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Lu-Song J, Bakal JA, Younus S, Moran-Mendoza O, Harle I, Morales M, Rippon N, Barratt SL, Adamali H, Kalluri M. The Impact of Integrated Palliative Care on Survival in Idiopathic Pulmonary Fibrosis: A Retrospective Multicenter Comparison. Am J Hosp Palliat Care 2024; 41:610-618. [PMID: 37553275 PMCID: PMC11032628 DOI: 10.1177/10499091231194722] [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: 08/10/2023] Open
Abstract
Background: Early and integrated palliative care is recommended for patients with idiopathic pulmonary fibrosis. Unfortunately, palliative care delivery remains poor due to various barriers in practice. This study describes various palliative care delivery models in a real-world cohort of patients with idiopathic pulmonary fibrosis, examines the predictors of survival in this cohort of patients, and explores the impact of palliative care on survival. Design: Charts were reviewed retrospectively and analyzed. The primary outcome was survival during a 4-year follow-up period. Two multivariable models were created to examine the impact of therapeutic strategies including palliative intervention on survival. Results: 298 patients with idiopathic pulmonary fibrosis were enrolled from 3 interstitial lung disease clinics with different palliative care models in Edmonton, Canada; Bristol, UK; and Kingston, Canada. 200 (67%) patients received palliative care and 119 (40%) died during follow up. Primary palliative care models (Edmonton and Bristol) delivered palliative care to 96% and 100% respectively compared 21% in the referral model (Queens). Palliative care [adjusted hazard ratio (aHR) .28 (.12-.65)] along with the use of antifibrotics [aHR .56 (.37-.84)], and body mass index >30 [aHR .47 (.37-.85)] reduced the risk of death in our idiopathic pulmonary fibrosis cohort. Opioid use was associated with worse survival [aHR 2.11 (1.30-23.43)]. Conclusions: Both palliative care and antifibrotic use were associated with survival benefit in this cohort of patients with idiopathic pulmonary fibrosis after adjusting for covariates. The benefit was seen despite differences in disease severity and different palliative care delivery models.
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Affiliation(s)
- Jenny Lu-Song
- Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey A. Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | | | - Onofre Moran-Mendoza
- Division of Respirology and Sleep Medicine, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Ingrid Harle
- Department of Medicine, Division of Palliative Care, Queen’s University, Kingston, ON, Canada (Retired)
| | - Michelle Morales
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Naomi Rippon
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Shaney L. Barratt
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Meena Kalluri
- Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
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Watson S, Dixon G, Savill A, Gibbons MA, Barratt SL, Rodrigues JCL. Complications of fibrotic interstitial lung disease for the general radiologist. Clin Radiol 2024; 79:323-329. [PMID: 38429136 DOI: 10.1016/j.crad.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/01/2023] [Accepted: 01/16/2024] [Indexed: 03/03/2024]
Abstract
Interstitial lung diseases (ILDs) are a heterogeneous group of conditions characterised by non-infective inflammation and scarring of the lung parenchyma. They are not infrequently encountered by the general radiologist in both acute and outpatient reporting settings who may even be the first to make the diagnosis. In the acute setting, patients with ILD can present with respiratory deterioration due to a number of causes and in addition to the common causes of dyspnoea, an acute exacerbation of ILD needs to be considered. An exacerbation can be initiated by common triggers such as infection, pulmonary embolism (PE), and heart failure, and it can also be initiated by an insult to the lung or occur due to an unknown cause. Particular care needs to be taken when interpreting computed tomography (CT) examinations in these patients as the findings of an acute exacerbation are non-specific and patient and technical factors can cause spurious appearances including dependent changes, breathing artefact and contrast medium opacification. In the non-acute setting, patients with ILD are at increased risk of lung cancer and pulmonary hypertension (PH), with lung cancer being a particularly important consideration as treatments carry the risk of triggering an acute exacerbation or deterioration in lung function. Overall, this review aims to provide an overview for the general radiologist of additional factors to consider when interpreting scans in patients with ILD and how the presence of ILD impacts the differential diagnoses and complications that can occur in these patients in both acute and non-acute settings.
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Affiliation(s)
- S Watson
- Department of Radiology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - G Dixon
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK; South West Peninsula ILD Network, UK; Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK; Department of Clinical & Biomedical Sciences, University of Exeter, Exeter, UK
| | - A Savill
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - M A Gibbons
- South West Peninsula ILD Network, UK; Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - S L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK; Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - J C L Rodrigues
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK; Department of Health, University of Bath, Bath, UK.
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Tansley SL, McMorrow F, Cotton CV, Adamali H, Barratt SL, Betteridge ZE, Perurena-Prieto J, Gibbons MA, Kular R, Loganathan A, Lamb JA, Lu H, New RP, Pratt D, Rivera-Ortega P, Sayers R, Steward M, Stranks L, Vital E, Spencer LG, McHugh NJ, Cooper RG. Identification of connective tissue disease autoantibodies and a novel autoantibody anti-annexin A11 in patients with "idiopathic" interstitial lung disease. Clin Immunol 2024; 262:110201. [PMID: 38575043 DOI: 10.1016/j.clim.2024.110201] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/07/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Autoantibodies are a hallmark feature of Connective Tissue Diseases (CTD). Their presence in patients with idiopathic interstitial lung disease (ILD) may suggest covert CTD. We aimed to determine the prevalence of CTD autoantibodies in patients diagnosed with idiopathic ILD. METHODS 499 patient sera were analysed: 251 idiopathic pulmonary fibrosis (IPF), 206 idiopathic non-specific interstitial pneumonia (iNSIP) and 42 cryptogenic organising pneumonia (COP). Autoantibody status was determined by immunoprecipitation. RESULTS 2.4% of IPF sera had a CTD-autoantibody compared to 10.2% of iNSIP and 7.3% of COP. 45% of autoantibodies were anti-synthetases. A novel autoantibody targeting an unknown 56 kDa protein was found in seven IPF patients (2.8%) and two NSIP (1%) patients. This was characterised as anti-annexin A11. CONCLUSION Specific guidance on autoantibody testing and interpretation in patients with ILD could improve diagnostic accuracy. Further work is required to determine the clinical significance of anti-annexin A11.
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Affiliation(s)
- Sarah L Tansley
- Department of Life Sciences, University of Bath, Bath, UK; Royal National Hospital for Rheumatic Diseases, Bath, UK.
| | | | | | - Huzaifa Adamali
- Bristol Interstitial Lung Disease service, North Bristol NHS Trust, Bristol, UK
| | - Shaney L Barratt
- Bristol Interstitial Lung Disease service, North Bristol NHS Trust, Bristol, UK
| | | | | | - Michael A Gibbons
- College of Medicine & Health, University of Exeter; Royal Devon University Hospitals Foundation NHS Trust
| | - Raman Kular
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Janine A Lamb
- Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Hui Lu
- Department of Life Sciences, University of Bath, Bath, UK
| | - Robert P New
- Division of Musculoskeletal and dermatological Sciences, University of Manchester, UK
| | - Diane Pratt
- Bristol Interstitial Lung Disease service, North Bristol NHS Trust, Bristol, UK
| | | | - Ross Sayers
- College of Medicine & Health, University of Exeter
| | | | | | - Edward Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lisa G Spencer
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Neil J McHugh
- Department of Life Sciences, University of Bath, Bath, UK
| | - Robert G Cooper
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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4
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Thomas-Orogan O, Barratt SL, Zafran M, Kwok A, Simons A, Judge EP, Wells M, Daly R, Sharp C, Jeyabalan A, Plummeridge M, Chandratreya L, Spencer LG, Medford ARL, Adamali HI. A Retrospective Analysis of 2-Year Follow-Up of Patients with Incidental Findings of Sarcoidosis. Diagnostics (Basel) 2024; 14:237. [PMID: 38337753 PMCID: PMC10855033 DOI: 10.3390/diagnostics14030237] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Sarcoidosis is a multi-system granulomatous disease most commonly involving the lungs. It may be incidentally diagnosed during imaging studies for other conditions or non-specific symptoms. The appropriate follow-up of incidentally diagnosed asymptomatic stage 1 disease has not been well defined. OBJECTIVE To define the clinical course of incidentally diagnosed asymptomatic stage 1 sarcoidosis and propose an algorithm for the follow-up of these patients. METHODOLOGY A retrospective case note analysis was performed of all EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration)-confirmed cases of stage 1 sarcoidosis presenting incidentally to Bristol and Liverpool Interstitial Lung Disease services. Clinical history, serology results, imaging scans, and lung function parameters were examined at baseline, 12, and 24 months. A cost analysis was performed comparing the cost of the current 2-year follow-up guidance to a 1 year follow-up period. RESULTS Sixty-seven patients were identified as the final cohort. There was no significant change in the pulmonary function tests over the two-year follow-up period. Radiological disease stability was observed in the majority of patients (58%, n = 29), and disease regression was evidenced in 40% (n = 20) at 1 year. Where imaging was performed at 2 years, the majority (69.8%, n = 37) had radiological evidence of disease regression, and 30.2% (n = 16) showed radiological evidence of stability. All patients remained asymptomatic and did not require therapeutic intervention over the study period. CONCLUSIONS Our results show that asymptomatic patients with incidental findings of thoracic lymph nodal non-caseating granulomas do not progress over a 2-year period. Our results suggest that the prolonged secondary-care follow-up of such patients may not be necessary. We propose that these patients are followed up for 1 year with a further year of patient-initiated follow-up (PIFU) prior to discharge.
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Affiliation(s)
- Oluwabukola Thomas-Orogan
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | - Shaney L. Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | - Muhammad Zafran
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | - Apollo Kwok
- Liverpool Interstitial Lung Disease Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (A.K.); (A.S.)
| | - Anneliese Simons
- Liverpool Interstitial Lung Disease Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (A.K.); (A.S.)
| | - Eoin P. Judge
- Liverpool Interstitial Lung Disease Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (A.K.); (A.S.)
| | - Matthew Wells
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | - Richard Daly
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol BS10 5NB, UK;
| | - Charles Sharp
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | - Abiramy Jeyabalan
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | - Martin Plummeridge
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
| | | | - Lisa G. Spencer
- Liverpool Interstitial Lung Disease Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (A.K.); (A.S.)
| | | | - Huzaifa I. Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK; (O.T.-O.); (S.L.B.); (M.P.)
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Dixon G, Hague S, Mulholland S, Adamali H, Khin AMN, Thould H, Connon R, Minnis P, Murtagh E, Khan F, Toor S, Lawrence A, Naqvi M, West A, Coker RK, Ward K, Yazbeck L, Hart S, Garfoot T, Newman K, Rivera-Ortega P, Stranks L, Beirne P, Bradley J, Rowan C, Agnew S, Ahmad M, Spencer LG, Aigbirior J, Fahim A, Wilson AM, Butcher E, Chong SG, Saini G, Zulfikar S, Chua F, George PM, Kokosi M, Kouranos V, Molyneaux P, Renzoni E, Vitri B, Wells AU, Nicol LM, Bianchi S, Kular R, Liu H, John A, Barth S, Wickremasinghe M, Forrest IA, Grimes I, Simpson AJ, Fletcher SV, Jones MG, Kinsella E, Naftel J, Wood N, Chalmers J, Crawshaw A, Crowley LE, Dosanjh D, Huntley CC, Walters GI, Gatheral T, Plum C, Bikmalla S, Muthusami R, Stone H, Rodrigues JC, Tsaneva-Atanasova K, Scotton CJ, Gibbons MA, Barratt SL. Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK. ERJ Open Res 2024; 10:00529-2023. [PMID: 38226064 PMCID: PMC10789269 DOI: 10.1183/23120541.00529-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/17/2023] [Indexed: 01/17/2024] Open
Abstract
Background Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting. Methods 26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey. Results 24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD. Conclusion We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.
