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Richeldi L, Schiffman C, Behr J, Inoue Y, Corte TJ, Cottin V, Jenkins RG, Nathan SD, Raghu G, Walsh SLF, Jayia PK, Kamath N, Martinez FJ. Zinpentraxin Alfa for Idiopathic Pulmonary Fibrosis: The Randomized Phase III STARSCAPE Trial. Am J Respir Crit Care Med 2024; 209:1132-1140. [PMID: 38354066 DOI: 10.1164/rccm.202401-0116oc] [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] [Received: 01/12/2024] [Accepted: 02/14/2024] [Indexed: 02/16/2024] Open
Abstract
Rationale: A phase II trial reported clinical benefit over 28 weeks in patients with idiopathic pulmonary fibrosis (IPF) who received zinpentraxin alfa. Objectives: To investigate the efficacy and safety of zinpentraxin alfa in patients with IPF in a phase III trial. Methods: This 52-week phase III, double-blind, placebo-controlled, pivotal trial was conducted at 275 sites in 29 countries. Patients with IPF were randomized 1:1 to intravenous placebo or zinpentraxin alfa 10 mg/kg every 4 weeks. The primary endpoint was absolute change from baseline to Week 52 in FVC. Secondary endpoints included absolute change from baseline to Week 52 in percent predicted FVC and 6-minute walk distance. Safety was monitored via adverse events. Post hoc analysis of the phase II and phase III data explored changes in FVC and their impact on the efficacy results. Measurements and Main Results: Of 664 randomized patients, 333 were assigned to placebo and 331 to zinpentraxin alfa. Four of the 664 randomized patients were never administered study drug. The trial was terminated early after a prespecified futility analysis that demonstrated no treatment benefit of zinpentraxin alfa over placebo. In the final analysis, absolute change from baseline to Week 52 in FVC was similar between placebo and zinpentraxin alfa (-214.89 ml and -235.72 ml; P = 0.5420); there were no apparent treatment effects on secondary endpoints. Overall, 72.3% and 74.6% of patients receiving placebo and zinpentraxin alfa, respectively, experienced one or more adverse events. Post hoc analysis revealed that extreme FVC decline in two placebo-treated patients resulted in the clinical benefit of zinpentraxin alfa reported by phase II. Conclusions: Zinpentraxin alfa treatment did not benefit patients with IPF over placebo. Learnings from this program may help improve decision making around trials in IPF. Clinical trial registered with www.clinicaltrials.gov (NCT04552899).
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Affiliation(s)
- Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Jürgen Behr
- Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich, Germany
| | - Yoshikazu Inoue
- Clinical Research Center, NHO Kinki Chuo Chest Medical Center, Osaka, Japan
| | - Tamera J Corte
- Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon, National Research Institute for Agriculture, Food and the Environment, European Reference Network for Rare Respiratory Diseases, Lyon, France
| | - R Gisli Jenkins
- Imperial NIHR Biomedical Research Centre, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Steven D Nathan
- Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, Virginia
| | - Ganesh Raghu
- University of Washington Medical Center, Seattle, Washington
| | - Simon L F Walsh
- Imperial NIHR Biomedical Research Centre, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Nikhil Kamath
- Roche Products Ltd., Welwyn Garden City, United Kingdom; and
| | - Fernando J Martinez
- Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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Desai SR, Sivarasan N, Johannson KA, George PM, Culver DA, Devaraj A, Lynch DA, Milne D, Renzoni E, Nunes H, Sverzellati N, Spagnolo P, Baughman RP, Yadav R, Piciucchi S, Walsh SLF, Kouranos V, Wells AU. High-resolution CT phenotypes in pulmonary sarcoidosis: a multinational Delphi consensus study. Lancet Respir Med 2024; 12:409-418. [PMID: 38104579 DOI: 10.1016/s2213-2600(23)00267-9] [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] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/23/2023] [Accepted: 07/14/2023] [Indexed: 12/19/2023]
Abstract
One view of sarcoidosis is that the term covers many different diseases. However, no classification framework exists for the future exploration of pathogenetic pathways, genetic or trigger predilections, patterns of lung function impairment, or treatment separations, or for the development of diagnostic algorithms or relevant outcome measures. We aimed to establish agreement on high-resolution CT (HRCT) phenotypic separations in sarcoidosis to anchor future CT research through a multinational two-round Delphi consensus process. Delphi participants included members of the Fleischner Society and the World Association of Sarcoidosis and other Granulomatous Disorders, as well as members' nominees. 146 individuals (98 chest physicians, 48 thoracic radiologists) from 28 countries took part, 144 of whom completed both Delphi rounds. After rating of 35 Delphi statements on a five-point Likert scale, consensus was achieved for 22 (63%) statements. There was 97% agreement on the existence of distinct HRCT phenotypes, with seven HRCT phenotypes that were categorised by participants as non-fibrotic or likely to be fibrotic. The international consensus reached in this Delphi exercise justifies the formulation of a CT classification as a basis for the possible definition of separate diseases. Further refinement of phenotypes with rapidly achievable CT studies is now needed to underpin the development of a formal classification of sarcoidosis.
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Affiliation(s)
- Sujal R Desai
- Department of Radiology, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK; Margaret Turner Warwick Centre for Fibrosing Lung Disease, Imperial College London, London, UK.
| | | | | | - Peter M George
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK; Margaret Turner Warwick Centre for Fibrosing Lung Disease, Imperial College London, London, UK
| | - Daniel A Culver
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Anand Devaraj
- Department of Radiology, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK; Margaret Turner Warwick Centre for Fibrosing Lung Disease, Imperial College London, London, UK
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO, USA
| | - David Milne
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK; Margaret Turner Warwick Centre for Fibrosing Lung Disease, Imperial College London, London, UK
| | - Hilario Nunes
- Service de Pneumologie, Hôpital Avicenne, Université Sorbonne Paris Nord, Paris, France
| | | | - Paolo Spagnolo
- Section of Respiratory Diseases, University of Padova, Padova, Italy
| | - Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Ruchi Yadav
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sara Piciucchi
- Department of Radiology, GB Morgagni Hospital, Forlì, Italy
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Vasileios Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK; Margaret Turner Warwick Centre for Fibrosing Lung Disease, Imperial College London, London, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK; Margaret Turner Warwick Centre for Fibrosing Lung Disease, Imperial College London, London, UK
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3
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Kanne JP, Walker CM, Brixey AG, Brown KK, Chelala L, Kazerooni EA, Walsh SLF, Lynch DA. Progressive Pulmonary Fibrosis and Interstitial Lung Abnormalities: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024. [PMID: 38656115 DOI: 10.2214/ajr.24.31125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Progressive pulmonary fibrosis (PPF) and interstitial lung abnormalities (ILA) are relatively new concepts in interstitial lung disease (ILD) imaging and clinical management. Recognition of signs of PPF, as well as identification and classification of ILA, are important tasks during chest high-resolution CT interpretation, to optimize management of patients with ILD and those at risk of developing ILD. However, following professional society guidance, the role of imaging surveillance remains unclear in stable patients with ILD, asymptomatic patients with ILA who are at risk of progression, and asymptomatic patients at risk of developing ILD without imaging abnormalities. In this AJR Expert Panel Narrative Review, we summarize the current knowledge regarding PPF and ILA and describe the range of clinical practice with respect to imaging patients with ILD, those with ILA, and those at risk of developing ILD. In addition, we offer suggestions to help guide surveillance imaging in areas with an absence of published guidelines, where such decisions are currently driven primarily by local pulmonologists' preference.
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Affiliation(s)
- Jeffrey P Kanne
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christopher M Walker
- Department of Radiology, The University of Kansas Medical Center, Kansas City, KS
| | - Anupama G Brixey
- Department of Radiology, Portland VA Healthcare System, Oregon Health & Science University, Portland, OR
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO
| | - Lydia Chelala
- Department of Radiology, University of Chicago Medicine, Chicago, IL
| | - Ella A Kazerooni
- Departments of Radiology & Internal Medicine, University of Michigan Medical School / Michigan Medicine, Ann Arbor, MI
| | - Simon L F Walsh
- Department of Radiology, Imperial College, London, United Kingdom
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
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Behr J, Salisbury ML, Walsh SLF, Podolanczuk AJ, Hariri LP, Hunninghake GM, Kolb M, Ryerson CJ, Cottin V, Beasley MB, Corte T, Glanville AR, Adegunsoye A, Hogaboam C, Wuyts WA, Noth I, Oldham JM, Richeldi L, Raghu G, Wells AU. The Role of Inflammation and Fibrosis in ILD Treatment Decisions. Am J Respir Crit Care Med 2024. [PMID: 38484133 DOI: 10.1164/rccm.202401-0048pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/13/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Juergen Behr
- University of Munich, Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich, Germany;
| | - Margaret L Salisbury
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Simon L F Walsh
- Imperial College London, 4615, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Anna J Podolanczuk
- Weill Cornell Medical College, 12295, Department of Medicine, New York, New York, United States
| | - Lida P Hariri
- Massachusetts General Hospital, Pathology, Boston, Massachusetts, United States
| | - Gary M Hunninghake
- Brigham and Women's Hospital, 1861, Medicine, Boston, Massachusetts, United States
| | - Martin Kolb
- McMaster University, Hamilton, Ontario, Canada
| | | | - Vincent Cottin
- Louis Pradel University Hospital, Respiratory Medicine, Lyon, France
| | - Mary B Beasley
- Mount Sinai Medical Center, 5944, Department of Pathology, New York, New York, United States
| | - Tamera Corte
- Royal Prince Alfred Hospital, Department of Respiratory Medicine, Sydney, New South Wales, Australia
- University of Sydney, 4334, Medical School, Sydney, New South Wales, Australia
| | - Allan R Glanville
- St Vincent's Hospital, Respiratory and Sleep Medicine, Sydney, New South Wales, Australia
| | - Ayodeji Adegunsoye
- University of Chicago, Section of Pulmonary and Critical Care, Dept. of Medicine, Chicago, Illinois, United States
| | - Cory Hogaboam
- Cedars Sinai Medical Center, Department of Medicine, Los Angeles, California, United States
| | - Wim A Wuyts
- K U Leuven, respiratory medicine, Leuven, Belgium
| | - Imre Noth
- University of Virginia, 2358, Division of Pulmonary and Critical Care Medicine, Charlottesville, Virginia, United States
| | - Justin M Oldham
- University of California Davis, 8789, Pulmonary and Critical Care Medicine, Davis, California, United States
| | - Luca Richeldi
- Universita Cattolica del Sacro Cuore Sede di Roma, 96983, Pulmonary Medicine, Roma, Lazio, Italy
| | - Ganesh Raghu
- University of Washington Medical Center, 21617, Division of Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Athol U Wells
- Royal Brompton Hospital, Interstitial Lung Disease Unit, London, United Kingdom of Great Britain and Northern Ireland
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Wells AU, Walsh SLF. Quantifying Fibrosis in Fibrotic Lung Disease: A Good Human Plus a Machine Is the Best Combination? Ann Am Thorac Soc 2024; 21:204-205. [PMID: 38299920 PMCID: PMC10848908 DOI: 10.1513/annalsats.202311-954ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Affiliation(s)
- Athol U Wells
- Royal Brompton Hospital, London, United Kingdom; and
- Imperial College, London, United Kingdom
| | - Simon L F Walsh
- Royal Brompton Hospital, London, United Kingdom; and
- Imperial College, London, United Kingdom
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6
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Walsh SLF, Lafyatis RA, Cottin V. Imaging Features of Autoimmune Disease-Related Interstitial Lung Diseases. J Thorac Imaging 2023; 38:S30-S37. [PMID: 37732704 DOI: 10.1097/rti.0000000000000734] [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] [Indexed: 09/22/2023]
Abstract
Interstitial lung diseases (ILDs) associated with autoimmune diseases show characteristic signs of imaging. Radiologic signs are also used in the identification of ILDs with features suggestive of autoimmune disease that do not meet the criteria for a specific autoimmune disease. Radiologists play a key role in identifying these signs and assessing their relevance as part of multidisciplinary team discussions. A radiologist may be the first health care professional to pick up signs of autoimmune disease in a patient referred for assessment of ILD or with suspicion for ILD. Multidisciplinary team discussion of imaging findings observed during follow-up may inform a change in diagnosis or identify progression, with implications for a patient's treatment regimen. This article describes the imaging features of autoimmune disease-related ILDs and the role of radiologists in assessing their relevance.
