1
|
Krishna Boppana T, Mittal S, Madan K, Mohan A, Hadda V, Guleria R. Rituximab for rheumatoid arthritis-related interstitial lung disease: A systematic review and meta-analysis. Arch Rheumatol 2024; 39:317-329. [PMID: 38933731 PMCID: PMC11196234 DOI: 10.46497/archrheumatol.2024.10199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2024] Open
Abstract
Objectives This systematic review and meta-analysis aimed at summarizing the evidence of efficacy and safety of rituximab in rheumatoid arthritis-related interstitial lung disease (RA-ILD). Materials and methods PubMed and Embase databases were searched until June 22, 2022, to identify studies on RA-ILD treated with rituximab, confined to predefined inclusion and exclusion criteria. A systematic review and meta-analysis were performed on the included studies to assess the overall stabilization or improvement in ILD, changes in percent-predicted (%-predicted) forced vital capacity (FVC), and %-predicted diffusion capacity of lungs for carbon monoxide (DLCO) following rituximab therapy. Results A total of 15 studies (4 prospective and 11 retrospective studies) were included, with a total of 314 patients. There were 105 (60.7%) females out of 173 subjects for whom sex details were available from seven studies. The overall pooled proportion of patients with stabilization or improvement in ILD was 0.88 [95% confidence interval (CI): 0.76-0.96, p=0.02]. Rituximab improved FVC from baseline by 7.50% (95% CI: 1.35-13.65; p=0.02, fixed effect). Similarly, rituximab improved DLCO by 6.39% (95% CI: 1.366-14.43; p=0.12, random-effect). Two retrospective studies reported reduced mortality with rituximab therapy compared to tumor necrosis factor-alpha inhibitors. Conclusion Treatment with rituximab in RA-ILD was associated with a significant improvement in %-predicted FVC, as well as stabilization or improvement in ILD after one year of treatment.
Collapse
Affiliation(s)
- Tarun Krishna Boppana
- All India Institute of Medical Sciences, Pulmonary, Critical Care and Sleep Medicine, Delhi, India
| | - Saurabh Mittal
- All India Institute of Medical Sciences, Pulmonary, Critical Care and Sleep Medicine, Delhi, India
| | - Karan Madan
- All India Institute of Medical Sciences, Pulmonary, Critical Care and Sleep Medicine, Delhi, India
| | - Anant Mohan
- All India Institute of Medical Sciences, Pulmonary, Critical Care and Sleep Medicine, Delhi, India
| | - Vijay Hadda
- All India Institute of Medical Sciences, Pulmonary, Critical Care and Sleep Medicine, Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Pulmonary, Critical Care and Sleep Medicine, Delhi, India
| |
Collapse
|
2
|
Atienza-Mateo B, Fernández-Díaz C, Vicente-Rabaneda EF, Melero-González RB, Ortiz-Sanjuán F, Casafont-Solé I, Rodríguez-García SC, Ferraz-Amaro I, Castañeda S, Blanco R. Abatacept in usual and in non-specific interstitial pneumonia associated with rheumatoid arthritis. Eur J Intern Med 2024; 119:118-124. [PMID: 37673775 DOI: 10.1016/j.ejim.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/21/2023] [Accepted: 08/26/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To compare the effectiveness of abatacept (ABA) in Rheumatoid Arthritis-associated Interstitial Lung Disease (RA-ILD) according to the radiological patterns of usual (UIP) or non-specific interstitial pneumonia (NSIP). METHODS From an observational longitudinal multicentre study of 263 RA-ILD patients treated with ABA, those with UIP or NSIP were selected. Lung function, chest high resolution computerised tomography (HRCT) and dyspnoea were recorded and compared in both groups from baseline to the end of follow-up (progression definitions: improvement or worsening >10% of FVC or DLCO, changes in HRCT extension and 1-point change in the mMRC scale, respectively). Differences between final and baseline visits were calculated as the average difference (95% CI) through mixed effects models regression. RESULTS We studied 190 patients with UIP (n=106) and NSIP (n=84). General features were similar in both groups except for older age, positive rheumatoid factor, and previous sulfasalazine therapy, which were more frequent in patients with UIP. ILD duration up to ABA initiation was relatively short: median 16 [4-50] and 11 [2-36] months (p=0.36) in UIP and NSIP, respectively. Mean baseline FVC and DLCO were 82% and 63% in UIP and 89% and 65% in NSIP, respectively. Both parameters remained stable during 24 months with ABA. HRCT lesions and dyspnoea improved/stabilized in 73.1% and 90.5% and 72.9% and 94.6% of UIP and NSIP patterns, respectively. CONCLUSION ABA seems equally effective in stabilizing dyspnoea, lung function and radiological impairment in both UIP and NSIP patterns of RA-ILD. Early administration of ABA may prevent RA-ILD progression, regardless of the radiological pattern.
