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Lucà S, Pagliuca F, Perrotta F, Ronchi A, Mariniello DF, Natale G, Bianco A, Fiorelli A, Accardo M, Franco R. Multidisciplinary Approach to the Diagnosis of Idiopathic Interstitial Pneumonias: Focus on the Pathologist's Key Role. Int J Mol Sci 2024; 25:3618. [PMID: 38612431 PMCID: PMC11011777 DOI: 10.3390/ijms25073618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/14/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Idiopathic Interstitial Pneumonias (IIPs) are a heterogeneous group of the broader category of Interstitial Lung Diseases (ILDs), pathologically characterized by the distortion of lung parenchyma by interstitial inflammation and/or fibrosis. The American Thoracic Society (ATS)/European Respiratory Society (ERS) international multidisciplinary consensus classification of the IIPs was published in 2002 and then updated in 2013, with the authors emphasizing the need for a multidisciplinary approach to the diagnosis of IIPs. The histological evaluation of IIPs is challenging, and different types of IIPs are classically associated with specific histopathological patterns. However, morphological overlaps can be observed, and the same histopathological features can be seen in totally different clinical settings. Therefore, the pathologist's aim is to recognize the pathologic-morphologic pattern of disease in this clinical setting, and only after multi-disciplinary evaluation, if there is concordance between clinical and radiological findings, a definitive diagnosis of specific IIP can be established, allowing the optimal clinical-therapeutic management of the patient.
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Affiliation(s)
- Stefano Lucà
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Francesca Pagliuca
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Fabio Perrotta
- Department of Translational Medical Science, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.P.); (D.F.M.); (A.B.)
| | - Andrea Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Domenica Francesca Mariniello
- Department of Translational Medical Science, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.P.); (D.F.M.); (A.B.)
| | - Giovanni Natale
- Division of Thoracic Surgery, Università degli Studi della Campania “Luigi Vanvitelli”, Piazza Miraglia, 2, 80138 Naples, Italy; (G.N.); (A.F.)
| | - Andrea Bianco
- Department of Translational Medical Science, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.P.); (D.F.M.); (A.B.)
| | - Alfonso Fiorelli
- Division of Thoracic Surgery, Università degli Studi della Campania “Luigi Vanvitelli”, Piazza Miraglia, 2, 80138 Naples, Italy; (G.N.); (A.F.)
| | - Marina Accardo
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
| | - Renato Franco
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (F.P.); (A.R.); (M.A.)
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Ebert C, Walsh AM, Sereda L, Wilson CL, Schafer PH, Fischer A, Zhao L, Ramirez-Valle F, Gordon D, Schnapp LM. Circulating biomarker analyses in a longitudinal cohort of patients with IPF. Am J Physiol Lung Cell Mol Physiol 2024; 326:L303-L312. [PMID: 38226605 DOI: 10.1152/ajplung.00222.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/21/2023] [Accepted: 01/05/2024] [Indexed: 01/17/2024] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is an incurable interstitial lung disease characterized by fibrosis. Two FDA-approved drugs, pirfenidone and nintedanib, only modestly prolong survival. In this study, we asked whether levels of select circulating biomarkers in patients with IPF demonstrated changes in response to treatment over time and whether treatment with pirfenidone and nintedanib led to differential biomarker expression. Serial plasma samples from 48 patients with IPF on usual treatment and six healthy volunteers were analyzed to identify differentially expressed blood protein. Hypothesis-driven potential biomarker selection was based on recent literature, internal preclinical data, and the PROLIFIC Consortium (Schafer P. 6th Annual IPF Summit. Boston, MA, 2022) proposed biomarkers of pulmonary fibrosis. We compared our findings to public databases to provide insights into relevant signaling pathways in IPF. Of the 26 proteins measured, we found that 11 (SP-D, TIMP1, MMP7, CYFRA21-1, YKL40, CA125, sICAM, IP-10, MDC, CXCL13) were significantly elevated in patients with IPF compared with healthy volunteers but their levels did not significantly change over time. In the IPF samples, seven proteins were elevated in the treatment group compared with the no-treatment group. However, protein profiles were not distinguishable between patients on pirfenidone versus nintedanib. We demonstrated that most proteins differentially detected in our samples were predicted to be secreted from the lung epithelial or interstitial compartments. However, a significant minority of the proteins are not known to be transcriptionally expressed by lung cells, suggesting an ongoing systemic response. Understanding the contributions of the systemic response in IPF may be important as new therapeutics are developed.NEW & NOTEWORTHY In this study, we confirmed protein expression differences in only a subset of predicted biomarkers from IPF and control subjects. Most differentially expressed proteins were predicted to be secreted from lung cells. However, a significant minority of the proteins are not known to be transcriptionally expressed by lung cells, suggesting an ongoing systemic response. The contributions of the systemic response in IPF may be important as new therapeutics are developed.
