Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline

Polymorphisms and haplotypes of TOLLIP and MUC5B are associated with susceptibility and survival in patients with fibrotic hypersensitivity pneumonitis

INTRODUCTION AND OBJECTIVES

Hypersensitivity pneumonitis (HP) is an interstitial lung disease with diverse clinical features that can present a fibrotic phenotype similar to idiopathic pulmonary fibrosis (IPF) in genetically predisposed individuals. While several single nucleotide polymorphisms (SNPs) have been associated with IPF, the genetic factors contributing to fibrotic HP (fHP) remain poorly understood. This study investigated the association of MUC5B and TOLLIP variants with susceptibility, clinical presentation and survival in Portuguese patients with fHP.

MATERIAL AND METHODS

A case-control study was undertaken with 97 fHP patients and 112 controls. Six SNPs residing in the MUC5B and TOLLIP genes and their haplotypes were analyzed. Associations with risk, survival, and clinical, radiographic, and pathological features of fHP were probed through comparisons among patients and controls.

RESULTS

MUC5B rs35705950 and three neighboring TOLLIP variants (rs3750920, rs111521887, and rs5743894) were associated with increased susceptibility to fHP. Minor allele frequencies were greater among fHP patients than in controls (40.7% vs 12.1%, P<0.0001; 52.6% vs 40.2%, P = 0.011; 22.7% vs 13.4%, P = 0.013; and 23.2% vs 12.9%, P = 0.006, respectively). Haplotypes formed by these variants were also linked to fHP susceptibility. Moreover, carriers of a specific haplotype (G-T-G-C) had a significant decrease in survival (adjusted hazard ratio 6.92, 95% CI 1.73-27.64, P = 0.006). Additional associations were found between TOLLIP rs111521887 and rs5743894 variants and decreased lung function at baseline, and the MUC5B SNP and radiographic features, further highlighting the influence of genetic factors in fHP.

CONCLUSION

These findings suggest that TOLLIP and MUC5B variants and haplotypes may serve as valuable tools for risk assessment and prognosis in fibrotic hypersensitivity pneumonitis, potentially contributing to its patient stratification, and offer insights into the genetic factors influencing the clinical course of the condition.

Issue 3-The occupational burden of respiratory diseases, an update

INTRODUCTION AND AIMS

Workplace exposures are widely known to cause specific occupational diseases such as silicosis and asbestosis, but they also can contribute substantially to causation of common respiratory diseases. In 2019, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) published a joint statement on the occupational burden of respiratory diseases. Our aim on this narrative review is to summarise the most recent evidence published after the ATS/ERS statement as well as to provide information on traditional occupational lung diseases that can be useful for clinicians and researchers.

RESULTS

Newer publications confirm the findings of the ATS/ERS statement on the role of workplace exposure in contributing to the aetiology of the respiratory diseases considered in this review (asthma, COPD, chronic bronchitis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, infectious pneumonia). Except for COPD, chronic bronchitis and infectious pneumonia, the number of publications in the last 5 years for the other diseases is limited. For traditional occupational lung diseases such as silicosis and asbestosis, there are old as well as novel sources of exposure and their burden continues to be relevant, especially in developing countries.

CONCLUSIONS

Occupational exposure remains an important risk factor for airways and interstitial lung diseases, causing occupational lung diseases and contributing substantially in the aetiology of common respiratory diseases. This information is critical for public health professionals formulating effective preventive strategies but also for clinicians in patient care. Effective action requires shared knowledge among clinicians, researchers, public health professionals, and policy makers.

Diagnostic yield and safety of transbronchial lung cryobiopsy for diffuse parenchymal lung diseases diagnosis: Comparison between 1.7-mm and 1.9-mm probes

Purpose of the research: transbronchial lung cryobiopsy has been recently accepted as a valid and less invasive alternative to surgical lung biopsy. The purpose of this randomized controlled study was to evaluate, for the first time, the quality and safety of biopsy specimens obtained by using the new disposable 1.7-mm cryoprobe compared with the standard re-usable 1.9 mm cryoprobe in the diagnosis of diffuse parenchymal lung diseases. Methods: 60 consecutive patients were prospectively enrolled and randomly assigned to two different groups: 1.9 mm (group A) and 1.7 mm (group B); primary endpoints were pathological and multidisciplinary diagnostic yield, sample size and complication rate. Principal results: the pathological diagnostic yield of cryobiopsy was 100% in group A and 93.3% in group B (p = 0.718); cryobiopsy median diameter was 6.8 mm in group A and 6.7 mm in group B (p = 0,5241). Pneumothorax occurred in 9 patients in group A and 10 in group B (p = 0.951); mild-to-moderate bleeding in 7 cases and 9 cases in group A and B respectively (p = 0.559). No death or severe adverse events were observed. Conclusions: there was no statistically significant difference between the two groups, regarding diagnostic yield, adverse events and sampling adequacy.

Personalized Medicine for Systemic Sclerosis-Associated Interstitial Lung Disease

Purpose of the review

Systemic sclerosis (SSc) is a rare immune-mediated connective tissue disease with high morbidity and mortality. Interstitial lung disease (ILD) is now the leading cause of death for patients with SSc. While several therapeutic agents have been approved for SSc-ILD, opportunities remain for a personalized medicine approach to improve patient outcomes. The purpose of this narrative review is to summarize the current state of personalized medicine for SSc-ILD and future directions to facilitate earlier diagnosis, disease stratification, prognostication, and determination of treatment response. We also review opportunities for personalized medicine approaches within clinical trial design for SSc-ILD.

Recent findings

The management of SSc-ILD remains challenging due to its variable clinical course and current deficits in predicting which individuals will develop progressive pulmonary fibrosis. There have additionally been many challenges in clinical trial design due to limitations in enrichment strategies. Emerging data suggest that serum, radiologic, and other novel biomarkers could be utilized to assess disease activity and treatment response on an individual level.

Summary

Personalized medicine is emerging as a way to address unmet challenges in SSc-ILD and has applicability for identifying stratifying, prognostic, and therapeutic markers for routine clinical care and clinical trial design.

Discovery of potent anti-idiopathic pulmonary fibrosis (IPF) agents based on an o-aminopyridinyl alkynyl scaffold

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease with high mortality and limited treatment options. Targeting multiple kinase-driven pathological processes offers a promising strategy. Using epithelial-mesenchymal transition (EMT) phenotypic screening, we optimized a series of o-aminopyridinyl alkynyl compounds derived from CSF-1R relatively selective inhibitor, compound 1, through a structure-activity relationship (SAR) study, integrating liver and kidney cytotoxicity evaluations. Compound 22, emerged as the potent antifibrotic candidate, exhibiting low cytotoxic effects against human kidney (HEK293) and hepatocyte (L02) cell lines, and minimal hERG inhibition. In addition, 22 showed significant inhibition against other IPF-related processes, including fibroblast-to-myofibroblast transition (FMT)-driven fibrosis in both human fetal lung fibroblasts cell line (HFL1) and primary human lung fibroblasts (HLFs), as well as pro-fibrotic M2 polarization. In vivo, compound 22 exhibited the acceptable PK properties and low toxicity profiles. In addition, oral administration of 22 demonstrated superior anti-fibrotic efficacy compared to Nintedanib, significantly attenuating bleomycin-induced lung fibrosis, reducing inflammation and pro-fibrotic M2-associated cytokine levels, and improving lung function. Preliminary kinase profiling indicates that compound 22 likely targets CSF-1R, PDGFR-α and Src family kinases to inhibit IPF progression, while sparing VEGFRs, FGFRs and Abl to minimize off-target toxicity commonly associated with multi-kinase inhibitor treatment. These findings highlight the advantages and therapeutic potential of a multi-kinase targeting strategy, enabling selective inhibition key IPF-associated kinases to develop more effective and safer anti-IPF agents.

SIRT5-mediated desuccinylation prevents mitochondrial dysfunction in alveolar epithelial cells senescence and pulmonary fibrosis

Senescence of alveolar epithelial cells (AEC) is a key event in the onset and progression of Idiopathic pulmonary fibrosis (IPF). The pathogenic mechanisms that underlie the effects of AEC senescence remain largely unexplained. Some age-related diseases have an etiology linked to mitochondrial dysfunction induced by excessive lysine succinylation (Ksucc). SIRT5 can remove excessive Ksucc levels to maintain mitochondrial homeostasis. Therefore, this study aimed to determine the effects of SIRT5-mediated de-Ksucc on mitochondrial function and pulmonary fibrosis after AEC senescence. We found AEC in the lungs derived from IPF patients exhibit a marked accumulation of dysmorphic and dysfunctional mitochondria and excessive Ksucc levels. These mitochondrial abnormalities in AEC of normal mice with advancing age were associated with the downregulation of SIRT5. Increased SIRT5 expression by LV-SIRT5pcDNA in senescent AEC sustains mitochondrial integrity and reduces fibrotic effects of AEC senescence in established bleomycin (BLM)-aging mouse model. The level of ITGB1 K238 was upregulation in senescent AEC, LV-SIRT5pcDNA down-regulates the Ksucc level of ITGB1 K238 blocking the activation of ITGB1/STAT3 signaling pathway associated pulmonary fibrosis. Collectively, our findings indicate excessive lysine succinylation (hyperKsucc) is a fundamental basis for mitochondrial dysfunction in pulmonary fibrosis induced by the AEC senescence and SIRT5 alleviates AEC senescence by stabilizing the mitochondrial function.

Development and validation of a predictive equation for resting energy expenditure in Japanese patients with interstitial lung disease

BACKGROUND AND AIMS

This study developed a prediction equation for resting energy expenditure (REE) in patients with interstitial lung disease (ILD) using indirect calorimetry and examined the errors in the prediction equation.

METHODS

This study consisted of two key phases: Study 1 focused on developing the prediction equation for REE, whereas Study 2 evaluated the accuracy of this equation through validation and error analysis. In Study 1, REE was measured, and a regression model equation was created to predict REE using multiple regression analysis, with measured REE (mREE) as the dependent variable. In Study 2, a Bland-Altman analysis was conducted to examine the phylogenetic error and agreement between predicted REE (pREE) calculated from the prediction equations developed in Study 1 and mREE.

RESULTS

In Study 1, mREE was significantly associated with fat-free mass (FFM), and the prediction equation for REE was 456.988 + 22.539 × FFM. The addition error (0.4 ± 166.1, 95% confidence interval (CI): -55.8 to 56.6, P = 0.988) and proportional error (r = 0.223, P = 0.191) between mREE and pREE were not significantly different, with an agreement of 69.4%.

