Fatigue in sarcoidosis: a systematic review

The effect of web-designed education on medication adherence, asthma control and fatigue in patients with asthma: A randomized controlled trial

AIMS

This study aimed to determine the effect of web-designed education developed for asthma patients on drug adherence, asthma control and fatigue.

METHODS

This randomized controlled trial was conducted between August 2021 and January 2022 with 200 individuals suffering from poor asthma control who participated in web-designed education. After the intervention, the asthma patients were followed up for 6 weeks to measure Medication Adherence Report Scale (MARS), Chronic Obstructive Pulmonary Disease and Asthma Fatigue Scale (CAFS), Asthma Control Test (ACT) and Inhalation Devices Usage Techniques Knowledge Test (IDUSTKT). Data were analysed in the Statistical Package for the Social Sciences program using the Chi-square test, Independent t-test, Man-Whitney U test, Wilcoxon test, Paired t-test, Greenhouse-Geisser (F) test and Linear regression.

RESULTS

The web-designed education had a statistically significant effect on the total scores of CAFS, ACT and IDUSTKT for individuals with asthma (p < 0.001). This intervention decreased fatigue levels, improved asthma control and enhanced knowledge of inhalation device usage techniques. Although there was an improvement in medication adherence, this difference was not statistically significant.

CONCLUSION

These results suggest that web-based educational programs can be an effective tool in asthma management and may improve patients' quality of life. Future research should examine the long-term effects of such educational programs and their effectiveness across different demographic groups in more detail.

Obstructive Sleep Apnea and Sarcoidosis Interactions

Obstructive sleep apnea (OSA) is very prevalent in sarcoidosis patients. Sarcoidosis of the upper respiratory tract may affect upper airway patency and increase the risk of OSA. Weight gain due to steroid use, upper airway myopathy due to steroids and sarcoidosis itself, and interstitial lung disease with decreased upper airway patency are other reasons for the higher OSA prevalence seen in sarcoidosis. Several clinical manifestations such as fatigue, hypersomnolence, cognitive deficits, and pulmonary hypertension are common to both OSA and sarcoidosis. Therefore, early screening and treatment for OSA can improve symptoms and overall patient quality of life.

Recurrent Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, manifesting with bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint or eye lesions. Heerfordt-Waldenström Syndrome - a constellation of facial palsy, fever, uveitis and parotitis - is a rare presentation of this disorder. A 47-year-old Chinese woman presented with unintentional weight loss, lethargy with mediastinal and hilar lymphadenopathy. Biopsy of the right paratracheal lymph node via mediastinoscopy showed mycobacterial granulomatous lymphadenitis consistent with tuberculosis with several acid-fast bacilli identified. Lymphoproliferative disorder was ruled out. She was started on treatment for tuberculosis. Eleven weeks into treatment, she developed a right facial palsy accompanied with fever, uveitis and occipital headache. At this juncture, further history revealed a background of recurrent alternating facial palsy and parotid gland enlargement which was treated for Bell's palsy by three different doctors. New nodules appeared in the left lobe of the thyroid gland. Biopsy of a palpable thyroid nodule and a right supraclavicular lymph nodule showed histological features suggestive of sarcoidosis. Fungal and mycobacterial infections were ruled out. In addition, examination of her cerebral spinal fluid showed lymphocytic inflammation. The serum ACE level was not raised. A diagnosis of sarcoidosis with incomplete features of Heerfordt-Waldenström Syndrome along with thyroid and meningeal involvement was made. The patient was commenced on prednisolone and azathioprine and her symptoms responded shortly after. We present a rare case of Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman.

Quality of life in sarcoidosis

Having sarcoidosis often has a major impact on quality of life of patients and their families. Improving quality of life is prioritized as most important treatment aim by many patients with sarcoidosis, but current evidence and treatment options are limited. In this narrative review, we describe the impact of sarcoidosis on various aspects of daily life, evaluate determinants of health-related quality of life (HRQoL), and provide an overview of the different patient-reported outcome measures to assess HRQoL in sarcoidosis. Moreover, we review the current evidence for pharmacological and non-pharmacological interventions to improve quality of life for people with sarcoidosis.

The Clinical Manifestation of Immunosuppressive Therapy as a Tool to Improve Immune Monitoring in Renal Transplant Recipients

INTRODUCTION

Metrics for posttransplant immune monitoring to prevent over or under immunosuppression in renal transplant recipients (RTRs) are lacking.

METHODS

We surveyed 132 RTRs, 38 in the first year posttransplant and 94 >1-year posttransplant, to study the clinical expression of immunosuppressive therapy. A questionnaire administered to these RTRs was divided into physical (Q physical) and mental (Q mental) symptoms.

RESULTS

In multivariable models for the association between the calculated Q physical and Q mental scores and different clinical and biochemical variables in the 38 RTRs who filled out the questionnaire 130 times during the first year posttransplant, it was found that mycophenolic acid (MPA) and prednisone use increased the mean Q physical score by 0.59 (95% CI: 0.21-0.98, p = 0.002) and 0.53 (95% CI: 0.26-0.81, p = 0.00), respectively, while MPA use increased the mean Q mental score by 0.72 (95% CI: 0.31-1.12, p = 0.001). Among the 94 RTRs who each completed the questionnaire only once, the odds for the mean Q mental score to be above the median value were more than 3 times higher for RTRs treated versus non-treated with MPA (OR 3.38, 95% CI: 1.1-10.3, p = 0.03). MPA-treated RTRs had higher mean scores for questions related to sleep disorders (1.83 ± 1.06 vs. 1.32 ± 0.67 for not treated, p = 0.037), to difficulty falling asleep (1.72 ± 1.11 vs. 1.16 ± 0.5, p = 0.02), and to depression and anxiety.

CONCLUSION

We concluded that prednisone and MPA use are associated with an increased Q physical and Q mental scores in RTRs. Routine monitoring of physical and mental status of RTRs should be implemented to improve the diagnosis of overimmunosuppression. Dose reduction or discontinuation of MPA should be considered in RTRs who report sleep disorders, depression, and anxiety.

The management of sarcoidosis in the 2020's by the primary care physician

Sarcoidosis is an idiopathic granulomatous disease that occurs worldwide and may affect any organ. Because the presenting symptoms of sarcoidosis are not specific for the disease, the primary care physician is usually the first provider to assess these patients. In addition, patients who have previously been diagnosed with sarcoidosis are usually followed longitudinally by primary care physicians. Therefore, these physicians are often the first to address sarcoidosis patient symptoms related to exacerbations of the disease, as well as first observe complications of sarcoidosis medications. This article outlines the approach to the evaluation, treatment and monitoring of sarcoidosis patients by the primary care physician.

Sarcoidosis

Sarcoidosis is a disease of unknown cause characterized by granulomatous inflammation. Although the lung is almost universally involved, any organ can be affected. Complex pathogenesis and protean clinical manifestations are additional features of the disease. The diagnosis is one of exclusion, although the presence of noncaseating granulomas at disease sites is a prerequisite in most cases. The management of sarcoidosis requires a multidisciplinary approach, particularly when the heart, the brain, or the eyes are involved. The paucity of effective therapies and the lack of reliable predictors of disease behavior greatly contribute to making sarcoidosis a challenging disease to manage.

