Trends in mortality from idiopathic pulmonary fibrosis in the European Union: an observational study of the WHO mortality database from 2001-2013

Molecular Endotypes of Idiopathic Pulmonary Fibrosis: A Latent Class Analysis of Two Multicenter Observational Cohorts

Rationale: Idiopathic pulmonary fibrosis (IPF) causes irreversible fibrosis of the lung parenchyma. Although antifibrotic therapy can slow IPF progression, treatment response is variable. There exists a critical need to develop a precision medicine approach to IPF. Objectives: To identify and validate biologically driven molecular endotypes of IPF. Methods: Latent class analysis (LCA) was independently performed in prospectively recruited discovery (n = 875) and validation (n = 347) cohorts. Twenty-five plasma biomarkers associated with fibrogenesis served as class-defining variables. The association between molecular endotype and 4-year transplant-free survival was tested using multivariable Cox regression adjusted for baseline confounders. Endotype-dependent differential treatment response to future antifibrotic exposure was then assessed in a pooled cohort of patients naive to antifibrotic therapy at the time of biomarker measurement (n = 555). Measurements and Main Results: LCA independently identified two latent classes in both cohorts (P < 0.0001). WFDC2 (WAP four-disulfide core domain protein 2) was the most important determinant of class membership across cohorts. Membership in class 2 was characterized by higher biomarker concentrations and a higher risk of death or transplant (discovery, hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.64-2.48; P < 0.001; validation, HR, 1.95; 95% CI, 1.34-2.82; P < 0.001). In pooled analysis, significant heterogeneity in treatment effect was observed between endotypes (P = 0.030 for interaction), with a favorable antifibrotic response in class 2 (HR, 0.64; 95% CI, 0.45-0.93; P = 0.018) but not in class 1 (HR, 1.19; 95% CI, 0.77-1.84; P = 0.422). Conclusions: In this multicohort study, we identified two novel molecular endotypes of IPF with divergent clinical outcomes and responses to antifibrotic therapy. Pending further validation, these endotypes could enable a precision medicine approach for future IPF clinical trials.

Idiopathic pulmonary fibrosis (IPF): Diagnostic routes using novel biomarkers

Idiopathic pulmonary fibrosis (IPF) diagnosis is still the diagnosis of exclusion. Differentiating from other forms of interstitial lung diseases (ILDs) is essential, given the various therapeutic approaches. The IPF course is now unpredictable for individual patients, although some genetic factors and several biomarkers have already been associated with various IPF prognoses. Since its early stages, IPF may be asymptomatic, leading to a delayed diagnosis. The present review critically examines the recent literature on molecular biomarkers potentially useful in IPF diagnostics. The examined biomarkers are grouped into breath and sputum biomarkers, serologically assessed extracellular matrix neoepitope markers, and oxidative stress biomarkers in lung tissue. Fibroblasts and complete blood count have also gained recent interest in that respect. Although several biomarker candidates have been profiled, there has yet to be a single biomarker that proved specific to the IPF disease. Nevertheless, various IPF biomarkers have been used in preclinical and clinical trials to verify their predictive and monitoring potential.

Mortality trends in idiopathic pulmonary fibrosis in Europe between 2013 and 2018

BACKGROUND

Previous research has suggested that the incidence of idiopathic pulmonary fibrosis (IPF) is increasing in the UK and elsewhere. The aim of this study is to provide contemporary estimates of IPF mortality rates across 24 European Union (EU) countries from 2013 to 2018, using death certificate data from the European Statistics Institution (EUROSTAT) database.

METHODS

We extracted country data for IPF (International Classification of Diseases, 10th Revision: code J84.1) mortality from the EUROSTAT dataset. We calculated country-, age- and sex-specific death registration rates between 2013 and 2018. We used direct standardisation to compare rates between countries. We calculated annual trends in mortality rate ratios using a segmented regression model.

RESULTS

The overall standardised mortality rate in 24 EU countries during this period was 3.90 (95% CI 3.80-3.90) per 100 000 person-years, with the rate rising from 3.70 in 2013 to 4.00 in 2018 (average annual percent change 1.74%, 95% CI 0.91-2.59%). We observed substantial inter-country differences, with the highest rates detected in Ireland, the UK and Finland, the lowest rate in Bulgaria, and middle rates in Germany, Greece, Italy, the Netherlands, Portugal and Slovenia.

CONCLUSIONS

The IPF mortality rate is increasing across Europe. There are currently more than 17 000 deaths recorded from IPF each year in Europe but the marked geographical differences we observed suggest that this figure may underestimate the true rate considerably.

Interstitial Lung Disease and Progressive Pulmonary Fibrosis: a World Trade Center Cohort 20-Year Longitudinal Study

PURPOSE

World Trade Center (WTC) exposure is associated with obstructive airway diseases and sarcoidosis. There is limited research regarding the incidence and progression of non-sarcoidosis interstitial lung diseases (ILD) after WTC-exposure. ILD encompasses parenchymal diseases which may lead to progressive pulmonary fibrosis (PPF). We used the Fire Department of the City of New York's (FDNY's) WTC Health Program cohort to estimate ILD incidence and progression.

METHODS

This longitudinal study included 14,525 responders without ILD prior to 9/11/2001. ILD incidence and prevalence were estimated and standardized to the US 2014 population. Poisson regression modeled risk factors, including WTC-exposure and forced vital capacity (FVC), associated with ILD. Follow-up time ended at the earliest of incident diagnosis, end of study period/case ascertainment, transplant or death.

RESULTS

ILD developed in 80/14,525 FDNY WTC responders. Age, smoking, and gastroesophageal reflux disease (GERD) prior to diagnosis were associated with incident ILD, though FVC was not. PPF developed in 40/80 ILD cases. Among the 80 cases, the average follow-up time after ILD diagnosis was 8.5 years with the majority of deaths occurring among those with PPF (PPF: n = 13; ILD without PPF: n = 6).

CONCLUSIONS

The prevalence of post-9/11 ILD was more than two-fold greater than the general population. An exposure-response gradient could not be demonstrated. Half the ILD cases developed PPF, higher than previously reported. Age, smoking, and GERD were risk factors for ILD and PPF, while lung function was not. This may indicate that lung function measured after respirable exposures would not identify those at risk for ILD or PPF.

International trends in pulmonary hypertension mortality between 2001 and 2019: Retrospective analysis of the WHO mortality database

Background

There are limited published data on mortality trends in pulmonary hypertension (PH) worldwide. The objective of this study was to assess the PH-related mortality and time trends in the general population over the past 20 years.

Material and methods

We used country-level PH mortality data from the World Health Organization (WHO) mortality database (2000-19), using the International Classification of Diseases, tenth revision (ICD-10) codes (I27.0, I27.2, I27.8, or I27.9). The average annual percentage changes (AAPCs) were calculated to describe mortality trends.

Results

Fifty-four countries were included in this study. Between 2017 and 2019, the average age-standardized death rates (per 100,000) were 0.80 and 0.87 for males and females, respectively. Joinpoint analyses revealed a decreasing PH mortality trend for the overall population from 2000 to 2019 (AAPC -3.2 [95% confidence interval (CI) -4.1 to -2.4]), which was consistent between males and females (males: AAPC -5.3 [95% CI -6.2 to -4.4], females: AAPC -1.7 [95% CI -2.4 to -0.9]). When the estimates were stratified by etiology, we found that the mortality rates from idiopathic pulmonary arterial hypertension (I27.0) and pulmonary heart disease (unspecified, I27.9) had decreased significantly, while the mortality rates in other secondary PH (I27.2) and other specified pulmonary heart diseases (I27.8) had significantly increased. In addition, there were substantial differences in mortality rates and time trends across countries.

Conclusion

Although an overall decrease in PH mortality trends over the past two decades, there were substantial differences across countries. For countries with high or rising mortality rates, more efforts are needed to reduce the mortality.