CONCLUSIONS

The mREE prediction equation developed in this study showed no systematic errors and exhibited higher agreement compared with existing prediction equations. The prediction equation for REE specific to patients with ILD obtained in this study has the potential for clinical application.

Cough burden and quality of life in patients with progressive pulmonary fibrosis: A multicenter observational study

BACKGROUND

Cough is a prevalent symptom in patients with interstitial lung disease (ILD), often significantly impacting quality of life (QoL). However, there is limited data on cough's burden and its effects on QoL in patients with progressive pulmonary fibrosis (PPF).

AIM

This study aimed to evaluate the impact of cough burden on QoL among a cohort of patients with PPF.

PATIENTS AND METHOD

This multicenter, cross-sectional cohort study focused on PPF. Cough severity and its impact on QoL were assessed using the Visual Analogue Scale (VAS) and Leicester Cough Questionnaire (LCQ) scores.

RESULTS

Of the 248 patients included, 136 (54.8 %) had PPF due to rheumatic diseases, and 193 (77.8 %) reported experiencing cough. Patients with fibrotic nonspecific interstitial pneumonia had the highest cough frequency (p = 0.019). Correlations between cough measures and other variables were generally weak. The mean total LCQ score was 16.1 ± 4.7, with correlations between age and LCQ sub-scores. LCQ total scores positively correlated with FVC (%) (r = 0.202, p = 0.002), DLCO (%) (r = 0.255, p < 0.001), and 6MWT distance (r = 0.277, p = 0.001). VAS scores showed a negative correlation with DLCO, FVC (%), FVC (L), and 6MWT distance. No factor was significantly associated with cough presence in logistic regression, but longer antifibrotic treatment duration and higher LCQ scores were linked to lower VAS scores in linear regression.

CONCLUSION

Cough is highly prevalent in PPF patients and significantly impacts health-related QoL, underscoring the need for targeted management of this symptom in PPF.

Real-world evidence of the antifibrotic nintedanib in rheumatoid arthritis-interstitial lung disease. National multicenter study of 74 patients

OBJECTIVE

To assess the effectiveness and safety of the antifibrotic drug nintedanib in rheumatoid arthritis (RA)-related interstitial lung disease (ILD) and a progressive phenotype in clinical practice.

METHODS

National Spanish multicenter study of RA-ILD patients to whom nintedanib was added due to progressive fibrosing ILD. Outcome variables were effectiveness, retention rate and safety. Forced vital capacity (FVC) evolution was the primary endpoint. A comparative study between our cohort and those RA-ILD patients included in the INBUILD trial (n = 89, 42 treated with nintedanib) was performed.

RESULTS

A total of 74 patients (31 women/43 men) were collected, mean age of 69.3 ± 8.8 years. Median [IQR] ILD duration up to antifibrotic initiation was 51 [22-77.5] months. Besides corticosteroids (n = 54), nintedanib was used combined with cDMARD (n = 21), bDMARD (n = 46) and/or JAKi (n = 4) and monotherapy (n = 3). Mean FVC one year before nintedanib start was 81.9 ± 21.2 (% pred.), whilst mean baseline FVC was 73.7 ± 22.5 (% pred.). After a median follow-up of 15 [10-22, 4-9] months, no significant decline in mean FVC or DLCO values was observed. Moreover, the evolution of DLCO and FVC significantly differed from a predictive model that assumed their changes without the drug. The retention rate with nintedanib was 78.4 %. During the follow up, 16.7 % of patients showed ILD progression or progressive pulmonary fibrosis. Gastrointestinal adverse events were the most common reason for nintedanib discontinuation. Compared with INBUILD trial, patients from clinical practice were older, had a higher tobacco exposure, time since ILD diagnosis was longer and treatment with combined immunosuppressants was more frequent. However, baseline mean values of FVC and DLCO were similar in both groups.

CONCLUSION

Nintedanib seems to be effective and relatively safe in progressive fibrosing RA-ILD despite clinical differences with the INBUILD trial.

Chronic Cough and Pulmonary Manifestations of Laryngopharyngeal Reflux Disease

Laryngopharyngeal reflux plays an important role in respiratory diseases such as chronic cough, asthma, chronic obstructive pulmonary disease, interstitial lung disease, and lung transplantation, among others. In cases of refractory chronic cough, reflux testing (hypopharyngeal-esophageal multichannel intraluminal impedance with dual-PH sensor and high-resolution esophageal manometry) will assist the clinician in determining whether additional reflux treatment steps should be undertaken. It is important to consider all mechanisms of reflux pathophysiology to yield the optimal result in the management of a patient with chronic respiratory disease.

Treatment Response Biomarkers for Systemic Sclerosis-Associated Interstitial Lung Disease

OBJECTIVE

This study investigated whether changes in circulating biomarkers predict progressive pulmonary fibrosis (PPF) in patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) receiving treatment.

METHODS

Participants of the Scleroderma Lung Study II, which compared receiving mycophenolate mofetil (MMF) versus cyclophosphamide (CYC) for treating SSc-ILD, who had blood samples at baseline and 12 months were included. Levels for C-reactive protein (CRP), interleukin-6, C-X-C motif chemokine ligand (CXCL) 4, CCL18, and Krebs von den Lungen (KL)-6 were measured, and a logistic regression model evaluated relationships between changes in these biomarkers and the development of PPF by 24 months.

RESULTS

A total of 92 of the 142 randomized participants had longitudinal biomarker measurements and the required clinical outcome data, with 19 participants (21%) meeting criteria for PPF. In the whole cohort, changes in KL-6 levels were significantly correlated with PPF. KL-6 increased in patients who developed PPF and decreased in patients who did not (mean change ± SD 365.68 ± 434.41 vs -207.45 ± 670.26; P < 0.001). In the arm of participants who received MMF alone, changes in CRP and CXCL4 levels were also significantly correlated with PPF. When added to an existing prediction model based on baseline factors associated with PPF in this cohort (sex, baseline reflux severity, and CXCL4 levels), the change in KL-6 remained significantly associated with PPF (odds ratio 1.4; P = 0.0002).

CONCLUSION

Changes in the circulating levels of KL-6 after treatment with MMF or CYC predicted PPF, even after adjusting for baseline factors associated with PPF. Measuring longitudinal KL-6 in patients with SSc-ILD may improve how we personalize therapy in patients with SSc-ILD.

Evaluating the robustness of deep learning models trained to diagnose idiopathic pulmonary fibrosis using a retrospective study

BACKGROUND

Deep learning (DL)-based systems have not yet been broadly implemented in clinical practice, in part due to unknown robustness across multiple imaging protocols.

PURPOSE

To this end, we aim to evaluate the performance of several previously developed DL-based models, which were trained to distinguish idiopathic pulmonary fibrosis (IPF) from non-IPF among interstitial lung disease (ILD) patients, under standardized reference CT imaging protocols. In this study, we utilized CT scans from non-IPF ILD subjects, acquired using various imaging protocols, to assess the model performance.

METHODS

Three DL-based models, including one 2D and two 3D models, have been previously developed to classify ILD patients into IPF or non-IPF based on chest CT scans. These models were trained on CT image data from 389 IPF and 700 non-IPF ILD patients, retrospectively, obtained from five multicenter studies. For some patients, multiple CT scans were acquired (e.g., one at inhalation and one at exhalation) and/or reconstructed (e.g., thin slice and/or thick slice). Thus, for each patient, one CT image dataset was selected to be used in the construction of the classification model, so the parameters of that data set serve as the reference conditions. In one non-IPF ILD study, due to its specific study protocol, many patients had multiple CT image data sets that were acquired under both prone and supine positions and/or reconstructed under different imaging parameters. Therefore, to assess the robustness of the previously developed models under different (e.g., non-reference) imaging protocols, we identified 343 subjects from this study who had CT data from both the reference condition (used in model construction) and non-reference conditions (e.g., evaluation conditions), which we used in this model evaluation analysis. We reported the specificities from three model under the non-reference conditions. Generalized linear mixed effects model (GLMM) was utilized to identify the significant CT technical and clinical parameters that were associated with getting inconsistent diagnostic results between reference and evaluation conditions. Selected parameters include effective tube current-time product (known as "effective mAs"), reconstruction kernels, slice thickness, patient orientation (prone or supine), CT scanner model, and clinical diagnosis. Limitations include the retrospective nature of this study.

RESULTS

For all three DL models, the overall specificity of the previously trained IPF diagnosis model decreased (p < 0.05 for two out of three models). GLMM further suggests that for at least one out of three models, mean effective mAs across the scan is the key factor that leads to the decrease in model predictive performance (p < 0.001); the difference of mean effective mAs between the reference and evaluation conditions (p = 0.03) and slice thickness (3 mm; p = 0.03) are flagged as significant factors for one out of three models; other factors are not statistically significant (p > 0.05).

CONCLUSION

Preliminary findings demonstrated the lack of robustness of IPF diagnosis model when the DL-based model is applied to CT series collected under different imaging protocols, which indicated that care should be taken as to the acquisition and reconstruction conditions used when developing and deploying DL models into clinical practice.

Transcriptomics of interstitial lung disease: a systematic review and meta-analysis

OBJECTIVE

Gene expression (transcriptomics) studies have revealed potential mechanisms of interstitial lung disease, yet sample sizes of studies are often limited and between-subtype comparisons are scarce. The aim of this study was to identify and validate consensus transcriptomic signatures of interstitial lung disease subtypes.

METHODS

We performed a systematic review and meta-analysis of fibrotic interstitial lung disease transcriptomics studies using an individual participant data approach. We included studies examining bulk transcriptomics of human adult interstitial lung disease samples and excluded those focusing on individual cell populations. Patient-level data and expression matrices were extracted from 43 studies and integrated using a multivariable integrative algorithm to develop interstitial lung disease classification models.

RESULTS

Using 1459 samples from 24 studies, we identified transcriptomic signatures for idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, idiopathic nonspecific interstitial pneumonia and systemic sclerosis-associated interstitial lung disease against control samples, which were validated on 308 samples from eight studies (idiopathic pulmonary fibrosis area under receiver operating curve (AUC) 0.99, 95% CI 0.99-1.00; hypersensitivity pneumonitis AUC 0.91, 95% CI 0.84-0.99; nonspecific interstitial pneumonia AUC 0.94, 95% CI 0.88-0.99; systemic sclerosis-associated interstitial lung disease AUC 0.98, 95% CI 0.93-1.00). Significantly, meta-analysis allowed us to identify, for the first time, robust lung transcriptomics signatures to discriminate idiopathic pulmonary fibrosis (AUC 0.71, 95% CI 0.63-0.79) and hypersensitivity pneumonitis (AUC 0.76, 95% CI 0.63-0.89) from other fibrotic interstitial lung disease, and unsupervised learning algorithms identified putative molecular endotypes of interstitial lung disease associated with decreased forced vital capacity and diffusing capacity of the lungs for carbon monoxide % predicted. Transcriptomics signatures were reflective of both cell-specific and disease-specific changes in gene expression.

