 10.

University of Liverpool, Liverpool, UK.

Despite the high burden of tuberculosis (TB) worldwide, specific factors influencing disease transmission remain elusive. Long term epidemiological studies and in vitro experimental models provide evidence of variable relative fitness of strains but few such studies are available. Large sequence polymorphisms (LSP) are a robust molecular marker and are feasible as an epidemiological investigative tool. Few molecular epidemiological studies have been reported in Malawi owing to lack of laboratories with molecular tools. We characterized the genetic diversity of clinical isolates amongst TB patients in Blantyre, Malawi. We genotyped 64 Mtb clinical isolates using LSP-PCR, assigned specific lineages and confirmed 18 of the isolates using SMRT sequencing. The 64 isolates clustered into 4 lineages (L1-L4) with L4 predominating. There were 10/64 (16%) isolates belonging to L1, 6/64 (9%) belonging to L2, 2/64 (3%) belonging to L3 and 46/64 (72%) belonging to L4. Comparison with a previous study done in Karonga revealed concordance in L1 and L4 but discodance in L2 and L3. The phylogenetic tree constructed, comprised of 3/4 lineages present in Blantyre with 3/18 belonging to L1, 3/18 belonging to L2 and 12/18 belonging to L4. Four lineages were present in Blantyre with L4 predominating. Larger studies are needed to understand the molecular epidemiology of TB in Blantyre in light of increased bi-directional migration with South Africa.
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http://dx.doi.org/10.1016/j.heliyon.2019.e02638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812180PMC
October 2019

Long-term follow up after endoscopic valve therapy in patients with severe emphysema.

Ther Adv Respir Dis 2019 Jan-Dec;13:1753466619866101

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg, Germany.

Background And Objective: Endoscopic valve therapy is a treatment modality in patients with advanced emphysema and absent interlobar collateral ventilation (CV). So far, long-term outcome following valve implantation has been insufficiently evaluated. The aim of this study was to investigate the real-world efficacy of this interventional therapy over 3 years.

Methods: From 2006 to 2013, 256 patients with severe emphysema in whom absent CV was confirmed underwent valve therapy. The 3-year effectiveness was evaluated by pulmonary function testing (VC, FEV, RV, TLC), 6-minute-walk test (6-MWT) and dyspnea questionnaire (mMRC). Long-term outcome was also assessed according to the radiological outcome following valve placement.

Results: Of 256 patients treated with valves, 220, 200, 187, 100 and 66 patients completed the 3-month, 6-month, 1-year, 2-year and 3-year follow-up (FU) visit, respectively. All lung function parameters, 6-MWT and mMRC were significantly improved at 3- and 6-month FU. At 1-year FU, patients still experienced a significant improvement of all outcome parameters expect VC (L) and TLC (%). At 2 years, RV (L and %) and TLC (L and %) remained significantly improved compared to baseline. Three years after valve therapy, sustained significant improvement in mMRC was observed and the proportion of patients achieving a minimal clinically important difference from baseline in RV and 6-MWT was still 71% and 46%, respectively. Overall, patients with complete lobar atelectasis exhibited superior treatment outcome with 3-year responder rates to FEV, RV and 6-MWT of 10%, 79% and 53%, respectively.

Conclusions: Patients treated by valves experienced clinical improvement over 1 year following valve therapy. Afterwards, clinical benefit gradually declines more likely due to COPD progression.
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http://dx.doi.org/10.1177/1753466619866101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681249PMC
March 2020

Survival after Endoscopic Valve Therapy in Patients with Severe Emphysema.

Respiration 2019;97(2):145-152. Epub 2018 Sep 18.

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Endoscopic valve therapy leads to an improvement of lung function, exercise tolerance, and quality of life in a selected cohort of patients with advanced emphysema. So far, only few data exist on the long-term outcome.

Objectives: This analysis evaluated the impact of valve therapy on the survival of emphysema patients.

Methods: Survival rates of emphysema patients who underwent valve therapy were assessed according to their radiological outcome following valve placement.