LncRNA AP000487.1 regulates PRKCB DNA methylation-mediated TLR4/MyD88/NF-κB pathway in Nano NiO-induced collagen formation in BEAS-2B cells

Nickel oxide nanoparticles (Nano NiO) have been shown to cause pulmonary fibrosis; But, the underlying epigenetic mechanisms remain poorly understood. In this study, we aimed to investigate the role of lncRNA AP000487.1 in regulating PRKCB DNA methylation and the Toll-like receptor 4 (TLR4)/ Myeloid differentiation primary response 88 (MyD88)/ Nuclear factor kappa-B (NF-κB) pathway in Nano NiO-induced collagen formation. We found that lncRNA AP000487.1 was able to bind to the promoter region of the PRKCB gene by Chromosomal RNA pull-down experiments (Ch-RNA pull-down). Moreover, Nano NiO exposure led to down-regulation of lncRNA AP000487.1 expression and PRKCB DNA methylation, resulting in up-regulation of PRKCB expression, activation of the TLR4/MyD88/NF-κB pathway, and increased collagen formation in BEAS-2B cells. Conversely, overexpression of lncRNA AP000487.1 restored PRKCB expression, reduced its hypomethylation and attenuated TLR4/MyD88/NF-κB pathway activation and collagen formation. Furthermore, treatment with the DNA methylation inhibitor, decitabine, alleviated Nano NiO-induced PRKCB2 expression, TLR4/MyD88/NF-κB pathway activation, and collagen formation. Additionally, using PRKCB2 overexpression plasmid, PRKCB2 siRNA, and PRKCB2 protein inhibitor LY317615 influenced NF-κB pathway activity and collagen formation. Finally, TLR4 inhibitor (TAK-242) restrained Nano NiO-induced MyD88/NF-κB pathway activation and excessive collagen formation. In summary, we demonstrated that the down-regulated lncRNA AP000487.1 could cause PRKCB hypomethylation and increased expression, resulting in NF-κB pathway activation and collagen formation in Nano NiO-induced BEAS-2B cells. This is the first study to reveal the role of lncRNA AP000487.1 in regulating collagen formation in Nano NiO-exposed BEAS-2B cells. Our study identified that lncRNA AP000487.1/PRKCB hypomethylation/NF-κB pathway was a regulatory axis of BEAS-2B cells collagen excessive formation. Our findings indicate that lncRNA AP000487.1 and PRKCB DNA methylation may function as biomarkers or potential targets in response to Nano NiO exposure.

Disease stage-related survival in idiopathic pulmonary fibrosis patients treated with nintedanib and pirfenidone: An exploratory study

BACKGROUND

GAP (gender-age-physiology) and TORVAN are multi-parametric prognostication scores for idiopathic pulmonary fibrosis (IPF). We compared their prognostic value in patients treated with nintedanib or pirfenidone and explored their effect on patient survival in relation to disease staging.

STUDY DESIGN AND PATIENTS

Retrospective evaluation of 235 naïve IPF patients (M = 179; mean age 69.8 yrs±7.1; 102 treated with nintedanib and 133 with pirfenidone), referred to two Italian academic centers between February 2012 and December 2019.

RESULTS

During a median follow-up of 4.2 years, the incidence rate of death was 14.5 per 100 person-years (95% CI: 12 to 17.4), with no differences between nintedanib and pirfenidone (log-rank p = 0.771). According to time-ROC analysis, GAP and TORVAN showed a similar discrimination performance at 1, 2, and 5 years. Survival of GAP-2/GAP-3 IPF patients treated with nintedanib was worse than that of patients in GAP-1 (HR 4.8, 95% CI: 2.2 to 10.5 and HR 9.4, 95% CI: 3.8 to 23.2). TORVAN I patients treated with nintedanib exhibited better survival than those in stages III (HR 3.1, 95% CI: 1.4 to 6.6) and IV (HR 10.5, 95% CI: 3.5 to 31.6). A significant treatment x stage interaction was observed for both disease staging indexes (p = 0.042 for treatment by GAP interaction and p = 0.046 for treatment by TORVAN interaction). A better survival was associated with nintedanib in patients with mild disease (GAP-1 or TORVAN I stage) and with pirfenidone in GAP-3 or TORVAN IV cases, although these findings did not always reach statistical significance.

CONCLUSIONS

GAP and TORVAN similarly perform in IPF patients on anti-fibrotic therapy. However, the survival of patients treated with nintedanib and pirfenidone appears to be differently affected by disease staging.

Is there a role for specialized pro-resolving mediators in pulmonary fibrosis?

Pulmonary fibrotic diseases are characterized by proliferation of lung fibroblasts and myofibroblasts and excessive deposition of extracellular matrix proteins. Depending on the specific form of lung fibrosis, there can be progressive scarring of the lung, leading in some cases to respiratory failure and/or death. Recent and ongoing research has demonstrated that resolution of inflammation is an active process regulated by families of small bioactive lipid mediators termed "specialized pro-resolving mediators." While there are many reports of beneficial effects of SPMs in animal and cell culture models of acute and chronic inflammatory and immune diseases, there have been fewer reports investigating SPMs and fibrosis, especially pulmonary fibrosis. Here, we will review evidence that resolution pathways are impaired in interstitial lung disease, and that SPMs and other similar bioactive lipid mediators can inhibit fibroblast proliferation, myofibroblast differentiation, and accumulation of excess extracellular matrix in cell culture and animal models of pulmonary fibrosis, and we will consider future therapeutic implications of SPMs in fibrosis.

Bufei huoxue capsule alleviates bleomycin-induced pulmonary fibrosis in mice via TGF-β1/Smad2/3 signaling

ETHNOPHARMACOLOGICAL RELEVANCE

Bufei huoxue (BFHX) is a Traditional Chinese Medicine formulation that consists of Astragalus Exscapus L, Paeonia Lactiflora Pall, and Psoralea Aphylla L. It can ameliorate collagen deposition and inhibit EMT. However, it remains unknown whether and how BFHX alleviates IPF.

AIM OF THE STUDY

Our work aimed to explore the therapeutic efficacy of BFHX on IPF and dissect the mechanisms involved.

MATERIALS AND METHODS

A mouse model of IPF was induced by bleomycin. BFHX was administered on the first day of modeling and maintained for 21 days. Pulmonary fibrosis and inflammation were evaluated by micro-CT, lung histopathology, pulmonary function assessment, and cytokines in BALF. In addition, we examined the signaling molecules involved in EMT and ECM by immunofluorescence, western Blot, EdU, and MMP (Δψm) assays.

RESULTS

BFHX alleviated lung parenchyma fibrosis as evidenced by Hematoxylin-eosin (H&E), Masson's trichrome staining, and micro-CT, and it improved lung function. In addition, BFHX treatment not only decreased the levels of interleukin (IL)-6 and tumor necrosis factor-α (TNF-α), but also upregulated E-cadherin (E-Cad) and downregulated α-smooth muscle actin (α-SMA), collagen Ӏ (Col Ӏ), vimentin, and fibronectin (FN). Mechanistically, BFHX repressed TGF-β1-driven Smad2/3 phosphorylation, which, in turn, suppressed EMT and transition of fibroblasts to myofibroblasts in vivo and in vitro.

CONCLUSION

BFHX effectively reduces the occurrence of EMT and inhibits the production of ECM by inhibiting the TGF-β1/Smad2/3 signaling pathway, which provides a potential novel therapeutic strategy for IPF.

Nintedanib in Idiopathic Pulmonary Fibrosis: Tolerability and Safety in a Real Life Experience in a Single Centre in Patients also Treated with Oral Anticoagulant Therapy

Idiopathic pulmonary fibrosis (IPF) is a rare and severe disease with a median survival of ~3 years. Nintedanib (NTD) has been shown to be useful in controlling interstitial lung disease (ILD) in IPF. Here we describe the experience of NTD use in IPF in a real-life setting. Objective. Our objective was to examine the safety profile and efficacy of nintedanib even in subjects treated with anticoagulants. Clinical data of patients with IPF treated with NTD at our center were retrospectively evaluated at baseline and at 6 and 12 months after the introduction of NTD. The following parameters were recorded: IPF clinical features, NTD tolerability, and pulmonary function tests (PFT) (i.e., Forced Vital Capacity (FVC) and carbon monoxide diffusing capacity (DLCO)). In total, 56 IPF patients (34% female and 66% male, mean onset age: 71 ± 11 years, mean age at baseline: 74 ± 9 years) treated with NTD were identified. At enrollment, HRCT showed an UIP pattern in 45 (80%) and a NSIP in 11 (20%) patients. For FVC and FEV1 we found no significant change between baseline and 6 months, but for DLCO we observed a decrease (p = 0.012). We identified a significant variation between baseline and 12 months for FEV1 (p = 0.039) and for DLCO (p = 0.018). No significant variation was observed for FVC. In the cohort, 18 (32%) individuals suspended NTD and 10 (18%) reduced the dosage. Among individuals that suspended the dosage, 14 (78%) had gastrointestinal (GI) collateral effects (i.e., diarrhea being the most common complaint (67%), followed by nausea/vomiting (17%) and weight loss (6%). Bleeding episodes have also not been reported in patients taking anticoagulant therapy. (61%). One patient died within the first 6 months and two subjects died within the first 12 months. In a real-life clinical scenario, NTD may stabilize the FVC values in IPF patients. However, GI side effects are frequent and NTD dose adjustment may be necessary to retain the drug in IPF patients. This study confirms the safety of NTD, even in patients treated with anticoagulant drugs.

