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Huang BK, Elicker BM, Henry TS, Kallianos KG, Hahn LD, Tang M, Heng F, McCulloch CE, Bhakta NR, Majumdar S, Choi J, Denlinger LC, Fain SB, Hastie AT, Hoffman EA, Israel E, Jarjour NN, Levy BD, Mauger DT, Sumino K, Wenzel SE, Castro M, Woodruff PG, Fahy JV, Sarp FTNSARP. Persistent mucus plugs in proximal airways are consequential for airflow limitation in asthma. JCI Insight 2024; 9:e174124. [PMID: 38127464 DOI: 10.1172/jci.insight.174124] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUNDInformation about the size, airway location, and longitudinal behavior of mucus plugs in asthma is needed to understand their role in mechanisms of airflow obstruction and to rationally design muco-active treatments.METHODSCT lung scans from 57 patients with asthma were analyzed to quantify mucus plug size and airway location, and paired CT scans obtained 3 years apart were analyzed to determine plug behavior over time. Radiologist annotations of mucus plugs were incorporated in an image-processing pipeline to generate size and location information that was related to measures of airflow.RESULTSThe length distribution of 778 annotated mucus plugs was multimodal, and a 12 mm length defined short ("stubby", ≤12 mm) and long ("stringy", >12 mm) plug phenotypes. High mucus plug burden was disproportionately attributable to stringy mucus plugs. Mucus plugs localized predominantly to airway generations 6-9, and 47% of plugs in baseline scans persisted in the same airway for 3 years and fluctuated in length and volume. Mucus plugs in larger proximal generations had greater effects on spirometry measures than plugs in smaller distal generations, and a model of airflow that estimates the increased airway resistance attributable to plugs predicted a greater effect for proximal generations and more numerous mucus plugs.CONCLUSIONPersistent mucus plugs in proximal airway generations occur in asthma and demonstrate a stochastic process of formation and resolution over time. Proximal airway mucus plugs are consequential for airflow and are in locations amenable to treatment by inhaled muco-active drugs or bronchoscopy.TRIAL REGISTRATIONClinicaltrials.gov; NCT01718197, NCT01606826, NCT01750411, NCT01761058, NCT01761630, NCT01716494, and NCT01760915.FUNDINGAstraZeneca, Boehringer-Ingelheim, Genentech, GlaxoSmithKline, Sanofi-Genzyme-Regeneron, and TEVA provided financial support for study activities at the Coordinating and Clinical Centers beyond the third year of patient follow-up. These companies had no role in study design or data analysis, and the only restriction on the funds was that they be used to support the SARP initiative.
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Affiliation(s)
- Brendan K Huang
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Travis S Henry
- Department of Radiology, Duke University, Durham, North Carolina, USA
| | - Kimberly G Kallianos
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Lewis D Hahn
- Department of Radiology, UCSD, San Diego, California, USA
| | - Monica Tang
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and
| | | | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
| | - Nirav R Bhakta
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and
| | - Sharmila Majumdar
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Jiwoong Choi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Loren C Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sean B Fain
- Department of Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Annette T Hastie
- Department of Internal Medicine, Section for Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nizar N Jarjour
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dave T Mauger
- Division of Biostatistics and Bioinformatics, Penn State College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Kaharu Sumino
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, USA
| | - Sally E Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Prescott G Woodruff
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and
- Cardiovascular Research Institute and
| | - John V Fahy
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and
- Cardiovascular Research Institute and
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Elicker BM. Radiologists' Imminent Demise at the Hand of Artificial Intelligence: Not Quite Yet! Radiol Cardiothorac Imaging 2023; 5:e230089. [PMID: 37124640 PMCID: PMC10141445 DOI: 10.1148/ryct.230089] [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: 03/29/2023] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
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Elicker BM. Chronic Obstructive Pulmonary Disease and Small Airways Diseases. Semin Respir Crit Care Med 2022; 43:825-838. [PMID: 36252610 DOI: 10.1055/s-0042-1755567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The small airways are a common target of injury within the lungs and may be affected by a wide variety of inhaled, systemic, and other disorders. Imaging is critical in the detection and diagnosis of small airways disease since significant injury may occur prior to pulmonary function tests showing abnormalities. The goal of this article is to describe the typical imaging findings and patterns of small airways diseases. An approach which divides the imaging appearances into four categories (tree-in-bud opacities, poorly defined centrilobular nodules, mosaic attenuation, and emphysema) will provide a framework in which to formulate appropriate and focused differential diagnoses.
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Affiliation(s)
- Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
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Tang M, Elicker BM, Henry T, Gierada DS, Schiebler ML, Huang BK, Peters MC, Castro M, Hoffman EA, Fain SB, Ash SY, Choi J, Hall C, Phillips BR, Mauger DT, Denlinger LC, Jarjour NN, Israel E, Phipatanakul W, Levy BD, Wenzel SE, Bleecker ER, Woodruff PG, Fahy JV, Dunican EM. Mucus Plugs Persist in Asthma, and Changes in Mucus Plugs Associate with Changes in Airflow over Time. Am J Respir Crit Care Med 2022; 205:1036-1045. [PMID: 35104436 PMCID: PMC9851493 DOI: 10.1164/rccm.202110-2265oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [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: 10/05/2021] [Accepted: 01/31/2022] [Indexed: 02/07/2023] Open
Abstract
Rationale: Cross-sectional analysis of mucus plugs in computed tomography (CT) lung scans in the Severe Asthma Research Program (SARP)-3 showed a high mucus plug phenotype. Objectives: To determine if mucus plugs are a persistent asthma phenotype and if changes in mucus plugs over time associate with changes in lung function. Methods: In a longitudinal analysis of baseline and Year 3 CT lung scans in SARP-3 participants, radiologists generated mucus plug scores to assess mucus plug persistence over time. Changes in mucus plug score were analyzed in relation to changes in lung function and CT air trapping measures. Measurements and Main Results: In 164 participants, the mean (range) mucus plug score was similar at baseline and Year 3 (3.4 [0-20] vs. 3.8 [0-20]). Participants and bronchopulmonary segments with a baseline plug were more likely to have plugs at Year 3 than those without baseline plugs (risk ratio, 2.8; 95% confidence interval [CI], 2.0-4.1; P < 0.001; and risk ratio, 5.0; 95% CI, 4.5-5.6; P < 0.001, respectively). The change in mucus plug score from baseline to Year 3 was significantly negatively correlated with change in FEV1% predicted (rp = -0.35; P < 0.001) and with changes in CT air trapping measures (all P values < 0.05). Conclusions: Mucus plugs identify a persistent asthma phenotype, and susceptibility to mucus plugs occurs at the subject and the bronchopulmonary segment level. The association between change in mucus plug score and change in airflow over time supports a causal role for mucus plugs in mechanisms of airflow obstruction in asthma.