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Affiliation(s)
| | - Alice M Walsh
- Bristol Myers Squibb, Princeton, New Jersey, United States
| | - Larisa Sereda
- Bristol Myers Squibb, Princeton, New Jersey, United States
| | - Carole L Wilson
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States
- Medical University of South Carolina, Charleston, South Carolina, United States
| | | | - Aryeh Fischer
- Bristol Myers Squibb, Princeton, New Jersey, United States
| | - Lei Zhao
- Bristol Myers Squibb, Princeton, New Jersey, United States
| | | | - David Gordon
- Bristol Myers Squibb, Princeton, New Jersey, United States
| | - Lynn M Schnapp
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States
- Medical University of South Carolina, Charleston, South Carolina, United States
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John J, Clark AR, Kumar H, Vandal AC, Burrowes KS, Wilsher ML, Milne DG, Bartholmai B, Levin DL, Karwoski R, Tawhai MH. Pulmonary vessel volume in idiopathic pulmonary fibrosis compared with healthy controls aged > 50 years. Sci Rep 2023; 13:4422. [PMID: 36932117 PMCID: PMC10023743 DOI: 10.1038/s41598-023-31470-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/13/2023] [Indexed: 03/19/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is characterised by progressive fibrosing interstitial pneumonia with an associated irreversible decline in lung function and quality of life. IPF prevalence increases with age, appearing most frequently in patients aged > 50 years. Pulmonary vessel-like volume (PVV) has been found to be an independent predictor of mortality in IPF and other interstitial lung diseases, however its estimation can be impacted by artefacts associated with image segmentation methods and can be confounded by adjacent fibrosis. This study compares PVV in IPF patients (N = 21) with PVV from a healthy cohort aged > 50 years (N = 59). The analysis includes a connected graph-based approach that aims to minimise artefacts contributing to calculation of PVV. We show that despite a relatively low extent of fibrosis in the IPF cohort (20% of the lung volume), PVV is 2-3 times higher than in controls. This suggests that a standardised method to calculate PVV that accounts for tree connectivity could provide a promising tool to provide early diagnostic or prognostic information in IPF patients and other interstitial lung disease.
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Affiliation(s)
- Joyce John
- Auckland Bioengineering Institute, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Alys R Clark
- Auckland Bioengineering Institute, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Haribalan Kumar
- Auckland Bioengineering Institute, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Alain C Vandal
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - Kelly S Burrowes
- Auckland Bioengineering Institute, The University of Auckland, Private Bag 92019, Auckland, New Zealand
| | | | - David G Milne
- Radiology, Auckland City Hospital, Auckland, New Zealand
| | | | | | | | - Merryn H Tawhai
- Auckland Bioengineering Institute, The University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Patel AS, Miller E, Regis SM, Hunninghake GM, Price LL, Gawlik M, McKee AB, Rieger-Christ KM, Pinto-Plata V, Liesching TN, Wald C, Hashim J, McKee BJ, Gazourian L. Interstitial lung abnormalities in a large clinical lung cancer screening cohort: association with mortality and ILD diagnosis. Respir Res 2023; 24:49. [PMID: 36782326 PMCID: PMC9926562 DOI: 10.1186/s12931-023-02359-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/06/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Interstitial lung abnormalities (ILA) are CT findings suggestive of interstitial lung disease in individuals without a prior diagnosis or suspicion of ILD. Previous studies have demonstrated that ILA are associated with clinically significant outcomes including mortality. The aim of this study was to determine the prevalence of ILA in a large CT lung cancer screening program and the association with clinically significant outcomes including mortality, hospitalizations, cancer and ILD diagnosis. METHODS This was a retrospective study of individuals enrolled in a CT lung cancer screening program from 2012 to 2014. Baseline and longitudinal CT scans were scored for ILA per Fleischner Society guidelines. The primary analyses examined the association between baseline ILA and mortality, all-cause hospitalization, and incidence of lung cancer. Kaplan-Meier plots were generated to visualize the associations between ILA and lung cancer and all-cause mortality. Cox regression proportional hazards models were used to test for this association in both univariate and multivariable models. RESULTS 1699 subjects met inclusion criteria. 41 (2.4%) had ILA and 101 (5.9%) had indeterminate ILA on baseline CTs. ILD was diagnosed in 10 (24.4%) of 41 with ILA on baseline CT with a mean time from baseline CT to diagnosis of 4.47 ± 2.72 years. On multivariable modeling, the presence of ILA remained a significant predictor of death, HR 3.87 (2.07, 7.21; p < 0.001) when adjusted for age, sex, BMI, pack years and active smoking, but not of lung cancer and all-cause hospital admission. Approximately 50% with baseline ILA had progression on the longitudinal scan. CONCLUSIONS ILA identified on baseline lung cancer screening exams are associated with all-cause mortality. In addition, a significant proportion of patients with ILA are subsequently diagnosed with ILD and have CT progression on longitudinal scans. TRIAL REGISTRATION NUMBER ClinicalTrials.gov; No.: NCT04503044.
