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Pellicano C, Vantaggio L, Colalillo A, Pocino K, Basile V, Marino M, Basile U, Rosato E. Type 2 cytokines and scleroderma interstitial lung disease. Clin Exp Med 2023; 23:3517-3525. [PMID: 37392249 PMCID: PMC10618297 DOI: 10.1007/s10238-023-01125-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
Interstitial lung disease (ILD) is a life-threatening complication of systemic sclerosis (SSc). Type 2 (Th2) cytokines play a pivotal role in airway disease. Study aim was to evaluate serum level of Th2 interleukin (IL) and chemokine in SSc-ILD. Serum levels of IL-4, IL-5, IL-11, IL-13, IL-21, IL-31 and CXCL-13 were measured by Bio-Plex Multiplex Immunoassays in 60 SSc patients and 20 healthy controls (HC). Pulmonary function tests with diffusion lung capacity for carbon monoxide (DLco) and high resolution computed tomography (HRCT) were performed in SSc patients. ILD is defined as fibrotic changes (ground glass, reticular and honeycombing), assessed by Computer-Aided Lung Informatics for Pathology Evaluation and Ratings (CALIPER) software, affecting at least 10% of the lungs. Serum levels of Th2 cytokines were higher in SSc patients than HC. A linear correlation was observed between ground glass and IL-13 (r = 0.342, p < 0.01), IL-21 (r = 0.345, p < 0.01), IL-31 (r = 0.473, p < 0.001), IL-4 (r = 0.863, p < 0.001), IL-5 (r = 0.249, p < 0.05) and peripheral blood eosinophils (r = 0.463, p < 0.001). We found a negative correlation between DLco and IL-4 (r = - 0.511, p < 0.001) and peripheral blood eosinophils (r = - 0.446, p < 0.001). In the logistic regression analysis, IL-4 is associated with DLco ≤ 60% of the predicted [OR 1.039 (CI 95%: 1.015-1.064), p < 0.001], whilst mRSS [OR 1.138 (CI 95%: 1.023-1.266), p < 0.05] and IL-4 [OR 1.017 (CI 95%: 1-1.034), p < 0.05] were associated with ILD. Th2 inflammation could play a key role in early phase of SSc-ILD.
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Affiliation(s)
- Chiara Pellicano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale Dell'Università 37, 00185, Rome, Italy
| | - Lorenzo Vantaggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale Dell'Università 37, 00185, Rome, Italy
| | - Amalia Colalillo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale Dell'Università 37, 00185, Rome, Italy
| | - Krizia Pocino
- UOC of Clinical Pathology, General Hospital San Pietro Fatebenefratelli, 00189, Rome, Italy
| | - Valerio Basile
- Clinical Pathology Unit and Cancer Biobank, Department of Research and Advanced Technologies, IRCCS Regina Elena National Cancer Institute, 00144, Rome, Italy
| | - Mariapaola Marino
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli IRCCS, 00168, Rome, Italy
| | - Umberto Basile
- UOC Clinical Pathology DEA II Level, Hospital Santa Maria Goretti-ASL Latina, 04100, Latina, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale Dell'Università 37, 00185, Rome, Italy.
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Orlandi M, Meliante LA, Damiani A, Tofani L, Bruni C, Guiducci S, Matucci-Cerinic M, Bellando-Randone S, Tomassetti S. The Role of Bronchoalveolar Lavage in Systemic Sclerosis Interstitial Lung Disease: A Systematic Literature Review. Pharmaceuticals (Basel) 2022; 15:ph15121584. [PMID: 36559035 PMCID: PMC9781787 DOI: 10.3390/ph15121584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
The role of Bronchoalveolar Lavage (BAL) in the evaluation of systemic sclerosis (SSc) interstitial lung disease (ILD) is still controversial. The aim of this systematic literature review was to investigate the use of BAL in SSc-ILD, and to focus on the pros and cons of its real-life application. Methods: PubMed, Cochrane, and Embase were questioned from inception until 31 December 2021. Results: Eighteen papers were finally analyzed. A positive correlation was observed between lung function and BAL cytology; in particular, BAL neutrophilia/granulocytosis was related to lower diffusing capacity for carbon monoxide (DLCO) values and lower forced vital capacity (FVC). Moreover, a positive correlation between BAL cellularity and high-resolution computed tomography (HRCT) findings has been reported by several authors. Cytokines, chemokines, growth factors, coagulation factors, and eicosanoids have all been shown to be present, more often and in higher quantities in SSc-ILD patients than in the health control and, in some cases, they were related to more severe pulmonary disease. There was no consensus regarding the role of BAL cellularity as a predictor of mortality.
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Affiliation(s)
- Martina Orlandi
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
| | - Laura Antonia Meliante
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
| | - Arianna Damiani
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
| | - Lorenzo Tofani
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
| | - Cosimo Bruni
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
| | - Serena Guiducci
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
- Correspondence: ; Tel.: +39-055-794-7066
| | - Marco Matucci-Cerinic
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, 20132 Milan, Italy
| | - Silvia Bellando-Randone
- Scleroderma Unit, Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Florence, Italy
| | - Sara Tomassetti
- Department of Clinical and Experimental Medicine, University of Florence, and Division of Interventional Pulmonology, Careggi University Hospital, 50134 Florence, Italy
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Renaud A, Pautre R, Morla O, Achille A, Durant C, Espitia O, Frampas E, Agard C. Thoracic lymphadenopathies in diffuse systemic sclerosis: an observational study on 48 patients using computed tomography. BMC Pulm Med 2022; 22:44. [PMID: 35078448 PMCID: PMC8788097 DOI: 10.1186/s12890-022-01837-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 01/05/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Thoracic multidetector computed tomography (MDCT) is essential for the detection of interstitial lung disease (ILD) in patients with systemic sclerosis (SSc). Thoracic MDCT assessment can reveal the presence of thoracic lymphadenopathies (LAP) whose signification remains uncertain. The purpose of the study was to describe the characteristics and to assess the significance of thoracic LAP in patients with diffuse SSc.
Methods
We conducted a monocentric observational study on adult patients with diffuse SSc, and collected general patient and first thoracic MDCT characteristics, PET-CT and outcome data. Comparisons were made between patients with and without thoracic LAP.
Results
Forty-eight patients were included. There were 30 patients (62.5%) with an ILD and 23 (48%) with at least one thoracic LAP on the first MDCT assessment. Median number per patient of thoracic LAP was 3 [1–8], with a mean size of 11.7 ± 1.7 mm, mainly located in right para-tracheal area (22.8% of the total number of LAP), right hilar area (20.3%), left hilar area (6.5%), and sub-carinal area (15.2%). PET-CT showed lymph node hypermetabolism in 11/15 patients (73.3%) with mean SUVmax at 4 ± 1.3. There were significantly more males (p = 0.002) and more patients exposed to silica (p = 0.001) in patients with thoracic LAP. ILD was significantly more extended according to Goh score (p = 0.03), and using semi-quantitative score for mixed ground-glass reticulation (p = 0.01) and global abnormalities (p = 0.03) in patients with thoracic LAP and ILD. Thirteen patients (27.1%) died during follow-up without significant difference according to the presence or not of thoracic LAP (p = 0.15). There was also no significant difference concerning immunosuppressive treatment initiation (p = 0.17).
Conclusions
Thoracic LAP are common in diffuse SSc and are generally multiple, not bulky, moderately hypermetabolic, and located at the base of the mediastinum lymph node chains. Their presence correlates with the extent of ILD. In absence of ILD, thoracic LAP presence seems to be often explained by silica exposure.
Trial Registration: NA.
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Kondoh Y, Makino S, Ogura T, Suda T, Tomioka H, Amano H, Anraku M, Enomoto N, Fujii T, Fujisawa T, Gono T, Harigai M, Ichiyasu H, Inoue Y, Johkoh T, Kameda H, Kataoka K, Katsumata Y, Kawaguchi Y, Kawakami A, Kitamura H, Kitamura N, Koga T, Kurasawa K, Nakamura Y, Nakashima R, Nishioka Y, Nishiyama O, Okamoto M, Sakai F, Sakamoto S, Sato S, Shimizu T, Takayanagi N, Takei R, Takemura T, Takeuchi T, Toyoda Y, Yamada H, Yamakawa H, Yamano Y, Yamasaki Y, Kuwana M. 2020 guide for the diagnosis and treatment of interstitial lung disease associated with connective tissue disease. Respir Investig 2021; 59:709-740. [PMID: 34602377 DOI: 10.1016/j.resinv.2021.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 01/29/2023]
Abstract
The prognosis of patients with connective tissue disease (CTD) has improved significantly in recent years, but interstitial lung disease (ILD) associated with connective tissue disease (CTD-ILD) remains a refractory condition, which is a leading cause of mortality. Because it is an important prognostic factor, many observational and interventional studies have been conducted to date. However, CTD is a heterogeneous group of conditions, which makes the clinical course, treatment responses, and prognosis of CTD-ILD extremely diverse. To summarize the current understanding and unsolved questions, the Japanese Respiratory Society and the Japan College of Rheumatology collaborated to publish the world's first guide focusing on CTD-ILD, based on the evidence and expert consensus of pulmonologists and rheumatologists, along with radiologists, pathologists, and dermatologists. The task force members proposed a total of 27 items, including 7 for general topics, 9 for disease-specific topics, 3 for complications, 4 for pharmacologic treatments, and 4 for non-pharmacologic therapies, with teams of 2-4 authors and reviewers for each item to prepare a consensus statement based on a systematic literature review. Subsequently, public opinions were collected from members of both societies, and a critical review was conducted by external reviewers. Finally, the task force finalized the guide upon discussion and consensus generation. This guide is expected to contribute to the standardization of CTD-ILD medical care and is also useful as a tool for promoting future research by clarifying unresolved issues.