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Affiliation(s)
- Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | - Robert A Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, PA
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Claude Bernard University Lyon 1, Lyon, France
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7
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Calandriello L, Walsh SLF. Do we need computational analysis of high-resolution CT images in fibrotic interstitial lung disease? Eur Radiol 2023; 33:8226-8227. [PMID: 37667142 DOI: 10.1007/s00330-023-10187-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023]
Affiliation(s)
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College London, London, UK
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8
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Barnett JL, Maher TM, Quint JK, Adamson A, Wu Z, Smith DJF, Rawal B, Nair A, Walsh SLF, Desai SR, George PM, Kokosi M, Jenkins G, Kouranos V, Renzoni EA, Rice A, Nicholson AG, Chua F, Wells AU, Molyneaux PL, Devaraj A. Combination of BAL and Computed Tomography Differentiates Progressive and Non-progressive Fibrotic Lung Diseases. Am J Respir Crit Care Med 2023; 208:975-982. [PMID: 37672028 DOI: 10.1164/rccm.202305-0796oc] [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: 05/02/2023] [Accepted: 09/05/2023] [Indexed: 09/07/2023] Open
Abstract
Rationale: Identifying patients with pulmonary fibrosis (PF) at risk of progression can guide management. Objectives: To explore the utility of combining baseline BAL and computed tomography (CT) in differentiating progressive and nonprogressive PF. Methods: The derivation cohort consisted of incident cases of PF for which BAL was performed as part of a diagnostic workup. A validation cohort was prospectively recruited with identical inclusion criteria. Baseline thoracic CT scans were scored for the extent of fibrosis and usual interstitial pneumonia (UIP) pattern. The BAL lymphocyte proportion was recorded. Annualized FVC decrease of >10% or death within 1 year was used to define disease progression. Multivariable logistic regression identified the determinants of the outcome. The optimum binary thresholds (maximal Wilcoxon rank statistic) at which the extent of fibrosis on CT and the BAL lymphocyte proportion could distinguish disease progression were identified. Measurements and Main Results: BAL lymphocyte proportion, UIP pattern, and fibrosis extent were significantly and independently associated with disease progression in the derivation cohort (n = 240). Binary thresholds for increased BAL lymphocyte proportion and extensive fibrosis were identified as 25% and 20%, respectively. An increased BAL lymphocyte proportion was rare in patients with a UIP pattern (8 of 135; 5.9%) or with extensive fibrosis (7 of 144; 4.9%). In the validation cohort (n = 290), an increased BAL lymphocyte proportion was associated with a significantly lower probability of disease progression in patients with nonextensive fibrosis or a non-UIP pattern. Conclusions: BAL lymphocytosis is rare in patients with extensive fibrosis or a UIP pattern on CT. In patients without a UIP pattern or with limited fibrosis, a BAL lymphocyte proportion of ⩾25% was associated with a lower likelihood of progression.
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Affiliation(s)
- Joseph L Barnett
- Department of Radiology, Royal Free Hospital, London, United Kingdom
| | - Toby M Maher
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Alex Adamson
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Zhe Wu
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - David J F Smith
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | | | - Arjun Nair
- Department of Radiology, University College Hospital, London, United Kingdom
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Sujal R Desai
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Radiology
| | - Peter M George
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Radiology
| | - Maria Kokosi
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Gisli Jenkins
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Vasilis Kouranos
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Elisabetta A Renzoni
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Alex Rice
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Histopathology, Royal Brompton Hospital, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom; and
| | - Andrew G Nicholson
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Histopathology, Royal Brompton Hospital, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom; and
| | - Felix Chua
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Athol U Wells
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Interstitial Lung Disease Unit, and
| | - Anand Devaraj
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Radiology
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Guiot J, Walsh SLF. The ERS PROFILE.net Clinical Research Collaboration is dedicated to the set-up of an academic network to enhance imaging-based management of progressive pulmonary fibrosis. Eur Respir J 2023; 62:2300577. [PMID: 37690785 DOI: 10.1183/13993003.00577-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/05/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Julien Guiot
- Respiratory Medicine Department, University Hospital of Liège, Liège, Belgium
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
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10
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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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11
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Lucas SEM, Raspin K, Mackintosh J, Glaspole I, Reynolds PN, Chia C, Grainge C, Kendall P, Troy L, Schwartz DA, Wood-Baker R, Walsh SLF, Moodley Y, Robertson J, Macansh S, Walters EH, Chambers D, Corte TJ, Dickinson JL. Preclinical interstitial lung disease in relatives of familial pulmonary fibrosis patients. Pulmonology 2023; 29:257-260. [PMID: 36216738 DOI: 10.1016/j.pulmoe.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 05/05/2023] Open
Affiliation(s)
- S E M Lucas
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - K Raspin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - J Mackintosh
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia; QLD Lung Transplant Service, Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - I Glaspole
- Department of Respiratory Medicine, Alfred Health, Melbourne, VIC, Australia; Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - P N Reynolds
- Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - C Chia
- Launceston General Hospital, Launceston, TAS, Australia
| | - C Grainge
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - P Kendall
- Respiratory Medicine Service, Albany, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - L Troy
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; School of Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - D A Schwartz
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - R Wood-Baker
- Tasmanian School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - S L F Walsh
- National Heart and Lung Institute, Imperial College London, London, England, UK
| | - Y Moodley
- University of Western Australia, Institute for Respiratory Health, Perth, WA, Australia; Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - J Robertson
- Border Physicians Group, West Albury, NSW, Australia
| | - S Macansh
- Lung Foundation Australia, Brisbane, QLD, Australia
| | - E H Walters
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia; Tasmanian School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - D Chambers
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia; QLD Lung Transplant Service, Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - T J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; School of Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - J L Dickinson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.
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12
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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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13
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Humphries SM, Mackintosh JA, Jo HE, Walsh SLF, Silva M, Calandriello L, Chapman S, Ellis S, Glaspole I, Goh N, Grainge C, Hopkins PMA, Keir GJ, Moodley Y, Reynolds PN, Walters EH, Baraghoshi D, Wells AU, Lynch DA, Corte TJ. Quantitative computed tomography predicts outcomes in idiopathic pulmonary fibrosis. Respirology 2022; 27:1045-1053. [PMID: 35875881 PMCID: PMC9796832 DOI: 10.1111/resp.14333] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Prediction of disease course in patients with progressive pulmonary fibrosis remains challenging. The purpose of this study was to assess the prognostic value of lung fibrosis extent quantified at computed tomography (CT) using data-driven texture analysis (DTA) in a large cohort of well-characterized patients with idiopathic pulmonary fibrosis (IPF) enrolled in a national registry. METHODS This retrospective analysis included participants in the Australian IPF Registry with available CT between 2007 and 2016. CT scans were analysed using the DTA method to quantify the extent of lung fibrosis. Demographics, longitudinal pulmonary function and quantitative CT metrics were compared using descriptive statistics. Linear mixed models, and Cox analyses adjusted for age, gender, BMI, smoking history and treatment with anti-fibrotics were performed to assess the relationships between baseline DTA, pulmonary function metrics and outcomes. RESULTS CT scans of 393 participants were analysed, 221 of which had available pulmonary function testing obtained within 90 days of CT. Linear mixed-effect modelling showed that baseline DTA score was significantly associated with annual rate of decline in forced vital capacity and diffusing capacity of carbon monoxide. In multivariable Cox proportional hazard models, greater extent of lung fibrosis was associated with poorer transplant-free survival (hazard ratio [HR] 1.20, p < 0.0001) and progression-free survival (HR 1.14, p < 0.0001). CONCLUSION In a multi-centre observational registry of patients with IPF, the extent of fibrotic abnormality on baseline CT quantified using DTA is associated with outcomes independent of pulmonary function.
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Affiliation(s)
| | - John A. Mackintosh
- Department of Thoracic MedicineThe Prince Charles HospitalBrisbaneQueenslandAustralia,NHMRC Centre of Research Excellence in Pulmonary FibrosisCamperdownNew South WalesAustralia
| | - Helen E. Jo
- NHMRC Centre of Research Excellence in Pulmonary FibrosisCamperdownNew South WalesAustralia,Department of Respiratory MedicineRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Simon L. F. Walsh
- Department of RadiologyKing's College Hospital Foundation TrustLondonUK
| | - Mario Silva
- Section of "Scienze Radiologiche", Department of Medicine and Surgery (DiMeC)University of ParmaParmaItaly,Department of RadiologyUniversity of Massachusetts Medical School, UMass Memorial Health CareWorcesterMassachusettsUSA
| | - Lucio Calandriello
- Dipartimento di Diagnostica per immagini, Radioterapia, Oncologia ed EmatologiaFondazione Policlinico Universitario A. Gemelli, IRCCSRomeItaly
| | - Sally Chapman
- Respiratory ConsultantsAdelaideSouth AustraliaAustralia
| | - Samantha Ellis
- Department of RadiologyAlfred HealthMelbourneVictoriaAustralia
| | - Ian Glaspole
- NHMRC Centre of Research Excellence in Pulmonary FibrosisCamperdownNew South WalesAustralia,Department of Allergy and Respiratory MedicineAlfred HospitalMelbourneVictoriaAustralia
| | - Nicole Goh
- Respiratory and Sleep MedicineAustin HospitalMelbourneVictoriaAustralia
| | - Christopher Grainge
- Department of Respiratory MedicineJohn Hunter HospitalNewcastleNew South WalesAustralia
| | - Peter M. A. Hopkins
- Department of Thoracic MedicineThe Prince Charles HospitalBrisbaneQueenslandAustralia,Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
| | - Gregory J. Keir
- Department of Respiratory MedicinePrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Yuben Moodley
- School of Medicine & PharmacologyUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Paul N. Reynolds
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - E. Haydn Walters
- Department of MedicineUniversity of TasmaniaHobartTasmaniaAustralia
| | - David Baraghoshi
- Division of BiostatisticsNational Jewish HealthDenverColoradoUSA
| | - Athol U. Wells
- Royal Brompton and Harefield NHS Foundation TrustLondonUK,National Heart and Lung InstituteImperial College LondonLondonUK
| | - David A. Lynch
- Department of RadiologyNational Jewish HealthDenverColoradoUSA
| | - Tamera J. Corte
- NHMRC Centre of Research Excellence in Pulmonary FibrosisCamperdownNew South WalesAustralia,Department of Respiratory MedicineRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
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14
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Wells AU, Walsh SLF. Quantitative computed tomography and machine learning: recent data in fibrotic interstitial lung disease and potential role in pulmonary sarcoidosis. Curr Opin Pulm Med 2022; 28:492-497. [PMID: 35861463 DOI: 10.1097/mcp.0000000000000902] [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] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to summarize quantitative computed tomography (CT) and machine learning data in fibrotic lung disease and to explore the potential application of these technologies in pulmonary sarcoidosis. RECENT FINDINGS Recent data in the use of quantitative CT in fibrotic interstitial lung disease (ILD) are covered. Machine learning includes deep learning, a branch of machine learning particularly suited to medical imaging analysis. Deep learning imaging biomarker research in ILD is currently undergoing accelerated development, driven by technological advances in image processing and analysis. Fundamental concepts and goals related to deep learning imaging research in ILD are discussed. Recent work highlighted in this review has been performed in patients with idiopathic pulmonary fibrosis (IPF). Quantitative CT and deep learning have not been applied to pulmonary sarcoidosis, although there are recent deep learning data in cardiac sarcoidosis. SUMMARY Pulmonary sarcoidosis presents unsolved problems for which quantitative CT and deep learning may provide unique solutions: in particular, the exploration of the long-standing question of whether sarcoidosis should be viewed as a single disease or as an umbrella term for disorders that might usefully be considered as separate diseases.
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15
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Robbie H, Wells AU, Fang C, Jacob J, Walsh SLF, Nair A, Camoras R, Desai SR, Devaraj A. Serial decline in lung volume parameters on computed tomography (CT) predicts outcome in idiopathic pulmonary fibrosis (IPF). Eur Radiol 2022; 32:2650-2660. [PMID: 34716781 PMCID: PMC7615167 DOI: 10.1007/s00330-021-08338-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In patients with IPF, this study aimed (i) to examine the relationship between serial change in CT parameters of lung volume and lung function, (ii) to identify the prognostic value of serial change in CT parameters of lung volume, and (iii) to define a threshold for serial change in CT markers of lung volume that optimally captures disease progression. METHODS Serial CTs were analysed for progressive volume loss or fibrosis progression in 81 IPF patients (66 males, median age = 67 years) with concurrent forced vital capacity (FVC) (median follow-up 12 months, range 6-23 months). Serial CT measurements of volume loss comprised oblique fissure posterior retraction distance (OFPRD), aortosternal distance (ASD), lung height corrected for body habitus (LH), and automated CT-derived total lung volumes (ALV) (measured using commercially available software). Fibrosis progression was scored visually. Serial changes in CT markers and FVC were compared using regression analysis, and evaluated against mortality using Cox proportional hazards. RESULTS There were 58 deaths (72%, median survival = 17 months). Annual % change in ALV was most significantly related to annual % change in FVC (R2 = 0.26, p < 0.0001). On multivariate analysis, annual % change in ASD predicted mortality (HR = 0.97, p < 0.001), whereas change in FVC did not. A 25% decline in annual % change in ASD best predicted mortality, superior to 10% decline in FVC and fibrosis progression. CONCLUSION In IPF, serial decline in CT markers of lung volume and, specifically, annualised 25% reduction in aortosternal distance provides evidence of disease progression, not always identified by FVC trends or changes in fibrosis extent. KEY POINTS • Serial decline in automated and surrogate markers of lung volume on CT corresponds to changes in FVC. • Annualised reductions in the distance between ascending aorta and posterior border of the sternum on CT predict mortality beyond annualised percentage change in FVC.