CONCLUSION

We present the first systematic review and largest meta-analysis of fibrotic interstitial lung disease transcriptomics to date, identifying reproducible transcriptomic signatures with clinical relevance.

Pulmonary Calcification and Ossification: Pathogenesis, CT Appearance, and Specific Disorders

Pulmonary high attenuation may be caused by calcification or ossification, both of which are common phenomena with distinct pathogeneses, histologies, and radiologic appearances. Pulmonary calcification is divided into metastatic pulmonary calcification (MPC), caused by systemic hypercalcemia, and dystrophic pulmonary calcification (DPC), caused by local lung injury. MPC often demonstrates diffuse calcified nodules, which can be subtle and amorphous on CT images, with associated sandlike, fine ground-glass, or consolidative opacities. Conversely, DPC often appears nodular and is localized to areas of lung injury and thus is associated with other signs of lung damage, such as prior infection, fibrosis, or scarring. In contrast to calcification, pulmonary ossification is not a consequence of a localized or systemic metabolic abnormality but instead is found in the setting of chronic lung disease, which induces fibroblast-to-osteoblast transformation and bone deposition. Pulmonary ossification can be divided into nodular (NPO) and dendriform (DPO) patterns. NPO often appears as multiple small well-defined round nodules that are uniform in size and appearance. NPO classically is seen with chronic venous congestion in a subpleural predominant distribution and increasingly is recognized in pathologic findings in the setting of fibrosing interstitial lung disease (ILD). DPO appears more commonly as peripheral irregular branching opacities and can be seen with ILD. Additionally, pulmonary calcification or ossification can occur in association with protein deposition disease, including pulmonary amyloidosis, or in benign neoplasms or metastatic malignancies. Pulmonary alveolar microlithiasis is a distinct entity relating to phosphate metabolism. Pulmonary calcification and ossification can provide insight into patients' underlying disease processes and clinical context for radiologic study interpretation. ©RSNA, 2025 Supplemental material is available for this article.

Rare variants and survival of patients with idiopathic pulmonary fibrosis: analysis of a multicentre, observational cohort study with independent validation

BACKGROUND

Rare pathogenic variants in telomere-related genes are associated with poorer clinical outcomes in idiopathic pulmonary fibrosis (IPF). We aimed to assess whether rare qualifying variants in monogenic adult-onset pulmonary fibrosis genes are associated with IPF survival. Using polygenic risk scores (PRS), we also evaluated the influence of common IPF risk variants in patients carrying the qualifying variants.

METHODS

We identified qualifying variants in telomere and non-telomere genes using whole-genome sequences from individuals clinically diagnosed with IPF and enrolled in the Pulmonary Fibrosis Foundation Patient Registry (PFFPR), a large multicentre, observational cohort study (March 29, 2016 to June 15, 2018, n=888). We also derived a PRS for IPF (PRS-IPF) from known common sentinel IPF variants. The primary outcome was the association between qualifying variants and survival. The secondary outcome was the association between qualifying variants and PRS-IPF. We used logistic regression models adjusted for sex, age at diagnosis, and principal components of genetic heterogeneity to examine the mutual relationship of qualifying variants and PRS-IPF. The association between qualifying variants and PRS-IPF with survival was tested using Cox proportional hazard models adjusted for baseline confounders. Validation of the results was sought in data from an independent multicentre, prospective, observational cohort study of IPF in the UK (PROFILE, May 17, 2010 to Sept 5, 2017, n=472), and results were meta-analysed under a fixed-effects model.

FINDINGS

We included 888 patients from PFFPR and 472 from PROFILE, totalling 1360 participants. In the PFFPR, carriers of qualifying variants in monogenic adult-onset pulmonary fibrosis genes were associated with lower PRS-IPF (odds ratio 1·79 [95% CI 1·15-2·81]; p=0·010) and shorter survival (hazard ratio 1·53 [1·12-2·10]; p=7·33 × 10-3). Individuals with the lowest PRS-IPF also had worse survival (1·61 [1·25-2·07]; p=1·87 × 10-4). These findings were validated in PROFILE and the meta-analysis of the results showed a consistent direction of effect across both cohorts.

INTERPRETATION

We found non-additive effects between qualifying variants and common risk variants in IPF survival, suggesting distinct disease subtypes and raising the possibility of using PRS to guide sequencing prioritisation. Assessing the carrier status for qualifying variants and modelling PRS-IPF promises to further contribute to predicting disease progression among patients with IPF.

FUNDING

Instituto de Salud Carlos III; Instituto Tecnológico y de Eenergías Renovables; Cabildo Insular de Tenerife; Fundación DISA; National Heart, Lung, and Blood Institute of the US National Institutes of Health; and UK Medical Research Council.

Depression and its association with mortality in idiopathic pulmonary fibrosis: A real-world data analysis

BACKGROUND AND OBJECTIVE

Comorbid depression in idiopathic pulmonary fibrosis (IPF) has been linked to reduced quality of life and worsened symptoms. However, the incidence of depression and its association with mortality in IPF, based on large-scale epidemiological data, remains unclear. This study investigated the clinical significance of depression in patients with IPF using the National Database of Health Insurance Claims and Specific Health Checkups of Japan.

METHODS

We analysed data from 31,386 patients with IPF. The prevalence of depression at IPF diagnosis, its post-diagnosis incidence rates and its associations with mortality and anti-fibrotic therapy were evaluated using propensity score matching, landmark analysis and a Cox model with time-dependent covariates.

RESULTS

The prevalence of depression at IPF diagnosis was 6.7% and the annual incidence rate post-diagnosis was 32.4 cases per 1,000 person-years. Pre-existing depression was not associated with mortality (hazard ratio [HR] 0.978; 95% confidence interval [CI] 0.887-1.080). Conversely, depression developing post-IPF diagnosis significantly increased the mortality risk (HR 2.71; 95% CI 2.55-2.87). While pre-existing depression was not associated with the cumulative initiation rate of anti-fibrotic therapy, depression developing post-IPF diagnosis was associated with a lower cumulative initiation rate.

CONCLUSIONS

Depression arising after an IPF diagnosis was associated with both a lower cumulative initiation rate of anti-fibrotic therapy and increased mortality, emphasising the need for the early detection and management of mental health issues in patients with IPF. Given the high incidence of depression post-IPF diagnosis, integrating mental health care into comprehensive management strategies is crucial for improving patient outcomes.

Clinical significance of anti-neutrophil cytoplasmic antibody in idiopathic interstitial pneumonia: a retrospective observational study

BACKGROUND

Patients with anti-neutrophil cytoplasmic antibody (ANCA)-positive interstitial lung disease (ILD) but without evidence of systemic vasculitis have been reported in studies and are classified as isolated ANCA-positive idiopathic interstitial pneumonia (IIP). However, the clinical significance of ANCA, particularly myeloperoxidase (MPO) -ANCA in IIP remains poorly understood. This study aims to investigate the differences between ANCA-positive and ANCA-negative IIP patients and further explore the impact of MPO-ANCA on clinical manifestations and prognostic outcomes.

METHODS

We reviewed 408 ILD patients with available ANCA results from January 2012 to September 2021. 61 patients diagnosed with microscopic polyangiitis-associated ILD were not included in the analysis. A comparative analysis was performed between 61 isolated ANCA-positive IIP patients (ANCA-IIP group) and 286 ANCA-negative IIP patients (IIP group). We further conducted subgroup analyses based on the status of MPO-ANCA.

RESULTS

Baseline clinical characteristics, pulmonary function tests, radiological features and all-cause mortality were similar between ANCA-IIP and IIP groups. When comparing the MPO-ANCA-IIP group with the IIP group and the non-MPO-ANCA-IIP group separately, a higher proportion of fibrotic features was observed on imaging (P = 0.004 vs IIP group; P = 0.031 vs non-MPO-ANCA-IIP group). After one year of treatment, the MPO-ANCA-IIP group showed a significantly greater decline in pulmonary function parameters compared to both the IIP group and the non-MPO-ANCA-IIP group. The frequency of pulmonary function decline was significantly higher in the MPO-ANCA-IIP group compared to the non-MPO-ANCA-IIP group (P = 0.026). Additionally, MPO-ANCA was not found to be statistically associated with mortality among patients with IIP.

CONCLUSION

ANCA-IIP patients had similar clinical characteristics and prognoses with IIP patients. MPO-ANCA-IIP patients had more prominent fibrosis on imaging and a greater decline in pulmonary function following treatment. Special attention should be paid to MPO-ANCA positivity during the diagnosis and treatment of IIP patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04413149, May 2020.

Real-world insights into safety, tolerability, and predictive factors of adverse drug reactions in treating idiopathic pulmonary fibrosis with pirfenidone and nintedanib

Background

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, life-threatening lung disease with a global incidence of 0.09-1.30 per 10,000 individuals. Pirfenidone and nintedanib are the approved treatments for IPF.

Objectives

This study evaluated the real-world safety and tolerability profiles of pirfenidone and nintedanib in IPF patients treated at the Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS ISMETT). A comparative analysis was conducted based on the number, types, and severity of adverse drug reactions (ADRs) and to identify potential predictors of treatment discontinuation or ADR onset based on patient characteristics.

Design

A retrospective observational study was conducted on 531 IPF patients treated at IRCCS ISMETT with either pirfenidone or nintedanib.

Methods

Eligible patients were selected based on the logged monthly dispensations provided by the pharmacy service for both therapies. Covariates were extracted from electronic medical records (age, sex, body mass index, smoking history, comorbidities, forced vital capacity (FVC) %, diffusing capacity of the lung for carbon monoxide (DLCO) %, 6-minute walk test (6-MWT), polytherapy, oxygen therapy, drug switch, etc.). ADRs were categorized by severity and follow-up status, and further classified according to the Medical Dictionary for Regulatory Activities, specifying the Preferred Terms and the related System Organ Classes. Chi-square or Fisher's exact test was used for categorical variables, and univariate and multiple logistic regression identified potential risk factors for ADR onset. Backward Stepwise logistic regression (BSLR) was used to determine independent variables associated with ADR occurrence.

