1
|
Papaioannou AI, Hillas G, Loukides S, Vassilakopoulos T. Mortality prevention as the centre of COPD management. ERJ Open Res 2024; 10:00850-2023. [PMID: 38887682 PMCID: PMC11181087 DOI: 10.1183/23120541.00850-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/14/2024] [Indexed: 06/20/2024] Open
Abstract
COPD is a major healthcare problem and cause of mortality worldwide. COPD patients at increased mortality risk are those who are more symptomatic, have lower lung function and lower diffusing capacity of the lung for carbon monoxide, decreased exercise capacity, belong to the emphysematous phenotype and those who have concomitant bronchiectasis. Mortality risk seems to be greater in patients who experience COPD exacerbations and in those who suffer from concomitant cardiovascular and/or metabolic diseases. To predict the risk of death in COPD patients, several composite scores have been created using different parameters. In previous years, large studies (also called mega-trials) have evaluated the efficacy of different therapies on COPD mortality, but until recently only nonpharmaceutical interventions have proven to be effective. However, recent studies on fixed combinations of triple therapy (long-acting β-agonists, long-acting muscarinic antagonists and inhaled corticosteroids) have provided encouraging results, showing for the first time a reduction in mortality compared to dual therapies. The aim of the present review is to summarise available data regarding mortality risk in COPD patients and to describe pharmacological therapies that have shown effectiveness in reducing mortality.
Collapse
Affiliation(s)
- Andriana I. Papaioannou
- 1st Department of Pulmonary Medicine, National and Kapodistrian University of Athens, Medical School, “Sotiria” Chest Hospital, Athens, Greece
| | - Georgios Hillas
- 5th Pulmonary Department, “Sotiria” Chest Hospital, Athens, Greece
| | - Stelios Loukides
- National and Kapodistrian University of Athens, Medical School, 2nd Respiratory Medicine Department, Attikon University Hospital, Athens, Greece
| | - Theodoros Vassilakopoulos
- National and Kapodistrian University of Athens, Laboratory of Physiology, Medical School of NKUA, Critical Care and Pulmonary (2nd) Department, Henry Dunant Hospital Center, Athens, Greece
| |
Collapse
|
2
|
Kraemer R, Smith HJ, Reinstaedtler J, Gallati S, Matthys H. Predicting parameters of airway dynamics generated from inspiratory and expiratory plethysmographic airway loops, differentiating subtypes of chronic obstructive diseases. BMJ Open Respir Res 2024; 11:e002142. [PMID: 38460977 PMCID: PMC11148667 DOI: 10.1136/bmjresp-2023-002142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/09/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND The plethysmographic shift volume-flow loop (sRaw-loop) measured during tidal breathing allows the determination of several lung function parameters such as the effective specific airway resistance (sReff), calculated from the ratio of the integral of the resistive aerodynamic specific work of breathing (sWOB) and the integral of the corresponding flow-volume loop. However, computing the inspiratory and expiratory areas of the sRaw-loop separately permits the determination of further parameters of airway dynamics. Therefore, we aimed to define the discriminating diagnostic power of the inspiratory and expiratory sWOB (sWOBin, sWOBex), as well as of the inspiratory and expiratory sReff (sReff IN and sReff EX), for discriminating different functional phenotypes of chronic obstructive lung diseases. METHODS Reference equations were obtained from measurement of different databases, incorporating 194 healthy subjects (35 children and 159 adults), and applied to a collective of 294 patients with chronic lung diseases (16 children with asthma, aged 6-16 years, and 278 adults, aged 17-92 years). For all measurements, the same type of plethysmograph was used (Jaeger Würzburg, Germany). RESULTS By multilinear modelling, reference equations of sWOBin, sWOBex, sReff IN and sReff EX were derived. Apart from anthropometric indices, additional parameters such as tidal volume (VT), the respiratory drive (P0.1), measured by means of a mouth occlusion pressure measurement 100 ms after inspiration and the mean inspiratory flow (VT/TI) were found to be informative. The statistical approach to define reference equations for parameters of airway dynamics reveals the interrelationship between covariants of the actual breathing pattern and the control of breathing. CONCLUSIONS We discovered that sWOBin, sWOBex, sReff IN and sReff EX are new discriminating target parameters, that differentiate much better between chronic obstructive diseases and their subtypes, especially between chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap (ACO), thus strengthening the concept of precision medicine.
Collapse
Affiliation(s)
- Richard Kraemer
- Center of Pneumology, Hirslanden Salem-Spital, Bern, Switzerland
- School of Biomedical and Precision Engineering, University of Bern, Bern, Switzerland
| | - Hans-Jürgen Smith
- Research in Respiratory Diagnostics, Medical Development, Berlin, Germany
| | | | - Sabina Gallati
- Hirslanden Precise, Genetic Medicine, Zollikon/Zürich, Switzerland
| | - Heinrich Matthys
- Department of Pneumology, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
3
|
Kraemer R, Baty F, Smith HJ, Minder S, Gallati S, Brutsche MH, Matthys H. Assessment of functional diversities in patients with Asthma, COPD, Asthma-COPD overlap, and Cystic Fibrosis (CF). PLoS One 2024; 19:e0292270. [PMID: 38377145 PMCID: PMC10878531 DOI: 10.1371/journal.pone.0292270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/17/2023] [Indexed: 02/22/2024] Open
Abstract
The objectives of the present study were to evaluate the discriminating power of spirometric and plethysmographic lung function parameters to differenciate the diagnosis of asthma, ACO, COPD, and to define functional characteristics for more precise classification of obstructive lung diseases. From the databases of 4 centers, a total of 756 lung function tests (194 healthy subjects, 175 with asthma, 71 with ACO, 78 with COPD and 238 with CF) were collected, and gradients among combinations of target parameters from spirometry (forced expiratory volume one second: FEV1; FEV1/forced vital capacity: FEV1/FVC; forced expiratory flow between 25-75% FVC: FEF25-75), and plethysmography (effective, resistive airway resistance: sReff; aerodynamic work of breathing at rest: sWOB), separately for in- and expiration (sReffIN, sReffEX, sWOBin, sWOBex) as well as static lung volumes (total lung capacity: TLC; functional residual capacity: FRCpleth; residual volume: RV), the control of breathing (mouth occlusion pressure: P0.1; mean inspiratory flow: VT/TI; the inspiratory to total time ratio: TI/Ttot) and the inspiratory impedance (Zinpleth = P0.1/VT/TI) were explored. Linear discriminant analyses (LDA) were applied to identify discriminant functions and classification rules using recursive partitioning decision trees. LDA showed a high classification accuracy (sensitivity and specificity > 90%) for healthy subjects, COPD and CF. The accuracy dropped for asthma (~70%) and even more for ACO (~60%). The decision tree revealed that P0.1, sRtot, and VT/TI differentiate most between healthy and asthma (68.9%), COPD (82.1%), and CF (60.6%). Moreover, using sWOBex and Zinpleth ACO can be discriminated from asthma and COPD (60%). Thus, the functional complexity of obstructive lung diseases can be understood, if specific spirometric and plethysmographic parameters are used. Moreover, the newly described parameters of airway dynamics and the central control of breathing including Zinpleth may well serve as promising functional marker in the field of precision medicine.