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Affiliation(s)
- Giles Dixon
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Samuel Hague
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Sarah Mulholland
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Aye Myat Noe Khin
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Hannah Thould
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Roisin Connon
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Paul Minnis
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Eoin Murtagh
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Fasihul Khan
- Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sameen Toor
- Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Marium Naqvi
- Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Alex West
- Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Robina K. Coker
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katie Ward
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Leda Yazbeck
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Simon Hart
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Theresa Garfoot
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kate Newman
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Pilar Rivera-Ortega
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lachlan Stranks
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paul Beirne
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Sarah Agnew
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospital NHS FT, Liverpool, UK
| | - Mahin Ahmad
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospital NHS FT, Liverpool, UK
| | - Lisa G. Spencer
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospital NHS FT, Liverpool, UK
| | - Joshua Aigbirior
- New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ahmed Fahim
- New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Andrew M. Wilson
- Norfolk and Norwich University Hospital NHS Foundation Trust, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Sy Giin Chong
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gauri Saini
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Felix Chua
- Royal Brompton and Harefield Hospitals, London, UK
| | | | - Maria Kokosi
- Royal Brompton and Harefield Hospitals, London, UK
| | | | | | | | | | | | | | - Stephen Bianchi
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Raman Kular
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - HuaJian Liu
- Southern Health and Social Care Trust, Portadown, UK
| | | | - Sarah Barth
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian A. Forrest
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ian Grimes
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - A. John Simpson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Sophie V. Fletcher
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Respiratory Biomedical Research Centre and School of Clinical and Experimental Sciences, Faulty of Medicine, University of Southampton, Southampton, UK
| | - Mark G. Jones
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Respiratory Biomedical Research Centre and School of Clinical and Experimental Sciences, Faulty of Medicine, University of Southampton, Southampton, UK
| | - Emma Kinsella
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Jennifer Naftel
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Nicola Wood
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Jodie Chalmers
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anjali Crawshaw
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Louise E. Crowley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Davinder Dosanjh
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christopher C. Huntley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gareth I. Walters
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Gatheral
- University Hospitals of Morecambe Bay NHS Foundation Trust, Lancashire and South Cumbria ILD Service, Lancaster, UK
| | - Catherine Plum
- University Hospitals of Morecambe Bay NHS Foundation Trust, Lancashire and South Cumbria ILD Service, Lancaster, UK
| | - Shiva Bikmalla
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Raja Muthusami
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Helen Stone
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Jonathan C.L. Rodrigues
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department of Health, University of Bath, Bath, UK
| | - Krasimira Tsaneva-Atanasova
- Department of Mathematics and Statistics, Faculty of Environment, Science and Economy, University of Exeter, Exeter, UK
- EPSRC Hub for Quantitative Modelling in Healthcare, University of Exeter, Exeter, UK
- Living Systems Institute, University of Exeter, Exeter, UK
| | - Chris J. Scotton
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Michael A. Gibbons
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
- These authors contributed equally
| | - Shaney L. Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- These authors contributed equally
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Harding S, Williams L, Smith N, Soomro DES, Allawi S, Singh K, Chowdhury M, Deogan V, Staples A, Leung N, Srivastava S, Adamali H, Barratt SL. Animal-derived medicinal products: community representatives' views of their use. Future Healthc J 2023; 10:291-295. [PMID: 38162195 PMCID: PMC10753222 DOI: 10.7861/fhj.2023-0005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
In the UK, there are a variety of religious or cultural beliefs and preferences that guide people in a range of lifestyle decisions. This qualitative study aimed to better understand the views of the public around prescribing animal-derived products, in particular low-molecular-weight heparin (LMWH), from a potential patient perspective. A series of quality improvement focus groups with stakeholders were undertaken to understand perceptions and to evaluate and inform an established treatment pathway. Stakeholders discussed finding out about the porcine nature of LMWH asking 'Why don't they tell us?', suggesting that they 'shouldn't have to give out clues' about their personal preferences. Participants' thoughts about 'how' information be provided, by 'whom' and 'when' were gained. The stakeholders indicated that current practice is unacceptable for patients. They require greater knowledge and transparency regarding product components and recommend that healthcare professionals provide more dialogue and choice to patients.
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Affiliation(s)
- Sam Harding
- Research and Innovation North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Leonie Williams
- QSIT Team Ground Floor, Beaufort House, Southmead Hospital, NHS North Bristol Trust, Bristol, UK
| | | | | | | | - Katie Singh
- Reset & Recovery Office, Southmead Hospital, Bristol, UK
| | - Monira Chowdhury
- diversity and inclusion, HR Division, Southmead Hospital, Bristol, UK
| | - Vardeep Deogan
- Clinical Governance Division, Southmead Hospital, Bristol, UK
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Smith N, Williams L, Harding S, Singh K, Soomro DES, Alawi S, Chowdhury M, Deogan V, Parker E, Henson A, Easton F, Leung N, Staples A, Srivastava S, Adamali H, Barratt SL. Factoring patients' beliefs and values into decisions around anticoagulation: a community-led multi-cycle quality improvement project. Future Healthc J 2023; 10:301-305. [PMID: 38162220 PMCID: PMC10753224 DOI: 10.7861/fhj.2023-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Low-molecular-weight heparin (LMWH), prescribed for prophylaxis of venous thromboembolism, is derived from porcine animal products. An audit in our Trust showed that most healthcare professionals (95%, n=58/61) did not consider religious or dietary preferences when prescribing LMWH. Focus groups with local stakeholders helped develop project aims. Quality improvement methods were used to develop, test and optimise interventions over two cycles in our medical unit. Interventions included written and audiovisual information for patients, a staff eLearning module, a policy to guide switching from LMWH to a synthetic alternative and a written prompt reminding doctors to consent patients before prescribing LMWH. The proportion of patients being appropriately consented for LMWH prescriptions increased following our interventions (from <5% at baseline to >80%). Patient and staff feedback was positive, with high demand for a non-animal-derived alternative to LMWH. Simple measures, increasing awareness and knowledge among staff and patients, can improve the number of patients being appropriately consented for LMWH prescriptions.
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Roofeh D, Brown KK, Kazerooni EA, Tashkin D, Assassi S, Martinez F, Wells AU, Raghu G, Denton CP, Chung L, Hoffmann-Vold AM, Distler O, Johannson KA, Allanore Y, Matteson EL, Kawano-Dourado L, Pauling JD, Seibold JR, Volkmann ER, Walsh SLF, Oddis CV, White ES, Barratt SL, Bernstein EJ, Domsic RT, Dellaripa PF, Conway R, Rosas I, Bhatt N, Hsu V, Ingegnoli F, Kahaleh B, Garcha P, Gupta N, Khanna S, Korsten P, Lin C, Mathai SC, Strand V, Doyle TJ, Steen V, Zoz DF, Ovalles-Bonilla J, Rodriguez-Pinto I, Shenoy PD, Lewandoski A, Belloli E, Lescoat A, Nagaraja V, Ye W, Huang S, Maher T, Khanna D. Systemic sclerosis associated interstitial lung disease: a conceptual framework for subclinical, clinical and progressive disease. Rheumatology (Oxford) 2023; 62:1877-1886. [PMID: 36173318 PMCID: PMC10152284 DOI: 10.1093/rheumatology/keac557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Received: 04/17/2022] [Revised: 08/05/2022] [Accepted: 09/17/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To establish a framework by which experts define disease subsets in systemic sclerosis associated interstitial lung disease (SSc-ILD). METHODS A conceptual framework for subclinical, clinical and progressive ILD was provided to 83 experts, asking them to use the framework and classify actual SSc-ILD patients. Each patient profile was designed to be classified by at least four experts in terms of severity and risk of progression at baseline; progression was based on 1-year follow-up data. A consensus was reached if ≥75% of experts agreed. Experts provided information on which items were important in determining classification. RESULTS Forty-four experts (53%) completed the survey. Consensus was achieved on the dimensions of severity (75%, 60 of 80 profiles), risk of progression (71%, 57 of 80 profiles) and progressive ILD (60%, 24 of 40 profiles). For profiles achieving consensus, most were classified as clinical ILD (92%), low risk (54%) and stable (71%). Severity and disease progression overlapped in terms of framework items that were most influential in classifying patients (forced vital capacity, extent of lung involvement on high resolution chest CT [HRCT]); risk of progression was influenced primarily by disease duration. CONCLUSIONS Using our proposed conceptual framework, international experts were able to achieve a consensus on classifying SSc-ILD patients along the dimensions of disease severity, risk of progression and progression over time. Experts rely on similar items when classifying disease severity and progression: a combination of spirometry and gas exchange and quantitative HRCT.
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Affiliation(s)
- David Roofeh
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Ella A Kazerooni
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
- Department of Radiology, Division of Cardiothoracic Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Donald Tashkin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shervin Assassi
- Department of Internal Medicine, Division of Rheumatology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Fernando Martinez
- Department of Internal Medicine, Division of Pulmonary Critical Care Medicine, Weill Cornell School of Medicine, New York, NY, USA
| | - Athol U Wells
- Department of Internal Medicine, Division of Pulmonology, Royal Brompton Hospital and National Heart and Lung Institute, London, UK
| | - Ganesh Raghu
- Department of Internal Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Christopher P Denton
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Lorinda Chung
- Department of Internal Medicine, Division of Immunology and Rheumatology, Stanford University, and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kerri A Johannson
- Departments of Medicine and Community Health Sciences, Section of Respiratory Medicine, University of Calgary, Calgary, Canada
| | - Yannick Allanore
- Department of Rheumatology A, Cochin Hospital, APHP, Université de Paris, Paris, France
| | - Eric L Matteson
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Leticia Kawano-Dourado
- HCor Research Institute, Hospital do Coração, São Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
- INSERM 1152, University of Paris, Paris, France
| | - John D Pauling
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Rheumatology, North Bristol NHS Trust, Southmead, Bristol, UK
| | | | - Elizabeth R Volkmann
- Department of Internal Medicine, Division of Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Chester V Oddis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric S White
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Shaney L Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Southmead, Bristol, UK
| | - Elana J Bernstein
- Department of Internal Medicine, Division of Rheumatology, Columbia University School of Medicine, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Robyn T Domsic
- Department of Internal Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul F Dellaripa
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Conway
- Department of Internal Medicine, Division of Rheumatology, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Ivan Rosas
- Department of Internal Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Nitin Bhatt
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vivien Hsu
- Department of Internal Medicine, Division of Rheumatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Francesca Ingegnoli
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milano, Italy
| | - Bashar Kahaleh
- Department of Internal Medicine, Division of Rheumatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Puneet Garcha
- Department of Internal Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Nishant Gupta
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Surabhi Khanna
- Department of Internal Medicine, Division of Rheumatology, University of Cincinnati, Cincinnati, OH, USA
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Celia Lin
- Genentech, Inc, San Francisco, CA, USA
| | - Stephen C Mathai
- Department of Internal Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vibeke Strand
- Department of Internal Medicine, Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Tracy J Doyle
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Virginia Steen
- Department of Internal Medicine, Division of Rheumatology, Georgetown University School of Medicine, Washington, DC, USA
| | - Donald F Zoz
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Juan Ovalles-Bonilla
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ignasi Rodriguez-Pinto
- Autoimmune Disease Unit. Deaprtment of Internal Medicine. Hospital Mutua de Terrassa, University of Barcelona, Barcelona, Spain
| | - Padmanabha D Shenoy
- Department of Rheumatology, Center for Arthritis and Rheumatism Excellence, Kochi, Kerala, India
| | - Andrew Lewandoski
- Department of Internal Medicine, Division of Rheumatology, University of Michigan-Metro Health, Grand Rapids, MI, USA
| | - Elizabeth Belloli
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alain Lescoat
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Vivek Nagaraja
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Wen Ye
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Suiyuan Huang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Toby Maher
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
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Williams RL, Hyams C, Robertshaw J, Gonzalez MG, Szasz-Benczur Z, White P, Maskell NA, Finn A, Barratt SL. Use of illness severity scores to predict mortality in interstitial lung disease patients hospitalised with acute respiratory deterioration. Respir Med 2023; 212:107220. [PMID: 36997098 DOI: 10.1016/j.rmed.2023.107220] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Hospitalisations relating to acute respiratory deteriorations (ARD) in Interstitial Lung Disease (ILD) have poor outcomes. Factors predicting adverse outcomes are not fully understood and data addressing the use of illness severity scores in prognostication are limited. OBJECTIVE To investigate the use of CURB-65 and NEWS-2 severity scores in the prediction of mortality following ARD-ILD hospitalisation, using prospective methodology and to validate previously determined cut-offs, derived from a retrospective study cohort. METHODS A dual-centre prospective observational cohort study of all adults (≥18y) hospitalised with ARD-ILD in Bristol, UK (n = 179). Gender-Age-Physiology (GAP), CURB-65 and NEWS-2 scores were calculated for each eligible admission. Receiver operating characteristics (ROC) curve analysis was used to quantify the strength of discrimination for NEWS-2 and CURB-65 scores. Univariable and multivariable logistic regression analyses were performed to explore the relationship between baseline severity scores and mortality. RESULTS GAP showed some merit at predicting 30-day mortality (AUC = 0.64, P = 0.015); whereas CURB-65 showed modest predictive value for in-hospital (AUC = 0.72, P < 0.001) and 90-day mortality (AUC = 0.67, P < 0.001). NEWS-2 showed higher predictive value for in-hospital (AUC = 0.80, P < 0.001) and 90-day mortality (AUC = 0.75, P < 0.001), with an optimal derived cut-off ≥6.5 found to be sensitive and specific for predicting in-hospital (83% and 63%) and 90-day (73% and 72%) mortality. In exploratory analyses, GAP score addition improved the predictive ability of NEWS-2 against 30-day mortality and CURB-65 across all time-periods. CONCLUSION NEWS-2 has good discriminatory value for predicting in-hospital mortality and moderate discriminatory value for predicting 90-day mortality. The optimal NEWS-2 cut-off value determined was the same as in a previous retrospective cohort, confirming the NEWS-2 score shows promise in predicting mortality following ARD-ILD hospitalisation.
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Affiliation(s)
- Rachel L Williams
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK; Research and Innovation, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK
| | - Catherine Hyams
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK; Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK; Bristol Vaccine Centre, Schools of Population Health Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, BS2 8AE, UK; Vaccine and Testing Team, UHBW NHS Trust, Bristol, UK
| | - Joe Robertshaw
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK; Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK
| | - Maria Garcia Gonzalez
- Bristol Vaccine Centre, Schools of Population Health Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, BS2 8AE, UK; Vaccine and Testing Team, UHBW NHS Trust, Bristol, UK
| | - Zsuzsa Szasz-Benczur
- Bristol Vaccine Centre, Schools of Population Health Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, BS2 8AE, UK
| | - Paul White
- University of the West of England, Bristol, BS16 1QY, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK
| | - Adam Finn
- Bristol Vaccine Centre, Schools of Population Health Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, BS2 8AE, UK
| | - Shaney L Barratt
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK; Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Southmead, Bristol, BS10 5NB, UK.
