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Lo KH, Donohue J, Judson MA, Wu Y, Barnathan ES, Baughman RP. The St. George's Respiratory Questionnaire in Pulmonary Sarcoidosis. Lung 2020; 198:917-924. [PMID: 32979072 DOI: 10.1007/s00408-020-00394-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/19/2020] [Indexed: 01/17/2023]
Abstract
RATIONALE The Saint George's Respiratory Questionnaire (SGRQ) is a frequently used tool to assess health status in pulmonary disease patients. However, its performance characteristics in sarcoidosis patients are not well characterized. METHODS Data from a clinical trial of 138 symptomatic adults with sarcoidosis were used to examine the performance characteristics of SGRQ. Data were available at both baseline and week 24. Other assessments included FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6-min walk distance (6MWD), and Short Form-36 Physical Component Summary (SF-36 PCS) score. RESULTS Baseline SGRQ was 46.8, indicating impaired health status. At baseline, SGRQ total score correlated significantly with % predicted FVC, FEV1, ATS dyspnea score, Borg's CR 10 dyspnea score, 6MWD, and SF-36 PCS (r = - 0.37, - 0.32, 0.57, 0.40, - 0.55, and - 0.80, respectively, p < 0.001). Change from baseline in SGRQ score also statistically significantly correlated with change from baseline in these parameters at week 24: r = - 0.25, - 0.20, 0.30, 0.22, - 0.20, - 0.45, respectively (p < 0.05). CONCLUSIONS The SGRQ correlated with other outcome measures in sarcoidosis initially and with treatment. Improvement in FVC % predicted correlated with improvement in SGRQ. These data suggest the SGRQ may function as a reliable endpoint in clinical sarcoidosis trials.
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Jaitovich A, Dumas CL, Itty R, Chieng HC, Khan MMHS, Naqvi A, Fantauzzi J, Hall JB, Feustel PJ, Judson MA. ICU admission body composition: skeletal muscle, bone, and fat effects on mortality and disability at hospital discharge-a prospective, cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:566. [PMID: 32958059 PMCID: PMC7507825 DOI: 10.1186/s13054-020-03276-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023]
Abstract
Background Reduced body weight at the time of intensive care unit (ICU) admission is associated with worse survival, and a paradoxical benefit of obesity has been suggested in critical illness. However, no research has addressed the survival effects of disaggregated body constituents of dry weight such as skeletal muscle, fat, and bone density. Methods Single-center, prospective observational cohort study of medical ICU (MICU) patients from an academic institution in the USA. Five hundred and seven patients requiring CT scanning of chest or abdomen within the first 24 h of ICU admission were evaluated with erector spinae muscle (ESM) and subcutaneous adipose tissue (SAT) areas and with bone density determinations at the time of ICU admission, which were correlated with clinical outcomes accounting for potential confounders. Results Larger admission ESM area was associated with decreased odds of 6-month mortality (OR per cm2, 0.96; 95% CI, 0.94–0.97; p < 0.001) and disability at discharge (OR per cm2, 0.98; 95% CI, 0.96–0.99; p = 0.012). Higher bone density was similarly associated with lower odds of mortality (OR per 100 HU, 0.69; 95% CI, 0.49–0.96; p = 0.027) and disability at discharge (OR per 100 HU, 0.52; 95% CI, 0.37–0.74; p < 0.001). SAT area was not significantly associated with these outcomes’ measures. Multivariable modeling indicated that ESM area remained significantly associated with 6-month mortality and survival after adjusting for other covariates including preadmission comorbidities, albumin, functional independence before admission, severity scores, age, and exercise capacity. Conclusion In our cohort, ICU admission skeletal muscle mass measured with ESM area and bone density were associated with survival and disability at discharge, although muscle area was the only component that remained significantly associated with survival after multivariable adjustments. SAT had no association with the analyzed outcome measures.