Collapse
Affiliation(s)
- Richard Kraemer
- Centre of Pulmonary Medicine, Hirslanden Hospital Group, Salem-Hospital, Bern, Switzerland
- Department of Paediatrics, University of Bern, Bern, Switzerland
- School of Biomedical and Precision Engineering (SBPE), University of Bern, Bern, Switzerland
| | - Florent Baty
- Department of Pneumology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Hans-Jürgen Smith
- Medical Development, Research in Respiratory Diagnostics, Berlin, Germany
| | - Stefan Minder
- Centre of Pulmonary Medicine, Hirslanden Hospital Group, Salem-Hospital, Bern, Switzerland
| | - Sabina Gallati
- Department of Paediatrics, University of Bern, Bern, Switzerland
- Hirslanden Precise, Genomic Medicine, Hirslanden Hospital Group, Zollikon/Zürich, Switzerland
| | - Martin H. Brutsche
- Department of Pneumology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Heinrich Matthys
- Department of Pneumology, University Hospital of Freiburg, Freiburg, Germany
| |
Collapse
|
4
|
Moll M, Silverman EK. Precision Approaches to Chronic Obstructive Pulmonary Disease Management. Annu Rev Med 2024; 75:247-262. [PMID: 37827193 DOI: 10.1146/annurev-med-060622-101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD heterogeneity has hampered progress in developing pharmacotherapies that affect disease progression. This issue can be addressed by precision medicine approaches, which focus on understanding an individual's disease risk, and tailoring management based on pathobiology, environmental exposures, and psychosocial issues. There is an urgent need to identify COPD patients at high risk for poor outcomes and to understand at a mechanistic level why certain individuals are at high risk. Genetics, omics, and network analytic techniques have started to dissect COPD heterogeneity and identify patients with specific pathobiology. Drug repurposing approaches based on biomarkers of specific inflammatory processes (i.e., type 2 inflammation) are promising. As larger data sets, additional omics, and new analytical approaches become available, there will be enormous opportunities to identify high-risk individuals and treat COPD patients based on their specific pathophysiological derangements. These approaches show great promise for risk stratification, early intervention, drug repurposing, and developing novel therapeutic approaches for COPD.
Collapse
Affiliation(s)
- Matthew Moll
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; ,
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Pulmonary, Critical Care, Sleep and Allergy, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin K Silverman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; ,
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Chalmers JD, Shoemark A. Inhaled Corticosteroids in COPD and Bronchiectasis: Use Biomarkers Rather Than Disease Labels. Chest 2023; 164:809-811. [PMID: 37805235 DOI: 10.1016/j.chest.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 10/09/2023] Open
Affiliation(s)
- James D Chalmers
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, Scotland.
| | - Amelia Shoemark
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, Scotland
| |
Collapse
|
6
|
Wang J, Wang P, Shao Y, He D. Advancing Treatment Strategies: A Comprehensive Review of Drug Delivery Innovations for Chronic Inflammatory Respiratory Diseases. Pharmaceutics 2023; 15:2151. [PMID: 37631365 PMCID: PMC10458134 DOI: 10.3390/pharmaceutics15082151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic inflammatory respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis, present ongoing challenges in terms of effective treatment and management. These diseases are characterized by persistent inflammation in the airways, leading to structural changes and compromised lung function. There are several treatments available for them, such as bronchodilators, immunomodulators, and oxygen therapy. However, there are still some shortcomings in the effectiveness and side effects of drugs. To achieve optimal therapeutic outcomes while minimizing systemic side effects, targeted therapies and precise drug delivery systems are crucial to the management of these diseases. This comprehensive review focuses on the role of drug delivery systems in chronic inflammatory respiratory diseases, particularly nanoparticle-based drug delivery systems, inhaled corticosteroids (ICSs), novel biologicals, gene therapy, and personalized medicine. By examining the latest advancements and strategies in these areas, we aim to provide a thorough understanding of the current landscape and future prospects for improving treatment outcomes in these challenging conditions.
Collapse
Affiliation(s)
- Junming Wang
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
| | - Pengfei Wang
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
| | - Yiru Shao
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
| | - Daikun He
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai 201508, China; (J.W.); (P.W.); (Y.S.)