Collapse
Affiliation(s)
- Belén Atienza-Mateo
- Rheumatology, Hospital Universitario Marqués de Valdecilla, Immunopathology group, IDIVAL, Santander, Avda.Valdecilla s/n., ES, 39008, Spain
| | | | | | | | | | | | | | - Iván Ferraz-Amaro
- Rheumatology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Santos Castañeda
- Rheumatology, Hospital de La Princesa, IIS-Princesa, Madrid, Spain; Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ricardo Blanco
- Rheumatology, Hospital Universitario Marqués de Valdecilla, Immunopathology group, IDIVAL, Santander, Avda.Valdecilla s/n., ES, 39008, Spain.
| |
Collapse
|
3
|
Mihai A, Caruntu C, Jurcut C, Blajut FC, Casian M, Opris-Belinski D, Ionescu R, Caruntu A. The Spectrum of Extraglandular Manifestations in Primary Sjögren's Syndrome. J Pers Med 2023; 13:961. [PMID: 37373950 DOI: 10.3390/jpm13060961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Extraglandular manifestations (EGMs) in primary Sjogren's syndrome (pSS) represent the clinical expression of the systemic involvement in this disease. EGMs are characterized by a wide heterogeneity; virtually any organ or system can be affected, with various degrees of dysfunction. The existing gaps of knowledge in this complex domain of extraglandular extension in pSS need to be overcome in order to increase the diagnostic accuracy of EGMs in pSS. The timely identification of EGMs, as early as from subclinical stages, can be facilitated using highly specific biomarkers, thus preventing decompensated disease and severe complications. To date, there is no general consensus on the diagnostic criteria for the wide range of extraglandular involvement in pSS, which associates important underdiagnosing of EGMs, subsequent undertreatment and progression to severe organ dysfunction in these patients. This review article presents the most recent basic and clinical science research conducted to investigate pathogenic mechanisms leading to EGMs in pSS patients. In addition, it presents the current diagnostic and treatment recommendations and the trends for future therapeutic strategies based on personalized treatment, as well as the latest research in the field of diagnostic and prognostic biomarkers for extraglandular involvement in pSS.
Collapse
Affiliation(s)
- Ancuta Mihai
- Department of Internal Medicine, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Rheumatology, Faculty of General Medicine, Titu Maiorescu University, 031593 Bucharest, Romania
| | - Constantin Caruntu
- Department of Physiology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Dermatology, Prof. N.C. Paulescu National Institute of Diabetes, Nutrition and Metabolic Diseases, 011233 Bucharest, Romania
| | - Ciprian Jurcut
- Department of Internal Medicine, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
| | - Florin Cristian Blajut
- Department of General Surgery, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Medical-Surgical Specialties, "Titu Maiorescu" University of Bucharest, 040441 Bucharest, Romania
| | - Mihnea Casian
- Emergency Institute for Cardiovascular Diseases Prof. Dr. C.C. Iliescu, 022328 Bucharest, Romania
- Department of Cardiology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniela Opris-Belinski
- Internal Medicine and Rheumatology Department, Sfanta Maria Clinical Hospital, 011172 Bucharest, Romania
- Internal Medicine and Rheumatology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ruxandra Ionescu
- Internal Medicine and Rheumatology Department, Sfanta Maria Clinical Hospital, 011172 Bucharest, Romania
| | - Ana Caruntu
- Department of Oral and Maxillofacial Surgery, Carol Davila Central Military Emergency Hospital, 010825 Bucharest, Romania
- Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Titu Maiorescu University, 031593 Bucharest, Romania
| |
Collapse
|
4
|
Zekić T. Rituximab as the first-line therapy in anti-synthetase syndrome-related interstitial lung disease. Rheumatol Int 2023; 43:1015-1021. [PMID: 36928934 DOI: 10.1007/s00296-023-05302-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
Anti-synthetase syndrome (ASS) is an idiopathic inflammatory myopathy (IIM). In comparison to interstitial lung disease (ILD) in polymyositis and dermatomyositis (PM/DM), ILD in ASS is more frequent, has a more aggressive phenotype, a greater involvement of the lungs, and a more rapid onset of pulmonary symptoms. Continuous declines in predicted forced vital capacity (FVC) and dyspnea were the main features of patients who developed end-stage ILD. The severity of ASS at diagnosis dictates when and which immunosuppressant will be started. There is an experience for the usage of RTX in the first, second, and subsequent lines, as well as for reintroduction and salvage therapies. Not all ASS patients will develop severe illness and require intense immunosuppression. Some features associated with poor prognosis include older age, acute or subacute onset, lack of response to steroids, and lower baseline values for FVC and DLCO. Here we hypothesize that RTX should be the first line of treatment for high-risk ILD in ASS to preserve lung function and then maintenance therapy should be continued with the same or another drug depending on the recovery of lung function.