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Affiliation(s)
- Avignat S. Patel
- grid.415731.50000 0001 0725 1353Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA ,grid.67033.310000 0000 8934 4045Tufts University School of Medicine, Boston, MA 02111 USA
| | - Ezra Miller
- grid.415731.50000 0001 0725 1353Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA ,grid.67033.310000 0000 8934 4045Tufts University School of Medicine, Boston, MA 02111 USA
| | - Shawn M. Regis
- grid.415731.50000 0001 0725 1353Division of Radiation Oncology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Gary M. Hunninghake
- grid.62560.370000 0004 0378 8294Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA 02115 USA
| | - Lori Lyn Price
- grid.67033.310000 0000 8934 4045Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111 USA ,grid.429997.80000 0004 1936 7531Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA 02111 USA
| | - Melissa Gawlik
- grid.415731.50000 0001 0725 1353Quality and Safety, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Andrea B. McKee
- grid.415731.50000 0001 0725 1353Division of Radiation Oncology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Kimberly M. Rieger-Christ
- grid.415731.50000 0001 0725 1353Translational Research, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Victor Pinto-Plata
- grid.415731.50000 0001 0725 1353Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA ,grid.67033.310000 0000 8934 4045Tufts University School of Medicine, Boston, MA 02111 USA
| | - Timothy N. Liesching
- grid.415731.50000 0001 0725 1353Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA ,grid.67033.310000 0000 8934 4045Tufts University School of Medicine, Boston, MA 02111 USA
| | - Christoph Wald
- grid.415731.50000 0001 0725 1353Department of Radiology, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Jeffrey Hashim
- grid.415731.50000 0001 0725 1353Department of Radiology, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Brady J. McKee
- grid.415731.50000 0001 0725 1353Department of Radiology, Lahey Hospital and Medical Center, Burlington, MA 01805 USA
| | - Lee Gazourian
- grid.415731.50000 0001 0725 1353Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, MA 01805 USA ,grid.67033.310000 0000 8934 4045Tufts University School of Medicine, Boston, MA 02111 USA
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Mai TH, Han LW, Hsu JC, Kamath N, Pan L. Idiopathic pulmonary fibrosis therapy development: a clinical pharmacology perspective. Ther Adv Respir Dis 2023; 17:17534666231181537. [PMID: 37392011 PMCID: PMC10333628 DOI: 10.1177/17534666231181537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/26/2023] [Indexed: 07/02/2023] Open
Abstract
Drug development for idiopathic pulmonary fibrosis (IPF) has been challenging due to poorly understood disease etiology, unpredictable disease progression, highly heterogeneous patient populations, and a lack of robust pharmacodynamic biomarkers. Moreover, because lung biopsy is invasive and dangerous, making the extent of fibrosis as a direct longitudinal measurement of IPF disease progression unfeasible, most clinical trials studying IPF can only assess progression of fibrosis indirectly through surrogate measures. This review discusses current state-of-art practices, identifies knowledge gaps, and brainstorms development opportunities for preclinical to clinical translation, clinical populations, pharmacodynamic endpoints, and dose optimization strategies. This article highlights clinical pharmacology perspectives in leveraging real-world data as well as modeling and simulation, special population considerations, and patient-centric approaches for designing future studies.
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Affiliation(s)
- Tu H. Mai
- Genentech Inc., South San Francisco, CA,
USA
| | | | - Joy C. Hsu
- Genentech Inc., South San Francisco, CA,
USA
| | | | - Lin Pan
- Genentech, Inc., 1 DNA Way, South San
Francisco, CA 94008, USA
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Salonen J, Purokivi M, Hodgson U, Kaarteenaho R. National data on prevalence of idiopathic pulmonary fibrosis and antifibrotic drug use in Finnish specialised care. BMJ Open Respir Res 2022; 9:9/1/e001363. [PMID: 36571594 PMCID: PMC9462099 DOI: 10.1136/bmjresp-2022-001363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/26/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The previous data concerning the prevalence of idiopathic pulmonary fibrosis (IPF) and the frequency of antifibrotic drug use in Finland were based on research registries and medical records whereas nationwide data on the number of patients with IPF in specialised care and those on antifibrotic treatment have not been published. METHODS We made an information request to the Finnish National Hospital Discharge Register (Hilmo) covering the whole population of Finland to find out the annual numbers of patients with IPF treated in specialised care in 2016-2021. The numbers of the patients initiating and using pirfenidone and nintedanib were requested from the Social Insurance Institution of Finland (Kela) for the same time period. RESULTS The estimated prevalence of IPF in specialised care was 36.0 per 100 000 in 2021, having increased since 2016. The number of antifibrotic drug users and their proportion of outpatients with IPF had also risen during the follow-up period. In 2021, 35% of the patients with IPF used pirfenidone or nintedanib. The number of inpatients treated in specialised care because of IPF had declined during 2016-2021. CONCLUSIONS The prevalence of IPF was higher than expected in Finnish specialised care and had increased during the 6-year follow-up time. The increase in the number of patients with IPF using antifibrotic drugs might have diminished the need for IPF-related hospitalisations.