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Chopra A, Avadhani V, Tiwari A, Riemer EC, Sica G, Judson MA. Granulomatous lung disease: clinical aspects. Expert Rev Respir Med 2020; 14:1045-1063. [PMID: 32662705 DOI: 10.1080/17476348.2020.1794827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Granulomatous lung diseases (GLD) are heterogeneous group of diseases that can be broadly categorized as infectious or noninfectious. This distinction is extremely important, as the misdiagnosis of a GLD can have serious consequences. In this manuscript, we describe the clinical manifestations, histopathology, and diagnostic approach to GLD. We propose an algorithm to distinguish infectious from noninfectious GLD. AREAS COVERED We have searched PubMed and Medline database from 1950 to December 2019, using multiple keywords as described below. Major GLDs covered include those caused by mycobacteria and fungi, sarcoidosis, hypersensitivity pneumonitis, and vasculidities. EXPERT OPINION The cause of infectious GLD is usually identified through microbiological culture and molecular techniques. Most noninfectious GLD are diagnosed by clinical and laboratory criteria, often with exclusion of infectious pathogens. Further understanding of the immunopathogenesis of the granulomatous response may allow improved diagnosis and treatment of GLD.
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Judson MA. The epidemic of drug-induced sarcoidosis-like reactions: a side effect that we can live with. J Intern Med 2020; 288:373-375. [PMID: 31724232 DOI: 10.1111/joim.13008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Balnis J, Adam AP, Chopra A, Chieng HC, Drake LA, Martino N, Ramos RB, Feustel PJ, Overmyer KA, Shishkova E, Coon JJ, Singer HA, Judson MA, Jaitovich A. Unique inflammatory profile is associated with higher SARS-CoV-2 acute respiratory distress syndrome (ARDS) mortality. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.05.21.20051300. [PMID: 32511515 PMCID: PMC7273283 DOI: 10.1101/2020.05.21.20051300] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The COVID19 pandemic is likely to cause more than a million of deaths worldwide, primarily due to complications from COVID19-associated acute respiratory distress syndrome (ARDS). Controversy surrounds the circulating cytokine/chemokine profile of COVID19-associated ARDS, with some groups suggesting that it is similar to non-COVID19 ARDS patients and others observing substantial differences. Moreover, while a hyperinflammatory phenotype associates with higher mortality in non-COVID19 ARDS, there is little information on the inflammatory landscape's association with mortality in COVID19 ARDS patients. Even though the circulating leukocytes' transcriptomic signature has been associated with distinct phenotypes and outcomes in critical illness including ARDS, it is unclear whether the mortality-associated inflammatory mediators from COVID19 patients are transcriptionally regulated in the leukocyte compartment. Here, we conducted a prospective cohort study of 41 mechanically ventilated patients with COVID19 infection using highly calibrated methods to define the levels of plasma cytokines/chemokines and their gene expressions in circulating leukocytes. Plasma IL1RA and IL8 were found positively associated with mortality while RANTES and EGF negatively associated with that outcome. However, the leukocyte gene expression of these proteins had no statistically significant correlation with mortality. These data suggest a unique inflammatory signature associated with severe COVID19.
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Abstract
As sarcoidosis may involve any organ, sarcoidosis patients should be evaluated for occult disease. Screening for some organ involvement may not be warranted if it is unlikely to cause symptoms, organ dysfunction, or affect clinical outcome. Even organ involvement that affects clinical outcome does not necessarily require screening if early detection fails to change the patient's quality of life or prognosis. On the other hand, early detection of some forms of sarcoidosis may improve outcomes and survival. This manuscript describes the approach to screening sarcoidosis patients for previously undetected disease. Screening for sarcoidosis should commence with a meticulous medical history and physical examination. Many sarcoidosis patients present with physical signs or symptoms of sarcoidosis that have not been recognized as manifestations of the disease. Detection of sarcoidosis in these instances depends on the clinician's familiarity with the varied clinical presentations of sarcoidosis. In addition, sarcoidosis patients may present with symptoms or signs that are not related to specific organ involvement that have been described as parasarcoidosis syndromes. It is conjectured that parasarcoidosis syndromes result from systemic release of inflammatory mediators from the sarcoidosis granuloma. Certain forms of sarcoidosis may cause permanent and serious problems that can be prevented if they are detected early in the course of their disease. These include (1) ocular involvement that may lead to permanent vision impairment; (2) vitamin D dysregulation that may lead to hypercalcemia, nephrolithiasis, and permanent kidney injury; and (3) cardiac sarcoidosis that may lead to a cardiomyopathy, ventricular arrhythmias, heart block, and sudden death. Screening for these forms of organ involvement requires detailed screening approaches.