Collapse
Affiliation(s)
- Tatjana Zekić
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Clinical Hospital Center Rijeka, University of Rijeka, Rijeka, Croatia.
| |
Collapse
|
5
|
Richter P, Cardoneanu A, Dima N, Bratoiu I, Rezus C, Burlui AM, Costin D, Macovei LA, Rezus E. Interstitial Lung Disease in Systemic Lupus Erythematosus and Systemic Sclerosis: How Can We Manage the Challenge? Int J Mol Sci 2023; 24:ijms24119388. [PMID: 37298342 DOI: 10.3390/ijms24119388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Interstitial lung disease (ILD) is a severe and frequent manifestation of connective tissue diseases (CTD). Due to its debilitating potential, it requires serious evaluation and treatment. The prevalence of ILD in systemic lupus erythematosus (SLE) is still controversial. Therefore, in order to establish the diagnosis of ILD, an overlap syndrome must be excluded. Increasing the identification of SLE-associated ILD cases should become a target. To treat this complication, various therapies are now being proposed. To date, no placebo-controlled studies were conducted. Regarding another CTD, systemic sclerosis (SSc), SSc-associated ILD is considered one of the leading causes of mortality. The incidence of ILD varies among disease subtypes, being influenced by diagnostic method, but also by disease duration. Due to the high prevalence of this complication, all SSc patients should be investigated for ILD at the time of SSc diagnosis and during the course of the disease. Fortunately, progress was made in terms of treatment. Nintedanib, a tyrosine kinases inhibitor, showed promising results. It appeared to decrease the rate of progression of ILD compared to placebo. This review aimed to provide up-to-date findings related to SLE-associated ILD and SSc-associated ILD, in order to raise awareness of their diagnosis and management.
Collapse
Affiliation(s)
- Patricia Richter
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Anca Cardoneanu
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Nicoleta Dima
- Department of Internal Medicine, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- "Sf. Spiridon" Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- "Sf. Spiridon" Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Alexandra Maria Burlui
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Damiana Costin
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Luana Andreea Macovei
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology, "Grigore T Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| |
Collapse
|
6
|
Wang Y, Li L. Rituximab for connective tissue disease-associated interstitial lung disease: A systematic review and meta-analysis. Int J Rheum Dis 2023; 26:225-235. [PMID: 36378118 DOI: 10.1111/1756-185x.14495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/21/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the efficacy of rituximab (RTX) on lung function and the prevalence of adverse events (AEs) in connective tissue disease-associated interstitial lung disease (CTD-ILD) by meta-analysis. METHODS EMBASE, Web of Science, PubMed and ClinicalKey were searched up to July 16, 2021. The lung function (forced vital capacity, FVC% predicted, and diffusing capacity of the lung for carbon monoxide, DLCO% predicted) and prevalence of AEs of RTX in CTD-ILD were analyzed by meta-analysis, and 95% confidence interval (CI) was calculated. Subgroup analyses and meta-regression were used to explore the heterogeneity. RESULTS We identified 29 studies, including 827 CTD-ILD patients with a median age of 53.05 years. In observational studies, FVC% (mean difference - 1.24, 95% CI [-2.35, -0.12]; P = .030) and DLCO% (-7.71, [-11.79, -3.63]; P = .014) of CTD-ILD decreased significantly after RTX treatment. In randomized controlled trials, FVC% of CTD-ILD decreased after RTX treatment (-5.24, [-9.94, - 0.54]; P = .029), but the difference of DLCO% was not significant (1.15, [-4.33, 6.63]; P = .681). The prevalence of AEs, all-cause mortality and infections was 29.7% (95% CI [0.17, 0.42]), 11.6% (95% CI [0.08, 0.16]) and 20.9% (95% CI [0.15, 0.27]), respectively. CONCLUSIONS RTX was associated with AEs such as decreased pulmonary function, all-cause mortality, and infections in CTD-ILD. Adverse reactions during and after RTX treatment should be carefully monitored. Further prospective studies are needed to compare RTX with other immunosuppressants, antifibrotic drugs or placebos, which can provide therapeutic approaches for CTD-ILD.
