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Soskis A, Rice MB, Bloch DB, Putman RK, Rubio AA, Vera KZ, Bermea RS, Sauer AJ, Sinow CO, Shen M, Vera MP, Baron RM, Hallowell RW. High prevalence of circulating myositis-associated antibodies in non-COVID critical illness. Respir Med Res 2024; 85:101088. [PMID: 38657302 DOI: 10.1016/j.resmer.2024.101088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/04/2023] [Accepted: 01/13/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Alyssa Soskis
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary B Rice
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | | | | | | | - Max Shen
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Hariri LP, Sharma A, Nandy S, Berigei SR, Yamamoto S, Raphaely RA, Flashner BM, Muniappan A, Auchincloss HG, Lanuti M, Hallowell RW, Shea BS, Keyes CM. Endobronchial Optical Coherence Tomography as a Novel Method for In Vivo Microscopic Assessment of Interstitial Lung Abnormalities. Am J Respir Crit Care Med 2024. [PMID: 38207094 DOI: 10.1164/rccm.202310-1871le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024] Open
Affiliation(s)
- Lida P Hariri
- Massachusetts General Hospital, Pathology, Boston, Massachusetts, United States;
| | - Amita Sharma
- Massachusetts General Hospital, Radiology, Boston, Massachusetts, United States
| | - Sreyankar Nandy
- Massachusetts General Hospital, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Sarita R Berigei
- Massachusetts General Hospital, 2348, Boston, Massachusetts, United States
| | - Satomi Yamamoto
- Massachusetts General Hospital, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Rebecca A Raphaely
- University of Washington, 7284, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Bess M Flashner
- Beth Israel Deaconess Medical Center, 1859, Internal Medicine, Boston, Massachusetts, United States
| | - Ashok Muniappan
- Massachusetts General Hospital, Thoracic Surgery, Boston, Massachusetts, United States
| | - Hugh G Auchincloss
- Massachusetts General Hospital, Thoracic Surgery, Boston, Massachusetts, United States
| | - Michael Lanuti
- Massachusetts General Hospital, Thoracic Surgery, Boston, Massachusetts, United States
| | - Robert W Hallowell
- Massachusetts General Hospital, 2348, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Barry S Shea
- Massachusetts General Hospital, 2348, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Colleen M Keyes
- Massachusetts General Hospital, Interventional Pulmonology, Boston, Massachusetts, United States
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Abstract
Although interstitial lung disease (ILD) is a leading cause of morbidity and mortality in patients with inflammatory myopathies, the current definition and diagnostic criteria of autoimmune myositis remain inadequate to capture the large proportion of patients with lung-dominant disease. As a result, these patients present unique diagnostic and treatment challenges for even the most experienced clinicians. This article highlights the emerging role of autoantibodies in the diagnosis, classification, and management of patients with ILD. We propose alternative nomenclature to facilitate research on this unique patient population. Additionally, evidence supporting the various therapies used in the treatment of myositis-associated ILD is reviewed. The classification and treatment of patients with myositis-associated ILD remains challenging. A standardized therapeutic approach to these patients is lacking, and prospective studies in the field are needed to determine optimal treatment regimens.