Fatigue in Patients with Sarcoidosis in Denmark

INTRODUCTION

Sarcoidosis is a systemic granulomatous disease of unknown etiology, primarily affecting the lungs and thoracic lymph nodes. Fatigue is a frequent and disabling symptom in sarcoidosis with a significant impact on quality of life. In Denmark, the incidence of sarcoidosis has increased; however, the extent and risk factors of fatigue have not been investigated and no recent reports of the characteristics of patients with sarcoidosis in Denmark exist.

AIM

To assess the frequency of fatigue in patients with sarcoidosis in Denmark at diagnosis and to investigate if fatigue correlated with relevant disease parameters. Moreover, to characterize patients with sarcoidosis in Denmark at time of diagnosis.

METHODS

Data were collected in 150 patients with recently diagnosed sarcoidosis. Fatigue was measured using the Fatigue Assessment Scale (FAS). Patients with fatigue were compared to non-fatigue patients regarding clinical parameters.

RESULTS

FAS was completed by 145 of 150 patients. Fifty-one percent reported significant fatigue. Mean FAS score was 23.6 and 51% had a FAS score ≥ 22. Fatigue in 89 incident patients did not correlate significantly with demographics, physiological, or clinical parameters. Fifty-nine percent were males. Mean age was 47 years; mean values (% predicted) for pulmonary function tests were normal and 71% at Scadding stage 0-I.

CONCLUSION

In Denmark, fatigue was frequent in patients with sarcoidosis. The majority of patients had mild disease at diagnosis and were older but lower at Scadding stage at diagnosis compared to previous cohorts.

Diagnostic delay of sarcoidosis: Protocol for an integrated systematic review

INTRODUCTION

Sarcoidosis is a rare systemic inflammatory granulomatous disease of unknown cause. It can manifest in any organ. The incidence of sarcoidosis varies across countries, and by ethnicity and gender. Delays in the diagnosis of sarcoidosis can lead to extension of the disease and organ impairment. Diagnosis delay is attributed in part to the lack of a single diagnostic test or unified commonly used diagnostic criteria, and to the diversity of disease manifestations and symptom load. There is a paucity of evidence examining the determinants of diagnostic delay in sarcoidosis and the experiences of people with sarcoidosis related to delayed diagnosis. We aim to systematically review available evidence about diagnostic delay in sarcoidosis to elucidate the factors associated with diagnostic delay for this disease in different contexts and settings, and the consequences for people with sarcoidosis.

METHODS AND ANALYSIS

A systematic search of the literature will be conducted using PubMed/Medline, Scopus, and ProQuest databases, and sources of grey literature, up to 25th of May 2022, with no limitations on publication date. We will include all study types (qualitative, quantitative, and mixed methods) except review articles, examining diagnostic delay, incorrect diagnosis, missed diagnosis or slow diagnosis of all types of sarcoidosis across all age groups. We will also examine evidence of patients' experiences associated with diagnostic delay. Only studies in English, German and Indonesian will be included. The outcomes we examine will be diagnostic delay time, patients' experiences, and factors associated with diagnostic delay in sarcoidosis. Two people will independently screen the titles and abstracts of search results, and then the remaining full-text documents against the inclusion criteria. Disagreements will be resolved with a third reviewer until consensus is reached. Selected studies will be appraised using the Mixed Methods Appraisal Tool (MMAT). A meta-analysis and subgroup analyses of quantitative data will be conducted. Meta-aggregation methods will be used to analyse qualitative data. If there is insufficient data for these analyses, a narrative synthesis will be conducted.

DISCUSSION

This review will provide systematic and integrated evidence on the diagnostic delay, associated factors, and experiences of diagnosis delay among people with all types of sarcoidosis. This knowledge may shed light on ways to improve diagnosis delays in diagnosis across different subpopulations, and with different disease presentations.

ETHICS AND DISSEMINATION

Ethical approval will not be required as no human recruitment or participation will be involved. Findings of the study will be disseminated through publications in peer-reviewed journals, conferences, and symposia.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42022307236. URL of the PROSPERO registration: https://www.crd.york.ac.uk/PROSPEROFILES/307236_PROTOCOL_20220127.pdf.

Study of the Effects of Melatonin on Sleep Disorders in Pulmonary Sarcoidosis Patients

Background

The symptoms of pulmonary sarcoidosis may lead to fatigue, excessive daytime sleepiness, poor sleep quality, and a decrease in quality of life in these patients.

Objectives

This study was designed to evaluate the effects of oral melatonin on sleep disorders of patients with pulmonary sarcoidosis.

Methods

A randomized, single-blinded clinical trial was conducted on patients with pulmonary sarcoidosis. Eligible patients were randomly allocated into melatonin and control groups. Patients in the melatonin group were given 3 mg melatonin one hour before bedtime for three months. Sleep quality, daytime sleepiness, fatigue status, and quality of life were assessed applying General Sleep Disturbance Scale (GSDS), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Fatigue Assessment Scale (FAS), and the Patient-Reported Outcomes Measurement Information System (PROMIS), respectively, as well as the 12-item Short Form Survey (SF-12) scores at the baseline and three months after treatment.

Results

There was a significant change in the GSDS (P < 0.001), PSQI (P < 0.001), ESS (P = 0.002), and FAS (P < 0.001) scores, which were decreased, compared to those of the control group. After intervention¸ global physical health and global mental health raw scores were improved comparing to the control group (P = 0.006, P = 0.02, respectively). The 12-item Short Form Survey evaluation showed that there was a significant difference between the melatonin (3.38 ± 4.61) and control (0.55 ± 7.25) groups in PCS-12 score after three months of therapy (P = 0.02).

Conclusions

Our findings showed that supplemental melatonin could significantly improve sleep problems, quality of life, and excessive daytime sleepiness in sarcoidosis patients.

Severity, predictors and clinical correlates of Post-COVID syndrome (PCS) in Germany: A prospective, multi-centre, population-based cohort study

BACKGROUND

Post-COVID syndrome (PCS) is an important sequela of COVID-19, characterised by symptom persistence for >3 months, post-acute symptom development, and worsening of pre-existing comorbidities. The causes and public health impact of PCS are still unclear, not least for the lack of efficient means to assess the presence and severity of PCS.

METHODS

COVIDOM is a population-based cohort study of polymerase chain reaction (PCR) confirmed cases of SARS-CoV-2 infection, recruited through public health authorities in three German regions (Kiel, Berlin, Würzburg) between November 15, 2020 and September 29, 2021. Main inclusion criteria were (i) a PCR confirmed SARS-CoV-2 infection and (ii) a period of at least 6 months between the infection and the visit to the COVIDOM study site. Other inclusion criteria were written informed consent and age ≥18 years. Key exclusion criterion was an acute reinfection with SARS-CoV-2. Study site visits included standardised interviews, in-depth examination, and biomaterial procurement. In sub-cohort Kiel-I, a PCS (severity) score was developed based upon 12 long-term symptom complexes. Two validation sub-cohorts (Würzburg/Berlin, Kiel-II) were used for PCS score replication and identification of clinically meaningful predictors. This study is registered at clinicaltrials.gov (NCT04679584) and at the German Registry for Clinical Studies (DRKS, DRKS00023742).

