Alpha One International Registry Research


ADAPT Research
Professor R. A. Stockley started work into the pathogenesis of chronic lung disease in the early 1970s. He established many of the biochemical and cell biological methods that are currently used for the assessment of lung inflammation in the research and management of chronic lung disease. This led to Professor Stockley being awarded a Doctor of Science degree at the University of Birmingham in 1986. Professor Stockley established the lung immunobiochemical research laboratory in 1979 which put together a unique blend of clinical medicine and basic research. Together with Dr. S. L. Hill, Professor Stockley developed an extensive clinical research programme into understanding the causes, effects and management of chronic lung disease. This programme has resulted in new understandings of the processes involved in lung disease and the development of new treatments based on this understanding.

The research group has published in excess of 250 peer reviewed papers on different aspects of acute and chronic lung disease. In addition more than 50 chapters and review articles have been published and Professor Stockley has edited 5 books on the basic science of chronic lung disease. Over the years more than 50 Clinicians and scientists have been trained in the management of patients and research into chronic lung disease. This has resulted in 18 Clinicians and Scientists obtaining PhDs and 8 Clinicians obtaining MDs over the past 20 years. In the last 2 years 15 papers on alpha-1-antitrypsin deficiency have been published by the group and 4 chapters have been written and are currently in press in major text books on the causes and management of lung disease especially in ?1 AT deficiency.

Of most importance the group has confirmed and established the importance of high resolution CT scanning to assess and monitor the lung disease of alpha-1-antitrypsin deficiency. This work alone has led to realisation of the first controlled clinical trial to be carried out in alpha-1-antitrypsin deficiency.

The current research programme includes further understanding of the methods of assessing exercise to determine the impact of alpha-1-antitrypsin deficiency, the role of chronic cough and sputum production, the influence of bacteria in the airways, the nature, role and management of exacerbations and the relationship of all these factors to the patients health and symptoms.

Most notably the first controlled clinical trial of inhaled alpha-1-antitrypsin deficiency is about to be undertaken as a collaborative programme on an international basis the ADAPT centre will be co-ordinating between 100 and 200 patients in the UK alone (which is almost half the patients needed for the clinical trial). The study will be carried out predominantly in Birmingham but in collaboration with centres being established in Edinburgh under the management of Professor W. MacNee, in Leeds under Dr. M. Elliott and in Cambridge under Professor D. Lomas.

Whilst the clinical trial is underway other studies are planned including the role and management of asthma in alpha-1-antitrypsin deficiency, the role of pollution, genetic factors other than alpha-1-antitrypsin deficiency that influence the development of disease and its progression, newer ways of treating alpha-1-antitrypsin deficiency and finally the relationship of the severity of lung disease in alpha-1-antitrypsin deficiency to the use of healthcare resources.

Thorax 2003 Jan;58(1):73-80

Chronic obstructive pulmonary disease . 6: The aetiology of exacerbations of
chronic obstructive pulmonary disease.

White AJ, Gompertz S, Stockley RA.

Department of Respiratory Medicine, Queen Elizabeth Hospital, Edgbaston,
Birmingham B15 2TH, UK.

Exacerbations of COPD are thought to be caused by interactions between host
factors, bacteria, viruses, and changes in air quality to produce increased
inflammation in the lower airway. The evidence for this and the potential
mechanisms by which they result in the characteristic symptoms of exacerbations
is reviewed. A better understanding of the causes and processes is needed for
the appropriate use of existing treatments and the development of new ones.
Future studies need to define populations clearly, stratify for known
confounding factors, and should aim to identify clinical correlates so that
clinical practice can be modified appropriately.

Eur Respir J 2002 Oct;20(4):1050-6

Alpha1-antitrypsin deficiency: a report from the 2nd meeting of the Alpha One
International Registry, Rapallo (Genoa, Italy), 2001.

Luisetti M, Miravitlles M, Stockley RA.

Dept of Respiratory Diseases, IRCCS San Matteo, Pavia, Italy.
m.luisetti@smatteo.pv.it

The Alpha One International Registry is a scientific foundation established to
comply with a World Health Organization recommendation to develop a
multinational registry of alpha1-antitrypsin deficiency, with the aim of
creating a common database of subjects recognised in a standardised way. A
commitment of the Alpha One International Registry members, belonging to 15
national registries, is to meet every 2 yrs in an open scientific conference to
provide a scientific and clinical update on the deficiency. The second Alpha One
International Registry meeting was held in Rapallo (Genoa, Italy) on September
27th-28th, 2001, and 26 speakers provided an exhaustive overview of all aspects
of alpha1-antitrypsin deficiency, including epidemiology, genetics,
biochemistry, associated conditions, established and novel therapeutic options,
and markers of efficacy. In the framework of a rare and often under-recognised
condition, this meeting is likely to be central to improving understanding and
increasing awareness of alpha1-antitrypsin deficiency.

Chest 2002 Oct;122(4):1247-55

The relationship of chronic sputum expectoration to physiologic, radiologic, and
health status characteristics in alpha(1)-antitrypsin deficiency (PiZ).

Dowson LJ, Guest PJ, Stockley RA.

Lung Investigation Unit, Nuffield House, Queen Elizabeth University Hospital,
Birmingham B15 2TH, UK.

STUDY OBJECTIVES: First, to determine the relationships among chronic sputum
expectoration (CSE), exacerbations, airflow obstruction, and emphysema in
patients with alpha(1)-antitrypsin deficiency (alpha(1)-ATD) [PiZ]. Second, to
use multivariate analysis to determine how these factors influence health
status. DESIGN: Cross-sectional, single-center. SETTING: UK center for
alpha(1)-ATD, university teaching hospital. PATIENTS: One hundred seventeen
nonsmoking patients underwent lung function testing, high-resolution CT (HRCT)
scanning with density mask analysis, and health status assessment using the St.
George's Respiratory Questionnaire (SGRQ) and short form 36 (SF-36) health
survey questionnaire. RESULTS: Patients with CSE (n = 50) had worse
postbronchodilator airflow obstruction than those who did not (p = 0.03), with a
median FEV(1) of 1.15 L (interquartile range [IQR], 0.76 to 1.82) vs 1.44 L
(IQR, 0.99 to 2.93), respectively, and higher HRCT scan voxel index (VI) values
indicating more extensive emphysema (patients with CSE: median lower zone VI,
50; IQR, 28 to 61; patients without CSE: median lower zone VI, 41; IQR, 5 to 53;
p = 0.04). Patients with CSE also had worse health status, as assessed by the
SGRQ (p < 0.01 for all domains) and SF-36 questionnaire (p < 0.05 for seven of
nine domains). Exacerbation frequency was greater in those patients with CSE (p
< 0.001), with a median of two episodes per year (IQR, 1 to 3) vs 0.66 episodes
per year (IQR, 0 to 2) for those without CSE. Stepwise linear regression
analysis revealed FEV(1), exacerbation frequency, and lower zone VI to be the
most important predictors of health status. CONCLUSIONS: Among patients with
alpha(1)-ATD, those with CSE expectoration exhibit greater physiologic
impairment and more extensive emphysema than those without. This is reflected in
an inferior health status, which is also influenced independently by an
increased exacerbation frequency in those with CSE.

Thorax 2002 Aug;57(8):709-14

Sputum chemotactic activity in chronic obstructive pulmonary disease: effect of
alpha(1)-antitrypsin deficiency and the role of leukotriene B(4) and interleukin
8.

Woolhouse IS, Bayley DL, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

BACKGROUND: Neutrophil recruitment to the airway is thought to be an important
component of continuing inflammation and progression of chronic obstructive
pulmonary disease (COPD), particularly in the presence of severe
alpha(1)-antitrypsin (alpha(1)-AT) deficiency. However, the chemoattractant
nature of secretions from these patients has yet to be clarified. METHODS: The
chemotactic activity of spontaneous sputum from patients with stable COPD, with
(n=11) and without (n=11) alpha(1)-AT deficiency (PiZ), was assessed using the
under-agarose assay. The contribution of leukotriene B(4) (LTB(4)) and
interleukin 8 (IL-8) to the chemotactic activity was examined using an LTB(4)
receptor antagonist (BIIL 315 ZW) and an IL-8 monoclonal antibody, respectively.
RESULTS: Sputum neutrophil chemotactic activity (expressed as %
n-formylmethionyl leucylphenylalanine (fMLP) control) was significantly higher
in patients with alpha(1)-AT deficiency (mean (SE) 63.4 (8.9)% v 36.7 (5.5)%;
mean difference 26.7% (95% CI 4.9 to 48.4), p<0.05). The mean (SE) contribution
of both LTB(4) and IL-8 (expressed as % fMLP control) was also significantly
higher in alpha(1)-AT deficient patients than in patients with COPD with normal
levels of alpha(1)-AT (LTB(4): 31.9 (6.3)% v 18.0 (3.7)%; mean difference 13.9%
(95% CI -1.4 to 29.1), p<0.05; IL-8: 24.1 (5.2)% v 8.1 (1.2)%; mean difference
15.9% (95% CI 4.7 to 27.2), p<0.05). When all the subjects were considered
together the mean (SE) contribution of LTB(4) (expressed as % total chemotactic
activity) was significantly higher than IL-8 (46.8 (3.5)% v 30.8 (4.6)%; mean
difference 16.0% (95% CI 2.9 to 29.2), p<0.05). This difference was not
significantly influenced by alpha(1)-AT phenotype (p=0.606). CONCLUSIONS: These
results suggest that the bronchial secretions of COPD patients with alpha(1)-AT
deficiency have increased neutrophil chemotactic activity. This relates to the
increased levels of IL-8 and, in particular LTB(4), which accounted most of the
sputum chemotactic activity in the patients with COPD as a whole. Increased
chemotactic activity, together with inhibitor deficiency, may contribute to the
more rapid disease progression seen in alpha(1)-AT deficiency via increased
neutrophil recruitment and release of neutrophil elastase.