Wilms Tumor 1-Driven Fibroblast Activation and Subpleural Thickening in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease that is often fatal due to the formation of irreversible scar tissue in the distal areas of the lung. Although the pathological and radiological features of IPF lungs are well defined, the lack of insight into the fibrogenic role of fibroblasts that accumulate in distinct anatomical regions of the lungs is a critical knowledge gap. Fibrotic lesions have been shown to originate in the subpleural areas and extend into the lung parenchyma through processes of dysregulated fibroproliferation, migration, fibroblast-to-myofibroblast transformation, and extracellular matrix production. Identifying the molecular targets underlying subpleural thickening at the early and late stages of fibrosis could facilitate the development of new therapies to attenuate fibroblast activation and improve the survival of patients with IPF. Here, we discuss the key cellular and molecular events that contribute to (myo)fibroblast activation and subpleural thickening in IPF. In particular, we highlight the transcriptional programs involved in mesothelial to mesenchymal transformation and fibroblast dysfunction that can be targeted to alter the course of the progressive expansion of fibrotic lesions in the distal areas of IPF lungs.

Sexual Dimorphism in Interstitial Lung Disease

Interstitial lung diseases (ILD) are a group of heterogeneous progressive pulmonary disorders, characterised by tissue remodelling and/or fibrotic scarring of the lung parenchyma. ILD patients experience lung function decline with progressive symptoms, poor response to treatment, reduced quality of life and high mortality. ILD can be idiopathic or associated with systemic or connective tissue diseases (CTD) but idiopathic pulmonary fibrosis (IPF) is the most common form. While IPF has a male predominance, women are affected more greatly by CTD and therefore associated ILDs. The mechanisms behind biological sex differences in these progressive lung diseases remain unclear. However, differences in environmental exposures, variable expression of X-chromosome related inflammatory genes and sex hormones play a role. Here, we will outline sex-related differences in the incidence, progression and mechanisms of action of these diseases and discuss existing and novel cellular and pre-clinical studies. Furthermore, we will highlight how sex-differences are not adequately considered in pre-clinical disease models, how gender bias exists in clinical diagnosis and how women are underrepresented in clinical trials. Future action on these observations will hopefully shed light on the role of biological sex in disease development, identify potential targets for intervention and increase female participant numbers in clinical trials.

Targeting the LPA1 signalling pathway for fibrosis therapy: a patent review (2010-present)

INTRODUCTION

Fibrosis is a disease that damages organs and even causes death. Because of the complicated pathogenesis, the development of drugs for fibrosis is challenging. In the lysophosphatidic acid receptor type 1 (LPA1) signalling pathway, LPA1 and its downstream Rho-associated coiled-coil forming protein kinase (ROCK) are related to the process of fibrosis. Targeting LPA1 signalling pathway is a potential strategy for the treatment of fibrosis.

AREA COVERED

This review describes the process of fibrosis mediated by the LPA1 signalling pathway and then summarizes LPA1 antagonist patents reported since 2010 and ROCK inhibitor patents since 2017 according to their scaffolds based on the Cortellis Drug Discovery Intelligence database. Information on LPA1 antagonists entering clinical trials is integrated.

EXPERT OPINION

Over the past decade, a large number of antagonists targeting the LPA1 signalling pathway have been patented for fibrosis therapy. A limited number of compounds have entered clinical trials. Different companies and research groups have used different scaffolds when designing compounds for fibrosis therapy. Therefore, LPA1 and ROCK are competitive targets for the development of new therapies for fibrosis to provide a potential treatment method for fibrosis in the future.

Risk factors associated with mortality in hypersensitivity pneumonitis: a meta-analysis

BACKGROUND

Hypersensitivity pneumonitis (HP) related deaths have increased substantially in recent years. It is important to identify the risk factors of HP significantly associated with mortality to ensure close patient monitoring and assess disease progression.

RESEARCH DESIGN AND METHODS

Extensive literature search was conducted in accordance with the PRISMA checklist. Literature search of PUBMED, EMBASE and Cochrane Library database between January 2009 and April 2021 using the terms "hypersensitivity pneumonitis", "hazard ratio", and "mortality" identified 325 articles. A total of 22 independent original studies focusing on mortality of HP patients were assessed.

RESULTS

This systematic review and meta-analysis suggests that increased age, male sex, honeycombing and traction bronchiectasis patterns on high-resolution computed tomography (HRCT) images are the major mortality-related risk factors of patients with HP. In case of chronic HP, antigen exposure appeared to be an additional risk factor.

CONCLUSIONS

The clinico-radiological risk factors of mortality identified for HP will enable effective and close monitoring of patients, prognostication and guide towards appropriate management decisions. However, association between the type of antigen and mortality remains to be explored.

Interstitial lung disease incidence and mortality in the United Kingdom and the European Union: an observational study, 2001–2017

Objective

To compare the trends in age-standardised incidence and mortality from interstitial lung diseases (ILD) in the UK and the European Union (EU).

Methods

This was an observational study using data obtained from the Global Burden of Disease Study on residents of the UK and of the 27 EU countries. The main outcome measures were ILD age-standardised incidence rates per 100 000 (ASIR), age-standardised death rates per 100 000 (ASDR) and mortality-to-incidence ratios (MIRs), which are presented for men and women separately for each country for the years 2001–2017. Trends were analysed using joinpoint regression analysis.

Results

In 2017, the median incidence of ILD was 7.22 (IQR 5.57–8.96) per 100 000 population for men and 4.34 (IQR 3.36–6.29) per 100 000 population for women. In 2017, the median ASDR attributed to ILD was 2.04 (IQR 1.13–2.71) per 100 000 population for men and 1.02 (0.68–1.37) per 100 000 population for women. There was an overall increase in ASDR during the observation period, with a median increase of +20.42% (IQR 5.44–31.40) for men and +15.44% (IQR −1.01–31.52) for women. Despite increases in mortality over the entire observation period, there were decreasing mortality trends in the majority of countries at the end of the observation period (75% for men and 86% for women).

Conclusion

Over the past two decades, there have been increases in the incidence and mortality of ILD in Europe. The most recent trends, however, demonstrate decreases in mortality from ILD in the majority of European countries for both men and women. These data support the ongoing improvements in the diagnosis and management of ILD.

Recent improvements in the diagnosis and management of interstitial lung disease, as well as the introduction of therapeutic agents, have resulted in significant decreases in mortality in the majority of European countrieshttps://bit.ly/3JHkEyO

The effect of nanoparticles on pulmonary fibrosis: a systematic review and Meta-analysis of preclinical studies

Air pollution is a big ecumenical problem associated with public health around the world. The rapid development of nanotechnology worldwide resulted in a significant increase in human exposure with unknown particles, and ultimately leading to an increase in acute and chronic diseases. The effect of nanoparticles on pulmonary fibrosis has been reported in vivo and in vitro studies; however, the results are inconsistent. The present systematic review and meta-analysis of animal preclinical studies was conducted to assess the effect of nanoparticles on pulmonary fibrosis. A systematic search of online databases and gray literature as well as reference lists of retrieved studies was performed up to February 2019 to identify preclinical animal studies. Studies were assessed for methodological quality using the SYstematic Review Center for Laboratory animal Experimentation bias risk tool (SYRCLE's ROB tool). Pooled standardized mean difference (SMD) estimate with corresponding 95% CI was calculated using inverse-variance weights method while random effects meta-analysis was used, taking into account conceptual heterogeneity. To assess the robustness of pooled estimates as well as heterogeneity across studies, sensitivity analysis and Cochran Q statistic (with I² statistic) was carried out using Stata 11.0. Of 6494 retrieved studies, 85 were reviewed in depth for eligibility. 16 studies met the criteria for inclusion in this systematic review. The meta-analysis was conducted on 10 studies which had reported the mean of TGF-β in 7 days after exposure by nanoparticles jointly (exposure compared to no exposure). Findings showed that exposure to nanoparticles significantly induced pulmonary fibrosis (SMD: 4.12, 95% CI: 2.57-5.67). A statistical heterogeneity was found [P < 0.001 (Q statistics), I² = 83.0%] across studies. Nanoparticles were the most influencing in inducing pulmonary fibrosis in animal models. Sensitivity analysis demonstrated consistency of the results, indicating that the meta-analysis model was robust. Publication bias (using visual inspection and statistical tests) was unlikely in the association between nanoparticles and pulmonary fibrosis. We found that the nanoparticles significantly induce pulmonary fibrosis through increasing proinflammatory cytokine TGF-β and histopathological changes.