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Affiliation(s)
- Johanna Salonen
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, Oulu, Finland,Center of Internal and Respiratory Medicine, Medical Research Center (MRC) Oulu, Oulu University Hospital, Oulu, Finland
| | - Minna Purokivi
- Center of Medicine and Clinical Research, Division of Respiratory Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Ulla Hodgson
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland,Social Insurance Institution of Finland, Helsinki, Finland
| | - Riitta Kaarteenaho
- Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu, Oulu, Finland,Center of Internal and Respiratory Medicine, Medical Research Center (MRC) Oulu, Oulu University Hospital, Oulu, Finland
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Hoffman TW, van Es HW, Biesma DH, Grutters JC. Potential interstitial lung abnormalities on chest X-rays prior to symptoms of idiopathic pulmonary fibrosis. BMC Pulm Med 2022; 22:329. [PMID: 36038862 PMCID: PMC9426013 DOI: 10.1186/s12890-022-02122-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Idiopathic pulmonary fibrosis (IPF) often has significant diagnostic delay. At present it is not well-known what factors associate with time to diagnosis and if this is associated with survival after the diagnosis. There has also been increasing attention for interstitial lung abnormalities on chest CT-scans. In this study we assessed what factors associate with time to diagnosis in patients with IPF, and whether early stages of pulmonary fibrosis can be seen on chest X-rays prior to the start of symptoms. Methods In this retrospective study, 409 Dutch patients with IPF were included. Clinical characteristics, including patient demographics, medical history, time of start of symptoms, time of first visit to pulmonologist, and any previous radiographic imaging reports were collected from patient records. Results In 96 patients (23%) a chest X-ray was available that had been made prior to the start of symptoms (median of 50.5 months (IQR 26.3–83.3 months)), and this showed potential interstitial lung abnormalities in 56 patients (58%). The median time from the start of symptoms to the final diagnosis was 24.0 months (interquartile range 9.0–48.0 months). In a multivariate model that corrected for diffusion capacity of the lung for carbon monoxide, forced vital capacity, sex, and age at diagnosis, time to diagnosis did not associate with survival (hazard ratio 1.051 (95% CI 0.800–1.380; p = 0.72)). Conclusions There is a significant diagnostic delay for patients with IPF, but longer time to diagnosis did not associate with survival. Interstitial lung abnormalities were seen in more than half of the patients in whom a chest X-ray had been made prior to the start of symptoms. This illustrates that a computed tomography scan should be strongly considered for analysis of unexplained abnormalities on a chest X-ray. This could facilitate early detection and possibly prevention of disease progression for patients with pulmonary fibrosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02122-8.
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Affiliation(s)
- T W Hoffman
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
| | - H W van Es
- Department of Radiology, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - D H Biesma
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J C Grutters
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center, Utrecht, The Netherlands
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Hoyer N, Prior TS, Bendstrup E, Shaker SB. Diagnostic delay in IPF impacts progression-free survival, quality of life and hospitalisation rates. BMJ Open Respir Res 2022; 9:9/1/e001276. [PMID: 35798532 PMCID: PMC9263910 DOI: 10.1136/bmjresp-2022-001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/27/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The diagnosis of idiopathic pulmonary fibrosis (IPF) is often delayed up to several years. The objective of this study was to assess the impact of the diagnostic delay on progression-free survival, quality of life and hospitalisation rates. METHODS A total of 264 incident patients with IPF were included immediately after their diagnosis and followed for up to 5 years, with regular collection of clinical data, quality-of-life questionnaires and assessment of disease progression. Hospitalisation data were extracted from electronic patient records. Analyses were performed on the entire cohort and strata according to forced vital capacity (FVC) at diagnosis. RESULTS A long diagnostic delay (>1 year) was associated with worse progression-free survival compared with a short diagnostic delay (<1 year) (HR: 1.70, 95% CI: 1.18 to 2.46, p=0.004) especially in patients with mild disease at the time of diagnosis (FVC>80% predicted). Mean total scores of the St. George's respiratory questionnaire (SGRQ), a derived IPF-specific version of the SGRQ and the chronic obstructive pulmonary disease assessment test (CAT) were consistently higher in patients with long diagnostic delays, indicating worse quality of life. Mean hospitalisation rates were higher during the first year after diagnosis (Incidence rate ratio [IRR]: 3.28, 95% CI: 1.35 to 8.55, p=0.01) and during the entire follow-up (IRR: 1.74, 95% CI: 1.01 to 3.02, p=0.04). CONCLUSION A diagnostic delay of more than 1 year negatively impacts progression-free survival, quality of life and hospitalisation rates in patients with IPF. These findings highlight the importance of an early diagnosis for proper management of IPF. TRIAL REGISTRATION NUMBER NCT02755441.