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Affiliation(s)
- Robert W Hallowell
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Sonye K Danoff
- Division of Pulmonary Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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4
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Kilgore K, Leinfelder J, Campbell J, Wayne PM, Hallowell RW, Barakat A. A Tai Chi Class Collaboratively Developed for Persons With Interstitial and Other Lung Diseases: An Ethnographic Investigation. Glob Adv Integr Med Health 2023; 12:27536130231206122. [PMID: 37901846 PMCID: PMC10605663 DOI: 10.1177/27536130231206122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/02/2023] [Accepted: 09/18/2023] [Indexed: 10/31/2023]
Abstract
Background Participating in physical activity (PA) can be challenging for persons with chronic and significant lung disease due to the multifaceted disruptive effects of their symptoms and variable disease course. Objectives Our study investigates a novel approach to increasing PA by collaboratively and adaptively developing a Tai Chi (TC) class for and by persons with lung diseases and explores participants' perceptions of their experiences in the co-developed TC class. Methods We initiated a collaboration between the Interstitial Lung Disease (ILD) Collaborative and the Tai Chi Foundation to develop a TC class appropriate for persons with ILD and other lung diseases. The TC class was offered online, during the early phases of the COVID-19 pandemic, when pulmonary patients were isolated socially. TC class sessions were held twice weekly for 12 weeks with 12 participants. Ethnographic field methods were used to collect observations and conduct interviews with teachers and students. The Social Ecological Model (SEM) for understanding factors in intrapersonal, interpersonal, social, and organizational contexts was used to explore ways in which wellness practices, particularly those involving changes in health behaviors, can be collaboratively conceived, and developed by persons with the lived experience of illness and community organizations that are sensitive to their personal and social contexts. The constant comparative method was used for data analysis. Results Our findings include the importance of (1) creating a supportive class environment, characterized by interactive and reciprocal relationships among students and teachers; (2) alternating segments of movement and meditation to avoid fatigue and breathlessness; (3) cultivating sensory awareness and body trust, resting when needed and rejoining the movements when ready; (4) increasing the capacity to meditate through deepening presence and renewing the vital connection with inner and outer sources of energy; (5) reducing, through meditative movement, the persistent anxiety, isolation, and sense of loss that accompany chronic disease diagnosis and progression. Conclusion We documented a collaboration between the TC and pulmonary communities to design a TC class for persons with chronic and significant lung disease. We employed the SEM to provide insights into how teachers, informed by their students, can use effective pedagogical skills to create core curricula with modifications appropriate for a specific population.
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Affiliation(s)
- Karen Kilgore
- Interstitial Lung Disease Collaborative, Pulmonary Care and Research Collaborative, Boston, MA, USA
- Osher Center for Integrative Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | - Peter M. Wayne
- Osher Center for Integrative Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert W. Hallowell
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Aliaa Barakat
- Interstitial Lung Disease Collaborative, Pulmonary Care and Research Collaborative, Boston, MA, USA
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5
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Fisher DA, Murphy MC, Montesi SB, Hariri LP, Hallowell RW, Keane FK, Lanuti M, Mooradian MJ, Fintelmann FJ. Diagnosis and Treatment of Lung Cancer in the Setting of Interstitial Lung Disease. Radiol Clin North Am 2022; 60:993-1002. [PMID: 36202484 PMCID: PMC9969995 DOI: 10.1016/j.rcl.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Interstitial lung disease (ILD) including idiopathic pulmonary fibrosis increases the risk of developing lung cancer. Diagnosing and staging lung cancer in patients with ILD is challenging and requires careful interpretation of computed tomography (CT) and fluorodeoxyglucose PET/CT to distinguish nodules from areas of fibrosis. Minimally invasive tissue sampling is preferred but may be technically challenging given tumor location, coexistent fibrosis, and pneumothorax risk. Current treatment options include surgery, radiation therapy, percutaneous thermal ablation, and systemic therapy; however, ILD increases the risks associated with each treatment option, especially acute ILD exacerbation.
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Affiliation(s)
- Dane A Fisher
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Mark C Murphy
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Sydney B Montesi
- Division of Pulmonology and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lida P Hariri
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Robert W Hallowell
- Division of Pulmonology and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael Lanuti
- Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Meghan J Mooradian
- Massachusetts General Hospital Cancer Center, 55 Fruit Street, Boston, MA 02114, USA
| | - Florian J Fintelmann
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Hallowell RW, Paik JJ. Myositis-associated interstitial lung disease: a comprehensive approach to diagnosis and management. Clin Exp Rheumatol 2022; 40:373-383. [DOI: 10.55563/clinexprheumatol/brvl1v] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Robert W. Hallowell
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, USA.
