Abstract Reactive oxygen species (ROS) can cause severe damage to cells and organs but they are also important mediators of inflammatory responses and cellular signalling. Due to the significant role of ROS, the cells have evolved a broad antioxidative system to regulate the concentration of these species. Peroxiredoxins (Prxs) are enzymes that participate in the regulation of the cellular redox-homeostasis by detoxifying hydrogen peroxide. Prxs are not classified as conventional antioxidant enzymes and their physiological role, whether protective or regulatory, is still unclear. The aim of this project was to study the localization and regulation of Prxs in normal human lung and also their role in selected lung disorders (pulmonary sarcoidosis, pleural mesothelioma, lung carcinomas and chronic obstructive disorder, COPD). Additionally the expression of thioredoxin (Trx) and thioredoxin reductase (TrxR) was analysed in the lung of smokers and COPD patients. These enzymes are important reductants in cell and Prxs are one of their targets. Lung is an important organ in the field of ROS and antioxidant research since it is especially vulnerable to exogenous oxidative stress caused by pollutants, cigarette smoke and also by high oxygen pressure. The results showed that all six human Prxs were expressed in healthy human lung but in a cell-specific manner. The most prominent expression was detected in the epithelium and in macrophages, the cells most prone to oxidative stress. There were also differences in subcellular locations of Prxs. The expression of Prxs in non-malignant lung diseases (pulmonary sarcoidosis and COPD) and in smoker's lung was very similar with that in normal lung. Higher expression of Prx V and VI was detected in a subpopulation of macrophages sampled from COPD patients' lung. In contrast, Trx expression was induced in the bronchial epithelium of smoker's lung. Differences in the expression compared to normal lung were seen in lung malignancies (pleural mesothelioma and lung carcinomas). Interestingly, different Prxs were highly expressed in different types of carcinomas. In pleural mesothelioma, all Prxs except Prx IV were highly expressed when compared to normal pleura, in adenocarcinoma Prxs I, II, VI and especially IV, and in squamous cell carcinoma Prxs I, II and IV were upregulated. Tests performed on cultured cells in vitro revealed only a minor increase in the Prx expression after severe oxidant stress in malignant lung cell line originating from alveolar type II pneumocytes (A549) or non-malignant cell line derived from bronchial epithelium. None of the tested growth factors or cytokines affected Prx expression or oxidation state, but severe oxidant stress influenced remarkably the oxidation state of the Prxs.

Abstract Reactive nitrogen species (RNS) and reactive oxygen species (ROS) have been linked with the pathogenesis of lung malignancies and chronic obstructive pulmonary disease (COPD). In vitro studies indicated that mesothelioma and lung carcinoma cell lines synthesize nitric oxide synthases (NOS) mRNA. The Comet-assay indicated that asbestos fibers caused DNA single -strand breaks in mesothelial cells, and this effect was enhanced by glutathione depletion. The use of FPG in the Comet assay indicated that the asbestos induced DNA strand breaks were oxidant mediated. In vivo non-neoplastic pleura was mostly negative for inducible NOS (iNOS), while inflamed pleura was positive. The immunohistochemical expression of iNOS was detected in 74% and 96% of malignant mesotheliomas and metastatic pleural adenocarcinomas, respectively. Epithelial and mixed mesotheliomas expressed more often intense iNOS immunoreactivity compared to the sarcomatoid subtype. Normal mesothelial cells showed occasional positivity for endothelial NOS (eNOS), but reactive mesothelial cells were strongly stained. eNOS was found in 89% of mesotheliomas. Vascular endothelial growth factor (VEGF) was identified in 47%, a VEGF receptor FLK1 in 69% and the VEGF receptor, FLT1, in 71% of mesotheliomas. FLK1 or FLT1 immunoreactivities were more often seen in epithelioid and biphasic mesotheliomas than in sarcomatoid mesotheliomas. In lung samples of non-smokers, smokers and COPD patients, the levels of nitrotyrosine were higher in alveolar macrophages of smokers and COPD patients than in the non-smokers and in the alveolar epithelium of smokers and COPD patients than in the non-smokers. The iNOS expression was weak in the bronchial and alveolar epithelium in all groups but eNOS was most prominently expressed in alveolar macrophages while neuronal NOS (nNOS) was negative in all of the major cell types of the lung. Bronchial metaplasia-dysplasia-sequence was clearly positive for iNOS, nNOS and nitrotyrosine. Thus, smoking can cause protein nitration also in normal lung. Prominent iNOS and nNOS immunoreactivity in metaplasia-dysplasia-lesions suggests a divergent role of NOSs in carcinogenesis and destruction of alveolar epithelium in emphysematous lung. In lung cancer samples, iNOS was detected in 40% cases, while 89% and 81% cases were positive for eNOS and nNOS, respectively. Intense eNOS staining was seen more often in adenocarcinomas than in squamous cells carcinomas, and iNOS immunoreactivity was seen more often in grade I-II tumors than in grade III tumors. The patients with tumors showing high expression of iNOS, eNOS and nNOS, exhibited better survival, but this was not an independent prognostic factor.

