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McDonald VM, Gibson PG. Treatable traits-Where we are, where we are headed. Respirology 2024. [PMID: 38804093 DOI: 10.1111/resp.14758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Vanessa Marie McDonald
- Centre of Excellence in Treatable Traits, College of Health Medical and Wellbeing, New Lambton, New South Wales, Australia
- Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Peter Gerard Gibson
- Centre of Excellence in Treatable Traits, College of Health Medical and Wellbeing, New Lambton, New South Wales, Australia
- Asthma and Breathing Research Program, Hunter Medical Research Institute, New Lambton, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, New South Wales, Australia
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Amati F, Stainer A, Maruca G, De Santis M, Mangiameli G, Torrisi C, Bossi P, Polelli V, Blasi F, Selmi C, Marulli G, Balzarini L, Terracciano LM, Gatti R, Aliberti S. First Report of the Prevalence at Baseline and after 1-Year Follow-Up of Treatable Traits in Interstitial Lung Diseases. Biomedicines 2024; 12:1047. [PMID: 38791009 PMCID: PMC11117749 DOI: 10.3390/biomedicines12051047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Different factors, not limited to the lung, influence the progression of ILDs. A "treatable trait" strategy was recently proposed for ILD patients as a precision model of care to improve outcomes. However, no data have been published so far on the prevalence of TTs in ILD. A prospective, observational, cohort study was conducted within the ILD Program at the IRCCS Humanitas Research Hospital (Milan, Italy) between November 2021 and November 2023. TTs were selected according to recent literature and assigned during multidisciplinary discussion (MDD) to one of the following categories: pulmonary, etiological, comorbidities, and lifestyle. Patients were further divided into four groups according to their post-MDD diagnosis: idiopathic ILD, sarcoidosis, connective tissue disease-ILD, and other ILD. The primary study outcome was the prevalence of each TT in the study population. A total of 116 patients with ILD [63.9% male; median (IQR) age: 69 (54-78) years] were included in the study. All the TTs identified in the literature were found in our cohort, except for intractable chronic cough. We also recognized differences in TTs across the ILD groups, with less TTs in patients with sarcoidosis. This analysis provides the first ancillary characterization of TTs in ILD patients in a real setting to date.
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Affiliation(s)
- Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Giacomo Maruca
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (G.M.); (F.B.)
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, 20122 Milan, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Giuseppe Mangiameli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Chiara Torrisi
- Department of Diagnostic and Interventional Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Paola Bossi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Pathology Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Veronica Polelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Physiotherapy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (G.M.); (F.B.)
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, 20122 Milan, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Giuseppe Marulli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Luca Balzarini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Department of Diagnostic and Interventional Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Luigi Maria Terracciano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Pathology Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Roberto Gatti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- Physiotherapy Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy; (A.S.); (M.D.S.); (G.M.); (P.B.); (V.P.); (C.S.); (G.M.); (L.B.); (L.M.T.); (R.G.); (S.A.)
- IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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Selman M, Pardo A. Idiopathic Pulmonary Fibrosis: From Common Microscopy to Single-Cell Biology and Precision Medicine. Am J Respir Crit Care Med 2024; 209:1074-1081. [PMID: 38289233 DOI: 10.1164/rccm.202309-1573pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico; and
| | - Annie Pardo
- Facultad de Ciencias, Universidad Nacional Autónoma de México, Mexico City, Mexico
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Lee CT, Selvan K, Adegunsoye A, Strykowski RK, Parker WF, Dignam JJ, Lauderdale DS, Strek ME, Press VG. Risk Factors for Hospital Readmission in Patients With Interstitial Lung Disease. Respir Care 2024; 69:586-594. [PMID: 38199762 PMCID: PMC11147622 DOI: 10.4187/respcare.11459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/07/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND Little is known about the rates, causes, or risk factors for hospital readmission among patients with interstitial lung disease (ILD). We investigated the prevalence, features, and comorbidities of subjects hospitalized with ILD and their subsequent re-hospitalizations in this retrospective study. METHODS A retrospective analysis of subjects enrolled in the University of Chicago ILD Natural History registry was conducted. Demographic data, comorbidities, and timing and cause of subsequent hospitalizations were collected from the medical record. The primary outcome was time to first readmission via a cause-specific Cox hazards model with a sensitivity analysis with the Fine-Gray cumulative hazard model; the secondary outcome was the number of hospitalizations per subject via a Poisson multivariable model. RESULTS Among 1,796 patients with ILD, 443 subjects were hospitalized, with 978 total hospitalizations; 535 readmissions were studied, 282 (53%) for a respiratory indication. For the outcome of time to readmission, Black race was the only subject characteristic associated with an increased hazard of readmission in the Cox model (hazard ratio 1.50, P = .03) while Black race, hypersensitivity pneumonitis, and sarcoidosis were associated with increased hazard of readmission in the Fine-Gray model. Black race, female sex, atrial fibrillation, obstructive lung disease, and pulmonary hypertension were associated with an increased number of hospitalizations in the Poisson model. CONCLUSIONS We demonstrated that hospital readmission from any cause was a common occurrence in subjects with ILD. Further efforts to improve quality of life among these subjects could focus on risk scores for readmission, mitigating racial health disparities, and treatment of comorbidities.
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Affiliation(s)
- Cathryn T Lee
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois.
| | - Kavitha Selvan
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Ayodeji Adegunsoye
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Rachel K Strykowski
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - William F Parker
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; and Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Diane S Lauderdale
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Mary E Strek
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Valerie G Press
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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Donaldson MA, Donohoe K, Assayag D, Durand C, Fisher JH, Johannson K, Kolb M, Lok SD, Manganas H, Marcoux V, Min B, Morisset J, Marinescu DC, Ryerson CJ. Characteristics of pulse oximetry and arterial blood gas in patients with fibrotic interstitial lung disease. BMJ Open Respir Res 2024; 11:e002250. [PMID: 38479819 PMCID: PMC10941153 DOI: 10.1136/bmjresp-2023-002250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Fibrotic interstitial lung disease (ILD) is frequently associated with abnormal oxygenation; however, little is known about the accuracy of oxygen saturation by pulse oximetry (SpO2) compared with arterial blood gas (ABG) saturation (SaO2), the factors that influence the partial pressure of carbon dioxide (PaCO2) and the impact of PaCO2 on outcomes in patients with fibrotic ILD. STUDY DESIGN AND METHODS Patients with fibrotic ILD enrolled in a large prospective registry with a room air ABG were included. Prespecified analyses included testing the correlation between SaO2 and SpO2, the difference between SaO2 and SpO2, the association of baseline characteristics with both the difference between SaO2 and SpO2 and the PaCO2, the association of baseline characteristics with acid-base category, and the association of PaCO2 and acid-base category with time to death or transplant. RESULTS A total of 532 patients with fibrotic ILD were included. Mean resting SaO2 was 92±4% and SpO2 was 95±3%. Mean PaCO2 was 38±6 mmHg, with 135 patients having PaCO2 <35 mmHg and 62 having PaCO2 >45 mmHg. Correlation between SaO2 and SpO2 was mild to moderate (r=0.39), with SpO2 on average 3.0% higher than SaO2. No baseline characteristics were associated with the difference in SaO2 and SpO2. Variables associated with either elevated or abnormal (elevated or low) PaCO2 included higher smoking pack-years and lower baseline forced vital capacity (FVC). Lower baseline lung function was associated with an increased risk of chronic respiratory acidosis. PaCO2 and acid-base status were not associated with time to death or transplant. INTERPRETATION SaO2 and SpO2 are weakly-to-moderately correlated in fibrotic ILD, with limited ability to accurately predict this difference. Abnormal PaCO2 was associated with baseline FVC but was not associated with outcomes.
