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Amati F, Spagnolo P, Ryerson CJ, Oldham JM, Gramegna A, Stainer A, Mantero M, Sverzellati N, Lacedonia D, Richeldi L, Blasi F, Aliberti S. Walking the path of treatable traits in interstitial lung diseases. Respir Res 2023; 24:251. [PMID: 37872563 PMCID: PMC10594881 DOI: 10.1186/s12931-023-02554-8] [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: 08/25/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023] Open
Abstract
Interstitial lung diseases (ILDs) are complex and heterogeneous diseases. The use of traditional diagnostic classification in ILD can lead to suboptimal management, which is worsened by not considering the molecular pathways, biological complexity, and disease phenotypes. The identification of specific "treatable traits" in ILDs, which are clinically relevant and modifiable disease characteristics, may improve patient's outcomes. Treatable traits in ILDs may be classified into four different domains (pulmonary, aetiological, comorbidities, and lifestyle), which will facilitate identification of related assessment tools, treatment options, and expected benefits. A multidisciplinary care team model is a potential way to implement a "treatable traits" strategy into clinical practice with the aim of improving patients' outcomes. Multidisciplinary models of care, international registries, and the use of artificial intelligence may facilitate the implementation of the "treatable traits" approach into clinical practice. Prospective studies are needed to test potential therapies for a variety of treatable traits to further advance care of patients with ILD.
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Affiliation(s)
- Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia and Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, Canada
| | - Justin M Oldham
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrea Gramegna
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Marco Mantero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Nicola Sverzellati
- Unit of Scienze Radiologiche, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Donato Lacedonia
- Department of Medical and Occupational Sciences, Institute of Respiratory Disease, Università degli Studi di Foggia, Foggia, Italy
| | - Luca Richeldi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
- IRCCS Humanitas Research Hospital, Respiratory Unit, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
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Li T, Chen Y, Li Y, Chen G, Zhao Y, Su G. Antifibrotic effect of AD-1 on lipopolysaccharide-mediated fibroblast injury in L929 cells and bleomycin-induced pulmonary fibrosis in mice. Food Funct 2022; 13:7650-7665. [PMID: 35735105 DOI: 10.1039/d1fo04212b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
20(R)-25-methoxyl-dammarane-3β,12β,20-triol (25-OCH3-PPD, AD-1) is a dammarane ginsenoside that is isolated from Panax notoginseng. The present study aimed to explore its anti-pulmonary fibrosis (PF) effect in vitro and in vivo. L929 cells were treated with 10 μg mL-1 lipopolysaccharide (LPS) to establish a PF model in vitro and mice were administered with 3.5 mg kg-1 bleomycin (BLM) by endotracheal intubation to establish a PF model in vivo for investigating the anti-PF effect and its potential mechanism. The results demonstrated that AD-1 reduced the injury, extracellular matrix (ECM) buildup and α-smooth muscle actin (α-SMA) protein expression levels of L929 induced by LPS. Oral administration of AD-1 downregulated the expression of interleukins (such as IL-1β, IL-6 and IL-18), increased the expression of superoxide dismutase (SOD) and glutathione (GSH), reduced the lung coefficient and the content of hydroxyproline (HYP), and mediated the Bax/Bcl-2 protein ratio and P-p53, β-catenin and SIRT3 expression in the lung tissue of mice. Furthermore, AD-1 inhibited the expression levels of TGF-β1, TIMP-1 and α-SMA and reduced inflammatory cell infiltration and collagen deposition in the lung tissue of PF mice. These results indicated that AD-1 could alleviate PF both in vitro and in vivo, and the underlying mechanism may be related to the decrease in ECM deposition and inflammation, the enhancement of antioxidant capacity, and the mediation of lung cell apoptosis and the TGF-β1/TIMP-1/α-SMA signaling pathway, which provide a theoretical basis for the rehabilitation treatment of PF.