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Affiliation(s)
- Nils Hoyer
- Department of Respiratory Medicine, Gentofte University Hospital, Hellerup, Hovedstaden, Denmark
| | - Thomas Skovhus Prior
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Elisabeth Bendstrup
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Saher Burhan Shaker
- Department of Respiratory Medicine, Gentofte University Hospital, Hellerup, Hovedstaden, Denmark
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Jovanovic DM, Šterclová M, Mogulkoc N, Lewandowska K, Müller V, Hájková M, Studnicka M, Tekavec-Trkanjec J, Littnerová S, Vašáková M. Comorbidity burden and survival in patients with idiopathic pulmonary fibrosis: the EMPIRE registry study. Respir Res 2022; 23:135. [PMID: 35624513 PMCID: PMC9145164 DOI: 10.1186/s12931-022-02033-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients with idiopathic pulmonary fibrosis (IPF) frequently have multiple comorbidities, which may influence survival but go under-recognised in clinical practice. We therefore report comorbidity, antifibrotic treatment use and survival of patients with IPF observed in the multi-national EMPIRE registry. Methods For this prospective IPF cohort, demographics, comorbidities, survival and causes of death were analysed. Comorbidities were noted by the treating physician based on the patient’s past medical history or as reported during follow-up. Comorbidities were defined as prevalent when noted at enrolment, or as incident when recorded during follow-up. Survival was analysed by Kaplan–Meier estimates, log-rank test, and Cox proportional hazards models. Hazard ratios (HR) were adjusted for gender, age, smoking status and FVC at enrolment. Results A population of 3,580 patients with IPF from 11 Central and Eastern European countries was followed every 6 months for up to 6 years. At enrolment, 91.3% of patients reported at least one comorbidity, whereas more than one-third (37.8%) reported four or more comorbidities. Five-year survival was 53.7% in patients with no prevalent comorbidities, whereas it was 48.4%, 47.0%, 43.8% and 41.1% in patients with 1, 2, 3 and ≥ 4 comorbidities, respectively. The presence of multiple comorbidities at enrolment was associated with significantly worse survival (log-rank test P = 0.007). Adjusted HRs indicate that risk of death was increased by 44% in patients with IPF reporting ≥ 4 comorbidities at baseline compared with no comorbidity (P = 0.021). The relationship between number of comorbidities and decreased survival was also seen in patients receiving antifibrotic treatment (63% of all patients; log-rank test P < 0.001). Comorbidity as cause of death was identified in at least 26.1% of deaths. Conclusions The majority of patients with IPF demonstrate comorbidities, and many have comorbidity-related deaths. Increasing numbers of comorbidities are associated with worse survival; and this pattern is also present in patients receiving antifibrotic therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02033-6.
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Affiliation(s)
| | - Martina Šterclová
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University, Thomayer Hospital, Prague, Czech Republic
| | - Nesrin Mogulkoc
- Department of Pulmonary Medicine, Ege University Medical School, Izmir, Turkey
| | - Katarzyna Lewandowska
- Department of Pulmonary Diseases, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Marta Hájková
- Clinic of Pneumology and Phthisiology, University Hospital Bratislava, Bratislava, Slovakia
| | - Michael Studnicka
- Department of Pneumology, Paracelsus Medical University, Salzburg, Austria
| | | | - Simona Littnerová
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Martina Vašáková
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University, Thomayer Hospital, Prague, Czech Republic.
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The Impact of the Envisia Genomic Classifier in the Diagnosis and Management of Patients with Idiopathic Pulmonary Fibrosis. Ann Am Thorac Soc 2021; 19:916-924. [PMID: 34889723 DOI: 10.1513/annalsats.202107-897oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The diagnosis of idiopathic pulmonary fibrosis (IPF) remains challenging and can result in delayed or misdiagnosis. IPF diagnosis is based upon the presence of either a radiographic or histologic usual interstitial pneumonia (UIP) pattern in the absence of an identifiable etiology. The Envisia Genomic Classifier is a clinically validated molecular diagnostic test that identifies UIP in transbronchial biopsies. OBJECTIVE To determine the impact of the Envisia Genomic Classifier on physician's clinical decision making in the diagnosis and management of IPF. METHODS This prospective randomized decision impact survey was designed to test the hypothesis that including an Envisia UIP positive (UIP+) result will increase IPF diagnoses, diagnostic confidence levels, and the recommendation for antifibrotic therapy. The survey included patients from the BRAVE study who had an HRCT scan without a typical UIP pattern, an Envisia UIP+ result, and a final diagnosis of IPF by multidisciplinary team discussion. Each case was presented in three different formats: a pre-post cohort where each case is presented initially without and then with Envisia, and two independent cohorts where each case is presented without and with Envisia, respectively. RESULTS U.S. based pulmonologists from community and academic centers in geographically diverse practices were approached for inclusion in this study. 103 (65%) US-based pulmonologists met the inclusion criteria and provided 605 case reviews of 11 patient cases. The number of IPF diagnoses increased with Envisia by an absolute difference of 39% from 47 (30%) pre-Envisia to 107 (69%) post-Envisia in the pre-post cohort and by 13% in the independent cohorts. High confidence (> 90%) of ILD diagnoses was more commonly seen with Envisia in both the pre-post cohort and in the independent cohorts. Recommendation for antifibrotic treatment increased with Envisia by an absolute difference of 36% from 15 (10%) pre-Envisia to 72 (46.4%) post-Envisia in the pre-post cohort and by 11% in the independent cohorts. CONCLUSIONS This decision impact survey suggests the clinical utility of the Envisia Classifier by demonstrating a significant increase in IPF diagnoses, diagnostic confidence, and recommendation for antifibrotic therapies to assist physicians to effectively manage patients to improve outcomes of patients with IPF.