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Affiliation(s)
- Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Shigeki Makino
- Rheumatology Division, Osaka Medical College Mishima-Minami Hospital, Takatsuki, Osaka, Japan
| | - Takashi Ogura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Hirofumi Amano
- Department of Internal Medicine and Rheumatology, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masaki Anraku
- Department of Thoracic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Itabashi, Tokyo, Japan
| | - Noriyuki Enomoto
- Health Administration Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hidenori Ichiyasu
- Department of Respiratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Meguro, Tokyo, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yasushi Kawaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Hideya Kitamura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ran Nakashima
- Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Sakyo, Kyoto, Japan
| | - Yasuhiko Nishioka
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Tokushima, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Masaki Okamoto
- Department of Respirology, National Hospital Organization Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Susumu Sakamoto
- Department of Respiratory Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Shinji Sato
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya, Saitama, Japan
| | - Reoto Takei
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuko Toyoda
- Department of Respiratory Medicine, Japanese Red Cross Kochi Hospital, Kochi, Kochi, Japan
| | - Hidehiro Yamada
- Center for Rheumatic Diseases, Seirei Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yoshioki Yamasaki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
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Štorkánová H, Oreská S, Špiritović M, Heřmánková B, Bubová K, Komarc M, Pavelka K, Vencovský J, Distler JHW, Šenolt L, Bečvář R, Tomčík M. Plasma Hsp90 levels in patients with systemic sclerosis and relation to lung and skin involvement: a cross-sectional and longitudinal study. Sci Rep 2021; 11:1. [PMID: 33414495 PMCID: PMC7791137 DOI: 10.1038/s41598-020-79139-8] [Citation(s) in RCA: 3242] [Impact Index Per Article: 1080.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/03/2020] [Indexed: 11/11/2022] Open
Abstract
Our previous study demonstrated increased expression of Heat shock protein (Hsp) 90 in the skin of patients with systemic sclerosis (SSc). We aimed to evaluate plasma Hsp90 in SSc and characterize its association with SSc-related features. Ninety-two SSc patients and 92 age-/sex-matched healthy controls were recruited for the cross-sectional analysis. The longitudinal analysis comprised 30 patients with SSc associated interstitial lung disease (ILD) routinely treated with cyclophosphamide. Hsp90 was increased in SSc compared to healthy controls. Hsp90 correlated positively with C-reactive protein and negatively with pulmonary function tests: forced vital capacity and diffusing capacity for carbon monoxide (DLCO). In patients with diffuse cutaneous (dc) SSc, Hsp90 positively correlated with the modified Rodnan skin score. In SSc-ILD patients treated with cyclophosphamide, no differences in Hsp90 were found between baseline and after 1, 6, or 12 months of therapy. However, baseline Hsp90 predicts the 12-month change in DLCO. This study shows that Hsp90 plasma levels are increased in SSc patients compared to age-/sex-matched healthy controls. Elevated Hsp90 in SSc is associated with increased inflammatory activity, worse lung functions, and in dcSSc, with the extent of skin involvement. Baseline plasma Hsp90 predicts the 12-month change in DLCO in SSc-ILD patients treated with cyclophosphamide.
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Affiliation(s)
- Hana Štorkánová
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Sabína Oreská
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Maja Špiritović
- Institute of Rheumatology, Prague, Czech Republic
- Department of Physiotherapy, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - Barbora Heřmánková
- Department of Physiotherapy, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - Kristýna Bubová
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Komarc
- Department of Methodology, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiří Vencovský
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jörg H W Distler
- Department of Internal Medicine III and Institute for Clinical Immunology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ladislav Šenolt
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Radim Bečvář
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Tomčík
- Institute of Rheumatology, Prague, Czech Republic.
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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da Silva SO, da Paz AS, Farias IMVC, Moreira DS, Ribeiro MAF, Alves TSGN, Lemos ACM, Santiago MB. Bronchoalveolar Lavage in Systemic Sclerosis Patients: A Systematic Review. Curr Rheumatol Rev 2020; 17:176-183. [PMID: 33185168 DOI: 10.2174/1573397116666201113091655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION We performed a systematic review of the literature to determine the value of bronchoalveolar lavage (BAL) in evaluating the pulmonary involvement of systemic sclerosis (SSc). METHODS Articles published between 1980 and 2019 were retrieved from the databases: PubMed and Scielo. The search was restricted to clinical trials published in English, utilizing the keywords "scleroderma, systemic sclerosis, interstitial lung disease, and bronchoalveolar lavage". RESULTS Twenty-two papers were analyzed. A positive correlation was observed between increased BAL cellularity (alveolitis) and worsening clinical symptoms, pulmonary function, and radiological pattern in 2, 11, and 15 studies, respectively. The majority of BAL studies that evaluated interleukin levels, including TNF-α, IL-6, IL-7, and IL-8, observed higher levels in patients with impaired pulmonary function and increased lung involvement. CONCLUSIONS Alveolitis and the increase of some cytokines/chemokines in BAL were related to more severe pulmonary disease in SSc in the majority of the studies and seemed to be markers of worse prognosis, but it is unknown whether BAL adds clinical value to the use of the other non-invasive diagnostic procedures.
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Affiliation(s)
- Sérgio Oliveira da Silva
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
| | - Adriane Souza da Paz
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
| | | | - Damille Sandes Moreira
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
| | - Marianna Alegro Fontes Ribeiro
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
| | - Tatiana Senna Galvão Nonato Alves
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
| | - Antônio Carlos Moreira Lemos
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
| | - Mittermayer Barreto Santiago
- Complexo Hospitalar Universitário Professor Edgard Santos, Rua Doutor Augusto Viana, s/n, Canela, CEP 40110-060, Salvador, Bahia, Brazil
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Davidson KR, Ha DM, Schwarz MI, Chan ED. Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases. J Thorac Dis 2020; 12:4991-5019. [PMID: 33145073 PMCID: PMC7578496 DOI: 10.21037/jtd-20-651] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.