Research on sex and gender in chronic obstructive pulmonary disease (COPD) has primarily focused on differences in pulmonary function. Detailed gender- and sex-based analyses of other aspects of COPD, including epidemiology, risk factors other than cigarette smoke, pathophysiology, and measurement tools are warranted. In Chapter Two we analyzed administrative health services data to compare the prevalence, mortality and use of drugs and spirometry in men and women with COPD. Contrary to recent predictions, we did not detect a dramatic increase in the prevalence or mortality of COPD over time in women compared to men. We discuss how different coding practices in medical billing can impact the results. In Chapter Three we examined sex differences in COPD phenotypes. We hypothesized that male smokers would have more emphysema whereas female smokers would have more airway wall remodeling using data from high resolution computed tomography (HRCT) scans. We did detect more emphysema in male smokers but there was no evidence of increased airway remodeling in women. We discuss the limits of HRCT to detect airway differences in women and men. In Chapter Four we examined the use of HRCT in assessing emphysema. We hypothesized that the computer-derived estimates of emphysema (the fractal value and the % low attenuation area (%LAA)) would differentiate COPD from non-COPD as accurately as the radiologist’s emphysema scores, and would provide similar predictions in both men and women. Instead, we found that the subjective rating of emphysema best differentiated COPD, and the fractal value (a measure of emphysematous lesion size) better differentiated COPD compared with an established objective measurement, the %LAA. These results were generally the same in men and women. In Chapter Five we examined characteristics of COPD in women exposed to biomass smoke. We hypothesized that biomass smoke would induce an airway disease-predominant phenotype. We found that women with biomass smoke-exposed COPD had greater airway remodeling and less emphysema than women with tobacco smoke-exposed COPD. In summary, these findings suggest that sex and gender differences are present in COPD epidemiology and pathophysiology. However, current research measurement tools may limit the ability to accurately measure these differences. / Graduate and Postdoctoral Studies / Graduate

As a leading cause of disability that often leads to death, chronic obstructive pulmonary disease (COPD) can be characterized as both a chronic illness and a life-threatening one. As a result, the experience of individuals with COPD can include psychological concerns that are associated with both rehabilitation and palliative care. At the same time, the often-uncertain trajectory of COPD obscures a clear transition from rehabilitation to palliative care. It is not surprising, therefore, that treatments aimed at addressing patients’ rehabilitative and palliative needs largely proceed independently of each other. This dissertation contains two studies conducted with patients participating in a pulmonary rehabilitation program for COPD (N = 242). Separately, each study stems from a research tradition grounded in either the rehabilitative or palliative approach to treatment. Together, the studies highlight an opportunity for a model of more integrated care. Study 1 is derived from the rehabilitation literature and focuses on the issue of “catastrophizing” about breathlessness. Catastrophizing is characterized by a magnification of a symptom’s threat value, rumination about its perceived negative impact, and a sense of helplessness in addressing it. In some medical conditions with a primary symptom, such as chronic pain, catastrophizing demonstrates a strong relationship with the development of disability. Study 1 examines whether this relationship is found in the context of breathlessness. The study also reports the initial validation of the Breathlessness Catastrophizing Scale (BCS) as a means of assessing this phenomenon. Study 2 has its conceptual basis in the palliative care literature and highlights patients’ existential concerns around loss of dignity. Loss of dignity is a central construct in recent health care debates, because it is a primary reason underlying the requests of terminally ill individuals to seek medically hastened deaths (i.e., euthanasia or assisted suicide). Until now, however, loss of dignity has only been examined among patients with cancer. Study 2 examines whether loss of dignity is as prevalent among those with advanced COPD, and whether it improves with treatment. In Study 1 the BCS was found to be a reliable measure of breathlessness catastrophizing, with good convergent validity and sensitivity to change. Interestingly, it appears that breathlessness catastrophizing need not be a barrier to functional improvement in COPD. In Study 2, a “fractured” sense of dignity was found among 13% of patients with advanced COPD, suggesting that it is at least as prevalent as among those receiving palliative cancer care. It was also evident that loss of dignity is amenable to change with appropriate rehabilitation. This finding is important for societal debates regarding the provision of medically hastened deaths, which are often described as offering “death with dignity”. Together these studies demonstrate that in an interdisciplinary environment, such as the pulmonary rehabilitation program, not only is collaboration possible, but the distinct rehabilitative and palliative needs of patients can be met.