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Affiliation(s)
- Tao Li
- Shenyang Pharmaceutical University, Shenyang 110016, China. .,Key Laboratory of Nature Medicines of the Changbai Mountain, Ministry of Education, Yanbian University, Yanji 133002, P.R. China.
| | - Yu Chen
- Shenyang Pharmaceutical University, Shenyang 110016, China.
| | - Yuan Li
- Shenyang Pharmaceutical University, Shenyang 110016, China. .,Basic medical teaching and Research Department, Liaoning Vocational College of Medicine, Shenyang 110101, China
| | - Gang Chen
- Shenyang Pharmaceutical University, Shenyang 110016, China.
| | - Yuqing Zhao
- Key Laboratory of Nature Medicines of the Changbai Mountain, Ministry of Education, Yanbian University, Yanji 133002, P.R. China.
| | - Guangyue Su
- Shenyang Pharmaceutical University, Shenyang 110016, China.
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Kolonics-Farkas AM, Šterclová M, Mogulkoc N, Lewandowska K, Müller V, Hájková M, Kramer M, Jovanovic D, Tekavec-Trkanjec J, Studnicka M, Stoeva N, Littnerová S, Vašáková M. Differences in Baseline Characteristics and Access to Treatment of Newly Diagnosed Patients With IPF in the EMPIRE Countries. Front Med (Lausanne) 2022; 8:729203. [PMID: 35004713 PMCID: PMC8733326 DOI: 10.3389/fmed.2021.729203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/22/2021] [Indexed: 12/12/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a rare lung disease with poor prognosis. The diagnosis and treatment possibilities are dependent on the health systems of countries. Hence, comparison among countries is difficult due to data heterogeneity. Our aim was to analyse patients with IPF in Central and Eastern Europe using the uniform data from the European Multipartner IPF registry (EMPIRE), which at the time of analysis involved 10 countries. Newly diagnosed IPF patients (N = 2,492, between March 6, 2012 and May 12, 2020) from Czech Republic (N = 971, 39.0%), Turkey (N = 505, 20.3%), Poland (N = 285, 11.4%), Hungary (N = 216, 8.7%), Slovakia (N = 149, 6.0%), Israel (N = 120, 4.8%), Serbia (N = 95, 3.8%), Croatia (N = 87, 3.5%), Austria (N = 55, 2.2%), and Bulgaria (N = 9, 0.4%) were included, and Macedonia, while a member of the registry, was excluded from this analysis due to low number of cases (N = 5) at this timepoint. Baseline characteristics, smoking habit, comorbidities, lung function values, CO diffusion capacity, high-resolution CT (HRCT) pattern, and treatment data were analysed. Patients were significantly older in Austria than in the Czech Republic, Turkey, Hungary, Slovakia, Israel, and Serbia. Ever smokers were most common in Croatia (84.1%) and least frequent in Serbia (39.2%) and Slovakia (42.6%). The baseline forced vital capacity (FVC) was >80% in 44.6% of the patients, between 50 and 80% in 49.3%, and <50% in 6.1%. Most IPF patients with FVC >80% were registered in Poland (63%), while the least in Israel (25%). A typical usual interstitial pneumonia (UIP) pattern was present in 67.6% of all patients, ranging from 43.5% (Austria) to 77.2% (Poland). The majority of patients received antifibrotic therapy (64.5%); 37.4% used pirfenidone (range 7.4–39.8% between countries); and 34.9% nintedanib (range 12.6–56.0% between countries) treatment. In 6.8% of the cases, a therapy switch was initiated between the 2 antifibrotic agents. Significant differences in IPF patient characteristics and access to antifibrotic therapies exist in EMPIRE countries, which needs further investigation and strategies to improve and harmonize patient care and therapy availability in this region.