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Affiliation(s)
- Monica Tang
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | | | - Travis Henry
- Duke Radiology, Department of Radiology, Duke University, Durham, North Carolina
| | - David S. Gierada
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Mark L. Schiebler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brendan K. Huang
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Michael C. Peters
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Eric A. Hoffman
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Sean B. Fain
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Samuel Y. Ash
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jiwoong Choi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Chase Hall
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas School of Medicine, Kansas City, Kansas
| | - Brenda R. Phillips
- Center for Biostatistics and Epidemiology, Pennsylvania State University School of Medicine, Harrisburg, Pennsylvania
| | - David T. Mauger
- Division of Biostatistics and Bioinformatics, Penn State College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Loren C. Denlinger
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nizar N. Jarjour
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Elliot Israel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Wanda Phipatanakul
- Asthma, Allergy, Dermatology, Rheumatology, and Immunology, Boston Children’s Hospital, Boston, Massachusetts
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sally E. Wenzel
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eugene R. Bleecker
- Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Prescott G. Woodruff
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - John V. Fahy
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Eleanor M. Dunican
- Education and Research Centre, St. Vincent’s University Hospital, Dublin, Ireland; and
- UCD School of Medicine, University College Dublin, Dublin, Ireland
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Affiliation(s)
- Brett M Elicker
- Professor of Clinical Radiology Chief, Cardiac & Pulmonary Imaging Section Department of Radiology & Biomedical Imaging University of California, San Francisco
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Elicker BM. Breakthrough COVID-19 Infections: What Are They and What Do They Look Like? Radiol Cardiothorac Imaging 2022; 4:e210301. [PMID: 35782761 PMCID: PMC8893206 DOI: 10.1148/ryct.210301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Brett M. Elicker
- From the Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143
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7
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Mummy DG, Dunican EM, Carey KJ, Evans MD, Elicker BM, Newell JD, Gierada DS, Nagle SK, Schiebler ML, Sorkness RL, Jarjour NN, Denlinger LC, Fahy JV, Fain SB. Mucus Plugs in Asthma at CT Associated with Regional Ventilation Defects at 3He MRI. Radiology 2021; 303:184-190. [PMID: 34931858 PMCID: PMC8962781 DOI: 10.1148/radiol.2021204616] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background Airway mucus plugs in asthma are associated with exacerbation frequency, increased eosinophilia, and reduced lung function. The relationship between mucus plugs and spatially overlapping ventilation abnormalities observed at hyperpolarized gas MRI has not been assessed quantitatively. Purpose To assess regional associations between CT mucus plugs scored by individual bronchopulmonary segment and corresponding measurements of segmental ventilation defect percentage (VDP) at hyperpolarized helium 3 (3He) MRI. Materials and Methods In this secondary analysis of a Health Insurance Portability and Accountability Act-compliant prospective observational cohort, participants in the Severe Asthma Research Program (SARP) III (NCT01760915) between December 2012 and August 2015 underwent hyperpolarized 3He MRI to determine segmental VDP. Segmental mucus plugs at CT were scored by two readers, with segments scored as plugged only if both readers agreed independently. A linear mixed-effects model controlling for interpatient variability was then used to assess differences in VDP in plugged versus plug-free segments. Results Forty-four participants with asthma were assessed (mean age ± standard deviation, 47 years ± 15; 29 women): 19 with mild-to-moderate asthma and 25 with severe asthma. Mucus plugs were observed in 49 total bronchopulmonary segments across eight of 44 patients. Segments containing mucus plugs had a median segmental VDP of 25.9% (25th-75th percentile, 7.3%-38.3%) versus 1.4% (25th-75th percentile, 0.1%-5.2%; P < .001) in plug-free segments. Similarly, the model estimated a segmental VDP of 18.9% (95% CI: 15.7, 22.2) for mucus-plugged segments versus 5.1% (95% CI: 3.3, 7.0) for plug-free segments (P < .001). Participants with one or more mucus plugs had a median whole-lung VDP of 11.1% (25th-75th percentile, 7.1%-18.9%) versus 3.1% (25th-75th percentile, 1.1%-4.4%) in those without plugs (P < .001). Conclusion Airway mucus plugging at CT was associated with reduced ventilation in the same bronchopulmonary segment at hyperpolarized helium 3 MRI, suggesting that mucus plugging may be an important cause of ventilation defects in asthma. © RSNA, 2021 Online supplemental material is available for this article.