Thorax 2002 Aug;57(8):667-71

Effect of sputum processing with dithiothreitol on the detection of inflammatory
mediators in chronic bronchitis and bronchiectasis.

Woolhouse IS, Bayley DL, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

BACKGROUND: Sputum analysis is used increasingly to assess airway inflammation
in patients with chronic obstructive pulmonary disease, including those with
chronic bronchitis and bronchiectasis. However, it is not known whether
dithiothreitol (DTT), a reducing mucolytic agent regularly used to homogenise
sputum, affects the detection of inflammatory mediators in the sputum soluble
phase from such patients. METHODS: Thirty two spontaneous sputum samples were
collected from 13 patients with chronic bronchitis and 17 with bronchiectasis.
An aliquot from each sample was treated with either freshly prepared 0.1% DTT
plus normal saline (NaCl) or NaCl alone, then ultracentrifuged to obtain the
sputum sol phase. Interleukin (IL)-1beta, IL-6, IL-8, leukotriene B(4) (LTB(4)),
secretory leukoprotease inhibitor (SLPI), alpha-1-antitrypsin (alpha(1)-AT), and
tumour necrosis factor alpha (TNFalpha) were measured by ELISA, and neutrophil
elastase (NE) and myeloperoxidase (MPO) by chromogenic substrate assay. The
effect of DTT on the detection of assay standards was also determined. RESULTS:
Median levels of IL-1beta, IL-6, IL-8, SLPI, and NE were similar in the DTT and
NaCl treated samples. There was a significant reduction in median (IQR) levels
of detectable TNFalpha (0.07 (0.00-0.47) pM v 0.90 (0.06-6.98) pM, p<0.001),
LTB(4) (1.67 (1.31-2.64) nM v 2.29 (0.95-4.22) nM, p<0.05) and MPO (0.00
(0.00-0.00) mg/l v 4.48 (0.00-33.66) mg/l, p<0.001) and a small increase in the
median alpha(1)-AT concentration (0.05 (0.03-0.08) nM v 0.03 (0.02-0.08) nM,
p<0.01) in the DTT treated samples. DTT had no effect on the assay standards for
IL-1beta, IL-8 or TNFalpha, but at higher concentrations it did affect IL-6,
SLPI, NE, and LTB(4) standards (43%, 70%, 76% and 643% of control value for top
standard, respectively) and at all concentrations DTT completely abolished MPO
activity. CONCLUSIONS: Sputum processing with DTT significantly reduces the
detectable concentration of TNFalpha, LTB(4) and MPO, and produces a small but
significant increase in median alpha(1)-AT levels. To avoid this problem we
recommend that an untreated aliquot of sputum be retained for cytokine analysis,
unless the assay has been specifically validated.

Chest 2002 Jul;122(1):289-94

A randomized, placebo-controlled trial of a leukotriene synthesis inhibitor in
patients with COPD.

Gompertz S, Stockley RA.

Department of Respiratory Medicine, Queen Elizabeth Hospital, Birmingham, UK.
sgomp@doctors.org.uk

STUDY OBJECTIVE: Patients with COPD classically have neutrophilic bronchial
inflammation and raised airway concentrations of the neutrophil chemoattractant
leukotriene B(4) (LTB(4)). A small phase II trial was conducted to assess the
effects of a leukotriene synthesis inhibitor on bronchial inflammation in
patients with stable COPD. DESIGN: A randomized, double-blind,
placebo-controlled, parallel-group study. SETTING: Respiratory medicine
department of a university hospital. PATIENTS AND INTERVENTION: Seventeen
patients with chronic bronchitis and COPD (mean FEV(1), 35.5% predicted; SD,
14.8% predicted) were randomized to receive 14 days of the oral leukotriene
synthesis inhibitor BAYx1005 (500 mg bid) or placebo. MEASUREMENTS AND RESULTS:
Spontaneous sputum samples obtained at baseline and at the end of treatment were
assayed for LTB(4), myeloperoxidase (an indirect marker of neutrophil numbers
and/or activation), and chemotactic activity (Boyden chamber). After 14 days,
there were no significant differences (p > 0.05) in absolute LTB(4)
concentrations between the two treatment groups. However, BAYx1005 treatment
produced a significantly greater median reduction in LTB(4) of - 3.1 nM
(interquartile range [IQR], - 9.6 to - 0.2 nM) vs 3.0 nM (IQR, - 0.3 to 8.5 nM)
[p = 0.001], with concentrations decreasing from 8.0 nM (IQR, 4.3 to 24.4 nM) at
baseline to 4.2 nM (IQR, 1.9 to 11.9 nM) at the end of treatment (p = 0.03).
There were no changes in the placebo group and no differences in sputum
myeloperoxidase concentration or chemotaxis between the two treatment arms (p >
0.05). CONCLUSIONS: This small study suggests that a leukotriene synthesis
inhibitor can produce modest reductions in some measures of neutrophilic
bronchial inflammation in patients with COPD. This class of anti-inflammatory
agent requires further study in larger numbers of patients to determine clinical
benefit.

Am J Respir Crit Care Med 2002 Jun 1;165(11):1494-8

The effect of augmentation therapy on bronchial inflammation in
alpha1-antitrypsin deficiency.

Stockley RA, Bayley DL, Unsal I, Dowson LJ.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, United
Kingdom. r.a.stockley@bham.ac.uk

alpha1-Antitrypsin (AAT) deficiency predisposes to bronchitis and emphysema
associated with neutrophilic airway inflammation. The efficacy of augmentation
therapy has not been proven clinically or by demonstrating an effect on airway
inflammation. We treated 12 patients with four infusions of Prolastin (60 mg/kg)
at weekly intervals and monitored both the serum and secretion concentrations of
AAT as well as markers of neutrophilic inflammation, including myeloperoxidase,
elastase, and the neutrophil chemoattractants interleukin-8 and leukotriene
B(4). Serum AAT rose and was maintained above the protective threshold. In
addition, AAT concentrations in the sputum rose from a mean of 0.17 microM (SEM
+/- 0.04) before therapy to concentrations similar to nondeficient subjects
(0.43 +/- 0.12) 1 week after the first infusion (p < 0.01). This was associated
with a reduction in elastase activity (p < 0.002) and the chemoattractant
leukotriene B(4) (p < 0.02), which fell from a median baseline value of 13.46 nM
(range, 4.17-55.00) to 8.62 nM (4.23-21.59) the day following the last infusion.
Although median values for myeloperoxidase and interleukin-8 also fell, the
changes failed to achieve statistical significance. In summary, short-term
therapy with AAT increased lung secretion concentrations and was associated with
a fall in leukotriene B(4), which is thought to be central to the airway
inflammation of AAT deficiency.

Chest 2002 May;121(5 Suppl):151S-155S

Neutrophils and the pathogenesis of COPD.

Stockley RA.

Lung Resource Center, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH,
UK. r.a.stockley@bham.ac.uk

Am J Respir Crit Care Med 2002 Jan 1;165(1):132

Inflammatory markers in bacterial exacerbations of COPD.

Murphy TF, Sethi S, Hill SL, Stockley RA.

Am J Respir Crit Care Med 2001 Nov 15;164(10 Pt 1):1805-9

Longitudinal changes in physiological, radiological, and health status
measurements in alpha(1)-antitrypsin deficiency and factors associated with
decline.

Dowson LJ, Guest PJ, Stockley RA.

Lung Investigation Unit, Nuffield House, Queen Elizabeth Hospital, Birmingham,
United Kingdom.

The FEV(1) declines rapidly in alpha(1)-antitrypsin deficiency (alpha(1)-ATD)
but less is known about other measures of disease severity and the factors,
other than smoking, that are associated with progression of emphysema. The
natural history of alpha(1)-ATD was studied prospectively in 43 patients with
the PiZ phenotype and emphysema at a single center over 2 yr. The mean +/- SE
change in FEV(1) was -67 +/- 14 ml/yr, accompanied by a reduction in transfer
factor (mean change in diffusing capacity of the lung for CO [DL(CO)] -1.07 +/-
0.21 ml/min/mm Hg/yr; p < 0.001) and lung density in the upper zones as assessed
by quantitative high-resolution computed tomography (HRCT) (mean change in voxel
index 2.8 +/- 0.6%/yr; p < 0.001). The decline in FEV(1) related to baseline
FEV(1) (r = -0.56, p < 0.001), bronchodilator reversibility (r = 0.52, p <
0.001), and (for patients with FEV(1) > 35% predicted) exacerbation frequency (r
= -0.38, p = 0.02). There was also a decline in the St. George's Respiratory
Questionnaire (SGRQ) Activity score (mean change -4.3 +/- 1.2 units/yr, p <
0.001) that correlated with FEV(1) decline (r = 0.45, p = 0.002). Progression of
emphysema in alpha(1)-ATD is dependent on baseline physiology and exacerbation
frequency and may be detected by several different measurements of which HRCT
density mask analysis and DL(CO) appear most sensitive.