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Overmyer KA, Shishkova E, Miller IJ, Balnis J, Bernstein MN, Peters-Clarke TM, Meyer JG, Quan Q, Muehlbauer LK, Trujillo EA, He Y, Chopra A, Chieng HC, Tiwari A, Judson MA, Paulson B, Brademan DR, Zhu Y, Serrano LR, Linke V, Drake LA, Adam AP, Schwartz BS, Singer HA, Swanson S, Mosher DF, Stewart R, Coon JJ, Jaitovich A. Large-scale Multi-omic Analysis of COVID-19 Severity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.07.17.20156513. [PMID: 32743614 PMCID: PMC7388490 DOI: 10.1101/2020.07.17.20156513] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We performed RNA-Seq and high-resolution mass spectrometry on 128 blood samples from COVID-19 positive and negative patients with diverse disease severities. Over 17,000 transcripts, proteins, metabolites, and lipids were quantified and associated with clinical outcomes in a curated relational database, uniquely enabling systems analysis and cross-ome correlations to molecules and patient prognoses. We mapped 219 molecular features with high significance to COVID-19 status and severity, many involved in complement activation, dysregulated lipid transport, and neutrophil activation. We identified sets of covarying molecules, e.g., protein gelsolin and metabolite citrate or plasmalogens and apolipoproteins, offering pathophysiological insights and therapeutic suggestions. The observed dysregulation of platelet function, blood coagulation, acute phase response, and endotheliopathy further illuminated the unique COVID-19 phenotype. We present a web-based tool (covid-omics.app) enabling interactive exploration of our compendium and illustrate its utility through a comparative analysis with published data and a machine learning approach for prediction of COVID-19 severity.
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Mei L, Zheng YM, Song T, Yadav VR, Joseph LC, Truong L, Kandhi S, Barroso MM, Takeshima H, Judson MA, Wang YX. Rieske iron-sulfur protein induces FKBP12.6/RyR2 complex remodeling and subsequent pulmonary hypertension through NF-κB/cyclin D1 pathway. Nat Commun 2020; 11:3527. [PMID: 32669538 PMCID: PMC7363799 DOI: 10.1038/s41467-020-17314-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 06/17/2020] [Indexed: 02/07/2023] Open
Abstract
Ca2+ signaling in pulmonary arterial smooth muscle cells (PASMCs) plays an important role in pulmonary hypertension (PH). However, the underlying specific ion channel mechanisms remain largely unknown. Here, we report ryanodine receptor (RyR) channel activity and Ca2+ release both are increased, and association of RyR2 by FK506 binding protein 12.6 (FKBP12.6) is decreased in PASMCs from mice with chronic hypoxia (CH)-induced PH. Smooth muscle cell (SMC)-specific RyR2 knockout (KO) or Rieske iron-sulfur protein (RISP) knockdown inhibits the altered Ca2+ signaling, increased nuclear factor (NF)-κB/cyclin D1 activation and cell proliferation, and CH-induced PH in mice. FKBP12.6 KO or FK506 treatment enhances CH-induced PH, while S107 (a specific stabilizer of RyR2/FKBP12.6 complex) produces an opposite effect. In conclusion, CH causes RISP-dependent ROS generation and FKBP12.6/RyR2 dissociation, leading to PH. RISP inhibition, RyR2/FKBP12.6 complex stabilization and Ca2+ release blockade may be potentially beneficial for the treatment of PH.