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10
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Stewart I, Jacob J, George PM, Molyneaux PL, Porter JC, Allen RJ, Aslani S, Baillie JK, Barratt SL, Beirne P, Bianchi SM, Blaikley JF, Chalmers JD, Chambers RC, Chadhuri N, Coleman C, Collier G, Denneny EK, Docherty A, Elneima O, Evans RA, Fabbri L, Gibbons MA, Gleeson FV, Gooptu B, Greening NJ, Guio BG, Hall IP, Hanley NA, Harris V, Harrison EM, Heightman M, Hillman TE, Horsley A, Houchen-Wolloff L, Jarrold I, Johnson SR, Jones MG, Khan F, Lawson R, Leavy O, Lone N, Marks M, McAuley H, Mehta P, Parekh D, Hanley KP, Platé M, Pearl J, Poinasamy K, Quint JK, Raman B, Richardson M, Rivera-Ortega P, Saunders L, Saunders R, Semple MG, Sereno M, Shikotra A, Simpson AJ, Singapuri A, Smith DJF, Spears M, Spencer LG, Stanel S, Thickett DR, Thompson AAR, Thorpe M, Walsh SLF, Walker S, Weatherley ND, Weeks ME, Wild JM, Wootton DG, Brightling CE, Ho LP, Wain LV, Jenkins GR. Residual Lung Abnormalities after COVID-19 Hospitalization: Interim Analysis of the UKILD Post-COVID-19 Study. Am J Respir Crit Care Med 2023; 207:693-703. [PMID: 36457159 PMCID: PMC10037479 DOI: 10.1164/rccm.202203-0564oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [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] [Received: 03/21/2022] [Accepted: 12/01/2022] [Indexed: 12/04/2022] Open
Abstract
Rationale: Shared symptoms and genetic architecture between coronavirus disease (COVID-19) and lung fibrosis suggest severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may lead to progressive lung damage. Objectives: The UK Interstitial Lung Disease Consortium (UKILD) post-COVID-19 study interim analysis was planned to estimate the prevalence of residual lung abnormalities in people hospitalized with COVID-19 on the basis of risk strata. Methods: The PHOSP-COVID-19 (Post-Hospitalization COVID-19) study was used to capture routine and research follow-up within 240 days from discharge. Thoracic computed tomography linked by PHOSP-COVID-19 identifiers was scored for the percentage of residual lung abnormalities (ground-glass opacities and reticulations). Risk factors in linked computed tomography were estimated with Bayesian binomial regression, and risk strata were generated. Numbers within strata were used to estimate posthospitalization prevalence using Bayesian binomial distributions. Sensitivity analysis was restricted to participants with protocol-driven research follow-up. Measurements and Main Results: The interim cohort comprised 3,700 people. Of 209 subjects with linked computed tomography (median, 119 d; interquartile range, 83-155), 166 people (79.4%) had more than 10% involvement of residual lung abnormalities. Risk factors included abnormal chest X-ray (risk ratio [RR], 1.21; 95% credible interval [CrI], 1.05-1.40), percent predicted DlCO less than 80% (RR, 1.25; 95% CrI, 1.00-1.56), and severe admission requiring ventilation support (RR, 1.27; 95% CrI, 1.07-1.55). In the remaining 3,491 people, moderate to very high risk of residual lung abnormalities was classified at 7.8%, and posthospitalization prevalence was estimated at 8.5% (95% CrI, 7.6-9.5), rising to 11.7% (95% CrI, 10.3-13.1) in the sensitivity analysis. Conclusions: Residual lung abnormalities were estimated in up to 11% of people discharged after COVID-19-related hospitalization. Health services should monitor at-risk individuals to elucidate long-term functional implications.
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Affiliation(s)
- Iain Stewart
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | | | - Peter M. George
- Royal Brompton and Harefield Clinical Group, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Philip L. Molyneaux
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | | | - Richard J. Allen
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | | | | | | | - Paul Beirne
- Leeds Teaching Hospitals NHS Foundation Trust, Leeds, United Kingdom
| | - Stephen M. Bianchi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | | | | | | | | | | | | | | | | | - Omer Elneima
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Rachael A. Evans
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Laura Fabbri
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | | | - Fergus V. Gleeson
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Bibek Gooptu
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Neil J. Greening
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Beatriz Guillen Guio
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Ian P. Hall
- University of Nottingham, Nottingham, United Kingdom
| | | | - Victoria Harris
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | | | | | | | - Alex Horsley
- University of Manchester, Manchester, United Kingdom
| | | | | | | | - Mark G. Jones
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Fasihul Khan
- University of Nottingham, Nottingham, United Kingdom
| | - Rod Lawson
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Olivia Leavy
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Michael Marks
- University College London Hospital, London, United Kingdom
| | - Hamish McAuley
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Puja Mehta
- University College London Hospital, London, United Kingdom
| | - Dhruv Parekh
- University of Birmingham, Brimingham, United Kingdom
| | - Karen Piper Hanley
- University of Manchester, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Manuela Platé
- University College London Hospital, London, United Kingdom
| | - John Pearl
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Jennifer K. Quint
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Betty Raman
- University of Oxford, Oxford, United Kingdom
| | | | | | | | - Ruth Saunders
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | | | - Marco Sereno
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Aarti Shikotra
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | | | - Amisha Singapuri
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - David J. F. Smith
- Royal Brompton and Harefield Clinical Group, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Mark Spears
- Perth Royal Infirmary, NHS Tayside, Perth, United Kingdom; and
| | - Lisa G. Spencer
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Stefan Stanel
- University of Manchester, Manchester, United Kingdom
| | | | | | | | - Simon L. F. Walsh
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | | | | | - Mark E. Weeks
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Jim M. Wild
- University of Sheffield, Sheffield, United Kingdom
| | | | | | - Ling-Pei Ho
- University of Oxford, Oxford, United Kingdom
| | - Louise V. Wain
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom
| | - Gisli R. Jenkins
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
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11
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Raman L, Stewart I, Barratt SL, Chua F, Chaudhuri N, Crawshaw A, Gibbons M, Hogben C, Hoyles R, Kouranos V, Martinovic J, Mulholland S, Myall KJ, Naqvi M, Renzoni EA, Saunders P, Steward M, Suresh D, Thillai M, Wells AU, West A, Mitchell JA, George PM. Nintedanib for non-IPF progressive pulmonary fibrosis: 12-month outcome data from a real-world multicentre observational study. ERJ Open Res 2023; 9:00423-2022. [PMID: 36949962 PMCID: PMC10026008 DOI: 10.1183/23120541.00423-2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022] Open
Abstract
Background Nintedanib slows lung function decline for patients with non-idiopathic pulmonary fibrosis progressive pulmonary fibrosis (PPF) in clinical trials, but the real-world safety and efficacy are not known. Methods In this retrospective cohort study, standardised data were collected from patients in whom nintedanib was initiated for PPF between 2019 and 2020 through an early-access programme across eight centres in the United Kingdom. Rate of lung function change in the 12 months pre- and post-nintedanib initiation was the primary analysis. Symptoms, drug safety, tolerability and stratification by interstitial lung disease subtype and computed tomography pattern were secondary analyses. Results 126 patients were included; 67 (53%) females; mean±sd age 60±13 years. At initiation of nintedanib, mean forced vital capacity (FVC) was 1.87 L (58% predicted) and diffusing capacity of the lung for carbon monoxide (D LCO) was 32.7% predicted. 68% of patients were prescribed prednisolone (median dose 10 mg) and 69% were prescribed a steroid-sparing agent. In the 12 months after nintedanib initiation, lung function decline was significantly lower than in the preceding 12 months: FVC -88.8 mL versus -239.9 mL (p=0.004), and absolute decline in D LCO -2.1% versus -6.1% (p=0.004). Response to nintedanib was consistent in sensitivity and secondary analyses. 89 (71%) out of 126 patients reported side-effects, but 86 (80%) of the surviving 108 patients were still taking nintedanib at 12 months with patients reporting a reduced perception of symptom decline. There were no serious adverse events. Conclusion In PPF, the real-world efficacy of nintedanib replicated that of clinical trials, significantly attenuating lung function decline. Despite the severity of disease, nintedanib was safe and well tolerated in this real-world multicentre study.
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Affiliation(s)
- Lavanya Raman
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
- These authors contributed equally
| | - Iain Stewart
- National Heart and Lung Institute, Imperial College London, London, UK
- These authors contributed equally
| | | | - Felix Chua
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Nazia Chaudhuri
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Anjali Crawshaw
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael Gibbons
- College of Medicine and Health, University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Rachel Hoyles
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | | | | | - Marium Naqvi
- Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Elisabetta A. Renzoni
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Peter Saunders
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Corresponding author: Peter George ()
| | | | - Dharmic Suresh
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Muhunthan Thillai
- Royal Papworth Hospital NHS Foundation Trust, ILD unit Royal Papworth Hospital, Cambridge, UK
| | - Athol U. Wells
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Alex West
- Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jane A. Mitchell
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Peter M. George
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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12
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Mikolasch TA, George PM, Sahota J, Nancarrow T, Barratt SL, Woodhead FA, Kouranos V, Cope VS, Creamer AW, Fidan S, Ganeshan B, Hoy L, Mackintosh JA, Shortman R, Duckworth A, Fallon J, Garthwaite H, Heightman M, Adamali HI, Lines S, Win T, Wollerton R, Renzoni EA, Steward M, Wells AU, Gibbons M, Groves AM, Gooptu B, Scotton CJ, Porter JC. Multi-center evaluation of baseline neutrophil-to-lymphocyte (NLR) ratio as an independent predictor of mortality and clinical risk stratifier in idiopathic pulmonary fibrosis. EClinicalMedicine 2023; 55:101758. [PMID: 36483266 PMCID: PMC9722446 DOI: 10.1016/j.eclinm.2022.101758] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal disorder with a variable disease trajectory. The aim of this study was to assess the potential of neutrophil-to-lymphocyte ratio (NLR) to predict outcomes in IPF. Methods We adopted a two-stage discovery (n = 71) and validation (n = 134) design using patients from the UCL partners (UCLp) cohort. We then combined discovery and validation cohorts and included an additional 794 people with IPF, using real-life data from 5 other UK centers, to give a combined cohort of 999 patients. Data were collected from patients presenting over a 13-year period (2006-2019) with mean follow up of 3.7 years (censoring: 2018-2020). Findings In the discovery analysis, we showed that high values of NLR (>/ = 2.9 vs < 2.9) were associated with increased risk of mortality in IPF (HR 2.04, 95% CI 1.09-3.81, n = 71, p = 0.025). This was confirmed in the validation (HR 1.91, 95% CI 1.15-3.18, n = 134, p = 0.0114) and combined cohorts (HR 1.65, n = 999, 95% CI 1.39-1.95; p < 0·0001). NLR correlated with GAP stage and GAP index (p < 0.0001). Stratifying patients by NLR category (low/high) showed significant differences in survival for GAP stage 2 (p < 0.0001), however not for GAP stage 1 or 3. In a multivariate analysis, a high NLR was an independent predictor of mortality/progression after adjustment for individual GAP components and steroid/anti-fibrotic use (p < 0·03). Furthermore, incorporation of baseline NLR in a modified GAP-stage/index, GAP-index/stage-plus, refined prognostic ability as measured by concordance (C)-index. Interpretation We have identified NLR as a widely available test that significantly correlates with lung function, can predict outcomes in IPF and refines cohort staging with GAP. NLR may allow timely prioritisation of at-risk patients, even in the absence of lung function. Funding Breathing Matters, GSK, CF Trust, BLF-Asthma, MRC, NIHR Alpha-1 Foundation.