Thorax 2001 Dec;56(12):972-7

Animal models of chronic obstructive pulmonary disease.

Dawkins PA, Stockley RA.

Lung Investigation Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham B15
2TH, UK.

Thorax 2001 Dec;56(12):947-53

Symptom resolution assessed using a patient directed diary card during treatment
of acute exacerbations of chronic bronchitis.

Woolhouse IS, Hill SL, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.

BACKGROUND: Acute exacerbations of chronic bronchitis are common and the
presenting symptoms vary, although it is not clear how this should influence
management. From a health care perspective, an understanding of the speed of
symptom resolution is of importance to determine the success of treatment or
when a change is indicated because of treatment failure. METHODS: The response
of 63 patients treated at home for exacerbations of chronic bronchitis was
assessed using a patient directed diary card incorporating sputum
characteristics and symptoms. Treatment was given according to the nature of the
sputum at presentation; patients with purulent sputum received an antibiotic for
5 or 10 days (randomised, double blind) whereas patients with mucoid sputum
received high dose inhaled steroid or placebo for 14 days (randomised, double
blind). RESULTS: The mean (SE) total diary card score at presentation was
significantly higher in the purulent group than in the mucoid group (19.7 (0.9)
v 16.3 (0.9); mean difference -3.4 (95% CI -6.1 to -0.7), p<0.05). In the
purulent group sputum colour and volume improved rapidly and in both groups the
mean (SE) total diary card score had improved by the fifth day of treatment to
13.0 (0.7) in the purulent group (mean difference -6.6 (95% CI -8.8 to -4.4),
p<0.001) and 14.6 (0.8) in the mucoid group (mean difference -1.7 (95% CI -4.0
to 0.8), p<0.05), which was no longer significantly different from the stable
state. Diary card scores did not differ significantly between patients who
received antibiotics for 5 or 10 days in the purulent group or between patients
who received inhaled fluticasone or placebo in the mucoid group. CONCLUSIONS:
Exacerbations of chronic bronchitis associated with purulent sputum have
significantly worse symptoms at presentation than those with mucoid sputum. In
both groups these symptoms resolve rapidly so that by the fifth day of treatment
they are no different from the stable state. No significant effect was found on
symptom resolution of antibiotic duration (5 v 10 days) in the purulent group or
of inhaled fluticasone in the mucoid group, which resolved without antibiotics.
Larger numbers may be required to demonstrate a statistically (if not
clinically) significant difference.

Chest 2001 Oct;120(4):1422-3

Inflammation and acute exacerbations of chronic bronchitis.

Stockley RA.

Eur Respir J 2001 Jun;17(6):1112-9

Changes in bronchial inflammation during acute exacerbations of chronic
bronchitis.

Gompertz S, O'Brien C, Bayley DL, Hill SL, Stockley RA.

Dept of Respiratory Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham,
UK.

There are little data describing noncellular changes in bronchial inflammation
during exacerbations of chronic bronchitis. The relationship between sputum
colour and airway inflammation at presentation has been assessed during an
exacerbation in patients with chronic bronchitis and a primary care diagnosis of
chronic obstructive pulmonary disease. Sputum myeloperoxidase, neutrophil
elastase, leukotriene B4 (LTB4), interleukin-8 (IL-8), sol:serum albumin ratio
and serum C-reactive protein were measured in patients presenting with an
exacerbation and mucoid (n = 27) or purulent sputum (n = 42). Mucoid
exacerbations were associated with little bronchial or systemic inflammation at
presentation, and sputum bacteriology was similar to that obtained in the stable
state. Purulent exacerbations were associated with marked bronchial and systemic
inflammation (p < 0.025 for all features) and positive sputum cultures (90%).
Resolution was related to a significant reduction in LTB4 (p < 0.01), but no
change in IL-8, suggesting that LTB4 may be more important in neutrophil
recruitment in these mild, purulent exacerbations. In the stable state, IL-8
remained higher in patients who had experienced a purulent exacerbation (2p <
0.02). The presented results indicate that exacerbations of chronic bronchitis,
defined by sputum colour, differ in the degree of bronchial and systemic
inflammation. Purulent exacerbations are related to bacterial infection, and are
associated with increased neutrophilic inflammation and increased leukotriene B4
concentrations.

Eur Respir J 2001 Jun;17(6):1097-104

High-resolution computed tomography scanning in alpha1-antitrypsin deficiency:
relationship to lung function and health status.

Dowson LJ, Guest PJ, Hill SL, Holder RL, Stockley RA.

Lung Investigation Unit, Queen Elizabeth Hospital, Birmingham, UK.

The development of computed tomography (CT) has enabled emphysema to be assessed
noninvasively. Objective quantification of lung density correlates well with
lung function in patients with chronic obstructive pulmonary disease and has
been shown to be a sensitive tool for monitoring disease progression. In order
to determine the clinical impact of changes seen on high-resolution computed
tomography (HRCT), the relationship between the objective quantification of
emphysema on HRCT, lung function and health status in 111 patients with
alpha1-antitrypsin deficiency was examined (PiZ). The degree of HRCT scan
abnormality correlated well (p<0.001 for all comparisons) with forced expiratory
volume in one second (r = -0.60- -0.75), specific airway conductance (r =
-0.67-0.76), residual volume/total lung capacity (r = 0.46-0.58) and transfer
factor of the lung for carbon monoxide (r = -0.64- -0.81). In addition, the CT
scans correlated (p<0.001) with health status as assessed by the St. George's
Respiratory Questionnaire (SGRQ total: r = -0.38-0.50) and the Short-Form health
survey (e.g. physical functioning: r = -0.39-0.54). In summary, other workers
have shown high-resolution computed tomography to be a sensitive indicator of
disease progression. This study confirms the relationship between
high-resolution computed tomography and lung physiology, and suggests the
relationship is even stronger in patients with predominantly lower zone
pan-lobular emphysema than in usual chronic obstructive pulmonary disease.
High-resolution computed tomography also relates to patients disability and
impairment as defined by health status questionnaires and, therefore, should be
considered as an alternative outcome measure particularly in alpha1-antitrypsin
deficiency.

Eur Respir J 2001 Mar;17(3):356-9

Alpha-1-antitrypsin genotyping with mouthwash specimens.

Stockley RA, Campbell EJ.

Dept. of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

Alpha1-antitrypsin (alpha1-AT) deficiency is diagnosed as a two-stage procedure
(concentration and phenotype). However the latter does not provide clues to the
presence of null genes without family studies and obtaining blood from patients
at a distance often proves difficult. The aim of the study was to assess the
feasibility of genotyping alpha1-AT using buccal cells. Mouthwash specimens were
sent by 84 patients (with a variety of phenotypes of alpha1-antitrypsin) through
the post. Deoxyribonucleic acid (DNA) was isolated from buccal cells in each
sample and subjected to polymerase chain reaction (PCR) using a genotyping kit
to detect the S and Z alleles. Eighty-three of 84 samples received were suitable
for amplification. The specific primers successfully identified the S and Z
alleles in each case. However, five of the 35 samples obtained from patients
thought to be Z allele homozygotes were found to be heterozygotes for another
severe deficiency allele. These data confirm the feasibility of "at distance"
testing for alpha1-antitrypsin deficiency alleles using buccal cells from
mouthwash samples. The results raise the possibility that other deficiency
alleles are more common than has previously been suspected.

Thorax 2001 May;56(5):366-72

Assessment of airway neutrophils by sputum colour: correlation with airways
inflammation.

Stockley RA, Bayley D, Hill SL, Hill AT, Crooks S, Campbell EJ.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH,
UK. r.a.stockley@bham.ac.uk

BACKGROUND: Airway inflammation, with recruitment of neutrophils to the airway
lumen, results in purulent secretions and a variety of potential adverse
consequences for patients with chronic bronchitis and bronchiectasis. We
hypothesised that gradations of sputum colour would correlate directly with the
myeloperoxidase content of sputum and with various other indicators of the
activity and consequences of bronchial diseases. METHODS: To test this
hypothesis, we quantified sputum colour by reference to a sensitive nine point
colour chart and correlated this assessment with indices of a number of
inflammatory mediators in sputum. RESULTS: The results indicate that
standardised visual measurements of sputum colour correlated strongly with
myeloperoxidase, interleukin 8, leucocyte elastase (both activity and total
quantity), sputum volume, protein leak, and secretory leucocyte proteinase
inhibitor (p<0.001 for all). In addition, there was a strong direct correlation
between leucocyte elastase and both myeloperoxidase (p<0.003) and sputum volume
(p<0.001), but a strong negative correlation with secretory leucocyte proteinase
inhibitor (p<0.001). CONCLUSIONS: These results indicate that sputum colour
graded visually relates to the activity of the underlying markers of bronchial
inflammation. The results of this simple visual analysis of sputum provides
guidance concerning underlying inflammation and its damaging potential. It also
provides a useful scientific tool for improving the monitoring of chronic
airways diseases and response to treatment.