Results

The nintedanib group had more frequent ADRs related to gastrointestinal and hepatobiliary disorders, with nausea, diarrhea, anorexia, and weight loss as the most common. The pirfenidone group had more ADRs related to skin, nervous system, and vascular disorders, such as rash, nausea, dizziness, and blood pressure imbalances. Significant baseline differences between groups included age, smoking status, FVC (%), DLCO (%), and 6-MWT, with the nintedanib cohort showing worse baseline characteristics. A total of 450 ADRs were reported: 59.6% for nintedanib and 40.4% for pirfenidone. Independent variables that significantly increased the likelihood of experiencing ADR were drug change, treatment type, gender, and age.

Conclusion

Identifying ADR predictors is essential for personalizing treatment strategies. Both pirfenidone and nintedanib are crucial in managing IPF, highlighting the need for further research to optimize personalized therapies and patient outcomes.

Outcomes of lung transplantation for end stage lung disease with connective tissue disease: a systematic review and meta-analysis

BACKGROUND

Lung transplantation is the most important treatment for end-stage lung disease. However, the clinical outcomes of lung transplantation in patients with connective tissue disease(CTD) complicated with end-stage pulmonary complications are unclear. Consequently, we performed a systematic review and meta-analysis to compare the survival rates and incidences of adverse events between patients with and without CTD who underwent lung transplantation for end-stage lung disease.

METHODS

We searched the PubMed, Embase, Web of Science, Cochrane, Wanfang, VIP, CNKI, and CBM databases from their inception until October 18, 2023, for eligible studies. A meta-analysis of each study was performed using State14.0 with a 95% confidence interval (CI). A randomized or fixed-effect model was applied according to the heterogeneity test. The systematic review was registered in PROSPERO (CRD42023483687).

RESULTS

Our final analysis included 12 publications on 369 patients with CTD and 2,165 without, all of whom underwent lung transplantation. The survival at 1 month (OR = 2.20, 95% CI: 0.75-6.47, P = 0.485), 6 months (OR = 0.61, 95% CI: 0.33-1.14, P = 0.099), 1 year (OR = 1.05, 95% CI: 0.66-1.66, P = 0.982), 2 years (OR = 0.50, 95% CI: 0.23-1.06, P = 0.096), 3 years(OR = 1.11, 95% CI: 0.70-1.78, P = 0.703) and 5 years (OR = 2.08, 95% CI: 1.11-3.91, P = 0.027), grade 3 primary graft dysfunction (PGD) incidence (OR = 1.33, 95% CI: 0.68-2.60, P = 0.184), rejection events incidence (OR = 1.19, 95% CI: 0.61-2.32, P = 0.607) and intensive care unit (ICU) LOS (SMD = 0.54, 95% CI:-0.26-1.34, P = 0.187) were similar between the two groups. Patients with CTD had a greater risk of PGD incidence (OR = 2.91, 95% CI: 1.43-5.95, P = 0.003), a longer post-transplant hospital length of stay (LOS) (SMD = 0.52, 95% CI: 0.09-0.96, P = 0.009) and post-transplant time to extubation (SMD = 0.68, 95% CI: 0.12-1.25, P = 0.023).

CONCLUSIONS

The survival rate and the incidence of grade 3 PGD in CTD patients after lung transplantation are comparable to those of other patients undergoing lung transplantation for end-stage lung disease. Thus, Lung transplantation should be a strongly considered therapeutic option for patients with CTD who are suffering from end-stage lung disease. Nevertheless, when selecting patients with CTD for lung transplantation, it is crucial to focus on enhancing perioperative management to reduce the burden of hospitalization post-transplantation.

Exploring the role of serum adiponectin and its holigomerization in fibrotic interstitial lung diseases: results from a cross-sectional study

Intestitial lung diseases (ILDs) include a group of inflammatory and fibrotic pulmonary disorders with different etiologies which in several patients might lead to a progressive reduction of respiratory capacities and chronic respiratory failure. Nowadays, biomarkers for predicting the ILD progression and response to therapies are lacking. Adiponectin, the most abundant peptide secreted by adipocytes, has emerged as a potential response biomarker in fibrotic progressive ILDs. The aim of this observational prospective single-center cross-sectional study is therefore to verify whether serum adiponectin levels were altered in patients with fibrotic ILDs (f-ILDs) and its correlation with clinical and pulmonary function data. Sixty-four f-ILDs patients - divided in three subgroups IPF, CTD-ILDs and other f-ILDs - and 45 healthy subjects were recruited. Serum adiponectin concentration were measured by enzyme-linked immunosorbent assay (ELISA). Pulmonary function tests and clinical data were systematically collected. The results showed that patients with f-ILDs have reduced circulating levels of serum adiponectin (12.5 [10.8-15.4] versus 19.3 [17.3-20.8] p < 0.001). No significant difference in adiponectin levels were observed in the different f-ILDs subgroups (p = 0.619). Adiponectin levels were not associated with progression of f-ILDs (p = 0.745). High molecular weight adiponectin isoform was highly reduced in patients with f-ILDs. In patients with CTD-ILDs - but not in other subgroups - adiponectin levels were associated with pulmonary function and GAP index. These resuls support a potential role of adiponectin as diagnostic and prognostic biomarker of f-ILDs.

Qualitative and quantitative CT analyses of the solid component in lung adenocarcinoma for predicting invasiveness

PURPOSE

This study aimed to evaluate the CT findings of lung adenocarcinoma with solid components and to determine the difference between adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) with invasive adenocarcinoma (IAC).

MATERIALS AND METHODS

A total of 54 cases were included in this study. The diagnoses of lung adenocarcinoma consisted of AIS or MIA (n = 20) and IAC (n = 34). The following factors were evaluated on CT images: part-solid nodule or solid nodule, presence of air bronchogram, air space, calcification within the tumor, presence of interstitial pneumonia and emphysema, diameters of the tumor and solid component, and CT values of the solid component. The volume and CT number histograms, including the 50th, 75th, and 100th percentiles of solid component were obtained using a software program. The CT criteria were compared between AIS, MIA, and IAC, and an indicator of differentiation was considered.

RESULTS

Part-solid nodules were observed more frequently in AIS and MIA (85.0%) than in IAC (55.9%). All criteria for quantitative analysis showed significant differences between AIS or MIA and IAC, and the diameter of the solid component in the mediastinal window was an indicator of differentiation (p = 0.0006; odds ratio, 1.4; 95% confidence interval, 1.2-1.8).

CONCLUSION

The diameter of the solid component on the mediastinal window was considered an indicator of differentiation between AIS, MIA, and IAC.

CONDENSED ABSTRACT

Quantitative data of solid component, including both manual measurements and evaluation using CT software, are correlated with pathological invasiveness. Diameter of the solid component in the mediastinal window would be an indicator of IAC.

Clinical impact of radiological pleuroparenchymal fibroelastosis-like lesions in fibrotic hypersensitivity pneumonitis and efficacy of antigen avoidance

BACKGROUND

Pleuroparenchymal fibroelastosis (PPFE)-like lesions are frequently observed on high-resolution computed tomography in patients with fibrotic hypersensitivity pneumonitis (f-HP). This study aimed to evaluate the association of these lesions with overall survival and disease progression in f-HP patients and to examine the efficacy of antigen avoidance.

METHODS

A retrospective observational study of patients with f-HP was conducted in a single center. High-resolution computed tomography was used to assess the presence of radiological PPFE-like lesions.

RESULTS

Radiological PPFE-like lesions were detected in 48 of the 107 patients analyzed (44.9 %). Lesions were significantly associated with death from any cause (hazard ratio, 2.32; 95 % confidence interval [CI], 1.13-4.95; p = 0.024) and disease progression (odds ratio, 2.90; 95 % CI, 1.17-7.50; p = 0.024). Antigen non-avoidance was a significant predictor of worse overall survival (hazard ratio, 2.67; 95 % CI, 1.31-5.76; p = 0.008) and disease progression (odds ratio, 3.62; 95 % CI, 1.52-8.96; p = 0.004). Overall survival was significantly better (p = 0.116) and annual decline in forced vital capacity was significantly smaller (p = 0.002) in patients with radiological PPFE-like lesions who achieved antigen avoidance than in those who did not.

CONCLUSIONS

Radiological PPFE-like lesions were associated with worse survival and decline in forced vital capacity in patients with f-HP. Antigen avoidance may improve survival and prevent disease progression in f-HP patients with lesions.

Patient characteristics and pharmacologic treatment patterns in antifibrotic-treated patients with fibrosing interstitial lung diseases: real-world results from a claims database

BACKGROUND

Antifibrotics have been approved for use in many countries, including Japan, based on the results of several phase III clinical trials in patients with IPF, SSc-ILD, and PPF, which showed slower lung function decline with antifibrotic treatment. There is a paucity of information on the real-world use of antifibrotics in clinical practice.

METHODS

Baseline characteristics, comorbidities, and drugs used prior to and concomitant with antifibrotics were collected for patients with IPF, SSc-ILD, and PPF using a health insurance claims database in Japan from 1 January 2013 to 30 June 2023. Descriptive statistics were generated for all study variables.

RESULTS

This study included 657 nintedanib users with IPF; 418 pirfenidone users with IPF; 4160 nintedanib users with PPF; 18,403 users of glucocorticoids/immunosuppressants for ILD treatment with PPF; 676 nintedanib users with SSc-ILD; and 698 users of glucocorticoids/immunosuppressants for ILD treatment with SSc-ILD. At index, pirfenidone users with IPF were the oldest (mean [SD] 74.8 [7.3] years), and nintedanib users with SSc-ILD were the youngest (mean [SD] 65.6 [11.7] years). In nintedanib users with IPF, 76.7% were prescribed nintedanib as monotherapy, and 75.6% of pirfenidone users were prescribed pirfenidone, as monotherapy. In patients with IPF, 75.2% were prescribed nintedanib, and 76.1% were prescribed pirfenidone, as first-line therapy. In patients with SSc-ILD, 34.9% were prescribed nintedanib as monotherapy for ILD treatment, and 38.6% as first-line therapy. Approximately half of patients with PPF were prescribed nintedanib concomitantly with other glucocorticoids/immunosuppressant drugs, and after one or more glucocorticoids/immunosuppressant drugs. The most common concomitant drug in all patient groups was glucocorticoids. In patients with IPF, 18.6% of nintedanib users and 18.2% of pirfenidone users were prescribed glucocorticoids concomitantly. Concomitant glucocorticoid use was 52.7% for nintedanib users with SSc-ILD, and 44.1% for nintedanib users with PPF.

CONCLUSIONS

These results provide real-world evidence of antifibrotic use in clinical practice. Most patients with IPF were prescribed antifibrotics as monotherapy for ILD treatment whereas antifibrotics were used concomitantly with glucocorticoids/immunosuppressants in many patients with SSc-ILD and PPF. While most patients with IPF were prescribed antifibrotics as first-line therapy, patients with SSc-ILD and PPF were more likely to be prescribed nintedanib as second-line or later-line treatment after glucocorticoids/immunosuppressants.