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Affiliation(s)
- Hasti Robbie
- King's College Hospital NHS Foundation Trust, Denmark Hill, Brixton, SE5 9RS, London , UK.
| | - Athol U Wells
- Royal Brompton and Harefield NHS Foundation Trust, Sydney St, Chelsea, SW3 6NP, London, UK
- National Heart and Lung Institute (NHLI), Dovehouse St, Chelsea, SW3 6LY, London, UK
- Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
| | - Cheng Fang
- King's College Hospital NHS Foundation Trust, Denmark Hill, Brixton, SE5 9RS, London , UK
| | - Joseph Jacob
- Centre for Medical Image Computing, 90 High Holborn, London, UK
- UCL Respiratory, Rayne building, 5 University Street, London, UK
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | - Arjun Nair
- University College London Hospital, 235 Euston Rd, Fitzrovia, NW1 2BU, London, UK
| | - Rose Camoras
- Royal Brompton and Harefield NHS Foundation Trust, Sydney St, Chelsea, SW3 6NP, London, UK
| | - Sujal R Desai
- Royal Brompton and Harefield NHS Foundation Trust, Sydney St, Chelsea, SW3 6NP, London, UK
| | - Anand Devaraj
- Royal Brompton and Harefield NHS Foundation Trust, Sydney St, Chelsea, SW3 6NP, London, UK
- National Heart and Lung Institute (NHLI), Dovehouse St, Chelsea, SW3 6LY, London, UK
- Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
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16
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Polke M, Kondoh Y, Wijsenbeek M, Cottin V, Walsh SLF, Collard HR, Chaudhuri N, Avdeev S, Behr J, Calligaro G, Corte TJ, Flaherty K, Funke-Chambour M, Kolb M, Krisam J, Maher TM, Molina Molina M, Morais A, Moor CC, Morisset J, Pereira C, Quadrelli S, Selman M, Tzouvelekis A, Valenzuela C, Vancheri C, Vicens-Zygmunt V, Wälscher J, Wuyts W, Bendstrup E, Kreuter M. Management of Acute Exacerbation of Idiopathic Pulmonary Fibrosis in Specialised and Non-specialised ILD Centres Around the World. Front Med (Lausanne) 2021; 8:699644. [PMID: 34646836 PMCID: PMC8502934 DOI: 10.3389/fmed.2021.699644] [Citation(s) in RCA: 4] [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: 04/23/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is a severe complication associated with a high mortality. However, evidence and guidance on management is sparse. The aim of this international survey was to assess differences in prevention, diagnostic and treatment strategies for AE-IPF in specialised and non-specialised ILD centres worldwide. Material and Methods: Pulmonologists working in specialised and non-specialised ILD centres were invited to participate in a survey designed by an international expert panel. Responses were evaluated in respect to the physicians' institutions. Results: Three hundred and two (65%) of the respondents worked in a specialised ILD centre, 134 (29%) in a non-specialised pulmonology centre. Similarities were frequent with regards to diagnostic methods including radiology and screening for infection, treatment with corticosteroids, use of high-flow oxygen and non-invasive ventilation in critical ill patients and palliative strategies. However, differences were significant in terms of the use of KL-6 and pathogen testing in urine, treatments with cyclosporine and recombinant thrombomodulin, extracorporeal membrane oxygenation in critical ill patients as well as antacid medication and anaesthesia measures as preventive methods. Conclusion: Despite the absence of recommendations, approaches to the prevention, diagnosis and treatment of AE-IPF are comparable in specialised and non-specialised ILD centres, yet certain differences in the managements of AE-IPF exist. Clinical trials and guidelines are needed to improve patient care and prognosis in AE-IPF.
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Affiliation(s)
- Markus Polke
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Marlies Wijsenbeek
- Department of Respiratory Medicine, Centre for Interstitial Lung Diseases and Sarcoidosis, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Vincent Cottin
- National Coordinating Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Simon L F Walsh
- Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Harold R Collard
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Nazia Chaudhuri
- North West Interstitial Lung Disease Unit, Manchester University NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom
| | - Sergey Avdeev
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, LMU Klinikum, University of Munich, Munich, Germany.,German Center for Lung Research (DZL), Marburg, Germany
| | - Gregory Calligaro
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamera J Corte
- Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Kevin Flaherty
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Manuela Funke-Chambour
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Kolb
- Department of Medicine, Firestone Institute for Respiratory Health, Research Institute at St Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Toby M Maher
- Hastings Centre for Pulmonary Research and Division of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.,Interstitial Lung Disease Unit, Imperial College London, National Heart and Lung Institute, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Maria Molina Molina
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University Hospital of Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Antonio Morais
- Department of Pneumology, Faculdade de Medicina, Centro Hospitalar São João, Universidade do Porto, Porto, Portugal
| | - Catharina C Moor
- Department of Respiratory Medicine, Centre for Interstitial Lung Diseases and Sarcoidosis, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Julie Morisset
- Département de Médecine, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Carlos Pereira
- Lung Disease Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Silvia Quadrelli
- Hospital Británico, Buenos Aires, Argentina.,Sanatorio Güemes, Buenos Aires, Argentina
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Argyrios Tzouvelekis
- Department of First Academic Respiratory, Sotiria General Hospital for Thoracic Diseases, University of Athens, Athens, Greece
| | - Claudia Valenzuela
- ILD Unit, Pulmonology Department Hospital Universitario de La Princesa, Universidad Autonoma de Madrid, Madrid, Spain
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, A.O.U. Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Vanesa Vicens-Zygmunt
- Unit of Interstitial Lung Diseases, Department of Pneumology, Pneumology Research Group, IDIBELL, L'Hospitalet de Llobregat, University Hospital of Bellvitge, Barcelona, Spain
| | - Julia Wälscher
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,Department of Pulmonary Medicine, Centre for Interstitial and Rare Lung Diseases, Ruhrlandklinik University Hospital Essen, Essen, Germany
| | - Wim Wuyts
- Unit for Interstitial Lung Diseases, Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus C, Denmark
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,German Center for Lung Research (DZL), Marburg, Germany
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17
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Flaherty KR, Wells AU, Cottin V, Devaraj A, Inoue Y, Richeldi L, Walsh SLF, Kolb M, Koschel D, Moua T, Stowasser S, Goeldner RG, Schlenker-Herceg R, Brown KK. Nintedanib in progressive interstitial lung diseases: data from the whole INBUILD trial. Eur Respir J 2021; 59:13993003.04538-2020. [PMID: 34475231 PMCID: PMC8927709 DOI: 10.1183/13993003.04538-2020] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [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: 12/16/2020] [Accepted: 07/24/2021] [Indexed: 11/23/2022]
Abstract
Background The primary analysis of the INBUILD trial showed that in subjects with progressive fibrosing interstitial lung diseases (ILDs), nintedanib slowed the decline in forced vital capacity (FVC) over 52 weeks. We report the effects of nintedanib on ILD progression over the whole trial. Methods Subjects with fibrosing ILDs other than idiopathic pulmonary fibrosis, who had ILD progression within the 24 months before screening despite management deemed appropriate in clinical practice, were randomised to receive nintedanib or placebo. Subjects continued on blinded randomised treatment until all subjects had completed the trial. Over the whole trial, mean±sd exposure to trial medication was 15.6±7.2 and 16.8±5.8 months in the nintedanib and placebo groups, respectively. Results In the nintedanib (n=332) and placebo (n=331) groups, respectively, the proportions of subjects who had ILD progression (absolute decline in FVC ≥10% predicted) or died were 40.4% and 54.7% in the overall population (hazard ratio (HR) 0.66, 95% CI 0.53–0.83; p=0.0003) and 43.7% and 55.8% among subjects with a usual interstitial pneumonia (UIP)-like fibrotic pattern on high-resolution computed tomography (HRCT) (HR 0.69, 95% CI 0.53–0.91; p=0.009). In the nintedanib and placebo groups, respectively, the proportions who had an acute exacerbation of ILD or died were 13.9% and 19.6% in the overall population (HR 0.67, 95% CI 0.46–0.98; p=0.04) and 15.0% and 22.8% among subjects with a UIP-like fibrotic pattern on HRCT (HR 0.62, 95% CI 0.39–0.97; p=0.03). Conclusion Based on data from the whole INBUILD trial, nintedanib reduced the risk of events indicating ILD progression. In patients with fibrosing ILDs other than IPF who had shown progression of ILD within the prior 2 years, events indicating further progression occurred frequently. Over a 16-month period, nintedanib reduced the risk of such events versus placebo.https://bit.ly/3yiZXnS
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Affiliation(s)
- Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Athol U Wells
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, UMR 754, Lyon, France
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | - Martin Kolb
- McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | - Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
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18
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Maher TM, Brown KK, Kreuter M, Devaraj A, Walsh SLF, Lancaster LH, Belloli EA, Padilla M, Behr J, Goeldner RG, Tetzlaff K, Schlenker-Herceg R, Flaherty KR. Effects of nintedanib by inclusion criteria for progression of interstitial lung disease. Eur Respir J 2021; 59:13993003.04587-2020. [PMID: 34210788 PMCID: PMC8812469 DOI: 10.1183/13993003.04587-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/04/2021] [Indexed: 11/19/2022]
Abstract
Background The INBUILD trial investigated nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs). We investigated the decline in forced vital capacity (FVC) in subgroups based on the inclusion criteria for ILD progression. Methods Subjects had a fibrosing ILD other than idiopathic pulmonary fibrosis and met the following criteria for ILD progression within the 24 months before screening despite management deemed appropriate in clinical practice: Group A, relative decline in FVC ≥10% predicted; Group B, relative decline in FVC ≥5–<10% predicted with worsened respiratory symptoms and/or increased extent of fibrosis on high-resolution computed tomography (HRCT); Group C, worsened respiratory symptoms and increased extent of fibrosis on HRCT only. Results In the placebo group, the rates of FVC decline over 52 weeks in Groups A, B and C, respectively, were −241.9, −133.1 and −115.3 mL per year in the overall population (p=0.0002 for subgroup-by-time interaction) and −288.9, −156.2 and −100.1 mL per year among subjects with a usual interstitial pneumonia (UIP)-like fibrotic pattern on HRCT (p=0.0005 for subgroup-by-time interaction). Nintedanib had a greater absolute effect on reducing the rate of FVC decline in Group A than in Group B or C. However, the relative effect of nintedanib versus placebo was consistent across the subgroups (p>0.05 for heterogeneity). Conclusions The inclusion criteria used in the INBUILD trial, based on FVC decline or worsening of symptoms and extent of fibrosis on HRCT, were effective at identifying patients with progressive fibrosing ILDs. Nintedanib reduced the rate of decline in FVC across the subgroups based on the inclusion criteria related to ILD progression. In the INBUILD trial in patients with fibrosing ILDs, the relative effect of nintedanib versus placebo on reducing the rate of FVC decline was consistent across subgroups based on the criteria regarding ILD progression that patients fulfilled on trial entryhttps://bit.ly/35jpOiE
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Affiliation(s)
- Toby M Maher
- National Heart and Lung Institute, Imperial College London, London, UK, National Institute for Health Research Clinical Research Facility, Royal Brompton Hospital, London, UK and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Care Medicine, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Anand Devaraj
- Department of Radiology, Royal Brompton Hospital, London; National Heart and Lung Institute, Imperial College, London, UK
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - Elizabeth A Belloli
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Maria Padilla
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juergen Behr
- Department of Medicine V, University Hospital, LMU Munich and Asklepios Klinik München-Gauting, Member of the German Centre for Lung Research, Germany
| | | | - Kay Tetzlaff
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany.,Department of Sports Medicine, University of Tübingen, Tübingen, Germany
| | | | - Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
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19
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Ryerson CJ, Corte TJ, Myers JL, Walsh SLF, Guler SA. A contemporary practical approach to the multidisciplinary management of unclassifiable interstitial lung disease. Eur Respir J 2021; 58:13993003.00276-2021. [PMID: 34140296 PMCID: PMC8674517 DOI: 10.1183/13993003.00276-2021] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/04/2021] [Indexed: 11/05/2022]
Abstract
Fibrotic interstitial lung diseases (ILDs) frequently have nonspecific and overlapping clinical and radiological features, resulting in approximately 10-20% of patients with ILD lacking a clear diagnosis and thus being labelled with unclassifiable ILD. The objective of this review is to describe how patients with unclassifiable ILD should be evaluated and what impact specific clinical, radiological, and histopathological features may have on management decisions, focusing on patients with a predominantly fibrotic phenotype. We highlight recent data that have suggested an increasing role for antifibrotic medications in a variety of fibrotic ILDs, but justify the ongoing importance of making an accurate ILD diagnosis given the benefit of immunomodulatory therapies in many patient populations. We provide a practical approach to support management decisions that can be used by clinicians and tested by clinical researchers, and further identify the need for additional research to support a rational and standardised approach to the management of patients with unclassifiable ILD.