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Affiliation(s)
- Mira A Donaldson
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathryn Donohoe
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Deborah Assayag
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Celine Durand
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Jolene H Fisher
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kerri Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martin Kolb
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey D Lok
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Hélène Manganas
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Veronica Marcoux
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Bohyung Min
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie Morisset
- Département de Médecine, Centre de Recherche du Centre Hospitalier de l'Universite de Montreal, Montreal, Québec, Canada
| | - Daniel-Costin Marinescu
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher J Ryerson
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Cottin V, Valenzuela C. C-reactive protein as a candidate biomarker in fibrotic interstitial lung disease. Respirology 2024; 29:195-198. [PMID: 38296837 DOI: 10.1111/resp.14666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
See related article
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Affiliation(s)
- Vincent Cottin
- Department of Respiratory Medicine, National Reference Centre for Rare Pulmonary Diseases, member of ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon 1, Lyon, France
| | - Claudia Valenzuela
- Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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McDonald VM, Holland AE. Treatable traits models of care. Respirology 2024; 29:24-35. [PMID: 38087840 DOI: 10.1111/resp.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/22/2023] [Indexed: 12/22/2023]
Abstract
Treatable traits is a personalized approach to the management of respiratory disease. The approach involves a multidimensional assessment to understand the traits present in individual patients. Traits are phenotypic and endotypic characteristics that can be identified, are clinically relevant and can be successfully treated by therapy to improve clinical outcomes. Identification of traits is followed by individualized and targeted treatment to those traits. First proposed for the management of asthma and chronic obstructive pulmonary disease (COPD) the approach is recommended in many other areas of respiratory and now immunology medicine. Models of care for treatable traits have been proposed in different diseases and health care setting. In asthma and COPD traits are identified in three domains including pulmonary, extrapulmonary and behavioural/lifestyle/risk-factors. In bronchiectasis and interstitial lung disease, a fourth domain of aetiological traits has been proposed. As the core of treatable traits is personalized and individualized medicine; there are several key aspects to treatable traits models of care that should be considered in the delivery of care. These include person centredness, consideration of patients' values, needs and preferences, health literacy and engagement. We review the models of care that have been proposed and provide guidance on the engagement of patients in this approach to care.
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Affiliation(s)
- Vanessa M McDonald
- Centre of Excellence in Treatable Traits, National Health and Medical Research Council, Newcastle, New South Wales, Australia
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Anne E Holland
- Centre of Excellence in Treatable Traits, National Health and Medical Research Council, Newcastle, New South Wales, Australia
- Department of Immunology, Respiratory Research@Alfred, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
- Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
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Scarlata S, Finamore P, Antonelli Incalzi R. Treatable traits: the added value of comprehensive geriatric assessment. Eur Respir J 2023; 62:2301366. [PMID: 37945045 DOI: 10.1183/13993003.01366-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Simone Scarlata
- Internal Medicine Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Panaiotis Finamore
- Internal Medicine Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Khor YH, Ryerson CJ. Reply: The concept and application of the treatable traits approach in interstitial lung disease and other chronic respiratory diseases. Eur Respir J 2023; 62:2301744. [PMID: 37945043 DOI: 10.1183/13993003.01744-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/14/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Yet H Khor
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
- Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
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Moran-Mendoza O, Coppola-Lamas MA, Alrubai E, Paredes C. Treatable traits: a comprehensive precision medicine approach in interstitial lung disease, but why were acute exacerbations not considered? Eur Respir J 2023; 62:2301449. [PMID: 37734844 DOI: 10.1183/13993003.01449-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Onofre Moran-Mendoza
- Division of Respirology and Sleep Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Center, Kingston, ON, Canada
| | - Maria A Coppola-Lamas
- Division of Respirology and Sleep Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Center, Kingston, ON, Canada
| | - Elham Alrubai
- Division of Respirology and Sleep Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Center, Kingston, ON, Canada
| | - Carla Paredes
- Kingston Health Sciences Center, Kingston, ON, Canada
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