Association between inhaled corticosteroids and incidence of idiopathic pulmonary fibrosis: nationwide population-based study

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive disease found primarily in older people, with the use of systemic steroids linked to poor outcomes. However, the role of inhaled corticosteroids (ICSs) in IPF remains unclear. This study investigated the association between ICS use and IPF risk using national insurance data, particularly in individuals with chronic airway diseases.

METHODS

Using the National Health Insurance Service-National Sample Cohort database, our study included patients diagnosed with chronic obstructive pulmonary disease or asthma. ICS exposure was assessed via treatment claims, and IPF cases were identified using broad and narrow criteria. We used inverse probability of treatment weighting (IPTW) with propensity scores for balanced covariate analysis.

RESULTS

Of 57 456 patients (mean age: 55.9 years, 42.3% men), 16.5% used ICS and 83.5% did not. ICS users showed higher rates of broad (0.98 vs 0.41 per 1000) and narrow IPF (0.61 vs 0.21 per 1000) than non-users. Pre-IPTW, ICS use was associated with increased IPF risk; however, this was not significant post-IPTW. Post-IPTW, both ICS dose as a continuous variable (broad adjusted HR per 100 µg/day: 1.03, 95% CI: 1.02 to 1.04; narrow adjusted HR per 100 µg/day: 1.03, 95% CI: 1.01 to 1.04 post-IPTW) and high-dose ICS (≥1000 µg/day) (broad adjusted HR: 3.89, 95% CI: 1.61 to 9.41; narrow adjusted HR: 3.99, 95% CI: 1.19 to 13.41) use correlated with an elevated IPF risk.

CONCLUSION

While no overall significant association between ICS use and IPF risk was observed post-IPTW, there may be an increased risk in patients using high-dose ICS.

Huaxian formula alleviates nickel oxide nanoparticle-induced pulmonary fibrosis via PI3K/AKT signaling

As a progressive fibrotic lung disorder with high mortality, pulmonary fibrosis (PF) suffers from inadequate treatment options. While the traditional Chinese medicine (TCM) formulation Huaxian Formula (HXF) demonstrates multi-target therapeutic potential against PF, the identity of its active components and their mechanistic basis of action require systematic investigation. To elucidate the therapeutic effects and pharmacological mechanisms of HXF in treating PF induced by nickel oxide nanoparticles (nano NiO), utilizing network pharmacology (NP), molecular docking, as well as in vivo and in vitro experiments. A comprehensive analysis of authoritative databases identified 121 active compounds, 202 potential therapeutic targets, and 1664 PF-related genes. Among these, 105 overlapping targets were found between HXF and PF. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses identified the PI3K/AKT signaling pathway as both a pivotal mechanism in PF pathogenesis and a primary target of HXF's therapeutic effects. Molecular docking studies revealed that the six core compounds (quercetin, luteolin, kaempferol, β-sitosterol, isorhamnetin, and formononetin) of HXF exhibited strong binding affinity to proteins involved in the PI3K/AKT pathway. In the rat and A549 cell model, HXF treatment reduced collagen deposition and downregulated the expression of type I collagen (Col-I). Mechanistically, HXF inhibited the phosphorylation of PI3K and AKT. Collectively, these findings suggested that HXF alleviated PF by modulating the PI3K/AKT signaling pathway, providing valuable insights and methods for the development of TCM for PF.

Dynamic perfusion area-detector CT in non-small cell lung cancer with progressive fibrosing interstitial lung disease

OBJECTIVES

To determine the capability of dynamic contrast-enhanced (CE-) perfusion area-detector CT (ADCT) for detecting pathological structural changes in stage I non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

Sixty-three consecutive stage I NSCLC patients with progressive fibrosing interstitial lung disease (PF-ILD) underwent dynamic CE-perfusion ADCT analyzed by dual-input maximum slope (DMS) methods for total, pulmonary arterial and systemic arterial perfusion (TPDMS, PAPDMS and SAPDMS) maps, surgical treatment and pathological examination. Multicentric ROIs were then placed over sites assessed as normal lung, pulmonary emphysema, GGO or reticular pattern without traction bronchiectasis, reticular pattern with traction bronchiectasis and honeycombing in the resected lung. Next, an analysis of variance (ANOVA) followed by Tukey's honest significant difference (HSD) multiple comparison test was performed for a comparison of each of the perfusion parameters for five groups. Finally, discrimination accuracy for evaluation of lung parenchymal change was compared for all indexes and combined methods.

RESULTS

PAPDMSs of abnormal lungs were significantly lower than that of normal lungs (p < 0.0001). SAPDMSs of normal or emphysematous lungs were significantly lower than those of others (p < 0.0001). SAPDMS of GGO or reticular pattern without traction bronchiectasis was significantly lower than that for reticular pattern with traction bronchiectasis and honeycombing (p < 0.0001). Discrimination accuracy of combined perfusion index was significantly higher than that of each index (p < 0.0001).

CONCLUSION

Dynamic CE-perfusion ADCT is useful for detecting pathological structural changes in stage I NSCLC patients with PF-ILD.

KEY POINTS

Question Can dynamic first-pass contrast-enhanced perfusion matrices evaluate parenchymal lung changes and disease severity of parenchymal diseases in stage I non-small cell lung cancer (NSCLC) patients? Findings Perfusion indexes differentiated significantly among normal lung, emphysema, GGO or reticular pattern without traction bronchiectasis, reticular pattern with traction bronchiectasis and honeycombing and significantly improved discrimination accuracy by combined methods. Clinical relevance Dynamic first-pass contrast-enhanced perfusion area-detector CT has the potential to assess underlying pathologies and pulmonary functional changes in stage I non-small cell carcinoma patients with progressive fibrosing interstitial lung disease.

Influence of content-based image retrieval on the accuracy and inter-reader agreement of usual interstitial pneumonia CT pattern classification

OBJECTIVES

To investigate whether a content-based image retrieval (CBIR) of similar chest CT images can help usual interstitial pneumonia (UIP) CT pattern classifications among readers with varying levels of experience.

MATERIALS AND METHODS

This retrospective study included patients who underwent high-resolution chest CT between 2013 and 2015 for the initial workup for fibrosing interstitial lung disease. UIP classifications were assigned to CT images by three thoracic radiologists, which served as the ground truth. One hundred patients were selected as queries. The CBIR retrieved the top three similar CT images with UIP classifications using a deep learning algorithm. The diagnostic accuracies and inter-reader agreement of nine readers before and after CBIR were evaluated.

RESULTS

Of 587 patients (mean age, 63 years; 356 men), 100 query cases (26 UIP patterns, 26 probable UIP patterns, 5 indeterminate for UIP, and 43 alternative diagnoses) were selected. After CBIR, the mean accuracy (61.3% to 67.1%; p = 0.011) and inter-reader agreement (Fleiss Kappa, 0.400 to 0.476; p = 0.003) were slightly improved. The accuracies of the radiologist group for all CT patterns except indeterminate for UIP increased after CBIR; however, they did not reach statistical significance. The resident and pulmonologist groups demonstrated mixed results: accuracy decreased for UIP pattern, increased for alternative diagnosis, and varied for others.

CONCLUSION

CBIR slightly improved diagnostic accuracy and inter-reader agreement in UIP pattern classifications. However, its impact varied depending on the readers' level of experience, suggesting that the current CBIR system may be beneficial when used to complement the interpretations of experienced readers.

KEY POINTS

Question CT pattern classification is important for the standardized assessment and management of idiopathic pulmonary fibrosis, but requires radiologic expertise and shows inter-reader variability. Findings CBIR slightly improved diagnostic accuracy and inter-reader agreement for UIP CT pattern classifications overall. Clinical relevance The proposed CBIR system may guide consistent work-up and treatment strategies by enhancing accuracy and inter-reader agreement in UIP CT pattern classifications by experienced readers whose expertise and experience can effectively interact with CBIR results.

Nerandomilast in Patients with Progressive Pulmonary Fibrosis

BACKGROUND

Nerandomilast (BI 1015550) is an orally administered preferential inhibitor of phosphodiesterase 4B with antifibrotic and immunomodulatory properties. Nerandomilast has been shown to slow the progression of idiopathic pulmonary fibrosis, but an assessment of its effects in other types of progressive pulmonary fibrosis is needed.

METHODS

In a phase 3, double-blind trial, we randomly assigned patients with progressive pulmonary fibrosis in a 1:1:1 ratio to receive nerandomilast at a dose of 18 mg twice daily, nerandomilast at a dose of 9 mg twice daily, or placebo, with stratification according to background therapy (nintedanib vs. none) and fibrotic pattern on high-resolution computed tomography (usual interstitial pneumonia-like pattern vs. other patterns). The primary end point was the absolute change from baseline in the forced vital capacity (FVC), measured in milliliters, at week 52.

RESULTS

A total of 1176 patients received at least one dose of nerandomilast or placebo, of whom 43.5% were taking background nintedanib therapy at baseline. The adjusted mean change in the FVC at week 52 was -98.6 ml (95% confidence interval [CI], -123.7 to -73.4) in the nerandomilast 18-mg group, -84.6 ml (95% CI, -109.6 to -59.7) in the nerandomilast 9-mg group, and -165.8 ml (95% CI, -190.5 to -141.0) in the placebo group. The adjusted difference between the nerandomilast 18-mg group and the placebo group was 67.2 ml (95% CI, 31.9 to 102.5; P<0.001), and the adjusted difference between the nerandomilast 9-mg group and the placebo group was 81.1 ml (95% CI, 46.0 to 116.3; P<0.001). The most frequent adverse event was diarrhea, reported in 36.6% of the patients in the nerandomilast 18-mg group, 29.5% of those in the nerandomilast 9-mg group, and 24.7% of those in the placebo group. Serious adverse events occurred in similar percentages of patients in the trial groups.

CONCLUSIONS

In patients with progressive pulmonary fibrosis, treatment with nerandomilast led to a smaller decline in the FVC than placebo over a period of 52 weeks. (Funded by Boehringer Ingelheim; FIBRONEER-ILD ClinicalTrials.gov number, NCT05321082.).