Results: From 2005 to 2013, 449 emphysema patients (mean age 64 ± 7 years) underwent valve therapy and were followed for a mean time of 37.3 ± 21.3 months. A total of 128 patients (29%) developed complete lobar atelectasis, 34 out of these also experienced a pneumothorax; 50 patients (11%) developed pneumothorax without lobar atelectasis, and 261 patients (58%) target lobe volume reduction or no volume change. Patients with atelectasis showed significantly better baseline forced expiratory volume in 1 second (%), residual volume (L), total lung capacity (L), and transfer factor for carbon monoxide (%; all p < 0.05), but there was no significant difference in the BODE score (p = 0.195). Patients with valve-induced lobar atelectasis had a significant survival benefit compared to patients without atelectasis (p = 0.009; 5-year survival rate 65.3 vs. 43.9%). The advent of pneumothorax in 84 patients did not influence survival (p = 0.52).

Conclusions: Lobar atelectasis following endoscopic valve therapy is associated with a survival benefit.
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http://dx.doi.org/10.1159/000492274DOI Listing
April 2020

Clinical and quantitative computed tomography predictors of response to endobronchial lung volume reduction therapy using coils.

Int J Chron Obstruct Pulmon Dis 2018 20;13:2215-2223. Epub 2018 Jul 20.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany,

Objectives: Bronchoscopic lung volume reduction using coils (LVRC) is a well-known treatment option for severe emphysema. The purpose of this study was to identify quantitative computed tomography (QCT) and clinical parameters associated with positive treatment outcome.

Patients And Methods: The CT scans, pulmonary function tests (PFT), and 6-minute walk test (6-MWT) data were collected from 72 patients with advanced emphysema prior to and at 3 months after LVRC treatment. The procedure involved placing 10 coils unilaterally. Various QCT parameters were derived using Apollo imaging software (VIDA). Independent predictors of clinically relevant outcome (Δ6-MWT ≥ 26 m, ΔFEV ≥ 12%, ΔRV ≥ 10%) were identified through stepwise linear regression analysis.

Results: The response outcome for Δ6-MWT, for ΔFEV and for ΔRV was met by 55%, 32% and 42%, respectively. For Δ6-MWT ≥ 26 m a lower baseline 6-MWT ( = 0.0003) and a larger standard deviation (SD) of low attenuation cluster (LAC) sizes in peripheral regions of treated lung ( = 0.0037) were significantly associated with positive outcome. For ΔFEV ≥ 12%, lower baseline FEV ( = 0.02) and larger median LAC sizes in the central regions of treated lobe ( = 0.0018) were significant predictors of good response. For ΔRV ≥ 10% a greater baseline TLC ( = 0.0014) and a larger SD of LAC sizes in peripheral regions of treated lung ( = 0.007) tended to respond better.

Conclusion: Patients with lower FEV and 6-MWT, with higher TLC and specific QCT characteristics responded more positively to LVRC treatment, suggesting a more targeted CT-based approach to patient selection could lead to greater efficacy in treatment response.
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http://dx.doi.org/10.2147/COPD.S159355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055902PMC
January 2019

Endoscopic Valve Removal >180 Days since Implantation in Patients with Severe Emphysema.

Respiration 2018;96(4):348-354. Epub 2018 Jul 24.

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Valve implantation provides a reversible effective therapy in a selected group of emphysema patients. Knowing predictors for successful therapy, the rate of treatment failure has decreased. Some patients, however, do not benefit, so that the valves may have to be removed.

Objectives: To assess implant-related events, complications during valve removal, and clinical outcome after endoscopic procedure.

Methods: The data of 76 consecutive emphysema patients who underwent valve removal > 6 months since implantation were collected.