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Affiliation(s)
- Christopher J Ryerson
- Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St. Paul"s Hospital, Vancouver, Canada
| | - Tamera J Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney; University of Sydney; Centre of Research Excellence for Pulmonary Fibrosis, Sydney, Australia
| | - Jeffrey L Myers
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Sabina A Guler
- Department of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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20
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Calandriello L, Walsh SLF. Artificial intelligence for thoracic radiology: from research tool to clinical practice. Eur Respir J 2021; 57:57/5/2100625. [PMID: 34016606 DOI: 10.1183/13993003.00625-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Lucio Calandriello
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia - Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
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21
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Hetzel J, Wells AU, Costabel U, Colby TV, Walsh SLF, Verschakelen J, Cavazza A, Tomassetti S, Ravaglia C, Böckeler M, Spengler W, Kreuter M, Eberhardt R, Darwiche K, Torrego A, Pajares V, Muche R, Musterle R, Horger M, Fend F, Warth A, Heußel CP, Piciucchi S, Dubini A, Theegarten D, Franquet T, Lerma E, Poletti V, Häntschel M. Transbronchial cryobiopsy increases diagnostic confidence in interstitial lung disease: a prospective multicentre trial. Eur Respir J 2020; 56:13993003.01520-2019. [PMID: 32817003 DOI: 10.1183/13993003.01520-2019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 07/15/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The accurate diagnosis of individual interstitial lung diseases (ILD) is often challenging, but is a critical determinant of appropriate management. If a diagnosis cannot be made after multidisciplinary team discussion (MDTD), surgical lung biopsy is the current recommended tissue sampling technique according to the most recent guidelines. Transbronchial lung cryobiopsy (TBLC) has been proposed as an alternative to surgical lung biopsy. METHODS This prospective, multicentre, international study analysed the impact of TBLC on the diagnostic assessment of 128 patients with suspected idiopathic interstitial pneumonia by a central MDTD board (two clinicians, two radiologists, two pathologists). The level of confidence for the first-choice diagnoses were evaluated in four steps, as follows: 1) clinicoradiological data alone; 2) addition of bronchoalveolar lavage (BAL) findings; 3) addition of TBLC interpretation; and 4) surgical lung biopsy findings (if available). We evaluated the contribution of TBLC to the formulation of a confident first-choice MDTD diagnosis. RESULTS TBLC led to a significant increase in the percentage of cases with confident diagnoses or provisional diagnoses with high confidence (likelihood ≥70%) from 60.2% to 81.2%. In 32 out of 52 patients nondiagnostic after BAL, TBLC provided a diagnosis with a likelihood ≥70%. The percentage of confident diagnoses (likelihood ≥90%) increased from 22.7% after BAL to 53.9% after TBLC. Pneumothoraces occurred in 16.4% of patients, and moderate or severe bleeding in 15.7% of patients. No deaths were observed within 30 days. INTERPRETATION TBLC increases diagnostic confidence in the majority of ILD patients with an uncertain noninvasive diagnosis, with manageable side-effects. These data support the integration of TBLC into the diagnostic algorithm for ILD.
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Affiliation(s)
- Jürgen Hetzel
- Dept of Medical Oncology and Pneumology, Eberhard Karls University, Tübingen, Germany .,Division of Internal Medicine, Dept of Pneumology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, UK
| | - Ulrich Costabel
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Thomas V Colby
- Dept of Pathology and Laboratory Medicine (retired), Mayo Clinic, Scottsdale, AZ, USA
| | - Simon L F Walsh
- Dept of Radiology, National Heart and Lung Institute, Imperial College, London, UK
| | | | - Alberto Cavazza
- Dept of Pathology, Azienda USL/IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Sara Tomassetti
- Dept of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy
| | - Claudia Ravaglia
- Dept of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy
| | - Michael Böckeler
- Dept of Medical Oncology and Pneumology, Eberhard Karls University, Tübingen, Germany
| | - Werner Spengler
- Dept of Medical Oncology and Pneumology, Eberhard Karls University, Tübingen, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Ralf Eberhardt
- Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research (DZL), Heidelberg, Germany.,Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Kaid Darwiche
- Dept of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Alfons Torrego
- Respiratory Dept, Hospital de la Santa Creu I Sant Pau (HSCSP), Barcelona, Spain
| | - Virginia Pajares
- Respiratory Dept, Hospital de la Santa Creu I Sant Pau (HSCSP), Barcelona, Spain
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Regina Musterle
- Dept of Medical Oncology and Pneumology, Eberhard Karls University, Tübingen, Germany
| | - Marius Horger
- Dept for Diagnostic and Interventional Radiology, Eberhard-Karls University, Tübingen, Germany
| | - Falko Fend
- Institute of Pathology and Neuropathology, Reference Center for Hematopathology University Hospital, Tuebingen Eberhard-Karls-University, Tübingen, Germany
| | - Arne Warth
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany.,Institute for Pathology, Wetzlar, Germany
| | - Claus Peter Heußel
- Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research (DZL), Heidelberg, Germany.,Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | | | | | - Dirk Theegarten
- Dept of Pathology, University Medicine Essen - Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
| | - Tomas Franquet
- Radiology Dept, Hospital de la Santa Creu I Sant Pau (HSCSP), Barcelona, Spain
| | - Enrique Lerma
- Pathology Dept, Hospital de la Santa Creu I Sant Pau (HSCSP), Barcelona, Spain
| | - Venerino Poletti
- Dept of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy.,Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Maik Häntschel
- Dept of Medical Oncology and Pneumology, Eberhard Karls University, Tübingen, Germany.,Division of Internal Medicine, Dept of Pneumology, Kantonsspital Winterthur, Winterthur, Switzerland
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22
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Johannson KA, Barnes H, Bellanger AP, Dalphin JC, Fernández Pérez ER, Flaherty KR, Huang YCT, Jones KD, Kawano-Dourado L, Kennedy K, Millerick-May M, Miyazaki Y, Morisset J, Morell F, Raghu GR, Robbins C, Sack CS, Salisbury ML, Selman M, Vasakova M, Walsh SLF, Rose CS. Exposure Assessment Tools for Hypersensitivity Pneumonitis. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 17:1501-1509. [PMID: 33258669 PMCID: PMC7706597 DOI: 10.1513/annalsats.202008-942st] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This report is based on proceedings from the Exposure Assessment Tools for Hypersensitivity Pneumonitis (HP) Workshop, sponsored by the American Thoracic Society, that took place on May 18, 2019, in Dallas, Texas. The workshop was initiated by members from the Environmental, Occupational, and Population Health and Clinical Problems Assemblies of the American Thoracic Society. Participants included international experts from pulmonary medicine, occupational medicine, radiology, pathology, and exposure science. The meeting objectives were to 1) define currently available tools for exposure assessment in evaluation of HP, 2) describe the evidence base supporting the role for these exposure assessment tools in HP evaluation, 3) identify limitations and barriers to each tool's implementation in clinical practice, 4) determine which exposure assessment tools demonstrate the best performance characteristics and applicability, and 5) identify research needs for improving exposure assessment tools for HP. Specific discussion topics included history-taking and exposure questionnaires, antigen avoidance, environmental assessment, specific inhalational challenge, serum-specific IgG testing, skin testing, lymphocyte proliferation testing, and a multidisciplinary team approach. Priorities for research in this area were identified.
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23
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Raghu G, Remy-Jardin M, Ryerson CJ, Myers JL, Kreuter M, Vasakova M, Bargagli E, Chung JH, Collins BF, Bendstrup E, Chami HA, Chua AT, Corte TJ, Dalphin JC, Danoff SK, Diaz-Mendoza J, Duggal A, Egashira R, Ewing T, Gulati M, Inoue Y, Jenkins AR, Johannson KA, Johkoh T, Tamae-Kakazu M, Kitaichi M, Knight SL, Koschel D, Lederer DJ, Mageto Y, Maier LA, Matiz C, Morell F, Nicholson AG, Patolia S, Pereira CA, Renzoni EA, Salisbury ML, Selman M, Walsh SLF, Wuyts WA, Wilson KC. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:e36-e69. [PMID: 32706311 PMCID: PMC7397797 DOI: 10.1164/rccm.202005-2032st] [Citation(s) in RCA: 411] [Impact Index Per Article: 102.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax.Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions.Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.
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24
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Brown KK, Martinez FJ, Walsh SLF, Thannickal VJ, Prasse A, Schlenker-Herceg R, Goeldner RG, Clerisme-Beaty E, Tetzlaff K, Cottin V, Wells AU. The natural history of progressive fibrosing interstitial lung diseases. Eur Respir J 2020; 55:13993003.00085-2020. [PMID: 32217654 PMCID: PMC7315005 DOI: 10.1183/13993003.00085-2020] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [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: 01/15/2020] [Accepted: 02/20/2020] [Indexed: 12/31/2022]
Abstract
We used data from the INBUILD and INPULSIS trials to investigate the natural history of progressive fibrosing interstitial lung diseases (ILDs). Subjects in the two INPULSIS trials had a clinical diagnosis of idiopathic pulmonary fibrosis (IPF) while subjects in the INBUILD trial had a progressive fibrosing ILD other than IPF and met protocol-defined criteria for ILD progression despite management. Using data from the placebo groups, we compared the rate of decline in forced vital capacity (FVC) (mL·year−1) and mortality over 52 weeks in the INBUILD trial with pooled data from the INPULSIS trials. The adjusted mean annual rate of decline in FVC in the INBUILD trial (n=331) was similar to that observed in the INPULSIS trials (n=423) (−192.9 mL·year−1 and −221.0 mL·year−1, respectively; nominal p-value=0.19). The proportion of subjects who had a relative decline in FVC >10% predicted at Week 52 was 48.9% in the INBUILD trial and 48.7% in the INPULSIS trials, and the proportion who died over 52 weeks was 5.1% in the INBUILD trial and 7.8% in the INPULSIS trials. A relative decline in FVC >10% predicted was associated with an increased risk of death in the INBUILD trial (hazard ratio 3.64) and the INPULSIS trials (hazard ratio 3.95). These findings indicate that patients with fibrosing ILDs other than IPF, who are progressing despite management, have a subsequent clinical course similar to patients with untreated IPF, with a high risk of further ILD progression and early mortality. Analyses of data from the INBUILD and INPULSIS trials suggest that progressive fibrosing ILDs other than IPF have a clinical course similar to IPF, irrespective of underlying ILD diagnosis or the fibrotic pattern on HRCThttp://bit.ly/3apG0Q5
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Affiliation(s)
- Kevin K Brown
- Dept of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | - Victor J Thannickal
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Antje Prasse
- Dept of Respiratory Medicine, MHH Hannover Medical School and Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover, Germany
| | | | | | | | - Kay Tetzlaff
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany.,Dept of Sports Medicine, University of Tübingen, Tübingen, Germany
| | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, UMR 754, Claude Bernard University Lyon 1, Lyon, France
| | - Athol U Wells
- National Heart and Lung Institute, Imperial College, London, UK.,National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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25
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Assayag D, Morisset J, Johannson KA, Wells AU, Walsh SLF. Patient gender bias on the diagnosis of idiopathic pulmonary fibrosis. Thorax 2020; 75:407-412. [DOI: 10.1136/thoraxjnl-2019-213968] [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: 08/14/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 01/20/2023]
Abstract
BackgroundPatient sex has clinical and prognostic implications in idiopathic pulmonary fibrosis (IPF). It is not known if sex-related and gender-related discrepancies exist when establishing a diagnosis of IPF. The aim was to determine how patient gender influences the diagnosis of IPF and the physician’s diagnostic confidence.MethodsThis study was performed using clinical cases compiled from a single centre, then scored by respiratory physicians for a prior study. Using clinical information, physicians were asked to provide up to five diagnoses, together with their diagnostic confidence. Logistic regression was used to assess the odds of receiving a diagnosis of IPF based on patient gender. Prognostic discrimination between IPF and non-IPF was used to assess diagnostic accuracy with Cox proportional hazards modelling.ResultsSixty cases were scored by 404 physicians. IPF was diagnosed more frequently in men compared with women (37.8% vs 10.6%; p<0.0001), and with greater mean diagnostic confidence (p<0.001). The odds of a male patient receiving an IPF diagnosis was greater than that of female patients, after adjusting for confounders (OR=3.05, 95% CI: 2.81 to 3.31), especially if the scan was not definite for the usual interstitial pneumonia pattern. Mortality was higher in women (HR=2.21, 95% CI: 2.02 to 2.41) than in men with an IPF diagnosis (HR=1.26, 95% CI: 1.20 to 1.33), suggesting that men were more often misclassified as having IPF.ConclusionPatient gender influences diagnosis of IPF: women may be underdiagnosed and men overdiagnosed with IPF.