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Judson MA. Causes of Poor Medication Adherence in Sarcoidosis: Poor Patient-Doctor Communication and Suboptimal Drug Regimens. Chest 2020; 158:17-18. [PMID: 32654702 DOI: 10.1016/j.chest.2020.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/02/2020] [Indexed: 11/29/2022] Open
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Conuel EJ, Chieng HC, Fantauzzi J, Pokhrel K, Goldman C, Smith TC, Tiwari A, Chopra A, Judson MA. Cannabinoid Oil Vaping-Associated Lung Injury and its Radiographic Appearance. Am J Med 2020; 133:865-867. [PMID: 31751528 DOI: 10.1016/j.amjmed.2019.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/06/2019] [Accepted: 10/07/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lung injury associated with cannabinoid oil vaping is rapidly becoming a serious public health concern. We describe the clinical and radiographic presentations of 5 patients with lung injury associated with vaping cannabinoid oils seen at a single institution. RESULTS Of the 5 patients with suspected vaping-associated lung injury seen at our institution, 4 required supplemental oxygen, and all these 4 were admitted to the hospital. Three patients required admission to the intensive care unit. None of the patients required mechanical ventilation. All patients demonstrated a consistent radiologic appearance of diffuse bilateral ground-glass lung opacities that spared the extreme periphery. Three patients underwent bronchoalveolar lavage, which revealed lipid-laden macrophages in 2 of them. All patients were successfully discharged from the hospital. Four received only supportive care, while the fifth required intravenous followed by oral corticosteroids. CONCLUSIONS We report the clinical and radiographic presentation of 5 patients at our institution with cannabinoid oil vaping-associated lung injury. All patients displayed a consistent chest radiographic pattern of injury. Most responded to supportive care, although one required the addition of corticosteroids. Bronchoalveolar lavage results suggest that this injury may related to a toxic form of lipoid pneumonia.
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Harper LJ, Gerke AK, Wang XF, Ribeiro Neto ML, Baughman RP, Beyer K, Drent M, Judson MA, Maier LA, Serchuck L, Singh N, Culver DA. Income and Other Contributors to Poor Outcomes in U.S. Patients with Sarcoidosis. Am J Respir Crit Care Med 2020; 201:955-964. [PMID: 31825646 DOI: 10.1164/rccm.201906-1250oc] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rationale: Socioeconomic factors are associated with worse disease severity at presentation in sarcoidosis, but the relative importance of socioeconomic variables on morbidity and disease burden has not been fully elucidated.Objectives: To determine the association between income and sarcoidosis outcomes after controlling for socioeconomic and disease-related factors.Methods: Using the Sarcoidosis Advanced Registry for Cures database, we analyzed data from 2,318 patients with sarcoidosis in the United States to determine the effect of income and other variables on outcomes. We divided comorbidities arising after diagnosis into those likely related to steroid use and those likely related to sarcoidosis. We assessed the development of health-related, functional, and socioeconomic outcomes following the diagnosis of sarcoidosis.Measurements and Main Results: In multivariate analysis, low-income patients had significantly higher rates of new sarcoidosis-related comorbidities (<$35,000, odds ratio [OR], 2.4 [1.7-3.3]; $35,000-84,999, OR, 1.4 [1.1-1.9]; and ≥$85,000 [reference (Ref)]) and new steroid-related comorbidities (<$35,000, OR, 1.3 [0.9-2.0]; $35,000-84,999, OR, 1.5 [1.1-2.1]; and ≥$85,000 [Ref]), had lower health-related quality of life as assessed by the Sarcoidosis Health Questionnaire (P < 0.001), and experienced more impact on family finances (<$35,000, OR, 7.9 [4.9-12.7]; $35,000-84,999, OR, 2.7 [1.9-3.9]; and ≥$85,000 [Ref]). The use of supplemental oxygen, need for assistive devices, and job loss were more common in lower income patients. Development of comorbidities after diagnosis of sarcoidosis occurred in 63% of patients and were strong independent predictors of poor outcomes. In random forest modeling, income was consistently a leading predictor of outcome.Conclusions: These results suggest the burden from sarcoidosis preferentially impacts the economically disadvantaged.
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Crouser ED, Maier LA, Wilson KC, Bonham CA, Morgenthau AS, Patterson KC, Abston E, Bernstein RC, Blankstein R, Chen ES, Culver DA, Drake W, Drent M, Gerke AK, Ghobrial M, Govender P, Hamzeh N, James WE, Judson MA, Kellermeyer L, Knight S, Koth LL, Poletti V, Raman SV, Tukey MH, Westney GE. Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e26-e51. [PMID: 32293205 PMCID: PMC7159433 DOI: 10.1164/rccm.202002-0251st] [Citation(s) in RCA: 437] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure. Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability. Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality. Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.