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai 201508, China
- Department of General Practice, Jinshan Hospital, Fudan University, Shanghai 201508, China
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| |
Collapse
|
7
|
Calzetta L, Pistocchini E, Chetta A, Rogliani P, Cazzola M. Experimental drugs in clinical trials for COPD: Artificial Intelligence via Machine Learning approach to predict the successful advance from early-stage development to approval. Expert Opin Investig Drugs 2023. [PMID: 37364225 DOI: 10.1080/13543784.2023.2230138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/23/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Therapeutic advances in drug therapy of chronic obstructive pulmonary disease (COPD) really effective in suppressing the pathological processes underlying the disease deterioration are still needed. Artificial Intelligence (AI) via Machine Learning (ML) may represent an effective tool to predict clinical development of investigational agents. AREAL COVERED Experimental drugs in Phase I and II development for COPD from early 2014 to late 2022 were identified in the ClinicalTrials.gov database. Different ML models, trained from prior knowledge on clinical trial success, were used to predict the probability that experimental drugs will successfully advance toward approval in COPD, according to Bayesian inference as follows: ≤25% low probability, >25% and ≤ 50% moderate probability, >50% and ≤ 75% high probability, and > 75% very high probability. EXPERT OPINION The Artificial Neural Network and Random Forest ML models indicated that, among the current experimental drugs in clinical trials for COPD, only the bifunctional muscarinic antagonist - β2-adrenoceptor agonists (MABA) navafenterol and batefenterol, the inhaled corticosteroid (ICS)/MABA fluticasone furoate/batefenterol, and the bifunctional phosphodiesterase (PDE) 3/4 inhibitor ensifentrine resulted to have a moderate to very high probability of being approved in the next future, however not before 2025.
Collapse
Affiliation(s)
- Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Pistocchini
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alfredo Chetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Cazzola
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
8
|
Stolz D, Matera MG, Rogliani P, van den Berge M, Papakonstantinou E, Gosens R, Singh D, Hanania N, Cazzola M, Maitland-van der Zee AH, Fregonese L, Mathioudakis AG, Vestbo J, Rukhadze M, Page CP. Current and future developments in the pharmacology of asthma and COPD: ERS seminar, Naples 2022. Breathe (Sheff) 2023; 19:220267. [PMID: 37377851 PMCID: PMC10292790 DOI: 10.1183/20734735.0267-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/28/2023] [Indexed: 06/29/2023] Open
Abstract
Pharmacological management of airway obstructive diseases is a fast-evolving field. Several advances in unravelling disease mechanisms as well as intracellular and molecular pathways of drug action have been accomplished. While the clinical translation and implementation of in vitro results to the bedside remains challenging, advances in comprehending the mechanisms of respiratory medication are expected to assist clinicians and scientists in identifying meaningful read-outs and designing clinical studies. This European Respiratory Society Research Seminar, held in Naples, Italy, 5-6 May 2022, focused on current and future developments of the drugs used to treat asthma and COPD; on mechanisms of drug action, steroid resistance, comorbidities and drug interactions; on prognostic and therapeutic biomarkers; on developing novel drug targets based on tissue remodelling and regeneration; and on pharmacogenomics and emerging biosimilars. Related European Medicines Agency regulations are also discussed, as well as the seminar's position on the above aspects.
Collapse
Affiliation(s)
- Daiana Stolz
- Clinic of Pulmonary Medicine, Department of Internal Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital of Basel, Basel, Switzerland
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, School of Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Maarten van den Berge
- Groningen Research Institute for Asthma and COPD, and Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eleni Papakonstantinou
- Clinic of Pulmonary Medicine, Department of Internal Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital of Basel, Basel, Switzerland
| | - Reinoud Gosens
- Groningen Research Institute for Asthma and COPD, and Department of Molecular Pharmacology, Groningen Research Institute of Pharmacy, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicola Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | | | | | - Alexander G. Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Maia Rukhadze
- Center of Allergy and Immunology, Teaching University Geomedi LLC, Tbilisi, Georgia
| | - Clive P. Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| |
Collapse
|
9
|
Effendi WI, Nagano T. Epigenetics Approaches toward Precision Medicine for Idiopathic Pulmonary Fibrosis: Focus on DNA Methylation. Biomedicines 2023; 11:biomedicines11041047. [PMID: 37189665 DOI: 10.3390/biomedicines11041047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
Genetic information is not transmitted solely by DNA but by the epigenetics process. Epigenetics describes molecular missing link pathways that could bridge the gap between the genetic background and environmental risk factors that contribute to the pathogenesis of pulmonary fibrosis. Specific epigenetic patterns, especially DNA methylation, histone modifications, long non-coding, and microRNA (miRNAs), affect the endophenotypes underlying the development of idiopathic pulmonary fibrosis (IPF). Among all the epigenetic marks, DNA methylation modifications have been the most widely studied in IPF. This review summarizes the current knowledge concerning DNA methylation changes in pulmonary fibrosis and demonstrates a promising novel epigenetics-based precision medicine.
Collapse
|
10
|
Bartziokas K, Papaporfyriou A, Hillas G, Papaioannou AI, Loukides S. Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations: strengths and concerns for future needs. Postgrad Med 2022; 135:327-333. [PMID: 36226501 DOI: 10.1080/00325481.2022.2135893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is already the third leading cause of death worldwide and simultaneously a major cause of morbidity and mortality. Global initiative for Chronic Obstructive Lung Disease (also known as GOLD) committee, has been created in 1997 to increase the awareness regarding the burden of COPD. GOLD recommendations have been contributing to diagnosis, management and therapy of COPD since 2001. Through these years, by reviewing published articles, GOLD aimed to provide state-of-the-art information not only for pulmonologists, but also for non-respiratory physicians, and to encourage research on COPD. From 2011, GOLD annual reports have changed the way of COPD evaluation from based entirely on spirometric parameters to more clinical indices, such as the assessment of symptoms and dyspnea alongside with exacerbations. Moreover, according to recent developments in pathophysiology of COPD, there is a trend in identifying new pre-clinical stages, contributing to prevention and early COPD treatment. In the field of therapeutic algorithms, changes turn to a more personalized approach. However, it is not clear in what extent this personalized disease management would be feasible and the real challenge for current recommendations is to include more patient characteristics such as co-morbidities and multidimensional scores in disease evaluation.