| | - Julie J. Paik
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kronen R, Ziehr DR, Kane AE, VanderLaan PA, Kholdani CA, Hallowell RW. Pulmonary amyloidosis as the presenting finding in a patient with multiple myeloma. Respir Med Case Rep 2022; 37:101626. [PMID: 35342704 PMCID: PMC8943293 DOI: 10.1016/j.rmcr.2022.101626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/19/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ryan Kronen
- Department of Medicine, University of Washington, Seattle, WA, USA
- Corresponding author. Department of Medicine University of Washington, 1959 NE Pacific Street Seattle, WA, 98195, USA.
| | - David R. Ziehr
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ashley E.D. Kane
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Paul A. VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Cyrus A. Kholdani
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W. Hallowell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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8
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Rubin J, Hallowell RW, Witkin AS, Shelton K, Raz Y. Response. Chest 2021; 160:e681-e682. [PMID: 34872691 DOI: 10.1016/j.chest.2021.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jonah Rubin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Robert W Hallowell
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Alison S Witkin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Kenneth Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Harvard Medical School, Boston, MA
| | - Yuval Raz
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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9
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Flashner BM, VanderLaan PA, Nurhussien L, Rice MB, Hallowell RW. Pulmonary histopathology of interstitial lung disease associated with antisynthetase antibodies. Respir Med 2021; 191:106697. [PMID: 34864634 DOI: 10.1016/j.rmed.2021.106697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND We aimed to determine if antibody type is an indicator of pulmonary histopathology, using antisynthetase antibody positive interstitial lung disease (ILD) cases with lung biopsy or autopsy findings. METHODS We conducted a comprehensive review of the English language literature in PubMed to identify ILD histopathology results for cases with antibodies against anti-aminoacyl-transfer RNA (tRNA) synthetases (anti-ARS antibodies), including Jo1, PL-12, PL-7, KS, ES, and OJ. We additionally identified patients who had ILD, anti-ARS antibodies, and a lung biopsy between 2015 and 2020 at Beth Israel Deaconess Medical Center. For each case, we documented the specific anti-ARS antibody and major histopathologic patterns identified on biopsy or autopsy, including usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), and acute lung injury (ALI). To determine if histopathology varied by antibody type, we compared the proportion of each of four major patterns by antibody type using the Fisher's Exact test. RESULTS We identified 310 cases with pathology findings and anti-ARS antibody positivity, including 12 cases from our institution. The proportion of NSIP differed significantly across antibody type, found in 31% of Jo1 (p < 0.01), 67% of EJ (p < 0.01), and 63% of KS (p < 0.01) cases. OP was common in Jo1 (23%, p = 0.07), but rare in EJ (4%, p = 0.04) and KS (4%, p = 0.04). UIP was common in PL-12 alone (36%, p = 0.03). CONCLUSION The frequency of histopathologic findings in ILD with anti-ARS positivity varies significantly by antibody type, and NSIP occurs in less than half of all cases.
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Affiliation(s)
- Bess M Flashner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lina Nurhussien
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary B Rice
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W Hallowell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Rubin J, Black KE, Hallowell RW, Witkin AS, Lydston M, Shelton K, Crowley J, Vogel Y, Raz Y. Veno-Venous Extracorporeal Membrane Oxygenation (ECMO) for Myositis-Associated Rapidly Progressive Interstitial Lung Disease (RP-ILD). Chest 2021; 160:2163-2167. [PMID: 34284003 DOI: 10.1016/j.chest.2021.06.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jonah Rubin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Katharine E Black
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Robert W Hallowell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Alison S Witkin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Melissa Lydston
- Treadwell Library, Massachusetts General Hospital, Boston, MA
| | - Kenneth Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Harvard Medical School, Boston, MA
| | - Jerome Crowley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Harvard Medical School, Boston, MA
| | - Yehuda Vogel
- Queens College, City University of New York, Flushing, NY