Am J Respir Crit Care Med 2001 Mar;163(4):936-41

Exercise capacity predicts health status in alpha(1)-antitrypsin deficiency.

Dowson LJ, Newall C, Guest PJ, Hill SL, Stockley RA.

Lung Investigation Unit, Nuffield House, Queen Elizabeth University Hospital,
Birmingham, United Kingdom.

Resting lung function is only weakly related to health status in chronic
obstructive pulmonary disease, reflecting the multifactorial causes of
impairment and the heterogeneous nature of the condition. The current study
examined whether density mask analysis of high-resolution computed tomography
(HRCT) or exercise capacity were better surrogates for health status in a
well-defined, homogeneous group of patients with alpha(1)-antitrypsin deficiency
(PiZ). Twenty-nine patients with predominantly lower zone emphysema on HRCT were
studied. Exercise was assessed by incremental treadmill (V O(2) peak) and
shuttle walking tests (ISWT) and health status by the St. George's Respiratory
Questionnaire (SGRQ) and SF-36. Although lower zone expiratory HRCT was related
to exercise capacity (rho = -0.64 and -0.63 for V O(2) peak and ISWT,
respectively, p < 0.001), multiple regression analysis suggested that FEV(1) was
a marginally better predictor (rho = -0.64 and -0.65, p < 0.001). HRCT also
related significantly to health status (rho = -0.37 for SGRQ activity, p <
0.05), although again FEV(1) showed a stronger relationship (rho = -0.43, p =
0.01). However, exercise capacity was the best predictor of health status with
the ISWT accounting for up to 55% of the variability seen in SGRQ total and up
to 53% of the SF-36 domain scores (physical functioning). Although both HRCT and
lung function relate to health status, exercise capacity is the best predictor
of patients disability in these patients with predominantly lower zone
emphysema.

Novartis Found Symp 2001;234:189-99; discussion 199-204

Proteases and antiproteases.

Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH,
UK.

Serine proteases have been implicated in the pathogenesis of chronic obstructive
pulmonary disease (COPD) since the identification of alpha 1-antitrypsin
deficiency in 1963. This inhibitor efficiently inactivates several enzymes
released by activated neutrophils including neutrophil elastase, cathepsin G and
proteinase 3, all of which have been shown to generate features of COPD in
animal models. Recent studies have identified the mechanisms of enzyme release
from activated neutrophils and indicate that the concentrations are usually two
orders of magnitude above that of normal alpha 1-antitrypsin. This results in an
area of obligate proteolysis in the immediate vicinity of a migrating
neutrophil. The area is greatly enlarged in alpha 1-antitrypsin deficiency
explaining the increased susceptibility of such patients to develop lung damage.
The migration into and activation of neutrophils in the lung is likely to be a
major determinant of the development of COPD. Understanding the processes has
important implications for the design of new therapeutic strategies.

Thorax 2001 Jan;56(1):36-41

Relationship between airway inflammation and the frequency of exacerbations in
patients with smoking related COPD.

Gompertz S, Bayley DL, Hill SL, Stockley RA.

Department of Respiratory Medicine, Queen Elizabeth Hospital, Birmingham B15
2TH, UK. sgompertz@doctors.net

BACKGROUND: Patients with more frequent exacerbations of chronic obstructive
pulmonary disease (COPD) may have increased bronchial inflammation. Airway
inflammation was measured in patients who had been thoroughly investigated with
full pulmonary function testing, thoracic HRCT scanning, and sputum microbiology
to examine further the relationship between exacerbation frequency and bronchial
inflammation. METHODS: Airway inflammation (spontaneous sputum sol phase
myeloperoxidase (MPO), elastase, leukotriene (LT)B(4), interleukin (IL)-8,
secretory leukoprotenase inhibitor (SLPI), protein leakage) and serum levels of
C reactive protein (CRP) were compared in 40 patients with stable, smoking
related COPD, divided into those with frequent (> or =3/year) or infrequent (<
or =2/year) exacerbations according to the number of primary care consultations
during the preceding year. The comparisons were repeated after excluding eight
otherwise clinically indistinguishable patients who had tubular bronchiectasis
on the HRCT scan. RESULTS: Patients with frequent (n=12) and infrequent (n=28)
exacerbations were indistinguishable in terms of their clinical, pulmonary
function, and sputum characteristics, CRP concentrations, and all of their
bronchial inflammatory parameters (p>0.05). The patients without evidence of
tubular bronchiectasis (n=32) were equally well matched but the sputum
concentrations of SLPI were significantly lower in the frequent exacerbators
(n=8) in this subset analysis (p<0.05). CONCLUSIONS: There are several clinical
features that directly influence bronchial inflammation in COPD. When these were
carefully controlled for, patients with more frequent reported exacerbations had
lower sputum concentrations of SLPI. This important antiproteinase is also known
to possess antibacterial and antiviral activity. Further studies are required
into the nature of recurrent exacerbations and, in particular, the regulation
and role of SLPI in affected individuals.

Thorax 2000 Nov;55(11):970-7

Factors influencing airway inflammation in chronic obstructive pulmonary
disease.

Hill A, Gompertz S, Stockley R.

Department of Respiratory Medicine, Queen Elizabeth Hospital, Birmingham B15
2TH, UK.

Am J Med 2000 Sep;109(4):288-95

Association between airway bacterial load and markers of airway inflammation in
patients with stable chronic bronchitis.

Hill AT, Campbell EJ, Hill SL, Bayley DL, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

PURPOSE: Viable bacteria are often isolated from airway secretions in clinically
stable patients with chronic bronchitis. We hypothesized that the number of
organisms and bacterial species might be important modulators of airway
inflammation. SUBJECTS AND METHODS: We performed quantitative sputum cultures in
160 stable patients [55 with chronic obstructive pulmonary disease (COPD) and
normal serum alpha(1)-antitrypsin levels, 62 with COPD and severe
alpha(1)-antitrypsin deficiency (PiZ), and 43 with idiopathic bronchiectasis].
The results were related to several indicators of the mechanisms and severity of
airway inflammation. RESULTS: Airway bacterial load correlated with sputum
myeloperoxidase level, an indirect measure of neutrophil activation and number
(r = 0.50, P<0. 001); sputum neutrophil chemoattractants [interleukin-8 level (r
= 0. 68, P<0.001) and leukotriene B4 level (r = 0.53, P<0.001)]; sputum
leukocyte elastase activity (r = 0.55, P<0.001); and albumin leakage from serum
to sputum (r = 0.26, P<0.01). Markers of inflammation increased at bacterial
loads of 10(6) to 10(7) colony-forming units per milliliter, and increased
progressively with increasing bacterial load. For example, the median
(interquartile range) sputum myeloperoxidase level was 0.3 U/mL (0.1 to 0.5
U/mL) for patients who were not colonized or who had mixed normal oropharyngeal
flora alone; 0.5 U/mL (0.2 to 0.7 U/mL) for patients with 10(5) to 10(6)
colony-forming units per milliliter (P = 0.07); 0.5 U/mL (0.3 to 1.2 U/mL) for
patients with 10(6) to 10(7) colony-forming units per milliliter (P<0.01); 0.7
U/mL (0.3 to 1.2 U/mL) for patients with 10(7) to 10(8) colony-forming units per
milliliter (P <0.005); and 2.4 U/mL (0.7 to 4.8 U/mL) for patients with 10(8) or
greater colony-forming units per milliliter (P<0.0001). The bacterial species
influenced airway inflammation; for example, sputum myeloperoxidase activity was
greater (P<0.005) in patients colonized with Pseudomonas aeruginosa [median 32
U/mL (interquartile range, 20 to 65 U/mL)] than those colonized with nontypeable
Hemophilus influenzae [4 U/mL (2 to 31 U/mL)], which in turn was greater (P =
0.01) than among those colonized with Moraxella catarrhalis [1.1 U/mL (0.6 to
1.8 U/mL)]. We did not find a relation between bacterial load and lung
function.CONCLUSIONS: The bacterial load and species contribute to airway
inflammation in patients with stable chronic bronchitis. Further studies are
required to determine the consequences of bacterial colonization on patient
morbidity and decline in lung function.

Thorax 2000 Jul;55(7):629-30

Cell and cytokine markers in COPD.

Stockley RA, Hill SL.

Thorax 2000 Aug;55(8):635-42

Physiological and radiological characterisation of patients diagnosed with
chronic obstructive pulmonary disease in primary care.