FINDINGS

In Kiel-I (n = 667, 57% women), 90% of participants had received outpatient treatment for acute COVID-19. Neurological ailments (61·5%), fatigue (57·1%), and sleep disturbance (57·0%) were the most frequent persisting symptoms at 6-12 months after infection. Across sub-cohorts (Würzburg/Berlin, n = 316, 52% women; Kiel-II, n = 459, 56% women), higher PCS scores were associated with lower health-related quality of life (EQ-5D-5L-VAS/-index: r = -0·54/ -0·56, all p < 0·0001). Severe, moderate, and mild/no PCS according to the individual participant's PCS score occurred in 18·8%, 48·2%, and 32·9%, respectively, of the Kiel-I sub-cohort. In both validation sub-cohorts, statistically significant predictors of the PCS score included the intensity of acute phase symptoms and the level of personal resilience.

INTERPRETATION

PCS severity can be quantified by an easy-to-use symptom-based score reflecting acute phase disease burden and general psychological predisposition. The PCS score thus holds promise to facilitate the clinical diagnosis of PCS, scientific studies of its natural course, and the development of therapeutic interventions.

FUNDING

The COVIDOM study is funded by the Network University Medicine (NUM) as part of the National Pandemic Cohort Network (NAPKON).

Cognitive Difficulties and Health-Related Quality of Life in Sarcoidosis: An Analysis of the GRADS Cohort

Rationale: Subjective cognitive difficulties are common among sarcoidosis patients; however, previous studies have not modeled the link between cognitive difficulties and health-related quality of life (HRQOL). Objectives: To determine whether cognitive difficulties are associated with HRQOL in sarcoidosis patients after adjusting for demographics, fatigue, and physical disease severity measures. Methods: We performed a secondary analysis of the Genomic Research in Alpha-1 antitrypsin Deficiency and Sarcoidosis (GRADS) study data. We examined the association between self-reported cognitive difficulties (Cognitive Failures Questionnaire (CFQ)) and HRQOL (SF12v2 mental and physical component scores) while adjusting for the demographics, fatigue, and physical disease severity measures (i.e., organ involvement, forced vital capacity). Results: Approximately one-fourth of the patients with sarcoidosis endorsed cognitive difficulties. More frequent cognitive difficulties and more severe fatigue were significantly associated with worse mental HRQOL in the fully adjusted model, while older age was associated with better mental HRQOL. The association between cognitive difficulties and physical HRQOL was not significant in the final model. More severe fatigue, joint involvement, and reduced forced vital capacity (FVC) were associated with worse physical HRQOL, while higher income and higher education were associated with better physical HRQOL. Conclusions: Perceived cognitive difficulties are associated with diminished HRQOL after adjusting for demographics, organ involvement, pulmonary function, and fatigue. The association between cognitive difficulties and reduced HRQOL primarily occurs through the impact on mental components of HRQOL.

The fatigue and quality of life in patients with chronic pulmonary diseases

BACKGROUND

Patients with pulmonary diseases often experience fatigue. Severe fatigue is associated with a worse health status and worse physical and social functioning. The study aimed to evaluate the relationship between fatigue and quality of life in patients with nonmalignant pulmonary diseases.

METHODS

The St George's Respiratory Questionnaire (SGRQ) was used to assess health status and the Fatigue Impact Scale (MFIS) to measure the level of fatigue. The Shapiro-Wilk test was used to test for normal distribution. Correlations were described as Spearman's rank correlation coefficient.

RESULTS

The study included 200 consecutive patients (mean age, 57.7) with the following diagnoses: COPD (26%), asthma (36%), obstructive sleep apnoea (19%), pneumonia or bronchitis of various aetiologies (8.5%), bronchiectasis (2.5%), interstitial lung disease (3%). The mean score in the SGRQ was 44.62 ± 24.94. The mean score in the MFIS was 28.64 ± 15.8. The strongest correlations appeared between quality-of-life scales and fatigue as measured by physical functioning (symptoms r = 0.622; activity r = 0.632; impact r = 0.692; p < 0.001 for all subscales); however, all the correlations between SGRQ and MFIS were significant.

CONCLUSIONS

Patients with chronic pulmonary diseases were revealed to have a reduced level of quality of life and an increased level of fatigue. The negative influence of fatigue on quality of life highlights the need for careful and routine assessment of this symptom in pulmonary patients. Treating fatigue may improve quality of life and increase the ability of patients with chronic pulmonary diseases to perform activities in daily life.

ERS clinical practice guidelines on treatment of sarcoidosis

BACKGROUND

The major reasons to treat sarcoidosis are to lower the morbidity and mortality risk or to improve quality of life (QoL). The indication for treatment varies depending on which manifestation is the cause of symptoms: lungs, heart, brain, skin, or other manifestations. While glucocorticoids (GC) remain the first choice for initial treatment of symptomatic disease, prolonged use is associated with significant toxicity. GC-sparing alternatives are available. The presented treatment guideline aims to provide guidance to physicians treating the very heterogenous sarcoidosis manifestations.

MATERIALS AND METHODS

A European Respiratory Society Task Force (TF) committee composed of clinicians, methodologists, and patients with experience in sarcoidosis developed recommendations based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology. The committee developed eight PICO (Patients, Intervention, Comparison, Outcomes) questions and these were used to make specific evidence-based recommendations.

RESULTS

The TF committee delivered twelve recommendations for seven PICOs. These included treatment of pulmonary, cutaneous, cardiac, and neurologic disease as well as fatigue. One PICO question regarding small fiber neuropathy had insufficient evidence to support a recommendation. In addition to the recommendations, the committee provided information on how they use alternative treatments, when there was insufficient evidence to support a recommendation.

CONCLUSIONS

There are many treatments available to treat sarcoidosis. Given the diverse nature of the disease, treatment decisions require an assessment of organ involvement, risk for significant morbidity, and impact on QoL of the disease and treatment.

MESSAGE

An evidence based guideline for treatment of sarcoidosis is presented. The panel used the GRADE approach and specific recommendations are made. A major factor in treating patients is the risk of loss of organ function or impairment of quality of life.

The Short- and Long-Term Impact of Pulmonary Rehabilitation in Subjects with Sarcoidosis: A Prospective Study and Review of the Literature

BACKGROUND

Sarcoidosis is a heterogeneous multisystemic disorder of unknown etiology. Dyspnea and fatigue are two of the most common and debilitating symptoms experienced by subjects with sarcoidosis. There is limited evidence regarding the short- and long-term impact of pulmonary rehabilitation (PR) on exercise capacity and fatigue in these individuals.

OBJECTIVE

To evaluate the benefit of PR in subjects with pulmonary sarcoidosis at different severity stages and to review the current literature about PR in sarcoidosis.

METHODS

PR included a 12-week training program of a twice-weekly 90-min workouts. Fifty-two subjects with stable pulmonary sarcoidosis were recruited. Maximal exercise capacity, defined as VO2max, was measured using the cardiopulmonary exercise test (CPET). Pulmonary function tests, 6-min walking distance (6MWD), St. George's Respiratory Questionnaire (SGRQ), and the modified Medical Research Council (mMRC) and Hospital Anxiety and Depression Scale (HADS) questionnaires were given before and after PR and following 6 months (follow-up).