| | - Yuval Raz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Synn AJ, Li W, Hunninghake GM, Washko GR, San José Estépar R, O'Connor GT, Kholdani CA, Hallowell RW, Bankier AA, Mittleman MA, Rice MB. Vascular Pruning on CT and Interstitial Lung Abnormalities in the Framingham Heart Study. Chest 2021; 159:663-672. [PMID: 32798523 PMCID: PMC7856535 DOI: 10.1016/j.chest.2020.07.082] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 06/17/2020] [Accepted: 07/31/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Pulmonary vascular disease is associated with poor outcomes in individuals affected by interstitial lung disease. The pulmonary vessels can be quantified with noninvasive imaging, but whether radiographic indicators of vasculopathy are associated with early interstitial changes is not known. RESEARCH QUESTION Are pulmonary vascular volumes, quantified from CT scans, associated with interstitial lung abnormalities (ILA) in a community-based sample with a low burden of lung disease? STUDY DESIGN AND METHODS In 2,386 participants of the Framingham Heart Study, we used CT imaging to calculate pulmonary vascular volumes, including the small vessel fraction (a surrogate of vascular pruning). We constructed multivariable logistic regression models to investigate associations of vascular volumes with ILA, progression of ILA, and restrictive pattern on spirometry. In secondary analyses, we additionally adjusted for diffusing capacity and emphysema, and performed a sensitivity analysis restricted to participants with normal FVC and diffusing capacity. RESULTS In adjusted models, we found that lower pulmonary vascular volumes on CT were associated with greater odds of ILA, antecedent ILA progression, and restrictive pattern on spirometry. For example, each SD lower small vessel fraction was associated with 1.81-fold greater odds of ILA (95% CI, 1.41-2.31; P < .0001), and 1.63-fold greater odds of restriction on spirometry (95% CI, 1.18-2.24; P = .003). Similar patterns were seen after adjustment for diffusing capacity for carbon monoxide, emphysema, and among participants with normal lung function. INTERPRETATION In this cohort of community-dwelling adults not selected on the basis of lung disease, more severe vascular pruning on CT was associated with greater odds of ILA, ILA progression, and restrictive pattern on spirometry. Pruning on CT may be an indicator of early pulmonary vasculopathy associated with interstitial lung disease.
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Affiliation(s)
- Andrew J Synn
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Wenyuan Li
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Gary M Hunninghake
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - George R Washko
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; The NHLBI's Framingham Heart Study, Framingham, MA
| | - Raúl San José Estépar
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - George T O'Connor
- The NHLBI's Framingham Heart Study, Framingham, MA; Pulmonary Center, Boston University School of Medicine, Boston, MA
| | - Cyrus A Kholdani
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robert W Hallowell
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alexander A Bankier
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Murray A Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Mary B Rice
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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12
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Hallowell RW, Schwartzstein R, O'Donnell CR, Sheridan A, Banzett RB. Controlled Delivery of 80 mg Aerosol Furosemide Does Not Achieve Consistent Dyspnea Relief in Patients. Lung 2020; 198:113-120. [PMID: 31728632 PMCID: PMC11001166 DOI: 10.1007/s00408-019-00292-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Aerosol furosemide may be an option to treat refractory dyspnea, though doses, methods of delivery, and outcomes have been variable. We hypothesized that controlled delivery of high dose aerosol furosemide would reduce variability of dyspnea relief in patients with underlying pulmonary disease. METHODS Seventeen patients with chronic exertional dyspnea were recruited. Patients rated recently recalled breathing discomfort on a numerical rating scale (NRS) and the multidimensional dyspnea profile (MDP). They then performed graded exercise using an arm-ergometer. The NRS was completed following each exercise grade, and the MDP was repeated after a pre-defined dyspnea threshold was reached. During separate visits, patients received either aerosol saline or 80 mg of aerosol furosemide in a randomized, double-blind, crossover design. After treatment, graded exercise to the pre-treatment level was repeated, followed by completion of the NRS and MDP. Treatment effect was defined as the difference between pre- and post-treatment NRS at end exercise, expressed in absolute terms as % Full Scale. "Responders" were defined as those showing treatment effect ≥ 20% of full scale. RESULTS Final analysis included 15 patients. Neither treatment produced a statistically significant change in NRS and there was no significant difference between treatments (p = 0.45). There were four "responders" and one patient whose dyspnea worsened with furosemide; two patients were responders with saline, of whom one also responded to furosemide. No adverse events were reported. CONCLUSIONS High dose controlled delivery aerosol furosemide was not statistically different from saline placebo at reducing exercise-induced dyspnea. However, a clinically meaningful improvement was noted in some patients.