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Liu S, Chung MP, Ley B, French S, Elicker BM, Fiorentino DF, Chung LS, Boin F, Wolters PJ. Peripheral blood leucocyte telomere length is associated with progression of interstitial lung disease in systemic sclerosis. Thorax 2021; 76:1186-1192. [PMID: 34272332 DOI: 10.1136/thoraxjnl-2020-215918] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Peripheral blood leucocyte telomere length (PBL-TL) is associated with outcomes in patients with idiopathic pulmonary fibrosis. Whether PBL-TL is associated with progression of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is unknown. METHODS A retrospective observational cohort study was performed using prospectively collected data from 213 patients with SSc followed at the University of California San Francisco (UCSF) Scleroderma Center. PBL-TL was measured by quantitative PCR of DNA isolated from peripheral blood. Associations between PBL-TL and pulmonary function test trends in patients with SSc-ILD were assessed by longitudinal analysis using Generalised Linear Mixed Models. Findings were validated in a cohort of 61 patients with SSc-ILD enrolled in the Stanford University Scleroderma Center database. RESULTS Patients with UCSF SSc with ILD were found to have shorter PBL-TL compared with those without ILD (6554±671 base pairs (bp) vs 6782±698 bp, p=0.01). Shorter PBL-TL was associated with the presence of ILD (adjusted OR 2.1 per 1000 bp TL decrease, 95% CI [1.25 to 3.70], p=0.006). PBL-TL was shorter in patients with SSc-ILD lacking SSc-specific autoantibodies compared with seropositive subjects (6237±647 bp vs 6651±653 bp, p=0.004). Shorter PBL-TL was associated with increased risk for lung function deterioration with an average of 67 mL greater loss in per year for every 1000 bp decrease in PBL-TL in the combined SSc-ILD cohorts (longitudinal analysis, adjusted model: 95% CI -104 mL to -33 mL, p<0.001). CONCLUSIONS These findings suggest that telomere dysfunction may be associated with SSc-ILD progression and that PBL-TL measurement may be useful for stratifying risk for SSc-ILD progression.
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Affiliation(s)
- Shuo Liu
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA.,Pulmonary and Critical Care Medicine, Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Melody P Chung
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Brett Ley
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sarah French
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Brett M Elicker
- Division of Radiology, University of California San Francisco, San Francisco, California, USA
| | - David F Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Lorinda S Chung
- Division of Immunology and Rheumatology, Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Paul J Wolters
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Dunican EM, Elicker BM, Henry T, Gierada DS, Schiebler ML, Anderson W, Barjaktarevic I, Barr RG, Bleecker ER, Boucher RC, Bowler R, Christenson SA, Comellas A, Cooper CB, Couper D, Criner GJ, Dransfield M, Doerschuk CM, Drummond MB, Hansel NN, Han MK, Hastie AT, Hoffman EA, Krishnan JA, Lazarus SC, Martinez FJ, McCulloch CE, O’Neal WK, Ortega VE, Paine R, Peters S, Schroeder JD, Woodruff PG, Fahy JV. Mucus Plugs and Emphysema in the Pathophysiology of Airflow Obstruction and Hypoxemia in Smokers. Am J Respir Crit Care Med 2021; 203:957-968. [PMID: 33180550 PMCID: PMC8048745 DOI: 10.1164/rccm.202006-2248oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [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: 06/08/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022] Open
Abstract
Rationale: The relative roles of mucus plugs and emphysema in mechanisms of airflow limitation and hypoxemia in smokers with chronic obstructive pulmonary disease (COPD) are uncertain.Objectives: To relate image-based measures of mucus plugs and emphysema to measures of airflow obstruction and oxygenation in patients with COPD.Methods: We analyzed computed tomographic (CT) lung images and lung function in participants in the Subpopulations and Intermediate Outcome Measures in COPD Study. Radiologists scored mucus plugs on CT lung images, and imaging software automatically quantified emphysema percentage. Unadjusted and adjusted relationships between mucus plug score, emphysema percentage, and lung function were determined using regression.Measurements and Main Results: Among 400 smokers, 229 (57%) had mucus plugs and 207 (52%) had emphysema, and subgroups could be identified with mucus-dominant and emphysema-dominant disease. Only 33% of smokers with high mucus plug scores had mucus symptoms. Mucus plug score and emphysema percentage were independently associated with lower values for FEV1 and peripheral oxygen saturation (P < 0.001). The relationships between mucus plug score and lung function outcomes were strongest in smokers with limited emphysema (P < 0.001). Compared with smokers with low mucus plug scores, those with high scores had worse COPD Assessment Test scores (17.4 ± 7.7 vs. 14.4 ± 13.3), more frequent annual exacerbations (0.75 ± 1.1 vs. 0.43 ± 0.85), and shorter 6-minute-walk distance (329 ± 115 vs. 392 ± 117 m) (P < 0.001).Conclusions: Symptomatically silent mucus plugs are highly prevalent in smokers and independently associate with lung function outcomes. These data provide rationale for targeting patients with mucus-high/emphysema-low COPD in clinical trials of mucoactive treatments.Clinical trial registered with www.clinicaltrials.gov (NCT01969344).