Mortality and survival in idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Background

There are substantial advances in diagnosis and treatment for idiopathic pulmonary fibrosis (IPF), but without much evidence available on recent mortality and survival trends.

Methods

A narrative synthesis approach was used to investigate the mortality trends, then meta-analyses for survival trends were carried out based on various time periods.

Results

Six studies reported the mortality data for IPF in 22 countries, and 62 studies (covering 63 307 patients from 20 countries) reported survival data for IPF. Age-standardised mortality for IPF varied from ∼0.5 to ∼12 per 100 000 population per year after year 2000. There were increased mortality trends for IPF in Australia, Brazil, Belgium, Canada, Czech Republic, Finland, France, Germany, Hungary, Italy, Lithuania, the Netherlands, Poland, Portugal, Spain, Sweden and UK, while Austria, Croatia, Denmark, Romania and the USA showed decreased mortality trends. The overall 3-year and 5-year cumulative survival rates (CSRs) were 61.8% (95% CI 58.7-64.9; I2=97.1%) and 45.6% (95% CI 41.5-49.7; I2=97.7%), respectively. Prior to 2010, the pooled 3-year CSR was 59.9% (95% CI 55.8-64.1; I2=95.8%), then not significantly (p=0.067) increased to 66.2% (95% CI 62.9-69.5; I2=92.6%) in the 2010s decade. After excluding three studies in which no patients received antifibrotics after year 2010, the pooled 3-year CSRs significantly (p=0.039) increased to 67.4% (95% CI 63.9-70.9; I2=93.1%) in the 2010s decade.

Discussion

IPF is a diagnosis associated with high mortality. There was no observed increasing survival trend for patients with IPF before year 2010, with then a switch to an improvement, which is probably multifactorial.

Trends of HIV-Related Cancer Mortality between 2001 and 2018: An Observational Analysis

The burden of AIDS-defining cancers has remained relatively steady for the past two decades, whilst the burden of non-AIDS-defining cancer has increased. Here, we conduct a study to describe mortality trends attributed to HIV-associated cancers in 31 countries. We extracted HIV-related cancer mortality data from 2001 to 2018 from the World Health Organization Mortality Database. We computed age-standardized death rates (ASDRs) per 100,000 population using the World Standard Population. Data were visualized using Locally Weighted Scatterplot Smoothing (LOWESS). Data for females were available for 25 countries. Overall, there has been a decrease in mortality attributed to HIV-associated cancers among most of the countries. In total, 18 out of 31 countries (58.0%) and 14 out of 25 countries (56.0%) showed decreases in male and female mortality, respectively. An increasing mortality trend was observed in many developing countries, such as Malaysia and Thailand, and some developed countries, such as the United Kingdom. Malaysia had the greatest increase in male mortality (+495.0%), and Canada had the greatest decrease (−88.5%). Thailand had the greatest increase in female mortality (+540.0%), and Germany had the greatest decrease (−86.0%). At the endpoint year, South Africa had the highest ASDRs for both males (16.8/100,000) and females (19.2/100,000). The lowest was in Japan for males (0.07/100,000) and Egypt for females (0.028/100,000).

Wet-dry-wet drug screen leads to the synthesis of TS1, a novel compound reversing lung fibrosis through inhibition of myofibroblast differentiation

Therapies halting the progression of fibrosis are ineffective and limited. Activated myofibroblasts are emerging as important targets in the progression of fibrotic diseases. Previously, we performed a high-throughput screen on lung fibroblasts and subsequently demonstrated that the inhibition of myofibroblast activation is able to prevent lung fibrosis in bleomycin-treated mice. High-throughput screens are an ideal method of repurposing drugs, yet they contain an intrinsic limitation, which is the size of the library itself. Here, we exploited the data from our "wet" screen and used "dry" machine learning analysis to virtually screen millions of compounds, identifying novel anti-fibrotic hits which target myofibroblast differentiation, many of which were structurally related to dopamine. We synthesized and validated several compounds ex vivo ("wet") and confirmed that both dopamine and its derivative TS1 are powerful inhibitors of myofibroblast activation. We further used RNAi-mediated knock-down and demonstrated that both molecules act through the dopamine receptor 3 and exert their anti-fibrotic effect by inhibiting the canonical transforming growth factor β pathway. Furthermore, molecular modelling confirmed the capability of TS1 to bind both human and mouse dopamine receptor 3. The anti-fibrotic effect on human cells was confirmed using primary fibroblasts from idiopathic pulmonary fibrosis patients. Finally, TS1 prevented and reversed disease progression in a murine model of lung fibrosis. Both our interdisciplinary approach and our novel compound TS1 are promising tools for understanding and combating lung fibrosis.

Idiopathic Pulmonary Comorbidities and Mechanisms

Idiopathic pulmonary fibrosis (IPF) is a disease with an unknown etiology mainly characterized by a progressive decline of lung function due to the scarring of the tissue deep in the lungs. The overall survival after diagnosis remains low between 3 and 5 years. IPF is a heterogeneous disease and much progress has been made in the past decade in understanding the disease mechanisms that contributed to the development of two new drugs, pirfenidone and nintedanib, which improved the therapeutic management of the disease. The understanding of the cofactors and comorbidities of IPF also contributed to improved management of the disease outcome. In the present review, we evaluate scientific evidence which indicates IPF as a risk factor for other diseases based on the complexity of molecular and cellular mechanisms involved in the disease development and of comorbidities. We conclude from the existing literature that while much progress has been made in understating the mechanisms involved in IPF development, further studies are still necessary to fully understand IPF pathogenesis which will contribute to the identification of novel therapeutic targets for IPF management as well as other diseases for which IPF is a major risk factor.

Lung cancer mortality in Europe and the USA between 2000 and 2017: an observational analysis

BACKGROUND

The lung is the most common site for cancer and has the highest worldwide cancer-related mortality. Our study reports and compares trends in lung cancer mortality in the USA and 26 European countries.

STUDY DESIGN AND METHODS

Lung cancer mortality data were extracted for males and females for each of the years 2000-2017 from the World Health Organization (WHO) Mortality and the Centers for Disease Control and Prevention (CDC) WONDER databases. Lung cancer mortality trends were compared using Joinpoint regression analysis, and male-to-female mortality ratios were calculated.

RESULTS

Down-trending lung cancer mortality rates were observed in males in all countries except Cyprus and Portugal between 2000 and 2017. In females, increasing mortality rates were observed in 22 of the 27 countries analysed. Latvia had the highest estimated annual percentage change (EAPC) in male mortality (-9.6%) between 2013 and 2015. In the USA, EAPCs were -5.1% for males and -4.2% for females between 2014 and 2017. All countries had an overall decrease in the ratio of male-to-female lung cancer mortality. The most recent observation of median male-to-female mortality was 2.26 (IQR 1.92-4.05). The countries with the greatest current sex disparity in lung cancer mortality were Lithuania (5.51) and Latvia (5.00).

CONCLUSION

Between 2000 and 2017, lung cancer mortality rates were decreasing for males in Europe and the USA, whereas increasing lung cancer mortality rates were generally observed in females. There is a persistent but decreasing sex-mortality gap, with men having persistently greater lung cancer mortality but with rates decreasing faster than women.