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Affiliation(s)
- Theresia A. Mikolasch
- CITR, UCL Respiratory, UCL, London, UK
- Interstitial Lung Disease Service, UCLH NHS Trust, London, UK
| | - Peter M. George
- Interstitial Lung Disease Unit, Royal Brompton Hospital, UK
- National Heart and Lung Institute, Imperial College London, UK
| | - Jagdeep Sahota
- CITR, UCL Respiratory, UCL, London, UK
- Interstitial Lung Disease Service, UCLH NHS Trust, London, UK
| | - Thomas Nancarrow
- College of Medicine & Health, University of Exeter, Exeter, UK
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Shaney L. Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Felix A. Woodhead
- Institute for Lung Health and Leicester Interstitial Lung Disease Service and NIHR Leicester Biomedical Research Centre - Respiratory, Glenfield Hospital, Groby Road, Leicester, LE3, UK
- Department of Respiratory Sciences and Leicester Institute of Structural & Chemical Biology University of Leicester, Henry Wellcome Building, Lancaster Road, Leicester, LE1 5HB, UK
| | - Vasilis Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, UK
- National Heart and Lung Institute, Imperial College London, UK
| | | | - Andrew W. Creamer
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Silan Fidan
- Institute for Lung Health and Leicester Interstitial Lung Disease Service and NIHR Leicester Biomedical Research Centre - Respiratory, Glenfield Hospital, Groby Road, Leicester, LE3, UK
- Department of Respiratory Sciences and Leicester Institute of Structural & Chemical Biology University of Leicester, Henry Wellcome Building, Lancaster Road, Leicester, LE1 5HB, UK
| | - Balaji Ganeshan
- Institute of Nuclear Medicine, UCL and Department of Nuclear Medicine UCLH, UK
| | - Luke Hoy
- Institute of Nuclear Medicine, UCL and Department of Nuclear Medicine UCLH, UK
| | - John A. Mackintosh
- Interstitial Lung Disease Unit, Royal Brompton Hospital, UK
- The Prince Charles Hospital, Queensland, Australia
| | - Robert Shortman
- Institute of Nuclear Medicine, UCL and Department of Nuclear Medicine UCLH, UK
| | - Anna Duckworth
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Janet Fallon
- Department of Respiratory Medicine, Somerset Lung Centre, Musgrove Park Hospital, Taunton, UK
| | | | | | - Huzaifa I. Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Sarah Lines
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Thida Win
- Lister Hospital, North East Herts Trust, Stevenage UK
| | - Rebecca Wollerton
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Elisabetta A. Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, UK
- National Heart and Lung Institute, Imperial College London, UK
| | - Matthew Steward
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, UK
- National Heart and Lung Institute, Imperial College London, UK
| | - Michael Gibbons
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Ashley M. Groves
- Institute of Nuclear Medicine, UCL and Department of Nuclear Medicine UCLH, UK
| | - Bibek Gooptu
- Institute for Lung Health and Leicester Interstitial Lung Disease Service and NIHR Leicester Biomedical Research Centre - Respiratory, Glenfield Hospital, Groby Road, Leicester, LE3, UK
- Department of Respiratory Sciences and Leicester Institute of Structural & Chemical Biology University of Leicester, Henry Wellcome Building, Lancaster Road, Leicester, LE1 5HB, UK
| | - Chris J. Scotton
- College of Medicine & Health, University of Exeter, Exeter, UK
- Academic Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Joanna C. Porter
- CITR, UCL Respiratory, UCL, London, UK
- Interstitial Lung Disease Service, UCLH NHS Trust, London, UK
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13
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Wells M, Alawi S, Thin KYM, Gunawardena H, Brown AR, Edey A, Pauling JD, Barratt SL, Adamali HI. A multidisciplinary approach to the diagnosis of antisynthetase syndrome. Front Med (Lausanne) 2022; 9:959653. [PMID: 36186825 PMCID: PMC9515890 DOI: 10.3389/fmed.2022.959653] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Antisynthetase syndrome is a subtype of idiopathic inflammatory myopathy, strongly associated with the presence of interstitial lung disease. Diagnosis is made by identifying myositis-specific antibodies directed against aminoacyl tRNA synthetase, and relevant clinical and radiologic features. Given the multisystem nature of the disease, diagnosis requires the careful synthesis of subtle clinical and radiological features with the interpretation of specialized autoimmune serological testing. This is provided in a multidisciplinary environment with input from rheumatologists, respiratory physicians, and radiologists. Differentiation from other idiopathic interstitial lung diseases is key; treatment and prognosis differ between patients with antisynthetase syndrome and idiopathic interstitial lung disease. In this review article, we look at the role of the multidisciplinary team and its individual members in the initial diagnosis of the antisynthetase syndrome, including the role of physicians, radiologists, and the wider team.
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Affiliation(s)
- Matthew Wells
- Department of Rheumatology, North Bristol NHS Trust, Bristol, United Kingdom
| | - Sughra Alawi
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Kyaing Yi Mon Thin
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Harsha Gunawardena
- Department of Rheumatology, North Bristol NHS Trust, Bristol, United Kingdom
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Adrian R Brown
- Immunology Laboratory, North Bristol NHS Trust, Bristol, United Kingdom
| | - Anthony Edey
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - John D Pauling
- Department of Rheumatology, North Bristol NHS Trust, Bristol, United Kingdom
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Huzaifa I Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
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14
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Hardacre CJ, Robertshaw JA, Barratt SL, Adams HL, MacKenzie Ross RV, Robinson GRE, Suntharalingam J, Pauling JD, Rodrigues JCL. Diagnostic test accuracy of artificial intelligence analysis of cross-sectional imaging in pulmonary hypertension: a systematic literature review. Br J Radiol 2021; 94:20210332. [PMID: 34541861 PMCID: PMC8631018 DOI: 10.1259/bjr.20210332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/28/2021] [Accepted: 08/31/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To undertake the first systematic review examining the performance of artificial intelligence (AI) applied to cross-sectional imaging for the diagnosis of acquired pulmonary arterial hypertension (PAH). METHODS Searches of Medline, Embase and Web of Science were undertaken on 1 July 2020. Original publications studying AI applied to cross-sectional imaging for the diagnosis of acquired PAH in adults were identified through two-staged double-blinded review. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies and Checklist for Artificial Intelligence in Medicine frameworks. Narrative synthesis was undertaken following Synthesis Without Meta-Analysis guidelines. This review received no funding and was registered in the International Prospective Register of Systematic Reviews (ID:CRD42020196295). RESULTS Searches returned 476 citations. Three retrospective observational studies, published between 2016 and 2020, were selected for data-extraction. Two methods applied to cardiac-MRI demonstrated high diagnostic accuracy, with the best model achieving AUC=0.90 (95% CI: 0.85-0.93), 89% sensitivity and 81% specificity. Stronger results were achieved using cardiac-MRI for classification of idiopathic PAH, achieving AUC=0.97 (95% CI: 0.89-1.0), 96% sensitivity and 87% specificity. One study reporting CT-based AI demonstrated lower accuracy, with 64.6% sensitivity and 97.0% specificity. CONCLUSIONS Automated methods for identifying PAH on cardiac-MRI are emerging with high diagnostic accuracy. AI applied to cross-sectional imaging may provide non-invasive support to reduce diagnostic delay in PAH. This would be helped by stronger solutions in other modalities. ADVANCES IN KNOWLEDGE There is a significant shortage of research in this important area. Early detection of PAH would be supported by further research advances on the promising emerging technologies identified.
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Affiliation(s)
| | | | - Shaney L Barratt
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
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15
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Roofeh D, Barratt SL, Wells AU, Kawano-Dourado L, Tashkin D, Strand V, Seibold J, Proudman S, Brown KK, Dellaripa PF, Doyle T, Leonard T, Matteson EL, Oddis CV, Solomon JJ, Sparks JA, Vassallo R, Maxwell L, Beaton D, Christensen R, Townsend W, Khanna D. Outcome measurement instrument selection for lung physiology in systemic sclerosis associated interstitial lung disease: A systematic review using the OMERACT filter 2.1 process. Semin Arthritis Rheum 2021; 51:1331-1341. [PMID: 34493396 PMCID: PMC8678187 DOI: 10.1016/j.semarthrit.2021.08.001] [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] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The Outcome Measures in Rheumatology (OMERACT) is a research organization focused on improving health care outcomes for patients with autoimmune and musculoskeletal diseases. The Connective Tissue Disease-Interstitial Lung Disease (CTD-ILD) Working Group on Lung Physiology is a group within OMERACT charged with identifying outcome measures that should be implemented in studies of patients with CTD-ILD. The OMERACT Filter 2.1 is an evidence-based algorithm used to identify outcome measures that are truthful, feasible, and able to discriminate between groups of interest. Our objective was to summate evidence (published literature, key opinion leader input, patient perspectives) that would influence the CTD-ILD Working Group's vote to accept or reject the use of two measures of lung physiology, the forced vital capacity (FVC) and the diffusion capacity of carbon monoxide (DLco) for use in randomized controlled trials (RTCs) and longitudinal observational studies (LOSs) involving patients with systemic sclerosis associated ILD (SSc-ILD). METHODS Patient Research Partners (those afflicted with SSc-ILD) and the CTD-ILD Working Group on Lung Physiology were polled to assess their opinion on the FVC and DLco in terms of feasibility; the CTD-ILD Working Group was also queried on these instruments' face and content validity. We then conducted a systematic literature review to identify articles in the SSc-ILD population that assessed the following measurement properties of FVC and DLco: (1) construct validity, (2) test-retest reliability, (3) longitudinal construct validity, (4) clinical trial discrimination/sensitivity to detect change in clinical trials, and (5) thresholds of meaning. Results were summarized in a Summary of Measurement Properties (SOMP) table for each instrument. OMERACT CTD-ILD Working Group members discussed and voted on the strength of evidence supporting these two instruments and voted to endorse, provisionally endorse, or not endorse either instrument. RESULTS Forty Patient Research Partners reported these two measures are feasible (are not an unnecessary burden or represent an infeasible longitudinal assessment of their disease). A majority of the 18 CTD-ILD Working Group members voted that both the FVC and DLco are feasible and have face and content validity. The systematic literature review returned 1,447 non-duplicated articles, of which 177 met eligibility for full text review. Forty-eight studies (13 RCTs, 35 LOSs) were included in the qualitative analysis. The FVC SOMP table revealed high quality, consistent data with evidence of good performance for all five measurement properties, suggesting requisite published evidence to proceed with endorsement. The DLco SOMP table showed a lack of data to support test-retest reliability and inadequate evidence to support clinical trial discrimination. There was unanimous agreement (15 [100%]) among voting CTD-ILD Working Group members to endorse the FVC as an instrument for lung physiology in RCTs and LOSs in SSc-ILD. Based on currently available evidence, DLco did not meet the OMERACT criteria and is not recommended for use in RCTs to represent lung physiology of SSc-ILD. The OMERACT Technical Advisory Group agreed with these decisions. CONCLUSION The OMERACT Filter 2.1 was successfully applied to the domain of lung physiology in patients with SSc-ILD. The FVC was endorsed for use in RCTs and LOSs based on the Working Group's vote; DLco was not endorsed.
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Affiliation(s)
- David Roofeh
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Shaney L. Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, UK; Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Southmead, Bristol, UK
| | - Athol U Wells
- Department of Internal Medicine, Division of Pulmonology, Royal Brompton Hospital and National Heart and Lung Institute; London, UK
| | - Leticia Kawano-Dourado
- HCor Research Institute, Hospital do Coração, São Paulo, Brazil; Pulmonary Division, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Donald Tashkin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, California, USA
| | - James Seibold
- Scleroderma Research Consultants, Aiken, South Carolina, USA
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital and Professor Discipline of Medicine, University of Adelaide, Adelaide, AUS
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Hospital, Denver, Colorado, USA
| | - Paul F Dellaripa
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tracy Doyle
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Leonard
- Clinical Development and Medical Affairs, Specialty Care Boehringer Ingelheim Pharmaceuticals, Inc
| | - Eric L Matteson
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chester V Oddis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joshua J Solomon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Hospital, Denver, Colorado, USA
| | - Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Vassallo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lara Maxwell
- Faculty of Medicine, University of Ottawa, Ottawa, CA
| | - Dorcas Beaton
- Institute for Work & Health and Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, CA
| | - Robin Christensen
- Musculoskeletal Statistics Unit, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Whitney Townsend
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, Scleroderma Program, University of Michigan, Ann Arbor, Michigan, USA
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Hyams C, Hettle D, Bibby A, Adamali HA, Barratt SL. Utility of illness severity scores to predict mortality in patients hospitalized with respiratory deterioration of idiopathic pulmonary fibrosis. QJM 2021; 114:559-567. [PMID: 32609364 DOI: 10.1093/qjmed/hcaa214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/19/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION In the context of idiopathic pulmonary fibrosis (IPF), respiratory-related admissions to hospital are associated with a high morbidity and short-term mortality with significant burden on secondary care services. It has yet to be determined how to accurately identify patients at risk of acute respiratory deterioration (ARD) or the prognosticating factors. AIM We sought to define the characteristics of hospitalized ARD-IPF patients in a real-world cohort and investigate factors associated with worse outcomes. Specifically, we wished to determine the association between baseline CURB-65 and NEWS-2 and mortality in IPF, given illness severity scores have not previously been validated in this cohort. METHODS Single-centre retrospective observational cohort study. RESULTS Of 172 first hospitalizations for ARD, 27 admissions (15.7%) were due to an acute exacerbation of IPF (AE-IPF), 28 (16.3%) secondary to cardiac failure/fluid overload and 17 due to pneumonia (9.9%). Other admissions related to lower respiratory tract infection, extra-parenchymal causes and those without a specific trigger. Baseline patient characteristics were comparable for all underlying aetiologies of ARD-IPF. Treatment pathways did not differ significantly between AE-IPF and other causes of ARD-IPF. Short-term mortality was high, with ∼22% patients dying within 30 days. Illness severity scores (NEWS-2 and CURB-65) were independent predictors of mortality in multivariable logistic regression modelling. CONCLUSIONS Our findings suggest significant mortality related to hospitalization with ARD-IPF of any underlying cause. Our data support the use of CURB-65 and NEWS-2 scores as illness severity scores that can provide a simple tool to help future prognostication in IPF. Research should be aimed at refining the management of these episodes, to try to reduce mortality, where possible, or to facilitate palliative care for those with adverse prognostic characteristics.