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Affiliation(s)
| | - Martina Šterclová
- Department of Respiratory Diseases of the First Faculty of Medicine Charles University, University Thomayer Hospital, Prague, Czechia
| | - Nesrin Mogulkoc
- Department of Pulmonary Medicine, Ege University Medical School, Izmir, Turkey
| | - Katarzyna Lewandowska
- First Department of Pulmonary Diseases, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Marta Hájková
- Clinic of Pneumology and Phthisiology, University Hospital Bratislava, Bratislava, Slovakia
| | - Mordechai Kramer
- Rabin Medical Center, Institute of Pulmonary Medicine, Petah Tikva, Israel
| | | | | | | | | | - Simona Littnerová
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czechia
| | - Martina Vašáková
- Department of Respiratory Diseases of the First Faculty of Medicine Charles University, University Thomayer Hospital, Prague, Czechia
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Hilberg O, Hoffmann-Vold AM, Smith V, Bouros D, Kilpeläinen M, Guiot J, Morais A, Clemente S, Daniil Z, Papakosta D, Fretheim H, Neves S, Alfaro TM, Antoniou KM, Valveny N, Asijee G, Soulard S, Wuyts W. Epidemiology of interstitial lung diseases and their progressive-fibrosing behaviour in six European countries. ERJ Open Res 2021; 8:00597-2021. [PMID: 35083316 PMCID: PMC8784757 DOI: 10.1183/23120541.00597-2021] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/08/2021] [Indexed: 12/23/2022] Open
Abstract
The PERSEIDS study aimed to estimate incidence/prevalence of interstitial lung diseases (ILDs), fibrosing interstitial lung diseases (F-ILDs), idiopathic pulmonary fibrosis (IPF), systemic sclerosis-associated ILD (SSc-ILD), other non-IPF F-ILDs and their progressive-fibrosing (PF) forms in six European countries, as current data are scarce. This retrospective, two-phase study used aggregate data (2014–2018). In Phase 1, incident/prevalent cases of ILDs above were identified from clinical databases through an algorithm based on codes/keywords, and incidence/prevalence was estimated. For non-IPF F-ILDs, the relative percentage of subtypes was also determined. In Phase 2, a subset of non-IPF F-ILD cases was manually reviewed to determine the percentage of PF behaviour and usual interstitial pneumonia-like (UIP-like) pattern. A weighted mean percentage of progression was calculated for each country and used to extrapolate incidence/prevalence of progressive-fibrosing ILDs (PF-ILDs). In 2018, incidence/105 person-years ranged between 9.4 and 83.6 (ILDs), 7.7 and 76.2 (F-ILDs), 0.4 and 10.3 (IPF), 6.6 and 71.7 (non-IPF F-ILDs), and 0.3 and 1.5 (SSc-ILD); and prevalence/105 persons ranged between 33.6 and 247.4 (ILDs), 26.7 and 236.8 (F-ILDs), 2.8 and 31.0 (IPF), 22.3 and 205.8 (non-IPF F-ILDs), and 1.4 and 10.1 (SSc-ILD). Among non-IPF F-ILDs, sarcoidosis was the most frequent subtype. PF behaviour and UIP-like pattern were present in a third of non-IPF F-ILD cases each and hypersensitivity pneumonitis showed the highest percentage of progressive behaviour. Incidence of PF-ILDs ranged between 2.1 and 14.5/105 person-years, and prevalence between 6.9 and 78.0/105 persons. To our knowledge, PERSEIDS is the first study assessing incidence, prevalence and rate of progression of ILDs across several European countries. Still below the threshold for orphan diseases, the estimates obtained were higher and more variable than reported in previous studies, but differences in study design/population must be considered. The PERSEIDS study provides updated and detailed epidemiological data for ILDs across six European countries. Prevalences ranged between 26.7–236.8 (F-ILDs), 2.8–31.0 (IPF), 22.3–205.8 (non-IPF F-ILDs). A third of non-IPF F-ILD cases showed PF behaviour.https://bit.ly/3wLH7pF
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Pesonen I, Carlson L, Murgia N, Kaarteenaho R, Sköld CM, Myllärniemi M, Ferrara G. Delay and inequalities in the treatment of idiopathic pulmonary fibrosis: the case of two Nordic countries. Multidiscip Respir Med 2018; 13:14. [PMID: 29785264 PMCID: PMC5950183 DOI: 10.1186/s40248-018-0126-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Idiopathic pulmonary fibrosis (IPF) is characterized by progressive loss of lung function with high mortality within the first 5 years from diagnosis. In 2011-2014, two drugs, pirfenidone and nintedanib, have been approved worldwide for prevention of IPF progression. National IPF-registries have been established in both Finland and Sweden. Our study explored