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Abstract
Sarcoidosis is a multisystem granulomatous disease that may affect any body organ. Sarcoidosis is associated with many environmental and occupational exposures. Because the exact immunopathogenesis of sarcoidosis is unknown, it is not known whether these exposures are truly causing sarcoidosis, rendering the immune system more susceptible to the development of sarcoidosis, exacerbating subclinical cases of sarcoidosis, or causing a granulomatous condition distinct from sarcoidosis. This manuscript outlines what is known about the immunopathogenesis of sarcoidosis and postulates mechanisms whereby these exposures could cause or exacerbate the disease. We also describe the varied environmental and occupational exposures that have been associated with sarcoidosis. This includes potential infectious exposures such as mycobacteria and Propionibacterium acnes, a skin commensal bacterium, as well as non-infectious environmental exposures including inhaled bioaerosols, metal dusts and products of combustion. Further insights concerning the relationship of environmental exposures to the development of sarcoidosis may have a major impact on the prevention and treatment of this enigmatic disease.
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Conuel EJ, Chieng HC, Fantauzzi J, Pokhrel K, Goldman C, Smith TC, Tiwari A, Chopra A, Judson MA. The Reply. Am J Med 2020; 133:e206-e207. [PMID: 32450951 DOI: 10.1016/j.amjmed.2019.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 12/31/2019] [Indexed: 11/29/2022]
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Sweiss NJ, Korsten P, Syed HJ, Syed A, Baughman RP, Yee AMF, Culver DA, Sosenko T, Azuma A, Bonella F, Costabel U, Drake WP, Drent M, Lower EE, Israel-Biet D, Mostard RLM, Nunes H, Rottoli P, Spagnolo P, Wells AU, Wuyts WA, Judson MA. When the Game Changes: Guidance to Adjust Sarcoidosis Management During the Coronavirus Disease 2019 Pandemic. Chest 2020; 158:892-895. [PMID: 32360495 PMCID: PMC7189863 DOI: 10.1016/j.chest.2020.04.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Shkolnik B, Judson MA, Austin A, Hu K, D'Souza M, Zumbrunn A, Huggins JT, Yucel R, Chopra A. Diagnostic Accuracy of Thoracic Ultrasonography to Differentiate Transudative From Exudative Pleural Effusion. Chest 2020; 158:692-697. [PMID: 32194059 DOI: 10.1016/j.chest.2020.02.051] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/11/2020] [Accepted: 02/16/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There are limited data examining the diagnostic accuracy of thoracic ultrasonography (TUS) in distinguishing transudative from exudative pleural effusions. RESEARCH QUESTION What is the diagnostic accuracy of TUS in distinguishing transudative from exudative effusions in consecutive patients with pleural effusion? STUDY DESIGN AND METHODS Consecutive patients who underwent TUS and subsequently a diagnostic thoracentesis with a pleural fluid analysis were identified. TUS images of the pleural effusions were interpreted by previously published criteria. We evaluated the diagnostic performance of TUS findings in predicting a transudative vs exudative pleural effusions and specific pleural diagnoses. RESULTS We evaluated 300 consecutive pleural effusions in 285 patients. The pleural effusions were classified as exudative in 229 of 300 cases (76%). TUS showed anechoic effusions in 122 of 300 cases (40%) and complex effusions in 178 of 300 cases (60%). An anechoic appearance on TUS was associated with exudative effusions (68/122; 56%) as compared with transudative effusions (54/122; 44%). The presence of a complex-appearing effusion on TUS was highly predictive of an exudative effusion (positive predictive value of 90%). However, none of the four TUS characteristics were highly specific of a pleural diagnosis. INTERPRETATION Thoracic ultrasonography is inadequate to diagnose a transudative pleural effusion reliably. Although the TUS findings of a complex effusion may suggest an exudative pleural effusion, specific pleural diagnoses cannot be predicted confidently.