Collapse
Affiliation(s)
| | | | - Georgios Hillas
- 5th Respiratory Medicine Department Sotiria Chest Hospital, Athens, Greece
| | | | - Stelios Loukides
- 2nd Respiratory Medicine Department, "Attikon" University Hospital, Athens, Greece
| |
Collapse
|
11
|
Buhl R, Wilke T, Picker N, Schmidt O, Hechtner M, Kondla A, Maywald U, Vogelmeier CF. Real-World Treatment of Patients Newly Diagnosed with Chronic Obstructive Pulmonary Disease: A Retrospective German Claims Data Analysis. Int J Chron Obstruct Pulmon Dis 2022; 17:2355-2367. [PMID: 36172035 PMCID: PMC9512029 DOI: 10.2147/copd.s375190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/21/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to describe the real-world treatment of German incident COPD patients, compare that treatment with clinical guidelines, and provide insight into disease development after incident diagnosis. In addition, the economic burden of the disease by assessing COPD-related healthcare costs was described. Patients and Methods Based on a German claims dataset, continuously insured individuals (04/2014-03/2019) aged 40 years or older with at least two incident pulmonologist's diagnoses or one inpatient diagnosis of COPD (ICD-10-GM code J44.-; no respective diagnosis in a 12-month baseline period) were selected. Treatment patterns after incident diagnosis considering inhaled maintenance therapies identified by ATC codes (outpatient prescriptions) were analyzed. Prescription patterns were compared with recommendations of German COPD treatment guidelines. Severe exacerbations were assessed as hospitalizations with main diagnosis ICD-10-GM code J44.1. COPD-associated costs from the perspective of the health insurance fund AOK PLUS were calculated per patient-year (PY). Results The sample comprised 17,464 incident COPD patients with a mean age of 71.5 years. 58.9% were male and the mean Charlson-Comorbidity-Index was 5.3. During follow-up (median: 2.0 years), 57.1% of the patients received at least one prescription of an inhaled maintenance therapy, whereas 42.9% did not. Among treated patients, 35.2% started their treatment with LABA/LAMA, 25.3% with LAMA monotherapy, 16.2% with LABA/ICS, and 7.8% with LABA/LAMA/ICS therapy. Within four weeks after initial diagnosis, ICS-containing therapies were prescribed in 14.1% of patients. Of all patients with a prescribed triple therapy, 68.9% had no corresponding exacerbation history documented. On average, 0.16 severe exacerbations and 0.19 COPD-related hospitalizations were observed per PY during available follow-up. Direct COPD-related costs were 3,693 €/PY, with COPD-related hospitalizations being responsible for about 79.2% of these costs. Conclusion Long-acting bronchodilators are the mainstay of pharmacological treatment of incident COPD patients in Germany, in line with guideline recommendations. Yet, a considerable proportion of incident COPD patients did not receive any inhaled maintenance therapy.
Collapse
Affiliation(s)
- Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | - Nils Picker
- Cytel Inc - Ingress-Health HWM GmbH, Wismar, Germany
| | | | | | - Anke Kondla
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, Germany
| |
Collapse
|
12
|
Bamodu OA, Wu SM, Feng PH, Sun WL, Lin CW, Chuang HC, Ho SC, Chen KY, Chen TT, Tseng CH, Liu WT, Lee KY. lnc-IL7R Expression Reflects Physiological Pulmonary Function and Its Aberration Is a Putative Indicator of COPD. Biomedicines 2022; 10:biomedicines10040786. [PMID: 35453536 PMCID: PMC9031132 DOI: 10.3390/biomedicines10040786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 02/04/2023] Open
Abstract
Despite rapidly evolving pathobiological mechanistic demystification, coupled with advances in diagnostic and therapeutic modalities, chronic obstructive pulmonary disease (COPD) remains a major healthcare and clinical challenge, globally. Further compounded by the dearth of available curative anti-COPD therapy, it is posited that this challenge may not be dissociated from the current lack of actionable COPD pathognomonic molecular biomarkers. There is accruing evidence of the involvement of protracted ‘smoldering’ inflammation, repeated lung injury, and accelerated lung aging in enhanced predisposition to or progression of COPD. The relatively novel uncharacterized human long noncoding RNA lnc-IL7R (otherwise called LOC100506406) is increasingly designated a negative modulator of inflammation and regulator of cellular stress responses; however, its role in pulmonary physiology and COPD pathogenesis remains largely unclear and underexplored. Our previous work suggested that upregulated lnc-IL7R expression attenuates inflammation following the activation of the toll-like receptor (TLR)-dependent innate immune system, and that the upregulated lnc-IL7R is anti-correlated with concomitant high PM2.5, PM10, and SO2 levels, which is pathognomonic for exacerbated/aggravated COPD in Taiwan. In the present study, our quantitative analysis of lnc-IL7R expression in our COPD cohort (n = 125) showed that the lnc-IL7R level was significantly correlated with physiological pulmonary function and exhibited COPD-based stratification implications (area under the curve, AUC = 0.86, p < 0.001). We found that the lnc-IL7R level correctly identified patients with COPD (sensitivity = 0.83, specificity = 0.83), precisely discriminated those without emphysematous phenotype (sensitivity = 0.48, specificity = 0.89), and its differential expression reflected disease course based on its correlation with the COPD GOLD stage (r = −0.59, p < 0.001), %LAA-950insp (r = −0.30, p = 0.002), total LAA (r = −0.35, p < 0.001), FEV1(%) (r = 0.52, p < 0.001), FVC (%) (r = 0.45, p < 0.001), and post-bronchodilator FEV1/FVC (r = 0.41, p < 0.001). Consistent with other data, our bioinformatics-aided dose−response plot showed that the probability of COPD decreased as lnc-IL7R expression increased, thus, corroborating our posited anti-COPD therapeutic potential of lnc-IL7R. In conclusion, reduced lnc-IL7R expression not only is associated with inflammation in the airway epithelial cells but is indicative of impaired pulmonary function, pathognomonic of COPD, and predictive of an exacerbated/ aggravated COPD phenotype. These data provide new mechanistic insights into the ailing lung and COPD progression, as well as suggest a novel actionable molecular factor that may be exploited as an efficacious therapeutic strategy in patients with COPD.