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Affiliation(s)
- Eleanor M. Dunican
- Education and Research Centre, St. Vincent’s University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | | | - David S. Gierada
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Mark L. Schiebler
- Department of Medical Physics and
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Wayne Anderson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - R. Graham Barr
- Division of General Medicine, Department of Medicine, Columbia University, New York City, New York
| | - Eugene R. Bleecker
- Division of Genetics, Genomics, and Precision Medicine, Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - Russell Bowler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Stephanie A. Christenson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Cardiovascular Research Institute, and
| | - Alejandro Comellas
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine
| | - Christopher B. Cooper
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - David Couper
- Collaborative Studies Coordinating Center, Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pennsylvania
| | - Mark Dransfield
- Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Nadia N. Hansel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - MeiLan K. Han
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan at Ann Arbor, Ann Arbor, Michigan
| | - Annette T. Hastie
- Pulmonary, Critical Care, Allergy, and Immunologic Medicine, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Eric A. Hoffman
- Department of Radiology
- Department of Medicine, and
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa
| | - Jerry A. Krishnan
- Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Stephen C. Lazarus
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Cardiovascular Research Institute, and
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine and New York-Presbyterian Weill Cornell Medical Center, New York, New York
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, San Francisco, California
| | | | - Victor E. Ortega
- Pulmonary, Critical Care, Allergy, and Immunologic Medicine, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Robert Paine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah Hospitals and Clinics, Salt Lake City, Utah
- Department of Veterans Affairs Medical Center, Salt Lake City, Utah; and
| | - Stephen Peters
- Pulmonary, Critical Care, Allergy, and Immunologic Medicine, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Joyce D. Schroeder
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Prescott G. Woodruff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Cardiovascular Research Institute, and
| | - John V. Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
- Cardiovascular Research Institute, and
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Lee JS, La J, Aziz S, Dobrinskikh E, Brownell R, Jones KD, Achtar-Zadeh N, Green G, Elicker BM, Golden JA, Matthay MA, Kukreja J, Schwartz DA, Wolters PJ. Molecular markers of telomere dysfunction and senescence are common findings in the usual interstitial pneumonia pattern of lung fibrosis. Histopathology 2021; 79:67-76. [PMID: 33432658 PMCID: PMC8195814 DOI: 10.1111/his.14334] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 11/02/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 12/20/2022]
Abstract
AIMS Idiopathic pulmonary fibrosis (IPF) is a genetically mediated, age-associated, progressive form of pulmonary fibrosis characterised pathologically by a usual interstitial pneumonia (UIP) pattern of fibrosis. The UIP pattern is also found in pulmonary fibrosis attributable to clinical diagnoses other than IPF (non-IPF UIP), whose clinical course is similarly poor, suggesting common molecular drivers. This study investigates whether IPF and non-IPF UIP lungs similarly express markers of telomere dysfunction and senescence. METHODS AND RESULTS To test whether patients with IPF and non-IPF UIP share molecular drivers, lung tissues from 169 IPF patients and 57 non-IPF UIP patients were histopathologically and molecularly compared. Histopathological changes in both IPF and non-IPF UIP patients included temporal heterogeneity, microscopic honeycombing, fibroblast foci, and dense collagen fibrosis. Non-IPF UIP lungs were more likely to have lymphocytic infiltration, non-caseating granulomas, airway-centred inflammation, or small airways disease. Telomeres were shorter in alveolar type II (AECII) cells of both IPF and non-IPF UIP lungs than in those of age-similar, unused donor, controls. Levels of molecular markers of senescence (p16 and p21) were elevated in lysates of IPF and non-IPF UIP lungs. Immunostaining localised expression of these proteins to AECII cells. The mucin 5B (MUC5B) gene promoter variant minor allele frequency was similar between IPF and non-IPF UIP patients, and MUC5B expression was similar in IPF and non-IPF UIP lungs. CONCLUSIONS Molecular markers of telomere dysfunction and senescence are pathologically expressed in both IPF and non-IPF UIP lungs. These findings suggest that common molecular drivers may contribute to the pathogenesis of UIP-associated pulmonary fibrosis, regardless of the clinical diagnosis.
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Affiliation(s)
- Joyce S Lee
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA
| | - Janet La
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Sara Aziz
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Evgenia Dobrinskikh
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA
| | - Robert Brownell
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Natalia Achtar-Zadeh
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Gary Green
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Brett M Elicker
- Department of Radiology, University of California, San Francisco, CA, USA
| | - Jeffrey A Golden
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Michael A Matthay
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, San Francisco, CA, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, CA, USA
| | - David A Schwartz
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA
| | - Paul J Wolters
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA
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Elicker BM. Lung Nodule Risk Calculator and Cost-Effectiveness of Different Lung Cancer Screening Algorithms. Radiol Cardiothorac Imaging 2021; 3:e210050. [PMID: 33970153 PMCID: PMC8098093 DOI: 10.1148/ryct.2021210050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Brett M. Elicker
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143
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Affiliation(s)
- Brett M. Elicker
- From the Professor of Clinical Radiology Department of Radiology and Biomedical Imaging University of California, San Francisco Box 0628 San Francisco, CA 94143
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Elicker BM, Sohn JH. Radiomics and Computerized Analysis of CT Images: Looking Forward. Radiol Cardiothorac Imaging 2020; 2:e200589. [PMID: 33779641 PMCID: PMC7977988 DOI: 10.1148/ryct.2020200589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Brett M. Elicker
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, Box 0628, San Francisco, CA 94143
| | - Jae Ho Sohn
- From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, Box 0628, San Francisco, CA 94143
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14
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Ley B, Liu S, Elicker BM, Henry TS, Vittinghoff E, Golden JA, Jones KD, Wolters PJ. Telomere length in patients with unclassifiable interstitial lung disease: a cohort study. Eur Respir J 2020; 56:2000268. [PMID: 32341108 DOI: 10.1183/13993003.00268-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/31/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Brett Ley
- Dept of Medicine, University of California San Francisco, San Francisco, CA, USA
- Dept of Pulmonary and Critical Care Medicine, Kaiser Permanente San Francisco, San Francisco, CA, USA
| | - Shuo Liu
- Dept of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- Dept of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Travis S Henry
- Dept of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Dept of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Golden
- Dept of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Dept of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Paul J Wolters
- Dept of Medicine, University of California San Francisco, San Francisco, CA, USA
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15
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Kallianos KG, Muhoozi BN, Gottschalk A, Yom SS, Chan JW, Henry TS, Elicker BM, Ordovas KG, Naeger DM. Dedicated Diagnostic Radiology/Radiation Oncology Rounds: Added Value Beyond Traditional Tumor Boards. Curr Probl Diagn Radiol 2020; 49:248-253. [DOI: 10.1067/j.cpradiol.2019.05.004] [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: 01/22/2019] [Revised: 04/15/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
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16
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Ward LM, Peluso MJ, Budak JZ, Elicker BM, Chin-Hong PV, Lampiris H, Mulliken JS. Opportunistic coinfection with Pneumocystis jirovecii and Coccidioides immitis associated with idelalisib treatment in a patient with chronic lymphocytic leukaemia. BMJ Case Rep 2020; 13:13/4/e234113. [PMID: 32354764 DOI: 10.1136/bcr-2019-234113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of opportunistic coinfections with Coccidioides immitis and Pneumocystis jirovecii following treatment with idelalisib, a phosphoinositide 3-kinase inhibitor, for chronic lymphocytic leukaemia. This is the first case of pulmonary coccidioidomycosis reported in association with idelalisib. We review challenges related to diagnosis of opportunistic infections in this context. This report illustrates (1) the uncommon occurrence of two opportunistic infections concurrently or in rapid succession, (2) the importance of maintaining a broad differential diagnosis in the setting of an atypical imaging finding, slow clinical response or when immunomodulatory drugs are used, and (3) the challenges associated with non-invasive serological testing in individuals with haematological malignancy on immunomodulatory therapy.