Collapse
Affiliation(s)
- Yilin Wang
- School of Medicine and Nursing, Huzhou University, Huzhou, China
| | - Liren Li
- School of Medicine, Nantong University, Nantong, China
| |
Collapse
|
7
|
Shin JI, Lee KH, Park S, Yang JW, Kim HJ, Song K, Lee S, Na H, Jang YJ, Nam JY, Kim S, Lee C, Hong C, Kim C, Kim M, Choi U, Seo J, Jin H, Yi B, Jeong SJ, Sheok YO, Kim H, Lee S, Lee S, Jeong YS, Park SJ, Kim JH, Kronbichler A. Systemic Lupus Erythematosus and Lung Involvement: A Comprehensive Review. J Clin Med 2022; 11:jcm11226714. [PMID: 36431192 PMCID: PMC9698564 DOI: 10.3390/jcm11226714] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with multiorgan manifestations, including pleuropulmonary involvement (20-90%). The precise mechanism of pleuropulmonary involvement in SLE is not well-understood; however, systemic type 1 interferons, circulating immune complexes, and neutrophils seem to play essential roles. There are eight types of pleuropulmonary involvement: lupus pleuritis, pleural effusion, acute lupus pneumonitis, shrinking lung syndrome, interstitial lung disease, diffuse alveolar hemorrhage (DAH), pulmonary arterial hypertension, and pulmonary embolism. DAH has a high mortality rate (68-75%). The diagnostic tools for pleuropulmonary involvement in SLE include chest X-ray (CXR), computed tomography (CT), pulmonary function tests (PFT), bronchoalveolar lavage, biopsy, technetium-99m hexamethylprophylene amine oxime perfusion scan, and (18)F-fluorodeoxyglucose positron emission tomography. An approach for detecting pleuropulmonary involvement in SLE includes high-resolution CT, CXR, and PFT. Little is known about specific therapies for pleuropulmonary involvement in SLE. However, immunosuppressive therapies such as corticosteroids and cyclophosphamide are generally used. Rituximab has also been successfully used in three of the eight pleuropulmonary involvement forms: lupus pleuritis, acute lupus pneumonitis, and shrinking lung syndrome. Pleuropulmonary manifestations are part of the clinical criteria for SLE diagnosis. However, no review article has focused on the involvement of pleuropulmonary disease in SLE. Therefore, this article summarizes the literature on the epidemiology, pathogenesis, diagnosis, and management of pleuropulmonary involvement in SLE.
Collapse
Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Hyung Ju Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Kwanhyuk Song
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seungyeon Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyeyoung Na
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yong Jun Jang
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ju Yun Nam
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Soojin Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chaehyun Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chanhee Hong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chohwan Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Minhyuk Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Uichang Choi
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jaeho Seo
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyunsoo Jin
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - BoMi Yi
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Se Jin Jeong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yeon Ook Sheok
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Haedong Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sangmin Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sangwon Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Young Soo Jeong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Se Jin Park
- Department of Pediatrics, Eulji University School of Medicine, Daejeon 34824, Republic of Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 26426, Republic of Korea
- Correspondence:
| | | |
Collapse
|
8
|
Yang J, Xu H, Li C, Li Z, Hu Z. An explorative study for leveraging transcriptomic data of embryonic stem cells in mining cancer stemness genes, regulators, and networks. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2022; 19:13949-13966. [PMID: 36654075 DOI: 10.3934/mbe.2022650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Due to the exquisite ability of cancer stemness to facilitate tumor initiation, metastasis, and cancer therapy resistance, targeting cancer stemness is expected to have clinical implications for cancer treatment. Genes are fundamental for forming and maintaining stemness. Considering shared genetic programs and pathways between embryonic stem cells and cancer stem cells, we conducted a study analyzing transcriptomic data of embryonic stem cells for mining potential cancer stemness genes. Firstly, we integrated co-expression and regression models and predicted 820 stemness genes. Results of gene enrichment analysis confirmed the good prediction performance for enriched signatures in cancer stem cells. Secondly, we provided an application case using the predicted stemness genes to construct a breast cancer stemness network. Mining on the network identified CD44, SOX2, TWIST1, and DLG4 as potential regulators of breast cancer stemness. Thirdly, using the signature of 31,028 chemical perturbations and their correlation with stemness marker genes, we predicted 67 stemness inhibitors with reasonable accuracy of 78%. Two drugs, namely Rigosertib and Proscillaridin A, were first identified as potential stemness inhibitors for melanoma and colon cancer, respectively. Overall, mining embryonic stem cell data provides a valuable way to identify cancer stemness regulators.