O'Brien C, Guest PJ, Hill SL, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common although
often poorly characterised, particularly in primary care. However, application
of guidelines to the management of such patients needs a clear understanding of
the phenotype. In particular, the British guidelines for the management of COPD
recommend that the diagnosis is based on appropriate symptoms and evidence of
airflow obstruction as determined by a forced expiratory volume in one second
(FEV(1)) of <80% of the predicted value and an FEV(1)/VC ratio of <70%. METHODS:
A study was undertaken of 110 patients aged 40-80 years who had presented to
their general practitioner with an acute exacerbation of COPD. The episode was
treated at home and, when patients had recovered to the stable state (two months
later), they were characterised by full lung function tests and a high
resolution computed tomographic (HRCT) scan of the chest. RESULTS: There was a
wide range of impairment of FEV(1) which was in the normal range (>/=80%) in
30%, mildly impaired (60-79%) in 18%, moderately impaired (40-59%) in 33%, and
severely impaired (<40%) in 19% of patients. A reduced FEV(1)/VC ratio was
present in all patients with an FEV(1) of <80% predicted but also in 41% of
those with an FEV(1) of >/=80% predicted. Only 5% of patients had a substantial
bronchodilator response suggesting a diagnosis of asthma. Emphysema was present
in 51% of patients and confined to the upper lobes in most (73% of these
patients). HRCT evidence of bronchiectasis was noted in 29% of patients and was
predominantly tubular; most (81%) were current or ex-smokers. A solitary
pulmonary nodule was seen on 9% of scans and unsuspected lung malignancy was
diagnosed in two patients. CONCLUSIONS: This study confirms that COPD in primary
care is a heterogeneous condition. Some patients do not fulfil the proposed
diagnostic criteria with FEV(1) of >/=80% predicted but they may nevertheless
have airflow obstruction. Bronchiectasis is common in this group of patients, as
is unsuspected malignancy. These findings should be considered when developing
recommendations for the investigation and management of COPD in the community.

Eur Respir J 2000 Jun;15(6):1039-45

MEKC of desmosine and isodesmosine in urine of chronic destructive lung disease
patients.

Viglio S, Iadarola P, Lupi A, Trisolini R, Tinelli C, Balbi B, Grassi V,
Worlitzsch D, Doring G, Meloni F, Meyer KC, Dowson L, Hill SL, Stockley RA,
Luisetti M.

Dipartimento di Biochemical, Istituto di Ricovero e Cura a Carattere Scientifico
(IRCCS) Policlinico San matteo, Universita degli nStudi di Pavia.

Degradation of extracellular matrix components is central to many pathological
features of chronic destructive lung disorders. Desmosine and isodesmosine are
elastin-derived cross-linked amino acids whose urine levels are considered
representative of elastin breakdown. The aim of this study was to apply a novel
methodology, based on high-performance capillary electrophoresis, to the
quantification of desmosine and isodesmosine in 11 patients with stable chronic
obstructive pulmonary disease (COPD), 10 with an exacerbation of COPD, nine with
alpha1-antitrypsin deficiency, 13 with bronchiectasis, and 11 adults with cystic
fibrosis, in comparison to 24 controls. It was found that, in patients with
stable COPD, urinary desmosine levels were higher than in controls (p=0.03), but
lower than in COPD subjects with an exacerbation (p< or =0.05). The highest
desmosine levels were found in subjects with alpha1-antitrypsin deficiency,
bronchiectasis and cystic fibrosis (p<0.001 versus stable COPD). In a short-term
longitudinal study, five stable COPD patients showed a constant rate of
desmosine excretion (mean coefficient of variation <8% over three consecutive
days). In conclusion, the present method is simple and suitable for the
determination of elastin-derived cross-linked amino acid excretion in urine,
giving results similar to those obtained using other separation methods. In
addition, evidence is presented that urinary desmosine excretion is increased in
conditions characterized by airway inflammation, such as exacerbations of
chronic obstructive pulmonary disease, bronchiectasis and cystic fibrosis.
Results obtained in subjects with alphal-antitrypsin deficiency suggest that
this method might be used to evaluate the putative efficacy of replacement
therapy.

Chest 2000 Jun;117(6):1638-45

Relationship of sputum color to nature and outpatient management of acute
exacerbations of COPD.

Stockley RA, O'Brien C, Pye A, Hill SL.

Department of Respiratory Medicine, Queen Elizabeth Hospital, Edgbaston,
Birmingham, UK.

STUDY OBJECTIVES: To stratify COPD patients presenting with an acute
exacerbation on the basis of sputum color and to relate this to the isolation
and viable numbers of bacteria recovered on culture. DESIGN: Open, longitudinal
study of sputum characteristics and acute-phase proteins. SETTING: Patients
presenting to primary-care physicians in the United Kingdom. Patients were
followed up as outpatients in specialist clinic. PATIENTS: One hundred
twenty-one patients with acute exacerbations of COPD were assessed together with
a single sputum sample on the day of presentation (89 of whom produced a
satisfactory sputum sample for analysis). One hundred nine patients were
assessed 2 months later when they had returned to their stable clinical state.
INTERVENTIONS: The expectoration of green, purulent sputum was taken as the
primary indication for antibiotic therapy, whereas white or clear sputum was not
considered representative of a bacterial episode and the need for antibiotic
therapy. RESULTS: A positive bacterial culture was obtained from 84% of patients
sputum if it was purulent on presentation compared with only 38% if it was
mucoid (p < 0.0001). When restudied in the stable clinical state, the incidence
of a positive bacterial culture was similar for both groups (38% and 41%,
respectively). C-reactive protein concentrations were significantly raised (p <
0.0001) if the sputum was purulent (median, 4.5 mg/L; interquartile range [IQR],
6. 2 to 35.8). In the stable clinical state, sputum color improved significantly
in the group who presented with purulent sputum from a median color number of
4.0 (IQR, 4.0 to 5.0) to 3.0 (IQR, 2.0 to 4. 0; p < 0.0001), and this was
associated with a fall in median C-reactive protein level to 2.7 mg/L (IQR, 1.0
to 6.6; p < 0.0001). CONCLUSIONS: The presence of green (purulent) sputum was
94.4% sensitive and 77.0% specific for the yield of a high bacterial load and
indicates a clear subset of patient episodes identified at presentation that is
likely to benefit most from antibiotic therapy. All patients who produced white
(mucoid) sputum during the acute exacerbation improved without antibiotic
therapy, and sputum characteristics remained the same even when the patients had
returned to their stable clinical state.

Thorax 2000 Jul;55(7):623-4

A case of Haemophilus parainfluenzae pneumonia.

Pillai A, Mitchell JL, Hill SL, Stockley RA.

Department of Respiratory Medicine, Queen Elizabeth Hospital, Edgbaston,
Birmingham B15 2TH, UK.

A 41 year old woman presented with community acquired pneumonia (CAP) which
failed to resolve following treatment with amoxycillin and cefaclor prior to
referral. Quantitative culture of sputum revealed a pure growth of Haemophilus
parainfluenzae and, following antibiotic susceptibility testing of the isolate,
ciprofloxacin was prescribed resulting in resolution of the infection.
Immunological investigations showed that the patient had a high titre of H
parainfluenzae specific IgM. The combination of a pure growth of H
parainfluenzae, a response to appropriate antimicrobial therapy, and the
presence of a specific antibody response indicated that this organism had a
pathogenic role in the patient's pneumonia and should be considered in the
differential diagnosis of CAP.

Thorax 2000 Jul;55(7):614-8

Alpha-1-antitrypsin deficiency: what next?

Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH,
UK. r.a.stockley@bham.ac.uk

Eur Respir J 2000 May;15(5):886-90

Airways inflammation in chronic bronchitis: the effects of smoking and
alpha1-antitrypsin deficiency.

Hill AT, Bayley DL, Campbell EJ, Hill SL, Stockley RA.

Dept of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

Airways inflammation in chronic bronchitis is thought predominantly to be a
direct consequence of neutrophil recruitment and release of elastase in response
to factors such as cigarette smoke. The aims of this study were to assess the
role of smoking and determine whether the serum elastase inhibitor
alpha1-antitrypsin (alpha1AT) influenced the process. Airways inflammation was
compared between patients with chronic obstructive bronchitis with (n=39) and
without (n=42) severe alpha1AT deficiency. The authors assessed the sputum
concentration of the neutrophil chemoattractants interleukin-8 (IL-8) and
leukotriene (LT)B4, myeloperoxidase (MPO) as a marker of neutrophil influx,
neutrophil elastase activity and its natural inhibitors, alpha1AT and secretory
leukoprotease inhibitor (SLPI). Finally serum alpha1AT was measured to determine
the degree of protein leakage (sputum sol serum alpha1AT ratio). Compared to
current smokers, the exsmokers had a lower concentration of the chemoattractant
IL-8 (p<0.05) and a lower MPO concentration, although this failed to reach
conventional statistical significance (p=0.06). Patients with alpha1AT
deficiency had greater inflammation in the larger airways with increased LTB4
(p<0.005), MPO (p<0.001), neutrophil elastase activity (p<0.01), protein leak
(p<0.001), and were found to have a lower anti-proteinase screen with both
reduced sputum alpha1AT (p<0.001) and SLPI concentrations (p<0.05). The
reduction in sputum interleukin-8 levels in exsmokers may decrease neutrophil
influx and thus explain the slower rate of neutrophil mediated progression of
lung disease compared to subjects who continue to smoke. Patients with
alpha1-antitrypsin deficiency had greater inflammation suggesting that
alpha1-antitrypsin plays an important role in protecting the larger airways from
the inflammatory effects of elastase activity and may explain their more rapid
progression of disease.