La bronchopneumopathie chronique obstructive (BPCO) est une maladie caractérisée par une réaction inflammatoire intense avec une destruction du parenchyme pulmonaire et une perte d’élasticité du poumon conduisant à une obstruction quasi-irréversible des voies aériennes. L’utilisation du tabac est le principal facteur de risque de cette maladie. La fumée de cigarette active les cellules épithéliales et les macrophages résidents en libérant des protéases et des chimiokines. Ces phénomènes sont responsables de l’infiltration de cellules inflammatoires dans le poumon, telles que les neutrophiles, les macrophages et les lymphocytes. Ces cellules libèrent des enzymes protéolytiques capables de dégrader les composants de la matrice extracellulaire. Parmi ces protéases, l’élastase du neutrophile (NE) semble stimuler la sécrétion de cytokines, participant ainsi à une inflammation chronique. De fortes évidences montrent que des infections bactériennes récurrentes contribuent à ce processus inflammatoire et par conséquent à l’aggravation de la BPCO. A partir de ces observations, nous nous sommes intéressés aux événements précoces du développement de la BPCO associés à une infection bactérienne récurrente. Dans un premier temps, nous avons montré que l’association d’un extrait de fumée de cigarette à de faibles doses de LPS est capable d’augmenter de façon synergique la libération des chimiokines par les cellules épithéliales alvéolaires. Ce phénomène implique l’activation des voies de signalisation MAP kinase ERK1/2 et JAK/STAT. Nous avons mis en évidence que l’inhibiteur de la phosphodiestérase 4, le roflumilast N-oxide, empêche la sécrétion de ces cytokines inactivant ainsi les voies JAK/STAT et ERK1/2. Dans un deuxième temps, nous avons démontré que la NE peut conduire à la libération de chimiokines par des cellules épithéliales alvéolaires en activant la voie de signalisation p38 et que le roflumilast N-oxide diminue le taux de ces chimiokines. Une approche in vitro sur un modèle de cellules épithéliales alvéolaires a permis de démontrer l’effet synergique du CSE associé au LPS sur la libération de cytokines et sur l’activation des voies de signalisation. Cet effet pourrait être responsable de la progression et de l’exacerbation de la BPCO. Notre étude montre aussi les effets du roflumilast sur la libération de cytokines induites par la NE ou par le CSE/LPS. Ces résultats mettent en lumière d’autres mécanismes par lesquels le roflumilast N-oxide exerce son effet anti-inflammatoire dans la BPCO. / Chronic obstructive pulmonary disease (COPD) is a pathology characterized by an abnormal inflammatory response and associated with a destruction of lung parenchyma and loss of lung elasticity, leading to an airway limitation not fully reversible. Tobacco smoking continues to be a major cause of COPD. Cigarette smoke activates epithelial cells and resident macrophages by releasing proteases and chemokines. This phenomenon is responsible of the migration of inflammatory cells in the lung tissue such as neutrophils, macrophages and lymphocytes. These cells are able to release proteolytic enzymes leading to the degradation of components of the extracellular matrix. Among these proteases, neutrophil elastase (NE) seems to stimulate the secretion of cytokines involved in chronic inflammation. Strong evidence shows that recurrent bacterial infections contribute to the inflammatory process and consequently to the worsening of COPD. Based on these observations, we studied the early events in the development of COPD associated with recurrent bacterial infection. Initially we showed that the combination of a cigarette smoke extract associated with low doses of LPS is able to synergistically increase the release of chemokines, by alveolar epithelial cells through the activation of MAP kinase signaling pathways ERK1/2 and JAK/STAT. We also demonstrated that the phosphodiesterase 4 inhibitor, roflumilast N-oxide (RNO) inhibits the secretion of these cytokines, thereby inactivating pathways JAK/STAT and ERK1/2. Moreover, we have demonstrated that neutrophil elastase (NE) can lead to the release of chemokines by alveolar epithelial cells by activating the p38 signaling pathway. Moreover the treatment of the cells with roflumilast N-oxide significantly reduces the production of these chemokines. This in vitro model demonstrates the synergistic effect of CSE associated with LPS on the release of cytokines and activation of signaling pathways. This effect could be responsible for the progression and exacerbation of COPD. Our study also shows the effect of RNO on the release of cytokines induced by NE or by the combination CSE/LPS. These results highlight other mechanisms by which Roflumilast N-oxide exerts its anti-inflammatory effect in COPD