Collapse
Affiliation(s)
- Jihong Yang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
- BoYu Intelligent Health Innovation Laboratory, Hangzhou 311121, China
| | - Hao Xu
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Guangdong 524001, China
| | - Congshu Li
- BoYu Intelligent Health Innovation Laboratory, Hangzhou 311121, China
| | - Zhenhao Li
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
- BoYu Intelligent Health Innovation Laboratory, Hangzhou 311121, China
| | - Zhe Hu
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Guangdong 524001, China
| |
Collapse
|
9
|
Liossis SNC, Bounia CA. Treating Autoimmune-Related Interstitial Lung Disease With B Cell Depletion. Front Med (Lausanne) 2022; 9:937561. [PMID: 35847798 PMCID: PMC9279739 DOI: 10.3389/fmed.2022.937561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Autoimmune rheumatic diseases may affect vital organs with lung involvement being severe and difficult to treat manifestation. Systemic sclerosis (SSc) commonly affects the lung in the form of interstitial lung disease (ILD). ILD may be also seen in patients with rheumatoid arthritis (RA), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE), inflammatory myositis (IM), antisynthetase syndrome (AS), and the ANCA-associated vasculitides (AAV). Rituximab (RTX) is an anti-CD20 B lymphocyte depleting mAb, often administered in the treatment of autoimmune rheumatic diseases. Although RTX is an off-label treatment for CTD–ILD, there are numerous reports providing data that is effective in improving both pulmonary function tests (PFTs) and chest computed tomography findings consistent with ILD. There are retrospective uncontrolled studies that assess RTX as a treatment of ILD in autoimmune diseases. These studies, apart from one, do not include patients with AAV-ILD. In SSc-ILD, in particular, there are both controlled and uncontrolled studies displaying encouraging results following B cell depletion. In addition, a number of retrospective uncontrolled studies and fewer prospective studies evaluate RTX in connective tissue diseases CTD–ILD. Although RTX is an approved treatment for AAV there are scarce only data focusing on patients with AAV-ILD specifically. The results of a handful of studies comparing treatment of CTD-ILD with RTX to treatment with other agents are in favor of RTX. Results from large, still ongoing controlled trials are awaited to ascertain RTX effects in ILD encountered in autoimmune rheumatic diseases. We review herein the results of the different RTX trials in patients with autoimmune disease–associated with ILD. Despite the heterogeneity of these studies, RTX may be considered an alternative and safe but still off-label treatment for patients with refractory CTD–ILD.
Collapse
Affiliation(s)
- Stamatis-Nick C. Liossis
- Division of Rheumatology, Patras University Hospital, Patras, Greece
- Department of Internal Medicine, University of Patras Medical School, Patras, Greece
- *Correspondence: Stamatis-Nick C. Liossis
| | | |
Collapse
|
10
|
Diesler R, Cottin V. Pulmonary fibrosis associated with rheumatoid arthritis: from pathophysiology to treatment strategies. Expert Rev Respir Med 2022; 16:541-553. [PMID: 35695895 DOI: 10.1080/17476348.2022.2089116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is the most common inflammatory autoimmune disease, characterised by symmetric destructive arthritis and synovitis. Lung involvement is frequent, including in the form of interstitial lung disease (ILD). RA-ILD often presents with a radiologic and pathologic pattern of usual interstitial pneumonia, similar to idiopathic pulmonary fibrosis, highlighting the similarities between the two diseases, but other patterns and pathological associations are described. AREAS COVERED This article reviews the pathogenesis of pulmonary fibrosis in the setting of rheumatoid arthritis as well as the current and future therapeutic options. EXPERT OPINION Pulmonary fibrosis in the setting of RA-ILD is an example of genotype-environment interaction and involves multiple mechanisms including autoimmunity, inflammation and fibrogenesis. Despite that ILD conveys most of the exceeding mortality in RA patients, there are no official guidelines for the management of RA-ILD. Attention should be paid to potential lung toxicity of RA treatment even though some of them might help stabilise the ILD. Current standard of care is often composed of glucocorticoids that may be associated with immunosuppressive therapy. Following the approval of antifibrotic therapy for ILDs with a progressive fibrosing phenotype, current works are evaluating the benefit of such treatment in RA-ILD.