Results: Seventy-six patients (mean age 62 years, 54% male) underwent removal of all valves after a mean time of 624 days (193-3,043 days) since implantation. Granulation tissue was observed in 39.5% (30/76) and significant secretion in 34.2% (26/76). In 5.3% (4/76), valve removal was complicated requiring another bronchoscopy in 2 of them. In 5.3% (4/76) of the patients, one valve could not be removed and remained in situ. Bleeding requiring intervention occurred in 3.9% (3/76) during valve removal. Following bronchoscopy, there was a need for antibiotics in 34.2% (26/76), glucocorticosteroids in 1.3% (1/76), and both in 6.6% (5/76) due to productive cough or chronic obstructive pulmonary disease (COPD) exacerbation. Due to respiratory failure, invasive ventilation or noninvasive ventilation was necessary in 2.6% (2/76) and 6.6% (5/76), respectively, following procedure. No statistical significant change in lung function was observed following valve removal.

Conclusions: Valve removal after > 6 months since implantation is feasible and associated with an acceptable safety profile. However, close monitoring of these patients with limited pulmonary reserve is recommended with particular attention to COPD exacerbations and respiratory failure.
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http://dx.doi.org/10.1159/000489887DOI Listing
October 2019

Endoscopic approaches for treating emphysema.

Expert Rev Respir Med 2018 08 4;12(8):641-650. Epub 2018 Jul 4.

a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.

Introduction: Surgical treatment of severe pulmonary emphysema has so far been associated with relatively high perioperative morbidity and mortality. In the past two decades, novel approaches to lung volume reduction and alternative minimally invasive endoscopic techniques have been developed. This review presents the different techniques (blocking and nonblocking) available until present as well as the appropriate patient selection and possible complications. Areas covered: All available randomized controlled trials (RCTs) have been evaluated. The only blocking technique is the reversible valve implantation. It results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation and its efficacy has been confirmed in various RCTs. Non-blocking techniques that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation, and the polymeric lung volume reduction both inducing inflammatory reaction. These methods have been up to date examined in a few RCTs only. Finally, the targeted lung denervation aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. Expert commentary: Future studies must address the predictors of clinical outcome as well as the reduction of complications to improve both outcome and safety.
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http://dx.doi.org/10.1080/17476348.2018.1491794DOI Listing
August 2018

New bacterial growth in bronchial secretions after bronchoscopic valve implantation.

Int J Chron Obstruct Pulmon Dis 2018 8;13:565-570. Epub 2018 Feb 8.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg.

Background: Bronchoscopic valve implantation is an established treatment in selected patients with severe lung emphysema. There is evidence in literature of increased bacterial colonization of various implants. So far, it is unclear if an increased bacterial colonization can also be observed after endoscopic valve therapy.

Methods: Retrospective analysis of patients with examination of the bronchial secretions for presence or change of bacterial growth before and after valve implantation.

Results: Overall, 144 patients who underwent bronchoscopic follow-up after valve implantation were included in this analysis. Prior to valve placement, only 7 out of 144 consecutive emphysema patients (5%) presented with evidence of bacterial colonization, whereas 137 patients (95%) showed no bacterial growth prior to valve placement. One hundred seven out of the 137 patients (78%) showed new bacterial growth after valve implantation. Almost 38% of the patients who presented with a new bacterial growth had evidence of , and species simultaneously, as bacterial colonization. Pathogenic bacterial growth was recorded for (18%), (13%) and (9%) microorganisms. There was also a significant bacterial growth by (26%) and anaerobic bacteria (23%), especially in patients with complete atelectasis after successful endoscopic lung volume reduction. For all of the 7 patients, the presented initial bacterial colonization showed a change in the flora after bronchoscopy valve implantation.

Conclusion: In this study we observed an increased bacterial colonization in the long term after valve implantation. This finding needs further evaluation regarding its possible clinical relevance but should be taken into consideration in the follow-up of these patients.
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http://dx.doi.org/10.2147/COPD.S148196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810521PMC
September 2018

Coil therapy for patients with severe emphysema and bilateral incomplete fissures - effectiveness and complications after 1-year follow-up: a single-center experience.

Int J Chron Obstruct Pulmon Dis 2017 23;12:383-394. Epub 2017 Jan 23.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg; Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany.