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Affiliation(s)
- C Hyams
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust Southmead Road, Bristol BS10 5NB, UK
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - D Hettle
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust Southmead Road, Bristol BS10 5NB, UK
| | - A Bibby
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust Southmead Road, Bristol BS10 5NB, UK
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - H A Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust Southmead Road, Bristol BS10 5NB, UK
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - S L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust Southmead Road, Bristol BS10 5NB, UK
- Academic Respiratory Unit, University of Bristol, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
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Barratt SL, Creamer AW, Adamali HI, Duckworth A, Fallon J, Fidan S, Nancarrow T, Wollerton R, Steward M, Gooptu B, Gibbons M, Woodhead FA, Scotton C. Use of peripheral neutrophil to lymphocyte ratio and peripheral monocyte levels to predict survival in fibrotic hypersensitivity pneumonitis (fHP): a multicentre retrospective cohort study. BMJ Open Respir Res 2021; 8:e001063. [PMID: 34794958 PMCID: PMC8603296 DOI: 10.1136/bmjresp-2021-001063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/20/2021] [Indexed: 02/04/2023] Open
Abstract
The factors determining disease course and survival in fibrotic hypersensitivity pneumonitis (fHP) have not been fully elucidated.The aim of this study was to describe the characteristics of patients with fHP in a real-world cohort and investigate factors associated with worse outcomes. We aimed to explore the use of neutrophil to lymphocyte ratio (NLR) and peripheral blood monocyte levels in predicting mortality. METHODS A retrospective, multicentre, observational UK cohort study. RESULTS Patients with fHP were significantly younger than those with idiopathic pulmonary fibrosis (IPF) (median age fHP 73 vs IPF 75 years) and were much more likely to be woman (fHP 61% vs IPF 26%). In almost half of all fHP cases (49%, n=104/211), no causative antigen was identified from either the history or specific antigen testing. Overall, fHP was associated with a better survival than IPF, although median survival of both groups was poor (fHP 62 months vs IPF 52 months).IPF survival in patients with a high NLR was significantly lower than those with a low NLR (44 vs 83 months). A monocyte count ≥0.95 K/uL also predicted significantly poorer outcomes for patients with IPF compared with <0.95 K/uL (33 vs 57 months). In contrast, NLR and monocyte count did not predict survival in the fHP cohort. CONCLUSIONS Although fHP has a statistically lower mortality than IPF, absolute survival time of both conditions is poor. High baseline NLR and absolute monocyte counts predict worse survival in IPF but not in fHP, highlighting the potential for divergence in their pathogenic mechanisms.
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Affiliation(s)
- Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Andrew W Creamer
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Huzaifa I Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Anna Duckworth
- Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, UK
| | - Janet Fallon
- Department of Respiratory Medicine, Somerset Lung Centre, Musgrove Park Hospital, Taunton, UK
| | - Silan Fidan
- Department of Respiratory Medicine, Institute for Lung Health, Leicester, UK
| | - Tom Nancarrow
- Department of Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Rebecca Wollerton
- Department of Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Matthew Steward
- Department of Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Bibek Gooptu
- University of Leicester, Leicester, Leicestershire, UK
| | - Michael Gibbons
- Department of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, Devon, UK
| | | | - Chris Scotton
- Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, UK
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18
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Wild JM, Porter JC, Molyneaux PL, George PM, Stewart I, Allen RJ, Aul R, Baillie JK, Barratt SL, Beirne P, Bianchi SM, Blaikley JF, Brooke J, Chaudhuri N, Collier G, Denneny EK, Docherty A, Fabbri L, Gibbons MA, Gleeson FV, Gooptu B, Hall IP, Hanley NA, Heightman M, Hillman TE, Johnson SR, Jones MG, Khan F, Lawson R, Mehta P, Mitchell JA, Platé M, Poinasamy K, Quint JK, Rivera-Ortega P, Semple M, Simpson AJ, Smith D, Spears M, Spencer LIG, Stanel SC, Thickett DR, Thompson AAR, Walsh SL, Weatherley ND, Weeks ME, Wootton DG, Brightling CE, Chambers RC, Ho LP, Jacob J, Piper Hanley K, Wain LV, Jenkins RG. Understanding the burden of interstitial lung disease post-COVID-19: the UK Interstitial Lung Disease-Long COVID Study (UKILD-Long COVID). BMJ Open Respir Res 2021; 8:e001049. [PMID: 34556492 PMCID: PMC8461362 DOI: 10.1136/bmjresp-2021-001049] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/19/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has led to over 100 million cases worldwide. The UK has had over 4 million cases, 400 000 hospital admissions and 100 000 deaths. Many patients with COVID-19 suffer long-term symptoms, predominantly breathlessness and fatigue whether hospitalised or not. Early data suggest potentially severe long-term consequence of COVID-19 is development of long COVID-19-related interstitial lung disease (LC-ILD). METHODS AND ANALYSIS The UK Interstitial Lung Disease Consortium (UKILD) will undertake longitudinal observational studies of patients with suspected ILD following COVID-19. The primary objective is to determine ILD prevalence at 12 months following infection and whether clinically severe infection correlates with severity of ILD. Secondary objectives will determine the clinical, genetic, epigenetic and biochemical factors that determine the trajectory of recovery or progression of ILD. Data will be obtained through linkage to the Post-Hospitalisation COVID platform study and community studies. Additional substudies will conduct deep phenotyping. The Xenon MRI investigation of Alveolar dysfunction Substudy will conduct longitudinal xenon alveolar gas transfer and proton perfusion MRI. The POST COVID-19 interstitial lung DiseasE substudy will conduct clinically indicated bronchoalveolar lavage with matched whole blood sampling. Assessments include exploratory single cell RNA and lung microbiomics analysis, gene expression and epigenetic assessment. ETHICS AND DISSEMINATION All contributing studies have been granted appropriate ethical approvals. Results from this study will be disseminated through peer-reviewed journals. CONCLUSION This study will ensure the extent and consequences of LC-ILD are established and enable strategies to mitigate progression of LC-ILD.
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Affiliation(s)
- Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Joanna C Porter
- Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, UK
- Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Respiratory Medicine, University College London, London, UK
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Peter M George
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Iain Stewart
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Raminder Aul
- Respiratory Medicine, St George's Hospital NHS Foundation Trust, London, UK
| | | | - Shaney L Barratt
- Bristol Interstitial Lung Diseases Service, North Bristol NHS Trust, Bristol, UK
| | - Paul Beirne
- Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Stephen M Bianchi
- Academic Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John F Blaikley
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jonathan Brooke
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Nazia Chaudhuri
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Respiratory Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Guilhem Collier
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Emma K Denneny
- Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, UK
- Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Respiratory Medicine, University College London, London, UK
| | - Annemarie Docherty
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Laura Fabbri
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael A Gibbons
- Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Bibek Gooptu
- Department of Molecular and Cell Biology, University of Leicester, Leicester, UK
- Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ian P Hall
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Neil A Hanley
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Wythenshaw Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Melissa Heightman
- Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Toby E Hillman
- Respiratory Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Simon R Johnson
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Mark G Jones
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Fasihul Khan
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Rod Lawson
- Academic Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Puja Mehta
- Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, UK
- School of Life & Medical Sciences, UCL, London, UK
| | - Jane A Mitchell
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Manuela Platé
- Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, UK
- UCL Respiratory, UCL, London, UK
| | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Pilar Rivera-Ortega
- Respiratory Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Djf Smith
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Mark Spears
- Respiratory Medicine, Perth Royal Infirmary, NHS Tayside, Perth, UK
- School of Medicine, University of Dundee, Dundee, UK
| | - LIsa G Spencer
- Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stefan C Stanel
- Respiratory Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology & Gastroenterology, The University of Manchester, Manchester, UK
| | - David R Thickett
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, UK
- Acute and Respiratory Medicine, University Hospitals Birmingham Foundation Trust, Birmingham, uk
| | - A A Roger Thompson
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Simon Lf Walsh
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Nicholas D Weatherley
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | | | - Dan G Wootton
- Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Institute of Infection Veterinary and Ecological Science, University of Liverpool, Liverpool, UK
| | - Chris E Brightling
- Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Rachel C Chambers
- Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, UK
| | - Ling-Pei Ho
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine Oncology, Oxford, UK
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | - Joseph Jacob
- Department of Respiratory Medicine, University College London, London, UK
- Centre for Medical Imaging and Computing, University College London, London, UK
| | - Karen Piper Hanley
- Division of Diabetes, Endocrinology & Gastroenterology, The University of Manchester, Manchester, UK
| | - Louise V Wain
- Department of Health Sciences, University of Leicester, Leicester, UK
- Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - R Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Interstitial Lung Disease, Royal Brompton and Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
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19
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Davis R, Dixon C, Millar AB, Maskell NA, Barratt SL. A role for cardiopulmonary exercise testing in detecting physiological changes underlying health status in Idiopathic pulmonary fibrosis: a feasibility study. BMC Pulm Med 2021; 21:147. [PMID: 33952224 PMCID: PMC8097115 DOI: 10.1186/s12890-021-01520-8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/12/2021] [Indexed: 01/11/2023] Open
Abstract
Introduction There is limited data available on the use of CPET as a predictive tool for disease outcomes in the setting of IPF. We investigated the feasibility of undertaking CPET and the relationship between CPET and quality of life measurements in a well-defined population of mild and moderate IPF patients. Methods A prospective, single-centre observational study. Results Thirty-two IPF patients (mild n = 23, moderate n = 9) participated in the study, n = 13 mild patients attended for repeat CPET testing at 12 months. At baseline, total K-BILD scores and total IPF-PROM scores significantly correlated with 6MWT distance, but not with baseline FVC % predicted, TLco % predicted, baseline or minimum SpO2. VO2 peak/kg at AT positively correlated with total scores, breathlessness/activity and chest domains of the K-BILD questionnaire (p < 0.05). VO2 peak significantly correlated with total IPF PROM scores and wellbeing domains (p < 0.05), with a trend towards statistical significance for total IPF-PROM and VO2 peak/kg at anaerobic threshold (p = 0.06). There was a statistically significant reduction in FVC% predicted at 12 months follow up, although the mean absolute decline was < 10% (p < 0.05). During this period VO2 peak significantly reduced (21.6 ml/kg/min ± 2.9 vs 19.1 ± 2.8; p = 0.017), with corresponding reductions in total K-BILD and breathlessness/activity domains that exceeded the MCID for responsiveness. Lower baseline VO2 peak/kg at anaerobic threshold correlated with greater declines in total K-BILD scores (r = − 0.62, 0.024) at 12 months. Whilst baseline FVC% predicted or TLco % predicted did not predict change in health status, Conclusion We have shown that it is feasible to undertake CPET in patients with mild to moderate IPF. CPET measures of VO2 peak correlated with both baseline and change in K-BILD measurements at 1 year, despite relatively stable standard lung function (declines of < 10% in FVC), suggesting its potential sensitivity to detect physiological changes underlying health status. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01520-8.
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Affiliation(s)
- R Davis
- Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Learning and Research Building, Bristol, BS10 5NB, UK
| | - C Dixon
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - A B Millar
- Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Learning and Research Building, Bristol, BS10 5NB, UK.,Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - N A Maskell
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - S L Barratt
- Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Learning and Research Building, Bristol, BS10 5NB, UK. .,Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK.
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20
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Arnold DT, Donald C, Lyon M, Hamilton FW, Morley AJ, Attwood M, Dipper A, Barratt SL. Krebs von den Lungen 6 (KL-6) as a marker for disease severity and persistent radiological abnormalities following COVID-19 infection at 12 weeks. PLoS One 2021; 16:e0249607. [PMID: 33914762 PMCID: PMC8084211 DOI: 10.1371/journal.pone.0249607] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 01/11/2021] [Accepted: 03/19/2021] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Acute presentations of COVID-19 infection vary, ranging from asymptomatic carriage through to severe clinical manifestations including acute respiratory distress syndrome (ARDS). Longer term sequelae of COVID-19 infection includes lung fibrosis in a proportion of patients. Krebs von den Lungen 6 (KL-6) is a mucin like glycoprotein that has been proposed as a marker of pulmonary epithelial cell injury. We sought to determine whether KL-6 was a marker of 1) the severity of acute COVID-19 infection, or 2) the persistence of symptoms/radiological abnormalities at medium term follow up. METHODS Prospective single centre observational study. RESULTS Convalescent KL-6 levels were available for 93 patients (male 63%, mean age 55.8 years) who attended an 12-week follow up appointment after being admitted to hospital with COVID-19. For 67 patients a baseline KL-6 result was available for comparison. There was no significant correlations between baseline KL-6 and the admission CXR severity score or clinical severity NEWS score. Furthermore, there was no significant difference in the baseline KL-6 level and an initial requirement for oxygen on admission or the severity of acute infection as measured at 28 days. There was no significant difference in the 12-week KL-6 level and the presence or absence of subjective breathlessness but patients with abnormal CT scans at 12 weeks had significantly higher convalescent KL-6 levels compared to the remainder of the cohort (median 1101 IU/ml vs 409 IU/ml). CONCLUSIONS The association between high KL-6 levels at 12 weeks and persisting CT abnormalities (GGO/fibrosis), is a finding that requires further exploration. Whether KL-6 may help differentiate those patients with persisting dyspnoea due to complications rather than deconditioning or dysfunctional breathing alone, is an important future research question.