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Affiliation(s)
- Kevin R Davidson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Duc M Ha
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Marvin I Schwarz
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,National Jewish Health, Denver, Colorado, USA
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Distler O, Assassi S, Cottin V, Cutolo M, Danoff SK, Denton CP, Distler JHW, Hoffmann-Vold AM, Johnson SR, Müller Ladner U, Smith V, Volkmann ER, Maher TM. Predictors of progression in systemic sclerosis patients with interstitial lung disease. Eur Respir J 2020; 55:13993003.02026-2019. [PMID: 32079645 PMCID: PMC7236865 DOI: 10.1183/13993003.02026-2019] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/09/2020] [Indexed: 12/17/2022]
Abstract
Systemic sclerosis (SSc) is a systemic autoimmune disease affecting multiple organ systems, including the lungs. Interstitial lung disease (ILD) is the leading cause of death in SSc. There are no valid biomarkers to predict the occurrence of SSc-ILD, although auto-antibodies against anti-topoisomerase I and several inflammatory markers are candidate biomarkers that need further evaluation. Chest auscultation, presence of shortness of breath and pulmonary function testing are important diagnostic tools, but lack sensitivity to detect early ILD. Baseline screening with high-resolution computed tomography (HRCT) is therefore necessary to confirm an SSc-ILD diagnosis. Once diagnosed with SSc-ILD, patients' clinical courses are variable and difficult to predict, although certain patient characteristics and biomarkers are associated with disease progression. It is important to monitor patients with SSc-ILD for signs of disease progression, although there is no consensus about which diagnostic tools to use or how often monitoring should occur. In this article, we review methods used to define and predict disease progression in SSc-ILD. There is no valid definition of SSc-ILD disease progression, but we suggest that either a decline in forced vital capacity (FVC) from baseline of ≥10%, or a decline in FVC of 5–9% in association with a decline in diffusing capacity of the lung for carbon monoxide of ≥15% represents progression. An increase in the radiographic extent of ILD on HRCT imaging would also signify progression. A time period of 1–2 years is generally used for this definition, but a decline over a longer time period may also reflect clinically relevant disease progression. Lung function tests and chest imaging help predict who has SSc-associated ILD and whether it will progress. In the absence of standardised methods for doctors, we recommend a strategy that combines both lung function tests and chest imaging.http://bit.ly/2uK9ZD2
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Affiliation(s)
- Oliver Distler
- Dept of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Shervin Assassi
- Dept of Rheumatology and Clinical Immunogenetics, McGovern Medical School, University of Texas, Houston, TX, USA
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon 1, UMR754, Lyon, France
| | - Maurizio Cutolo
- Research Laboratory, Clinical Division of Rheumatology, Dept of Internal Medicine DIMI, University of Genoa, IRCSS Polyclinic Hospital San Martino, Genoa, Italy
| | - Sonye K Danoff
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Christopher P Denton
- UCL Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
| | - Jörg H W Distler
- Dept of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Dept of Medicine, Toronto Western and Mount Sinai Hospitals, University of Toronto, Toronto, ON, Canada
| | - Ulf Müller Ladner
- Dept of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Campus Kerckhoff, Bad Nauheim, Germany
| | - Vanessa Smith
- Dept of Rheumatology, Ghent University Hospital, Ghent, Belgium.,Dept of Internal Medicine, Ghent University, Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Elizabeth R Volkmann
- Dept of Medicine, Division of Rheumatology, University of California, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Toby M Maher
- National Heart and Lung Institute, Imperial College London, London, UK.,NIHR Respiratory Clinical Research Facility, Royal Brompton Hospital, London, UK
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Perelas A, Silver RM, Arrossi AV, Highland KB. Systemic sclerosis-associated interstitial lung disease. Lancet Respir Med 2020; 8:304-320. [PMID: 32113575 DOI: 10.1016/s2213-2600(19)30480-1] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 12/15/2022]
Abstract
Systemic sclerosis is an autoimmune connective tissue disease, which is characterised by immune dysregulation and progressive fibrosis that typically affects the skin, with variable internal organ involvement. It is a rare condition that affects mostly young and middle-aged women, resulting in disproportionate morbidity and mortality. Currently, interstitial lung disease is the most common cause of death among patients with systemic sclerosis, with a prevalence of up to 30% and a 10-year mortality of up to 40%. Interstitial lung disease is more common among African Americans and in people with the diffuse cutaneous form of systemic sclerosis or anti-topoisomerase 1 antibodies. Systemic sclerosis-associated interstitial lung disease most commonly presents with dyspnoea, cough, and a non-specific interstitial pneumonia pattern on CT scan, with a minority of cases fulfilling the criteria for usual interstitial pneumonia. The standard therapy has traditionally been combinations of immunosuppressants, particularly mycophenolate mofetil or cyclophosphamide. These immunosuppressants can be supplemented by targeted biological and antifibrotic therapies, whereas autologous haematopoietic stem-cell transplantation and lung transplantation are reserved for refractory cases.
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Affiliation(s)
- Apostolos Perelas
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Richard M Silver
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | - Andrea V Arrossi
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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10
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Caron M, Hoa S, Hudson M, Schwartzman K, Steele R. Pulmonary function tests as outcomes for systemic sclerosis interstitial lung disease. Eur Respir Rev 2018; 27:170102. [PMID: 29769294 PMCID: PMC9488607 DOI: 10.1183/16000617.0102-2017] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/24/2018] [Indexed: 01/17/2023] Open
Abstract
Interstitial lung disease (ILD) is the leading cause of morbidity and mortality in systemic sclerosis (SSc). We performed a systematic review to characterise the use and validation of pulmonary function tests (PFTs) as surrogate markers for systemic sclerosis-associated interstitial lung disease (SSc-ILD) progression.Five electronic databases were searched to identify all relevant studies. Included studies either used at least one PFT measure as a longitudinal outcome for SSc-ILD progression (i.e. outcome studies) and/or reported at least one classical measure of validity for the PFTs in SSc-ILD (i.e. validation studies).This systematic review included 169 outcome studies and 50 validation studies. Diffusing capacity of the lung for carbon monoxide (DLCO) was cumulatively the most commonly used outcome until 2010 when it was surpassed by forced vital capacity (FVC). FVC (% predicted) was the primary endpoint in 70.4% of studies, compared to 11.3% for % predicted DLCO Only five studies specifically aimed to validate the PFTs: two concluded that DLCO was the best measure of SSc-ILD extent, while the others did not favour any PFT. These studies also showed respectable validity measures for total lung capacity (TLC).Despite the current preference for FVC, available evidence suggests that DLCO and TLC should not yet be discounted as potential surrogate markers for SSc-ILD progression.
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Affiliation(s)
- Melissa Caron
- Dept of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Respiratory Epidemiology and Clinical Research Unit (RECRU), Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Sabrina Hoa
- Dept of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Division of Rheumatology, Jewish General Hospital, Montreal, QC, Canada
| | - Marie Hudson
- Division of Rheumatology, Jewish General Hospital, Montreal, QC, Canada
| | - Kevin Schwartzman
- Dept of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Respiratory Epidemiology and Clinical Research Unit (RECRU), Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Russell Steele
- Dept of Mathematics and Statistics, McGill University, Montreal, QC, Canada
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11
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George PM, Wells AU. Disease staging and sub setting of interstitial lung disease associated with systemic sclerosis: impact on therapy. Expert Rev Clin Immunol 2018; 14:127-135. [DOI: 10.1080/1744666x.2018.1427064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Peter M. George
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
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12
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Largeau B, Dupont AC, Guilloteau D, Santiago-Ribeiro MJ, Arlicot N. TSPO PET Imaging: From Microglial Activation to Peripheral Sterile Inflammatory Diseases? Contrast Media Mol Imaging 2017; 2017:6592139. [PMID: 29114179 DOI: 10.1155/2017/6592139] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 02/07/2023]
Abstract
Peripheral sterile inflammatory diseases (PSIDs) are a heterogeneous group of disorders that gathers several chronic insults involving the cardiovascular, respiratory, gastrointestinal, or musculoskeletal system and wherein inflammation is the cornerstone of the pathophysiology. In PSID, timely characterization and localization of inflammatory foci are crucial for an adequate care for patients. In brain diseases, in vivo positron emission tomography (PET) exploration of inflammation has matured over the last 20 years, through the development of radiopharmaceuticals targeting the translocator protein-18 kDa (TSPO) as molecular biomarkers of activated microglia. Recently, TSPO has been introduced as a possible molecular target for PSIDs PET imaging, making this protein a potential biomarker to address disease heterogeneity, to assist in patient stratification, and to contribute to predicting treatment response. In this review, we summarized the major research advances recently made in the field of TSPO PET imaging in PSIDs. Promising preliminary results have been reported in bowel, cardiovascular, and rheumatic inflammatory diseases, consolidated by preclinical studies. Limitations of TSPO PET imaging in PSIDs, regarding both its large expression in healthy peripheral tissues, unlike in central nervous system, and the production of peripheral radiolabeled metabolites, are also discussed, regarding their possible consequences on TSPO PET signal's quantification.
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13
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Aydi Z, Rachdi I, Ben Dhaou B, Dridi M, Daoud F, Baili L, Boussema F. [Epidemiological, clinical and evolutionary peculiarities of interstitial lung disease in systemic sclerosis]. Rev Pneumol Clin 2016; 72:122-128. [PMID: 26651932 DOI: 10.1016/j.pneumo.2015.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 08/25/2015] [Accepted: 09/15/2015] [Indexed: 06/05/2023]
Abstract
Pulmonary involvement during systemic sclerosis (SS) is dominated by interstitial lung disease and arterial pulmonary hypertension. It is about a retrospective study analyzing 65 cases of SS over a period of 13 years. We compared cases with and without interstitial lung disease. The diagnosis of SS was retained according to American College of Rheumatology (ACR)/EULAR 2013 criteria. The diagnosis of interstitial lung disease was retained in TDM and EFR. Pulmonary hypertension is defined by a pulmonary arterial pression higher than 25 mmHg. The mean delay of diagnosis of interstitial lung disease and the diagnosis was of 48 months (extremes 0-78 months). The comparison between both groups according to average age of the patients, prevalence of pulmonary hypertension, frequency of Raynaud phenomenon and trophic disorders did not find any significant difference. Lung involvement was associated with an esophageal involvement in 71% of the cases (P=0.059). Antibodies anti-Scl 70 were noted more frequently in patient's with interstitial lung disease (79% of the cases, P=0.001). Patients were treated with colchicine and vitamin E. A corticotherapy had been indicated at a single patient. The evolution of SS was marked by the stabilisation of the restrictive syndrome in 71.8% of the cases and a worsening in 25% of the cases. Early and appropriate diagnosis of SS and screening of lung involvement are essential for a early care.