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Affiliation(s)
- Lindsey M Ward
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Michael J Peluso
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA .,Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Jehan Z Budak
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Brett M Elicker
- Division of Radiology, University of California, San Francisco, California, USA
| | - Peter V Chin-Hong
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Harry Lampiris
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA.,Infectious Disease Section, Medical Service, San Francisco Veterans' Affairs Medical Center, San Francisco, California, USA
| | - Jennifer S Mulliken
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA.,Infectious Disease Section, Medical Service, San Francisco Veterans' Affairs Medical Center, San Francisco, California, USA
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Affiliation(s)
- Jeffrey P Kanne
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, MC 3252, Madison, WI 53792-3252 (J.P.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (B.P.L.); Department of Radiology, University of Chicago, Chicago, Ill (J.H.C.); Department of Radiology, University of California San Francisco, San Francisco, Calif (B.M.E.); and Department of Radiology, University of New Mexico, Albuquerque, NM (L.H.K.)
| | - Brent P Little
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, MC 3252, Madison, WI 53792-3252 (J.P.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (B.P.L.); Department of Radiology, University of Chicago, Chicago, Ill (J.H.C.); Department of Radiology, University of California San Francisco, San Francisco, Calif (B.M.E.); and Department of Radiology, University of New Mexico, Albuquerque, NM (L.H.K.)
| | - Jonathan H Chung
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, MC 3252, Madison, WI 53792-3252 (J.P.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (B.P.L.); Department of Radiology, University of Chicago, Chicago, Ill (J.H.C.); Department of Radiology, University of California San Francisco, San Francisco, Calif (B.M.E.); and Department of Radiology, University of New Mexico, Albuquerque, NM (L.H.K.)
| | - Brett M Elicker
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, MC 3252, Madison, WI 53792-3252 (J.P.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (B.P.L.); Department of Radiology, University of Chicago, Chicago, Ill (J.H.C.); Department of Radiology, University of California San Francisco, San Francisco, Calif (B.M.E.); and Department of Radiology, University of New Mexico, Albuquerque, NM (L.H.K.)
| | - Loren H Ketai
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, MC 3252, Madison, WI 53792-3252 (J.P.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (B.P.L.); Department of Radiology, University of Chicago, Chicago, Ill (J.H.C.); Department of Radiology, University of California San Francisco, San Francisco, Calif (B.M.E.); and Department of Radiology, University of New Mexico, Albuquerque, NM (L.H.K.)