RESULTS

The PR program significantly increased the VO2max (1.8 ± 2.3 mL/kg/min, p = 0.002), following 12 weeks. mMRC and SGRQ scores were also improved (-0.3 ± 0.8, p = 0.03, and -3.87 ± 10.4, p = 0.03, respectively). The impact of PR on VO2max was more pronounced in subjects with pulmonary parenchymal involvement. The increase in VO2max correlated with initial disease severity (indicated by FEV1/FVC, p = 0.01). Subjects with FEV1/FVC <70% showed greater improvement in 6MWD. 6MWD also improved in those with a transfer coefficient of the lung for CO (KCO) above 80% predicted (p < 0.05). At 6-month follow-up, the VO2max, 6MWD, and SGRQ scores remained stable, thus suggesting lasting effects of PR.

CONCLUSION

PR is a promising complementary therapeutic intervention for subjects with sarcoidosis. Further study is needed to validate these findings.

Treatment of Sarcoidosis: A Multidisciplinary Approach

Sarcoidosis is a systemic disease of unknown etiology defined by the presence of noncaseating granulomatous inflammation that can cause organ damage and diminished quality of life. Treatment is indicated to protect organ function and decrease symptomatic burden. Current treatment options focus on interruption of granuloma formation and propagation. Clinical trials guiding evidence for treatment are lacking due to the rarity of disease, heterogeneous clinical course, and lack of prognostic biomarkers, all of which contribute to difficulty in clinical trial design and implementation. In this review, a multidisciplinary treatment approach is summarized, addressing immunuosuppressive drugs, managing complications of chronic granulomatous inflammation, and assessing treatment toxicity. Discovery of new therapies will depend on research into pathogenesis of antigen presentation and granulomatous inflammation. Future treatment approaches may also include personalized decisions based on pharmacogenomics and sarcoidosis phenotype, as well as patient-centered approaches to manage immunosuppression, symptom control, and treatment of comorbid conditions.

Screening Sarcoidosis Patients for Occult Disease

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.

Health-Related Quality of Life in Sarcoidosis

Health-related quality of life (HRQoL) describes an individual's perception of the impact of health, disease, and treatment on their quality of life (QoL). It is a reflection of how the manifestation of an illness and its treatment is personally experienced. Assessing HRQoL is particularly important in sarcoidosis because the attributable disease mortality is relatively low, and one of the major reasons for initiating treatment is to improve quality of life. HRQoL has been assessed in sarcoidosis using various generic and sarcoid-specific patient-reported outcome measures (PROMs). It is important that both the direct and indirect effects of the disease, as well as potential toxicities of therapy, are captured in the various PROMs used to assess HRQoL in sarcoidosis. This article provides a general overview of HRQoL in patients with sarcoidosis. It describes the various PROMs used to assess HRQoL in sarcoidosis and addresses the various factors that influence HRQoL in sarcoidosis. Specific attention is paid to fatigue, small fiber neuropathy, corticosteroid therapy, and other disease-specific factors that affect HRQoL in sarcoidosis. It also provides an insight into interventions that have been associated with improved HRQoL in sarcoidosis and offers suggestions for future research in this important area.

Pulmonary Rehabilitation in Patients with Pulmonary Sarcoidosis: Impact on Exercise Capacity and Fatigue

BACKGROUND

There is limited evidence regarding the impact of multidisciplinary pulmonary rehabilitation (PR) on exercise capacity and fatigue in patients with pulmonary sarcoidosis. The aim of this study was to evaluate the impact on exercise capacity and fatigue following PR, and to examine whether baseline fatigue was related to change in peak oxygen uptake (ΔV̇O2peak).

METHODS

Forty-one patients with pulmonary sarcoidosis attending a 4-week inpatient PR program were recruited to this pre-post study. Both maximal exercise capacity, defined as V̇O2peak and measured with a cardiopulmonary exercise test, and fatigue, assessed with the Fatigue Assessment Scale (score 10-50 points), were measured before and after PR.

RESULTS

There was a statistically significant improvement in V̇O2peak (1.2 ± 2.3 mL/kg/min, p = 0.002), and fatigue decreased significantly (-1.7 ± 3.9 points, p = 0.009) following PR. Unadjusted linear regression analyses demonstrated that age (B = -0.076, p = 0.017) and baseline fatigue (B = 0.196, p = 0.001) were predictors for change in V̇O2peak, while in adjusted analyses (age, sex, baseline V̇O2peak, baseline fatigue, and diffusion capacity of the lung for carbon monoxide), only baseline fatigue predicted change in V̇O2peak following PR (B = 0.165, p = 0.026).

CONCLUSION

A 4-week multidisciplinary PR program improves maximal exercise capacity and reduces fatigue in patients with pulmonary sarcoidosis. Baseline fatigue only partly predicted change in V̇O2peak following PR.

The acute impact of resistance training on fatigue in patients with pulmonary sarcoidosis

Fatigue is the most prevalent symptom among patients with sarcoidosis, and skeletal muscle dysfunction is a common clinical feature, making resistance training (RT) a recommended treatment strategy. Despite lacking knowledge regarding whether high-intensity RT will aggravate fatigue, low to moderate-intensity is routinely used even if the evidence for this protocol to improve muscle strength is inconclusive. This study aimed to investigate whether one single session of high-intensity RT induces a higher increase in fatigue than one single session of moderate-intensity RT. In this randomized crossover study, 41 patients with pulmonary sarcoidosis (age: 53 ± 11 yr) were recruited. They randomly performed one single session of high-intensity RT, 4 sets × 5 repetitions maximum (5RM), and one single session of moderate-intensity RT, 2 sets × 25 RM. Fatigue was assessed with the Visual Analogue Scale (0–100 mm) immediately before (T0), immediately after (T1) and 24 hours after (T2) each exercise session. Fatigue development from T0 to T1 was significantly lower after 5RM (−3 ± 18 mm) than after 25RM (5 ± 15 mm), p = 0.004. No difference was seen from T0 to T2 between 5RM (0 ± 17 mm) and 25RM (6 ± 18 mm), p = 0.147. The high-intensity 5RM session did not induce a larger increase in fatigue than the moderate-intensity 25RM session. RT appears feasible and safe in patients with pulmonary sarcoidosis irrespective of the intensity. Thus, the long-term effects of high-intensity RT on fatigue should be explored in a RT programme of longer duration.

Definition and Consensus Diagnostic Criteria for Neurosarcoidosis: From the Neurosarcoidosis Consortium Consensus Group

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.

The effects of High- versus Moderate-Intensity Exercise on Fatigue in Sarcoidosis

Background: Fatigue is a common symptom in patients with sarcoidosis. Despite lacking evidence on whether high-intensity interval training (HIIT) will aggravate fatigue, moderate-intensity exercise is often recommended. This study aimed to investigate whether a single session of HIIT would affect fatigue differently from a single session of moderate-intensity continuous training (MICT). Methods: Forty-one patients with pulmonary sarcoidosis were recruited to a cross-over study. All patients completed one treadmill session of HIIT (85% of peak heart rate (HRpeak)) and one of MICT (70% of HRpeak). Fatigue was assessed with the Visual Analogue Scale 0–100 mm, before (T0), after (T1), and 24 hours after (T2) each exercise session. Paired sample t-test was used to compare changes in fatigue from T0 to T1 and from T0 to T2 between HIIT and MICT. Results: No statistically significant difference in fatigue levels was found between HIIT and MICT, either at T1 (3.6 (13.5) and 1.4 (13.5)) or at T2 (8.2 (17.0) and 2.1 (17.1)). Conclusions: A single session of HIIT did not affect fatigue differently than a single session of MICT. These preliminary findings support the need for further research on the long-term effect of HIIT on fatigue in patients with sarcoidosis.