Collapse
Affiliation(s)
- Rémi Diesler
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| |
Collapse
|
11
|
Efficacy and Safety of Rituximab in Autoimmune Disease-Associated Interstitial Lung Disease: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11040927. [PMID: 35207203 PMCID: PMC8879100 DOI: 10.3390/jcm11040927] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To analyze the efficacy and safety of rituximab (RTX) in connective tissue disease associated with interstitial lung disease (CTD-ILD). METHODS We performed a multicenter, prospective, observational study of patients with CTD-ILD receiving rituximab between 2015 and 2020. The patients were assessed using high-resolution computed tomography and pulmonary function tests at baseline, at 12 months, and at the end of follow-up. The main outcome measure at the end of follow-up was forced vital capacity (FVC) > 10% or diffusing capacity of the lungs for carbon monoxide (DLCO) > 15% and radiological progression or death. We recorded clinical characteristics, time to initiation of RTX, concomitant treatment, infections, and hospitalization. A Cox regression analysis was performed to identify factors associated with worsening ILD. RESULTS We included 37 patients with CTD-ILD treated with RTX for a median (IQR) of 38.2 (17.7-69.0) months. At the end of the follow-up, disease had improved or stabilized in 23 patients (62.1%) and worsened in seven (18.9%); seven patients (18.9%) died. No significant decline was observed in median FVC (72.2 vs. 70.8; p = 0.530) or DLCO (55.9 vs. 52.2; p = 0.100). The multivariate analysis showed the independent predictors for worsening of CTD-ILD to be baseline DLCO (OR (95% CI), 0.904 (0.8-0.9); p = 0.015), time to initiation of RTX (1.01 (1.001-1.02); p = 0.029), and mycophenolate (0.202 (0.04-0.8); p = 0.034). Only 28 of the 37 patients (75.6%) were still undergoing treatment with RTX: two patients (5.4%) stopped treatment due to adverse events and seven patients (18.9%) died owing to progression of ILD and superinfection. CONCLUSION Lung function improved or stabilized in more than half of patients with CTD-ILD treated with RTX. Early treatment and combination with mycophenolate could reduce the risk of progression of ILD.
Collapse
|
12
|
van den Bosch L, Luppi F, Ferrara G, Mura M. Immunomodulatory treatment of interstitial lung disease. Ther Adv Respir Dis 2022; 16:17534666221117002. [PMID: 35938712 PMCID: PMC9364223 DOI: 10.1177/17534666221117002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF) have an array of immunomodulatory treatment options compared with IPF, due to their inflammatory component. However, there is a relative paucity of guidance on the management of this heterogeneous group of diseases. In ILDs other than IPF, immunosuppression is the cornerstone of therapy, with varying levels of evidence for different immunomodulatory agents and for each specific ILD. Classification of ILDs is important for guiding treatment decisions. Immunomodulatory agents mainly include corticosteroids, mycophenolate mofetil (MMF), azathioprine, methotrexate, cyclophosphamide and rituximab. In this review, the available evidence for single agents in the most common ILDs is first discussed. We then reviewed practical therapeutic approaches in connective tissue disease-related ILD and interstitial pneumonia with autoimmune features, scleroderma-related ILD, vasculitis and dermatomyositis with hypoxemic respiratory failure, idiopathic non-specific interstitial pneumonia, hypersensitivity pneumonitis sarcoidosis, fibrosing organizing pneumonia and eosinophilic pneumonia. The treatment of acute exacerbations of ILD is also discussed. Therapy augmentation in ILD is dictated by the recognition of progression of disease. Criteria for the evaluation of progression of disease are then discussed. Finally, specific protocol and measures to increase patients' safety are reviewed as well, including general monitoring and serologic surveillance, Pneumocystis jirovecii prophylaxis, patients' education, genetic testing for azathioprine, MMF serum levels and cyclophosphamide administration protocols. Immunomodulatory therapies are largely successful in the management of ILDs and can be safely managed with the application of specific protocols, precautions and monitoring.