Background: Lung volume reduction coil (LVRC) treatment is established in daily endoscopic lung volume reduction routine. The aim of this study was to evaluate the safety and efficacy of LVRC treatment.

Patients And Methods: This was a retrospective analysis of 86 patients (male/female: 40/46, mean age: 64±7 years) with severe COPD and bilateral incomplete fissures. A total of 10 coils were unilaterally implanted in a single lobe, and 28 out of 86 patients were treated bilaterally. At 90-, 180-, and 365-day follow-up, changes in pulmonary function test (PFT), 6-minute walk test (6MWT) and modified Medical Research Council (mMRC) dyspnea scale, as well as possible complications, were recorded.

Results: At 90 days, the forced expiratory volume in 1 second did improve (<0.001), but the improvement was not sustained at the 180- and 365-day follow-up (baseline: 0.71±0.21 vs 0.77±0.23 vs 0.73±0.22 vs 0.70±0.18 L). Both vital capacity and residual volume improved significantly (<0.001) at the 90- and 180-day follow-up, but the improvement was lost after 365 days. Total lung capacity decreased at the 90-day follow-up but returned to baseline values at the 180- and 365-day follow-up. 6MWT (=0.01) and mMRC (=0.007) also improved at 90 and 180 days (Δ6MWT of 31±54 and 20±60 m, respectively), but the improvement was also lost at the 365-day follow-up. No significant further improvement was evident at any point in the follow-up after the second procedure. A total of 4 out of 86 patients passed away due to complications. Significant complications in the first 3 months and then at 12 months included the following: severe hemoptysis in 4 (3.5%) and 4 (3.5%) patients, pneumonia requiring hospitalization in 32 (28.1%) and 9 (7.9%) patients and pneumothorax in 7 (6.1%) and 2 (1.7%) patients, respectively. Milder adverse events included self-limited hemoptysis, pneumonias, or COPD exacerbations treated orally.

Conclusion: LVRC improved PFT, 6MWT and mMRC initially, but the improvement was lost after 365 days. Furthermore, we observed 4 deaths and significant severe complications, which need to be further elucidated.
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http://dx.doi.org/10.2147/COPD.S117655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5271380PMC
August 2017

Lung Volume Reduction with Vapor Ablation in the Presence of Incomplete Fissures: 12-Month Results from the STEP-UP Randomized Controlled Study.

Respiration 2016 12;92(6):397-403. Epub 2016 Nov 12.

Department of Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany.

Background: Emphysema patients with collateral ventilation (CV) will not benefit from valve therapy, the most common endoscopic lung volume reduction procedure. A recent randomized controlled trial (STEP-UP) of the alternative bronchoscopic thermal vapor ablation (BTVA) included patients with (CV+) and without interlobar CV (CV-).

Objectives: This analysis evaluated the efficacy and safety of the CV+ population following BTVA.

Method: A post hoc fissure analysis of the baseline computed tomography of all treatment and control patients was performed with the VIDA Diagnostics Apollo software. A patient was considered to be CV+ if either of the treated upper lobes was adjacent to a fissure that was <90% complete. The primary endpoints, forced expiratory volume in 1 s (FEV1) and St. George's Respiratory Questionnaire (SGRQ-C), were calculated for these CV+ patients following BTVA and safety results summarized.

Results: 78% (35/45) of the patients in the treatment arm and 79% (19/24) of the patients in the control arm were found to be CV+. At 12 months, the FEV1 improvement of the treatment arm was 9.2%, as compared with a decrease of 5.4% in the control group, resulting in a mean between-group difference of 14.6% (p = 0.0137). The improvement in SGRQ-C of the treatment arm as compared to the control arm was 8.4 points (p = 0.0712). An increase in respiratory related serious adverse events was observed immediately following treatment, but most resolved with routine care.

Conclusion: BTVA can achieve safe and clinically meaningful improvement in pulmonary function and quality of life in patients with CV. These randomized controlled trial subgroup results offer proof of a viable solution for CV+ patients.
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http://dx.doi.org/10.1159/000452424DOI Listing
September 2017

Low interleukin (IL)-18 levels in sputum supernatants of patients with severe refractory asthma.