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Walsh SLF, Lederer DJ, Ryerson CJ, Kolb M, Maher TM, Nusser R, Poletti V, Richeldi L, Vancheri C, Wilsher ML, Antoniou KM, Behr J, Bendstrup E, Brown KK, Corte TJ, Cottin V, Crestani B, Flaherty KR, Glaspole IN, Grutters J, Inoue Y, Kondoh Y, Kreuter M, Johannson KA, Ley B, Martinez FJ, Molina-Molina M, Morais A, Nunes H, Raghu G, Selman M, Spagnolo P, Taniguchi H, Tomassetti S, Valeyre D, Wijsenbeek M, Wuyts WA, Wells AU. Diagnostic Likelihood Thresholds That Define a Working Diagnosis of Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2019; 200:1146-1153. [DOI: 10.1164/rccm.201903-0493oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Simon L. F. Walsh
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - David J. Lederer
- Department of Medicine and
- Department of Epidemiology, Columbia University Medical Center, New York, New York
| | - Christopher J. Ryerson
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Martin Kolb
- Department of Medicine and
- Department of Pathology and Molecular Medicine, Firestone Institute for Respiratory Health, McMaster University, Hamilton, Ontario, Canada
| | - Toby M. Maher
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- National Institute of Health Research Respiratory Clinical Research Facility and
| | - Richard Nusser
- Department of Respiratory Medicine, Summit Hospital, Oakland, California
| | - Venerino Poletti
- Department of Diseases of the Thorax, Ospedale G. B. Morgagni, Forlì, Italy
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli, Istituto di Ricovero e Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carlo Vancheri
- Department of Clinical and Experimental Medicine, Regional Referral Centre for Rare Lung Diseases, University-Hospital “Policlinico” Vittorio Emanuele, University of Catania, Catania, Italy
| | - Margaret L. Wilsher
- Auckland District Health Board, University of Auckland, Auckland, New Zealand
| | - Katerina M. Antoniou
- Department of Respiratory Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Juergen Behr
- Department of Medicine V, University of Munich and Asklepios Fachkliniken Gauting, Comprehensive Pneumology Center, member of the German Center for Lung Research [DZL], Munich, Germany
| | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Tamera J. Corte
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, UMR 754, Claude Bernard University Lyon 1, Lyon, France
| | - Bruno Crestani
- APHP, Hopital Bichat, Service de Pneumologie A, Université Paris Diderot, Paris, France
| | - Kevin R. Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ian N. Glaspole
- Alfred Health–Allergy, Immunology, and Respiratory Medicine, the Alfred Hospital, Melbourne, Australia
| | - Jan Grutters
- Division of Heart and Lungs, ILD Center of Excellence, St. Antonius Hospital, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki–Chuo Chest Medical Center, Osaka, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, member of the DZL, Heidelberg, Germany
| | | | - Brett Ley
- Kaiser Permanente San Francisco, San Francisco, California
| | | | | | - Antonio Morais
- Pulmonology, Faculdade de Medicina do Porto, Centro Hospitalar São João, Oporto, Portugal
| | - Hilario Nunes
- INSERM UMR 1272, Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France
| | - Ganesh Raghu
- Center for Interstitial Lung Disease, University of Washington, Seattle, Washington
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias “Ismael Cosio Villegas,” Mexico City, Mexico
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Sara Tomassetti
- Department of Diseases of the Thorax, Ospedale G. B. Morgagni, Forlì, Italy
| | - Dominique Valeyre
- INSERM UMR 1272, Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France
| | - Marlies Wijsenbeek
- Department of Pulmonary Diseases, Erasmus Medical Center, University Hospital Rotterdam, Rotterdam, the Netherlands; and
| | - Wim A. Wuyts
- Department of Pulmonary Medicine, Unit for Interstitial Lung Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton and Harefield Foundation Trust, London, United Kingdom
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Flaherty KR, Wells AU, Cottin V, Devaraj A, Walsh SLF, Inoue Y, Richeldi L, Kolb M, Tetzlaff K, Stowasser S, Coeck C, Clerisme-Beaty E, Rosenstock B, Quaresma M, Haeufel T, Goeldner RG, Schlenker-Herceg R, Brown KK. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases. N Engl J Med 2019; 381:1718-1727. [PMID: 31566307 DOI: 10.1056/nejmoa1908681] [Citation(s) in RCA: 1087] [Impact Index Per Article: 217.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preclinical data have suggested that nintedanib, an intracellular inhibitor of tyrosine kinases, inhibits processes involved in the progression of lung fibrosis. Although the efficacy of nintedanib has been shown in idiopathic pulmonary fibrosis, its efficacy across a broad range of fibrosing lung diseases is unknown. METHODS In this double-blind, placebo-controlled, phase 3 trial conducted in 15 countries, we randomly assigned patients with fibrosing lung disease affecting more than 10% of lung volume on high-resolution computed tomography (CT) to receive nintedanib at a dose of 150 mg twice daily or placebo. All the patients met criteria for progression of interstitial lung disease in the past 24 months despite treatment and had a forced vital capacity (FVC) of at least 45% of the predicted value and a diffusing capacity of the lung for carbon monoxide ranging from 30 to less than 80% of the predicted value. Randomization was stratified according to the fibrotic pattern (a pattern of usual interstitial pneumonia [UIP] or other fibrotic patterns) on high-resolution CT. The primary end point was the annual rate of decline in the FVC, as assessed over a 52-week period. The two primary populations for analysis were the overall population and patients with a UIP-like fibrotic pattern. RESULTS A total of 663 patients were treated. In the overall population, the adjusted rate of decline in the FVC was -80.8 ml per year with nintedanib and -187.8 ml per year with placebo, for a between-group difference of 107.0 ml per year (95% confidence interval [CI], 65.4 to 148.5; P<0.001). In patients with a UIP-like fibrotic pattern, the adjusted rate of decline in the FVC was -82.9 ml per year with nintedanib and -211.1 ml per year with placebo, for a difference of 128.2 ml (95% CI, 70.8 to 185.6; P<0.001). Diarrhea was the most common adverse event, as reported in 66.9% and 23.9% of patients treated with nintedanib and placebo, respectively. Abnormalities on liver-function testing were more common in the nintedanib group than in the placebo group. CONCLUSIONS In patients with progressive fibrosing interstitial lung diseases, the annual rate of decline in the FVC was significantly lower among patients who received nintedanib than among those who received placebo. Diarrhea was a common adverse event. (Funded by Boehringer Ingelheim; INBUILD ClinicalTrials.gov number, NCT02999178.).
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Affiliation(s)
- Kevin R Flaherty
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Athol U Wells
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Vincent Cottin
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Anand Devaraj
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Simon L F Walsh
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Yoshikazu Inoue
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Luca Richeldi
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Martin Kolb
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Kay Tetzlaff
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Susanne Stowasser
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Carl Coeck
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Emmanuelle Clerisme-Beaty
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Bernd Rosenstock
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Manuel Quaresma
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Thomas Haeufel
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Rainer-Georg Goeldner
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Rozsa Schlenker-Herceg
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
| | - Kevin K Brown
- From the Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor (K.R.F.); the National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust (A.U.W.), the National Heart and Lung Institute, Imperial College (A.U.W., A.D., S.L.F.W.), and the Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust (A.D.) - all in London; the National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, Unité Mixte de Recherche 754, Lyon, France (V.C.); the Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan (Y.I.); Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome (L.R.); McMaster University and St. Joseph's Healthcare, Hamilton, ON, Canada (M.K.); Boehringer Ingelheim International, Ingelheim am Rhein (K.T., S.S., E.C.-B., M.Q., T.H.), the Department of Sports Medicine, University of Tübingen, Tübingen (K.T.), and Boehringer Ingelheim Pharma, Biberach (B.R., R.-G.G.) - all in Germany; Boehringer Ingelheim, Brussels (C.C.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.S.-H.); and the Department of Medicine, National Jewish Health, Denver (K.K.B.)
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Affiliation(s)
- Simon L F Walsh
- 1 National Heart and Lung Institute Imperial College London London, United Kingdom and
| | - Luca Richeldi
- 2 Fondazione Policlinico A. Gemelli IRCCS Università Cattolica del Sacro Cuore Rome, Italy
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Walsh SLF, Richeldi L. Demystifying fibrotic hypersensitivity pneumonitis diagnosis: it's all about shades of grey. Eur Respir J 2019; 54:54/1/1900906. [PMID: 31345989 DOI: 10.1183/13993003.00906-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Simon L F Walsh
- National Heart and Lung Institute, Imperial College, London, UK
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Abstract
PURPOSE OF REVIEW The application of computer-based imaging analysis in patients with idiopathic pulmonary fibrosis is a rapidly developing field. The purpose of this review is to provide insights into the problems associated with visual interpretation of HRCT patterns and describe some of the current technologies used to provide objective quantification of disease on HRCT. Future directions are also discussed. RECENT FINDINGS Although there is strong evidence that visual quantification of disease on HRCT in idiopathic pulmonary fibrosis provides prognostic information, this approach is hampered by its subjective nature and interobserver variability. In contrast, computer-based quantification of disease on HRCT provides objective and reproducible data, which may help to predict mortality and time to decline in patients with idiopathic pulmonary fibrosis. The use of these technologies may also help to stratify clinical risk in patients enrolled in drug trials. SUMMARY The future of imaging-based biomarker research in idiopathic pulmonary fibrosis is undoubtedly computer-based HRCT evaluation. However, if this field is to continue to innovate, large, well annotated imaging datasets for developing and testing. new computer-based tools are needed as well as prospective trials for biomarker validation.
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Affiliation(s)
- Simon L F Walsh
- Department of Radiology, King's College Hospital Foundation Trust, Denmark Hill, Brixton, London SE5 9RS, United Kingdom
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Richeldi L, Launders N, Martinez F, Walsh SLF, Myers J, Wang B, Jones M, Chisholm A, Flaherty KR. The characterisation of interstitial lung disease multidisciplinary team meetings: a global study. ERJ Open Res 2019; 5:00209-2018. [PMID: 30949489 PMCID: PMC6441673 DOI: 10.1183/23120541.00209-2018] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [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: 12/07/2018] [Accepted: 02/05/2019] [Indexed: 01/04/2023] Open
Abstract
Multidisciplinary team (MDT) diagnosis of interstitial lung disease (ILD) has been proposed as a gold standard, but there are no formal recommendations for MDT process or composition and limited knowledge regarding prevalence in routine practice. We performed a systematic evaluation of ILD diagnostic practice across a range of healthcare settings around the world. Electronic questionnaires were distributed across all global regions via society and collaborators networks. Responses from 457 unique centres across 64 countries were included in the analysis. Of the 350 (76.6%) centres holding formal meetings, the majority held face-to-face MDT meetings (80%), for a minimum of 30 min (93%), and discussed diagnosis (96.9%) and patient management (94.9%) at the meetings. Compared with non-academic and academic non-ILD centres, ILD academic centres reported a higher ILD caseload, held more formal MDT meetings, and were more likely to include histopathology and rheumatology specialists in their diagnostic team. Of the centres holding MDT meetings, 5.5% routinely discussed all new cases at such meetings. An MDT approach to ILD diagnosis is consistently interpreted and widely implemented across a range of routine care settings around the world. This observation will inform future ILD diagnostic agreement studies and diagnostic pathway recommendations. In real-world practice, ILD diagnosis uses a multidisciplinary team approach, irrespective of country or healthcare settinghttp://ow.ly/I1Di30nMNTX
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Affiliation(s)
- Luca Richeldi
- Unità Operativa Complessa di Pneumologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Fernando Martinez
- Joan and Sanford I. Weill Dept of Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | | | - Jeffrey Myers
- Dept of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Bonnie Wang
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark Jones
- NIHR Southampton Biomedical Research Centre, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of Michigan, Ann Arbor, MI, USA
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32
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Walsh SLF. Mediastinal Lymphadenopathy in Interstitial Lung Disease. Time to Be Counted. Am J Respir Crit Care Med 2019; 199:685-687. [PMID: 30335464 PMCID: PMC6423108 DOI: 10.1164/rccm.201810-1892ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Simon L. F. Walsh
- National Heart and Lung InstituteImperial CollegeLondon, United Kingdom
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Wu X, Kim GH, Salisbury ML, Barber D, Bartholmai BJ, Brown KK, Conoscenti CS, De Backer J, Flaherty KR, Gruden JF, Hoffman EA, Humphries SM, Jacob J, Maher TM, Raghu G, Richeldi L, Ross BD, Schlenker-Herceg R, Sverzellati N, Wells AU, Martinez FJ, Lynch DA, Goldin J, Walsh SLF. Computed Tomographic Biomarkers in Idiopathic Pulmonary Fibrosis. The Future of Quantitative Analysis. Am J Respir Crit Care Med 2019; 199:12-21. [DOI: 10.1164/rccm.201803-0444pp] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Grace H. Kim
- Radiological Science, University of California Los Angeles School of Medicine, Los Angeles, California
| | | | | | | | - Kevin K. Brown
- Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, Colorado
| | | | | | | | | | - Eric A. Hoffman
- Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Joseph Jacob
- Respiratory Medicine and
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Toby M. Maher
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom
- Associate Editor, AJRCCM
| | - Ganesh Raghu
- Pulmonary and Critical Care Medicine, University of Washington Medical Center, Seattle, Washington
| | - Luca Richeldi
- Fondazione Policlinico Universitario A. Gemelli, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Brian D. Ross
- Radiology, University of Michigan Hospital, Ann Arbor, Michigan
| | | | - Nicola Sverzellati
- Radiology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom
| | | | | | - Jonathan Goldin
- Radiological Science, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Simon L. F. Walsh
- Radiology, Kings College Hospital National Health Service Foundation Trust, London, United Kingdom
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Walsh SLF, Devaraj A, Enghelmayer JI, Kishi K, Silva RS, Patel N, Rossman MD, Valenzuela C, Vancheri C. Role of imaging in progressive-fibrosing interstitial lung diseases. Eur Respir Rev 2018; 27:27/150/180073. [PMID: 30578332 PMCID: PMC9488692 DOI: 10.1183/16000617.0073-2018] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [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: 08/14/2018] [Accepted: 11/01/2018] [Indexed: 01/03/2023] Open
Abstract
Imaging techniques are an essential component of the diagnostic process for interstitial lung diseases (ILDs). Chest radiography is frequently the initial indicator of an ILD, and comparison of radiographs taken at different time points can show the rate of disease progression. However, radiography provides only limited specificity and sensitivity and is primarily used to rule out other diseases, such as left heart failure. High-resolution computed tomography (HRCT) is a more sensitive method and is considered central in the diagnosis of ILDs. Abnormalities observed on HRCT can help identify specific ILDs. HRCT also can be used to evaluate the patient's prognosis, while disease progression can be assessed through serial imaging. Other imaging techniques such as positron emission tomography-computed tomography and magnetic resonance imaging have been investigated, but they are not commonly used to assess patients with ILDs. Disease severity may potentially be estimated using quantitative methods, as well as visual analysis of images. For example, comprehensive assessment of disease staging and progression in patients with ILDs requires visual analysis of pulmonary features that can be performed in parallel with quantitative analysis of the extent of fibrosis. New approaches to image analysis, including the application of machine learning, are being developed. Imaging techniques, particularly HRCT, are the cornerstone for ILD diagnosis and new approaches to analysing HRCT images, including machine-learning technology, are being developedhttp://ow.ly/1R1e30mOqhn
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Affiliation(s)
- Simon L F Walsh
- Dept of Radiology, King's College NHS Foundation Trust, London, UK.,Both authors contributed equally
| | - Anand Devaraj
- Dept of Radiology, Royal Brompton & Harefield Hospital, London, UK.,Both authors contributed equally
| | - Juan Ignacio Enghelmayer
- División Neumonología, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Fundación Funef, Buenos Aires, Argentina
| | - Kazuma Kishi
- Dept of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
| | - Rafael S Silva
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Nina Patel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Milton D Rossman
- Pulmonary, Allergy & Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, University Hospital "Policlinico", Dept of Clinical and Respiratory Medicine, University of Catania, Catania, Italy
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35
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Nair A, Bartlett EC, Walsh SLF, Wells AU, Navani N, Hardavella G, Bhalla S, Calandriello L, Devaraj A, Goo JM, Klein JS, MacMahon H, Schaefer-Prokop CM, Seo JB, Sverzellati N, Desai SR. Variable radiological lung nodule evaluation leads to divergent management recommendations. Eur Respir J 2018; 52:13993003.01359-2018. [PMID: 30409817 DOI: 10.1183/13993003.01359-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/07/2018] [Indexed: 12/18/2022]
Abstract
Radiological evaluation of incidentally detected lung nodules on computed tomography (CT) influences management. We assessed international radiological variation in 1) pulmonary nodule characterisation; 2) hypothetical guideline-derived management; and 3) radiologists' management recommendations.107 radiologists from 25 countries evaluated 69 CT-detected nodules, recording: 1) first-choice composition (solid, part-solid or ground-glass, with percentage confidence); 2) morphological features; 3) dimensions; 4) recommended management; and 5) decision-influencing factors. We modelled hypothetical management decisions on the 2005 and updated 2017 Fleischner Society, and both liberal and parsimonious interpretations of the British Thoracic Society 2015 guidelines.Overall agreement for first-choice nodule composition was good (Fleiss' κ=0.65), but poorest for part-solid nodules (weighted κ 0.62, interquartile range 0.50-0.71). Morphological variables, including spiculation (κ=0.35), showed poor-to-moderate agreement (κ=0.23-0.53). Variation in diameter was greatest at key thresholds (5 mm and 6 mm). Agreement for radiologists' recommendations was poor (κ=0.30); 21% disagreed with the majority. Although agreement within the four guideline-modelled management strategies was good (κ=0.63-0.73), 5-10% of radiologists would disagree with majority decisions if they applied guidelines strictly.Agreement was lowest for part-solid nodules, while significant measurement variation exists at important size thresholds. These variations resulted in generally good agreement for guideline-modelled management, but poor agreement for radiologists' actual recommendations.