Collapse
Affiliation(s)
| | - Fabrizio Luppi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marco Mura
- London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, Room E6-203, London, ON N6A 5W9, Canada
| |
Collapse
|
13
|
Vicente-Rabaneda EF, Serra López-Matencio JM, Ancochea J, Blanco R, González-Gay MÁ, Castañeda S. Efficacy and safety of biological drugs in interstitial lung disease associated with connective tissue diseases. Expert Opin Drug Saf 2021; 21:311-333. [PMID: 34433372 DOI: 10.1080/14740338.2021.1973428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Interstitial lung disease (ILD) is one of the most important manifestations of connective tissue diseases (CTD) due to its association with high morbidity and mortality. AREAS COVERED Literature review focused on the evidence on efficacy and safety of biological therapy. EXPERT OPINION Rituximab (RTX) is the most studied drug, though tocilizumab (TCZ) has methodologically more robust evidence, whereas abatacept (ABA) has only anecdotal reports. RTX studies suggest a clinically relevant effect on lung function and fibrosis in refractory to conventional treatment patients, with a good safety profile. Its multi-level efficacy in systemic sclerosis and the potentially more favorable response of anti-synthetase syndrome, especially when administered early in acute-onset or exacerbated ILD stand out over current standard of care, pending the availability of randomized controlled clinical trials. The significant and clinically meaningful benefit found in lung function and fibrosis with TCZ in faSScinate and focuSSced trials represents a change with respect to the usual practice, reinforcing the importance of treatment in early subclinical or clinical SSc-ILD patients with risk factors for ILD progression. This evidence has led to the inclusion of both RTX and TCZ in the expert-based therapeutic algorithms or recommendations for CTD-ILD management.
Collapse
Affiliation(s)
| | | | - Julio Ancochea
- Pneumology Division, Hospital Universitario de La Princesa, Madrid, Spain.,Cathedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, Spain
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Spain
| | - Miguel Á González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Spain.,Department of Medicine, University of Cantabria, Santander, Spain.,Faculty of Health Sciences, University of Witwatersrand, Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, South Africa
| | - Santos Castañeda
- Rheumatology Division, Hospital Universitario de La Princesa, Madrid, Spain.,Cathedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, Spain
| |
Collapse
|
14
|
Progressive fibrosing interstitial lung disease: treatable traits and therapeutic strategies. Curr Opin Pulm Med 2021; 26:436-442. [PMID: 32657838 DOI: 10.1097/mcp.0000000000000712] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW In this review, the authors describe therapeutic strategies for a disease group called progressive fibrosing interstitial lung disease (PF-ILD) and highlight the importance of the definition of progression, prognosis, and treatment response. RECENT FINDINGS Although it is a relatively new concept, the term PF-ILD has been increasingly applied in clinical research and practice. Three domains commonly used to detect the disease progression include clinical symptoms, rate of forced vital capacity (FVC) decline and the extent of fibrosis on imaging. Although details of the pathogenesis of PF-ILD are still unclear, it has become apparent that genetic predisposition and an abnormal tissue microenvironment and host response are involved in the nature of the disease. Antifibrotic agents recently showed their efficacy on the treatment of PF-ILD. Both nintedanib and pirfenidone can slow the disease progression, as defined by a decline of FVC from baseline, of PF-ILD whenever compared with placebo, similar to the results in idiopathic pulmonary fibrosis (IPF) trials. This effect seems consistent irrespective of the underlying ILD diagnosis. SUMMARY Recent evidence supports the use of antifibrotic therapy in the management of the phenotype progressive non-IPF ILD. Ongoing studies exploring genetic and other molecular biomarkers could identify at-risk individuals or predict treatment response and prognosis (endotypes). This would support the concept of 'treatable traits' in the field of ILD.
Collapse
|
15
|
Di Bartolomeo S, Alunno A, Carubbi F. Respiratory Manifestations in Systemic Lupus Erythematosus. Pharmaceuticals (Basel) 2021; 14:276. [PMID: 33803847 PMCID: PMC8003168 DOI: 10.3390/ph14030276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by a wide spectrum of clinical manifestations. The respiratory system can be involved in up to 50-70% of patients and be the presenting manifestation of the disease in 4-5% of cases. Every part of the respiratory part can be involved, and the severity can vary from mild self-limiting to life threatening forms. Respiratory involvement can be primary (caused by SLE itself) or secondary (e.g., infections or drug toxicity), acute or chronic. The course, treatment and prognosis vary greatly depending on the specific pattern of the disease. This review article aims at providing an overview of respiratory manifestations in SLE along with an update about therapeutic approaches including novel biologic therapies.