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Affiliation(s)
- Robert W Hallowell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Carl R O'Donnell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew Sheridan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Robert B Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA.
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13
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Affiliation(s)
- Robert W Hallowell
- From the Department of Medicine, Beth Israel Deaconess Medical Center (R.W.H.), the Departments of Medicine (M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (R.W.H., M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Harvard Medical School - all in Boston
| | - Michael B Feldman
- From the Department of Medicine, Beth Israel Deaconess Medical Center (R.W.H.), the Departments of Medicine (M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (R.W.H., M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Harvard Medical School - all in Boston
| | - Brent P Little
- From the Department of Medicine, Beth Israel Deaconess Medical Center (R.W.H.), the Departments of Medicine (M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (R.W.H., M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Harvard Medical School - all in Boston
| | - Rebecca S Karp Leaf
- From the Department of Medicine, Beth Israel Deaconess Medical Center (R.W.H.), the Departments of Medicine (M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (R.W.H., M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Harvard Medical School - all in Boston
| | - Lida P Hariri
- From the Department of Medicine, Beth Israel Deaconess Medical Center (R.W.H.), the Departments of Medicine (M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (R.W.H., M.B.F., R.S.K.L.), Radiology (B.P.L.), and Pathology (L.P.H.), Harvard Medical School - all in Boston
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14
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Rice MB, Li W, Schwartz J, Di Q, Kloog I, Koutrakis P, Gold DR, Hallowell RW, Zhang C, O'Connor G, Washko GR, Hunninghake GM, Mittleman MA. Ambient air pollution exposure and risk and progression of interstitial lung abnormalities: the Framingham Heart Study. Thorax 2019; 74:1063-1069. [PMID: 31391318 DOI: 10.1136/thoraxjnl-2018-212877] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 06/10/2019] [Accepted: 07/01/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ambient air pollution accelerates lung function decline among adults, however, there are limited data about its role in the development and progression of early stages of interstitial lung disease. AIMS To evaluate associations of long-term exposure to traffic and ambient pollutants with odds of interstitial lung abnormalities (ILA) and progression of ILA on repeated imaging. METHODS We ascertained ILA on chest CT obtained from 2618 Framingham participants from 2008 to 2011. Among 1846 participants who also completed a cardiac CT from 2002 to 2005, we determined interval ILA progression. We assigned distance from home address to major roadway, and the 5-year average of fine particulate matter (PM2.5), elemental carbon (EC, a traffic-related PM2.5 constituent) and ozone using spatio-temporal prediction models. Logistic regression models were adjusted for age, sex, body mass index, smoking status, packyears of smoking, household tobacco exposure, neighbourhood household value, primary occupation, cohort and date. RESULTS Among 2618 participants with a chest CT, 176 (6.7%) had ILA, 1361 (52.0%) had no ILA, and the remainder were indeterminate. Among 1846 with a preceding cardiac CT, 118 (6.4%) had ILA with interval progression. In adjusted logistic regression models, an IQR difference in 5-year EC exposure of 0.14 µg/m3 was associated with a 1.27 (95% CI 1.04 to 1.55) times greater odds of ILA, and a 1.33 (95% CI 1.00 to 1.76) times greater odds of ILA progression. PM2.5 and O3 were not associated with ILA or ILA progression. CONCLUSIONS Exposure to EC may increase risk of progressive ILA, however, associations with other measures of ambient pollution were inconclusive.