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Hamzeh N, Judson MA, Maier LA. Proceedings of the 2015 AASOG conference: Reducing disparities in sarcoidosis through personalized care and increased detection. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2020; 34:264-268. [PMID: 32476856 PMCID: PMC7170104 DOI: 10.36141/svdld.v34i3.5666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 08/10/2017] [Indexed: 11/23/2022]
Abstract
The 2015 annual meeting of the Americas Association of Sarcoidosis and Other Granulomatous Disorders (AASOG) was held on September 25th and 26th at the University of Colorado Anschutz Medical Campus in Aurora, CO, U.S.A. The meeting was hosted by National Jewish Health and the theme of the meeting was "Reducing Disparities in Sarcoidosis through Personalized Care and Increased Detection". The meeting was endorsed by the American Thoracic Society (ATS) and the Foundation for Sarcoidosis Research (FSR), and was conducted through support provided by the National Institutes of Health (NIH), particularly the National Heart Lung and Blood Institute (NHLBI), and an unrestricted educational grant from Mallinckrodt, Inc. The meeting participants were predominantly from North America, and included preeminent experts and emerging clinical scientists engaged in sarcoidosis research. The AASOG meeting was held in parallel with a sarcoidosis patient conference that was organized and funded by the Foundation of Sarcoidosis Research (FSR). The AASOG talks covered various state-of-the-arts topics related to sarcoidosis research and care; most notable were talks focusing on preliminary and emerging data from the Genomic Research in Alpha-1 antitrypsin Deficiency and Sarcoidosis (GRADS) study, recent novel immunological and genomic discoveries that further our understanding of sarcoidosis disease pathogenesis, results from clinical trials in sarcoidosis and proposals of novel therapeutic targets for the treatment of sarcoidosis, the introduction of the FSR sponsored clinical studies network, insights from other granulomatous diseases, and a focus on extra-pulmonary sarcoidosis, particularly cardiac disease, small fiber neuropathy, and fatigue. A session dedicated to scientific abstracts from predominantly junior investigators and five oral abstract presentations brought the conference to a conclusion. A brief overview and selected excerpts of the 2015 AASOG meeting proceedings are provided herein. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 264-268).
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Abstract
Introduction: The treatment of pulmonary sarcoidosis is not standardized. Treatment involves a multi-step decision process beginning with whether treatment is warranted, determining initial therapy, then assessing when therapy requires modifications or can be discontinued.Areas covered: This manuscript will address the following issues concerning the treatment of pulmonary sarcoidosis: Treatment indications, initial anti-granulomatous therapy, therapy for chronic and fibrotic disease, glucocorticoid therapy, alternative therapy to glucocorticoids, non-granulomatous therapies, and managing complications of disease. Information was obtained through a literature search of PubMed and Web of Science databases.Expert opinion: Although glucocorticoids are highly effective for pulmonary sarcoidosis, their potential to cause significant side effects often mandates consideration of alternative agents. As the most common indication for the treatment of pulmonary sarcoidosis is quality of life impairment, traditional objective tests of lung function and radiographic imagining often have a minor role in therapeutic decision-making. The development of pulmonary fibrosis from sarcoidosis often causes major morbidity and mortality and should be a major focus of concern.
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Judson MA. Developing better drugs for pulmonary sarcoidosis: determining indications for treatment and endpoints to assess therapy based on patient and clinician concerns. F1000Res 2019; 8:F1000 Faculty Rev-2149. [PMID: 31942239 PMCID: PMC6944258 DOI: 10.12688/f1000research.20696.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 12/19/2022] Open
Abstract
Pulmonary sarcoidosis involves the deposition of granulomas within the lung. These granulomas may affect lung function and lead to pulmonary symptoms, pulmonary dysfunction, functional impairment, and worsening of quality of life. Corticosteroids are generally highly effective in resolving the granulomatous inflammation of sarcoidosis. However, despite the effectiveness of corticosteroids, many corticosteroid-responsive patients continue to experience significant problems because of the development of fibrosis from previously active or active smoldering granulomatous inflammation, inflammatory effects from sarcoidosis unrelated to granuloma deposition in lung tissue (parasarcoidosis syndromes), and the development of significant corticosteroid-related side effects. For these reasons, the decision to treat pulmonary sarcoidosis and endpoints to measure meaningful outcomes may extend beyond considerations of pulmonary granulomatous inflammation alone. In this article, we propose a conceptual framework to describe the mechanisms by which pulmonary sarcoidosis significantly impacts patients. This conceptual framework suggests that indications for the treatment of pulmonary sarcoidosis and endpoints to assess treatment depend on the specific mechanisms that are causing functional or quality-of-life impairment (or both) in patients with pulmonary sarcoidosis. We believe that these concepts are important to clinicians treating pulmonary sarcoidosis and to clinical researchers designing pulmonary sarcoidosis trials.