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Affiliation(s)
- David T. Arnold
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, United Kingdom
| | - Charmaine Donald
- Department of Immunology, North Bristol NHS Trust, Bristol, United Kingdom
| | - Max Lyon
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Fergus W. Hamilton
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, United Kingdom
| | - Anna J. Morley
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, United Kingdom
| | - Marie Attwood
- Bristol Centre for Antimicrobial Research (BCARE), North Bristol NHS Trust, Bristol, United Kingdom
| | - Alexandra Dipper
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, United Kingdom
| | - Shaney L. Barratt
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, United Kingdom
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
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21
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Simpson T, Barratt SL, Beirne P, Chaudhuri N, Crawshaw A, Crowley LE, Fletcher S, Gibbons MA, Hallchurch P, Horgan L, Jakaityte I, Lewis T, McLellan T, Myall KJ, Miller R, Smith DJF, Stanel S, Thillai M, Thompson F, Wallis T, Wu Z, Molyneaux PL, West AG. The burden of progressive fibrotic interstitial lung disease across the UK. Eur Respir J 2021; 58:13993003.00221-2021. [PMID: 33678609 PMCID: PMC8264777 DOI: 10.1183/13993003.00221-2021] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/26/2021] [Indexed: 11/16/2022]
Abstract
While idiopathic pulmonary fibrosis (IPF) remains the exemplar progressive fibrotic lung disease, there remains a cohort of non-IPF fibrotic lung diseases (fILD) which adopt a similar clinical behaviour to IPF despite therapy [1]. This phenotypically related group of conditions, where progression of disease is similar to that seen in IPF, have recently been described as progressive fibrotic interstitial lung diseases (PF-ILD) [2]. Historically, treatments for these cases have been limited though given the phenotypic similarities many cases may have been given a multidisciplinary working diagnosis of IPF based on their disease behaviour [3]. The INBUILD trial broadened the scope of treatable fILD by demonstrating a significant benefit of Nintedanib in patients with fILD and progressive disease [4]. In response to this the European Commission approved an additional indication for nintedanib in adults for the treatment of PF-ILD in July 2020. Almost 15% of new referrals with non-IPF fibrotic ILD go on to develop a progressive fibrotic phenotype and would benefit from antifibrotic therapyhttps://bit.ly/3uPhClN
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Affiliation(s)
- Thomas Simpson
- Dept of Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS trust, Southmead Hospital, Bristol, UK.,Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Paul Beirne
- Leeds Interstitial Lung Disease Service, St James's University Hospital, Leeds, UK
| | - Nazia Chaudhuri
- North West Lung Centre, Wythenshawe Hospital, Manchester, UK
| | - Anjali Crawshaw
- Birmingham Interstitial Lung Disease Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Louise E Crowley
- Birmingham Interstitial Lung Disease Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sophie Fletcher
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Michael A Gibbons
- South West Peninsula ILD Network, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
| | - Philippa Hallchurch
- Bristol Interstitial Lung Disease Service, North Bristol NHS trust, Southmead Hospital, Bristol, UK
| | - Laura Horgan
- Leeds Interstitial Lung Disease Service, St James's University Hospital, Leeds, UK
| | - Ieva Jakaityte
- South West Peninsula ILD Network, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
| | - Thomas Lewis
- Bristol Interstitial Lung Disease Service, North Bristol NHS trust, Southmead Hospital, Bristol, UK
| | - Tom McLellan
- Dept of Interstitial Lung Disease, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Katherine J Myall
- Dept of Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ryan Miller
- South West Peninsula ILD Network, Royal Devon and Exeter Foundation NHS Trust, Exeter, UK
| | | | - Stefan Stanel
- North West Lung Centre, Wythenshawe Hospital, Manchester, UK
| | - Muhunthan Thillai
- Dept of Interstitial Lung Disease, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Fiona Thompson
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Timothy Wallis
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Zhe Wu
- Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Philip L Molyneaux
- Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK.,Contributed equally as last authors
| | - Alex G West
- Dept of Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Contributed equally as last authors
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22
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Lyon M, Whiteway A, Darby M, Bhatt N, Barratt SL. The not so innocent bystander: an unusual cause of progressive breathlessness. Thorax 2021; 76:thoraxjnl-2020-216290. [PMID: 33479041 DOI: 10.1136/thoraxjnl-2020-216290] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/04/2022]
Abstract
This case report discusses a 76-year-old man who presented with symptomatic diffuse alveolar-septal and tracheobronchial amyloidosis with a low-grade monoclonal gammopathy. This patient had a combination of both symptomatic diffuse alveolar-septal interstitial disease and tracheobronchial amyloidosis, features that contradict the widely accepted presentations seen in this disease. First, tracheobronchial amyloidosis has been documented as localised disease without systemic involvement. Second, diffuse alveolar-septal interstitial disease is rarely identified with clinical symptoms unless there is significant cardiac involvement. This case highlights a number learning points in the diagnosis and management of systemic amyloid light chain amyloidosis;(1) There is a need for a high index of suspicion for diagnosis due to the potential subtlety of a plasma cell clone underlying AL amyloidosis, requiring serum-free light chain assays to increase sensitivity; (2) Haematological response and recovery of organ dysfunction are not a linear relationship due to the slower reversal of amyloid deposition; therefore, ongoing monitoring is required to identify those in need of repeated therapy. However, haematological response is a marker of overall survival and (3) Multisystem assessment and multidisciplinary collaboration are critical in optimising the care of patients with systemic AL amyloidosis.
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Affiliation(s)
- Max Lyon
- Department of Respiratory Medicine, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Alastair Whiteway
- Department of Haematology, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Michael Darby
- Department of Radiology, North Bristol NHS Trust, Bristol, UK
| | - Nidhi Bhatt
- Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
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23
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Barratt SL, Adamali HH, Cotton C, Mulhearn B, Iftikhar H, Pauling JD, Spencer L, Adamali HI, Gunawardena H. Clinicoserological features of antisynthetase syndrome (ASyS)-associated interstitial lung disease presenting to respiratory services: comparison with idiopathic pulmonary fibrosis and ASyS diagnosed in rheumatology services. BMJ Open Respir Res 2021; 8:8/1/e000829. [PMID: 33419741 PMCID: PMC7798409 DOI: 10.1136/bmjresp-2020-000829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Antisynthetase syndrome (ASyS) is a rare autoimmune connective tissue disease (CTD), associated with autoantibodies targeting tRNA synthetase enzymes, that can present to respiratory (interstitial lung disease (ILD)) or rheumatology (myositis, inflammatory arthritis and systemic features) services. The therapeutic management of CTD-associated ILD and idiopathic pulmonary fibrosis (IPF) differs widely, thus accurate diagnosis is essential. METHODS We undertook a retrospective, multicentre observational cohort study designed to (1) evaluate differences between ASyS-associated ILD with IPF, (2) phenotypic differences in patients with ASyS-ILD presenting to respiratory versus rheumatology services, (3) differences in outcomes between ASySassociated with Jo-1 versus non-Jo-1 autoantibodies and (4) compare long-term outcomes between these groups. RESULTS We identified 76 patients with ASyS-ILD and 78 with IPF. Patients with ASyS were younger at presentation (57 vs 77 years, p<0.001) with a female predominance (57% vs 33%, p=0.006) compared with IPF. Cytoplasmic staining on indirect immunofluorescence was a differentiating factor between ASyS and IPF (71% vs 0%, p<0.0001). Patients with ASyS presenting initially to respiratory services (n=52) had a higher prevalence of ASyS non-Jo-1 antibodies and significantly fewer musculoskeletal symptoms/biochemical evidence of myositis, compared with those presenting to rheumatology services (p<0.05), although lung physiology was similar in both groups. There were no differences in high-resolution CT appearances or outcomes in those with Jo-1 versus non-Jo-1 ASyS-ILD. CONCLUSIONS Extended autoimmune serology is needed to evaluate for ASyS autoantibodies in patients presenting with ILD, particularly in younger female patients. Musculoskeletal involvement is common in ASyS (typically Jo-1 autoantibodies) presenting to rheumatology but the burden of ILD is similar to those presenting to respiratory medicine.
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Affiliation(s)
- Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK .,School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Havra H Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Caroline Cotton
- Liverpool Interstitial Lung Disease Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ben Mulhearn
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, Somerset, UK
| | - Hina Iftikhar
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - John David Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, Somerset, UK.,School of Pharmacy and Pharmacology, University of Bath, Bath, Somerset, UK
| | - Lisa Spencer
- Liverpool Interstitial Lung Disease Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Huzaifa I Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Harsha Gunawardena
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
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24
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Arnold DT, Hamilton FW, Milne A, Morley AJ, Viner J, Attwood M, Noel A, Gunning S, Hatrick J, Hamilton S, Elvers KT, Hyams C, Bibby A, Moran E, Adamali HI, Dodd JW, Maskell NA, Barratt SL. Patient outcomes after hospitalisation with COVID-19 and implications for follow-up: results from a prospective UK cohort. Thorax 2020; 76:399-401. [PMID: 33273026 PMCID: PMC7716340 DOI: 10.1136/thoraxjnl-2020-216086] [Citation(s) in RCA: 340] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 12/17/2022]
Abstract
The longer-term consequences of SARS-CoV-2 infection are uncertain. Consecutive patients hospitalised with COVID-19 were prospectively recruited to this observational study (n=163). At 8-12 weeks postadmission, survivors were invited to a systematic clinical follow-up. Of 131 participants, 110 attended the follow-up clinic. Most (74%) had persistent symptoms (notably breathlessness and excessive fatigue) and limitations in reported physical ability. However, clinically significant abnormalities in chest radiograph, exercise tests, blood tests and spirometry were less frequent (35%), especially in patients not requiring supplementary oxygen during their acute infection (7%). Results suggest that a holistic approach focusing on rehabilitation and general well-being is paramount.
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Affiliation(s)
- David T Arnold
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | | | - Alice Milne
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Anna J Morley
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Jason Viner
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Marie Attwood
- Bristol Centre for Antimicrobial Research (BCARE), North Bristol NHS Trust, Bristol, UK
| | - Alan Noel
- Bristol Centre for Antimicrobial Research (BCARE), North Bristol NHS Trust, Bristol, UK
| | - Samuel Gunning
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Jessica Hatrick
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Sassa Hamilton
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Karen T Elvers
- Medicines Discovery Institute Cardiff, Cardiff University, Cardiff, South Glamorgan, UK
| | - Catherine Hyams
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Anna Bibby
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Ed Moran
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
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25
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George PM, Barratt SL, Condliffe R, Desai SR, Devaraj A, Forrest I, Gibbons MA, Hart N, Jenkins RG, McAuley DF, Patel BV, Thwaite E, Spencer LG. Respiratory follow-up of patients with COVID-19 pneumonia. Thorax 2020; 75:1009-1016. [PMID: 32839287 PMCID: PMC7447111 DOI: 10.1136/thoraxjnl-2020-215314] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic has led to an unprecedented surge in hospitalised patients with viral pneumonia. The most severely affected patients are older men, individuals of black and Asian minority ethnicity and those with comorbidities. COVID-19 is also associated with an increased risk of hypercoagulability and venous thromboembolism. The overwhelming majority of patients admitted to hospital have respiratory failure and while most are managed on general wards, a sizeable proportion require intensive care support. The long-term complications of COVID-19 pneumonia are starting to emerge but data from previous coronavirus outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) suggest that some patients will experience long-term respiratory complications of the infection. With the pattern of thoracic imaging abnormalities and growing clinical experience, it is envisaged that interstitial lung disease and pulmonary vascular disease are likely to be the most important respiratory complications. There is a need for a unified pathway for the respiratory follow-up of patients with COVID-19 balancing the delivery of high-quality clinical care with stretched National Health Service (NHS) resources. In this guidance document, we provide a suggested structure for the respiratory follow-up of patients with clinicoradiological confirmation of COVID-19 pneumonia. We define two separate algorithms integrating disease severity, likelihood of long-term respiratory complications and functional capacity on discharge. To mitigate NHS pressures, virtual solutions have been embedded within the pathway as has safety netting of patients whose clinical trajectory deviates from the pathway. For all patients, we suggest a holistic package of care to address breathlessness, anxiety, oxygen requirement, palliative care and rehabilitation.
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Affiliation(s)
- Peter M George
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Shaney L Barratt
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- University of Bristol School of Clinical Science, Bristol, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian Forrest
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Michael A Gibbons
- Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - R Gisli Jenkins
- Centre for Respiratory Research, University of Nottingham, Nottingham, UK
| | - Danny F McAuley
- Intensive Care Unit, Queen's University Belfast, Belfast, UK
| | - Brijesh V Patel
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK
| | - Erica Thwaite
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lisa G Spencer
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
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Flower VA, Barratt SL, Hart DJ, Mackenzie AB, Shipley JA, Ward SG, Pauling JD. High-frequency Ultrasound Assessment of Systemic Sclerosis Skin Involvement: Intraobserver Repeatability and Relationship With Clinician Assessment and Dermal Collagen Content. J Rheumatol 2020; 48:867-876. [PMID: 33132218 DOI: 10.3899/jrheum.200234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The modified Rodnan skin score (mRSS) remains the preferred method for skin assessment in systemic sclerosis (SSc). There are concerns regarding high interobserver variability of mRSS and negative clinical trials utilizing mRSS as the primary endpoint. High-frequency ultrasound (HFUS) allows objective assessment of cutaneous fibrosis in SSc. We investigated the relationship between HFUS with both mRSS and dermal collagen. METHODS Skin thickness (ST), echogenicity, and novel shear wave elastography (SWE) were assessed in 53 patients with SSc and 15 healthy controls (HCs) at the finger, hand, forearm, and abdomen. The relationship between HFUS parameters with mRSS (n = 53) and dermal collagen (10 patients with SSc and 10 HCs) was investigated. Intraobserver repeatability of HFUS was calculated using intraclass correlation coefficients (ICCs). RESULTS HFUS assessment of ST (hand/forearm) and SWE (finger/hand) correlated with local mRSS at some sites. Subclinical abnormalities in ST, echogenicity, and SWE were present in clinically uninvolved SSc skin. Additionally, changes in echogenicity and SWE were sometimes apparent despite objectively normal ST on HFUS. ST, SWE, and local mRSS correlated strongly with collagen quantification (r = 0.697, 0.709, 0.649, respectively). Intraobserver repeatability was high for all HFUS parameters (ICCs for ST = 0.946-0.978; echogenicity = 0.648-0.865; and SWE = 0.953-0.973). CONCLUSION Our data demonstrate excellent reproducibility and reassuring convergent validity with dermal collagen content. Detection of subclinical abnormalities is an additional benefit of HFUS. The observed correlations with collagen quantification support further investigation of HFUS as an alternative to mRSS in clinical trial settings.