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Affiliation(s)
- Z Aydi
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie
| | - I Rachdi
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie
| | - B Ben Dhaou
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie.
| | - M Dridi
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie
| | - F Daoud
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie
| | - L Baili
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie
| | - F Boussema
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Montfleury, Tunisie
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14
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Garner J, George PM, Renzoni E. Cough in interstitial lung disease. Pulm Pharmacol Ther 2015; 35:122-8. [DOI: 10.1016/j.pupt.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 12/15/2022]
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15
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Hua-Huy T, Rivière S, Tiev KP, Dinh-Xuan AT. [Use of pulmonary function tests and biomarkers studies to diagnose and follow-up interstitial lung disease in systemic sclerosis]. Rev Pneumol Clin 2014; 70:335-342. [PMID: 25457218 DOI: 10.1016/j.pneumo.2014.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 08/31/2014] [Accepted: 09/05/2014] [Indexed: 06/04/2023]
Abstract
Interstitial lung disease (ILD) is becoming one of the main causes of death of patients with systemic sclerosis (SSc). The prevalence of ILD associated with SSc (SSc-ILD) varies from 33% to 100% according to diagnostic methods. Clinical features such as dyspnea on exertion, dry cough, and chest pains are not specific and usually late-appearing, implying more specific tests in the diagnostic, prognosis, and follow-up of ILD in patients with SSc. High resolution thoracic CT scanner (HRCT) is more sensitive than chest X-ray in the detection of SSc-ILD. Pulmonary function tests (PFT) are non-invasive and periodically used to assess the impacts of SSc on respiratory function. Diagnostic values of bronchoalveolar lavage and histological examination on lung biopsy are controversial. However, these techniques are essential for studying cellular and molecular mechanisms underlying the pathophysiology of SSc-ILD. Several biomarkers such as surfactant-A (SP-A), -D (SP-D), mucin-like high molecular weight glycoprotein (KL-6), and chemokine CCL-18 have been implicated in SSc-PID. Serum levels of these proteins are correlated with the severity of SSc-ILD, as assessed by HRCT and/or PFT. Finally, alveolar concentration of exhaled nitric oxide can be used to screen SSc patients with high risk of deterioration of respiratory function, in whom immunosuppressant treatment could be useful in preventing the evolution to irreversible lung fibrosis.
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Affiliation(s)
- T Hua-Huy
- UPRES-EA 2511, service de physiologie-explorations fonctionnelles, hôpital Cochin, AP-HP, université Paris Descartes, Sorbonne Paris Cité, 75014 Paris, France
| | - S Rivière
- Service de médecine interne, Hôpital Saint-Antoine, université Pierre-et-Marie-Curie, 75012 Paris, France
| | - K P Tiev
- Hôpital privé de Vitry, site Pasteur, 94400 Vitry-sur-Seine, France
| | - A T Dinh-Xuan
- UPRES-EA 2511, service de physiologie-explorations fonctionnelles, hôpital Cochin, AP-HP, université Paris Descartes, Sorbonne Paris Cité, 75014 Paris, France.
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16
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Bayar N, Çay HF, Erkal Z, Sezer İ, Arslan Ş, Çağırcı G, Çay S, Yüksel İÖ, Köklü E. The importance of fragmented QRS in the early detection of cardiac involvement in patients with systemic sclerosis. Anatol J Cardiol 2014; 15:209-12. [PMID: 25333976 PMCID: PMC5337056 DOI: 10.5152/akd.2014.5191] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Systemic sclerosis (SSc) is an autoimmune connective tissue disorder characterized by fibrosis. The prognosis of the disease is bad when clinically symptomatic cardiac dysfunction is occurred, therefore early detection of cardiac dysfunction is important in patients with SSc. The aim of this study was to investigate the frequency of fQRS in superficial electrocardiography in cardiacally asymptomatic patients with SSc and its relation to the systolic pulmonary artery pressure (sPAP). Methods: This study included 31 cardiacally asymptomatic patients with SSc (23 females, 40.4±9.2 years) and 41 healthy volunteers as the control (31 females, 38.2±11.8 years). The ECGs with 12 derivations and transthoracic echocardiographies of the patients were evaluated. The presence of fQRS in the superficial ECG, and its relation to systolic pulmonary artery pressure (sPAP) were investigated. Results: The mean sPAP value in the SSc group was observed to be higher than that of the control group (26 mm Hg and 20 mm Hg, respectively, p<0.001). The presence of fQRS in the SSc group was more frequent than the control group (55% and 10%, respectively, p<0.001). In SSc patients presence of fQRS become relevant with ≥24 mm Hg sPAP by 88% sensitivity and 79% specificity. Conclusion: In our study, the presence of fQRS in SSc patients, were more frequent than in the normal population. Since pulmonary hypertension is the primary cause of mortality in patients with SSc, the correlation of fQRS with sPAP should also be considered.
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Affiliation(s)
- Nermin Bayar
- Clinic of Cardiology, Antalya Training and Research Hospital; Antalya-Turkey.
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17
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Abstract
Based on international collaborative data, interstitial lung disease is now the most frequent cause of death in systemic sclerosis (SSc), having supplanted renal crisis in that regard. Despite detailed explorations of candidate mediators, no primary pathway in the pathogenesis of interstitial lung disease associated with SSc (SSc-ILD) has been definitively identified and, therefore, treatment with current agents is only partially successful. However, as immunomodulatory agents do, on average, retard progression of lung disease, early identification of SSc-ILD, using thoracic high resolution computed tomography (HRCT), is highly desirable. The decision whether to introduce therapy immediately is often difficult as the balance of risk and benefit favours a strategy of careful observation when lung disease is very limited, especially in long-standing SSc. The threshold for initiating treatment is substantially reduced when lung disease is severe, systemic disease is short in duration or ongoing progression is evident, based on pulmonary function tests and symptoms. This review summarises epidemiology, pathogenesis, difficult clinical problems and management issues in SSc-ILD.
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Affiliation(s)
- Athol U Wells
- Royal Brompton hospital, interstitial lung disease unit, Sydney street, Chelsea, London SW3 6HP, United Kingdom.
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19
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Affiliation(s)
- Joshua J Solomon
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
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Hesselstrand R, Wildt M, Bozovic G, Andersson-sjöland A, Andréasson K, Scheja A, Westergren-thorsson G, Bjermer L, Wuttge DM. Biomarkers from bronchoalveolar lavage fluid in systemic sclerosis patients with interstitial lung disease relate to severity of lung fibrosis. Respir Med 2013; 107:1079-86. [DOI: 10.1016/j.rmed.2013.03.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 03/07/2013] [Accepted: 03/11/2013] [Indexed: 11/15/2022]
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21
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El Khattabi W, Afif H, Moussali N, Aichane A, Abdelouafi A, Bouayad Z. [Diffuse infiltrative lung disease in scleroderma. Analysis of radio-clinical and functional semiology]. Rev Pneumol Clin 2013; 69:132-138. [PMID: 23587414 DOI: 10.1016/j.pneumo.2013.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 01/10/2013] [Accepted: 02/25/2013] [Indexed: 06/02/2023]
Abstract
Scleroderma (SD) is a systemic disease that predominantly affects the skin. Diffuse infiltrative lung disease (DILD) is rare and occurs most often in the course of the disease. We analyzed seven cases of DILO of SD recorded between 2003 and 2010 among 196 PID (3.6%). Functional signs were limited to respiratory dyspnea, it was associated to dysphagia in six cases, dry syndrome in five cases and Raynaud's phenomenon in four cases. Clinical examination found crackles in the bases of the thorax in all cases and specific cutaneous signs in six cases. The chest radiograph showed that interstitial disease predominates at the lung bases in all cases with a large aspect of the pulmonary arteries in two cases. The chest CT scan confirmed the predominance of basal and peripheral damage with signs of fibrosis in six cases. The pulmonary function objectified a severe restrictive ventilatory defect in all cases. Bronchoscopy showed a normal macroscopic appearance in all cases, the broncho-alveolar lavage was predominated by neutrophilic formula in four cases. SCL 70 antibodies were positive in four cases. All patients were treated by steroids with improvement of dyspnea and stabilization of radiographs. A patient had died in an array of acute respiratory failure and one patient was lost to follow-up. DILD in scleroderma is rare and seldom reveals the disease, it affects the patient's prognosis especially when associated with arterial pulmonary hypertension.
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Affiliation(s)
- W El Khattabi
- Service des maladies respiratoires, hôpital du 20-Août, Casablanca, Maroc.