Collapse
Affiliation(s)
- Oluwaseun Adebayo Bamodu
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
- Department of Urology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
- Division of Hematology and Oncology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Sheng-Ming Wu
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Division of Clinical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
| | - Po-Hao Feng
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
| | - Wei-Lun Sun
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
| | - Cheng-Wei Lin
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Department of Biochemistry and Molecular Cell Biology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- International PhD Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Hsiao-Chi Chuang
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Shu-Chuan Ho
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Kuan-Yuan Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Tzu-Tao Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Chien-Hua Tseng
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Division of Clinical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei 106, Taiwan
| | - Wen-Te Liu
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: (W.-T.L.); (K.-Y.L.); Tel.: +886-02-2249-0088 (ext. 2714) (W.-T.L. & K.-Y.L.)
| | - Kang-Yun Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (O.A.B.); (S.-M.W.); (P.-H.F.); (W.-L.S.); (H.-C.C.); (S.-C.H.); (K.-Y.C.); (T.-T.C.); (C.-H.T.)
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- TMU Research Center of Thoracic Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: (W.-T.L.); (K.-Y.L.); Tel.: +886-02-2249-0088 (ext. 2714) (W.-T.L. & K.-Y.L.)
| |
Collapse
|
13
|
Khan MMKS, Cole AG, Mannino DM. Precision medicine in chronic obstructive pulmonary disease: how far have we come? Curr Opin Pulm Med 2022; 28:115-120. [PMID: 34652296 DOI: 10.1097/mcp.0000000000000837] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In this review, we will discuss the current status and recent developments in precision medicine in chronic obstructive pulmonary disease (COPD) through the lens of treatable traits. RECENT FINDINGS Although the term 'treatable traits' in the treatment of COPD is relatively recent, this concept has been used for many years if one considers interventions such as long-term oxygen therapy or alpha-1 antitrypsin replacement therapy. Recent advances have included expanding the definition of COPD to include a broader population of people with lower respiratory disease but not meeting the strict criteria for obstruction, advances in imaging to aid in the diagnosis and treatment of COPD, advances in understanding symptoms and exacerbations to define severity, using biomarkers to guide therapy and better understanding and addressing polymorbidity and frailty. In addition, there is a concerted effort to use these concepts to identify COPD patients earlier in the disease process wherein disease modification may be possible. SUMMARY Focusing on subsets of patients with COPD with certain characteristics should lead to better outcomes and fewer adverse effects from treatment. VIDEO ABSTRACT http://links.lww.com/COPM/A30.
Collapse
|
14
|
Alcázar-Navarrete B, Díaz-Lopez JM, García-Flores P, Ortega-Antelo M, Aguilar-Cruz I, Ruiz-Rodríguez O, Santiago-Diaz P, Romero Palacios PJ. T2 Biomarkers as Predictors of Exacerbations of Chronic Obstructive Pulmonary Disease. Arch Bronconeumol 2021; 58:595-600. [PMID: 35312535 DOI: 10.1016/j.arbres.2021.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/01/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Type 2 (T2) biomarkers such as blood eosinophil count (BEC) and FeNO have been related to a higher risk of exacerbations in COPD. It is unknown whether combining these biomarkers could be useful in forecasting COPD exacerbations. METHODS COPD patients were enrolled in this prospective, multicenter, observational study and followed up for 1 year, during which BEC were analysed at baseline (V0) while FeNO analyses were performed at baseline (V0), 6 months (V1) and 12 months (V2). The risk of moderate or severe exacerbation during follow up was assessed by Cox regression analysis, and the predictive capacity of both measurements was assessed by ROC curves and the DeLong test. Statistical significance was assumed at P<.05. RESULTS Of the 322 COPD patients initially recruited, 287 were followed up. At baseline, 28.0% were active smokers, and experienced moderate airflow limitation (mean FEV1 56.4%±17.0% predicted). Patients with at least one elevated T2 biomarker (n=125, 42.5%) were at increased risk of COPD exacerbation (HR 1.75, 95% CI 1.25-2.45, P=.001) and of shorter time to first COPD exacerbation. There was no difference between BEC and FeNO regarding the predictive capacity for moderate to severe exacerbation (AUC 0.584 vs 0.576, P=.183) but FeNO predicted severe episodes more accurately than BEC (AUC 0.607 vs 0.539, P<.05). Combining the two biomarkers enhanced the detection of moderate and severe COPD exacerbations. CONCLUSIONS Both eosinophil count and FeNO have limited utility for predicting COPD exacerbations. Combining these T2 biomarkers could enhance the detection of future COPD exacerbations.