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Affiliation(s)
- Mary B Rice
- Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Wenyuan Li
- Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Joel Schwartz
- Environmental Health, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Qian Di
- Environmental Health, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Itai Kloog
- Geography and Environmental Development, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Petros Koutrakis
- Environmental Health, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Diane R Gold
- Environmental Health, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Robert W Hallowell
- Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Chunyi Zhang
- Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - George O'Connor
- Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.,Framingham Heart Study, Framingham, Massachusetts, USA
| | - George R Washko
- Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary M Hunninghake
- Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Murray A Mittleman
- Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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15
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Shea M, Rangachari D, Hallowell RW, Hollie NI, Costa DB, VanderLaan PA. Radiologic and autopsy findings in a case of fatal immune checkpoint inhibitor-associated pneumonitis. Cancer Treat Res Commun 2018; 15:17-20. [PMID: 30207283 DOI: 10.1016/j.ctarc.2018.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 01/24/2018] [Accepted: 02/19/2018] [Indexed: 01/21/2023]
Abstract
Oncologists are increasingly managing drug-induced pneumonitis in lung cancer patients treated with PD-1/PD-L1 immune checkpoint inhibitors. To date only few studies on the topic have described both radiologic and pathologic findings in these patients. Here, we report a fatal case of immune checkpoint inhibitor-associated pneumonitis initially presenting with an organizing pneumonia, but who rapidly developed acute respiratory distress syndrome (confirmed histologically at the time of autopsy). As such, this case illustrates the need for clinicians to maintain a high index of suspicion for immune checkpoint inhibitor associated pneumonitis and have a low threshold to perform CT imaging in any symptomatic patient receiving checkpoint inhibition therapy. CLINICAL PRACTICE POINTS.
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Affiliation(s)
- Meghan Shea
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deepa Rangachari
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robert W Hallowell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Norris I Hollie
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel B Costa
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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16
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Hallowell RW, Collins SL, Craig JM, Zhang Y, Oh M, Illei PB, Chan-Li Y, Vigeland CL, Mitzner W, Scott AL, Powell JD, Horton MR. mTORC2 signalling regulates M2 macrophage differentiation in response to helminth infection and adaptive thermogenesis. Nat Commun 2017; 8:14208. [PMID: 28128208 PMCID: PMC5290163 DOI: 10.1038/ncomms14208] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 12/05/2016] [Indexed: 12/24/2022] Open
Abstract
Alternatively activated macrophages (M2) have an important function in innate immune responses to parasitic helminths, and emerging evidence also indicates these cells are regulators of systemic metabolism. Here we show a critical role for mTORC2 signalling in the generation of M2 macrophages. Abrogation of mTORC2 signalling in macrophages by selective conditional deletion of the adaptor molecule Rictor inhibits the generation of M2 macrophages while leaving the generation of classically activated macrophages (M1) intact. Selective deletion of Rictor in macrophages prevents M2 differentiation and clearance of a parasitic helminth infection in mice, and also abrogates the ability of mice to regulate brown fat and maintain core body temperature. Our findings define a role for mTORC2 in macrophages in integrating signals from the immune microenvironment to promote innate type 2 immunity, and also to integrate systemic metabolic and thermogenic responses.