potential differences in the care of IPF in these two countries. Methods Patients included consecutively in the Finnish and Swedish IPF-registries from January 1, 2014 through December 31, 2016 were included in the study. Data on demographics and lung function at the time of inclusion were collected. Access to antifibrotic drugs and data on disease outcomes, mortality and the proportion of patients who underwent lung transplantation, was collected during a 3-year follow up. Results One-hundred and fifty-two patients from the Finnish and 160 patients from the Swedish IPF-cohorts were included in the study. At inclusion, Finnish patients were significantly older than the Swedish patients (74.6 years vs 72.5 years, p = 0.017). The proportion of non-smokers was significantly higher in the Finnish cohort (41.7% vs 26.9%, p = 0.007). Forced vital capacity (FVC), % of predicted (78.2 vs 71.7 for Finnish and Swedish patients, respectively, p = 0.01) and diffusion capacity for carbon monoxide (DLCO), % of predicted (53.3 vs 48.2 for Finnish and Swedish patients, respectively, p = 0.002) were significantly higher in the Finnish cohort compared to the Swedish cohort at the time of inclusion. During the 3-year follow up period, 45 (29.6%) Finnish and 111 (69.4%) Swedish patients, respectively, were initiated on treatment with an antifibrotic drug (pirfenidone or nintedanib) (p < 0.001). When comparing possible determinants of treatment, patients with higher FVC % were less likely to start antifibrotic drugs (OR 0.96, 95%CI 0.93-1.00, p < 0.024). To be resident in Sweden was the main determinant for receiving antifibrotic drugs (OR 5.48, 95%CI 2.65-11.33, p < 0.0001). No significant difference in number of deaths and lung transplantation during the follow up period was found. Conclusions This study highlights differences concerning how IPF patients are treated in Finland and Sweden. How these differences will influence the long-term outcome of these patients is unknown.
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Affiliation(s)
- Ida Pesonen
- 1Department of Respiratory Medicine and Allergy, Karolinska University Hospital, SE-17176 Stockholm, Sweden.,2Respiratory Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lisa Carlson
- 1Department of Respiratory Medicine and Allergy, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Nicola Murgia
- 3Section of Occupational Medicine, Respiratory Diseases and Toxicology, University of Perugia, Perugia, Italy.,4Department of Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Riitta Kaarteenaho
- 5Research Unit of Internal Medicine, University of Oulu and Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Carl Magnus Sköld
- 1Department of Respiratory Medicine and Allergy, Karolinska University Hospital, SE-17176 Stockholm, Sweden.,2Respiratory Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marjukka Myllärniemi
- 6University of Helsinki and Helsinki University Hospital, Heart and Lung Center, Helsinki, Finland
| | - Giovanni Ferrara
- 1Department of Respiratory Medicine and Allergy, Karolinska University Hospital, SE-17176 Stockholm, Sweden.,2Respiratory Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Ferrara G, Luppi F, Birring SS, Cerri S, Caminati A, Sköld M, Kreuter M. Best supportive care for idiopathic pulmonary fibrosis: current gaps and future directions. Eur Respir Rev 2018; 27:27/147/170076. [PMID: 29436402 DOI: 10.1183/16000617.0076-2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/25/2017] [Indexed: 11/05/2022] Open
Abstract
Best supportive care (BSC) is generally defined as all the interventions and the multiprofessional approach aimed to improve and optimise quality of life (QoL) in patients affected by progressive diseases. In this sense, it excludes and might be complementary to other interventions directly targeting the disease. BSC improves survival in patients with different types of cancer. Patients with idiopathic pulmonary fibrosis (IPF) experience a vast range of symptoms during the natural history of the disease and might have a beneficial effect of BSC interventions. This review highlights the current evidence on interventions targeting QoL and gaps for the clinical assessment of BSC in the treatment of IPF patients. Very few interventions to improve QoL or improve symptom control are currently supported by well-designed studies. Sound methodology is paramount in evaluating BSC in IPF, as well as the use of validated tools to measure QoL and symptom control in this specific group of patients.