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Affiliation(s)
- Arjun Nair
- Dept of Radiology, University College London Hospitals NHS Foundation Trust, London, UK.,Both authors contributed equally
| | - Emily C Bartlett
- Dept of Radiology, King's College Hospital NHS Foundation Trust, London, UK.,Both authors contributed equally
| | - Simon L F Walsh
- Dept of Radiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Athol U Wells
- Dept of Respiratory Medicine, The Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK
| | - Neal Navani
- Dept of Thoracic Medicine, UCLH and Lungs for Living Centre, UCL Respiratory, University College London, London, UK
| | | | | | - Lucio Calandriello
- Radiologia Diagnostica e Interventistica Generale - Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anand Devaraj
- Dept of Radiology, The Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK
| | - Jin Mo Goo
- Seoul National University Hospital, Seoul, South Korea
| | - Jeffrey S Klein
- The University of Vermont Medical Center, Burlington, VT, USA
| | - Heber MacMahon
- Dept of Radiology, University of Chicago Medical Center, Chicago, IL, USA
| | | | - Joon-Beom Seo
- Dept of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Nicola Sverzellati
- Dept of Clinical Sciences, Division of Radiology, University of Parma, Parma, Italy
| | - Sujal R Desai
- Dept of Radiology, King's College Hospital NHS Foundation Trust, London, UK.,Dept of Radiology, The Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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36
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Walsh SLF, Calandriello L, Silva M, Sverzellati N. Deep learning for classifying fibrotic lung disease on high-resolution computed tomography: a case-cohort study. The Lancet Respiratory Medicine 2018; 6:837-845. [DOI: 10.1016/s2213-2600(18)30286-8] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 12/22/2022]
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Jacob J, Bartholmai BJ, Rajagopalan S, van Moorsel CHM, van Es HW, van Beek FT, Struik MHL, Kokosi M, Egashira R, Brun AL, Nair A, Walsh SLF, Cross G, Barnett J, de Lauretis A, Judge EP, Desai S, Karwoski R, Ourselin S, Renzoni E, Maher TM, Altmann A, Wells AU. Predicting Outcomes in Idiopathic Pulmonary Fibrosis Using Automated Computed Tomographic Analysis. Am J Respir Crit Care Med 2018; 198:767-776. [PMID: 29684284 PMCID: PMC6222463 DOI: 10.1164/rccm.201711-2174oc] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 04/20/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Quantitative computed tomographic (CT) measures of baseline disease severity might identify patients with idiopathic pulmonary fibrosis (IPF) with an increased mortality risk. We evaluated whether quantitative CT variables could act as a cohort enrichment tool in future IPF drug trials. OBJECTIVES To determine whether computer-derived CT measures, specifically measures of pulmonary vessel-related structures (VRSs), can better predict functional decline and survival in IPF and reduce requisite sample sizes in drug trial populations. METHODS Patients with IPF undergoing volumetric noncontrast CT imaging at the Royal Brompton Hospital, London, and St. Antonius Hospital, Utrecht, were examined to identify pulmonary function measures (including FVC) and visual and computer-derived (CALIPER [Computer-Aided Lung Informatics for Pathology Evaluation and Rating] software) CT features predictive of mortality and FVC decline. The discovery cohort comprised 247 consecutive patients, with validation of results conducted in a separate cohort of 284 patients, all fulfilling drug trial entry criteria. MEASUREMENTS AND MAIN RESULTS In the discovery and validation cohorts, CALIPER-derived features, particularly VRS scores, were among the strongest predictors of survival and FVC decline. CALIPER results were accentuated in patients with less extensive disease, outperforming pulmonary function measures. When used as a cohort enrichment tool, a CALIPER VRS score greater than 4.4% of the lung was able to reduce the requisite sample size of an IPF drug trial by 26%. CONCLUSIONS Our study has validated a new quantitative CT measure in patients with IPF fulfilling drug trial entry criteria-the VRS score-that outperformed current gold standard measures of outcome. When used for cohort enrichment in an IPF drug trial setting, VRS threshold scores can reduce a required IPF drug trial population size by 25%, thereby limiting prohibitive trial costs. Importantly, VRS scores identify patients in whom antifibrotic medication prolongs life and reduces FVC decline.
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Affiliation(s)
- Joseph Jacob
- Department of Respiratory Medicine
- Centre for Medical Image Computing, and
| | | | | | - Coline H. M. van Moorsel
- St. Antonius ILD Center of Excellence, Department of Pulmonology, and
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hendrik W. van Es
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Marjolijn H. L. Struik
- St. Antonius ILD Center of Excellence, Department of Pulmonology, and
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Ryoko Egashira
- Department of Radiology, Faculty of Medicine, Saga University, Saga City, Japan
| | - Anne Laure Brun
- Imaging Department, Hôpital Cochin, Paris-Descartes University, Paris, France
| | - Arjun Nair
- Department of Radiology, University College London, London, United Kingdom
| | - Simon L. F. Walsh
- Department of Radiology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gary Cross
- Department of Radiology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joseph Barnett
- Department of Radiology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Angelo de Lauretis
- Division of Pneumology, “Guido Salvini” Hospital, Garbagnate Milanese, Italy
| | - Eoin P. Judge
- Department of Respiratory Medicine, Aintree University Hospital, Liverpool, United Kingdom; and
| | - Sujal Desai
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Ronald Karwoski
- Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, Rochester, Minnesota
| | - Sebastien Ourselin
- Translational Imaging Group, Centre for Medical Image Computing, University College London, London, United Kingdom
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Walsh SLF, Kolb M. Radiological diagnosis of interstitial lung disease: is it all about pattern recognition? Eur Respir J 2018; 52:52/2/1801321. [PMID: 30115654 DOI: 10.1183/13993003.01321-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Simon L F Walsh
- Dept of Radiology, King's College Hospital Foundation Trust, London, UK
| | - Martin Kolb
- Departments of Medicine and Pathology/Molecular Medicine, McMaster University, Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
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Sgalla G, Walsh SLF, Sverzellati N, Fletcher S, Cerri S, Dimitrov B, Nikolic D, Barney A, Pancaldi F, Larcher L, Luppi F, Jones MG, Davies D, Richeldi L. "Velcro-type" crackles predict specific radiologic features of fibrotic interstitial lung disease. BMC Pulm Med 2018; 18:103. [PMID: 29914454 PMCID: PMC6006991 DOI: 10.1186/s12890-018-0670-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 04/07/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND "Velcro-type" crackles on chest auscultation are considered a typical acoustic finding of Fibrotic Interstitial Lung Disease (FILD), however whether they may have a role in the early detection of these disorders has been unknown. This study investigated how "Velcro-type" crackles correlate with the presence of distinct patterns of FILD and individual radiologic features of pulmonary fibrosis on High Resolution Computed Tomography (HRCT). METHODS Lung sounds were digitally recorded from subjects immediately prior to undergoing clinically indicated chest HRCT. Audio files were independently assessed by two chest physicians and both full volume and single HRCT sections corresponding to the recording sites were extracted. The relationships between audible "Velcro-type" crackles and radiologic HRCT patterns and individual features of pulmonary fibrosis were investigated using multivariate regression models. RESULTS 148 subjects were enrolled: bilateral "Velcro-type" crackles predicted the presence of FILD at HRCT (OR 13.46, 95% CI 5.85-30.96, p < 0.001) and most strongly the Usual Interstitial Pneumonia (UIP) pattern (OR 19.8, 95% CI 5.28-74.25, p < 0.001). Extent of isolated reticulation (OR 2.04, 95% CI 1.62-2.57, p < 0.001), honeycombing (OR 1.88, 95% CI 1.24-2.83, < 0.01), ground glass opacities (OR 1.74, 95% CI 1.29-2.32, p < 0.001) and traction bronchiectasis (OR 1.55, 95% CI 1.03-2.32, p < 0.05) were all independently associated with the presence of "Velcro-type" crackles. CONCLUSIONS "Velcro-type" crackles predict the presence of FILD and directly correlate with the extent of distinct radiologic features of pulmonary fibrosis. Such evidence provides grounds for further investigation of lung sounds as an early identification tool in FILD.