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Abstract
Sarcoidosis is a highly variable granulomatous multisystem syndrome. It affects individuals in the prime years of life; both the frequency and severity of sarcoidosis are greater in economically disadvantaged populations. The diagnosis, assessment, and management of pulmonary sarcoidosis have evolved as new technologies and therapies have been adopted. Transbronchial needle aspiration guided by endobronchial ultrasound has replaced mediastinoscopy in many centers. Advanced imaging modalities, such as fluorodeoxyglucose positron emission tomography scanning, and the widespread availability of magnetic resonance imaging have led to more sensitive assessment of organ involvement and disease activity. Although several new insights about the pathogenesis of sarcoidosis exist, no new therapies have been specifically developed for use in the disease. The current or proposed use of immunosuppressive medications for sarcoidosis has been extrapolated from other disease states; various novel pathways are currently under investigation as therapeutic targets. Coupled with the growing recognition of corticosteroid toxicities for managing sarcoidosis, the use of corticosteroid sparing anti-sarcoidosis medications is likely to increase. Besides treatment of granulomatous inflammation, recognition and management of the non-granulomatous complications of pulmonary sarcoidosis are needed for optimal outcomes in patients with advanced disease.
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Stern BJ, Royal W, Gelfand JM, Clifford DB, Tavee J, Pawate S, Berger JR, Aksamit AJ, Krumholz A, Pardo CA, Moller DR, Judson MA, Drent M, Baughman RP. Definition and Consensus Diagnostic Criteria for Neurosarcoidosis: From the Neurosarcoidosis Consortium Consensus Group. JAMA Neurol 2019; 75:1546-1553. [PMID: 30167654 DOI: 10.1001/jamaneurol.2018.2295] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance The Neurosarcoidosis Consortium Consensus Group, an expert panel of physicians experienced in the management of patients with sarcoidosis and neurosarcoidosis, engaged in an iterative process to define neurosarcoidosis and develop a practical diagnostic approach to patients with suspected neurosarcoidosis. This panel aimed to develop a consensus clinical definition of neurosarcoidosis to enhance the clinical care of patients with suspected neurosarcoidosis and to encourage standardization of research initiatives that address this disease. Observations The work of this collaboration included a review of the manifestations of neurosarcoidosis and the establishment of an approach to the diagnosis of this disorder. The proposed consensus diagnostic criteria, which reflect current knowledge, provide definitions for possible, probable, and definite central and peripheral nervous system sarcoidosis. The definitions emphasize the need to evaluate patients with findings suggestive of neurosarcoidosis for alternate causal factors, including infection and malignant neoplasm. Also emphasized is the need for biopsy, whenever feasible and advisable according to clinical context and affected anatomy, of nonneural tissue to document the presence of systemic sarcoidosis and support a diagnosis of probable neurosarcoidosis or of neural tissue to support a diagnosis of definite neurosarcoidosis. Conclusions and Relevance Diverse disease presentations and lack of specificity of relevant diagnostic tests contribute to diagnostic uncertainty. This uncertainty is compounded by the absence of a pathognomonic histologic tissue examination. The diagnostic criteria we propose are designed to focus investigations on NS as accurately as possible, recognizing that multiple pathophysiologic pathways may lead to the clinical manifestations we currently term NS. Research recognizing the clinical heterogeneity of this diagnosis may open the door to identifying meaningful biologic factors that may ultimately contribute to better treatments.