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Affiliation(s)
- Giovanni Ferrara
- Section of Respiratory Medicine, Dept of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden .,Division of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Fabrizio Luppi
- Center for Rare Lung Diseases, University Hospital of Modena, Modena, Italy
| | - Surinder S Birring
- Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Stefania Cerri
- Center for Rare Lung Diseases, University Hospital of Modena, Modena, Italy
| | - Antonella Caminati
- Section of Respiratory Medicine, San Giuseppe Hospital Multimedica, Milan, Italy
| | - Magnus Sköld
- Section of Respiratory Medicine, Dept of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Michael Kreuter
- University of Heidelberg and Center for Interstitial and Rare Lung Disease, Division of Respiratory Medicine, University of Heidelberg, Heidelberg, Germany
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Sköld CM, Bendstrup E, Myllärniemi M, Gudmundsson G, Sjåheim T, Hilberg O, Altraja A, Kaarteenaho R, Ferrara G. Treatment of idiopathic pulmonary fibrosis: a position paper from a Nordic expert group. J Intern Med 2017; 281:149-166. [PMID: 27862475 DOI: 10.1111/joim.12571] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a fatal progressive lung disease occurring in adults. In the last decade, the results of a number of clinical trials based on the updated disease classification have been published. The registration of pirfenidone and nintedanib, the first two pharmacological treatment options approved for IPF, marks a new chapter in the management of patients with this disease. Other nonpharmacological treatments such as lung transplantation, rehabilitation and palliation have also been shown to be beneficial for these patients. In this review, past and present management is discussed based on a comprehensive literature search. A treatment algorithm is presented based on available evidence and our overall clinical experience. In addition, unmet needs with regard to treatment are highlighted and discussed. We describe the development of various treatment options for IPF from the first consensus to recent guidelines based on evidence from large-scale, multinational, randomized clinical trials, which have led to registration of the first drugs for IPF.
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Affiliation(s)
- C M Sköld
- Respiratory Medicine Unit, Center for Molecular Medicine, Department of Medicine, Solna Karolinska Institutet, Stockholm, Sweden.,Lung-Allergy Clinic Karolinska University Hospital Solna, Stockholm, Sweden
| | - E Bendstrup
- Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - M Myllärniemi
- Transplantation laboratory and Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - G Gudmundsson
- Department of Respiratory Medicine and Sleep, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - T Sjåheim
- Department of Respiratory Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - O Hilberg
- Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - A Altraja
- Department of Pulmonary Medicine, University of Tartu, Tartu, Estonia.,Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - R Kaarteenaho
- Unit of Medicine and Clinical Research, Pulmonary Division, Division of Respiratory Medicine, University of Eastern Finland and Center of Medicine and Clinical Research, Kuopio, Finland.,Respiratory research, Research Unit of Internal Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland.,Kuopio University Hospital, Kuopio, Finland
| | - G Ferrara
- Respiratory Medicine Unit, Center for Molecular Medicine, Department of Medicine, Solna Karolinska Institutet, Stockholm, Sweden.,Lung-Allergy Clinic Karolinska University Hospital Solna, Stockholm, Sweden
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