This paper examines the influence of air pollution on humans. Suggesting the possible consequences of each action of air pollutants on human health but also the possible economic impacts of air pollution. It primarily exploers the effects of concentration of suspended particulate matter (PM10) on the incidence of chronic obstructive pulmonary disease. The response variable in the regression model serves to determine the effect of PM10 on the incidence of chronic obstructive pulmonary disease was a percentage share of patients with chronic obstructive pulmonary disease among the clients of the General Health Insurance Company in individual regions of the Czech Republic. Explanatory variables were the mean annual concentration of PM10 and gross added value per capita. The model suggests that there is a statistically significant positive correlation between the incidence of chronic obstructive pulmonary disease in the Czech Republic and PM10 concentrations.

Introduktion: Kroniskt obstruktiv lungsjukdom (KOL) är en sjukdom som kännetecknas av ihållande luftvägssymtom och begränsningar i luftflöde. Personer med KOL är betydligt mindre aktiva än friska individer. Sänkt fysisk aktivitet är en stark prediktor för mortalitet för personer med KOL.   Syfte: Syftet med denna studie var att undersöka om motiverande samtal om fysisk aktivitet kan användas som intervention för personer med KOL för att påverka self-efficacy (ESES) för fysisk aktivitet samt nivå av ångest och depression. Syftet är även att undersöka om det finns ett samband mellan förändring i self-efficacy samt förändring av fysisk förmåga.   Metod: Studien inkluderar data från 83 deltagare. Under en 6 månader lång interventionsfas har testdeltagarna fått motiverande samtal om fysisk aktivitet. Vår statistiska analys inkluderar hypotesprövning av skillnader på utvalda enkäter. Hypotesprövning av samband har gjorts med Pearsons r.    Resultat: Motiverande samtal ledde till en signifikant ökad self-efficacy gällande fysisk aktivitet efter intervention (m=23.8; sd=7.43) jämfört med före intervention (m=22.3; sd=7.04) med motiverande samtal (p=0.025). Ingen effekt påvisades beträffande ångest och depression. Det finns ett statistiskt signifikant samband (p = <0.001) mellan självskattad self-efficacy gällande fysisk aktivitet och fysisk förmåga mätt med 6-minuters gångtest efter 6 månader. Sambandet var svagt positivt (Pearsons r = 0.410).   Konklusion: Motiverande samtal har visats förbättra self-efficacy, det vill säga tilltro till egen förmåga att utföra fysisk aktivitet. Det finns ett samband mellan tilltro till egen förmåga samt fysisk kapacitet, vilket kan betyda att motiverande samtal är en bra intervention för svårt sjuka personer med KOL.

Chronic obstructive pulmonary disease (COPD) requiring long-term oxygen therapy (LTOT) is an incurable lung disease often complicated by other comorbidities. Research is limited for hospitalized COPD exacerbations with LTOT and palliative care services. The purpose of this quantitative research study was to determine the correlation between palliative care interventions and COPD patient outcomes specific to an intensive care unit (ICU) stay, invasive mechanical ventilator support, physician orders for cardiopulmonary resuscitation (CPR) code status, and hospital discharge to hospice care. The theoretical base for this study was Donabedian's quality improvement theory. The quasi-experimental, nonequivalent groups design divided COPD hospitalized patient sample into 2 groups, those with and those without palliative care, for comparison. An independent-samples t test, one-way MANOVA, and follow-up univariate ANOVAS was done to compare the means of ICU days and ventilator days; a cross tabulation, chi-square test of independence, and Fisher exact test was done to compare code status and place of hospital discharge. The mean number of the ICU days and ventilator days for palliative care patients was significantly higher than patients who did not receive palliative care. A significant interaction was found for palliative care and code status change from CPR to no CPR; however, data relating to palliative care and hospital discharge to hospice was insignificant. In conclusion, palliative care does not reduce costs by limiting the number of days spent in an ICU or the number of days on invasive mechanical ventilation; although, it may have an important role in the code status order change from CPR to no CPR to align with the patient's end of life care preference.