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Lancaster L, Bonella F, Inoue Y, Cottin V, Siddall J, Small M, Langley J. Idiopathic pulmonary fibrosis: Physician and patient perspectives on the pathway to care from symptom recognition to diagnosis and disease burden. Respirology 2021; 27:66-75. [PMID: 34611971 PMCID: PMC9135122 DOI: 10.1111/resp.14154] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/23/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Idiopathic pulmonary fibrosis (IPF) is a chronic progressive disease that requires ongoing care and is associated with considerable socioeconomic burden. We evaluated the IPF care pathway from symptom recognition to treatment. We describe the impact of IPF on healthcare resource use (HCRU), quality of life (QoL) and work impairment, and report differences in patient and physician perspectives using real-world data from France, Germany, Japan and the United States. METHODS Quantitative, point-in-time data were collected as part of the Adelphi IPF II Disease Specific Programme™. Physician-reported data (patient demographics, medical history, diagnoses, treatment) were matched to patient-reported data (HCRU, QoL, work impairment). HCRU was measured as physician visits and hospitalizations. QoL and work impairment were measured using the EuroQol-5 Dimensions (EQ-5D) and Work Productivity and Activity Impairment questionnaires. RESULTS Overall, 244 physicians reported data on 1249 patients, 739 of whom self-reported data. Diagnostic delays of 0.8 (Germany) to 2.0 (Japan) years after symptom onset were reported; treatment initiation was further delayed. In all countries, patients more often reported symptoms in the survey than did their physicians. On average, patients underwent 7-10 clinical tests before diagnosis. Antifibrotic use increased from 57% (2016) to 69% (2019); only 50% of patients with moderate/severe IPF were satisfied with their treatment. The 12-month hospitalization rates were 24% (Japan) to 64% (United States). Patients reported low QoL (mean EQ-5D visual analogue scale: 61.7/100). CONCLUSION Patients with IPF experience considerable diagnostic and treatment delays. More effective therapies and management are needed to reduce the disease burden.
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Affiliation(s)
- Lisa Lancaster
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Francesco Bonella
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik University Hospital, University Duisburg-Essen, Essen, Germany
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Vincent Cottin
- National Coordinating Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, University of Lyon, Lyon, France
| | - James Siddall
- Respiratory Research, Adelphi Real World, Bollington, UK
| | - Mark Small
- Respiratory Research, Adelphi Real World, Bollington, UK
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12
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Bae W, Lee CH, Lee J, Kim YW, Han K, Choi SM. Impact of smoking on the development of idiopathic pulmonary fibrosis: results from a nationwide population-based cohort study. Thorax 2021; 77:470-476. [PMID: 34593614 DOI: 10.1136/thoraxjnl-2020-215386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/23/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Smoking has been considered an important risk factor for idiopathic pulmonary fibrosis (IPF) incidence. However, there are no population-based large-scale studies demonstrating the effects of smoking on the development of IPF. We aimed to evaluate the effect of smoking on IPF development using a nationwide population-based cohort. METHODS Using the Korean National Health Information Database, we enrolled individuals who had participated in the health check-up service between 2009 and 2012. Participants having a prior diagnosis of IPF were excluded. The history of smoking status and quantity was collected by a questionnaire. We identified all cases of incident IPF through 2016 on the basis of ICD-10 codes for IPF and medical claims. Cox proportional hazards models were used to calculate the adjusted HR (aHR) of the development of IPF. RESULTS A total of 25 113 individuals (0.11%) with incident IPF were identified out of 23 242 836 participants registered in the database. The risk of IPF was significantly higher in current and former smokers than in never smokers, with an aHR of 1.66 (95% CI 1.61 to 1.72) and 1.42 (95% CI 1.37 to 1.48), respectively. Current smokers had a higher risk of IPF than former smokers (aHR 1.17, 95% CI 1.13 to 1.21). The risk of IPF development increased as the smoking intensity and duration increased. CONCLUSION Smoking significantly increased the risk of IPF development. Current smokers had a higher risk of IPF than former smokers. A dose-response relationship was observed between smoking and the development of IPF.