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Theodore AC, Tseng CH, Li N, Elashoff RM, Tashkin DP. Correlation of cough with disease activity and treatment with cyclophosphamide in scleroderma interstitial lung disease: findings from the Scleroderma Lung Study. Chest 2013; 142:614-621. [PMID: 22156609 DOI: 10.1378/chest.11-0801] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Cough is a significant symptom in patients with scleroderma interstitial lung disease (SSc-ILD), affecting 73% of the 158 patients enrolled in the Scleroderma Lung Study (SLS), a multicenter randomized trial of oral cyclophosphamide (CYC) vs placebo (PLA) in patients with active interstitial lung disease. METHODS We examined the correlation of cough frequency and severity and phlegm production at baseline in 156 SLS participants with other baseline variables representing SSc-ILD disease activity and the cough response to 1 year of treatment with CYC vs PLA. RESULTS Patients with cough at baseline had significantly lower diffusing capacity of the lung for carbon monoxide, dyspnea, the quality-of-life physical component summary, and the maximal fibrosis score on high-resolution CT imaging compared with those without cough at baseline. Cough severity and frequency correlated with FVC % predicted. After 12 months of treatment, cough frequency decreased in the CYC group compared with the PLA group and was significantly different from the PLA group at 18 months (6 months after discontinuation of CYC). However, the decreases in cough frequency did not correlate with the changes in FVC or diffusing capacity of the lung for carbon monoxide observed in the CYC group. Treatment-related improvements in cough frequency, as well as in FVC, were no longer apparent 12 months after discontinuation of CYC. CONCLUSIONS Cough is a common symptom in SSc-ILD and correlates with the extent of fibrosis. Cough frequency decreases significantly in response to treatment with CYC but returns to baseline 1 year after withdrawal of treatment. Cough may be a symptom of ongoing fibrosis and an independent variable in assessing therapeutic response to CYC. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT000004563; URL: www.clinicaltrials.gov
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Affiliation(s)
- Arthur C Theodore
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Boston University School of Medicine, Boston, MA.
| | - Chi-Hong Tseng
- Department of Biomathematics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Ning Li
- Biostatistics Core, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert M Elashoff
- Department of Biomathematics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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Abstract
Some of the most pressing challenges associated with interstitial lung disease (ILD) are how best to define, diagnose, and treat connective tissue disease-associated ILD (CTD-ILD)--disorders with potentially substantial morbidity and mortality. In this focused review, we address aspects of prognosis for CTD-ILD and what indices might predict outcome, together with lessons that can be learnt from clinical trials of systemic sclerosis-associated ILD and idiopathic pulmonary fibrosis and how these lessons might be applied to future studies of CTD-ILD.
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Affiliation(s)
- Aryeh Fischer
- Division of Rheumatology and Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
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Abstract
Pediatric scleroderma includes 2 major groups of clinical entities, systemic sclerosis (SSc) and localized scleroderma (LS). Although both share a common pathophysiology, their clinical manifestations differ. LS is typically confined to the skin and underlying subcutis, with up to a quarter of patients showing extracutaneous disease manifestations such as arthritis and uveitis. Vascular, cutaneous, gastrointestinal, pulmonary, and musculoskeletal involvement are most commonly seen in children with SSc. Treatment of both forms targets the active inflammatory stage and halts disease progression; however, progress needs to be made toward the development of more effective antifibrotic therapy to help reverse disease damage.
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25
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Roth MD, Tseng CH, Clements PJ, Furst DE, Tashkin DP, Goldin JG, Khanna D, Kleerup EC, Li N, Elashoff D, Elashoff RM. Predicting treatment outcomes and responder subsets in scleroderma-related interstitial lung disease. ACTA ACUST UNITED AC 2011; 63:2797-808. [PMID: 21547897 DOI: 10.1002/art.30438] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To identify baseline characteristics of patients with scleroderma-related interstitial lung disease (SSc-ILD) that could serve as predictors of the most favorable response to 12-month treatment with oral cyclophosphamide (CYC). METHODS Regression analyses were retrospectively applied to the Scleroderma Lung Study data in order to identify baseline characteristics that correlated with the absolute change in forced vital capacity (FVC) (% predicted values) and the placebo-adjusted change in % predicted FVC over time (the CYC treatment effect). RESULTS Completion of the CYC arm of the Scleroderma Lung Study was associated with a placebo-adjusted improvement in the % predicted FVC of 2.11% at 12 months, which increased to 4.16% when patients were followed up for another 6 months (P=0.014). Multivariate regression analyses identified the maximal severity of reticular infiltrates (assessed as maximum fibrosis scores) on high-resolution computed tomography (HRCT) at baseline, the modified Rodnan skin thickness score (MRSS) at baseline, and the Mahler baseline dyspnea index as independent correlates of treatment response. When patients were stratified on the basis of whether 50% or more of any lung zone was involved by reticular infiltrates on HRCT and/or whether patients exhibited an MRSS of at least 23, a subgroup of patients emerged in whom there was an average CYC treatment effect of 9.81% at 18 months (P<0.001). Conversely, there was no treatment effect (a -0.58% difference) in patients with less severe HRCT findings and a lower MRSS at baseline. CONCLUSION A retrospective analysis of the Scleroderma Lung Study data identified the severity of reticular infiltrates on baseline HRCT and the baseline MRSS as patient features that might be predictive of responsiveness to CYC therapy.
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Affiliation(s)
- Michael D Roth
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095-1690, USA.
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Bogatkevich GS, Highland KB, Akter T, Silver RM. The PPARγ Agonist Rosiglitazone Is Antifibrotic for Scleroderma Lung Fibroblasts: Mechanisms of Action and Differential Racial Effects. Pulm Med 2012; 2012:545172. [PMID: 22135743 DOI: 10.1155/2012/545172] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 08/26/2011] [Indexed: 12/29/2022] Open
Abstract
We present novel data demonstrating that the expression of PPARγ is reduced in lung fibroblasts from black SSc-ILD patients as compared to white patients. Activating PPARγ with the agonist rosiglitazone increased the expression of MMP-1 and inhibited collagen type I in lung fibroblasts isolated from white, but not black, SSc-ILD patients. Blocking the c-Met receptor abolishes rosiglitazone's effects on collagen and MMP-1 in lung fibroblasts isolated from white SSc-ILD patients, while augmenting the expression of the c-Met receptor in fibroblasts from black SSc-ILD patients replicates the effects of rosiglitazone seen in whites. We conclude that PPARγ agonists warrant consideration as potential antifibrotic drugs in patients with SSc-ILD. Differential therapeutic effects might be anticipated especially relative to racial differences and the functional expression of the c-Met receptor.
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Gorlova O, Martin JE, Rueda B, Koeleman BP, Ying J, Teruel M, Diaz-Gallo LM, Broen JC, Vonk MC, Simeon CP, Alizadeh BZ, Coenen MJ, Voskuyl AE, Schuerwegh AJ, van Riel PL, Vanthuyne M, van 't Slot R, Italiaander A, Ophoff RA, Hunzelmann N, Fonollosa V, Ortego-Centeno N, González-Gay MA, García-Hernández FJ, González-Escribano MF, Airo P, van Laar J, Worthington J, Hesselstrand R, Smith V, de Keyser F, Houssiau F, Chee MM, Madhok R, Shiels PG, Westhovens R, Kreuter A, de Baere E, Witte T, Padyukov L, Nordin A, Scorza R, Lunardi C, Lie BA, Hoffmann-Vold AM, Palm O, García de la Peña P, Carreira P, Varga J, Hinchcliff M, Lee AT, Gourh P, Amos CI, Wigley FM, Hummers LK, Nelson JL, Riemekasten G, Herrick A, Beretta L, Fonseca C, Denton CP, Gregersen PK, Agarwal S, Assassi S, Tan FK, Arnett FC, Radstake TR, Mayes MD, Martin J; Spanish Scleroderma Group. Identification of novel genetic markers associated with clinical phenotypes of systemic sclerosis through a genome-wide association strategy. PLoS Genet 2011; 7:e1002178. [PMID: 21779181 DOI: 10.1371/journal.pgen.1002178] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 05/25/2011] [Indexed: 11/19/2022] Open
Abstract
The aim of this study was to determine, through a genome-wide association study (GWAS), the genetic components contributing to different clinical sub-phenotypes of systemic sclerosis (SSc). We considered limited (lcSSc) and diffuse (dcSSc) cutaneous involvement, and the relationships with presence of the SSc-specific auto-antibodies, anti-centromere (ACA), and anti-topoisomerase I (ATA). Four GWAS cohorts, comprising 2,296 SSc patients and 5,171 healthy controls, were meta-analyzed looking for associations in the selected subgroups. Eighteen polymorphisms were further tested in nine independent cohorts comprising an additional 3,175 SSc patients and 4,971 controls. Conditional analysis for associated SNPs in the HLA region was performed to explore their independent association in antibody subgroups. Overall analysis showed that non-HLA polymorphism rs11642873 in IRF8 gene to be associated at GWAS level with lcSSc (P = 2.32×10−12, OR = 0.75). Also, rs12540874 in GRB10 gene (P = 1.27 × 10−6, OR = 1.15) and rs11047102 in SOX5 gene (P = 1.39×10−7, OR = 1.36) showed a suggestive association with lcSSc and ACA subgroups respectively. In the HLA region, we observed highly associated allelic combinations in the HLA-DQB1 locus with ACA (P = 1.79×10−61, OR = 2.48), in the HLA-DPA1/B1 loci with ATA (P = 4.57×10−76, OR = 8.84), and in NOTCH4 with ACA P = 8.84×10−21, OR = 0.55) and ATA (P = 1.14×10−8, OR = 0.54). We have identified three new non-HLA genes (IRF8, GRB10, and SOX5) associated with SSc clinical and auto-antibody subgroups. Within the HLA region, HLA-DQB1, HLA-DPA1/B1, and NOTCH4 associations with SSc are likely confined to specific auto-antibodies. These data emphasize the differential genetic components of subphenotypes of SSc. Scleroderma or systemic sclerosis is a complex autoimmune disease affecting one individual of every 100,000 in Caucasian populations. Even though current genetic studies have led to better understanding of the pathogenesis of the disease, much remains unknown. Scleroderma is a heterogeneous disease, which can be subdivided according to different criteria, such as the involvement of organs and the presence of specific autoantibodies. Such subgroups present more homogeneous genetic groups, and some genetic associations with these manifestations have already been described. Through reanalysis of a genome-wide association study data, we identify three novel genes containing genetic variations which predispose to subphenotypes of the disease (IRF8, GRB10, and SOX5). Also, we better characterize the patterns of associated loci found in the HLA region. Together, our findings lead to a better understanding of the genetic component of scleroderma.