Trends of HIV Mortality between 2001 and 2018: An Observational Analysis

Since the beginning of the epidemic in the early 1980s, HIV-related illnesses have led to the deaths of over 32.7 million individuals. The objective of this study was to describe current mortality rates for HIV through an observational analysis of HIV mortality data from 2001 to 2018 from the World Health Organization (WHO) Mortality Database. We computed age-standardized death rates (ASDRs) per 100,000 people using the World Standard Population. We plotted trends using locally weighted scatterplot smoothing (LOWESS). Data for females were available for 42 countries. In total, 31/48 (64.60%) and 25/42 (59.52%) countries showed decreases in mortality in males and females, respectively. South Africa had the highest ASDRs for both males (467.7/100,000) and females (391.1/100,000). The lowest mortalities were noted in Egypt for males (0.2/100,000) and in Japan for females (0.01/100,000). Kyrgyzstan had the greatest increase in mortality for males (+6998.6%). Estonia had the greatest increase in mortality for females (+5877.56%). The disparity between Egypt (the lowest) and South Africa (the highest) was 3042-fold for males. Between Japan and South Africa, the disparity was 43,454-fold for females. Although there was a decrease in mortality attributed to HIV among most of the countries studied, a rising trend remained in a number of developing countries.

Mortality differences in pulmonary fibrosis among the most populated states in the United States

BACKGROUND

Recent studies suggest that the mortality rate of pulmonary fibrosis (PF) in the U.S. is decreasing. However, the mortality trends and demographic differences of PF among the states have not been evaluated.

OBJECTIVE

To evaluate PF-related mortality rates and trends in the nine most populated states in the U.S.

METHODS

Population-based study using the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website. PF-related deaths were identified using ICD codes.

RESULTS

From 2004 to 2018, average annual mortality rates ranged from being the lowest in New York (110.8 per 1,000,000) to the highest in North Carolina (195.3 per 1,000,000). The mortality rates showed a decline in the majority of the states and were stable in the other states. The most significant declines were in California and Michigan. The average mortality rates in males were higher than females in all the states (rate ratio ranged from 1.56 in Texas to 1.81 in New York) and the decline in the mortality rates was more pronounced compared to males in most states. The mortality rates in Blacks were lower compared to Whites in all the states (rate ratio ranged from 0.47 in New York to 0.69 in Ohio) and the decline in the mortality rates over the period was more significant than in Whites.

CONCLUSIONS

There is substantial variation in mortality rates and mortality trends between states and different demographics. Further studies are needed to evaluate the environmental factors, diagnostic accuracy, and coding practices contributing to these differences.

Sex Differences in the Incidence and Outcomes of Patients Hospitalized by Idiopathic Pulmonary Fibrosis (IPF) in Spain from 2016 to 2019

(1) Background: To assess sex differences in the incidence, characteristics, procedures and outcomes of patients admitted with idiopathic pulmonary fibrosis (IPF); and to analyze variables associated with in-hospital mortality (IHM). (2) Methods: We analyzed data collected by the Spanish National Hospital Discharge Database, 2016-2019. (3) Results: We identified 13,278 hospital discharges (66.4% men) of IPF (primary diagnosis 32.33%; secondary diagnosis: 67.67%). Regardless of the diagnosis position, IPF incidence was higher among men than women, increasing with age. Men had 2.74 times higher IPF incidence than women. Comorbidity was higher for men in either primary or secondary diagnosis. After matching, men had higher prevalence of pulmonary embolism and pneumonia, and women of congestive heart failure, dementia, rheumatoid disease and pulmonary hypertension. Invasive ventilation, bronchoscopy and lung transplantation were received more often by men than women. IHM was higher among men with IPF as primary diagnosis than among women and increased with age in both sexes and among those who suffered cancer, pneumonia or required mechanical ventilation. (4) Conclusions: Incidence of IPF was higher among men than women, as well as comorbidity and use of bronchoscopy, ventilation and lung transplantation. IHM was worse among men than women with IPF as primary diagnosis, increasing with age, cancer, pneumonia or mechanical ventilation use.

All-cause mortality of patients with idiopathic pulmonary fibrosis: a nationwide population-based cohort study in Korea

Most epidemiologic studies of patients with idiopathic pulmonary fibrosis (IPF) have been conducted in North America and Europe. Moreover, there are limited data concerning the cause of death and cause-specific mortality rate of IPF patients in population-based studies. We analyzed information from the Korean National Health Insurance Service database from 2006 to 2016. Patients with a diagnosis code of IPF were extracted from the database and we included those who satisfied the narrow definition of IPF diagnosis. Age- and sex-matched controls were randomly selected at a case-to-control rate of 1:3. We included 42,777 patients newly diagnosed with IPF during the study period. Their mean age was 64.6 years, and 65.4% were male. The age-standardized mortality rates were 85.66 (95% confidence interval [CI] 84.45–86.89) per 1000 person-years. The survival rates of IPF patients 1, 2, 3, 5, and 10 years after IPF diagnosis were 84.5%, 77.4%, 71.9%, 62.9%, and 48.4%, respectively. The standardized mortality ratio of IPF patients compared to that of the normal population was 4.66. The leading cause of death in IPF patients was respiratory causes, followed by cancer. Patients with IPF in Korea showed significantly higher mortality compared to the general population.

Mortality Associated with Idiopathic Pulmonary Fibrosis in Northeastern Italy, 2008-2020: A Multiple Cause of Death Analysis

Mortality from idiopathic pulmonary fibrosis (IPF) is increasing in most European countries, but there are no data for Italy. We analysed the registry data from a region in northeastern Italy to assess the trends in IPF-related mortality during 2008–2019, to compare results of underlying vs. multiple cause of death analyses, and to describe the impact of the COVID-19 epidemic in 2020. We identified IPF (ICD-10 code J84.1) among the causes of death registered in 557,932 certificates in the Veneto region. We assessed time trends in annual age-standardized mortality rates by gender and age (40–74, 75–84, and ≥85 years). IPF was the underlying cause of 1310 deaths in the 2251 certificates mentioning IPF. For all age groups combined, the age-standardized mortality rate from IPF identified as the underlying cause of death was close to the European median (males and females: 3.1 and 1.3 per 100,000/year, respectively). During 2008–2019, mortality rates increased in men aged ≥85 years (annual percent change of 6.5%, 95% CI: 2.0, 11.2%), but not among women or for the younger age groups. A 72% excess of IPF-related deaths was registered in March–April 2020 (mortality ratio 1.72, 95% CI: 1.29, 2.24). IPF mortality was increasing among older men in northeastern Italy. The burden of IPF was heavier than assessed by routine statistics, since less than two out of three IPF-related deaths were directly attributed to this condition. COVID-19 was accompanied by a remarkable increase in IPF-related mortality.

Liquid Biopsy Is a Promising Tool for Genetic Testing in Idiopathic Pulmonary Fibrosis

Liquid biopsy, which allows the isolation of circulating cell-free (ccf) DNA from blood, is an emerging noninvasive tool widely used in oncology for diagnostic and prognosis purposes. Previous data have shown that serum cfDNA discriminates idiopathic pulmonary fibrosis (IPF) from other interstitial lung diseases. Our study aimed to measure plasma levels of ccfDNA in 59 consecutive therapy-naive and clinically stable IPF patients. The single nucleotide polymorphism (SNP) of the MUC5B gene promoter (rs35705950), associated with increased susceptibility of developing IPF, has been sought in plasma cfDNA and genomic DNA for comparison. Thirty-five age- and sex-matched healthy volunteers were recruited as the control group. Our results show that concentrations of small-size ccfDNA fragments were significantly higher in IPF patients than in controls and inversely correlated with lung function deterioration. Moreover, the median level of 104 ng/mL allowed discriminating patients with mild disease from those more advanced. The rs35705950 polymorphism was found in 11.8% of IPF patients and 8% of controls, with no differences. Complete concordance between ccfDNA and genomic DNA was detected in all control samples, while four out of seven IPF cases (57%) carrying the rs35705950 polymorphism were discordant from genomic DNA (7% of total IPF). Liquid biopsy is a suitable tool with optimistic expectations of application in the field of IPF. In analogy with cancer biology, finding some discrepancies between ccfDNA and genomic DNA in IPF patients suggests that the former may convey specific genetic information present in the primary site of the disease.