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Affiliation(s)
- Giacomo Sgalla
- Division of Respiratory Medicine, University Hospital “A. Gemelli”, Catholic University of Sacred Heart, Rome, Italy
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit and Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | | | | | - Sophie Fletcher
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit and Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Stefania Cerri
- Centre for Rare Lung Disease, University Hospital of Modena, Modena, Italy
| | - Borislav Dimitrov
- Medical Statistics, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Dragana Nikolic
- Institute for Sound and Vibration Research, University of Southampton, Southampton, UK
| | - Anna Barney
- Institute for Sound and Vibration Research, University of Southampton, Southampton, UK
| | | | - Luca Larcher
- DISMI, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Fabrizio Luppi
- Centre for Rare Lung Disease, University Hospital of Modena, Modena, Italy
| | - Mark G. Jones
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit and Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Donna Davies
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit and Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | - Luca Richeldi
- Division of Respiratory Medicine, University Hospital “A. Gemelli”, Catholic University of Sacred Heart, Rome, Italy
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit and Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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Ryerson CJ, Walsh SLF, Collard HR. Reply to Moodley: A Standardized Diagnostic Ontology for Fibrotic Interstitial Lung Disease. Am J Respir Crit Care Med 2018; 197:1366-1367. [DOI: 10.1164/rccm.201712-2515le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Simon L. F. Walsh
- King’s College Hospital NHS Foundation TrustLondon, United Kingdomand
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Ryerson CJ, Corte TJ, Lee JS, Richeldi L, Walsh SLF, Myers JL, Behr J, Cottin V, Danoff SK, Flaherty KR, Lederer DJ, Lynch DA, Martinez FJ, Raghu G, Travis WD, Udwadia Z, Wells AU, Collard HR. A Standardized Diagnostic Ontology for Fibrotic Interstitial Lung Disease. An International Working Group Perspective. Am J Respir Crit Care Med 2017; 196:1249-1254. [PMID: 28414524 DOI: 10.1164/rccm.201702-0400pp] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Christopher J Ryerson
- 1 Department of Medicine and Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,2 St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Tamera J Corte
- 3 Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia.,4 University of Sydney, Sydney, Australia
| | - Joyce S Lee
- 5 Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Luca Richeldi
- 6 Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Simon L F Walsh
- 7 Department of Radiology, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | | | - Jürgen Behr
- 9 Department of Internal Medicine V, Ludwig Maximilians University, Munich, Germany.,10 Asklepios Clinics, Gauting, Germany.,11 Comprehensive Pneumology Center Munich, Member of the German Center for Lung Research, Munich, Germany
| | - Vincent Cottin
- 12 Department of Medicine, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, University of Lyon, Lyon, France
| | - Sonye K Danoff
- 13 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kevin R Flaherty
- 14 Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - David J Lederer
- 15 Department of Medicine, Columbia University, New York, New York
| | - David A Lynch
- 16 Department of Radiology, National Jewish Health, Denver, Colorado
| | | | - Ganesh Raghu
- 18 Department of Medicine, University of Washington, Seattle, Washington
| | - William D Travis
- 19 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zarir Udwadia
- 20 Hinduja Hospital and Research Centre, Mumbai, India.,21 Breach Candy Hospital, Mumbai, India
| | - Athol U Wells
- 22 Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom; and
| | - Harold R Collard
- 23 Department of Medicine, University of California San Francisco, San Francisco, California
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Jacob J, Bartholmai BJ, Rajagopalan S, Karwoski R, Nair A, Walsh SLF, Barnett J, Cross G, Judge EP, Kokosi M, Renzoni E, Maher TM, Wells AU. Likelihood of pulmonary hypertension in patients with idiopathic pulmonary fibrosis and emphysema. Respirology 2017; 23:593-599. [PMID: 29237236 DOI: 10.1111/resp.13231] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/11/2017] [Accepted: 11/15/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE This study evaluated whether patients with combined pulmonary fibrosis and emphysema (CPFE) have an increased likelihood of pulmonary hypertension (PHT) when compared with idiopathic pulmonary fibrosis (IPF) patients without emphysema. METHODS Two consecutive IPF populations having undergone transthoracic echocardiography were examined (n = 223 and n = 162). Emphysema and interstitial lung disease (ILD) extent were quantified visually; ILD extent was also quantified by a software tool, CALIPER. Echocardiographic criteria categorized PHT risk. RESULTS The prevalence of an increased PHT likelihood was 29% and 31% in each CPFE cohort. Survival at 12 months was 60% across both CPFE cohorts with no significantly worsened outcome identified when compared with IPF patients without emphysema. Using logistic regression models in both cohorts, total computed tomography (CT) disease extent (ILD and emphysema) predicted the likelihood of PHT. After adjustment for total disease extent, CPFE had no stronger association with PHT likelihood than IPF patients without emphysema. CONCLUSION Our findings indicate that the reported association between CPFE and PHT is explained by the summed baseline CT extents of ILD and emphysema. Once baseline severity is taken into account, CPFE is not selectively associated with a malignant microvascular phenotype, when compared with IPF patients without emphysema.
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Affiliation(s)
- Joseph Jacob
- Division of Radiology, Mayo Clinic Rochester, Rochester, MN, USA
| | | | | | - Ronald Karwoski
- Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, Rochester, MN, USA
| | - Arjun Nair
- Department of Radiology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Simon L F Walsh
- Department of Radiology, Kings College Hospital NHS Foundation Trust, London, UK
| | - Joseph Barnett
- Department of Radiology, Royal Free Hospital, London, UK
| | - Gary Cross
- Department of Radiology, Royal Free Hospital, London, UK
| | - Eoin P Judge
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Toby M Maher
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Morisset J, Johannson KA, Jones KD, Wolters PJ, Collard HR, Walsh SLF, Ley B. Identification of Diagnostic Criteria for Chronic Hypersensitivity Pneumonitis: An International Modified Delphi Survey. Am J Respir Crit Care Med 2017; 197:1036-1044. [PMID: 29172641 DOI: 10.1164/rccm.201710-1986oc] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Current diagnosis of chronic hypersensitivity pneumonitis (cHP) involves considering a combination of clinical, radiological, and pathological information in multidisciplinary team discussions. However, this approach is highly variable with poor agreement between centers. OBJECTIVES We aimed to identify diagnostic criteria for cHP that reach consensus among international experts. METHODS A 3-round modified Delphi survey was conducted between April and August 2017. Forty-five experts in interstitial lung disease from 14 countries participated in the online survey. Diagnostic items included in round 1 were generated using expert interviews and literature review. During rounds 1 and 2, experts rated the importance of each diagnostic item on a 5-point Likert scale. The a priori threshold of consensus was ≥ 75% of experts rating a diagnostic item as very important or important. In the third round, experts graded the items that met consensus as important and provided their level of diagnostic confidence for a series of clinical scenarios. MEASUREMENTS AND MAIN RESULTS Consensus was achieved on 18 of the 40 diagnostic items. Among these, experts gave the highest level of importance to the identification of a causative antigen, time relation between exposure and disease, mosaic attenuation on chest imaging, and poorly formed non-necrotizing granulomas on pathology. In clinical scenarios, the diagnostic confidence of experts in cHP was heightened by the presence of these diagnostic items. CONCLUSION This consensus-based approach for the diagnosis of cHP represents a first step towards the development of international guidelines for the diagnosis of cHP.
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Affiliation(s)
- Julie Morisset
- Centre Hospitalier de L'Universite de Montreal, 25443, Montreal, Quebec, Canada ;
| | | | - Kirk D Jones
- University of California, San Francisco, Pathology, San Francisco, California, United States ;
| | - Paul J Wolters
- University of California, Medicine/CVRI, San Francisco, California, United States ;
| | - Harold R Collard
- University of California, San Francisco, Department of Medicine, San Francisco, California, United States ;
| | - Simon L F Walsh
- King's College, Hospital NHS Foundation Trust, Department of Radiology, London, United Kingdom of Great Britain and Northern Ireland ;
| | - Brett Ley
- University of California, San Francisco, Department of Medicine, San Francisco, California, United States ;
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Walsh SLF, Maher TM, Kolb M, Poletti V, Nusser R, Richeldi L, Vancheri C, Wilsher ML, Antoniou KM, Behr J, Bendstrup E, Brown K, Calandriello L, Corte TJ, Cottin V, Crestani B, Flaherty K, Glaspole I, Grutters J, Inoue Y, Kokosi M, Kondoh Y, Kouranos V, Kreuter M, Johannson K, Judge E, Ley B, Margaritopoulos G, Martinez FJ, Molina-Molina M, Morais A, Nunes H, Raghu G, Ryerson CJ, Selman M, Spagnolo P, Taniguchi H, Tomassetti S, Valeyre D, Wijsenbeek M, Wuyts W, Hansell D, Wells A. Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case-cohort study. Eur Respir J 2017; 50:50/2/1700936. [PMID: 28860269 DOI: 10.1183/13993003.00936-2017] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/30/2017] [Indexed: 11/05/2022]
Abstract
We conducted an international study of idiopathic pulmonary fibrosis (IPF) diagnosis among a large group of physicians and compared their diagnostic performance to a panel of IPF experts.A total of 1141 respiratory physicians and 34 IPF experts participated. Participants evaluated 60 cases of interstitial lung disease (ILD) without interdisciplinary consultation. Diagnostic agreement was measured using the weighted kappa coefficient (κw). Prognostic discrimination between IPF and other ILDs was used to validate diagnostic accuracy for first-choice diagnoses of IPF and were compared using the C-index.A total of 404 physicians completed the study. Agreement for IPF diagnosis was higher among expert physicians (κw=0.65, IQR 0.53-0.72, p<0.0001) than academic physicians (κw=0.56, IQR 0.45-0.65, p<0.0001) or physicians with access to multidisciplinary team (MDT) meetings (κw=0.54, IQR 0.45-0.64, p<0.0001). The prognostic accuracy of academic physicians with >20 years of experience (C-index=0.72, IQR 0.0-0.73, p=0.229) and non-university hospital physicians with more than 20 years of experience, attending weekly MDT meetings (C-index=0.72, IQR 0.70-0.72, p=0.052), did not differ significantly (p=0.229 and p=0.052 respectively) from the expert panel (C-index=0.74 IQR 0.72-0.75).Experienced respiratory physicians at university-based institutions diagnose IPF with similar prognostic accuracy to IPF experts. Regular MDT meeting attendance improves the prognostic accuracy of experienced non-university practitioners to levels achieved by IPF experts.
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Affiliation(s)
- Simon L F Walsh
- Dept of Radiology, King's College Hospital Foundation Trust, London, UK
| | - Toby M Maher
- Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, UK
| | - Martin Kolb
- Depts of Medicine and Pathology/Molecular Medicine, McMaster University, Firestone Institute for Respiratory Health, Hamilton, ON, Canada
| | - Venerino Poletti
- Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy.,Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Nusser
- Dept of Respiratory Medicine, Summit Hospital, Oakland, CA, USA
| | - Luca Richeldi
- Unità Operativa Complessa di Pneumologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Carlo Vancheri
- Dept of Clinical and Experimental Medicine, University of Catania, University - Hospital "Policlinico - Vitt. Emanuele", Catania, Italy
| | - Margaret L Wilsher
- Auckland District Health Board and the University of Auckland, Auckland, New Zealand
| | - Katerina M Antoniou
- Dept of Respiratory Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Jüergen Behr
- Dept of Medicine V, University of Munich and Asklepios Fachkliniken Gauting, Comprehensive Pneumology Center, member of the German Center for Lung Research, Munich, Germany
| | - Elisabeth Bendstrup
- Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lucio Calandriello
- Institute of Radiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Tamera J Corte
- Dept of Respiratory Medicine, Royal Prince Alfred Hospital, and University of Sydney, Sydney, Australia
| | | | - Bruno Crestani
- APHP, Hopital Bichat, Service de Pneumologie A, Université Paris Diderot, Paris, France
| | - Kevin Flaherty
- University of Michigan, Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI, USA
| | - Ian Glaspole
- Alfred Health - Allergy, Immunology and Respiratory Medicine, Melbourne, Australia
| | - Jan Grutters
- ILD Center of Excellence, St Antonius Hospital, Division Heart and Lungs, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Maria Kokosi
- Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Yasuhiro Kondoh
- Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan
| | - Vasileios Kouranos
- Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Michael Kreuter
- Center for interstitial and rare lung diseases, Pneumology and respiratory critical care medicine, Thoraxklinik, University of Heidelberg, and Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Eoin Judge
- Respiratory Medicine and National Lung Transplantation Unit, Mater Misericordiae University Hospital, Dublin , Ireland
| | - Brett Ley
- Medicine, University of California San Francisco, San Francisco, CA, USA
| | - George Margaritopoulos
- Dept of Respiratory Medicine, Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | | | | | - António Morais
- Centro Hospitalar São João - Pulmonology, Faculdade de Medicina do Porto, Alameda Professor Hernâni Monteiro, Oporto, Portugal
| | - Hilario Nunes
- Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France
| | - Ganesh Raghu
- University of Washington - Center for Interstitial Lung Disease, Seattle, WA, USA
| | | | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosio Villegas", Mexico City, Mexico
| | - Paolo Spagnolo
- Section of Respiratory Diseases, Dept of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Hiroyuki Taniguchi
- Tosei General Hospital, Dept of Respiratory Medicine and Allergy, Seto, Japan
| | - Sara Tomassetti
- Department of Diseases of the Thorax, Ospedale GB Morgagni, Forlì, Italy
| | - Dominique Valeyre
- Paris 13 University, Sorbonne Paris Cité, Service de Pneumologie, Hopital Avicenne, Bobigny, France
| | - Marlies Wijsenbeek
- Dept of Pulmonary Diseases, Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - Wim Wuyts
- Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - David Hansell
- Dept of Thoracic Imaging, Royal Brompton Hospital, London, UK
| | - Athol Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
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Jacob J, Bartholmai BJ, Rajagopalan S, Kokosi M, Maher TM, Nair A, Karwoski R, Renzoni E, Walsh SLF, Hansell DM, Wells AU. Functional and prognostic effects when emphysema complicates idiopathic pulmonary fibrosis. Eur Respir J 2017; 50:50/1/1700379. [PMID: 28679612 DOI: 10.1183/13993003.00379-2017] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 03/26/2017] [Indexed: 11/05/2022]
Abstract
This study aimed to investigate whether the combination of fibrosis and emphysema has a greater effect than the sum of its parts on functional indices and outcome in idiopathic pulmonary fibrosis (IPF), using visual and computer-based (CALIPER) computed tomography (CT) analysis.Consecutive patients (n=272) with a multidisciplinary IPF diagnosis had the extent of interstitial lung disease (ILD) scored visually and by CALIPER. Visually scored emphysema was subcategorised as isolated or mixed with fibrotic lung. The CT scores were evaluated against functional indices forced vital capacity (FVC), diffusing capacity of the lungs for carbon monoxide (DLCO), transfer coefficient of the lung for carbon monoxide (KCO), composite physiologic index (CPI)) and mortality.The presence and extent of emphysema had no impact on survival. Results were maintained following correction for age, gender, smoking status and baseline severity using DLCO, and combined visual emphysema and ILD extent. Visual emphysema quantitation indicated that relative preservation of lung volumes (FVC) resulted from tractionally dilated airways within fibrotic lung, ventilating areas of admixed emphysema (p<0.0001), with no independent effect on FVC from isolated emphysema. Conversely, only isolated emphysema (p<0.0001) reduced gas transfer (DLCO).There is no prognostic impact of emphysema in IPF, beyond that explained by the additive extents of both fibrosis and emphysema. With respect to the location of pulmonary fibrosis, emphysema distribution determines the functional effects of emphysema.