Chest 2000 May;117(5 Suppl 1):291S-3S

Bronchial inflammation: its relationship to colonizing microbial load and
alpha(1)-antitrypsin deficiency.

Stockley RA, Hill AT, Hill SL, Campbell EJ.

Department of Medicine, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.

Neutrophil elastase is capable of generating many of the features of chronic
bronchial disease. In patients with COPD, airways inflammation with neutrophil
recruitment and elastase release is positively correlated with colonizing
bacterial load in the stable clinical state (p < 0.0005). In addition,
alpha(1)-antitrypsin deficiency is associated with a greater neutrophil load,
higher elastase activity, leukotriene-B(4) concentration, and serum protein leak
than matched patients without deficiency (p < 0.005). These data confirm an
effect of bronchial colonization on airways inflammation in COPD and indicate
the role of alpha(1)-antitrypsin in its modulation.

Chest 2000 May;117(5 Suppl 1):293S

The role of haemophilus parainfluenzae in COPD

Hill SL, Mitchell JL, Stockley RA, Wilson R.

Department of Respiratory Medicine (Drs. Hill, Mitchell, and Stockey), Queen
Elizabeth Hospital, Birmingham.

Eur Respir J 2000 Apr;15(4):778-81

Validation of assays for inflammatory mediators in sputum.

Stockley RA, Bayley DL.

Dept of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

Commercially available immune assays are being used with increasing frequency in
the study of lung inflammation. However, their performance in complex biological
fluids is rarely assessed. The authors wished to assess their reliability to
determine whether the results obtained in sputum samples can be easily
interpreted. The reproducibility of several such assays was therefore determined
together with their ability to recover known amounts of pure reagent. Sputum sol
phase was obtained from several patients with chronic lung disease and used
together with the reagents in a series of "spiking" and dilutional experiments.
Results confirmed that the enzyme assay for myeloperoxidase and the immune
assays for interleukin-8, leukotriene B4 and secretory leukoproteinase inhibitor
were all reproducible (intra-assay coefficient of variation 3.8-7.7%).
Furthermore, each of these assays gave >85% recovery of a "spike" with pure
reagent. However, the immune assay for myeloperoxidase (although reproducible)
gave poor recovery and was dependent on the degree of sample dilution and
elastase content. These studies confirm that the reliabilities of fluid phase
measurements should be assessed before being widely applied to complex
biological samples.

Semin Respir Infect 2000 Mar;15(1):14-23

Inflammation--role of the neutrophil and the eosinophil.

Gompertz S, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

Neutrophils are regularly identified in the airway secretions of patients with
smoking-related chronic bronchitis and in those with chronic obstructive
pulmonary disease. The migration and activation of these cells plays a role that
is central to the secondary bronchial defences against potential bacterial
pathogens. Where these processes persist or are excessive, potent mediators
derived from the neutrophil may cause a perpetuation of bronchial inflammation
and result in bronchial epithelial damage and impairment of endobronchial
defences. Recent evidence has suggested that the eosinophil may also be present
in the airways of some patients with chronic bronchitis, although its role in
bronchial inflammation is not yet clear. In this article we have reviewed the
evidence relating to the roles of both the neutrophil and of the eosinophil in
the airway inflammation of chronic bronchitis.

Eur Respir J 2000 Feb;15(2):274-80

Bronchial inflammation in acute bacterial exacerbations of chronic bronchitis:
the role of leukotriene B4.

Crooks SW, Bayley DL, Hill SL, Stockley RA.

Dept of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.

Neutrophils recruited to the airways in chronic obstructive pulmonary disease
(COPD) are thought to mediate tissue destruction. Neutrophil recruitment is
increased during bacterial exacerbations. The inflammatory process was studied
in patients with an acute exacerbation of COPD in order to ascertain the role of
leukotriene B4 (LTB4). The sputum of eight subjects with a bacterial
exacerbation of COPD was analysed for neutrophil products (myeloperoxidase,
elastase) and chemoattractants (interleukin-8 (IL-8) and LTB4). The contribution
of LTB4 to the chemotactic activity of the sputum sol phase was determined using
the LTB4 receptor antagonist LY293111. The concentrations of the serum acute
phase proteins alpha1-proteinase inhibitor, alpha1-antichymotrypsin and
C-reactive protein were measured. All patients received appropriate
broad-spectrum antibiotic treatment for 7-14 days. Initially, the sputum
myeloperoxidase activity was high, indicating neutrophil influx; this was
associated with high levels of IL-8 and LTB4. All these concentrations fell with
treatment (p<0.01). The chemotactic activity of the sputum was raised on
presentation and fell with treatment (p<0.01). LTB4 contributed approximately
30% of the total chemotactic activity on presentation; this diminished with
therapy. All acute phase proteins were raised on presentation and fell with
therapy (p<0.01). These findings suggest that leukotriene B4 contributes to
neutrophil influx into the airway in chronic obstructive pulmonary disease and
may influence disease progression.

Chest 2000 Feb;117(2 Suppl):58S-62S

New approaches to the management of COPD.

Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, UK.

Airflow limitation in COPD is a result partially of bronchospasm, but it is also
caused by a reduction in airway caliber, the number of small airways, airway
collapse because of loss of connective tissue support, excess mucus in the
airways, and edema of the airway wall. Structural changes also occur because of
long-term destruction of interstitial connective tissue, including elastin.
Therefore, in addition to the traditional aim of reversing bronchospasm with
bronchodilators, disease-modifying approaches are being investigated. The enzyme
neutrophil elastase is implicated in the induction of bronchial disease causing
structural changes in lungs, impairment of mucociliary clearance, and impairment
of host defenses. The precise mechanism pathway of neutrophil elastase is
uncertain, but the effects of influencing the pathway in order to slow disease
progression are being investigated. Oxidants may also have a role in the
development of COPD, with increased levels activating airway cells and cytokine
production.

Am J Respir Crit Care Med 1999 Dec;160(6):1968-75

Evidence for excessive bronchial inflammation during an acute exacerbation of
chronic obstructive pulmonary disease in patients with alpha(1)-antitrypsin
deficiency (PiZ). Hill AT, Campbell EJ, Bayley DL, Hill SL, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, United
Kingdom.

Patients with homozygous (PiZ) alpha(1)-antitrypsin (AAT) deficiency have not
only low baseline serum AAT levels (approximately 10 to 15% normal) but also an
attenuated acute phase response. They are susceptible to the development of
premature emphysema but may also be particularly susceptible to lung damage
during bacterial exacerbations when there will be a significant neutrophil
influx. The purposes of the present study were to assess the inflammatory nature
of acute bacterial exacerbations of chronic obstructive pulmonary disease (COPD)
in subjects with AAT deficiency, to compare this with COPD patients without
deficiency, and to monitor the inflammatory process and its resolution following
appropriate antibacterial therapy. At the start of the exacerbation, patients
with AAT deficiency had lower sputum AAT (p < 0.001) and secretory leukoprotease
inhibitor (SLPI; p = 0.02) with higher elastase activity (p = 0.02) compared
with COPD patients without deficiency. Both groups had a comparable acute phase
response as assessed by C-reactive protein (CRP) but the AAT-deficient patients
had a minimal rise in serum AAT (to < 6 microM). After treatment with
antibiotics, in patients with AAT deficiency, there were significant changes in
many sputum proteins including a rise in SLPI levels, and a reduction in
myeloperoxidase (MPO) and elastase activity (p < 0. 005 for all measures); the
sputum chemoattractants interleukin-8 (IL-8) and leukotriene B(4) (LTB(4)) fell
(p < 0.01), and protein leak (sputum/serum albumin ratio) became lower (p <
0.01). The changes were rapid and within 3 d of the commencement of antibiotic
therapy the biochemical markers had decreased significantly, but took a variable
time thereafter to return to baseline values. In conclusion, patients with AAT
deficiency had evidence of increased elastase activity at the start of the
exacerbation when compared with nondeficient COPD patients which probably
reflects a deficient antiproteinase screen (lower sputum AAT and SLPI). The
increased bronchial inflammation at presentation resolved rapidly with 14 d of
antibiotic therapy.

Biochim Biophys Acta 2000 Jan 3;1500(1):108-18

Phenotypic changes in neutrophils related to anti-inflammatory therapy.

Barton AE, Bayley DL, Mikami M, Llewellyn-Jones CG, Stockley RA.

Respiratory Research Laboratory, Department of Medicine, The Queen Elizabeth
Hospital, Edgbaston, Birmingham, UK.