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18
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Elicker BM. Core-Needle Biopsy versus Fine-Needle Aspiration Biopsy in Patients with Hematologic Malignancy: Weighing the Risks and Benefits. Radiol Cardiothorac Imaging 2019; 1:e190232. [PMID: 33779638 PMCID: PMC7977691 DOI: 10.1148/ryct.2019190232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 12/02/2019] [Indexed: 06/12/2023]
Affiliation(s)
- Brett M. Elicker
- From the Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143
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19
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Ley B, Torgerson DG, Oldham JM, Adegunsoye A, Liu S, Li J, Elicker BM, Henry TS, Golden JA, Jones KD, Dressen A, Yaspan BL, Arron JR, Noth I, Hoffmann TJ, Wolters PJ. Rare Protein-Altering Telomere-related Gene Variants in Patients with Chronic Hypersensitivity Pneumonitis. Am J Respir Crit Care Med 2019; 200:1154-1163. [PMID: 31268371 PMCID: PMC6888660 DOI: 10.1164/rccm.201902-0360oc] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [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: 02/16/2019] [Accepted: 07/02/2019] [Indexed: 12/30/2022] Open
Abstract
Rationale: Rare genetic variants in telomere-related genes have been identified in familial, idiopathic, and rheumatoid arthritis-associated pulmonary fibrosis. Short peripheral blood leukocyte (PBL) telomere length predicts poor outcomes in chronic hypersensitivity pneumonitis (CHP).Objectives: Determine the prevalence and clinical relevance of rare protein-altering variants in telomere-related genes in patients with CHP.Methods: Next-generation sequences from two CHP cohorts were analyzed to identify variants in TERT (telomerase reverse transcriptase), TERC (telomerase RNA component), DKC1 (dyskerin pseudouridine synthase 1), RTEL1 (regulator of telomere elongation helicase 1), PARN (poly[A]-specific RNase), and TINF2 (TERF1-interacting nuclear factor 2). To qualify, variants were required to have a minor allele frequency less than 0.005 and be predicted to be damaging to protein function. Variant status (binary variable) was used in statistical association tests, including Cox proportional hazard models for transplant-free survival. PBL telomere length was measured using quantitative PCR.Measurements and Main Results: Qualifying variants were identified in 16 of 144 patients (11.1%; 95% confidence interval [CI], 6.5-17.4) in the discovery cohort and 17 of 209 patients (8.1%; 95% CI, 4.8-12.7) in the replication cohort. Age- and ancestry-adjusted PBL telomere length was significantly shorter in the presence of a variant in both cohorts (discovery: -561 bp; 95% CI, -933 to -190; P = 0.003; replication: -612 bp; 95% CI, -870 to -354; P = 5.30 × 10-6). Variant status was significantly associated with transplant-free survival in both cohorts (discovery: age-, sex-, and ancestry-adjusted hazard ratio, 3.73; 95% CI, 1.92-7.28; P = 0.0001; replication: hazard ratio, 2.72; 95% CI, 1.26-5.88; P = 0.011).Conclusions: A substantial proportion of patients diagnosed with CHP have rare, protein-altering variants in telomere-related genes, which are associated with short peripheral blood telomere length and significantly reduced transplant-free survival.
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Affiliation(s)
| | - Dara G. Torgerson
- Department of Human Genetics, McGill University and Genome Quebec Innovation Centre, Montreal, Quebec, Canada
| | - Justin M. Oldham
- Department of Medicine, University of California Davis, Davis, California
| | | | - Shuo Liu
- Department of Respiratory Medicine, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Jie Li
- University of California Davis Bioinformatics Core, Davis, California
| | | | | | | | | | - Amy Dressen
- Genentech, South San Francisco, California; and
| | | | | | - Imre Noth
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Thomas J. Hoffmann
- Department of Epidemiology and Biostatistics, Institute for Human Genetics, University of California San Francisco, San Francisco, California
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Abstract
Imaging, specifically computed tomography (CT), is a key component in the characterization, management, and follow-up of patients with connective tissue disease (CTD)-related diffuse lung disease. The main role of CT is to help direct treatment by determining the primary pattern of lung injury present. Other roles include follow-up of lung disease over time, evaluation of acute symptoms, and monitoring for treatment complications. Although diagnosis is typically made using clinical and serologic criteria, CT plays an important role when lung disease is the dominant presenting feature. This article delineates the roles of CT in patients with CTD-related lung disease.
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Affiliation(s)
- Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA.
| | - Kimberly G Kallianos
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA
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21
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Elicker BM. Pleural Invasion in Subsolid and Solid Lung Cancers: Predictive Features at CT and Their Clinical Significance. Radiol Cardiothorac Imaging 2019; 1:e190145. [PMID: 33779654 PMCID: PMC7977959 DOI: 10.1148/ryct.2019190145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 06/12/2023]
Affiliation(s)
- Brett M. Elicker
- From the Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143
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22
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Tanizawa K, Ley B, Vittinghoff E, Elicker BM, Henry TS, Wolters PJ, Brownell R, Liu S, Collard HR, Jones KD. Significance of bronchiolocentric fibrosis in patients with histopathological usual interstitial pneumonia. Histopathology 2019; 74:1088-1097. [PMID: 30742318 DOI: 10.1111/his.13840] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 09/24/2018] [Accepted: 02/07/2019] [Indexed: 01/01/2023]
Abstract
AIMS To evaluate the clinical significance of bronchiolocentric fibrosis (BCF) in patients with a histopathological pattern of usual interstitial pneumonia (UIP). METHODS AND RESULTS Two hundred and fifty-two patients with pathological UIP pattern were identified. Two hundred and fifteen of these patients (215 of 252) had the multidisciplinary diagnosis of idiopathic pulmonary fibrosis (IPF). Prospectively defined clinical, radiological and pathological features (including BCF) were recorded, and peripheral blood MUC5B genotype and telomere length were measured. BCF was observed in 38% (96 of 252) of all patients and 33% (72 of 215) of IPF patients; its presence was associated with a non-IPF diagnosis on multivariate analysis (odds ratio = 3.71, 95% confidence interval = 1.68-8.19). BCF was not significantly associated with environmental exposures, gastroesophageal reflux, cigarette smoking or radiological patterns. There was no significant association of BCF with MUC5B genotype or telomere length. BCF has no significant impact on survival time. CONCLUSIONS Most patients with BCF and a histopathological pattern of UIP have IPF. However, this combined fibrotic pattern is associated with a non-IPF multidisciplinary diagnosis, with approximately one-quarter of these patients being diagnosed as chronic hypersensitivity pneumonia or unclassifiable interstitial fibrosis. The presence of BCF in these patients is not significantly associated with presumed clinical risk factors for bronchiolocentric involvement, radiological findings, MUC5B genotype, telomere length or survival time.