Respir Med 2015 May 19;109(5):580-7. Epub 2015 Mar 19.

National and Kapodistrian University of Athens, 2nd Department of Pulmonary Medicine, "Atticon" Hospital, Athens Medical School, Greece.

Background: Severe refractory asthma (SRA) is characterized by persistent asthma symptoms, amplified airway inflammation despite treatment with high dose inhaled steroids and increased airway bacterial colonization. Interleukin (IL)-18 is a pleiotropic pro-inflammatory cytokine that modulates airway inflammation. Furthermore, as a product of the inflammasome, IL-18 is involved in host defence against viral and bacterial stimuli by modulating the immune response.

Objective: To determine IL-18 levels in sputum supernatants of patients with asthma and to investigate whether underlying severity affects its levels. Furthermore, possible associations with atopy and mediators and cells involved in the inflammatory process of the airways were examined.

Methods: Forty-five patients with mild intermittent asthma (21 smokers) and 18 patients with SRA in stable state were studied. All subjects underwent lung function tests, skin prick tests, and sputum induction for cell count identification. IL-18 and ECP levels were measured in sputum supernatants. Furthermore, sputum samples were examined for the commonest respiratory pathogens and viruses by real time polymerase chain reaction (RT-PCR).

Results: Patients with SRA had significantly lower IL-18 levels in sputum supernatants compared to mild asthmatics (p < 0.001). Twelve out of eighteen patients with SRA were colonized by viruses and/or bacterial pathogens. IL-18 levels correlated with the percentage of macrophages (r = 0.635, p = 0.026) and inversely correlated with the percentage of neutrophils in sputum (r = -0.715, p = 0.009). No correlations were found between IL-18, ECP and the percentage of eosinophils in the sputum of SRA.

Conclusions: In SRA IL-18 is possibly involved in chronic airway inflammation through an eosinophil independent pathway. The decreased levels of IL-18 in SRA support the hypothesis of deregulated inflammasome activation, justifying the susceptibility of these patients for bacterial colonization or infection.
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http://dx.doi.org/10.1016/j.rmed.2015.03.002DOI Listing
May 2015

Endoscopic lung volume reduction with endobronchial valves in patients with severe emphysema and established pulmonary hypertension.

Respiration 2015 4;89(1):41-8. Epub 2014 Dec 4.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: One of the most common forms of pulmonary hypertension (PH) is that associated with chronic obstructive pulmonary disease (COPD). So far, patients with severe emphysema and established PH have been excluded from endoscopic lung volume reduction (ELVR) therapy due to the risk of right heart decompensation.

Objective: The aim of this pilot study was to evaluate the feasibility and efficacy of ELVR using one-way endobronchial valves (EBV) in this specific group of patients.

Methods: We prospectively included 6 patients with COPD, severe heterogeneous emphysema, and established PH who underwent right heart catheterization and clinical assessments before and 90 days after ELVR with unilateral EBV placement.

Results: This study was not powered to measure any statistical differences in endpoints. Ninety days after ELVR, the symptoms, lung function, and hemodynamics improved in 5 out of 6 patients (1 patient normalized and 1 slightly worsened). The mean hemodynamics improved from baseline to 90 days after ELVR as follows: mean pulmonary artery pressure, -2.5 ± 3.5 mm Hg; pulmonary arterial wedge pressure, -4.3 ± 8.3 mm Hg; cardiac index, +0.3 ± 0.6 l/min/m(2), and 6-min walk distance, +59 ± 99 m. ELVR was performed without PH-related complications in all patients.

Conclusion: To our knowledge, this is the first prospective, single-center pilot study to evaluate the feasibility and efficacy of ELVR in patients with established PH. ELVR was feasible and resulted in an improvement of clinical and hemodynamic parameters in 5 out of 6 patients. These results have to be further confirmed in larger-scale controlled studies.
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http://dx.doi.org/10.1159/000368369DOI Listing
December 2015

Effectiveness of endobronchial coil treatment for lung volume reduction in patients with severe heterogeneous emphysema and bilateral incomplete fissures: a six-month follow-up.