Previous work from the group has shown that non-steroidal anti-inflammatory
agents given to volunteers and patients inhibit PMN function possibly by
affecting the developing neutrophil during the differentiation process. In this
study indomethacin treatment in vivo reduced neutrophil chemotaxis and
proteolytic degradation of fibronectin, with a maximal effect after 14 days.
Stimulated neutrophil adherence to fibronectin was also reduced but this was not
due to quantitative changes in beta(2) integrin expression or function.
L-Selectin expression on resting and stimulated neutrophils was increased after
14 days and there was a small decrease in plasma levels of soluble L-selectin.
These effects, however, could not be reproduced by treatment of neutrophils with
indomethacin in vitro, suggesting they are due to effects on
differentiating/maturing PMNs. In an attempt to interpret these changes, studies
were performed with dexamethasone, which is known to alter neutrophil function
and kinetics. Dexamethasone treatment reduced chemotaxis and increased
superoxide generation after 1 day and was associated with increased expression
of activated beta(2) integrins and reduced L-selectin expression on resting
neutrophils. This suggests the appearance of mainly 'activated' cells as a
result of demargination and indicates that the effects of indomethacin are
distinctive and not related to changes in compartmentalisation.

Biochim Biophys Acta 2000 Jan 3;1500(1):70-6

Migration of CD18-deficient neutrophils in vitro: evidence for a
CD18-independent pathway induced by IL-8.

Morland CM, Morland BJ, Darbyshire PJ, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.

Neutrophils isolated from a child with severe leukocyte adhesion deficiency 1
(LAD1) had a complete absence of expression of the CD11/CD18 beta2 integrin
family of adhesion molecules, and were shown to be deficient in the in vitro
adhesion and migration properties. However, we found that interleukin-8 (IL8), a
potent chemoattractant for neutrophils, and sputum sol phase induced these LAD1
neutrophils to migrate through an endothelial cell layer in vitro, and confirmed
that this migration was CD18-independent. These findings add to evidence of
CD18-independent mechanisms of neutrophil recruitment, in particular neutrophil
infiltration into the lungs, where IL8 may be an important recruitment factor.

Am J Respir Crit Care Med 1999 Nov;160(5 Pt 2):S49-52

Neutrophils and protease/antiprotease imbalance.

Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, United
Kingdom.

An imbalance between neutrophil proteases and the surrounding antiproteases is
critical in the normal functioning of the neutrophil. Enzyme activity is of
importance in cell migration and may play a role in some beneficial aspects of
host defense. However, when persistent or excessive this imbalance can be
detrimental and (even in the absence of antiprotease deficiency) central to most
of the pathogenic processes in COPD. Understanding of these complex
relationships that alter a beneficial host defense response to a destructive one
will be critical in the development of long-term therapeutic strategies.
Stockley RA. Neutrophils and protease/antiprotease imbalance.

Eur Respir J 1999 Jul;14(1):39-45

Quality of life in elderly subjects with a diagnostic label of asthma from
general practice registers.

Dyer CA, Hill SL, Stockley RA, Sinclair AJ.

Dept of Geriatric Medicine & Gerontology, University of Birmingham, UK.

The aim of this study was to assess health-related quality of life (QoL) in
elderly subjects with a diagnostic label of asthma from a general practice
population, and to determine the main contributory factors. Sixty people aged >
or =70 yrs with a primary care diagnostic label of asthma, and 43 control
subjects were recruited. Assessment of bronchodilator response, and oral steroid
trials were conducted where possible. The main outcome measures were QoL scores
for the Short Form (SF)-36 and the St George's Respiratory Questionnaire (SGRQ).
In the asthma group, 29 subjects demonstrated a significant airway response to
bronchodilators or steroids. Mean SF-36 scores were significantly worse in the
total asthma group for components of physical function, physical role
limitation, and general health, although psychological scores were similar. QoL
remained worse than controls in those subjects with a significant bronchodilator
response. Dyspnoea and depression accounted for 61% of the variance in the SGRQ,
but forced expiratory volume in one second was not an independent variable.
Quality of life is impaired in elderly people with a diagnosis of asthma,
including those with demonstrable airway variability. Many older subjects with
asthma note a variety of symptoms, highlighting the need for further research
into the adequacy and efficacy of their treatment.

Am J Respir Crit Care Med 1999 Sep;160(3):893-8

The interrelationship of sputum inflammatory markers in patients with chronic
bronchitis.

Hill AT, Bayley D, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, United Kingdom.

Many of the features of bronchial disease are believed to be caused by damage to
the airways by elastase released by recruited neutrophils. There have been few
studies of the mechanisms involved and the interrelationships between components
of the inflammatory process. We studied secretions from patients with chronic
bronchitis in the stable state. We assessed the presence of neutrophils by
measuring myeloperoxidase (MPO) activity and active neutrophil elastase (NE).
These results were compared with the chemoattractants interleukin-8 (IL-8) and
leukotriene B(4) (LTB(4)), the bronchial inhibitor secretory leukoprotease
inhibitor (SLPI), and protein leak (sputum/serum albumin ratio). MPO correlated
with NE activity (r = 0.68, p < 0.001) and both IL-8 (r = 0.52, p < 0.001) and
LTB(4) (r = 0.41, p < 0.001) indicating an association with the
chemoattractants. Elastase activity correlated with IL-8 (r = 0.55, p < 0.001)
and LTB(4) (r = 0.41, p < 0.001) but negatively with SLPI (r = -0.49, p <
0.001). NE also correlated positively with protein leak (r = 0.36, p < 0.001),
suggesting a cause and effect. MPO and protein leak correlated negatively with
FEV(1) (percentage of predicted) only in patients with chronic obstructive
pulmonary disease (COPD) without alpha(1)-antitrypsin deficiency (r = -0.37, p <
0.001; r = -0.42, p < 0.01, respectively). These complex interactions provide a
template for future studies with specific inhibitors or agonists which will
clarify the role of individual factors.

Respir Med 1999 Jul;93(7):481-90

Chronic obstructive pulmonary disease, with and without alpha-1-antitrypsin
deficiency: management practices in the U.K.

Hill AT, Campbell EJ, Ward AM, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Birmingham, U.K.

Alpha-1-antitrypsin deficiency is a common genetic defect associated with the
development of severe and rapidly progressive lung disease. This study was
undertaken to determine whether respiratory physicians manage patients with
alpha-1-antitrypsin (AAT) deficiency differently from patients with chronic
obstructive pulmonary disease (COPD) without alpha-1-antitrypsin deficiency. In
addition we obtained physicians' views on who should be tested for AAT
deficiency. A questionnaire was administered to 88 respiratory physicians based
throughout the U.K. (44 in teaching hospitals). The main outcome measures were
pulmonary function tests, radiological assessment, frequency of repeat testing,
follow-up and screening protocol for alpha-1-antitrypsin deficiency. Subjects
with homozygous (PiZ) AAT deficiency were more likely to: 1. have baseline and
full pulmonary function testing including dynamic flow rates, static lung
volumes, and gas transfer; 2. have more comprehensive assessment with high
resolution computed tomography (HRCT) thorax and repeated radiological
assessment (with annual chest radiography); 3. be followed-up routinely; and 4.
have family members tested for alpha-1-antitrypsin deficiency. Testing remains
limited for AAT deficiency and is mainly restricted to young patients with COPD.
COPD assessment and management is influenced by the presence of AAT deficiency,
which may reflect the poorer prognosis of such patients due to more rapid
decline. Assessment and monitoring could be simplified to forced expired
manoeuvres, although limited HRCT thorax and tests of gas transfer may prove
more sensitive to progression of emphysema. Testing for AAT deficiency in the
U.K. remains restricted, which will influence the detection rate for AAT
deficiency. A wider policy of testing was advocated by the WHO will detect more
patients and also influence our understanding of the natural history of the
condition.

Biochim Biophys Acta 1999 Mar 19;1430(2):179-90

Interaction between leukocyte elastase and elastin: quantitative and catalytic
analyses.

Morrison HM, Welgus HG, Owen CA, Stockley RA, Campbell EJ.

Department of Internal Medicine, Respiratory and Critical Care, Jewish Hospital
at Washington University Medical Center, St. Louis, MO 63110, USA.

Solubilization of elastin by human leukocyte elastase (HLE) cannot be analyzed
by conventional kinetic methods because the biologically relevant substrate is
insoluble and the concentration of enzyme-substrate complex has no physical
meaning. We now report quantitative measurements of the binding and catalytic
interaction between HLE and elastin permitted by analogy to receptor-ligand
systems. Our results indicated that a limited and relatively constant number of
enzyme binding sites were available on elastin, and that new sites became
accessible as catalysis proceeded. The activation energies and solvent deuterium
isotope effects were similar for catalysis of elastin and a soluble peptide
substrate by HLE, yet the turnover number for HLE digestion of elastin was
200-2000-fold lower than that of HLE acting on soluble peptide substrates.
Analysis of the binding of HLE to elastin at 0 degrees C, in the absence of
significant catalytic activity, demonstrated two classes of binding sites
(Kd=9.3x10(-9) M and 2.5x10(-7) M). The higher affinity sites accounted for only
6% of the total HLE binding capacity, but essentially all of the catalytic
activity, and dissociation of HLE from these sites was minimal. Our studies
suggest that interaction of HLE with elastin in vivo may be very persistent and
permit progressive solubilization of this structurally important extracellular
matrix component.

Eur Respir J 1998 Dec;12(6):1250-1

Proteolytic enzymes and airway diseases.

Nadel JA, Stockley RA.