Paired analysis of tumor mutation burden for lung adenocarcinoma and associated idiopathic pulmonary fibrosis

Genetic alterations underlying the development of lung cancer in individuals with idiopathic pulmonary fibrosis (IPF) have remained unclear. To explore whether genetic alterations in IPF tissue contribute to the development of IPF-associated lung cancer, we here evaluated tumor mutation burden (TMB) and somatic variants in 14 paired IPF and tumor samples from patients with IPF-associated lung adenocarcinoma. We also determined TMB for 22 samples of lung adenocarcinoma from patients without IPF. TMB for IPF-associated lung adenocarcinoma was significantly higher than that for matched IPF tissue (median of 2.94 vs. 1.26 mutations/Mb, P = 0.002). Three and 102 somatic variants were detected in IPF and matched lung adenocarcinoma samples, respectively, with only one pair of specimens sharing one somatic variant. TMB for IPF-associated lung adenocarcinoma was similar to that for lung adenocarcinoma samples with driver mutations (median of 2.94 vs. 2.51 mutations/Mb) and lower than that for lung adenocarcinoma samples without known driver mutations (median of 2.94 vs. 5.03 mutations/Mb, P = 0.130) from patients without IPF. Our findings suggest that not only the accumulation of somatic mutations but other factors such as inflammation and oxidative stress might contribute to the development and progression of lung cancer in patients with IPF.

Azithromycin for the Treatment of Chronic Cough in Idiopathic Pulmonary Fibrosis: A Randomized Controlled Cross-over Trial

RATIONALE

Patients with idiopathic pulmonary fibrosis (IPF) frequently suffer from difficult to treat chronic cough, which substantially affects their quality of life. Azithromycin has been demonstrated to relieve chronic cough in some populations, however this has not been investigated in IPF.

OBJECTIVES

To determine the safety and efficacy of azithromycin for the treatment of chronic cough in patients with IPF.

METHODS

In a double-blind randomized controlled cross-over trial, patients with IPF underwent two 12-week intervention periods (azithromycin 500mg or placebo 3 times per week). The primary outcome was change in cough-related quality of life measured by the Leicester cough questionnaire (LCQ). Secondary outcomes included cough severity measured using Visual Analog Scale (VAS), health-related quality of life assessed by the St. George's Respiratory Questionnaire (SGRQ), and objective cough frequency using audiovisual readings from 24h respiratory polygraphy.

RESULTS

25 patients were randomized (23 men, 2 women), 20 patients completed the study. Mean (standard deviation, SD) age was 67 (8) years, mean (SD) forced vital capacity (FVC) was 65 (16) %-predicted, and diffusion capacity (DLCO) 43 (16) %-predicted. Mean (SD) baseline LCQ was 11.7 (3.7) and 11.3 (3.3) for the azithromycin and the placebo period, respectively, and the corresponding mean (SD) cough VAS 5.6 (2.3) and 5.8 (2.1). There was no significant change in LCQ and VAS with azithromycin or placebo. Similarly, there was no significant difference in change in polygraphy measured cough frequency between the azithromycin and placebo periods. Gastrointestinal adverse effects were more frequent with azithromycin than with placebo (diarrhea 43% vs 5%, p=0.03).

CONCLUSIONS

This randomized controlled trial does not support the use of low dose azithromycin for chronic cough in patients with IPF. Clinical trial registered with ClinicalTrials.gov (NCT02173145).

Fully Automated Segmentation of Pulmonary Fibrosis Using Different Software Tools

OBJECTIVE

Evaluation of software tools for segmentation, quantification, and characterization of fibrotic pulmonary parenchyma changes will strengthen the role of CT as biomarkers of disease extent, evolution, and response to therapy in idiopathic pulmonary fibrosis (IPF) patients.

METHODS

418 nonenhanced thin-section MDCTs of 127 IPF patients and 78 MDCTs of 78 healthy individuals were analyzed through 3 fully automated, completely different software tools: YACTA, LUFIT, and IMBIO. The agreement between YACTA and LUFIT on segmented lung volume and 80th (reflecting fibrosis) and 40th (reflecting ground-glass opacity) percentile of the lung density histogram was analyzed using Bland-Altman plots. The fibrosis and ground-glass opacity segmented by IMBIO (lung texture analysis software tool) were included in specific regression analyses.

RESULTS

In the IPF-group, LUFIT outperformed YACTA by segmenting more lung volume (mean difference 242 mL, 95% limits of agreement -54 to 539 mL), as well as quantifying higher 80th (76 HU, -6 to 158 HU) and 40th percentiles (9 HU, -73 to 90 HU). No relevant differences were revealed in the control group. The 80th/40th percentile as quantified by LUFIT correlated positively with the percentage of fibrosis/ground-glass opacity calculated by IMBIO (r = 0.78/r = 0.92).

CONCLUSIONS

In terms of segmentation of pulmonary fibrosis, LUFIT as a shape model-based segmentation software tool is superior to the threshold-based YACTA, tool, since the density of (severe) fibrosis is similar to that of the surrounding soft tissues. Therefore, shape modeling as used in LUFIT may serve as a valid tool in the quantification of IPF, since this mainly affects the subpleural space.

Characterization of stress degradation products of nintedanib by UPLC, UHPLC-Q-TOF/MS/MS and NMR: Evidence of a degradation product with a structure alert for mutagenicity

Nintedanib is an anti-cancer drug used for the treatment of idiopathic pulmonary fibrosis and non-small cell lung cancer. The purpose of this study was to explore its degradation chemistry under various stress conditions recommended in ICH guidelines Q1A R(2). The drug was subjected to hydrolytic, photolytic, thermal and oxidative (H₂O₂, AIBN, FeCl₃ and FeSO₄) stress conditions. The degradation products formed in stressed solutions were successfully separated on an ACQUITY UPLC CSH C18 (2.1 × 100 mm, 1.7 μm) column, using a gradient UPLC-PDA method, developed with acetonitrile:methanol (90:10) and 0.1 % formic acid (pH 3.0) as the mobile phase. The drug proved to be labile to acidic, neutral and alkaline hydrolytic, and H₂O₂/AIBN oxidative conditions. It was stable to photolytic and thermal stress conditions, and even in oxidative reaction solutions containing FeCl₃ or FeSO₄. Additionally, the drug exhibited instability when its powder with added sodium bicarbonate was stored at 40 °C/75 % RH for 3 months. In total, nine degradation products (DPs 1-9) were formed. To characterize them, a comprehensive mass fragmentation pathway of the drug was first established using UHPLC-Q-TOF/MS/MS data. Similarly, the mass studies were then carried out on the stressed samples using the developed UPLC method. All the degradation products were primarily characterized through comparison of their mass fragmentation profiles with that of the drug. To confirm the structure in one case (DP 3), additional nuclear magnetic resonance (NMR) studies were carried out on the isolated product. Subsequently, mechanisms for their formation were laid down. A significant finding was the formation of a degradation product upon acid hydrolysis having a free aromatic amine moiety, which is considered as a structural alert for mutagenicity. Furthermore, the physicochemical and ADMET properties of the drug and its degradation products were predicted using ADMET predictor™ software.

Interstitial lung disease in a veterans affairs regional network; a retrospective cohort study

Background

The epidemiology of Interstitial Lung Diseases (ILD) in the Veterans Health Administration (VHA) is presently unknown.

Research question

Describe the incidence/prevalence, clinical characteristics, and outcomes of ILD patients within the Veteran’s Administration Mid-Atlantic Health Care Network (VISN6).

Study design and methods

A multi-center retrospective cohort study was performed of veterans receiving hospital or outpatient ILD care from January 1, 2008 to December 31^st, 2015 in six VISN6 facilities. Patients were identified by at least one visit encounter with a 515, 516, or other ILD ICD-9 code. Demographic and clinical characteristics were summarized using median, 25th and 75th percentile for continuous variables and count/percentage for categorical variables. Characteristics and incidence/prevalence rates were summarized, and stratified by ILD ICD-9 code. Kaplan Meier curves were generated to define overall survival.

Results

3293 subjects met the inclusion criteria. 879 subjects (26%) had no evidence of ILD following manual medical record review. Overall estimated prevalence in verified ILD subjects was 256 per 100,000 people with a mean incidence across the years of 70 per 100,000 person-years (0.07%). The prevalence and mean incidence when focusing on people with an ILD diagnostic code who had a HRCT scan or a bronchoscopic or surgical lung biopsy was 237 per 100,000 people (0.237%) and 63 per 100,000 person-years respectively (0.063%). The median survival was 76.9 months for 515 codes, 103.4 months for 516 codes, and 83.6 months for 516.31.