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Affiliation(s)
- Won Bae
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Pulmonary, Allergy and Critical Care Medicine, Seongnam Citizens Medical Center, Seongnam, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Whan Kim
- Department of Respiratory-Allergy & Clinical Immunology, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea .,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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van der Sar IG, Jones S, Clarke DL, Bonella F, Fourrier JM, Lewandowska K, Bermudo G, Simidchiev A, Strambu IR, Wijsenbeek MS, Parfrey H. Patient Reported Experiences and Delays During the Diagnostic Pathway for Pulmonary Fibrosis: A Multinational European Survey. Front Med (Lausanne) 2021; 8:711194. [PMID: 34422866 PMCID: PMC8371687 DOI: 10.3389/fmed.2021.711194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Pulmonary fibrosis includes a spectrum of diseases and is incurable. There is a variation in disease course, but it is often progressive leading to increased breathlessness, impaired quality of life, and decreased life expectancy. Detection of pulmonary fibrosis is challenging, which contributes to considerable delays in diagnosis and treatment. More knowledge about the diagnostic journey from patients' perspective is needed to improve the diagnostic pathway. The aims of this study were to evaluate the time to diagnosis of pulmonary fibrosis, identify potential reasons for delays, and document patients emotions. Methods: Members of European patient organisations, with a self-reported diagnosis of pulmonary fibrosis, were invited to participate in an online survey. The survey assessed the diagnostic pathway retrospectively, focusing on four stages: (1) time from initial symptoms to first appointment in primary care; (2) time to hospital referral; (3) time to first hospital appointment; (4) time to final diagnosis. It comprised open-ended and closed questions focusing on time to diagnosis, factors contributing to delays, diagnostic tests, patient emotions, and information provision. Results: Two hundred and seventy three participants (214 idiopathic pulmonary fibrosis, 28 sarcoidosis, 31 other) from 13 countries responded. Forty percent of individuals took ≥1 year to receive a final diagnosis. Greatest delays were reported in stage 1, with only 50.2% making an appointment within 3 months. For stage 2, 73.3% reported a hospital referral within three primary care visits. However, 9.9% reported six or more visits. After referral, 76.9% of patients were assessed by a specialist within 3 months (stage 3) and 62.6% received a final diagnosis within 3 months of their first hospital visit (stage 4). Emotions during the journey were overall negative. A major need for more information and support during and after the diagnostic process was identified. Conclusion: The time to diagnose pulmonary fibrosis varies widely across Europe. Delays occur at each stage of the diagnostic pathway. Raising awareness about pulmonary fibrosis amongst the general population and healthcare workers is essential to shorten the time to diagnosis. Furthermore, there remains a need to provide patients with sufficient information and support at all stages of their diagnostic journey.
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Affiliation(s)
| | - Steve Jones
- Action for Pulmonary Fibrosis, Lichfield, United Kingdom
| | | | | | | | - Katarzyna Lewandowska
- Department of Pulmonary Diseases, National Research Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | | | - Irina R Strambu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Serra López-Matencio JM, Gómez M, Vicente-Rabaneda EF, González-Gay MA, Ancochea J, Castañeda S. Pharmacological Interactions of Nintedanib and Pirfenidone in Patients with Idiopathic Pulmonary Fibrosis in Times of COVID-19 Pandemic. Pharmaceuticals (Basel) 2021; 14:ph14080819. [PMID: 34451916 PMCID: PMC8400767 DOI: 10.3390/ph14080819] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022] Open
Abstract
The discovery of antifibrotic agents have resulted in advances in the therapeutic management of idiopathic pulmonary fibrosis (IPF). Currently, nintedanib and pirfenidone have become the basis of IPF therapy based on the results of large randomized clinical trials showing their safety and efficacy in reducing disease advancement. However, the goal of completely halting disease progress has not been reached yet. Administering nintedanib with add-on pirfenidone is supposed to enhance the therapeutic benefit by simultaneously acting on two different pathogenic pathways. All this becomes more important in the context of the ongoing global pandemic of coronavirus disease 2019 (COVID-19) because of the fibrotic consequences following SARS-CoV-2 infection in some patients. However, little information is available about their drug–drug interaction, which is important mainly in polymedicated patients. The aim of this review is to describe the current management of progressive fibrosing interstitial lung diseases (PF-ILDs) in general and of IPF in particular, focusing on the pharmacokinetic drug-drug interactions between these two drugs and their relationship with other medications in patients with IPF.