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Trang G, Steele R, Baron M, Hudson M. Corticosteroids and the risk of scleroderma renal crisis: a systematic review. Rheumatol Int 2012; 32:645-53. [DOI: 10.1007/s00296-010-1697-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 11/21/2010] [Indexed: 11/26/2022]
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Abstract
Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc) and mainly encountered in patients with diffuse disease and/or anti-topoisomerase 1 antibodies. ILD develops in up to 75% of patients with SSc overall. However, SSc-ILD evolves to end-stage respiratory insufficiency in only a few patients. Initial pulmonary function tests (PFT) with measurement of carbon monoxide diffusing capacity, together with high-resolution computed tomography, allows for early diagnosis of SSc-ILD, before the occurrence of dyspnea. Unlike idiopathic ILD, SSc-ILD corresponds to non-specific interstitial pneumonia in most cases, whereas usual interstitial pneumonia is less frequently encountered. Therefore, the prognosis of SSc-ILD is better than that for idiopathic ILD. Nevertheless, ILD represents one of the two main causes of death in SSc patients. To detect SSc-ILD early, PFT must be repeated regularly, every 6 months to 1 year, depending on disease worsening. Conversely, broncho-alveolar lavage is not needed to evaluate disease activity in SSc-ILD but may be of help in diagnosing opportunistic infection. The treatment of SSc-ILD is not well established. Cyclophosphamide, which has been used for 20 years, has recently been evaluated in two prospective randomized studies that failed to demonstrate a major benefit for lung function. Open studies reported mycophenolate mofetil, azathioprine and rituximab as alternatives to cyclophosphamide. On failure of immunosuppressive agent treatment, lung transplantation can be proposed in the absence of other major organ involvement or severe gastro-esophageal reflux.
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Affiliation(s)
- Guillaume Bussone
- Université Paris Descartes, Institut Cochin, Inserm U1016, Paris, France
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Kowal-bielecka O, Kowal K, Chyczewska E. Utility of Bronchoalveolar Lavage in Evaluation of Patients with Connective Tissue Diseases. Clin Chest Med 2010; 31:423-31. [DOI: 10.1016/j.ccm.2010.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yoshizaki A, Yanaba K, Iwata Y, Komura K, Ogawa A, Akiyama Y, Muroi E, Hara T, Ogawa F, Takenaka M, Shimizu K, Hasegawa M, Fujimoto M, Tedder TF, Sato S. Cell adhesion molecules regulate fibrotic process via Th1/Th2/Th17 cell balance in a bleomycin-induced scleroderma model. J Immunol 2010; 185:2502-15. [PMID: 20624949 PMCID: PMC3733122 DOI: 10.4049/jimmunol.0901778] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mice s.c. injected with bleomycin, an experimental model for human systemic sclerosis, develop skin and lung fibrosis, which is mediated by inflammatory cell infiltration. This process is highly regulated by multiple adhesion molecules and does not require Ag sensitization. To assess the role of adhesion molecules in this pathogenetic process, bleomycin-induced fibrosis was examined in mice lacking adhesion molecules. L-selectin and/or ICAM-1 deficiency inhibited skin and lung fibrosis with decreased Th2 and Th17 cytokines and increased Th1 cytokines. In contrast, P-selectin deficiency, E-selectin deficiency with or without P-selectin blockade, or P-selectin glycoprotein ligand 1 (PSGL-1) deficiency augmented the fibrosis in parallel with increased Th2 and Th17 cytokines and decreased Th1 cytokines. Furthermore, loss of L-selectin and/or ICAM-1 reduced Th2 and Th17 cell numbers in bronchoalveolar lavage fluid, whereas loss of P-selectin, E-selectin, or PSGL-1 reduced Th1 cell numbers. Moreover, Th1 cells exhibited higher PSGL-1 expression and lower expression of LFA-1, a ligand for ICAM-1, whereas Th2 and Th17 cells showed higher LFA-1 and lower PSGL-1 expression. This study suggests that L-selectin and ICAM-1 regulate Th2 and Th17 cell accumulation into the skin and lung, leading to the development of fibrosis, and that P-selectin, E-selectin, and PSGL-1 regulate Th1 cell infiltration, resulting in the inhibition of fibrosis.
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Affiliation(s)
- Ayumi Yoshizaki
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koichi Yanaba
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yohei Iwata
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Komura
- Department of Dermatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Asako Ogawa
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuichiro Akiyama
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Eiji Muroi
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toshihide Hara
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Fumihide Ogawa
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Motoi Takenaka
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Shimizu
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Thomas F. Tedder
- Department of Immunology, Duke University Medical Center, Durham, NC 27710, USA
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Kowal-Bielecka O, Kowal K, Highland KB, Silver RM. Bronchoalveolar Lavage Fluid in Scleroderma Interstitial Lung Disease: Technical Aspects and Clinical Correlations: Review of the Literature. Semin Arthritis Rheum 2010; 40:73-88. [DOI: 10.1016/j.semarthrit.2008.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 10/01/2008] [Accepted: 10/18/2008] [Indexed: 01/23/2023]
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Serra W, Chetta A, Santilli D, Mozzani F, Dall'Aglio PP, Olivieri D, Cattabiani MA, Ardissino D, Gherli T. Echocardiography may help detect pulmonary vasculopathy in the early stages of pulmonary artery hypertension associated with systemic sclerosis. Cardiovasc Ultrasound 2010; 8:25. [PMID: 20598164 PMCID: PMC2908574 DOI: 10.1186/1476-7120-8-25] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 07/05/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) in patients with systemic sclerosis is associated with a poor prognosis, but this can be improved by early disease detection. Abnormal pulmonary and cardiac function can be detected early by means of echocardiography, whereas right heart catheterization is usually performed later. OBJECTIVES The purpose of this prospective study was to detect early the presence of pulmonary artery vasculopathy in patients with verified systemic sclerosis without significant pulmonary fibrosis, normal lung volumes and a mildly reduced lung diffusion capacity of carbon monoxide (DLCO). METHODS Nineteen consecutive female NYHA class I-II patients with scleroderma and a PAPs of < 35 mm/Hg measured by echocardiography, were enrolled between September 2007 and September 2009. They had a mean age of 51 +/- 13 years, body mass index of 25 +/- 5 kg/m2). They all underwent complete Doppler echocardiography, CPET, a pulmonary ventilation test (carbon monoxide lung diffusion, DLCO), HRCT. To investigate PAH by means of complete resting Doppler echocardiography estimates of systolic pulmonary artery pressure (PAPs) derived from tr icuspid regurgitation, mean PAP derived from pulmonary regurgitation, pulmonary vessel resistance (PVR) derived from the acceleration time of the pulmonary outflow tract (ACTpo), and right ventricular function derived from tricuspid annular plane systolic excursion (TAPSE). Right heart catheterisation was conducted only, if pulmonary hypertension was suggested by echocardiography and an abnormal ventilator test.The data are given as mean values +/- SD, unless otherwise stated. The correlations between the variables were analysed using Pearson's r coefficient, and the predictive value of the variables was calculated using linear regression analysis. A p value of > 0.05 was considered significant. RESULTS Right heart catheterization detected PAH in 15/19 patients; mean PAP was 30.5 mm/Hg and RVP 3.6 UW. Coronary angiography of the patients aged more than 55 years showed some evidence of significant coronary artery disease. Echocardiography showed high systolic PAP values (46 +/- 8 mmHg), whereas right ventricular function was normal (TAPSE 23 +/- 3 mm), and in line with the NYHA class. ACTpo was reduced in the patients with a systolic PAP of < 46 mm/Hg (p > 0.001) and positively correlated with DLCO (p > 0.001) and the hemodynamic data.There was a good correlation between ACTpo and PVR (hemodynamic data) (r = -0615; p > 0.01). CONCLUSIONS Although they need to be confirmed by studies of larger series of patients, our findings suggest that, in comparison with hemodynamic data, non-invasive echocardiographic measurements are an excellent means of identifying early-stage PAH.