Interpretation

This retrospective cohort study defines high ILD incidence/prevalence within the VA. Therefore, ILD is an important VA health concern.

Nutritional status and quality of life in interstitial lung disease: a prospective cohort study

Background

Malnutrition and altered body composition are well-documented in chronic pulmonary diseases; however, investigation of nutritional status in interstitial lung disease (ILD) is limited. This study aimed to describe the nutritional status of ILD patients within three diagnostic groups and explore the relationship between nutritional status and quality of life (QoL).

Methods

Consecutive patients attending an ILD clinic within a tertiary referral hospital in Sydney, Australia were studied. Weight, body-mass-index, anthropometrics, handgrip strength (HGS), subjective global assessment and QoL questionnaires (EQ-5D-5L and King’s-Brief Interstitial-Lung-Disease ‘K-BILD’) were collected. Associations between nutritional status and QoL were analysed.

Results

Ninety participants were recruited and categorised: (1) Idiopathic Pulmonary Fibrosis (IPF) (2) Connective-Tissue Disease associated-ILD (CTD-ILD) or (3) Other (non-IPF/non-CTD ILD). Median age was 66.5 (18) years. Four-percent of patients were underweight and 50% were overweight or obese. Median HGS was 71%-(25.3) of predicted and was correlated to all measures of QoL including EQ-5D health-state index (r = 0.376, p < 0.0001), patient-reported EQ-5D-5L Visual Analogue Score (r = 0.367, p < 0.0001) and K-BILD total score (r = 0.346, p = 0.001). Twenty-three percent of the variance in K-BILD total score (F = 12.888, p < 0.0001) was explained by HGS (ß = 0.273, p = 0.006) and forced vital capacity % predicted (ß = 0.331, p = 0.001).

Conclusions

Although a small number of ILD patients were malnourished, a large proportion of the cohort were overweight or obese. Handgrip strength was compromised and correlated to QoL. Future research with a larger cohort is required to explore the role of HGS as a predictor of QoL.

Idiopathic pulmonary fibrosis and gastroesophageal reflux disease: A population-based, case-control study

BACKGROUND

It is unknown whether gastroesophageal reflux disease (GERD) is a risk factor or consequence of idiopathic pulmonary fibrosis (IPF). This study aimed to determine whether patients with IPF were more likely to have GERD compared with age- and sex-matched controls who either had 1) interstitial lung disease (ILD) other than IPF or 2) no diagnosed lung disease (population control).

METHODS

We used the medical records-linkage system of the Rochester Epidemiology Project (REP) to identify patients with IPF who resided in Olmsted County, Minnesota, from January 1, 1997, through June 30, 2017. IPF cases were each matched with patients from 2 control groups (non-IPF ILD controls and population controls). We used conditional logistic regression to model associations between GERD diagnosis and IPF case status. P values were adjusted for multiple comparisons by using the Bonferroni adjustment (P values < .025 were considered statistically significant).

RESULTS

One hundred thirteen IPF cases were identified and matched to 226 population controls and 226 controls with non-IPF ILD. After multivariable adjustment, the odds of having GERD were 1.78 times higher (95% CI, 1.09-2.91; P = .02) in IPF cases compared with population controls. After multivariable adjustment, the odds of having GERD were 0.46 times lower (95% CI, 0.23-0.94; P = .03) in IPF cases compared with non-IPF ILD controls.

CONCLUSION

GERD may be an important contributor to the development of lung fibrosis. Thus, it should be investigated and addressed adequately when detected in patients with IPF and patients with non-IPF ILD.

Three-Dimensional Multiscale Fuzzy Entropy: Validation and Application to Idiopathic Pulmonary Fibrosis

Idiopathic Pulmonary Fibrosis (IPF) is a chronic, severe, and progressive lung disease with short life expectancy. Based on information theory and entropy measurement, a three-dimensional multiscale fuzzy entropy (MFE _3D) algorithm is proposed to identify IPF patients from their computed tomography (CT) volumetric data. First, the validation of the algorithm was performed by analyzing several volumetric synthetic noises (white, blue, brown, and pink), MIX(p) processes-based volumes, and texture-based volumes. The entropy values obtained by MFE _3D were consistent with the values obtained using the one, and two-dimensional versions, validating its use in biomedical data. Hence, MFE _3D was applied to CT scans to identify the existence of IPF within two different groups, one of healthy subjects (26) and another of IPF patients (26). Statistical differences were found (p < 0.05) between the entropy values of each group in 5 scale factors out of 10. These results demonstrate that MFE _3D could be an interesting metric to identify IPF in CT scans.

Machine Learning Analysis of the Bleomycin Mouse Model Reveals the Compartmental and Temporal Inflammatory Pulmonary Fingerprint

The bleomycin mouse model is the extensively used model to study pulmonary fibrosis; however, the inflammatory cell kinetics and their compartmentalization is still incompletely understood. Here we assembled historical flow cytometry data, totaling 303 samples and 16 inflammatory-cell populations, and applied advanced data modeling and machine learning methods to conclusively detail these kinetics. Three days post-bleomycin, the inflammatory profile was typified by acute innate inflammation, pronounced neutrophilia, especially of SiglecF+ neutrophils, and alveolar macrophage loss. Between 14 and 21 days, rapid responders were increasingly replaced by T and B cells and monocyte-derived alveolar macrophages. Multicolour imaging revealed the spatial-temporal cell distribution and the close association of T cells with deposited collagen. Unbiased immunophenotyping and data modeling exposed the dynamic shifts in immune-cell composition over the course of bleomycin-triggered lung injury. These results and workflow provide a reference point for future investigations and can easily be applied in the analysis of other datasets.

Functional parameters of small airways can guide bronchodilator use in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) may present comorbid obstructive lung diseases with small airway dysfunction (SAD). Existing guidelines suggest that inhaled bronchodilators should be used if the ratio of forced expiratory volume in the 1st second and forced vital capacity (FEV₁/FVC) < 0.7 in IPF. However, most IPF patients have FEV₁/FVC > 0.7 even with coexisting emphysema. We retrospectively enrolled IPF patients who were registered at our outpatient clinic. At baseline, 63 patients completed computed tomography (CT) scans, lung function measurements, and symptom questionnaires. Among these patients, 54 (85.71%) underwent antifibrotic treatment and 38 (60.32%) underwent long-acting bronchodilator treatment. The median FEV₁/FVC was 0.86. Not all patients treated with bronchodilators showed significant changes in lung function. IPF patients with SAD, determined by IOS parameters, showed significant improvement in FEV₁, FEF_25–75%, and symptom scores after bronchodilator treatment. Bronchodilator efficacy was not observed in patients without SAD. CT-confirmed emphysema was seen in 34.92% of patients. There were no changes in lung function or symptom scores after bronchodilator treatment in patients with emphysema. In conclusion, FEV₁/FVC cannot reflect the airflow limitation in IPF. Emphysema in IPF is not a deciding factor in whether patients should receive bronchodilator treatment. IOS parameters may be useful to guide bronchodilator therapy in patients with IPF coexisting with SAD.

YAP/TAZ affects the development of pulmonary fibrosis by regulating multiple signaling pathways

YAP and TAZ are important co-activators of various biological processes in human body. YAP/TAZ plays a vital role in the development of pulmonary fibrosis. Dysregulation of the YAP/TAZ signaling pathway is one of the most important causes of pulmonary fibrosis. Therefore, considering its crucial role, summary of the signal mechanism of YAP/TAZ is of certain guiding significance for the research of YAP/TAZ as a therapeutic target. The present review provided a detailed introduction to various YAP/TAZ-related signaling pathways and clarified the specific role of YAP/TAZ in these pathways. In the meantime, we summarized and evaluated possible applications of YAP/TAZ in the treatment of pulmonary fibrosis. Overall, our study is of guiding significance for future research on the functional mechanism of YAP/TAZ underlying lung diseases as well as for identification of novel therapeutic targets specific to pulmonary fibrosis.