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Affiliation(s)
- Victoria A Flower
- V.A. Flower, Consultant Rheumatologist, MBBS, PhD, J.D. Pauling, Consultant Rheumatologist and Senior Lecturer, BMBS, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, Department of Pharmacy and Pharmacology, University of Bath, Bath;
| | - Shaney L Barratt
- S.L. Barratt, BMBS, PhD, Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol
| | - Darren J Hart
- D.J. Hart, Clinical Scientist, PhD, J.A. Shipley, Clinical Scientist, PhD, Clinical Measurement and Imaging Department, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath
| | - Amanda B Mackenzie
- A.B. Mackenzie, Senior Lecturer, PhD, Department of Pharmacy and Pharmacology, University of Bath, Bath
| | - Jacqueline A Shipley
- D.J. Hart, Clinical Scientist, PhD, J.A. Shipley, Clinical Scientist, PhD, Clinical Measurement and Imaging Department, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath
| | - Stephen G Ward
- S.G. Ward, Professor, PhD, Centre for Therapeutic Innovation & Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - John D Pauling
- V.A. Flower, Consultant Rheumatologist, MBBS, PhD, J.D. Pauling, Consultant Rheumatologist and Senior Lecturer, BMBS, PhD, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, Department of Pharmacy and Pharmacology, University of Bath, Bath
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Barratt SL, Davis R, Sharp C, Pauling JD. The prognostic value of cardiopulmonary exercise testing in interstitial lung disease: a systematic review. ERJ Open Res 2020; 6:00027-2020. [PMID: 32832530 PMCID: PMC7430148 DOI: 10.1183/23120541.00027-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/22/2020] [Indexed: 01/05/2023] Open
Abstract
The heterogeneity of interstitial lung disease (ILD) results in prognostic uncertainty concerning end-of-life discussions and optimal timing for transplantation. Effective prognostic markers and prediction models are needed. Cardiopulmonary exercise testing (CPET) provides a comprehensive assessment of the physiological changes in the respiratory, cardiovascular and musculoskeletal systems in a controlled laboratory environment. It has shown promise as a prognostic factor for other chronic respiratory conditions. We sought to evaluate the prognostic value of CPET in predicting outcomes in longitudinal studies of ILD. MEDLINE, Embase and the Cochrane Database of Systematic Reviews were used to identify studies reporting the prognostic value of CPET in predicting outcomes in longitudinal studies of ILD. Study quality was assessed using the Quality in Prognosis Study risk of bias tool. Thirteen studies were included that reported the prognostic value of CPET in ILD. All studies reported at least one CPET parameter predicting clinical outcomes in ILD, with survival being the principal outcome assessed. Maximum oxygen consumption, reduced ventilatory efficiency and exercise-induced hypoxaemia were all reported to have prognostic value in ILD. Issues with study design (primarily due to inherent problems of retrospective studies, patient selection and presentation of numerous CPET parameters), insufficient adjustment for important confounders and inadequate statistical analyses limit the strength of the conclusions that can be drawn at this stage. There is insufficient evidence to confirm the value of CPET in facilitating “real-world” clinical decisions in ILD. Additional prospective studies are required to validate the putative prognostic associations reported in previous studies in carefully phenotyped patient populations. There is presently insufficient evidence to confirm the value of CPET in facilitating “real-world” clinical decisions in ILD. Additional prospective studies are required to validate the putative prognostic associations reported in previous studies.https://bit.ly/3dfp5kq
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Affiliation(s)
- Shaney L Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.,Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
| | - Richard Davis
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Charles Sharp
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - John D Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.,Royal National Hospital for Rheumatic Diseases, Royal United Hospitals NHS Foundation Trust, Bath, UK
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Zulfikar S, Mulholland S, Adamali H, Barratt SL. Inhibitors of the Autotaxin-Lysophosphatidic Acid Axis and Their Potential in the Treatment of Interstitial Lung Disease: Current Perspectives. Clin Pharmacol 2020; 12:97-108. [PMID: 32765123 PMCID: PMC7367740 DOI: 10.2147/cpaa.s228362] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022] Open
Abstract
Idiopathic pulmonary fibrosis is a progressive fibrosing interstitial lung disease for which there is no known cure. Currently available therapeutic options have been shown at best to slow the progression of the disease and thus there remains an urgent unmet need to identify new therapies. In this article, we will discuss the mechanisms of action, pre-clinical and clinical trial data surrounding inhibitors of the autotaxin-lysophosphatidic acid axis, which show promise as emerging novel therapies for fibrotic lung disease.
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Affiliation(s)
- Sabrina Zulfikar
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Sarah Mulholland
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
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Creamer AW, Barratt SL. Prognostic factors in chronic hypersensitivity pneumonitis. Eur Respir Rev 2020; 29:29/156/190167. [DOI: 10.1183/16000617.0167-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/03/2020] [Indexed: 12/11/2022] Open
Abstract
Hypersensitivity pneumonitis (HP) is an immunologically mediated lung disease resulting from exposure to inhaled environmental antigens. Prognosis is variable, with a subset of patients developing progressive fibrosis leading to respiratory failure and death. Therefore, there is an urgent need to identify factors which predict prognosis and survival in patients with HP. We undertook a narrative review of existing evidence to identify prognostic factors in patients with chronic HP. Patient demographics, smoking history, extent of antigen exposure and comorbidities all have reported associations with disease outcome, and physiological, radiological and laboratory markers have been shown to predict overall survival. While no single marker has been demonstrated to accurately and reliably predict prognosis, older age, more severe impairment of pulmonary function at baseline and established fibrosis on either biopsy or high-resolution computed tomography are consistently associated with worse survival. The vast majority of existing studies are retrospective, and this review identifies a need for prospective longitudinal studies with serial assessment of respiratory health to ascertain factors associated with nonfatal deterioration. Future developments, including the development of HP-specific composite scores may help further improve our ability to predict outcomes for individual patients.
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Creamer AW, Barratt SL. Does ambulatory oxygen improve quality of life in patients with fibrotic lung disease? Results from the AmbOx trial. Breathe (Sheff) 2019; 15:140-143. [PMID: 31191728 PMCID: PMC6544787 DOI: 10.1183/20734735.0002-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The fibrotic interstitial lung diseases (ILDs) encompass a heterogenous group of conditions affecting the lung parenchyma, resulting in progressive, irreversible scarring. While prognosis varies between conditions, they commonly have a significant adverse impact both on health-related quality of life (HRQoL) and on survival. For idiopathic pulmonary fibrosis (IPF), the most common and fatal ILD, antifibrotic therapies (nintedanib [1] and pirfenidone [2]) have been shown to slow rate of progression, but the disease remains incurable. Management of all fibrotic ILDs therefore requires symptomatic and supportive care as well as interventions aimed at modifying the disease course [3]. The AmbOx trial provides RCT evidence for ambulatory oxygen therapy improving HRQoL in patients with fibrotic ILDhttp://ow.ly/uHC030nEzsz
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Flower VA, Barratt SL, Ward S, Pauling JD. The Role of Vascular Endothelial Growth Factor in Systemic Sclerosis. Curr Rheumatol Rev 2019; 15:99-109. [DOI: 10.2174/1573397114666180809121005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/07/2018] [Accepted: 07/23/2018] [Indexed: 11/22/2022]
Abstract
The pathological hallmarks of Systemic Sclerosis (SSc) constitute an inter-related triad of autoimmunity, vasculopathy and tissue remodeling. Many signaling mediators have been implicated in SSc pathology; most focusing on individual components of this pathogenic triad and current treatment paradigms tend to approach management of such as distinct entities. The present review shall examine the role of Vascular Endothelial Growth Factor (VEGF) in SSc pathogenesis. We shall outline potential mechanisms whereby differential Vascular Endothelial Growth Factor-A (VEGF-A) isoform expression (through conventional and alternative VEGF-A splicing,) may influence the relevant burden of vasculopathy and fibrosis offering novel insight into clinical heterogeneity and disease progression in SSc. Emerging therapeutic approaches targeting VEGF signaling pathways might play an important role in the management of SSc, and differential VEGF-A splice isoform expression may provide a tool for personalized medicine approaches to disease management.
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Affiliation(s)
- Victoria A. Flower
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, United Kingdom
| | - Shaney L. Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, United Kingdom
| | - Stephen Ward
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, United Kingdom
| | - John D. Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, United Kingdom
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Davidson J, McErlane J, Aljboor K, Barratt SL, Jeyabalan A, Medford ARL, Borman AM, Adamali H. Musical instruments, fungal spores and hypersensitivity pneumonitis. QJM 2019; 112:287-289. [PMID: 30649525 DOI: 10.1093/qjmed/hcz020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 01/03/2019] [Indexed: 02/07/2023] Open
Affiliation(s)
- J Davidson
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - J McErlane
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - K Aljboor
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - S L Barratt
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - A Jeyabalan
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - A R L Medford
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - A M Borman
- UK National Mycology Reference Laboratory (MRL), Public Health England South-West, Southmead Hospital, Bristol, UK
| | - H Adamali
- North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, UK
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Barratt SL, Morales M, Speirs T, Al Jboor K, Lamb H, Mulholland S, Edwards A, Gunary R, Meek P, Jordan N, Sharp C, Kendall C, Adamali HI. Specialist palliative care, psychology, interstitial lung disease (ILD) multidisciplinary team meeting: a novel model to address palliative care needs. BMJ Open Respir Res 2018; 5:e000360. [PMID: 30622718 PMCID: PMC6307575 DOI: 10.1136/bmjresp-2018-000360] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/19/2018] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Patients with progressive idiopathic fibrotic interstitial lung disease (ILD), such as those with idiopathic pulmonary fibrosis (IPF), can have an aggressive disease course, with a median survival of only 3-5 years from diagnosis. The palliative care needs of these patients are often unmet. There are calls for new models of care, whereby the patient's usual respiratory clinician remains central to the integration of palliative care principles and practices into their patient's management, but the optimal model of service delivery has yet to be determined. METHODS We developed a novel, collaborative, multidisciplinary team (MDT) meeting between our palliative care, psychology and ILD teams with the principal aim of integrating specialist care to ensure the needs of persons with ILD, and their caregivers were identified and met by referral to the appropriate service. The objective of this study was to assess the effectiveness of this novel MDT meeting on the assessment of a patient's palliative care needs. RESULTS Significant increases in advance care planning discussions were observed, in conjunction with increased referrals to community courses and teams, following introduction of this novel MDT. CONCLUSIONS Our results suggest that our collaborative MDT is an effective platform to address patients' unmet palliative care needs. Further work is required to explore the effect of our model on achieving the preferred place of death and reductions in unplanned hospital admissions.
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Affiliation(s)
- Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Michelle Morales
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Toby Speirs
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Khaled Al Jboor
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Heather Lamb
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Sarah Mulholland
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Adrienne Edwards
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Rachel Gunary
- Department of Psychology, North Bristol NHS Trust, Bristol, UK
| | - Patricia Meek
- Department of Psychology, North Bristol NHS Trust, Bristol, UK
| | - Nikki Jordan
- Department of Palliative Care Medicine, North Bristol NHS Trust, Bristol, UK
| | - Charles Sharp
- Respiratory Medicine, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Clare Kendall
- Department of Palliative Care Medicine, North Bristol NHS Trust, Bristol, UK
| | - Huzaifa I Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
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Barratt SL, Mulholland S, Al Jbour K, Steer H, Gutsche M, Foley N, Srivastava R, Sharp C, Adamali HI. South-West of England's Experience of the Safety and Tolerability Pirfenidone and Nintedanib for the Treatment of Idiopathic Pulmonary Fibrosis (IPF). Front Pharmacol 2018; 9:1480. [PMID: 30618768 PMCID: PMC6304353 DOI: 10.3389/fphar.2018.01480] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/03/2018] [Indexed: 01/04/2023] Open
Abstract
Purpose: Pirfenidone and nintedanib are two novel antifibrotic agents licensed for the treatment IPF. Prior to being approved for use in England for patients with FVC >50% and <80%, these were made available for all IPF patients under the Mild Patient Program (MPP) and Patient In Need Scheme (PIN). Prescribing of these medications is restricted to specialist centers. We sought to characterize the population of patients prescribed antifibrotics and determine the drug tolerability of these medications in the Northern hub of the Southwest of England regional ILD network. Methods: A retrospective analysis of all patients treated with antifibrotics between August 2012 and July 2017 was undertaken. Baseline characteristics including patient demographics and pulmonary physiology, in addition to drug tolerability and reasons for treatment cessation were collated. Data were compared using unpaired student's t-test, Chi-squared, Mann-Whitney rank sum or ANOVA as appropriate. Logistic regression analysis evaluated clinical characteristics associated with discontinuation of pirfenidone therapy. P < 0.05 was considered statistically significant. Findings: A total of 164 patients, all with consensus diagnoses of IPF, were identified. Of these, 70.1% (115/164) received pirfenidone as their initial therapy. Baseline age, gender and pulmonary physiology did not differ significantly between groups. Drug discontinuation occurred most commonly due to adverse drug reactions events (ADRs) for both pirfenidone [40.0% (46/115)] and nintedanib [16.3% (8/49)]. Anorexia, rash and gastrointestinal disturbance were reported most commonly as the reason for cessation of pirfenidone; anorexia, nausea and weight loss for nintedanib. Duration of therapy prior to discontinuation because of ADRs did not differ significantly between medication groups but patients with a baseline FVC < 65% predicted, had a significantly shorter duration of pirfenidone prior to discontinuation due to ADRs, compared to those with a FVC 65-80% predicted. Multivariate logistic regression did not identify any independent baseline characteristics that predicted discontinuation of pirfenidone therapy prior to 52 weeks. Implications: Idiopathic pulmonary fibrosis (IPF) patients treated with nintedanib had comparable treatment emergent adverse event (TEAE) profiles in clinical practice to those reported in clinical trials. The TEAE profile of pirfenidone was higher than clinical trial data would suggest, although comparable to real-world datasets. Further work is required to explore the possible reasons underpinning this finding, including whether this is related to population co-morbidities or center threshold. No new safety concerns were identified.