Collapse
Affiliation(s)
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, 06123 Perugia, Italy;
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L’Aquila and Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, 67100 L’Aquila, Italy
| |
Collapse
|
16
|
Vacchi C, Manfredi A, Cassone G, Erre GL, Salvarani C, Sebastiani M. Efficacy and safety of rituximab in the treatment of connective tissue disease-related interstitial lung disease. Drugs Context 2021; 10:2020-8-7. [PMID: 33505478 PMCID: PMC7813433 DOI: 10.7573/dic.2020-8-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023] Open
Abstract
Interstitial lung disease (ILD) represents a severe pulmonary complication of connective tissue diseases, rheumatoid arthritis (RA), and antineutrophil cytoplasmic antibody-associated vasculitis. Treatment of ILD, mainly based on immunosuppression, remains challenging. Rituximab (RTX), a monoclonal antibody binding to CD20, is considered a valuable therapeutic choice in cases of refractory ILD. Here, we review the available efficacy and safety data on the use of RTX in the treatment of rheumatic disease-related ILD. Despite controversial efficacy data, RTX seems to be able to stabilize or improve ILD related to RA and antisynthetase syndrome and in established and severe ILD complicating systemic sclerosis. Fewer data are available regarding ILD related to Sjögren syndrome, systemic lupus erythematosus, and antineutrophil cytoplasmic antibody-associated vasculitis. To date, few prospective studies are available and randomized trials are still ongoing with the purpose of exploring the role of RTX in this condition, including the supposed relationship between efficacy and ILD radiologic patterns and safety data, up to now derived mainly from RA studies. Despite an overall acceptable safety profile, concerns remain regarding an increased infectious disease risk in patients with ILD as well as possible lung toxicity and the increased rate of immune-mediated reactions in patients with connective tissue diseases. In conclusion, RTX is a relevant therapeutic option for rheumatic disease-related ILD despite the existing uncertainties; ongoing trials are expected to clarify its use.
Collapse
Affiliation(s)
- Caterina Vacchi
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Andreina Manfredi
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Giulia Cassone
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Gian Luca Erre
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
| | - Carlo Salvarani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| |
Collapse
|
17
|
Rituximab in the Treatment of Interstitial Lung Disease Associated with Autoimmune Diseases: Experience from a Single Referral Center and Literature Review. J Clin Med 2020; 9:jcm9103070. [PMID: 32977717 PMCID: PMC7598697 DOI: 10.3390/jcm9103070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023] Open
Abstract
In the present study, we aimed to report our experience with rituximab (RTX) in the treatment of patients with ILD associated with AD (AD-ILD) at a single center. For this purpose, clinical characteristics, radiological findings, and pulmonary function tests (PFTs) of RTX-treated AD-ILD-patients seen from May 2016 until March 2020 at a referral center for individuals with ILD were retrospectively reviewed. Additionally, an updated literature review was conducted. A total of 26 patients (mean age 58.3 ± 11.1 years at ILD diagnosis) was included. The most common ADs related to ILD were systemic sclerosis, idiopathic inflammatory myositis (including anti-synthetase syndrome) and rheumatoid arthritis. Non-specific interstitial pneumonia (n = 12) and usual interstitial pneumonia (n = 11) were the predominant radiological patterns. The sustained improvement in PFTs was observed from the start of RTX, with a statistically significant increase in DLCO from basal to one year after RTX (mean + 4.2%, p = 0.024). Overall, there were no differences when comparing PFT outcome according to the radiological pattern or the specific type of AD. In conclusion, RTX constitutes a good therapeutic option to preserve lung function in patients with AD-ILD, regardless of the radiological pattern or the underlying AD.
Collapse
|
18
|
Choudhury S, Ramos M, Anjum H, Ali M, Surani S. Shrinking Lung Syndrome: A Rare Manifestation of Systemic Lupus Erythematosus. Cureus 2020; 12:e8216. [PMID: 32582477 PMCID: PMC7306665 DOI: 10.7759/cureus.8216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Shrinking lung syndrome (SLS) is a pulmonary complication of systemic lupus erythematosus (SLE) characterized by dyspnea, pleuritic chest pain, and progressive decrease in lung volumes with no evidence of pleural or interstitial disease on chest CT. We present a 51-year-old female with a 14-year history of SLE with symptoms of progressive shortness of breath, pleuritic chest pains, low grade fevers, and productive cough which was unresponsive to multiple courses of antibiotics. After careful review of her course of SLE and timeline of symptoms, she was diagnosed with SLS. Even though rare, clinicians should have a high suspicion of SLS in patients with a long-term history of SLE and worsening dyspnea. Early treatment can be initiated to help reduce long-term morbidity and mortality and maintain the quality of life.
Collapse
Affiliation(s)
- Saiara Choudhury
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Manuel Ramos
- Pulmonary Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Humayun Anjum
- Pulmonary/Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Mohammed Ali
- Pulmonary/Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA.,Internal Medicine, University of North Texas, Dallas, USA
| |
Collapse
|