HSP90 Inhibition and Modulation of the Proteome: Therapeutical Implications for Idiopathic Pulmonary Fibrosis (IPF)

Idiopathic Pulmonary fibrosis (IPF) is a catastrophic disease with poor outcomes and limited pharmacological approaches. Heat shock protein 90 (HSP90) has been recently involved in the wound-healing pathological response that leads to collagen deposition in patients with IPF and its inhibition represents an exciting drug target against the development of pulmonary fibrosis. Under physiological conditions, HSP90 guarantees proteostasis through the refolding of damaged proteins and the degradation of irreversibly damaged ones. Additionally, its inhibition, by specific HSP90 inhibitors (e.g., 17 AAG, 17 DAG, and AUY-922) has proven beneficial in different preclinical models of human disease. HSP90 inhibition modulates a complex subset of kinases and interferes with intracellular signaling pathways and proteome regulation. In this review, we evaluated the current evidence and rationale for the use of HSP90 inhibitors in the treatment of pulmonary fibrosis, discussed the intracellular pathways involved, described the limitations of the current understanding and provided insights for future research.

Expert consensus on the management of adverse events and prescribing practices associated with the treatment of patients taking pirfenidone for idiopathic pulmonary fibrosis: a Delphi consensus study

Background

In patients with idiopathic pulmonary fibrosis (IPF) treated with pirfenidone (Esbriet®, Genentech USA, Inc. South San Francisco, CA.), effectively managing treatment-related adverse events (AEs) may improve adherence. Due to a lack of clinical evidence and expertise, managing these AEs can be challenging for patients and physicians alike. In the absence of evidence, consensus recommendations from physicians experienced in using pirfenidone to treat IPF are beneficial.

Methods

Using a modified Delphi process, expert recommendations were developed by a panel of physicians experienced with using pirfenidone for IPF. Over three iterations, panelists developed and refined a series of statements on the use of pirfenidone in IPF. Their agreement on each statement was ranked using a Likert scale.

Results

A panel of 12 physicians participated and developed a total of 286 statements on dosing and administration, special populations, drug-drug interactions, laboratory analysis, warnings and precautions, and AE management. Expert recommendations were achieved with regard to slower initial titrations and slower titrations for AEs, dosing with meal(s) or substantial meals, and adding other prescribed pharmacological agents for AEs.

Conclusion

Until there is further clinical evidence, the resulting consensus recommendations are intended to provide direction on the practical management of IPF with pirfenidone, by encompassing a broad experience from the real world to complement data gleaned from clinical trials.

Trends in malignant melanoma mortality in 31 countries from 1985 to 2015

BACKGROUND

Malignant melanoma (MM) causes the highest absolute number of deaths among skin cancers. An up-to-date analysis of international MM mortality trends is required for assessing the burden of disease, and may support the assessment of the effectiveness of new diagnostic, therapeutic and preventative strategies.

OBJECTIVES

To report MM mortality trends between 1985 and 2015 using the World Health Organization (WHO) Mortality Database.

MATERIALS AND METHODS

We used country-level MM mortality data from the WHO Mortality Database for all countries with high usability death registration data. Mortality trends were described using Joinpoint regression modelling.

RESULTS

Thirty-one countries met the inclusion criteria. All countries, except the Czech Republic, demonstrated increased age-standardized death rates (ASDRs) in males over the observation period. More countries exhibited decreased or stable MM mortality in females. The median mortality rate for 2013-2015 was 2·57 deaths per 100 000 for males and 1·55 per 100 000 for females. Australia and Norway had the highest ASDRs for males (5·72 per 100 000 and 4·55 per 100 000, respectively). Norway and Slovenia had the highest ASDRs for females (3·02 per 100 000 and 2·58 per 100 000, respectively). MM mortality was greater for males than females in all countries, with sex disparity increasing across the period. Disparity in mortality between older and younger cohorts in several countries was also found.

CONCLUSIONS

An overall increase in MM mortality over the past 30 years was observed. However, there was notable variation in mortality trends between countries, as well as between males and females, and between different age groups.

Triptolide protects against TGF-β1-induced pulmonary fibrosis by regulating FAK/calpain signaling

The present study aimed to investigate the mechanism of anti-proliferative, anti-inflammatory and anti-fibrotic effects of triptolide (TPL) on activated lung fibroblasts by regulating the focal adhesion kinase (FAK) and calpain signaling pathways. The HFL-1 human foetal lung fibroblast cell line was cultured in vitro and treated with 50 ng/ml transforming growth factor (TGF)-β1 for 48 h to establish the model of pulmonary fibrosis. Subsequently, the cells were divided into five groups, including a control, model, TPL, FAK inhibitor and calpeptin group. Subsequently, the proliferation of lung fibroblasts was detected using the Cell Counting Kit-8 assay. The concentration of interleukin (IL)-6 in the cell culture supernatant was examined by ELISA and the mRNA expression levels of collagen type I (ColI)α and ColIII in lung fibroblasts were quantified by reverse transcription-quantitative PCR. The protein levels of FAK, phosphorylated (p)-FAK, calpain 1 and calpain 2 were detected by western blot analysis. TGF-β1 induced the proliferation of lung fibroblasts, whereas TPL inhibited this proliferation in a dose-dependent manner. TPL also decreased the TGF-β1-induced production of IL-6 and reduced the upregulation of ColIα, ColIII, FAK, p-FAK, and inhibited the decrease of calpain 1 and calpain 2 induced by TGF-β1. In addition, the FAK inhibitor acted synergistically with TPL to decrease TGF-β1-induced production of IL-6 and attenuate TGF-β1-induced synthesis of ColIα and ColIII, while calpeptin had an antagonistic effect on the function of TPL. Furthermore, treatment with the FAK inhibitor and TPL markedly decreased the protein levels of FAK and p-FAK, and increased the protein expression of calpain 1 and calpain 2 in lung fibroblasts stimulated by TGF-β1 to a greater extent than TPL alone, while calpeptin had an antagonistic effect on the action of TPL. In conclusion, the present study indicated that TPL protected against TGF-β1-induced proliferation, inflammation and fibrosis by regulating the FAK and calpain signaling pathways.

Demographics and survival of patients with idiopathic pulmonary fibrosis in the FinnishIPF registry

Idiopathic pulmonary fibrosis (IPF) is characterised by unpredictable disease course and poor survival. After the introduction of novel antifibrotic drugs, the prognosis of patients with IPF is probably changing. FinnishIPF, a nationwide registry of carefully characterised patients, was initiated in Finland in 2011. For the data analysis, we included 453 incident IPF patients diagnosed during 2011-2015. In this study, we describe the demographics and prognosis of these real-life patients. The median overall survival time of registered IPF patients was 4.5 years. The transplant-free survival at 1, 2, 3, 4 and 5 years was 95%, 83%, 70%, 58% and 45%, respectively. Smoking did not have any effect on survival. 117 (26%) patients received pirfenidone or nintedanib. Patients who received ≥6 months of treatment had better survival compared with those who did not receive treatment but this difference disappeared after age adjustment. The transplantation rate was 3%. Although IPF is diagnosed in Finland at a older age, the prognosis is better than expected due to a relatively well preserved lung function at diagnosis. Age and pulmonary function were identified as independent predictors of survival in the entire IPF patient population as well as in patients who had received antifibrotic treatment.

Metal-Induced Pulmonary Fibrosis

PURPOSE OF REVIEW

The incidence of pulmonary fibrosis is increasing worldwide and may, in part, be due to occupational and environmental exposures. Secondary fibrotic interstitial lung diseases may be mistaken for idiopathic pulmonary fibrosis with important implications for both disease management and prognosis. The purposes of this review are to shed light on possible underlying causes of interstitial pulmonary fibrosis and to encourage dialogue on the importance of acquiring a thorough patient history of occupational and environmental exposures.

RECENT FINDINGS

A recent appreciation for various occupational and environmental metals inducing both antigen-specific immune reactions in the lung and nonspecific "innate" immune system responses has emerged and with it a growing awareness of the potential hazards to the lung caused by low-level metal exposures. Advancements in the contrast and quality of high-resolution CT scans and identification of histopathological patterns of interstitial pulmonary fibrosis have improved clinical diagnostics. Moreover, recent findings indicate specific hotspots of pulmonary fibrosis within the USA. Increased prevalence of lung disease in these areas appears to be linked to occupational/environmental metal exposure and ethnic susceptibility/vulnerability. A systematic overview of possible occupational and environmental metals causing interstitial pulmonary fibrosis and a detailed evaluation of vulnerable/susceptible populations may facilitate a broader understanding of potential underlying causes and highlight risks of disease predisposition.