Collapse
Affiliation(s)
- Bernardino Alcázar-Navarrete
- Respiratory Department, HU Virgen de las Nieves, Granada, Spain; Facultad de Medicina, Universidad de Granada, Granada, Spain; Centro de Investigación Biomédica en red Enfermedades Respiratorias (CIBERES), Spain.
| | | | | | | | | | - Oliverio Ruiz-Rodríguez
- Respiratory Department, AIG de Medicina, Hospital de Alta Resolución de Loja, Agencia Sanitaria Hospital de Poniente, Loja, Granada, Spain
| | - Pablo Santiago-Diaz
- Cardiology Department, AIG de Medicina, Hospital de Alta Resolución de Loja, Agencia Sanitaria Hospital de Poniente, Loja, Granada, Spain
| | | |
Collapse
|
15
|
Suissa S. Ten Commandments for Randomized Trials of Pharmacological Therapy for COPD and Other Lung Diseases. COPD 2021; 18:485-492. [PMID: 34468248 DOI: 10.1080/15412555.2021.1968816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The randomized controlled trial is the quintessential scientific tool to evaluate the effectiveness and safety of medications. While early trials of drugs used for the treatment of chronic obstructive pulmonary disease (COPD) and other respiratory diseases were generally unambiguous, more recent studies have been controversial. It has become evident that the conduct, design and analysis of these trials were highly variable and may have been responsible for incoherencies in results and interpretation. With the advent of new studies, the need for guiding principles for the conduct of future randomized trials has become manifest. We describe the concept of the counterfactual principle as it applies to the treatment of patients and to the randomized trial. We then present ten methodological tenets for the design and statistical aspects of randomized controlled trials evaluating the effectiveness of drugs used in the treatment of several respiratory diseases. They include eight study design and two statistical analysis principles: 1) Study question; 2) Intervention; 3) Study population; 4) Blinding; 5) Run-in period; 6) Follow-up; 7) Outcome; 8) Safety; 9) Intent-to-treat; 10) Covariate adjustment. These tenets are described using mainly examples from trials of pharmacological treatments for COPD, as well as some from asthma and idiopathic pulmonary fibrosis, conducted over the last 30 years. The careful application of these principles in the conduct of randomized trials will provide rigorous studies and improve the validity of results. The ensuing clearer interpretation of findings will permit their well-founded contribution to treatment guidelines and optimal clinical management.
Collapse
Affiliation(s)
- Samy Suissa
- Centre for Clinical Epidemiology, Jewish General Hospital, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, Canada
| |
Collapse
|
16
|
Keir HR, Shoemark A, Huang JTJ, Chalmers JD. SPLUNC1 is a novel marker of disease severity and airway infection in bronchiectasis. Eur Respir J 2021; 58:13993003.01840-2021. [PMID: 34413156 DOI: 10.1183/13993003.01840-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Holly R Keir
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Amelia Shoemark
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.,Royal Brompton Hospital, Primary Ciliary Dyskinesia Centre, Paediatric Respiratory Medicine, London, UK
| | | | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| |
Collapse
|
17
|
Milne S, Eddy RL, Sin DD. Disease activity in COPD: time to make imaging biomarkers a PET project? ERJ Open Res 2021; 7:00445-2021. [PMID: 34476244 PMCID: PMC8405865 DOI: 10.1183/23120541.00445-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/05/2022] Open
Abstract
FDG uptake on PET/CT is a potential biomarker of pulmonary inflammation in COPD and may reflect disease activity, but does it have the characteristics of a "good" biomarker? https://bit.ly/3AXheEZ.
Collapse
Affiliation(s)
- Stephen Milne
- Centre for Heart Lung Innovation, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
- Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Rachel L. Eddy
- Centre for Heart Lung Innovation, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
- Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Don D. Sin
- Centre for Heart Lung Innovation, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
- Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
18
|
Mkorombindo T, Dransfield MT. COPD: COagulation-associated Pulmonary Disease? Respirology 2021; 26:290-291. [PMID: 33432655 DOI: 10.1111/resp.14000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 12/07/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Takudzwa Mkorombindo
- Lung Health Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - Mark T Dransfield
- Lung Health Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama, Birmingham, AL, USA
| |
Collapse
|
19
|
Yang A, Yu G, Wu Y, Wang H. Role of β2-adrenergic receptors in chronic obstructive pulmonary disease. Life Sci 2020; 265:118864. [PMID: 33301808 DOI: 10.1016/j.lfs.2020.118864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/19/2020] [Accepted: 11/29/2020] [Indexed: 01/14/2023]
Abstract
Beta-2 adrenergic receptors (β2-ARs) have important roles in the pathogenesis and treatment of chronic obstructive pulmonary disease (COPD). In recent years, progress has been made in the study of β2-ARs. Here, we introduce the basic concepts of β2-ARs, related pathways, as well as application of blockers/agonists of β2-ARs, and β2-AR autoantibodies in COPD. Drugs targeting the β2-AR are being developed rapidly, and we expect them to improve the symptoms and prognosis of COPD patients in the future.
Collapse
Affiliation(s)
- Ailin Yang
- Department of Respiratory Medicine, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xicheng District, Beijing 100050, China
| | - Ganggang Yu
- Department of Respiratory Medicine, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xicheng District, Beijing 100050, China
| | - Yanjun Wu
- Department of Respiratory Medicine, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xicheng District, Beijing 100050, China.
| | - Haoyan Wang
- Department of Respiratory Medicine, Beijing Friendship Hospital, Capital Medical University, 95 Yong An Road, Xicheng District, Beijing 100050, China.