First patient-centred set of outcomes for pulmonary sarcoidosis: a multicentre initiative

Introduction

Routine and international comparison of clinical outcomes enabling identification of best practices for patients with pulmonary sarcoidosis is lacking. The aim of this study was to develop a standard set of outcome measures for pulmonary sarcoidosis, using the value-based healthcare principles.

Methods

Six expert clinics for interstitial lung diseases in four countries participated in a consensus-driven RAND-modified Delphi study. A mixed-method approach was applied for the identification of an outcome measures set and initial conditions for patients with pulmonary sarcoidosis. The expert team consisted of multidisciplinary professionals (n=14) from Cleveland Clinic, Cincinnati MC, Erasmus MC, Leuven UZ, Royal Brompton and St. Antonius Hospital. During a ranking process, participants were instructed to rank variables on a scale from 1 to 10 based on whether it has (1) impact of the outcome on quality of life, (2) impact of quality of care on the outcome and (3) the number of patients negatively affected by the outcome.

Results

An outcome measures set was defined consisting of seven outcome measures: mortality, pulmonary function, soluble interleukin-2 receptor change as an activity biomarker, weight gain, quality of life, osteoporosis and clinical outcome status.

Discussion

Collecting outcomes in pulmonary sarcoidosis internationally and the use of a broadly accepted set can enable international comparison. Differences in outcomes can potentially be used as a starting point for quality improvement initiatives.

Design of a Study Assessing Disease Behaviour During the Peri-Diagnostic Period in Patients with Interstitial Lung Disease: The STARLINER Study

Background/Objectives

This study will aim to characterise disease behaviour during the peri-diagnostic period in patients with suspected interstitial lung disease (ILD), including idiopathic pulmonary fibrosis (IPF), using daily home spirometry and accelerometry. Additionally, this study will aim to increase collaboration between secondary and tertiary centres using a digital collaboration platform.

Methods

The STARLINER study (NCT03261037) will enrol approximately 180 symptomatic patients aged 50 years or more with radiological evidence of ILD/IPF from community and tertiary centres in Canada and Europe. Approximately two-thirds of sites will be community centres. Patients will be followed during pre-diagnosis (inclusion to diagnosis; up to a maximum of 12 months) and post-diagnosis (diagnosis to treatment initiation; up to a maximum of 6 months). The study will be facilitated by a digital ecosystem consisting of the devices used for home-based assessments and a digital collaboration platform enabling communication between community and tertiary centres, and between clinicians and patients.

Planned Outcomes

The primary endpoint will be time-adjusted semi-annual change in forced vital capacity (FVC; in millilitres) during the peri-diagnostic period. Physical functional capacity and patient-reported outcomes (PROs) will also be assessed. FVC and physical functional capacity will be measured using daily home spirometry and accelerometry, and at site visits using spirometry and the 6-min walk test. PROs will be assessed prior to, or during, site visits and will always be completed in the same order.

Conclusions

Findings from this study may help to facilitate the early and accurate diagnosis of ILDs by increasing knowledge about disease progression, enabling collaboration between community and tertiary centres and improving communication between clinicians and patients.

Trial Registration Number

NCT03261037.

Funding

F. Hoffmann-La Roche, Ltd., Basel, Switzerland.

Plain Language Summary

Plain language summary available for this article.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0845-3) contains supplementary material, which is available to authorized users.

Needs, Perceptions and Education in Sarcoidosis: A Live Interactive Survey of Patients and Partners

Objectives

Sarcoidosis is a chronic, multisystem disease with often a major impact on quality of life. Information on unmet needs of patients and their partners is lacking. We assessed needs and perceptions of sarcoidosis patients and their partners.

Methods

During patient information meetings in 2015 and 2017 in the Erasmus University Medical Center, we interviewed patients and partners using interactive voting boxes. Patients responded anonymously to 17 questions. Answers were projected directly on the screen in the room.

Results

210 patients and 132 partners participated. Sarcoidosis has a subjective significant impact on lives of both patients and partners. The vast majority of patients and partners feel regularly misunderstood because of the general unawareness of sarcoidosis. Many patients and partners experience anxiety. Three-quarters of patients would like to see more attention and support for their psychological problems. Additionally, more supportive care for partners of sarcoidosis patients is warranted. Interactive interviewing was considered educational (91%) and pleasant (84%).

Discussion

This study improves awareness of needs and perceptions of patients with sarcoidosis and their partners. Sarcoidosis leads to anxiety and psychological distress and impairs well-being of patients and their partners. Attention for psychological support, better disease education, and more supportive care for partners is warranted.

Daytime Sleepiness in Patients Diagnosed with Sarcoidosis Compared with the General Population

Background

The aim of this study was to analyze daytime sleepiness in a sample of patients diagnosed with sarcoidosis.

Methods

A sample of 1197 German sarcoidosis patients was examined with the Epworth Sleepiness Scale (ESS), the Fatigue Assessment Scale, the Hospital Anxiety and Depression Scale, the Pittsburgh Sleep Quality Index, and the Short-Form Health Survey (SF-8). The patients' ESS mean scores were compared with those obtained from a large general population sample.

Results

Exactly 50% of the patients reached the criterion (ESS > 10) for excessive daytime sleepiness, compared with only 22.1% in the general population. The effect size for the mean score difference between both samples was d=0.62. The number of affected organs and the number of concomitant diseases proved to be significant independent predictors of daytime sleepiness. Sleepiness was associated with fatigue (r=0.45), anxiety (r=0.23), depression (r=0.28), sleep problems (r=0.23), and detriments in physical (r=-0.29) and mental (r=-0.28) quality of life.

Conclusions

The issue of excessive daytime sleepiness should be considered in the management of sarcoidosis.

Case Report: Pulmonary and Liver Sarcoidosis Suspected of Metastasis

Introduction: Sarcoidosis is a granulomatous disease with unknown cause that can vary from an asymptomatic condition. Almost half of the patients with sarcoidosis have no symptoms. In this article, we describe a sarcoidosis patient with lung and liver engagement; it may be confused with metastasis.

Case report: A 39-year-old man, with known as hypothyroidism who had come to the emergency ward with dyspnea and coughing after exposure to detergents in a closed environment. The patient smoked for 10 years (3 pack/year). No other findings were found in clinical examinations except for wheezing in the right lung. The patient's chest radiography was shown a mass. For further investigation, spiral CT scan was performed. Large lymph nodes on the right side of the trachea, measuring about 23 mm and a mass of 70 × 77 mm in the vicinity of the right lung hilum and a hypodense nodule in the posterior part of the liver with malignancy suspicious were reported. After several biopsy results was shown chronic granulomatous inflammation, the most important differential diagnosis is tuberculosis (TB) and sarcoidosis. Sputum smear, culture, and PCR were performed for tuberculosis. Also, the level of angiotensin-converting enzyme (ACE) was measured for sarcoidosis. the results ruled out TB and shown a higher level of ACE (ACE = 88 IU/L).After diagnosis treatment started with prednisolone. Now, the patient is in the follow- up.