Respiration 2014 10;88(1):52-60. Epub 2014 May 10.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany.

Background: Treatment with lung volume reduction coils (LVRC) may be effective in patients with severe heterogeneous emphysema and incomplete fissures.

Objective: We hypothesized that LVRC placement improves pulmonary function, exercise tolerance and quality of life in these patients.

Methods: Twenty-six patients with chronic obstructive pulmonary disease (COPD), 13 males and 13 females, aged 66 ± 8 years with heterogeneous emphysema and incomplete fissures were included in this retrospective analysis. The coils were implanted unilaterally in the upper or lower lobe. Patients were followed up at 30, 90 and 180 days after treatment and changes in pulmonary function test and 6-minute-walk-test (6MWT) values as well as scores for the modified Medical Research Council (mMRC) dyspnea scale and the St. George's Respiratory Questionnaire (SGRQ) were recorded.

Results: FEV1 improved significantly at 90 days and tended to decrease at the 180-day follow-up (0.67 ± 0.17 vs. 0.78 ± 0.25 vs. 0.73 ± 0.21 liters, respectively, p < 0.001). The 6MWT score had improved significantly at 90 days and had tended to decrease at the 180-day follow-up (216 ± 107 vs. 262 ± 97 vs. 262 ± 112 m, respectively, p = 0.001). SGRQ was significantly improved at 90 days. Multivariate analysis showed that worse 6MWT performance at baseline was independently associated with a greater improvement in 6MWT at the 90-day follow-up. The total complication rate was 54% (n = 14) and included light hemorrhage in 6 patients, COPD exacerbation in 6, pneumothorax in 1 and both COPD exacerbation and pneumothorax in 1 patient.

Conclusions: This is the first study to show that LVRC in patients with heterogeneous emphysema and incomplete fissures improves exercise capacity, quality of life and lung function up to 90 days after the intervention. Further studies are needed to assess the long-term effects of LVRC in these patients.
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http://dx.doi.org/10.1159/000358441DOI Listing
March 2015

Levels of angiopoietins 1 and 2 in induced sputum supernatant in patients with COPD.

Cytokine 2012 Jun 6;58(3):455-60. Epub 2012 Apr 6.

2nd Respiratory Medicine Department, University of Athens Medical School, Attikon Hospital, Athens, Greece.

Pathological features of chronic obstructive pulmonary disease (COPD) include lung vascular remodeling and angiogenesis. Angiopoietin-1 (Ang-1), is an essential mediator of angiogenesis by establishing vascular integrity, whereas angiopoietin-2 (Ang-2) acts as its natural inhibitor. We determined the levels of angiopoietins in sputum supernatants of patients with COPD and investigated their possible association with mediators and cells involved in the inflammatory and remodeling process. Fifty-nine patients with COPD, 25 healthy smokers and 20 healthy non-smokers were studied. All subjects underwent lung function tests, sputum induction for cell count identification and Ang-1, Ang-2, VEGF, TGF-β1, MMP-2, LTB4, IL-8, albumin measurement in sputum supernatants. Airway vascular permeability (AVP) index was also assessed. Ang-2 levels were significantly higher in patients with COPD compared to healthy smokers and healthy non-smokers [median, interquartile ranges pg/ml, 267 (147-367) vs. 112 (67-171) and 98 (95-107), respectively; p<0.001]. Regression analysis showed a significant association between Ang-2 levels and AVP index, VEGF, IL-8 and MMP-2 levels in COPD, the strongest being with VEGF. Our results indicate that induced sputum Ang-2 levels are higher in COPD compared to healthy smokers and healthy non-smokers. Moreover, Ang-2 is associated with AVP, IL-8, MMP-2, and VEGF, indicating a possible role for Ang-2 in the pathogenesis of the disease.
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http://dx.doi.org/10.1016/j.cyto.2012.03.007DOI Listing
June 2012

Associations between BODE index and systemic inflammatory biomarkers in COPD.