Progressive Pulmonary Fibrosis: Current Status in Terminology and Future Directions

The latest clinical practice guidelines for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) were jointly published by the American Thoracic Society (ATS), European Respiratory Society (ERS), Japanese Respiratory Society (JRS), and Asociacion Latinoamericana de Thorax (ALAT) in 2022, and a new term-"PPF"-has been proposed to describe patients with non-IPF fibrosing interstitial lung diseases (ILDs), with defined criteria. However, the proposal of this new term has caused confusion amongst experts at a time when use of the term "progressive fibrosing interstitial lung disease" (PF-ILD), proposed in the phase 3 INBUILD trial of nintedanib, has become widely adopted by pulmonologists and rheumatologists in clinical practice. In this commentary, we discuss the background and concepts underpinning the terms PPF and PF-ILD and seek to provide pulmonologists and rheumatologists with a deeper understanding of the concept of PPF.

Diagnosis of early idiopathic pulmonary fibrosis: current status and future perspective

The standard approach to diagnosing idiopathic pulmonary fibrosis (IPF) includes identifying the usual interstitial pneumonia (UIP) pattern via high resolution computed tomography (HRCT) or lung biopsy and excluding known causes of interstitial lung disease (ILD). However, limitations of manual interpretation of lung imaging, along with other reasons such as lack of relevant knowledge and non-specific symptoms have hindered the timely diagnosis of IPF. This review proposes the definition of early IPF, emphasizes the diagnostic urgency of early IPF, and highlights current diagnostic strategies and future prospects for early IPF. The integration of artificial intelligence (AI), specifically machine learning (ML) and deep learning (DL), is revolutionizing the diagnostic procedure of early IPF by standardizing and accelerating the interpretation of thoracic images. Innovative bronchoscopic techniques such as transbronchial lung cryobiopsy (TBLC), genomic classifier, and endobronchial optical coherence tomography (EB-OCT) provide less invasive diagnostic alternatives. In addition, chest auscultation, serum biomarkers, and susceptibility genes are pivotal for the indication of early diagnosis. Ongoing research is essential for refining diagnostic methods and treatment strategies for early IPF.

Nerandomilast in Patients with Idiopathic Pulmonary Fibrosis

BACKGROUND

Nerandomilast (BI 1015550) is an orally administered preferential inhibitor of phosphodiesterase 4B with antifibrotic and immunomodulatory effects. In a phase 2 trial involving patients with idiopathic pulmonary fibrosis, treatment with nerandomilast stabilized lung function over a period of 12 weeks.

METHODS

In this phase 3, double-blind trial, we randomly assigned patients with idiopathic pulmonary fibrosis in a 1:1:1 ratio to receive nerandomilast at a dose of 18 mg twice daily, nerandomilast at a dose of 9 mg twice daily, or placebo, with stratification according to background antifibrotic therapy (nintedanib or pirfenidone vs. none). The primary end point was the absolute change from baseline in forced vital capacity (FVC), measured in milliliters, at week 52.

RESULTS

A total of 1177 patients underwent randomization, of whom 77.7% were taking nintedanib or pirfenidone at enrollment. Adjusted mean changes in FVC at week 52 were -114.7 ml (95% confidence interval [CI], -141.8 to -87.5) in the nerandomilast 18-mg group, -138.6 ml (95% CI, -165.6 to -111.6) in the nerandomilast 9-mg group, and -183.5 ml (95% CI, -210.9 to -156.1) in the placebo group. The adjusted difference between the nerandomilast 18-mg group and the placebo group was 68.8 ml (95% CI, 30.3 to 107.4; P<0.001), and the adjusted difference between the nerandomilast 9-mg group and the placebo group was 44.9 ml (95% CI, 6.4 to 83.3; P = 0.02). The most frequent adverse event in the nerandomilast groups was diarrhea, reported in 41.3% of the 18-mg group and 31.1% of the 9-mg group, as compared with 16.0% in the placebo group. Serious adverse events were balanced across trial groups.

CONCLUSIONS

In patients with idiopathic pulmonary fibrosis, treatment with nerandomilast resulted in a smaller decline in the FVC than placebo over a period of 52 weeks. (Funded by Boehringer Ingelheim; FIBRONEER-IPF ClinicalTrials.gov number, NCT05321069.).

Relationships between disease severity and measures of health status in people with interstitial lung disease in India: an observational study

The severity and progression of Interstitial Lung Disease (ILD) can vary due to environmental, cultural and genetic factors. The relationship between disease severity and factors that determine the health status of people with ILD living in lower middle-income countries like India has not been evaluated. This study aimed to determine whether there were relationships between disease severity with functional exercise capacity and Health Related Quality of Life (HRQoL) among people with ILD in India. This was a prospective, single center observational study. All participants performed Pulmonary Function Test (PFT) including Forced Vital Capacity (FVC) % predicted, Diffusing Capacity of the Lung for Carbon Monoxide (DLCO) % predicted, 6 min Walk Distance (6MWD), St. George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (mMRC) dyspnoea scale. Eighty participants with ILD were recruited from September 2020 and December 2022. There were strong correlations between 6MWD with DLCO % pred (Spearman rho 0.891) and between SGRQ Total score and DLCO % pred (Spearman rho 0.906). There were no correlations between 6MWD and FVC % pred (Spearman rho 0.206) or between SGRQ and FVC % pred (Spearman rho 0.113). This study demonstrated strong correlations between disease severity measured by DLCO % pred with both functional exercise capacity and HRQoL in people with ILD in India.

Insight into the efficacy and safety of pirfenidone: The treatment of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) has a poor prognosis if left untreated; therefore, early treatment with pirfenidone is crucial. Lei et al conducted a retrospective analysis to evaluate the effectiveness of early pirfenidone treatment on lung function in 113 patients with IPF. In addition to other research, pirfenidone has demonstrated efficacy in patients at all stages of IPF once correct diagnosis has been made. In advanced IPF, we include the requirement for pirfenidone. Therefore, it is essential to choose an appropriate method of administration method, such as inhalation. This may circumvent the drawbacks of the high cost and possible adverse effects of this drug.

The potential of semi-quantitative and quantitative methods in predicting progression in rheumatoid arthritis-associated interstitial lung disease

INTRODUCTION

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) presents with variable severity and progression, highlighting the need for effective tools to identify patients at risk. Although CT imaging plays a vital role in the management of RA-ILD, there is a lack of objective methods to predict disease progression. This study investigates the association between semi-quantitative and quantitative CT scoring methods and disease progression in early-stage RA-ILD.

METHODS

This observational study analyzed baseline and the first technically evaluable follow-up CT scans of patients who met the 2010 ACR/EULAR classification criteria for RA and were diagnosed with ILD. Only patients with ≤ 5 years between baseline and follow-up scans were included. Semi-quantitative assessments were conducted using the Goh and Warrick scoring systems, while quantitative analyses utilized Vitrea software to measure mean lung attenuation (MLA) and low-, medium-, and high-density lung volumes. Progression risk factors were evaluated using binary logistic regression, with progression defined by changes in CT parameters over time.

RESULTS

A total of 77 RA-ILD patients (45 females, 32 males) were included, with a median follow-up period of 20 months (interquartile range: 7.4-46 months). Disease progression was observed in 34 patients (44.2%). Baseline medium-density volume (MDV), follow-up mean lung attenuation (MLA), and low-density volume (LDV) differed significantly between the progression and non-progression groups (p < 0.05). Quantitative CT parameters demonstrated strong correlations with both the Goh and Warrick scoring systems. Binary logistic regression analysis identified the usual interstitial pneumonia (UIP) pattern on baseline imaging as the only independent predictor of disease progression (odds ratio: 3.1; 95% confidence interval: 1.1-12.4).

CONCLUSION

In this study of early-stage RA-ILD patients, only the usual interstitial pneumonia (UIP) pattern on baseline HRCT independently predicted disease progression. Neither semi-quantitative scores nor quantitative CT parameters were predictive of progression. However, quantitative CT metrics demonstrated strong correlations with traditional scoring systems, supporting their utility in objectively assessing disease extent.

Bayesian Integration of Bronchoalveolar Lavage miRNAs and KL-6 in Progressive Pulmonary Fibrosis Diagnosis

Background/Objectives: Progressive pulmonary fibrosis (PPF) represents one of the most severe and complex challenges in respiratory medicine, characterized by a rapid decline in lung function and often poor prognosis, making it a priority in research on interstitial lung diseases (ILDs). The aim of this study is to correlate classical clinical features and three genetic biomarkers with the diagnosis and prognosis of progressive pulmonary fibrosis in ILDs. Methods: This study involved 19 patients with progressive pulmonary fibrosis (PPF) and 20 patients with non-progressive pulmonary fibrosis (nPPF) from the S.C. of Respiratory System Diseases at the Policlinico of Foggia (Italy) between 2015 and 2022. All participants underwent pulmonary function tests (PFTs), a 6 min walk test (6MWT), and bronchoalveolar lavage (BAL) sampling, following the acquisition of written consent for these procedures. Bayesian analysis with generalized linear models has been applied for both diagnostic and prognostic classification. Results: The proposed Bayesian model enables the estimation of the contribution of each considered feature, and the quantification of the uncertainty that is consequential to the small size of the dataset. The analysis of miRNAs such as miR-21 and miR-92a, alongside the protein biomarker KL-6, was identified as a significant indicator for PPF diagnosis, enhancing both the sensitivity and specificity of predictions. Conclusions: The identification of specific genetic markers such as microRNAs and their integration with traditional clinical characteristics can significantly enhance the management of patients with the disease. This multidimensional approach, which integrates clinical data with omics data, could enable more precise identification and monitoring of the disease and potentially optimize future treatments through larger studies and extended follow-ups.

Sexual dimorphism of lung immune-regulatory units imprint biased pulmonary fibrosis

Pulmonary fibrosis (PF) is sexually dimorphic, with a relatively high prevalence and severity in males; however, the mechanism remains unclear. Our study revealed pronounced sexual dimorphism of immune cell genes in the lung, among which grancalcin (GCA) showed profound sex differences. GCA was produced by lung-infiltrating bone marrow macrophages triggered by heightened inflammation in the lung. However, a unique HTR2C+ alveolar macrophage population enriched in female lungs metabolically reprogramed bone marrow-derived macrophages and constrained local GCA amplification. As a novel chemokine, GCA bound to protein tyrosine phosphatase receptor type T (PTPRT) in Th17 cells and facilitated pathogenic lung infiltration by activating the ROCK1-MLC pathway, thus aggravating lung fibrosis. Notably, both GCA and Th17 cells abundantly accumulated in lung biopsies from male PF patients but not in those from female patients. GCA-neutralizing antibodies in combination with pirfenidone, a prescribed medication for treating fibrosis, provided superior effectiveness and survival rates against PF compared with treatment with pirfenidone alone. Overall, our findings reveal that sex-biased lung fibrosis is shaped by lung immune-regulatory units, which could be targeted to limit lung fibrosis.