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Affiliation(s)
- R W Hallowell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brooklyn Avenue, Boston, Massachusetts 02215, USA
| | - S L Collins
- Department of Medicine, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
| | - J M Craig
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, 650 North Wolfe Street, Baltimore, Maryland 21205, USA
| | - Y Zhang
- Department of Respiratory Diseases, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 1239 Siping Road, Shanghai 200433, China
| | - M Oh
- Department of Oncology, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
| | - P B Illei
- Department of Pathology, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
| | - Y Chan-Li
- Department of Medicine, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
| | - C L Vigeland
- Department of Medicine, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
| | - W Mitzner
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, 650 North Wolfe Street, Baltimore, Maryland 21205, USA
| | - A L Scott
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, 650 North Wolfe Street, Baltimore, Maryland 21205, USA
| | - J D Powell
- Department of Oncology, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
| | - M R Horton
- Department of Medicine, Johns Hopkins University School of Medicine, 735 North Broadway, Baltimore, Maryland 21205, USA
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17
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Zhao H, Chan-Li Y, Collins SL, Zhang Y, Hallowell RW, Mitzner W, Horton MR. Pulmonary delivery of docosahexaenoic acid mitigates bleomycin-induced pulmonary fibrosis. BMC Pulm Med 2014; 14:64. [PMID: 24742272 PMCID: PMC3998951 DOI: 10.1186/1471-2466-14-64] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/08/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Pulmonary fibrosis is an untreatable, fatal disease characterized by excess deposition of extracellular matrix and inflammation. Although the etiology of pulmonary fibrosis is unknown, recent studies have implicated dysregulated immune responses and wound healing. Since n-3 polyunsaturated fatty acids (n-3 PUFAs) may beneficially modulate immune responses in a variety of inflammatory disorders, we investigated the therapeutic role of docosahexaenoic acid (DHA), a single n-3 PUFA, in lung fibrosis. METHODS Intratracheal DHA or PBS was administered to mouse lungs 4 days prior to intratracheal bleomycin treatment. Body weight and survival were monitored for 21 days. Bronchoalveolar fluid (BALF) and lung inflammatory cells, cytokines, eicosanoids, histology and lung function were determined on serial days (0, 3, 7, 14, 21) after bleomycin injury. RESULTS Intratracheal administration of DHA mitigated bleomycin-induced lung injury. Mice pretreated with DHA had significantly less weight loss and mortality after bleomycin injury. The lungs from DHA-pretreated mice had markedly less fibrosis. DHA pretreatment also protected the mice from the functional changes associated with bleomycin injury. Bleomycin-induced cellular inflammation in BALF and lung tissue was blunted by DHA pretreatment. These advantageous effects of DHA pretreatment were associated with decreased IL-6, LTB4, PGE2 and increased IL-10. CONCLUSIONS Our findings demonstrate that intratracheal administration of DHA, a single PUFA, protected mice from the development of bleomycin-induced pulmonary inflammation and fibrosis. These results suggest that further investigations regarding the role of n-3 polyunsaturated fatty acids in fibrotic lung injury and repair are needed.
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Affiliation(s)
- Hongyun Zhao
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th floor, Baltimore, MD, USA
- Departments of Environmental Health Sciences, Division of Physiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yee Chan-Li
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th floor, Baltimore, MD, USA
| | - Samuel L Collins
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th floor, Baltimore, MD, USA
| | - Yuan Zhang
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Robert W Hallowell
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th floor, Baltimore, MD, USA
| | - Wayne Mitzner
- Departments of Environmental Health Sciences, Division of Physiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maureen R Horton
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th floor, Baltimore, MD, USA
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18
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Abstract
The idiopathic inflammatory myopathies are a group of connective tissue diseases marked by varying degrees of muscle inflammation and clinical involvement of multiple organs, most notably, the lung. Pulmonary manifestations consist primarily of interstitial lung disease (ILD), which is associated with significant morbidity and mortality in myositis patients. Several myositis-specific antibodies have been discovered, as well as antibodies targeting various aminoacyl-tRNA synthetase enzymes. These antibodies are associated with various clinical features and a risk for developing ILD, and their presence carries a prognostic value in myositis patients. Steroids remain the first-line treatment for myositis-associated ILD and the antisynthetase syndrome, though other traditional immunosuppressants have demonstrated efficacy in numerous studies. While a majority of patients experience either stabilization or improvement in lung imaging and function, fatal progression is still reported in a significant number of cases. Further research is needed to develop more effective and targeted therapies.