Conclusion: In hilar lymphadenopathy of lung sarcoidosis is the importance differential diagnosis that should be considered.

Sleep disturbance and symptom burden in sarcoidosis

INTRODUCTION

Sarcoidosis is a systemic inflammatory disease associated with myriad symptoms, including fatigue. It can affect physiological processes like sleep, leading to poor sleep quality and excessive daytime sleepiness. We hypothesized that sarcoidosis patients would report more severe sleep disturbance than healthy controls and that relationships would be found with sleep disturbance and the severity of other symptoms.

METHODS

We enrolled 84 sarcoidosis patients and 30 healthy controls and recorded demographic and clinical characteristics. Self-report measures were used to assess sleep disturbance, psychosocial symptoms, and quality of life at enrollment and longitudinally. Relationships between different self-report outcomes were analyzed using correlation statistics.

RESULTS

Using the General Sleep Disturbance Scale, 54% of sarcoidosis patients reported frequent and occasional sleep disturbance compared to only 17% of healthy controls (p < 0.0001). This significant increase in sleep disturbance found in sarcoidosis patients strongly correlated with multiple psychosocial symptoms, including fatigue, depression, and cognitive dysfunction, and negatively impacted quality of life (p < 0.01). Traditional measures of sarcoidosis disease severity or activity were not associated with sleep disturbance. Sleep disturbance scores remained stable at follow-up (mean time between first and last administration of questionnaire was 17.3 months) in 56 of the sarcoidosis patients.

CONCLUSIONS

Sarcoidosis patients experienced significant sleep disturbance that correlated with higher levels of fatigue, depression, and cognitive dysfunction, and poorer quality of life. These associations were present regardless of disease severity or activity and result in decrements in quality of life and mental health.

Risk of gastrointestinal events among patients with sarcoidosis: a population-based study 1976-2013

Background: An increased risk of gastrointestinal (GI) diseases has been observed in immune-mediated disease but the risk in patients with sarcoidosis is not known. Objectives: This study was undertaken to characterize the risk of GI diseases in patients with sarcoidosis. Methods: A population-based cohort of 345 incident cases of sarcoidosis among Olmsted County, Minnesota residents in 1976-2013 was identified. A cohort of 345 sex and age-matched comparators were also identified from the same underlying population. Medical records of both groups were reviewed for GI diseases. Cox models adjusted for age, sex and calendar year were used to compare the rate of development of GI diseases between the groups. In addition, Cox models were used to evaluate the association between use of immunosuppressive agents and the development of GI diseases among patients with sarcoidosis. Results: GI events occurred in 101 cases and 63 comparators, corresponding to an adjusted hazard ratio (HR) of 1.90 (95% confidence interval [CI] 1.38-2.61). Patients with sarcoidosis had an increased risk for both upper (HR 1.90; 95%CI 1.27-2.83) and lower GI events (HR 1.97; 95%CI 1.27-3.05) relative to comparators. By disease type, patients with sarcoidosis had a significantly elevated risk of upper GI ulcer, upper GI hemorrhage and diverticulitis. Regarding medication use, the only significant association was an increased risk of upper GI events among biologic agent users (HR 11.09; 95%CI 2.16-56.97). Conclusion: Patients with sarcoidosis have a higher risk of both upper and lower GI events compared with subjects without sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 239-244).

Relationship of emotional distress and physical concerns with fatigue severity in sarcoidosis

Background: Fatigue is one of the most common and disabling symptoms of sarcoidosis. The cause of fatigue remains unclear and is usually multifactorial. The majority of previous studies evaluated clinical parameters with only few of them including assessment of psychological factors as contributing to the severity of the symptoms. Objective: The aim of this study was to evaluate the relationship of emotional distress, physical concerns, and dyspnea in explaining fatigue in patients with sarcoidosis. Methods: Fifty-seven patients with sarcoidosis were enrolled to the study and filled out measures of fatigue (FAS), dyspnea (MRC), anxiety sensitivity (ASI-3), and anxiety and depression (HADS). Results: Linear regression revealed that distress and physical concerns subscale of ASI are significant predictors of fatigue explaining jointly 53.5% of fatigue variance. Conclusions: The results of the study emphasize the importance of including emotional distress and physical concerns into the diagnostic procedures and management of fatigue in sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 160-164).

Disease Burden and Variability in Sarcoidosis

Sarcoidosis is a systemic inflammatory disease with substantial morbidity and increasing mortality. As part of the National Heart, Lung, and Blood Institute's workshop to better understand this disease and improve the outcomes of patients with sarcoidosis, we reviewed the available data on health care burden and outcomes of this disease in the United States. Disparities in outcomes exist by race, ethnicity, sex, and socioeconomic groups, with African Americans having disproportionately more severe disease. Mortality rates are highest in African Americans, but may be increasing in white individuals. The health care burden of sarcoidosis is defined not only by its somatic manifestations, but is also greatly impacted by psychosocial, economic, and comorbid conditions associated with this disease. Fatigue, depression, cognitive dysfunction, treatment side effects, and pain syndromes are highly prevalent in this population and contribute to poor outcomes. The direct and indirect economic costs to patients and society are likely also substantial, although not well defined. We recommend leveraging existing and future technology and infrastructure to more accurately define and monitor the overall total sarcoidosis-attributable health care burden and patient outcomes in the United States.

Physical Activity and Fatigue in Patients with Sarcoidosis

BACKGROUND

Little is known about physical activity in daily life among patients with sarcoidosis. Fatigue is a frequent and disabling symptom that might negatively affect physical activity levels.

METHODS

In patients with sarcoidosis, we measured physical activity (steps per day) by accelerometry (SenseWear Armband) for 1 week. We assessed lung function (DLCO, FVC), exercise capacity (6-min walking distance [6MWD]), health-related quality of life (St George's Respiratory Questionnaire [SGRQ]), generic quality of life (12-Item Short-Form Health Survey [SF-12]), and fatigue (Multidimensional Fatigue Inventory [MFI-20]).

RESULTS

We investigated 57 patients with sarcoidosis (mean age 50 years, 56% male, mean DLCO 73% predicted, mean FVC 91% predicted, mean 6MWD 525 m, mean steps per day 7,490), of whom n = 14 (25%) had severe fatigue. The MFI-20 subscales "reduced activity" and "physical fatigue" were weakly associated with steps per day on a bivariate level (Spearman ρ = -0.274 and ρ = -0.277, respectively; p < 0.05), while the other subscales and the total score were not. 6MWD, SGRQ score, and SF-12 (physical health) score showed stronger associations with steps per day in bivariate analyses (Pearson r = 0.499, r = -0.386, and r = 0.467, respectively; p < 0.01), and were independent predictors of steps per day in multivariate linear regression analyses adjusting for confounders (p < 0.05). In ROC curve analyses, 6MWD, SGRQ score, and SF-12 (physical health) score properly identified sedentary patients (steps per day <5,000; AUROC 0.90, 0.81, and 0.80, respectively; p < 0.01). Fatigue was less predictive (MFI-20 subscale "general fatigue," AUROC 0.70; p = 0.03).