GPR40 activation alleviates pulmonary fibrosis by repressing M2 macrophage polarization through the PKD1/CD36/TGF-β1 pathway

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive interstitial lung disease characterized by complex aetiologies involving the accumulation of inflammatory cells, such as macrophages, in the alveoli. This process is driven by uncontrolled extracellular matrix (ECM) deposition and the development of fibrous connective tissues. Here, we observed that the mRNA expression of Ffar1, the gene encoding G protein-coupled receptor 40 (GPR40), is repressed, while Cd36 is increased in the bronchoalveolar lavage fluid (BALF), which is predominantly composed of alveolar macrophages, of IPF patients. Furthermore, the GPR40 protein was found to be largely adhered to macrophages and was pathologically downregulated in the lungs of bleomycin (BLM)-induced PF model mice (PF mice) compared with those of control mice. Specific knockdown of GPR40 in pulmonary macrophages by adeno-associated virus 9-F4/80-shGPR40 (AAV9-shGPR40) exacerbated the fibrotic phenotype in the PF mice, and activation of GPR40 by its determined agonist compound SC (1,3-dihydroxy-8-methoxy-9H-xanthen-9-one) effectively protected the PF mice from pathological exacerbation. Moreover, Ffar1 or Cd36 gene knockout mouse-based assays were performed to explore the mechanism underlying the regulation of GPR40 activation in pulmonary macrophages with compound SC as a probe. We found that compound SC mitigated pulmonary fibrosis progression by preventing M2 macrophage polarization from exerting profibrotic effects through the GPR40/PKD1/CD36 axis. Our results strongly support the therapeutic potential of targeting intrinsic GPR40 activation in pulmonary macrophages for IPF and highlight the potential of compound SC in treating this disease.

Exploring the Potential of a P2X3 Receptor Antagonist: Gefapixant in the Management of Persistent Cough Associated with Interstitial Lung Disease

Background: Interstitial lung disease (ILD) is characterized by pulmonary inflammation and fibrosis associated with persistent and refractory cough that significantly hinders quality of life. Conventional treatments for ILD-associated cough have shown limited efficacy, necessitating alternative therapeutic approaches. Gefapixant, a P2X3 receptor antagonist, can potentially alleviate chronic cough by inhibiting the ATP-mediated activation of sensory C-fibers, but its efficacy in ILD-associated cough remains unclear. This study observed the effects of gefapixant on ILD-associated refractory chronic cough. Methods: This prospective study enrolled patients with ILD-associated refractory chronic cough who received gefapixant at Sapporo Medical University Hospital between July 2022 and November 2023. Cough frequency, Leicester Cough Questionnaire (LCQ) score, cough severity visual analog scale (Cough VAS), and taste VAS were evaluated at baseline and at 2, 4, and 8 weeks after gefapixant administration. Results: Six patients completed the study. Their ILD subtypes included idiopathic pulmonary fibrosis (IPF), nonspecific interstitial pneumonia (NSIP), and connective tissue disease-associated ILDs (CTD-ILDs). After 8 weeks, the cough frequency decreased from 88.5 to 44.3 episodes per 30 min, LCQ scores increased from 8.3 to 13.6, and cough VAS scores decreased from 75.8 to 40.2. However, statistical significance was not reached due to high interindividual variability, with gefapixant being effective in some and ineffective in others. The most common adverse event was taste disorder, leading to discontinuation in one patient, but symptoms tended to lessen over the course of treatment. Conclusions: Gefapixant appears to be effective in reducing refractory cough related to ILD, although these results were not statistically significant because its effectivity widely varied across individuals. Further investigation is needed to identify patient subgroups with the greatest potential for treatment responsiveness.

Predicting the risk of subsequent progression in patients with systemic sclerosis-associated interstitial lung disease with progression: a multicentre observational cohort study

BACKGROUND

In patients with systemic sclerosis, it is common practice to treat interstitial lung disease (ILD) in patients in whom progression has already occurred. We sought to clarify whether observed progression of systemic sclerosis-associated ILD confers risk for subsequent progression.

METHODS

In this multicentre observational cohort study, based on an analysis of prospectively collected data, we included patients with systemic sclerosis-associated ILD aged 18 years or older at diagnosis, who fulfilled the 2013 American College of Rheumatology-European Association of Alliances in Rheumatology systemic sclerosis classification criteria. The main cohort (diagnosed between January 2001 and December 2019) was consecutively followed up annually over 4 years at the Department of Rheumatology at the Oslo University Hospital, Norway, and the Department of Rheumatology at the University Hospital Zurich, Switzerland. We applied four definitions of ILD progression: the primary definition was forced vital capacity (FVC) decline of 5% or more, and secondary definitions included FVC decline of 10% or more, progressive pulmonary fibrosis (PPF), and progressive fibrosing ILD (PF-ILD). We applied these definitions at each annual visit after the first (visit 1). We validated our findings in an enriched cohort that included patients from the main cohort with systemic sclerosis-associated ILD and short disease duration of less than 3 years along with patients diagnosed between January 2003 and September 2019 from the Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA. Multivariable logistic regression analyses were applied to predict ILD progression and its effect on mortality. There was no involvement of people with lived experience in this study.

FINDINGS

Of 231 patients with systemic sclerosis-associated ILD from the main cohort (mean age 48·0 years [SD 14·6], 176 [76%] female and 55 [24%] male), 71 (31%) had ILD progression as defined by an FVC decline of 5% or more between visit 1 and visit 2, 38 (16%) as defined by an FVC decline of 10% or more, 39 (17%) as defined by PPF, and 89 (39%) defined by PF-ILD. In multivariable logistic regression analyses, adjusted for risk factors for progressive systemic sclerosis-associated ILD and immunosuppressive treatment, we found that ILD progression, defined by FVC decline of 5% or more, from visit 1 to visit 2 reduced the risk for further progression from visit 2 to visit 3 (odds ratio [OR] 0·28 [95% CI 0·12-0·63]; p=0·002) and that there was no risk for subsequent progression using the other definitions (FVC decline of ≥10%: 0·57 [0·16-1·99; p=0·38]; PPF: 0·93 [0·39-2·22; p=0·88]; and PF-ILD: 0·69 [0·35-1·36]; p=0·28]). Using the primary definition of progression, we found the same results in the enriched systemic sclerosis-associated ILD cohort, wherein 41 (34%) of 121 patients had progression defined by an FVC decline of 5% or more (OR 0·22 [95% CI 0·06-0·87]; p=0·031). FVC decline of 5% or more was significantly associated with mortality (hazard ratio 1·66 [95% CI 1·05-2·62]; p=0·030) adjusted for other risk factors.

INTERPRETATION

Systemic sclerosis-associated ILD progression does not predict further ILD progression at the next annual follow-up visit, even in an enriched population, but progression was associated with mortality. These results have implications for clinical practice because they support a paradigm shift in treatment strategy, advocating for initiating therapy in patients at risk of progression. Further research is needed to confirm these findings.

FUNDING

None.

TRANSLATIONS

For the German and Norwegian translations of the abstract see Supplementary Materials section.

Natural products for anti-fibrotic therapy in idiopathic pulmonary fibrosis: marine and terrestrial insights

Idiopathic Pulmonary Fibrosis (IPF) is a chronic fibrotic interstitial lung disease (ILD) of unknown etiology, characterized by increasing incidence and intricate pathogenesis. Current FDA-approved drugs suffer from significant side effects and limited efficacy, highlighting the urgent need for innovative therapeutic agents for IPF. Natural products (NPs), with their multi-target and multifaceted properties, present promising candidates for new drug development. This review delineates the anti-fibrotic pathways and targets of various natural products based on the established pathological mechanisms of IPF. It encompasses over 20 compounds, including flavonoids, saponins, polyphenols, terpenoids, natural polysaccharides, cyclic peptides, deep-sea fungal alkaloids, and algal proteins, sourced from both terrestrial and marine environments. The review explores their potential roles in mitigating pulmonary fibrosis, such as inhibiting inflammatory responses, protecting against lipid peroxidation damage, suppressing mesenchymal cell activation and proliferation, inhibiting fibroblast migration, influencing the synthesis and secretion of pro-fibrotic factors, and regulating extracellular matrix (ECM) synthesis and degradation. Additionally, it covers various in vivo and in vitro disease models, methodologies for analyzing marker expression and signaling pathways, and identifies potential new therapeutic targets informed by the latest research on IPF pathogenesis, as well as challenges in bioavailability and clinical translation. This review aims to provide essential theoretical and technical insights for the advancement of novel anti-pulmonary fibrosis drugs.

Visual Diagnosis of Drug-Induced Pulmonary Fibrosis Based on a Mitochondrial Viscosity-Activated Red Fluorescent Probe

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and irreversible fatal disease, the prevalence of which has been increasing in recent years. Nonradiographic and noninvasive early diagnosis of pulmonary fibrosis could improve prognosis but is a formidable challenge. As one of the fundamental microenvironmental parameters, viscosity is relevant to various pathological states, such as acute inflammation. Nevertheless, the potential biological roles of viscosity during the IPF process have been relatively underexplored. To address this issue, herein, we developed a new viscosity-responsive probe (JZ-2), which displayed high sensitivity and selectivity for viscosity, as well as excellent characteristics for targeting mitochondria. JZ-2 was successfully applied to map the changes in mitochondrial viscosity in cells caused by various stimuli, such as nystatin and lipopolysaccharide. Besides, JZ-2 was capable of differentiating cancer cells from normal cells and even tissues. More importantly, JZ-2 has been demonstrated to be sufficiently sensitive for tumor detection and early identification of IPF in vivo, revealing a significant increase in the viscosity of lung fibrosis tissues. Thus, JZ-2 is expected to be a swift and reliable diagnostic modality for the prediction of IPF progression in clinical settings.

Minimum clinically important difference in Quantitative Lung Fibrosis score associated with all-cause mortality in idiopathic pulmonary fibrosis: subanalysis from two phase II trials of pamrevlumab

OBJECTIVES

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease. Chest high-resolution CT (HRCT) is instrumental in IPF management, and the Quantitative Lung Fibrosis (QLF) score is a computer-assisted metric for quantifying lung disease using HRCT. This study aimed to assess the change in QLF score associated with a minimum clinically important difference (MCID) of IPF symptoms and physiological lung function, and also determine the MCID of QLF change associated with all-cause mortality to serve as an imaging biomarker to confirm disease progression and response to therapy.

DESIGN AND STUDY SETTING

We conducted post hoc analyses of prospective data from two IPF phase II studies of pamrevlumab, a fully human monoclonal antibody that binds to and inhibits connective tissue growth factor activity.