Thorax 1998 Jun;53(6):463-8

IgG subclasses in the serum and sputum from patients with bronchiectasis.

Hill SL, Mitchell JL, Burnett D, Stockley RA.

Department of Medicine, University of Birmingham, UK.

BACKGROUND: IgG subclass deficiency is often associated with recurrent pulmonary
infections. The prevalence of deficiency in a large well characterised group of
patients with bronchiectasis has not previously been established. METHODS: Serum
IgG subclass concentrations in 89 patients with bronchiectasis were compared
with those obtained from a group of 82 age and sex matched normal healthy
controls. Sputum IgG subclass concentrations were also assessed in 44 of the
patients. Albumin was measured as a marker of protein transudation from plasma
to determine the degree of local IgG subclass production. RESULTS: The serum
concentrations of IgG1, IgG2 and IgG3 were increased in the patients compared
with the control group whereas IgG4 concentrations were not. There was an
overall incidence of deficiency of 1% for subclasses 1-3 and 5% for subclass 4
in patients with bronchiectasis based on observed concentrations being below the
lower limit of the control group range. The concentrations of IgG subclasses in
sputum were partly dependent upon the degree of inflammation as assessed by the
macroscopic appearance of purulence. A comparison of the ratio of sputum:serum
subclass concentration and sputum:serum albumin, however, revealed that all of
the subclasses were present at greater concentrations than could be accounted
for by transudation alone. CONCLUSIONS: A new normal control range for serum IgG
subclasses has been established and from this range it was found that IgG
subclass deficiency in a group of unselected patients with bronchiectasis was
comparatively rare. A significant degree of local IgG production was also
suggested in the lungs of these patients.

Biochim Biophys Acta 1998 Aug 14;1407(2):146-54

The effect of interleukin-8 and granulocyte macrophage colony stimulating factor
on the response of neutrophils to formyl methionyl leucyl phenylalanine.

Mikami M, Llewellyn-Jones CG, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH,
UK.

Neutrophils isolated from patients with chronic bronchitis and emphysema have
been shown to have enhanced responses to formyl peptides when assessed in vitro
compared to age, sex matched controls. It is currently unclear whether the
observed differences are due to a 'priming' effect by a second agent in vivo, or
whether this is a primary difference in the neutrophils. We have studied the
effects of interleukin-8, which is thought to be one of the major
pro-inflammatory cytokines in chronic lung disease and granulocyte macrophage
colony stimulating factor (GMCSF), in order to assess their effects on
neutrophil chemotaxis and connective tissue degradation. In addition, we have
assessed the effect of preincubation of these agents with neutrophils for 30 min
followed by stimulation with F-Met-Leu-Phe (FMLP) to investigate any possible
'priming' effect that may be relevant to our clinical data. We report
suppression of neutrophil chemotaxis to FMLP following incubation of the
neutrophils with both IL-8 and GMCSF. However, we have observed an additive
effect of IL-8 and FMLP for neutrophil degranulation leading to fibronectin
degradation. The results suggest that IL-8 does not 'prime' neutrophils for
subsequent FMLP stimulation as observed in vivo. Although the results for GMCSF
were similar for the chemotactic response, the agent also had a synergistic
effect on connective tissue degradation. However, it is concluded that neither
agent could explain the enhanced neutrophil responses seen in our patients.

Int J Biochem Cell Biol 1998 Feb;30(2):173-8

Leukotriene B4.

Crooks SW, Stockley RA.

Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
stephen.crooks@virgin.net

Leukotriene B4 is a pro-inflammatory mediator synthesised in myeloid cells from
arachidonic acid. Synthesis is catalysed by 5-lipoxygenase and leukotriene A4
hydrolase and is increased by inflammatory mediators including endotoxin,
complement fragments, tumor necrosis factor and interleukins. A nuclear membrane
protein, 5-lipoxygenase activating protein, is an essential co-factor for
5-lipoxygenase. Leukotriene B4 induces recruitment and activation of
neutrophils, monocytes and eosinophils. It also stimulates the production of a
number of proinflammatory cytokines and mediators indicating an ability to
augment and prolong tissue inflammation. Elevated levels of leukotriene B4 have
been found in a number of inflammatory diseases and levels are related to
disease activity in some of these. Initial data from pharmacological inhibition
studies support a role for leukotriene B4 in the pathogenesis of neutrophil
mediated tissue damage, and treatments which reduce its production or block its
effects may prove beneficial in neutrophil mediated inflammatory diseases.

Thorax 1998 Jan;53(1):58-62

Lung infections. 1. Role of bacteria in the pathogenesis and progression of
acute and chronic lung infection.

Stockley RA.

Queen Elizabeth Hospital, Birmingham, UK.

Am J Respir Crit Care Med 1998 Mar;157(3 Pt 1):723-8

The chemotactic activity of sputum from patients with bronchiectasis.

Mikami M, Llewellyn-Jones CG, Bayley D, Hill SL, Stockley RA.

The Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham,
United Kingdom.

Persistent polymorphonuclear neutrophil (PMN) recruitment to airway is thought
to be an important component of continuing inflammation and progression of
chronic destructive lung diseases. Although chemoattractants are required for
the PMN to migrate, the nature of the chemoattractants in the airways has not
yet been clarified. We therefore investigated the contribution of interleukin-8
(IL-8) and leukotriene-B4 (LTB4) to the chemotactic activity of lung secretions
by inhibiting their activity using a monoclonal antibody to IL-8 and an LTB4
receptor antagonist (LY293111 sodium). Fifty-nine sputum samples obtained from
19 patients with bronchiectasis were studied. In preliminary studies the
chemotactic responses to IL-8 and LTB4 were found to be additive, and we were
able to remove their contribution independently with the appropriate antibody
and antagonist. The chemotactic activity of the secretions was related to the
macroscopic appearance (mucoid, mucopurulent, and purulent), and this appeared
to be related to an increase in IL-8 contribution. Chemotactic activity was
reduced by antibiotic therapy and again that seemed to relate to a reduction in
the IL-8 contribution. The contributions of LTB4 were similar among the three
types of sputum in varying clinical states. These data suggest that LTB4 and
IL-8 are important chemotactic factors in lung secretions from such patients,
although IL-8 appears to play a more important role during acute exacerbations.
These results may be useful in determining therapeutic strategies for chronic
destructive lung diseases in the future.

Postgrad Med J 1996 May;72(847):290-2

The distribution of antibodies to streptokinase.

Lynch M, Pentecost BL, Littler WA, Stockley RA.

Department of Cardiology, General Hospital, Birmingham, UK.

To determine the distribution of antibodies to streptokinase that might be
anticipated in patients requiring treatment with streptokinase, specific
anti-streptokinase antibody titres were determined in a group of subjects from
the general population and in a group of patients presenting with acute
myocardial infarction. Enzyme-linked immunosorbent assays were developed to
measure specific anti-streptokinase IgG and subclass IgG1 in 95 subjects from
the general population and in 160 patients presenting with acute myocardial
infarction. Low titres of IgG1 were found in both the general population (median
= 5; range: 0-490) and in the myocardial infarction group (median = 7; range:
0-2000). A minority of subjects in both groups had high titres. The findings
suggest that low titres of antibody are widespread in the population. The
minority of subjects in both groups who had high titres may explain the
infrequent type III immune reactions encountered with streptokinase.

Am J Respir Crit Care Med 1996 Feb;153(2):616-21

Effect of fluticasone propionate on sputum of patients with chronic bronchitis
and emphysema.

Llewellyn-Jones CG, Harris TA, Stockley RA.

Lung Immunobiochemical Research Laboratory, General Hospital, Birmingham, United
Kingdom.

The effects of fluticasone propionate (FP) on sputum chemotactic activity,
elastase inhibitory potential, albumin concentrations, and peripheral neutrophil
function were studied in a group of patients with clinically stable,
smoking-related chronic bronchitis and emphysema. Seventeen patients (50 to 75
yr of age) were entered into a double-blind, placebo-controlled study of 1.5 mg
inhaled FP/d for 8 wk. Following treatment with FP the chemotactic activity of
the sputum sol phase was lower than the corresponding values for the placebo
group (p < 0.01). Values fell from a mean of 21.75 (+/- 1.58) during the run-in
period to 18.37 (+/- 1.46; p < 0.01) after 4 wk and 17.63 (+/- 1.86; p < 0.05)
after 8 wk treatment returning to 22.08 (+/- 1.26) cell/field after the washout
period. The neutrophil elastase inhibitory capacity of the sputum sol phase
increased (p < 0.025) with treatment from a mean of 0.177 microM elastase
inhibited/L (+/- 0.05) pretreatment to 0.413 microM (+/- 0.054) after 4 wk and
0.415 microM (+/- 0.054) after 8 wk returning to 0.270 microM (+/- 0.07) after
the washout period. Treatment with FP did not result in a change in the
peripheral neutrophil functions studied or sputum albumin and myeloperoxidase
concentrations. The results suggest that FP may play a protective role in these
patients through a reduction in the chemotactic activity of lung secretions and
potentially a reduction in the recruitment of neutrophils to the lung, and also
by directly affecting the proteinase/antiproteinase balance, in favor of
antiproteinases, within lung secretions.

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