| |
Collapse
|
20
|
Zhu T, Li S, Wang J, Liu C, Gao L, Zeng Y, Mao R, Cui B, Ji H, Chen Z. Induced sputum metabolomic profiles and oxidative stress are associated with chronic obstructive pulmonary disease (COPD) severity: potential use for predictive, preventive, and personalized medicine. EPMA J 2020; 11:645-659. [PMID: 33235638 PMCID: PMC7680486 DOI: 10.1007/s13167-020-00227-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a highly heterogeneous disease, and metabolomics plays a hub role in predictive, preventive, and personalized medicine (PPPM) related to COPD. This study thus aimed to reveal the role of induced sputum metabolomics in predicting COPD severity. In this pilot study, a total of 20 COPD patients were included. The induced sputum metabolites were assayed using a liquid chromatography-mass spectrometry (LC-MS/MS) system. Five oxidative stress products (myeloperoxidase (MPO), superoxide dismutase (SOD), glutathione (GSH), neutrophil elastase (NE), and 8-iso-PGF2α) in induced sputum were measured by ELISA, and the metabolomic profiles were distinguished by principal component analysis (PCA) and orthogonal projections to latent structures discriminant analysis (OPLS-DA). The Kyoto Encyclopedia of Genes and Genomes (KEGG) was used for pathway enrichment analysis, and a significant difference in induced sputum metabolomics was observed between moderate and severe COPD. The KEGG analysis revealed that the glycerophospholipid metabolism pathway was downregulated in severe COPD. Due to the critical role of glycerophospholipid metabolism in oxidative stress, significant negative correlations were discovered between glycerophospholipid metabolites and three oxidative stress products (SOD, MPO, and 8-iso-PGF2α). The diagnostic values of SOD, MPO, and 8-iso-PGF2α in induced sputum were found to exhibit high sensitivities and specificities in the prediction of COPD severity. Collectively, this study provides the first identification of the association between induced sputum metabolomic profiles and COPD severity, indicating the potential value of metabolomics in PPPM for COPD management. The study also reveals the correlation between glycerophospholipid metabolites and oxidative stress products and their value for predicting COPD severity. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-020-00227-w.
Collapse
Affiliation(s)
- Tao Zhu
- Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
| | - Shanqun Li
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| | - Jiajia Wang
- Rheumatology Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010 China
| | - Chunfang Liu
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| | - Lei Gao
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| | - Yuzhen Zeng
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| | - Ruolin Mao
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| | - Bo Cui
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| | - Hong Ji
- California National Primate Research Center, and Department of Anatomy, Physiology & Cell Biology, School of Veterinary Medicine, University of California, Davis, CA 95616 USA
| | - Zhihong Chen
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, 20032 China
| |
Collapse
|
21
|
Milne S, Sin DD. Vitamin D Deficiency in COPD. Chest 2020; 157:755-756. [DOI: 10.1016/j.chest.2019.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/15/2019] [Indexed: 11/24/2022] Open
|
22
|
Vogelmeier CF, Román-Rodríguez M, Singh D, Han MK, Rodríguez-Roisin R, Ferguson GT. Goals of COPD treatment: Focus on symptoms and exacerbations. Respir Med 2020; 166:105938. [PMID: 32250871 DOI: 10.1016/j.rmed.2020.105938] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/18/2020] [Indexed: 12/21/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is currently a leading cause of death worldwide, and its burden is expected to rise in the coming years. Common COPD symptoms include dyspnea, cough and/or sputum production. Some patients may experience acute worsening of symptoms (known as an exacerbation), and therefore require additional therapy. Exacerbations are mainly triggered by respiratory infections and environmental factors. Healthcare professionals face many challenges in COPD management, including the heterogeneity of the disease and under-reporting of symptoms. The authors review these challenges and provide recommendations for the best methods to assess COPD. The goals of COPD treatment include recognising the impact that both symptoms and exacerbations have on patients' lives when considering optimal patient-focused management. The review discusses the need for COPD management strategies to include both pharmacologic and non-pharmacologic approaches and provides recommendations for monitoring treatment outcomes and adjusting management strategies accordingly. Novel treatment strategies including precision medicine and point-of-care testing are also discussed.
Collapse
Affiliation(s)
- Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University of Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany.
| | - Miguel Román-Rodríguez
- Son Pisà Primary Health Care Centre, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma de Mallorca, Spain
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| |
Collapse
|
23
|
Gastmeier P. From ‘one size fits all’ to personalized infection prevention. J Hosp Infect 2020; 104:256-260. [DOI: 10.1016/j.jhin.2019.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/06/2019] [Indexed: 12/18/2022]
|
24
|
Corlateanu A, Mendez Y, Wang Y, Garnica RDJA, Botnaru V, Siafakas N. "Chronic obstructive pulmonary disease and phenotypes: a state-of-the-art.". Pulmonology 2020; 26:95-100. [PMID: 31740261 DOI: 10.1016/j.pulmoe.2019.10.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 10/26/2019] [Accepted: 10/28/2019] [Indexed: 02/08/2023] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous and multisystemic disease with progressive increasing morbidity and mortality. COPD is now widely accepted as a heterogeneous condition with multiple phenotypes and endotypes. This review will discuss the old and new concepts for the different types of COPD phenotypes, as well as the inclusion of them in current guidelines. Phenotypical approach to COPD is having huge impact on everyday practice and changed nonpharmacological and pharmacological management of COPD in last decade. However, phenotypical approach is small step to precision medicine in COPD management in the absence of big, specific and well-designed COPD trials with exact identification of phenotypes for more personalization of the treatment of COPD.
Collapse
Affiliation(s)
- Alexandru Corlateanu
- Department of Respiratory Medicine, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova.
| | - Yamely Mendez
- Research Physician at Faculty of Medicine "Dr. Alberto Romo Caballero", Universidad Autonoma de Tamaulipas. Research Assistant II at Baylor College of Medicine, Houston, Texas. USA
| | - Yafeng Wang
- Department of Epidemiology and Biostatistics, School of Health Sciences, Wuhan University, 185 Donghu Road, Wuchang District, Wuhan 430071, China.