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Affiliation(s)
- Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Sarah Mulholland
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Khaled Al Jbour
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
| | - Henry Steer
- Gloucestershire and Cheltenham General Hospitals, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Markus Gutsche
- Gloucestershire and Cheltenham General Hospitals, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Noeleen Foley
- Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
| | | | - Charles Sharp
- Gloucestershire and Cheltenham General Hospitals, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Huzaifa I Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, United Kingdom
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Creamer AW, Protheroe R, Gunawardena H, Barratt SL. Pancytopaenia and breathlessness: Hickam’s Dictum prevails! Thorax 2018; 73:1187-1190. [DOI: 10.1136/thoraxjnl-2018-212088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 11/04/2022]
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Barratt SL, Creamer A, Hayton C, Chaudhuri N. Idiopathic Pulmonary Fibrosis (IPF): An Overview. J Clin Med 2018; 7:jcm7080201. [PMID: 30082599 PMCID: PMC6111543 DOI: 10.3390/jcm7080201] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 02/07/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease characterised by chronic, progressive scarring of the lungs and the pathological hallmark of usual interstitial pneumonia. Current paradigms suggest alveolar epithelial cell damage is a key initiating factor. Globally, incidence of the disease is rising, with associated high morbidity, mortality, and economic healthcare burden. Diagnosis relies on a multidisciplinary team approach with exclusion of other causes of interstitial lung disease. Over recent years, two novel antifibrotic therapies, pirfenidone and nintedanib, have been developed, providing treatment options for many patients with IPF, with several other agents in early clinical trials. Current efforts are directed at identifying key biomarkers that may direct more customized patient-centred healthcare to improve outcomes for these patients in the future.
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Affiliation(s)
- Shaney L Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK.
- Academic Respiratory Unit, University of Bristol, Bristol BS16 1QY, UK.
| | - Andrew Creamer
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol BS10 5NB, UK.
| | - Conal Hayton
- North West Interstitial Lung Disease Unit, Manchester University NHS Foundation Trust, Wythenshawe, Manchester M23 9LT, UK.
| | - Nazia Chaudhuri
- North West Interstitial Lung Disease Unit, Manchester University NHS Foundation Trust, Wythenshawe, Manchester M23 9LT, UK.
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Barratt SL, Blythe T, Ourradi K, Jarrett C, Welsh GI, Bates DO, Millar AB. Effects of hypoxia and hyperoxia on the differential expression of VEGF-A isoforms and receptors in Idiopathic Pulmonary Fibrosis (IPF). Respir Res 2018; 19:9. [PMID: 29334947 PMCID: PMC5769544 DOI: 10.1186/s12931-017-0711-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/26/2017] [Indexed: 12/20/2022] Open
Abstract
Dysregulation of VEGF-A bioavailability has been implicated in the development of lung injury/fibrosis, exemplified by Idiopathic Pulmonary Fibrosis (IPF). VEGF-A is a target of the hypoxic response via its translational regulation by HIF-1α. The role of hypoxia and hyperoxia in the development and progression of IPF has not been explored. In normal lung (NF) and IPF-derived fibroblasts (FF) VEGF-Axxxa protein expression was upregulated by hypoxia, mediated through activation of VEGF-Axxxa gene transcription. VEGF-A receptors and co-receptors were differentially expressed by hypoxia and hyperoxia. Our data supports a potential role for hypoxia, hyperoxia and VEGF-Axxxa isoforms as drivers of fibrogenesis.
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Affiliation(s)
- Shaney L Barratt
- Academic Respiratory Unit, Learning and Research Building, Southmead Hospital, Bristol, UK.
| | - Thomas Blythe
- Academic Respiratory Unit, Learning and Research Building, Southmead Hospital, Bristol, UK
| | - Khadija Ourradi
- Academic Respiratory Unit, Learning and Research Building, Southmead Hospital, Bristol, UK
| | - Caroline Jarrett
- Academic Respiratory Unit, Learning and Research Building, Southmead Hospital, Bristol, UK
| | - Gavin I Welsh
- Bristol Renal, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - David O Bates
- Cancer Biology, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ann B Millar
- Academic Respiratory Unit, Learning and Research Building, Southmead Hospital, Bristol, UK
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Walker SP, Barratt SL, Thompson J, Maskell NA. Conservative Management in Traumatic Pneumothoraces: An Observational Study. Chest 2017; 153:946-953. [PMID: 29080710 DOI: 10.1016/j.chest.2017.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 04/07/2017] [Revised: 09/29/2017] [Accepted: 10/13/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Traumatic pneumothoraces are a common consequence of major trauma. Despite this, there is a paucity of literature regarding their optimal management, including the role of conservative treatment. The aim of this study was to assess the treatment, complications, and outcomes of traumatic pneumothoraces in patients presenting to a major trauma center. METHODS The prospectively collected Trauma Audit and Research Network (TARN) database was used to identify all patients presenting with traumatic pneumothoraces to a UK major trauma center from April 2012 to December 2016. Demographics, mechanism of injury, injury severity score (ISS), management, and outcomes were analyzed. RESULTS Six hundred two patients were included during the study period. Mean age was 48 years (SD, 22 years), and 73% were men. Mean ISS was 26 and inpatient mortality was 9%. Of the 602 traumatic pneumothoraces, 277 of 602 (46%) were initially treated conservatively. Two hundred fifty-two of 277 patients in this cohort (90%) did not require subsequent chest tube insertion, including the majority of patients (56 of 62 [90%]) who were receiving positive pressure ventilation (PPV) on admission. The hazard ratio (HR) for failure of conservative management showed no difference between the ventilated and nonventilated patients (HR, 1.1; P = .84). Only the presence of a large hemothorax was associated with an increased likelihood of failure of conservative management. CONCLUSIONS In the largest observational study of traumatic pneumothoraces published to date, > 90% of patients whose pneumothorax was managed conservatively never required subsequent tube drainage. Importantly, this also applies to patients requiring PPV, with no significant increased risk of failure of expectant management. These data support a role for conservative management in traumatic pneumothoraces.
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Affiliation(s)
- Steven P Walker
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England; North Bristol Lung Centre, Southmead Hospital, Bristol, England
| | - Shaney L Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England; North Bristol Lung Centre, Southmead Hospital, Bristol, England
| | - Julian Thompson
- Intensive Care Unit, Southmead Hospital, Bristol, England; Severn Major Trauma Network, North Bristol NHS Trust, Bristol, England.
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England; North Bristol Lung Centre, Southmead Hospital, Bristol, England
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Barratt SL, Blythe T, Jarrett C, Ourradi K, Shelley-Fraser G, Day MJ, Qiu Y, Harper S, Maher TM, Oltean S, Hames TJ, Scotton CJ, Welsh GI, Bates DO, Millar AB. Differential Expression of VEGF-A xxx Isoforms Is Critical for Development of Pulmonary Fibrosis. Am J Respir Crit Care Med 2017; 196:479-493. [PMID: 28661183 DOI: 10.1164/rccm.201603-0568oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Fibrosis after lung injury is related to poor outcome, and idiopathic pulmonary fibrosis (IPF) can be regarded as an exemplar. Vascular endothelial growth factor (VEGF)-A has been implicated in this context, but there are conflicting reports as to whether it is a contributory or protective factor. Differential splicing of the VEGF-A gene produces multiple functional isoforms including VEGF-A165a and VEGF-A165b, a member of the inhibitory family. To date there is no clear information on the role of VEGF-A in IPF. OBJECTIVES To establish VEGF-A isoform expression and functional effects in IPF. METHODS We used tissue sections, plasma, and lung fibroblasts from patients with IPF and control subjects. In a bleomycin-induced lung fibrosis model we used wild-type MMTV mice and a triple transgenic mouse SPC-rtTA+/-TetoCre+/-LoxP-VEGF-A+/+ to conditionally induce VEGF-A isoform deletion specifically in the alveolar type II (ATII) cells of adult mice. MEASUREMENTS AND MAIN RESULTS IPF and normal lung fibroblasts differentially expressed and responded to VEGF-A165a and VEGF-A165b in terms of proliferation and matrix expression. Increased VEGF-A165b was detected in plasma of progressing patients with IPF. In a mouse model of pulmonary fibrosis, ATII-specific deficiency of VEGF-A or constitutive overexpression of VEGF-A165b inhibited the development of pulmonary fibrosis, as did treatment with intraperitoneal delivery of VEGF-A165b to wild-type mice. CONCLUSIONS These results indicate that changes in the bioavailability of VEGF-A sourced from ATII cells, namely the ratio of VEGF-Axxxa to VEGF-Axxxb, are critical in development of pulmonary fibrosis and may be a paradigm for the regulation of tissue repair.
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Affiliation(s)
| | - Thomas Blythe
- 1 Academic Respiratory Unit, School of Clinical Sciences
| | | | | | - Golda Shelley-Fraser
- 2 Department of Histopathology, Cheltenham and Gloucestershire NHS Trust, Cheltenham, United Kingdom
| | | | | | | | - Toby M Maher
- 5 NIHR Respiratory Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom
| | - Sebastian Oltean
- 6 Department of Physiology and Pharmacology, University of Bristol, Bristol, United Kingdom
| | - Thomas J Hames
- 7 University of Exeter Medical School, Exeter, United Kingdom; and
| | - Chris J Scotton
- 7 University of Exeter Medical School, Exeter, United Kingdom; and
| | | | - David O Bates
- 8 Cancer Biology, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Ann B Millar
- 1 Academic Respiratory Unit, School of Clinical Sciences
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Ourradi K, Blythe T, Jarrett C, Barratt SL, Welsh GI, Millar AB. VEGF isoforms have differential effects on permeability of human pulmonary microvascular endothelial cells. Respir Res 2017; 18:116. [PMID: 28578669 PMCID: PMC5457598 DOI: 10.1186/s12931-017-0602-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/30/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Alternative splicing of Vascular endothelial growth factor-A mRNA transcripts (commonly referred as VEGF) leads to the generation of functionally differing isoforms, the relative amounts of which have potentially significant physiological outcomes in conditions such as acute respiratory distress syndrome (ARDS). The effect of such isoforms on pulmonary vascular permeability is unknown. We hypothesised that VEGF165a and VEGF165b isoforms would have differing effects on pulmonary vascular permeability caused by differential activation of intercellular signal transduction pathways. METHOD To test this hypothesis we investigated the physiological effect of VEGF165a and VEGF165b on Human Pulmonary Microvascular Endothelial Cell (HPMEC) permeability using three different methods: trans-endothelial electrical resistance (TEER), Electric cell-substrate impedance sensing (ECIS) and FITC-BSA passage. In addition, potential downstream signalling pathways of the VEGF isoforms were investigated by Western blotting and the use of specific signalling inhibitors. RESULTS VEGF165a increased HPMEC permeability using all three methods (paracellular and transcellular) and led to associated VE-cadherin and actin stress fibre changes. In contrast, VEGF165b decreased paracellular permeability and did not induce changes in VE-cadherin cell distribution. Furthermore, VEGF165a and VEGF165b had differing effects on both the phosphorylation of VEGF receptors and downstream signalling proteins pMEK, p42/44MAPK, p38 MAPK, pAKT and peNOS. Interestingly specific inhibition of the pMEK, p38 MAPK, PI3 kinase and eNOS pathways blocked the effects of both VEGF165a and VEGF165b on paracellular permeability and the effect of VEGF165a on proliferation/migration, suggesting that this difference in cellular response is mediated by an as yet unidentified signalling pathway(s). CONCLUSION This study demonstrates that the novel isoform VEGF165a and VEGF165b induce differing effects on permeability in pulmonary microvascular endothelial cells.
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Affiliation(s)
- Khadija Ourradi
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Thomas Blythe
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Caroline Jarrett
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Shaney L Barratt
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gavin I Welsh
- Bristol Renal, School of Clinical Sciences, University of Bristol, Bistol, UK
| | - Ann B Millar
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
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Barratt SL, Blythe T, Jarrett C, Ourradi K, Welsh GI, Scotton C, Bates DO, Millar AB. S64 Alveolar epithelial type II cell expression of VEGF-Axxxa is critical for development of Idiopathic Pulmonary Fibrosis (IPF): an anti-fibrotic role for VEGF-Axxxb anti-angiogenic isoforms? Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ourradi K, Jarrett C, Blythe T, Barratt SL, Welsh GI, Millar AB. S56 Unravelling VEGF165 Signalling in the Lung. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Barratt SL, Jarrett C, Blythe T, Welsh GI, Maher T, Bates DO, Millar AB. S68 Bioavailability of VEGF in Idiopathic Pulmonary Fibrosis. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
This study compared a creatininase method for the analysis at the bedside of creatinine (CR) in whole blood on a NOVA Biomedical M7 analyser, with rate-Jaffe and creatininase-based laboratory methods. Correlation and precision data were obtained and the effect of increased bilirubin concentration was assessed.
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Affiliation(s)
- D J Rowe
- Department of Chemical Pathology, Southampton University Hospitals, NHS Trust, SO16 6YD, Southampton, UK.
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