COPD 2011 Dec;8(6):408-13

2nd Respiratory Medicine Department, University of Athens Medical School, Attikon Hospital, Rimini 1, Athens, Greece.

Background: COPD is a multicomponent disease and systemic inflammation represents one of the possible mechanisms responsible for its systemic manifestations, including skeletal muscle weakness and cachexia. Fat-free mass index (FFMI) that reflects the skeletal muscle mass, has been shown to be associated with both dyspnoea and exercise capacity. We hypothesized that the multidimensional BODE index, that reflects the multicomponent nature of COPD, might be related to biomarkers of systemic inflammation. We further evaluated associations between FFMI and systemic inflammation.

Methods: BODE index and FFMI were calculated in 222 stable COPD patients and 132 smokers or ex-smokers with normal lung function. Systemic inflammation was evaluated with the measurement of leptin, adiponectin, CRP, IL-6, and TNF-α in serum samples of COPD patients.

Results: In patients with COPD, both BODE index and FFMI presented significant positive and negative associations respectively with leptin levels (R(2) 0.61 and 0.65, respectively), whereas FFMI presented an additional negative association with the levels of TNF-α (R(2) 0.38). No significant associations were observed in smokers or ex-smokers with normal lung function.

Conclusions: Both BODE index and FFMI, are related to the circulating levels of leptin in patients with COPD, suggesting a possible role for leptin in the systemic component of COPD. The additional association of FFMI with TNF-α may further support a role of systemic inflammation in muscle wasting in COPD.
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http://dx.doi.org/10.3109/15412555.2011.619599DOI Listing
December 2011

Exhaled breath condensate pH as a biomarker of COPD severity in ex-smokers.

Respir Res 2011 May 22;12:67. Epub 2011 May 22.

Respiratory Medicine Department, University of Thessaly Medical School, Larissa, Greece.

Endogenous airway acidification, as assessed by exhaled breath condensate (EBC) pH, is present in patients with stable COPD. The aim of this study was to measure EBC pH levels in a large cohort of COPD patients and to evaluate associations with functional parameters according to their smoking status.EBC was collected from 161 patients with stable COPD and 112 controls (current and ex-smokers). EBC pH was measured after Argon deaeration and all subjects underwent pulmonary function testing.EBC pH was lower in COPD patients compared to controls [7.21 (7.02, 7.44) vs. 7.50 (7.40, 7.66); p < 0.001] and ex-smokers with COPD had lower EBC pH compared to current smokers [7.16 (6.89, 7.36) vs 7.24 (7.09, 7.54), p = 0.03]. In ex-smokers with COPD, EBC pH was lower in patients with GOLD stage III and IV compared to patients with stage I disease (p = 0.026 and 0.004 respectively). No differences were observed among current smokers with different disease severity. EBC pH levels in ex-smokers were associated with static hyperinflation (as expressed by IC/TLC ratio), air trapping (as expressed by RV/TLC ratio) and diffusing capacity for carbon monoxide, whereas no associations were observed in current smokers.Endogenous airway acidification is related to disease severity and to parameters expressing hyperinflation and air trapping in ex-smokers with COPD. The possible role of EBC pH in COPD needs to be further evaluated in longitudinal studies.
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http://dx.doi.org/10.1186/1465-9921-12-67DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120669PMC
May 2011

Exhaled nitric oxide and exhaled breath condensate pH as predictors of sputum cell counts in optimally treated asthmatic smokers.

Respirology 2011 Jul;16(5):811-8

First Respiratory Medicine Department, University of Athens Medical School, Sotiria Chest Diseases Hospital, Athens, Greece.