Living with chronic obstructive pulmonary disease stage III or IV has a major impact on a person's everyday life. The aim of this licentiate thesis was to describe the experiences of women living with chronic obstructive pulmonary disease stage III or IV, as well as the experiences as a close relative to women with chronic obstructive pulmonary disease stage III or IV. In both studies, data were collected through individual, semi-structured interviews. The interview texts were then subjected to qualitative content analysis. A purposive sample of 15 women with either stage III or IV chronic obstructive pulmonary disease stage and a total of 9 close relatives participated in the studies. The findings showed that breathlessness restricted women with chronic obstructive pulmonary disease, to live with a breathing and body which they had to wait for. Stabilizing an ever-present breathlessness by restoring strength helped them manage everyday life and adapt to their limited abilities and energy. This restoration required detailed planning and a good knowledge of their breathing and bodies. Women were afraid of contracting life-threatening infections that would cause suffering. Fear led to isolation, and digital media were described as an important means of communication (I). Close relatives were of major importance to women with chronic obstructive pulmonary disease in their everyday life in terms of being flexible to accommodate the women’s needs. They were flexible, available, and on stand-by. The COVID-19 pandemic was experienced by close relatives as a reinforced threat to women with chronic obstructive pulmonary disease. Close relatives raised awareness of their vulnerability to potentially life-threatening infections, leading them to carefully avoid exposure and thus rely more on digital media. A more sedentary life was one effect of living in a gradually, yet controlled everyday life for close relatives. Women with chronic obstructive pulmonary disease stage III or IV and their close relatives expressed that they lacked continuity, participation, and support from healthcare professionals (I, II). In conclusion, the findings of this licentiate thesis show that women with chronic obstructive pulmonary disease stage III or IV and their close relatives experience both health and suffering in their everyday lives. By gaining understanding and insights into the lives of women with chronic obstructive pulmonary disease, as well as the needs and everyday challenges of their close relatives, better health outcomes can be supported. / <p>Vid tidpunkten för seminariet var följande delarbete opublicerat: delarbete 2 inskickat.</p><p>At the time of the licentiate seminar the following paper was unpublished: paper 2 submitted.</p>

Prior to the coronavirus disease-2019 (COVID-19) pandemic people with chronic obstructive pulmonary disease (COPD) were already experiencing social isolation due to the complex intersection of symptoms, and perceptions towards the illness. COPD is a chronic lung illness characterized by progressive shortness of breath, and decreasing lung function, with influenza and other respiratory illnesses more likely to have fatal consequences for this population. Societal beliefs and assumptions around behavioural risk factors, and in particular smoking, contribute to perceptions that COPD diagnosis, outcomes and experiences are self-inflicted and an individual responsibility. This is a perspective that fails to take into the account the complex contextual factors of the social determinants of health, where structural inequities result in higher smoking rates among populations with lower socioeconomic status. Further, these underlying societal values may compound the isolation experienced with COPD in which ongoing stigma towards the illness discourages people from identifying with a COPD diagnosis. The lack of identity may discourage developing a community where people can share experiences and strategies in living with COPD, and form a collective group that can advocate for change. Digital technologies (DTs), such as Facebook and Zoom offer new avenues to support social connectedness. However, little focus has been given on how people with COPD may (or may not) be using DTs to support their illness. This study explored the role DTs could serve in addressing social connectedness and experiences and outcomes for the COPD community. The study was informed by Mertens (2003, 2007) transformative approach where the knowledge of people living with COPD was prioritized in finding out what DTs they may be using to maintain social connectedness and to support their illness. The three stage mixed methods research design consisted of interviews, patient-reported outcome measures, patient-reported experience measures and a DT survey. Bazeley's (2018) approach was used to guide the integrative mixed analysis on data collected across the three stages. The overall findings were: 1) Participants’ experiences in living with COPD had uniquely prepared them for the COVID-19 pandemic, and it was the community that lacked capacity; 2) Dominant discourse around technology may be creating further harms to the COPD population that extend beyond the digital world; 3) Current digital health monitoring strategies for other chronic illnesses do not fully translate to the interests and needs for people living with COPD; 4) People living with COPD are using DTs, but prefer to keep their virtual world separate from their illness world; and 5) Considerations for DTs for COPD should move beyond managing outcomes, and include supporting experiences of living. Conducted between December 2018 and July 2020, and concurrent with the COVID-19 pandemic, the study demonstrated even greater importance with the onset of the pandemic in understanding how DTs may support social connectedness for people living with life-limiting chronic lung conditions. / Graduate / 2022-02-07