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Affiliation(s)
- Robert W Hallowell
- Division of Pulmonary and Critical Medicine, John Hopkins School of Medicine, Baltimore, Maryland
| | - Dana P Ascherman
- Division of Rheumatology, University of Miami Health System, Miami, Florida
| | - Sonye K Danoff
- Division of Pulmonary and Critical Medicine, John Hopkins School of Medicine, Baltimore, Maryland
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19
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Abstract
Thalidomide is an infamous drug whose use by pregnant women in the middle of last century tragically resulted in serious birth defects. However, as a result of its potent immunomodulatory, anti-inflammatory and antiangiogenic properties, thalidomide may be a potential therapy in many diseases. In recent years, thalidomide has been used effectively to treat various malignancies, including multiple myeloma, myelodysplastic syndromes, renal cell cancer, glioblastoma multiforme and prostate cancer. In addition, thalidomide has also proven effective against other immune-related diseases, including erythema nodosum leprosum and sarcoidosis. Idiopathic pulmonary fibrosis (IPF) is a deadly fibrotic disease with no effective treatment options. However, there is data to suggest that thalidomide may be useful in treating the chronic, disabling cough that accompanies IPF. It remains to be seen whether the immunomodulatory and antiangiogenic properties of thalidomide will also make it a potential therapy against the clinical progression of IPF.
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Affiliation(s)
- M R Horton
- Johns Hopkins University School of Medicine, Departmewnt of Medicine, Pulmonary and Critical Care Medicine, Baltimore, Maryland 21205, USA.
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20
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Abstract
Pulmonary hypertension (PH) is a common complication of interstitial lung disease (ILD), particularly in idiopathic pulmonary fibrosis (IPF) and ILD associated with connective tissue disease, where the underlying pathology is often a nonspecific interstitial pneumonia (NSIP) pattern. The degree of PH in ILD is typically mild to moderate and radiographic changes of ILD are usually prominent. We describe four patients with idiopathic NSIP and severe PH (mPAP > 40 mmHg). The average mean pulmonary artery pressure was 51±7 mmHg and pulmonary vascular resistance was 13±4 Wood's units. Pulmonary function was characterized by mild restriction (total lung capacity 63-94% predicted) and profound reductions in DLCO (19-53% predicted). Computed tomographic imaging revealed minimal to moderate interstitial thickening without honeycombing. In two of the cases, an initial clinical diagnosis of idiopathic pulmonary arterial hypertension was made. Both were treated with intravenous epoprostenol, which was associated with worsening of hypoxemia. All four patients died or underwent lung transplant within 4 years of PH diagnonsis. Lung pathology in all four demonstrated fibrotic NSIP with medial thickening of the small and medium pulmonary arteries, and proliferative intimal lesions that stained negative for endothelial markers (CD31 and CD34) and positive for smooth muscle actin. There were no plexiform lesions. Severe pulmonary hypertension can therefore occur in idiopathic NSIP, even in the absence of advanced radiographic changes. Clinicians should suspect underlying ILD as the basis for PH when DLCO is severely reduced or gas exchange deteriorates with pulmonary vasodilator therapy.
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Affiliation(s)
- Robert W Hallowell
- Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, Maryland, USA
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21
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Abstract
Pulmonary fibrosis is an untreatable, uniformly fatal disease of unclear etiology that is the result of unremitting chronic inflammation. Recent studies have implicated bone marrow derived fibrocytes and M2 macrophages as playing key roles in propagating fibrosis. While the disease process is characterized by the accumulation of lymphocytes in the lung parenchyma and alveolar space, their role remains unclear. In this report we definitively demonstrate the ability of T cells to regulate lung inflammation leading to fibrosis. Specifically we demonstrate the ability of intranasal vaccinia vaccination to inhibit M2 macrophage generation and fibrocyte recruitment and hence the accumulation of collagen and death due to pulmonary failure. Mechanistically, we demonstrate the ability of lung Th1 cells to prevent fibrosis as vaccinia failed to prevent disease in Rag−/− mice or in mice in which the T cells lacked IFN-γ. Furthermore, vaccination 3 months prior to the initiation of fibrosis was able to mitigate the disease. Our findings clearly demonstrate the role of T cells in regulating pulmonary fibrosis as well as suggest that vaccinia-induced immunotherapy in the lung may prove to be a novel treatment approach to this otherwise fatal disease.
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Affiliation(s)
- Samuel L. Collins
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Yee Chan-Li
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Robert W. Hallowell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jonathan D. Powell
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Maureen R. Horton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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