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Affiliation(s)
- Kiminobu Tanizawa
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Kyoto Central Clinic, Clinical Research Center, Kyoto, Japan
| | - Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Paul J Wolters
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Robert Brownell
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shuo Liu
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Respiratory Medicine, The Fourth Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Harold R Collard
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
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Affiliation(s)
- Brett M. Elicker
- From the Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143
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25
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Abstract
Smoke from cigarettes and other sources may induce a variety of patterns of lung injury. While smoking related lung diseases, in general, have a better prognosis than many other diffuse lung diseases, they may be a cause of significant symptoms and, in some cases, may even require lung transplantation. On histology, the manifestations of these patterns range from reversible inflammation to irreversible emphysema or fibrosis. High-resolution chest CT plays a critical role in the diagnosis of smoking related lung diseases. It has several roles including (1) helping determine diagnosis, (2) assessing the pattern of injury that is present, (3) evaluating the extent and severity of disease, and (4) determining the response to treatment. The practicing radiologist must have a knowledge of the clinical, pathologic, and imaging features of the differnent patterns of lung injury associated with smoke inhalation.
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Affiliation(s)
- Brett M Elicker
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA.
| | - Kimberly G Kallianos
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, CA
| | - Travis S Henry
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA
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26
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Wong ML, Shi Y, Fung KZ, Ngo S, Elicker BM, Brown JK, Hiatt RA, Tang VL, Walter LC. Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans. PLoS One 2018; 13:e0200496. [PMID: 30044854 PMCID: PMC6059441 DOI: 10.1371/journal.pone.0200496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 06/27/2018] [Indexed: 12/20/2022] Open
Abstract
Background Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy. Objectives To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008–09 compared to 2013–14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008–09 subgroup. Design Retrospective cohort study. Setting Urban Veterans Affairs Medical Center. Participants 243 veterans age ≥65 with newly diagnosed pulmonary nodules in 2008–09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013–14. Measurements The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65–74 with CCI 0 while limited life expectancy was defined as age ≥85 with CCI ≥1 or age ≥65 with CCI ≥4. Interaction by nodule size was also examined. Results From 2008–09 to 2013–14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008–09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ≥4 versus 0: adjusted RR 0.61, 95% CI 0.39–0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48–1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ≤6 mm. Conclusions We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.
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Affiliation(s)
- Melisa L. Wong
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, United States of America
- * E-mail:
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Kathy Z. Fung
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Sarah Ngo
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Brett M. Elicker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - James K. Brown
- Pulmonary, Critical Care, and Sleep Medicine Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Robert A. Hiatt
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Victoria L. Tang
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Louise C. Walter
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
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Merritt BA, Henry TS, Cha S, Ordovas KG, Kallianos KG, Elicker BM, Hope MD, Naeger DM. Tailoring Radiology Resident Education Using Aggregated Missed-Cases Data. J Am Coll Radiol 2018; 15:1013-1015. [DOI: 10.1016/j.jacr.2018.03.044] [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: 03/11/2018] [Revised: 03/14/2018] [Accepted: 03/16/2018] [Indexed: 10/16/2022]
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28
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Tsui JL, Estrada OA, Deng Z, Wang KM, Law CS, Elicker BM, Jones KD, Dell SD, Gudmundsson G, Hansdottir S, Helfgott SM, Volpi S, Gattorno M, Waterfield MR, Chan AY, Chung SA, Ley B, Shum AK. Analysis of pulmonary features and treatment approaches in the COPA syndrome. ERJ Open Res 2018; 4:00017-2018. [PMID: 29977900 PMCID: PMC6019741 DOI: 10.1183/23120541.00017-2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [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: 02/01/2018] [Accepted: 04/27/2018] [Indexed: 11/25/2022] Open
Abstract
The COPA syndrome is a monogenic, autoimmune lung and joint disorder first identified in 2015. This study sought to define the main pulmonary features of the COPA syndrome in an international cohort of patients, analyse patient responses to treatment and highlight when genetic testing should be considered. We established a cohort of subjects (N=14) with COPA syndrome seen at multiple centres including the University of California, San Francisco, CA, USA. All subjects had one of the previously established mutations in the COPA gene, and had clinically apparent lung disease and arthritis. We analysed cohort characteristics using descriptive statistics. All subjects manifested symptoms before the age of 12 years, had a family history of disease, and developed diffuse parenchymal lung disease and arthritis. 50% had diffuse alveolar haemorrhage. The most common pulmonary findings included cysts on chest computed tomography and evidence of follicular bronchiolitis on lung biopsy. All subjects were positive for anti-neutrophil cytoplasmic antibody, anti-nuclear antibody or both and 71% of subjects had rheumatoid factor positivity. All subjects received immunosuppressive therapy. COPA syndrome is an autoimmune disorder defined by diffuse parenchymal lung disease and arthritis. We analysed an international cohort of subjects with genetically confirmed COPA syndrome and found that common pulmonary features included cysts, follicular bronchiolitis and diffuse alveolar haemorrhage. Common extrapulmonary features included early age of onset, family history of disease, autoantibody positivity and arthritis. Longitudinal data demonstrated improvement on chest radiology but an overall decline in pulmonary function despite chronic treatment. When to consider COPA syndrome, a Mendelian disorder with lung disease and arthritis, plus a review of treatments usedhttp://ow.ly/hWv130k21vT
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Affiliation(s)
- Jessica L Tsui
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Oscar A Estrada
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Zimu Deng
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Kristin M Wang
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Christopher S Law
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- Dept of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Dept of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Sharon D Dell