PARTICIPANTS

Overall, 152 patients with follow-up visits after week 24.

METHODS

We used the anchor-based Jaeschke's method to estimate the MCID of the QLF score that corresponded with the already established MCID of St. George's Respiratory Questionnaire (SGRQ) and percent-predicted forced vital capacity (ppFVC). We also conducted a Cox regression analysis to establish a sensitive and robust MCID of the QLF score in predicting all-cause mortality.

RESULTS

QLF changes of 4.4% and 3.6% corresponded to the established MCID of a 5-point increase in SGRQ and a 3.4% reduction in ppFVC, respectively. QLF changes of 1% (HR=4.98, p=0.05), 2% (HR=4.04, p=0.041), 20 mL (HR=6.37, p=0.024) and 22 mL (HR=6.38, p=0.024) predicted mortality.

CONCLUSION

A conservative metric of 2% can be used as the MCID of QLF for predicting all-cause mortality. This may be considered in IPF trials in which the degree of structural fibrosis assessed via HRCT is an endpoint. The MCID of SGRQ and FVC corresponds with a greater amount of QLF and may reflect that a greater amount of change in fibrosis is required before there is functional change.

TRIAL REGISTRATION NUMBER

NCT01262001, NCT01890265.

Serum inflammatory markers as predictors of therapeutic response in non-idiopathic pulmonary fibrosis fibrotic interstitial lung disease: a retrospective cohort analysis

BACKGROUND

The role of chronic inflammation in non-idiopathic pulmonary fibrosis fibrotic interstitial lung disease (non-IPF f-ILD) remains unclear, with varied responses to anti-inflammatory or immunosuppressive therapy. A reliable predictor for guiding treatment response may enhance clinical decision-making and minimize adverse treatment effects. We hypothesized that elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may be associated with improved treatment response.

METHODS

Our retrospective cohort study compared treatment response to anti-inflammatory therapy in patients with non-IPF f-ILD stratified by baseline CRP and ESR levels. Treatment response was defined as: (1) relative increase in percent predicted forced vital capacity (FVC%) ≥ 5% in 6 months or ≥ 10% in 12 months; or (2) no change or any increase in FVC% if FVC% decline was noted prior to treatment. Logistic regression was used to delineate outcome predictors with FVC% change over time assessed with linear mixed effects models.

RESULTS

Of 832 non-IPF f-ILD patients screened, 167 received anti-inflammatory therapy and baseline inflammatory marker testing stratified into high vs. low-to-normal groups (104 vs. 63, respectively). Median age was 64 years, and 57% were diagnosed with a systemic autoimmune rheumatic disease (SARD). Treatment response was greater in those with elevated inflammatory markers (56% vs. 35%; OR 2.45 [1.243-4.828] P = 0.010) even after adjustment for a priori covariables. SARD diagnosis was associated with treatment response (OR 2.90 [1.45-5.81] P = 0.003), independent of inflammatory marker level. A positive FVC% slope was observed in treated patients with initially elevated inflammatory markers (P = 0.003).

CONCLUSION

Patients with non-IPF f-ILD and elevated inflammatory markers appear to be more responsive to anti-inflammatory therapy with slower FVC decline over time. These findings suggest baseline serum ESR and CRP may be feasible and reliable predictors of treatment response in certain subgroups.

Association Between Health-Related Physical Fitness and Depressive Symptoms in Chinese Adolescents: A Nationwide Cross-Sectional Study Under the Healthy China Initiative

Objective

This study explores the relationship between health-related physical fitness and depressive states in adolescents and examines the influence of gender, age, and parental education.

Methods

A stratified and cluster sampling method selected 689 students (grades 7, 8, 10, and 11) from a Beijing middle school. After screening, 441 adolescents (12-18 years, 55.3% male) were included. Measurements included body composition (BMI), cardiopulmonary fitness (vital capacity), muscular strength/endurance (grip strength, sit-ups, standing long jump), and flexibility (sit-and-reach). Depressive states were assessed using the depression subscale of the Achenbach Youth Self-Report Scale (YSR). Data were analyzed using SPSS 24.0 with descriptive statistics, stratified analysis, and Pearson correlation.

Results

Cardiopulmonary fitness was significantly negatively correlated with depressive states (r = -0.346, p < 0.001), while grip strength showed a weak positive correlation with depression (r = 0.137, p = 0.003). Standing long jump exhibited a slight positive correlation with depression scores (r = 0.114, p < 0.05), but the effect size was negligible. BMI, sit-ups, and sit-and-reach showed no significant correlation with depression scores (p > 0.05). Stratified analysis revealed that females aged 15-18 had significantly higher depression scores than their male counterparts (p < 0.001) and were negatively correlated with cardiopulmonary fitness (r = -0.32, p = 0.002). Grip strength in males significantly increased with age (r = 0.62, p < 0.001), while in females, it stabilized after age 15 and showed no significant correlation with depression (p > 0.05).

Conclusion

Cardiopulmonary fitness is a key factor in adolescent mental health, with a stronger impact than muscular strength. Late-adolescent females are at higher depression risk, likely due to lower cardiopulmonary fitness and increased stress. Findings highlight the need for interventions improving cardiopulmonary fitness to support adolescent mental health.

Oxygen desaturation and lung ultrasonography as markers of diffuse parenchymal lung diseases severity

PURPOSE

we aimed to evaluate lung ultrasound (LUS) and oxygen desaturation as markers for the severity of diffuse parenchymal lung disease (DPLD), specifically the fibrotic subtypes, and correlate the findings with high-resolution computed tomography (HRCT) and other physiologic parameters.

METHODS

A case-control study was conducted recruiting 31 DPLD patients and 20 age-matched healthy controls from our institution. All participants had a spirometry, HRCT, 6-minute walk test (6MWT), echocardiography and full-night cardio-respiratory polygraph. LUS for B-line quantification and pleural examination was performed on 6 zones bilaterally.

RESULTS

Compared to controls, patients had a statistically significant higher total number of B-lines, lower 6MWT nadir O2 and lower nadir nocturnal oxygen saturation (SpO2). Among patients; fibrotic DPLD (58.1%) had more B-lines, pleural irregularities with or without fragmentation, higher Warrick scores and lower 6MWT nadir SpO2 (p = 0.01, 0.008, < 0.005, 0.03 respectively). There was a statistically significant positive correlation between LUS findings and Warrick score that inversely correlated with the forced vital capacity (FVC)% predicted (p < 0.001). A score of LUS findings, 6MWT nadir SpO2 and time spent with SpO2 < 90% (T90) ≥2 points had a sensitivity of 91.7% and specificity of 66.7% in predicting severe fibrotic DPLD (area under curve (AUC)= 0.832, CI95% = 0.723-0.941, p = 0.001).

CONCLUSIONS

The number of B-lines and pleural irregularities in LUS, nocturnal desaturation and exercise desaturation can play a role as markers of DPLD severity.

nnU-Net-based high-resolution CT features quantification for interstitial lung diseases

OBJECTIVES

To develop a new high-resolution (HR)CT abnormalities quantification tool (CVILDES) for interstitial lung diseases (ILDs) based on the nnU-Net network structure and to determine whether the quantitative parameters derived from this new software could offer a reliable and precise assessment in a clinical setting that is in line with expert visual evaluation.

METHODS

HRCT scans from 83 cases of ILDs and 20 cases of other diffuse lung diseases were labeled section by section by multiple radiologists and were used as training data for developing a deep learning model based on nnU-Net, employing a supervised learning approach. For clinical validation, a cohort including 51 cases of interstitial pneumonia with autoimmune features (IPAF) and 14 cases of idiopathic pulmonary fibrosis (IPF) had CT parenchymal patterns evaluated quantitatively with CVILDES and by visual evaluation. Subsequently, we assessed the correlation of the two methodologies for ILD features quantification. Furthermore, the correlation between the quantitative results derived from the two methods and pulmonary function parameters (DLCO%, FVC%, and FEV%) was compared.

RESULTS

All CT data were successfully quantified using CVILDES. CVILDES-quantified results (total ILD extent, ground-glass opacity, consolidation, reticular pattern and honeycombing) showed a strong correlation with visual evaluation and were numerically close to the visual evaluation results (r = 0.64-0.89, p < 0.0001), particularly for the extent of fibrosis (r = 0.82, p < 0.0001). As judged by correlation with pulmonary function parameters, CVILDES quantification was comparable or even superior to visual evaluation.

CONCLUSION

nnU-Net-based CVILDES was comparable to visual evaluation for ILD abnormalities quantification.

KEY POINTS

Question Visual assessment of ILD on HRCT is time-consuming and exhibits poor inter-observer agreement, making it challenging to accurately evaluate the therapeutic efficacy. Findings nnU-Net-based Computer vision-based ILD evaluation system (CVILDES) accurately segmented and quantified the HRCT features of ILD, and results were comparable to visual evaluation. Clinical relevance This study developed a new tool that has the potential to be applied in the quantitative assessment of ILD.

The Role of Bronchoscopy in the Diagnosis of Interstitial Lung Disease: A State-of-the-Art Review

The diagnostic evaluation of interstitial lung diseases (ILDs) remains challenging due to their heterogeneous etiologies and overlapping clinical and radiographic patterns. A confident diagnosis often necessitates histopathological sampling, particularly when high-resolution computed tomography and serologic assessments are inconclusive. While surgical lung biopsy (SLB) has long been considered the diagnostic gold standard, its invasiveness, associated morbidity, and limited feasibility in high-risk patients have driven the pursuit of less invasive alternatives. Here, we review the current applications, diagnostic yield, procedural techniques, and complications of several bronchoscopic modalities. Bronchoalveolar lavage (BAL) aids in characterizing inflammatory profiles and differentiating among conditions such as hypersensitivity pneumonitis, sarcoidosis, and eosinophilic pneumonia. Endobronchial biopsies (EBBs) and endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) are valuable in diagnosing granulomatous diseases with lymphadenopathy. Transbronchial lung biopsy (TBLB) is effective for peribronchial and centrilobular diseases but is limited by small sample size and tissue distortion. Transbronchial lung cryobiopsy (TBC) enables acquisition of larger, well-preserved parenchymal tissue samples from the peripheral lung. Over recent years, studies have demonstrated that TBC, when interpreted within a multidisciplinary discussion (MDD), achieves diagnostic concordance rates with SLB exceeding 75%, and up to 95% in cases where high diagnostic confidence is reached. When performed in experienced centers using standardized protocols, TBC is considered a viable first-line histopathologic tool in the diagnostic evaluation of ILD. Adequate training and standardization of the TBC procedure are needed to ensure low complication rates and a high yield.