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Judson MA. The Diagnosis of Sarcoidosis: Attempting to Apply Rigor to Arbitrary and Circular Reasoning. Chest 2019; 154:1006-1007. [PMID: 30409355 DOI: 10.1016/j.chest.2018.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 06/07/2018] [Accepted: 06/08/2018] [Indexed: 10/27/2022] Open
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Abstract
PURPOSE OF REVIEW To review the diagnostic approach to sarcoidosis. There is no gold standard diagnostic test, procedure or algorithm for sarcoidosis. The diagnosis is based on a compatible clinical presentation, histologic findings of granulomatous inflammation, exclusion of alternative diseases, and evidence of systemic involvement. Occasionally, there may be exceptions to several of these requirements. RECENT FINDINGS The diagnostic specificity of several specific clinical features are discussed. Typical histologic findings of sarcoidosis are described. Several diseases that may mimic sarcoidosis are reviewed. SUMMARY The diagnosis of sarcoidosis usually involves weighing the clinical evidence for and against the diagnosis, coupled in most cases with histologic evidence of granulomatous inflammation. This approach requires knowledge of the varied presentations of the disease and other alternative conditions as well as histologic examination of an affected tissue in most instances.
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Abstract
PURPOSE OF REVIEW The review presents an overview of the scientific publications about patient perspectives in sarcoidosis. RECENT FINDINGS The literature on patient perspectives in sarcoidosis is limited. Patient perspectives in sarcoidosis encompass a myriad of topics that have been addressed to some degree in the literature: patient needs and perceptions, patient-reported burden of sarcoidosis, and patient treatment priorities. Similar findings across studies were high levels of reported fatigue, a need to incorporate psychological support into the treatment plan and easy access to sarcoidosis expert centers. Furthermore, largely similar results were found across countries. SUMMARY There is a growing focus in patient perspectives in terms of sarcoidosis treatment. A multidisciplinary approach including psychological support and attention to fatigue, may better reflect the needs of sarcoidosis patients. Further research on sarcoidosis patient perspectives in sarcoidosis is needed to optimize care.
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Chopra A, Judson MA, Doelken P, Maldonado F, Rahman NM, Huggins JT. The Relationship of Pleural Manometry With Postthoracentesis Chest Radiographic Findings in Malignant Pleural Effusion. Chest 2019; 157:421-426. [PMID: 31472154 DOI: 10.1016/j.chest.2019.08.1920] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/10/2019] [Accepted: 08/10/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Both elevated pleural elastance (E-PEL) and radiographic evidence of incomplete lung expansion following thoracentesis have been used to exclude patients with a malignant pleural effusion (MPE) from undergoing pleurodesis. This article reports on a cohort of patients with MPE in whom complete drainage was attempted with pleural manometry to determine the frequency of E-PEL and its relation with postthoracentesis radiographic findings. METHODS Seventy consecutive patients with MPE who underwent therapeutic pleural drainage with pleural manometry were identified. The pressure/volume curves were constructed and analyzed to determine the frequency of E-PEL and the relation of PEL to the postthoracentesis chest radiographic findings. RESULTS E-PEL and incomplete lung expansion were identified in 36 of 70 (51.4%) and 38 of 70 (54%) patients, respectively. Patients with normal PEL had an OR of 6.3 of having complete lung expansion compared with those with E-PEL (P = .0006). However, 20 of 70 (29%) patients exhibited discordance between postprocedural chest radiographic findings and the pleural manometry results. Among patients who achieved complete lung expansion on the postdrainage chest radiograph, 9 of 32 (28%) had an E-PEL. In addition, PEL was normal in 11 of 38 (34%) patients who had incomplete lung expansion as detected according to the postthoracentesis chest radiograph. CONCLUSIONS E-PEL and incomplete lung expansion postthoracentesis are frequently observed in patients with MPE. Nearly one-third of the cohort exhibited discordance between the postprocedural chest radiographic findings and pleural manometry results. These findings suggest that a prospective randomized trial should be performed to compare both modalities (chest radiograph and pleural manometry) in predicting pleurodesis outcome.
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