CONCLUSION

While exercise capacity and quality of life measurements were robust predictors of physical activity in patients with sarcoidosis, associations of objectively measured physical activity with fatigue were surprisingly weak. In sarcoidosis, fatigue might not preclude affected patients from being physically active, although this symptom is subjectively perceived as highly disabling.

Considerations regarding sarcoidosis in the bariatric surgical patient

The sarcoidosis patient who seeks surgical management for obesity presents many challenges. The interaction between sarcoidosis and obesity complicates both disorders and creates special issues to consider when contemplating surgery. This manuscript will review the approach to pre- and postoperative management of the sarcoidosis patient undergoing bariatric surgery.

Patient reported outcome measures (PROMs) in sarcoidosis

Patients with sarcoidosis present with a variety of symptoms which may impair many aspects of physical and mental well-being. Traditionally, clinicians have been concerned with physical health aspects of sarcoidosis, assessing disease activity and severity with radiological imaging, pulmonary function and blood tests. However, the most reported symptom of sarcoidosis patients, fatigue, has been shown not to correlate with the most commonly used parameters for monitoring disease activity. Studies have shown poor agreement between physicians and patients in assessing sarcoidosis symptoms. This underlines the importance of patient reported outcomes (PROs) in addition to traditional outcomes in order to provide a complete evaluation of the effects of interventions in clinical trials and everyday clinical assessment of sarcoidosis. We have undertaken a systematic review to identify and provide an overview of PRO concepts used in sarcoidosis assessment the past 20 years and to evaluate the tools used for measuring these concepts, called patient reported outcome measures (PROMs). Various PROMs have been used. By categorizing these PROMs according to outcome we identified the key PRO concepts for sarcoidosis to be Health Status and Quality of Life, Dyspnea, Fatigue, Depression, Anxiety and Stress and Miscellaneous. There is no perfect sarcoidosis-specific PROM to cover all concepts and future intervention studies should therefore contain multiple complementary questionnaires. Based on our findings we recommend the Fatigue Assessment Scale (FAS) for assessing fatigue. Dyspnea scores should be chosen based on their purpose; more research is needed to examine their validity in sarcoidosis. The Modified Medical Research Council Dyspnea Scale (MRC) can be used to screen for dyspnea and the Baseline Dyspnea Index (BDI) to detect changes in dyspnea. We recommend The World Health Organization Quality of Life assessment instrument (WHOQOL-100) for assessing quality of life, although a shorter questionnaire would be preferable. For assessing health status we recommend the Sarcoidosis Assessment Tool (SAT), and have great expectations for this new and promising assessment tool. Supplementary to the WASOG meeting of 2011's recommendation on assessing QoL, we recommend incorporating fatigue, dyspnea and HS assessment in clinical trials and everyday clinical assessment of sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 2-17).

Treatment of Sarcoidosis

Treatment of sarcoidosis is not required in all patients with the diagnosis. The decision to treat and the strategy for how to treat usually require input and shared decision making by the patient. Some common consequences of sarcoidosis are not caused by granulomatous inflammation, but may be the dominant disease manifestation and should be actively considered when formulating a treatment plan. The medication regimen should be tailored to each patient. Steroid-sparing medications should be prescribed early as part of a long-term strategy.

The Clinical Features of Sarcoidosis: A Comprehensive Review

Sarcoidosis has innumerable clinical manifestations, as the disease may affect every body organ. Furthermore, the severity of sarcoidosis involvement may range from an asymptomatic state to a life-threatening condition. This manuscript reviews a wide variety of common and less common clinical characteristics of sarcoidosis. These manifestations are presented organ by organ, although additional sections describe systemic and multiorgan presentations of sarcoidosis. The lung is the organ most commonly involved with sarcoidosis with at least 90 % of sarcoidosis patients demonstrating lung involvement in most series. The skin, eye, liver, and peripheral lymph node are the next most commonly clinically involved organs in most series, with the frequency of involvement ranging from 10 to 30 %. The actual frequency of sarcoidosis organ involvement is probably much higher as it is frequently asymptomatic and may avoid detection. This is particularly common with lung, liver, cardiac, and bone involvement. Cardiac sarcoidosis is present in 25 % of all sarcoidosis but only causes clinical problems in 5 % of them. Nevertheless, unlike sarcoidosis involvement of most other organs, it may be suddenly fatal. Therefore, it is important to screen for cardiac sarcoidosis in all sarcoidosis patients. All sarcoidosis patients should also be screened for eye involvement as asymptomatic patients may have eye involvement that may cause permanent vision impairment. Pulmonary fibrosis from sarcoidosis is usually slowly progressive but may be life-threatening because of the development of respiratory failure, pulmonary hypertension, or hemoptysis related to a mycetoma or bronchiectasis. Some manifestations of sarcoidosis are not organ-specific and probably are the result of a release of mediators from the sarcoid granuloma. Two such manifestations include small fiber neuropathy and fatigue syndromes, and they are observed in a large percentage of patients.

Interrelationship between sleep-disordered breathing and sarcoidosis

Sleep-disordered breathing (SDB) has a high prevalence in sarcoidosis. This high prevalence may be the result of increased upper airways resistance from sarcoidosis of the upper respiratory tract, corticosteroid-induced obesity, or parenchymal lung involvement from sarcoidosis. OSA is a form of SDB that is particularly common in patients with sarcoidosis. Sarcoidosis and SDB share many similar symptoms and clinical findings, including fatigue, gas exchange abnormalities, and pulmonary hypertension (PH). Sarcoidosis-associated fatigue is a common entity for which stimulants may be beneficial. Sarcoidosis-associated fatigue is a diagnosis of exclusion that requires an evaluation for the possibility of OSA. Hypercapnia is unusual in a patient with sarcoidosis without severe pulmonary dysfunction and, in this situation, should prompt evaluation for alternative causes of hypercapnia, such as SDB. PH is usually mild when associated with OSA, whereas the severity of sarcoidosis-associated PH is related to the severity of sarcoidosis. PH caused by OSA usually responds to CPAP, whereas sarcoidosis-associated PH commonly requires the use of vasodilators. Management of OSA in sarcoidosis is problematic because corticosteroid treatment of sarcoidosis may worsen OSA. Aggressive efforts should be made to place the patient on the lowest effective dose of corticosteroids, which involves early consideration of corticosteroid-sparing agents. Because of the significant morbidity associated with SDB, early recognition and treatment of SDB in patients with sarcoidosis may improve their overall quality of life.

ProKaSaRe Study Protocol: A Prospective Multicenter Study of Pulmonary Rehabilitation of Patients With Sarcoidosis

Background

Available data assessing the efficacy of pulmonary rehabilitation for patients with chronic sarcoidosis are scant; for Germany, there are none at all.

Objective

To gain information about the benefit of in-house pulmonary rehabilitation for patients with chronic sarcoidosis and for the health care system, we intend to collect data in a prospective multicenter “real-life” cohort trial.