| | | | - Victor Botnaru
- Department of Respiratory Medicine, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova
| | - Nikolaos Siafakas
- Professor of Thoracic Medicine, Department of Thoracic Medicine, University General Hospital, Heraklion, Greece
| |
Collapse
|
25
|
Sin DD. What's in the CART? A decision rule to predict short‐term mortality during COPD exacerbations. Respirology 2019; 24:716-717. [DOI: 10.1111/resp.13561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 03/28/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Don D. Sin
- UBC Centre for Heart Lung Innovation (HLI)St. Paul's Hospital Vancouver BC Canada
- Division of Respiratory MedicineUniversity of British Columbia Vancouver BC Canada
| |
Collapse
|
26
|
Brightling C, Greening N. Airway inflammation in COPD: progress to precision medicine. Eur Respir J 2019; 54:13993003.00651-2019. [PMID: 31073084 DOI: 10.1183/13993003.00651-2019] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/25/2019] [Indexed: 12/31/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide, and its prevalence is increasing. Airway inflammation is a consistent feature of COPD and is implicated in the pathogenesis and progression of COPD, but anti-inflammatory therapy is not first-line treatment. The inflammation has many guises and phenotyping this heterogeneity has revealed different patterns. Neutrophil-associated COPD with activation of the inflammasome, T1 and T17 immunity is the most common phenotype with eosinophil-associated T2-mediated immunity in a minority and autoimmunity observed in more severe disease. Biomarkers have enabled targeted anti-inflammatory strategies and revealed that corticosteroids are most effective in those with evidence of eosinophilic inflammation, whereas, in contrast to severe asthma, response to anti-interleukin-5 biologicals in COPD has been disappointing, with smaller benefits for the same intensity of eosinophilic inflammation questioning its role in COPD. Biological therapies beyond T2-mediated inflammation have not demonstrated benefit and in some cases increased risk of infection, suggesting that neutrophilic inflammation and inflammasome activation might be largely driven by bacterial colonisation and dysbiosis. Herein we describe current and future biomarker approaches to assess inflammation in COPD and how this might reveal tractable approaches to precision medicine and unmask important host-environment interactions leading to airway inflammation.
Collapse
Affiliation(s)
- Christopher Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Neil Greening
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
27
|
The Use of Non-Tumor-Related Liquid Biopsy in Respiratory Medicine. Arch Bronconeumol 2019; 55:555-556. [PMID: 31377108 DOI: 10.1016/j.arbres.2019.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 11/21/2022]
|
28
|
Hasanzad M, Sarhangi N, Aghaei Meybodi HR, Nikfar S, Khatami F, Larijani B. Precision Medicine in Non Communicable Diseases. INTERNATIONAL JOURNAL OF MOLECULAR AND CELLULAR MEDICINE 2019; 8:1-18. [PMID: 32351905 PMCID: PMC7175610 DOI: 10.22088/ijmcm.bums.8.2.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/20/2019] [Indexed: 12/12/2022]
Abstract
Non-communicable diseases (NCDs) are the leading cause of death and disease burden globally, cardiovascular diseases (CVDs) account for the major part of death related to NCDs followed by different types of cancer, chronic obstructive pulmonary disease (COPD), and diabetes. As the World Health Organization (WHO) and the United Nations have announced a 25% reduction in mortality of NCDs by 2025, different communities need to adopt preventive strategies for achieving this goal. Personalized medicine approach as a predictive and preventive strategy aims for a better therapeutic goal to the patients to maximize benefits and reduce harms. The clinical benefits of this approach are already realized in cancer targeted therapy, and its impact on other conditions needs more studies in different societies. In this review, we essentially describe the concept of personalized (or precision) medicine in association with NCDs and the future of precision medicine in prediction, prevention, and personalized treatment.
Collapse
Affiliation(s)
- Mandana Hasanzad
- Medical Genomics Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negar Sarhangi
- Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Aghaei Meybodi
- Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shekoufeh Nikfar
- Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Khatami
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Personalized Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
29
|
Franssen FME, Alter P, Bar N, Benedikter BJ, Iurato S, Maier D, Maxheim M, Roessler FK, Spruit MA, Vogelmeier CF, Wouters EFM, Schmeck B. Personalized medicine for patients with COPD: where are we? Int J Chron Obstruct Pulmon Dis 2019; 14:1465-1484. [PMID: 31371934 PMCID: PMC6636434 DOI: 10.2147/copd.s175706] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022] Open
Abstract
Chronic airflow limitation is the common denominator of patients with chronic obstructive pulmonary disease (COPD). However, it is not possible to predict morbidity and mortality of individual patients based on the degree of lung function impairment, nor does the degree of airflow limitation allow guidance regarding therapies. Over the last decades, understanding of the factors contributing to the heterogeneity of disease trajectories, clinical presentation, and response to existing therapies has greatly advanced. Indeed, diagnostic assessment and treatment algorithms for COPD have become more personalized. In addition to the pulmonary abnormalities and inhaler therapies, extra-pulmonary features and comorbidities have been studied and are considered essential components of comprehensive disease management, including lifestyle interventions. Despite these advances, predicting and/or modifying the course of the disease remains currently impossible, and selection of patients with a beneficial response to specific interventions is unsatisfactory. Consequently, non-response to pharmacologic and non-pharmacologic treatments is common, and many patients have refractory symptoms. Thus, there is an ongoing urgency for a more targeted and holistic management of the disease, incorporating the basic principles of P4 medicine (predictive, preventive, personalized, and participatory). This review describes the current status and unmet needs regarding personalized medicine for patients with COPD. Also, it proposes a systems medicine approach, integrating genetic, environmental, (micro)biological, and clinical factors in experimental and computational models in order to decipher the multilevel complexity of COPD. Ultimately, the acquired insights will enable the development of clinical decision support systems and advance personalized medicine for patients with COPD.
Collapse
Affiliation(s)
- Frits ME Franssen
- Department of Research and Education, CIRO, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Nadav Bar
- Department of Chemical Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Birke J Benedikter
- Institute for Lung Research, Universities of Giessen and Marburg Lung Centre, Philipps-University Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
- Department of Medical Microbiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | | | | | - Michael Maxheim
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Fabienne K Roessler
- Department of Chemical Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Martijn A Spruit
- Department of Research and Education, CIRO, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
- REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Emiel FM Wouters
- Department of Research and Education, CIRO, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Bernd Schmeck
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, Germany
- Institute for Lung Research, Universities of Giessen and Marburg Lung Centre, Philipps-University Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| |
Collapse
|