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Affiliation(s)
- Joseph Jacob
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Srinivasan Rajagopalan
- Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Toby M Maher
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Arjun Nair
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ronald Karwoski
- Department of Physiology and Biomedical Engineering, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Simon L F Walsh
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - David M Hansell
- Department of Radiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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46
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Walsh SLF. Multidisciplinary evaluation of interstitial lung diseases: current insights: Number 1 in the Series "Radiology" Edited by Nicola Sverzellati and Sujal Desai. Eur Respir Rev 2017; 26:26/144/170002. [PMID: 28515041 DOI: 10.1183/16000617.0002-2017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/18/2017] [Indexed: 11/05/2022] Open
Abstract
Multidisciplinary team (MDT) diagnosis is regarded as the diagnostic reference standard for interstitial lung disease (ILD). Several studies have reported that MDT diagnosis is associated with higher levels of diagnostic confidence and better interobserver agreement when compared to the individual components of the MDT in isolation. Although this recommendation is widely accepted, no guideline statement specifies what constitutes an MDT meeting and how its participants should govern it. Furthermore, the precise role of an MDT meeting in the setting of ILD may vary from one group to another. For example, in some cases, the meeting will confine its discussion to characterising the disease and formulating diagnosis. In others, management decisions may also be part of the discussion. Surprisingly, there is no consensus on how MDT diagnosis is validated. As multidisciplinary evaluation contains all the available clinical information on an individual patient, there is no reference standard against which the veracity of MDT diagnosis can be tested. Finally, many of these uncertainties surrounding MDT meeting practice are unlikely to be answered by traditional evidence-based studies, which create difficulties when generating guideline recommendations. There is clearly a need for expert consensus on what constitutes acceptable MDT meeting practice. This consensus will need to be flexible to accommodate the variability in resources available to fledgling MDT groups and the variable nature of patients requiring discussion.
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47
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Martinez FJ, Chisholm A, Collard HR, Flaherty KR, Myers J, Raghu G, Walsh SLF, White ES, Richeldi L. The diagnosis of idiopathic pulmonary fibrosis: current and future approaches. Lancet Respir Med 2016; 5:61-71. [PMID: 27932290 DOI: 10.1016/s2213-2600(16)30325-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 12/13/2022]
Abstract
With the recent development of two effective treatments for patients with idiopathic pulmonary fibrosis, an accurate diagnosis is crucial. The traditional approach to diagnosis emphasises the importance of thorough clinical and laboratory evaluations to exclude secondary causes of disease. High-resolution CT is a critical initial diagnostic test and acts as a tool to identify patients who should undergo surgical lung biopsy to secure a definitive histological diagnosis of usual interstitial pneumonia pattern. This diagnostic approach faces several challenges. Many patients with suspected idiopathic pulmonary fibrosis present with atypical high-resolution CT characteristics but are unfit for surgical lung biopsy, therefore preventing a confident diagnosis. The state of the art suggests an iterative, multidisciplinary process that incorporates available clinical, laboratory, imaging, and histological features. Recent research has explored genomic techniques to molecularly phenotype patients with interstitial lung disease. In the future, clinicians will probably use blood-specific or lung-specific molecular markers in combination with other clinical, physiological, and imaging features to enhance diagnostic efforts, refine prognostic recommendations, and influence the initial or subsequent treatment options. There is an urgent and increasing need for well designed, large, prospective studies measuring the effect of different diagnostic approaches. Ultimately, this will help to inform the development of guidelines and tailor clinical practice for the benefit of patients.
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Affiliation(s)
- Fernando J Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA.
| | | | - Harold R Collard
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kevin R Flaherty
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey Myers
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Ganesh Raghu
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Simon L F Walsh
- Department of Radiology, Royal Brompton Hospital, London, UK
| | - Eric S White
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Luca Richeldi
- Catholic University of the Sacred Heart, A. Gemelli University Hospital, Rome, Italy; Academic Unit of Clinical and Experimental Sciences, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Walsh SLF, Wells AU, Desai SR, Poletti V, Piciucchi S, Dubini A, Nunes H, Valeyre D, Brillet PY, Kambouchner M, Morais A, Pereira JM, Moura CS, Grutters JC, van den Heuvel DA, van Es HW, van Oosterhout MF, Seldenrijk CA, Bendstrup E, Rasmussen F, Madsen LB, Gooptu B, Pomplun S, Taniguchi H, Fukuoka J, Johkoh T, Nicholson AG, Sayer C, Edmunds L, Jacob J, Kokosi MA, Myers JL, Flaherty KR, Hansell DM. Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study. Lancet Respir Med 2016; 4:557-565. [PMID: 27180021 DOI: 10.1016/s2213-2600(16)30033-9] [Citation(s) in RCA: 286] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/17/2016] [Accepted: 03/22/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diffuse parenchymal lung disease represents a diverse and challenging group of pulmonary disorders. A consistent diagnostic approach to diffuse parenchymal lung disease is crucial if clinical trial data are to be applied to individual patients. We aimed to evaluate inter-multidisciplinary team agreement for the diagnosis of diffuse parenchymal lung disease. METHODS We did a multicentre evaluation of clinical data of patients who presented to the interstitial lung disease unit of the Royal Brompton and Harefield NHS Foundation Trust (London, UK; host institution) and required multidisciplinary team meeting (MDTM) characterisation between March 1, 2010, and Aug 31, 2010. Only patients whose baseline clinical, radiological, and, if biopsy was taken, pathological data were undertaken at the host institution were included. Seven MDTMs, consisting of at least one clinician, radiologist, and pathologist, from seven countries (Denmark, France, Italy, Japan, Netherlands, Portugal, and the UK) evaluated cases of diffuse parenchymal lung disease in a two-stage process between Jan 1, and Oct 15, 2015. First, the clinician, radiologist, and pathologist (if lung biopsy was completed) independently evaluated each case, selected up to five differential diagnoses from a choice of diffuse lung diseases, and chose likelihoods (censored at 5% and summing to 100% in each case) for each of their differential diagnoses, without inter-disciplinary consultation. Second, these specialists convened at an MDTM and reviewed all data, selected up to five differential diagnoses, and chose diagnosis likelihoods. We compared inter-observer and inter-MDTM agreements on patient first-choice diagnoses using Cohen's kappa coefficient (κ). We then estimated inter-observer and inter-MDTM agreement on the probability of diagnosis using weighted kappa coefficient (κw). We compared inter-observer and inter-MDTM confidence of patient first-choice diagnosis. Finally, we evaluated the prognostic significance of a first-choice diagnosis of idiopathic pulmonary fibrosis (IPF) versus not IPF for MDTMs, clinicians, and radiologists, using univariate Cox regression analysis. FINDINGS 70 patients were included in the final study cohort. Clinicians, radiologists, pathologists, and the MDTMs assigned their patient diagnoses between Jan 1, and Oct 15, 2015. IPF made up 88 (18%) of all 490 MDTM first-choice diagnoses. Inter-MDTM agreement for first-choice diagnoses overall was moderate (κ=0·50). Inter-MDTM agreement on diagnostic likelihoods was good for IPF (κw=0·71 [IQR 0·64-0·77]) and connective tissue disease-related interstitial lung disease (κw=0·73 [0·68-0·78]); moderate for non-specific interstitial pneumonia (NSIP; κw=0·42 [0·37-0·49]); and fair for hypersensitivity pneumonitis (κw=0·29 [0·24-0·40]). High-confidence diagnoses (>65% likelihood) of IPF were given in 68 (77%) of 88 cases by MDTMs, 62 (65%) of 96 cases by clinicians, and in 57 (66%) of 86 cases by radiologists. Greater prognostic separation was shown for an MDTM diagnosis of IPF than compared with individual clinician's diagnosis of this disease in five of seven MDTMs, and radiologist's diagnosis of IPF in four of seven MDTMs. INTERPRETATION Agreement between MDTMs for diagnosis in diffuse lung disease is acceptable and good for a diagnosis of IPF, as validated by the non-significant greater prognostic separation of an IPF diagnosis made by MDTMs than the separation of a diagnosis made by individual clinicians or radiologists. Furthermore, MDTMs made the diagnosis of IPF with higher confidence and more frequently than did clinicians or radiologists. This difference is of particular importance, because accurate and consistent diagnoses of IPF are needed if clinical outcomes are to be optimised. Inter-multidisciplinary team agreement for a diagnosis of hypersensitivity pneumonitis is low, highlighting an urgent need for standardised diagnostic guidelines for this disease. FUNDING National Institute of Health Research, Imperial College London.
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Affiliation(s)
| | | | - Sujal R Desai
- King's College Hospital NHS Foundation Trust, London, UK
| | - Venerino Poletti
- Department of Diseases of the Thorax, GB Morgagni Hospital, Forlì, Italy
| | - Sara Piciucchi
- Department of Radiology, GB Morgagni Hospital, Forlì, Italy
| | - Alessandra Dubini
- Department of Surgical Pathology, Morgagni Pierantoni Hospital, Forlì, Italy
| | - Hilario Nunes
- Université Paris, Sorbonne Paris Cité, EA2363 Réponses cellulaires et fonctionnelles à l'hypoxie, Bobigny, France; Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Avicenne, Bobigny, France
| | - Dominique Valeyre
- Université Paris, Sorbonne Paris Cité, EA2363 Réponses cellulaires et fonctionnelles à l'hypoxie, Bobigny, France; Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Avicenne, Bobigny, France
| | - Pierre Y Brillet
- Université Paris, Sorbonne Paris Cité, EA2363 Réponses cellulaires et fonctionnelles à l'hypoxie, Bobigny, France; Service de Radiologie, Hôpital Avicenne, Bobigny, France
| | | | - António Morais
- Serviço de Pneumologia, Porto, Portugal; Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | | | | | - Jan C Grutters
- ILD Center of Excellence St Antonius Hospital, Division Heart and Lungs, University, Medical Centre Utrecht, Netherlands
| | | | - Hendrik W van Es
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | | | | | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Finn Rasmussen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Line B Madsen
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Bibek Gooptu
- Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Sabine Pomplun
- Department of Cellular Pathology, University College Hospital London, London, UK
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, Itami, Japan
| | | | - Charlie Sayer
- Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Lilian Edmunds
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Joseph Jacob
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Jeffrey L Myers
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Kevin R Flaherty
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
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Abstract
Lung disease commonly occurs in connective tissue diseases (CTD) and is an important cause of morbidity and mortality. Imaging is central to the evaluation of CTD-associated pulmonary complications. In this article, a general discussion of radiologic considerations is followed by a description of the pulmonary appearances in individual CTDs, and the imaging appearances of acute and nonacute pulmonary complications. The contribution of imaging to monitoring disease, evaluating treatment response, and prognostication is reviewed. Finally, we address the role of imaging in the challenging multidisciplinary evaluation of interstitial lung disease where there is an underlying suspicion of an undiagnosed CTD.
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Affiliation(s)
- Arjun Nair
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Simon L F Walsh
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Sujal R Desai
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Walsh SLF, Calandriello L, Sverzellati N, Wells AU, Hansell DM. Interobserver agreement for the ATS/ERS/JRS/ALAT criteria for a UIP pattern on CT. Thorax 2015; 71:45-51. [PMID: 26585524 DOI: 10.1136/thoraxjnl-2015-207252] [Citation(s) in RCA: 198] [Impact Index Per Article: 22.0] [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: 04/30/2015] [Accepted: 10/15/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To establish the level of observer variation for the current ATS/ERS/JRS/ALAT criteria for a diagnosis of usual interstitial pneumonia (UIP) on CT among a large group of thoracic radiologists of varying levels of experience. MATERIALS AND METHODS 112 observers (96 of whom were thoracic radiologists) categorised CTs of 150 consecutive patients with fibrotic lung disease using the ATS/ERS/JRS/ALAT CT criteria for a UIP pattern (3 categories--UIP, possibly UIP and inconsistent with UIP). The presence of honeycombing, traction bronchiectasis and emphysema was also scored using a 3-point scale (definitely present, possibly present, absent). Observer agreement for the UIP categorisation and for the 3 CT patterns in the entire observer group and in subgroups stratified by observer experience, were evaluated. RESULTS Interobserver agreement across the diagnosis category scores among the 112 observers was moderate, ranging from 0.48 (IQR 0.18) for general radiologists to 0.52 (IQR 0.20) for thoracic radiologists of 10-20 years' experience. A binary score for UIP versus possible or inconsistent with UIP was examined. Observer agreement for this binary score was only moderate. No significant differences in agreement levels were identified when the CTs were stratified according to multidisciplinary team (MDT) diagnosis or patient age or when observers were categorised according to experience. Observer agreement for each of honeycombing, traction bronchiectasis and emphysema were 0.59±0.12, 0.42±0.15 and 0.43±0.18, respectively. CONCLUSIONS Interobserver agreement for the current ATS/ERS/JRS/ALAT CT criteria for UIP is only moderate among thoracic radiologists, irrespective of their experience, and did not vary with patient age or the MDT diagnosis.
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Affiliation(s)
- Simon L F Walsh
- Department of Radiology, Kings College Hospital Foundation Trust, London, UK
| | - Lucio Calandriello
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, Catholic University, "A. Gemelli" Hospital, Rome, Italy
| | - Nicola Sverzellati
- Department of Clinical Sciences, Section of Radiology, University of Parma, Parma, Italy
| | - Athol U Wells
- Interstitial Lung Diseases Unit, Royal Brompton Hospital, London, UK
| | - David M Hansell
- Department of Radiology, Royal Brompton Hospital, London, UK
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