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Affiliation(s)
| | - Manuel Gómez
- Methodology Unit, Health Research Institute Princesa (IIS-IP), c/Diego de León 62, 28006 Madrid, Spain;
| | | | - Miguel A. González-Gay
- Rheumatology Service, Marqués de Valdecilla Universitary Hospital, University of Cantabria, Av. de Valdecilla 25, 39008 Santander, Spain;
| | - Julio Ancochea
- Pneumology Service, Princesa Hospital, Autonomous University of Madrid (UAM), IIS-Princesa, c/Diego de León 62, 28006 Madrid, Spain;
- Department of Medicine, Autonomous University of Madrid (UAM), 28029 Madrid, Spain
| | - Santos Castañeda
- Rheumatology Service, Princesa Hospital, IIS-Princesa, c/Diego de León 62, 28006 Madrid, Spain;
- Department of Medicine, Autonomous University of Madrid (UAM), 28029 Madrid, Spain
- Correspondence: or ; Tel.: +34-915-202-473; Fax: +34-914-018-752
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Cosgrove GP, Lasky JA. A New Piece to Help Solve the Interstitial Lung Disease Diagnostic Puzzle. Am J Respir Crit Care Med 2021; 203:158-160. [PMID: 32926641 PMCID: PMC7874413 DOI: 10.1164/rccm.202008-3189ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Joseph A Lasky
- Department of Medicine Tulane University New Orleans, Louisiana
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16
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Lupacchini L, Maggi F, Tomino C, De Dominicis C, Mollinari C, Fini M, Bonassi S, Merlo D, Russo P. Nicotine Changes Airway Epithelial Phenotype and May Increase the SARS-COV-2 Infection Severity. Molecules 2020; 26:E101. [PMID: 33379366 PMCID: PMC7794754 DOI: 10.3390/molecules26010101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/17/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Nicotine is implicated in the SARS-COV-2 infection through activation of the α7-nAChR and over-expression of ACE2. Our objective was to clarify the role of nicotine in SARS-CoV-2 infection exploring its molecular and cellular activity. (2) Methods: HBEpC or si-mRNA-α7-HBEpC were treated for 1 h, 48 h or continuously with 10-7 M nicotine, a concentration mimicking human exposure to a cigarette. Cell viability and proliferation were evaluated by trypan blue dye exclusion and cell counting, migration by cell migration assay, senescence by SA-β-Gal activity, and anchorage-independent growth by cloning in soft agar. Expression of Ki67, p53/phospho-p53, VEGF, EGFR/pEGFR, phospho-p38, intracellular Ca2+, ATP and EMT were evaluated by ELISA and/or Western blotting. (3) Results: nicotine induced through α7-nAChR (i) increase in cell viability, (ii) cell proliferation, (iii) Ki67 over-expression, (iv) phospho-p38 up-regulation, (v) EGFR/pEGFR over-expression, (vi) increase in basal Ca2+ concentration, (vii) reduction of ATP production, (viii) decreased level of p53/phospho-p53, (ix) delayed senescence, (x) VEGF increase, (xi) EMT and consequent (xii) enhanced migration, and (xiii) ability to grow independently of the substrate. (4) Conclusions: Based on our results and on evidence showing that nicotine potentiates viral infection, it is likely that nicotine is involved in SARS-CoV-2 infection and severity.
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Affiliation(s)
- Leonardo Lupacchini
- Molecular and Cellular Neurobiology, IRCSS San Raffaele Pisana, Via di Val Cannuta 247, I-00166 Rome, Italy; (L.L.); (C.D.D.)
| | - Fabrizio Maggi
- Department of Medicine and Surgery, University of Insubria, viale Luigi Borri 57, I-21100 Varese, Italy;
| | - Carlo Tomino
- Scientific Direction, IRCSS San Raffaele Pisana, Via di Val Cannuta 247, I-00166 Rome, Italy;
| | - Chiara De Dominicis
- Molecular and Cellular Neurobiology, IRCSS San Raffaele Pisana, Via di Val Cannuta 247, I-00166 Rome, Italy; (L.L.); (C.D.D.)
| | - Cristiana Mollinari
- Institute of Translational Pharmacology, National Research Council, Via Fosso del Cavaliere 100, 00133 Rome, Italy;
- Department of Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena 299, I-00161 Rome, Italy;
| | - Massimo Fini
- Scientific Direction, IRCSS San Raffaele Pisana, Via di Val Cannuta 247, I-00166 Rome, Italy;
| | - Stefano Bonassi
- Clinical and Molecular Epidemiology, IRCSS San Raffaele Pisana, Via di Val Cannuta 247, I-00166 Rome, Italy;
- Department of Human Sciences and Quality of Life Promotion, San Raffaele University, Via di Val Cannuta 247, I-00166 Rome, Italy
| | - Daniela Merlo
- Department of Neuroscience, Istituto Superiore di Sanità, Viale Regina Elena 299, I-00161 Rome, Italy;
| | - Patrizia Russo
- Clinical and Molecular Epidemiology, IRCSS San Raffaele Pisana, Via di Val Cannuta 247, I-00166 Rome, Italy;
- Department of Human Sciences and Quality of Life Promotion, San Raffaele University, Via di Val Cannuta 247, I-00166 Rome, Italy
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