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Affiliation(s)
- Walter Serra
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
| | - Alfredo Chetta
- Cardiopulmonary Dept., Pneumology Unit, University Hospital, Parma, Italy
| | - Daniele Santilli
- Immunology Dept., Rheumatology Unit, University Hospital, Parma, Italy
| | - Flavio Mozzani
- Immunology Dept., Rheumatology Unit, University Hospital, Parma, Italy
| | | | - Dario Olivieri
- Cardiopulmonary Dept., Pneumology Unit, University Hospital, Parma, Italy
| | | | - Diego Ardissino
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
| | - Tiziano Gherli
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
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Abstract
Evaluation of: Tashkin, Elashoff, Clements PJ et al. Cyclophosphamide versus placebo in scleroderma lung disease. N. Engl. J. Med. 354(25), 2655-2666 (2006). Interstitial lung disease has become one of the leading causes of morbidity and mortality in systemic sclerosis. Currently, there remains a void in proven effective treatment strategies to provide clinical benefit to affected patients. The article under evaluation pioneers the efforts of investigating oral cyclophosphamide in treating scleroderma lung disease by designing a prospective, double-blinded, placebo-controlled study examining the drug's effect on outcome measures of forced vital capacity, patient subjective health assessment questionnaire disability scores, among others. We review the methods, results and overall conclusion of the study, which shows a significant, yet modest, result demonstrating the benefit of oral cyclophosphamide in the context of this disease setting. We conclude that although the study provides an excellent starting point for examining the efficacy of cyclophosphamide in certain forms of scleroderma lung disease, the study's high drop-out rate, choice of forced vital capacity as a primary outcome, side-effect profile of the drug and overall significance of the results make the conclusions difficult to incorporate into clinical practice.
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Affiliation(s)
- Steffan Schulz
- Thomas Jefferson University, Division of Rheumatology, 613 Curtis Building, 1015 Walnut Street, Philadelphia, PA 19107, USA.
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Colin G, Nunes H, Hatron PY, Cadranel J, Tillie I, Wallaert B. Étude des pneumopathies interstitielles diffuses de la connectivite mixte. Rev Mal Respir 2010; 27:238-46. [DOI: 10.1016/j.rmr.2010.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 09/16/2009] [Indexed: 10/19/2022]
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Goldin J, Elashoff R, Kim HJ, Yan X, Lynch D, Strollo D, Roth MD, Clements P, Furst DE, Khanna D, Vasunilashorn S, Li G, Tashkin DP. Treatment of scleroderma-interstitial lung disease with cyclophosphamide is associated with less progressive fibrosis on serial thoracic high-resolution CT scan than placebo: findings from the scleroderma lung study. Chest 2010; 136:1333-1340. [PMID: 19892673 DOI: 10.1378/chest.09-0108] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The Scleroderma Lung Study (SLS) demonstrated significant treatment-associated improvements in pulmonary function and symptoms when patients with scleroderma-related interstitial lung disease (SSc-ILD) were treated with a 1-year course of cyclophosphamide (CYC) in a randomized, double-blinded, placebo-controlled clinical trial. This study examined thoracic high-resolution CT (HRCT) scans obtained during the SLS for treatment-associated changes over time. METHODS Ninety-eight of the 158 subjects (CYC group, 49 subjects; placebo group, 49 subjects) participating in the SLS underwent thoracic HRCT scans both at baseline and after 12 months of treatment, which were available for analysis. Two independent radiologists visually scored the baseline HRCT scans for the presence of ground-glass opacities (GGOs), fibrosis (FIB), and honeycomb cysts (HCs) on a scale of 0 to 4. The treatment effect at 12 months was assessed by a blinded comparison of baseline and follow-up scans for evidence of stability and improvement (not worse) or deterioration (worse). RESULTS At the end of treatment, FIB was significantly worse in the placebo treatment group than in the CYC treatment group (p = 0.014). Furthermore, differences in the 12-month change in FIB between the CYC and placebo groups correlated significantly with other outcome measures, including the 12-month changes in FVC (p < 0.05), total lung capacity (p < 0.05), and dyspnea (p < 0.001) scores. However, no differences were noted between the two groups with respect to changes in either GGOs or HCs. CONCLUSIONS A 1-year course of treatment of SSc-ILD with CYC was associated with treatment-related changes in FIB scores on HRCT scans, which correlated with other measures of treatment response. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00004563.
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Affiliation(s)
- Jonathan Goldin
- Department of Radiologic Sciences, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Robert Elashoff
- Department of Biomathematics , School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Hyun J Kim
- Department of Radiologic Sciences, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Xaiohong Yan
- Department of Biomathematics , School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - David Lynch
- Department of Radiologic Sciences, National Jewish Hospital, Denver, CO
| | - Diane Strollo
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael D Roth
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Philip Clements
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Daniel E Furst
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Srainnapha Vasunilashorn
- Department of Radiologic Sciences, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Gang Li
- Department of David Geffen School of Medicine, and the Department of Biostatistics, School of Public Health, University of California Los Angeles, Los Angeles, CA
| | - Donald P Tashkin
- Department of Medicine, School of Public Health, University of California Los Angeles, Los Angeles, CA.
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Abstract
Although neither lung biopsy nor bronchoalveolar lavage (BAL) is recommended for routine clinical use in patients with SSc, studies employing lung biopsy material and BAL fluid (BALF) have provided insight into the pathogenesis of scleroderma-associated interstitial lung disease (SSc-ILD). Most often, SSc-ILD is classified as a non-specific interstitial pneumonia, with abundant myofibroblasts and evidence of both epithelial cell and endothelial cell injury. Recently, SSc-ILD fibroblasts have been shown to express reduced levels of the caveolin-1 protein which, in turn, may lead to activation of the signalling molecules associated with increased collagen production and overexpression of alpha-smooth muscle cell actin (alpha-SMA). BALF often contains increased numbers of inflammatory cells as well as myofibroblasts expressing alpha-SMA. Analysis of BALF suggests an imbalance between pro-fibrotic and anti-fibrotic factors, e.g. an overabundance of TGF-beta, connective tissue growth factor (CTGF), PDGF, leucotriene B4, etc. and in some cases a deficiency of hepatocyte growth factor, 15-hydroxyeicosatetraenoic acid (15-HETE), lipoxin A, etc. Until the pathogenesis is fully understood, lung biopsy and BAL will remain useful research tools to better understand the inflammatory and fibrosing processes that underlie SSc-ILD.
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Affiliation(s)
- R M Silver
- Department of Medicine, Division of Rheumatology & Immunology, Medical University of South Carolina, Charleston, SC 29425, USA.
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Hara T, Ogawa F, Yanaba K, Iwata Y, Muroi E, Komura K, Takenaka M, Shimizu K, Hasegawa M, Fujimoto M, Sato S. Elevated serum concentrations of polymorphonuclear neutrophilic leukocyte elastase in systemic sclerosis: association with pulmonary fibrosis. J Rheumatol 2009; 36:99-105. [PMID: 19208531 DOI: 10.3899/jrheum.080269] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the serum concentrations and clinical association of polymorphonuclear neutrophilic leukocyte (PMN) elastase in patients with systemic sclerosis (SSc). METHODS Serum PMN elastase levels from 21 patients with limited cutaneous SSc (lSSc) and 32 with diffuse cutaneous SSc (dSSc) were examined by ELISA. RESULTS Serum PMN elastase levels were elevated in patients with SSc, especially dSSc, compared to healthy controls. SSc patients with elevated serum PMN elastase levels had more frequent presence of pulmonary fibrosis, arthritis, contracture of phalanges, and diffuse pigmentation. Anticentromere antibody was detected less frequently in SSc patients with elevated serum PMN elastase levels than in controls. Consistently, serum PMN elastase levels also correlated positively with serum levels of KL-6 and surfactant protein-D, serological markers for pulmonary fibrosis. Serum PMN elastase levels were also associated with levels of serum 8-isoprostane, an oxidative stress marker in SSc. CONCLUSION Serum PMN elastase levels were elevated in patients with SSc, and it was more prominent in patients with pulmonary fibrosis, suggesting that serum PMN elastase is a novel serological marker for SSc-related pulmonary fibrosis.