Background And Objective: Smoking is thought to modify the pattern of airway inflammation. Induced sputum provides useful information on cellular phenotype in inflammatory airways disorders; however, it is time-consuming and difficult to implement in everyday clinical practice. The aim of this study was to determine whether exhaled NO (FeNO) and exhaled breath condensate (EBC) pH differed in asthmatic smokers compared with asthmatic non-smokers and healthy subjects, and to evaluate the performance of FeNO and EBC pH for predicting the cellular phenotype of induced sputum.

Methods: Asthmatic smokers (n = 40) and non-smoking asthmatic patients (n = 43) were recruited for the study. Healthy smoking (n = 30) or non-smoking (n = 30) subjects served as controls. FeNO and EBC pH were measured and all subjects underwent sputum induction for assessment of cell counts.

Results: EBC pH was significantly lower in asthmatic smokers compared with non-smokers (P < 0.01). FeNO levels were also significantly lower in asthmatic smokers compared with non-smokers (P < 0.001). EBC pH was inversely associated with sputum eosinophils in both asthmatic smokers and non-smokers (P < 0.001), whereas it was inversely associated with sputum neutrophils only in asthmatic smokers (P < 0.001). FeNO was positively associated with sputum eosinophils both in asthmatic smokers and non-smokers (P < 0.001) but was not associated with sputum neutrophils. In asthmatic smokers, FeNO was a better predictor of sputum eosinophilia, whereas EBC pH was a better predictor of sputum neutrophilia. A combination of FeNO ≤ 14 ppb together with EBC pH > 7.20 predicted the paucigranulocytic induced sputum phenotype.

Conclusions: EBC pH and FeNO levels were significantly lower in asthmatic smokers compared with non-smokers. Combined specific cut-off levels for FeNO and EBC pH may predict the paucigranulocytic phenotype in asthmatic smokers.
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http://dx.doi.org/10.1111/j.1440-1843.2011.01984.xDOI Listing
July 2011

DNA damage and repair capacity in lymphocytes from obstructive sleep apnea patients.

Environ Mol Mutagen 2007 Dec;48(9):722-7

Faculty of Human Sciences, Department of Pre-School Education, Biology Unit, University of Thessaly, Volos, Greece.

Obstructive sleep apnea (OSA) syndrome is a respiratory disease that is linked to heart attacks and high blood pressure. In the present study, we used the Comet assay to compare basal DNA damage and DNA damage induction by hydrogen peroxide, ethanol, and gamma-irradiation in lymphocytes from 35 OSA patients and 35 controls. We also measured the apoptosis and necrosis produced by these agents and the ability of the lymphocytes to repair the induced DNA damage. It was found that lymphocytes isolated from OSA patients had higher basal levels of DNA damage and were more sensitive to the effects of the DNA-damaging agents than lymphocytes from controls. OSA patients also had a reduced capacity to repair the DNA damage induced by the three agents, but apoptosis and necrosis were similar in OSA patients and the controls.
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http://dx.doi.org/10.1002/em.20351DOI Listing
December 2007

Effects of pesticides on occupationally exposed humans.

ScientificWorldJournal 2006 Sep 25;6:1211-20. Epub 2006 Sep 25.

Biology Unit, Department of Pre-School, Education, University of Thessaly, Argonafton and Filellinon Streets, Volos, Greece.

Pesticides are known to contain numerous genotoxic compounds; however, genotoxicity biomonitoring studies of workers occupationally exposed to pesticides have produced variable results. In this study, we employed the Comet assay to examine DNA damage in peripheral blood lymphocytes (PBLs) from 64 greenhouse workers from Almería in south-eastern Spain in comparison to PBLs from 50 men from the same area but not engaged in any agricultural work. The results indicated that there were no differences in the basal levels of DNA damage in the two study groups. In addition, exposure of PBL from the workers and controls to hydrogen peroxide or gamma-irradiation led to similar levels of DNA damage; the subsequent repair of the induced DNA damage was also similar for both study populations. Smoking had no impact on any of the responses. The results of this study indicate that the greenhouse workers had no detectable increase in DNA damage or alteration in the cellular response to DNA damage compared to our control population.
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http://dx.doi.org/10.1100/tsw.2006.207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5917114PMC
September 2006
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