Methods

ProKaSaRe (Prospektive Katamnesestudie Sarkoidose in der pneumologischen Rehabilitation) [Prospective Catamnesis Study of Sarcoidosis in Pulmonary Rehabilitation] will assess a multimodal 3-week inpatient pulmonary rehabilitation program for adult patients with chronic sarcoidosis over a 1-year follow-up time. Defined specific clinical measurements and tests will be performed at the beginning and the end of the rehabilitation. In addition, questionnaires concerning health-related quality of life and the patients’ symptoms will be provided to all patients. Inclusion criteria will be referral to one of the 6 participating pulmonary rehabilitation clinics in Germany for sarcoidosis and age between 18 and 80 years. Patients will only be excluded for a lack of German language skills or the inability to understand and complete the study questionnaires. To rule out seasonal influences, the recruitment will take place over a period of 1 year. In total, at least 121 patients are planned to be included. A descriptive statistical analysis of the data will be performed, including multivariate analyses. The primary outcomes are specific health-related quality of life (St George’s Respiratory Questionnaire) and exercise capacity (6-minute walk test). The secondary outcomes are several routine lung function and laboratory parameters, dyspnea scores and blood gas analysis at rest and during exercise, changes in fatigue, psychological burden, and generic health-related quality of life (36-item Short Form Health Survey).

Results

Funding was obtained on October 12, 2010; enrollment began on January 15, 2011 and was completed by January 14, 2012. Results are anticipated late summer 2015.

Conclusions

Due to the large number of participants, we expect to obtain representative findings concerning the effectiveness of pulmonary rehabilitation for patients with sarcoidosis and to provide a dataset of assessed objective and subjective short- and long-term changes due to pulmonary rehabilitation. The results should form the basis for the planning of a randomized controlled trial.

Trial Registration

German Clinical Trials Register: DRKS00000560; https://drks-neu.uniklinik-freiburg.de/ drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00000560 (Archived by WebCite® at http://www.webcitation.org/6dKb5X87R)

Lung sarcoidosis in children: update on disease expression and management

BACKGROUND

Sarcoidosis is a rare lung disease in children. The aim of the present study was to provide update information on disease presentation and progression, patient management and prognosis factors in a cohort of children with lung sarcoidosis.

METHODS

With the network of the French Reference Centre for Rare Lung Diseases (RespiRare), we collected information on a large cohort of paediatric thoracic sarcoidosis to provide information on disease presentation, management and outcome.

RESULTS

Forty-one patients were included with a median age at diagnosis of 11.8  years (1.1-15.8), mostly from Afro-Caribbean and Sub-Saharan origin. At diagnosis, 85% presented with a multi-organic disease, and no major differences were found regarding disease severity between the patients diagnosed before or after 10 years old. Corticosteroids were the most used treatment, with more intravenous pulses in the youngest patients. The 18-month outcome showed that patients diagnosed before 10 years old were more likely to recover (50% vs 29%), and presented fewer relapses (29% vs 58%). At 4-5 years of follow-up, relapses were mostly observed for patients diagnosed after 10 years old.

DISCUSSION

In the included children, mostly of Afro-Caribbean and Sub-Saharan origin, sarcoidosis seems severe, with multi-organic involvement and foreground general symptoms. Common prognosis factors are not suitable in paediatric patients, and a young age at diagnosis does not seem to be associated with a poorer prognosis. The study is ongoing to provide further information on the very-long-term follow-up of paediatric sarcoidosis.

Subjective sleep quality in sarcoidosis

BACKGROUND

Poor sleep is common among patients with medical disorders. Sleep disturbances can be a cause of fatigue and poor quality of life for patients suffering from sarcoidosis. Studies on subjective sleep quality or prevalence of insomnia have not been reported so far.

OBJECTIVES

The aim of this study was to investigate the subjectively reported sleep quality and its relation to psychological and physical factors in sarcoidosis patients.

METHODS

1197 patients from Germany diagnosed with sarcoidosis were examined using the Pittsburgh Sleep Quality Index (PSQI), the Medical Research Council (MRC) dyspnea scale, the Hospital Anxiety and Depression Scale (HADS) and the Multidimensional Fatigue Inventory (MFI).

RESULTS

802 patients (67%) had PSQI global scores >5, indicating subjectively poor quality of sleep. The mean PSQI score was 7.79 ± 4.00. Women reported a significantly inferior individual quality of sleep than men. The subjective quality of sleep was lowered significantly with increasing dyspnea for men and women. 294 patients (25%) had PSQI global scores >10 usually found in patients with clinically relevant insomnia. In this group 86% had high values for fatigue, 69% for anxiety, and 59% for depression. The prevalence of known sleep apnea was 8.7% and 15.7% for restless legs.

CONCLUSION

Poor subjective sleep quality in sarcoidosis patients is about twice as common as in the general population and is associated with fatigue, anxiety, depression and dyspnea. Questions about sleep complaints should therefore be included in the management of sarcoidosis.

Health status, health-related quality of life, and quality of life following ankle fractures: a systematic review

INTRODUCTION

The number of disabling short- and long-term consequences after ankle fracture (AF) is high. Therefore, it is important to consider the health status (HS), health-related quality of life (HRQOL), and quality of life (QOL) of these patients. The aim of this study was to provide a systematic overview of studies on HS, HRQOL, and QOL in patients with AF. In addition, the conceptualisation of HS, HRQOL, and QOL in these studies was evaluated.

METHODS

A systematic literature search was conducted in Pubmed, Embase, The Cochrane Library, and PsycINFO (January 1976 to April 2012).

RESULTS

Twenty-three studies were included of which almost half had a cross-sectional design. The assessment of HRQOL or QOL was an explicit objective in 17.4% of the studies. The SF-36 and SMFA were the instruments most often used and measure respectively HS and a combination of HS and HRQOL. However, they had been labelled as functional status. Inconclusive results were reported regarding the predictive value of age, sex, education level, alcohol use, smoking, fracture type, and the role of syndesmotic reduction with regard to HS and HRQOL. Also, inconclusive results were found comparing HS and HRQOL scores of patients with AF with norm population scores and regarding the course of HS and HRQOL over time. The additional value of early mobilisation after AF was not confirmed.

CONCLUSIONS

There are few quality studies on HS and HRQOL following AF and results are inconclusive. Future studies should measure these important patient-reported outcomes, including QOL. The concepts HS and HRQOL are not applied in agreement with the content of the instruments and instruments are downgraded to assess functional status. The correct terminology should be used to warrant clear communication in the field.

Influence of repeated maximal exercise testing on biomarkers and fatigue in sarcoidosis

Fatigue in the immune mediated inflammatory disease sarcoidosis is thought to be associated with impaired exercise tolerance. This prospective study assessed fatigue and recuperative capacity after repeated exercise, and examined whether changing concentrations in biomarkers upon exercise are associated with fatigue. Twenty sarcoidosis patients and 10 healthy volunteers performed maximal cardiopulmonary exercise tests on two successive days. Concentrations of cytokines, stress hormones, ACE and CK were assessed before and after the two exercise tests, and 3 days thereafter. All participants completed a sleep diary. Severely fatigued patients showed significant lower VO2 max (p=0.038, p=0.022) and maximal workload (p=0.034, p=0.028) on both exercise tests compared to healthy controls. No impairment of maximal exercise testing was demonstrated during the second cycling test in any group. Fatigue was not correlated with changes in concentrations of biomarkers upon exercise. Severely fatigued patients rated both tests as significantly more fatiguing, and reported significant lower mean subjective night sleeping time during the testing period. Fatigue in sarcoidosis patients cannot be objectified by reduction of exercise capacity after repeated maximal exercise testing, and is not correlated with significant changes in biomarkers. Severe fatigue is only and consistently featured by patient reported outcomes.