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Affiliation(s)
- Toshihide Hara
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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Hant FN, Ludwicka-Bradley A, Wang HJ, Li N, Elashoff R, Tashkin DP, Silver RM. Surfactant protein D and KL-6 as serum biomarkers of interstitial lung disease in patients with scleroderma. J Rheumatol 2009; 36:773-80. [PMID: 19286849 DOI: 10.3899/jrheum.080633] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess whether serum concentrations of surfactant protein D (SP-D) and Krebs von den Lungen-6 (KL-6), glycoproteins expressed by type II pneumocytes, correlate with the presence of "alveolitis" and measures of lung function in patients enrolled in the Scleroderma Lung Study (SLS). METHODS Serum obtained at baseline screening of patients with systemic sclerosis (SSc, scleroderma) in the SLS was assayed. "Alveolitis" was defined by either bronchoalveolar lavage or thoracic high-resolution computed tomography (HRCT) by SLS criteria. SP-D and KL-6 levels were measured by ELISA in 66 SSc patients (44 with "alveolitis," 22 without "alveolitis") and in 10 healthy controls. These were compared to clinical measures of lung disease and "alveolitis" in the SLS patients. RESULTS SP-D levels were 300+/-214 ng/ml (mean+/-SD) in the SSc patients compared to 40+/-51 ng/ml in controls (p<0.0001). KL-6 levels were 1225+/-984 U/ml in the SSc patients and 333+/-294 U/ml in controls (p<0.0001). SSc patients with "alveolitis" had higher levels of both SP-D and KL-6 than those without "alveolitis." The level of SP-D was 353+/-219 ng/ml in patients with "alveolitis" and 161+/-143 ng/ml without "alveolitis" (p=0.0002). The level of KL-6 was 1458+/-1070 U/ml in patients with "alveolitis" and 640+/-487 U/ml without "alveolitis" (p=0.0001). Receiver operator characteristic curve analysis demonstrated high sensitivity and specificity of both SP-D and KL-6 for the determination of "alveolitis." KL-6 and SP-D were positively correlated with maximum fibrosis scores, but not with maximum ground-glass opacities, on HRCT. CONCLUSION Serum levels of SP-D and KL-6 appear to be indicative of "alveolitis" in SSc patients as defined by the SLS, and are significantly higher than in SSc patients without "alveolitis." Serum SP-D and KL-6 may serve as noninvasive serological means of assessing interstitial lung disease in patients with SSc.
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Affiliation(s)
- Faye N Hant
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 912, Charleston, SC 29425-6370, USA.
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Branley HM, du Bois RM, Wells AU, Jones HA. PET scanning of macrophages in patients with scleroderma fibrosing alveolitis. Nucl Med Biol 2008; 35:901-9. [DOI: 10.1016/j.nucmedbio.2008.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 08/11/2008] [Accepted: 10/01/2008] [Indexed: 11/17/2022]
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Abstract
Gene expression studies in scleroderma have shown large and consistent changes in the gene expression of end-target tissues. These changes reflect the lymphocyte infiltration and pathway deregulation potentially linked to disease pathogenesis. Gene expression in scleroderma also reflects the clinical heterogeneity in the disease and can be used to categorize patients. Contained within these gene expression signatures are groups of genes that could serve as biomarkers for clinical end points and disease activity. The use of mechanism-derived gene expression signatures in scleroderma will provide a better understanding of the deregulated pathways contributing to disease pathogenesis.
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Wehling-Henricks M, Sokolow S, Lee JJ, Myung KH, Villalta SA, Tidball JG. Major basic protein-1 promotes fibrosis of dystrophic muscle and attenuates the cellular immune response in muscular dystrophy. Hum Mol Genet 2008; 17:2280-92. [PMID: 18430716 DOI: 10.1093/hmg/ddn129] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The immune response to dystrophin-deficient muscle promotes the pathology of Duchenne muscular dystrophy (DMD) and the mdx mouse model of DMD. In this investigation, we find that the release of major basic protein (MBP) by eosinophils is a prominent feature of DMD and mdx dystrophy and that eosinophils lyse muscle cells in vitro by the release of MBP-1. We also show that eosinophil depletions of mdx mice by injections of anti-chemokine receptor-3 reduce muscle cell lysis, although lysis of mdx muscle membranes is not reduced by null mutation of MBP-1 in vivo. However, ablation of MBP-1 expression in mdx mice produces other effects on muscular dystrophy. First, fibrosis of muscle and hearts, a major cause of mortality in DMD, is greatly reduced by null mutation of MBP-1 in mdx mice. Furthermore, either ablation of MBP-1 or eosinophil depletion causes large increases in cytotoxic T-lymphocytes (CTLs) in mdx muscles. The increase in CTLs in MBP-1-null mice does not reflect a general shift toward a Th1 inflammatory response, because the mutation had no significant effect on the expression of interferon-gamma, inducible nitric oxide synthase or tumor necrosis factor. Rather, MBP-1 reduces the activation and proliferation of splenocytes in vitro, indicating that MBP-1 acts in a more specific immunomodulatory role to affect the inflammatory response in muscular dystrophy. Together, these findings show that eosinophil-derived MBP-1 plays a significant role in regulating muscular dystrophy by attenuating the cellular immune response and promoting tissue fibrosis that can eventually contribute to increased mortality.
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Affiliation(s)
- Michelle Wehling-Henricks
- Department of Physiological Science, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA90095-1606, USA
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Abstract
INTRODUCTION Interstitial lung diseases (ILD) in systemic sclerosis (SSc) are mainly encountered in patients with diffuse disease although they may occur less frequently in patients with limited cutaneous disease. BACKGROUND In SSc early detection of ILD should be achieved by high resolution computed tomography and pulmonary function tests, including measurement of DLCO. In total up to 75% of patients with SSc develop ILD but it is progressive in only a minority of patients. Unlike idiopathic ILD, SSc associated ILD corresponds to non-specific interstitial pneumonia rather than usual interstitial pneumonia in the majority of cases. This explains the better prognosis of SSc associated ILD compared with idiopathic ILD. Nevertheless ILD represents one of the two main causes of death in SSc. VIEWPOINT The treatment of SSc associated ILD is not well established. Anti-fibrosing treatments have failed to demonstrate benefit and cyclophosphamide, which has been used for about 15 years in the treatment of this condition, has recently been evaluated in two prospective randomised studies which showed a significant but modest effect on respiratory function. CONCLUSION A subgroup of patients with rapidly progressive ILD might benefit from pulsed intravenous cyclophosphamide combined with prednisone 15 mg daily, but this remains to be confirmed.
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Affiliation(s)
- L Mouthon
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour la sclérodermie systémique, Assistance Publique-Hôpitaux de Paris et Université Paris-Descartes, Faculté de Médecine Paris-Descartes, Paris, France.
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Bérezné A, Valeyre D, Ranque B, Guillevin L, Mouthon L. Interstitial lung disease associated with systemic sclerosis: what is the evidence for efficacy of cyclophosphamide? Ann N Y Acad Sci 2007; 1110:271-84. [PMID: 17911442 DOI: 10.1196/annals.1423.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc) that may be responsible for severe restrictive lung disease and represents one of the two main causes of disease-related death in SSc patients. Since 1993, the beneficial effect of oral or intravenous cyclophosphamide (CYC) in the treatment of SSc-related ILD has been reported in retrospective studies, one study showing improvement of pulmonary function test scores and/or chest computed tomography at 1 year and improvement of survival at 16 months. The results of two controlled trials were recently reported. The Scleroderma Lung Study, a prospective randomized placebo-controlled trial, included 158 patients of whom 145 completed at least 6 months of treatment. The course of forced vital capacity (primary outcome) adjusted at 1 year was significantly better in the group treated with oral CYC (P < 0.03), although the effect of CYC was minor. The Fibrosing Alveolitis in Scleroderma Trial (FAST) included 45 patients with SSc-related ILD who were randomized to receive prednisolone (20 mg per day) and 6 CYC infusions (600 mg/m monthly) or placebo. This trial did not demonstrate significant improvement of the primary or secondary endpoints in the active treatment group versus placebo. Since with the exception of the study of Silver et al. none of the patients included in retrospective or prospective studies were selected on the basis of progression of ILD. Since only a minority of SSc patients develops severe ILD, we propose that further studies evaluating CYC should focus on the subgroup of SSc patients with worsening ILD.
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Affiliation(s)
- Alice Bérezné
- Paris Descartes University, Faculty of Medicine, UPRES EA 4058, Department of Internal Medicine and Reference Center for Necrotizing Vasculitides and Systemic Sclerosis, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
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Mittoo S, Wigley FM, Wise R, Xiao H, Hummers L. Persistence of abnormal bronchoalveolar lavage findings after cyclophosphamide treatment in scleroderma patients with interstitial lung disease. ACTA ACUST UNITED AC 2007; 56:4195-202. [DOI: 10.1002/art.23077] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Gabrielli A, Svegliati S, Moroncini G, Luchetti M, Tonnini C, Avvedimento EV. Stimulatory autoantibodies to the PDGF receptor: A link to fibrosis in scleroderma and a pathway for novel therapeutic targets. Autoimmun Rev 2007; 7:121-6. [DOI: 10.1016/j.autrev.2007.02.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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