- Dept of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Gunnar Gudmundsson
- Dept of Respiratory Medicine, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sif Hansdottir
- Dept of Respiratory Medicine, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Simon M Helfgott
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - Stefano Volpi
- Clinica Pediatrica e Reumatologia, Centro per le Malattie Autoinfiammatorie e Immunodeficienze, Instituto Giannina Gaslini, Genoa, Italy
| | - Marco Gattorno
- Clinica Pediatrica e Reumatologia, Centro per le Malattie Autoinfiammatorie e Immunodeficienze, Instituto Giannina Gaslini, Genoa, Italy
| | - Michael R Waterfield
- Dept of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Alice Y Chan
- Dept of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Sharon A Chung
- Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Brett Ley
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Anthony K Shum
- Dept of Medicine, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA, USA
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Flagg ER, Henry TS, Elicker BM, Kallianos KG, Ordovas KG, Naeger DM. Periprocedural Management in Transthoracic Needle Biopsy: Review of the Current Evidence. Curr Radiol Rep 2018. [DOI: 10.1007/s40134-018-0274-8] [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] [Indexed: 11/28/2022]
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30
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Dunican EM, Elicker BM, Gierada DS, Nagle SK, Schiebler ML, Newell JD, Raymond WW, Lachowicz-Scroggins ME, Di Maio S, Hoffman EA, Castro M, Fain SB, Jarjour NN, Israel E, Levy BD, Erzurum SC, Wenzel SE, Meyers DA, Bleecker ER, Phillips BR, Mauger DT, Gordon ED, Woodruff PG, Peters MC, Fahy JV. Mucus plugs in patients with asthma linked to eosinophilia and airflow obstruction. J Clin Invest 2018; 128:997-1009. [PMID: 29400693 DOI: 10.1172/jci95693] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The link between mucus plugs and airflow obstruction has not been established in chronic severe asthma, and the role of eosinophils and their products in mucus plug formation is unknown. METHODS In clinical studies, we developed and applied a bronchopulmonary segment-based scoring system to quantify mucus plugs on multidetector computed tomography (MDCT) lung scans from 146 subjects with asthma and 22 controls, and analyzed relationships among mucus plug scores, forced expiratory volume in 1 second (FEV1), and airway eosinophils. Additionally, we used airway mucus gel models to explore whether oxidants generated by eosinophil peroxidase (EPO) oxidize cysteine thiol groups to promote mucus plug formation. RESULTS Mucus plugs occurred in at least 1 of 20 lung segments in 58% of subjects with asthma and in only 4.5% of controls, and the plugs in subjects with asthma persisted in the same segment for years. A high mucus score (plugs in ≥ 4 segments) occurred in 67% of subjects with asthma with FEV1 of less than 60% of predicted volume, 19% with FEV1 of 60%-80%, and 6% with FEV1 greater than 80% (P < 0.001) and was associated with marked increases in sputum eosinophils and EPO. EPO catalyzed oxidation of thiocyanate and bromide by H2O2 to generate oxidants that crosslink cysteine thiol groups and stiffen thiolated hydrogels. CONCLUSION Mucus plugs are a plausible mechanism of chronic airflow obstruction in severe asthma, and EPO-generated oxidants may mediate mucus plug formation. We propose an approach for quantifying airway mucus plugging using MDCT lung scans and suggest that treating mucus plugs may improve airflow in chronic severe asthma. TRIAL REGISTRATION Clinicaltrials.gov NCT01718197, NCT01606826, NCT01750411, NCT01761058, NCT01761630, NCT01759186, NCT01716494, and NCT01760915. FUNDING NIH grants P01 HL107201, R01 HL080414, U10 HL109146, U10 HL109164, U10 HL109172, U10 HL109086, U10 HL109250, U10 HL109168, U10 HL109257, U10 HL109152, and P01 HL107202 and National Center for Advancing Translational Sciences grants UL1TR0000427, UL1TR000448, and KL2TR000428.
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Affiliation(s)
- Eleanor M Dunican
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - David S Gierada
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott K Nagle
- Department of Medical Physics and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mark L Schiebler
- Department of Medical Physics and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - John D Newell
- Division of Cardiovascular and Pulmonary Imaging, Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Wilfred W Raymond
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - Marrah E Lachowicz-Scroggins
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - Selena Di Maio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - Eric A Hoffman
- Division of Cardiovascular and Pulmonary Imaging, Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Sean B Fain
- Department of Medical Physics and Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nizar N Jarjour
- Allergy, Pulmonary and Critical Care Medicine Division, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Elliot Israel
- Pulmonary and Critical Care Medicine Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bruce D Levy
- Pulmonary and Critical Care Medicine Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Serpil C Erzurum
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sally E Wenzel
- Pulmonary, Allergy and Critical Care Medicine Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deborah A Meyers
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brenda R Phillips
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania, USA
| | - David T Mauger
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania, USA
| | - Erin D Gordon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - Prescott G Woodruff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - Michael C Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
| | - John V Fahy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and Cardiovascular Research Institute, and
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Zinter MS, Melton A, Sabnis AJ, Dvorak CC, Elicker BM, Nawaytou HM, Kameny RJ, Fineman JR. Pulmonary veno-occlusive disease in a pediatric hematopoietic stem cell transplant patient: a cautionary tale. Leuk Lymphoma 2017; 59:1494-1497. [PMID: 28958195 DOI: 10.1080/10428194.2017.1382697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- M S Zinter
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,b Department of Pediatrics, Division of Critical Care Medicine , University of California , San Francisco , CA , USA
| | - A Melton
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,c Department of Pediatrics, Division of Allergy, Immunology, and Blood and Marrow Transplantation , University of California , San Francisco , CA , USA
| | - A J Sabnis
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,d Department of Pediatrics, Division of Hematology and Oncology , University of California , San Francisco , CA , USA
| | - C C Dvorak
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,c Department of Pediatrics, Division of Allergy, Immunology, and Blood and Marrow Transplantation , University of California , San Francisco , CA , USA
| | - B M Elicker
- e Department of Radiology , University of California , San Francisco , CA , USA
| | - H M Nawaytou
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,f Department of Pediatrics, Division of Cardiology , University of California , San Francisco , CA , USA
| | - R J Kameny
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,b Department of Pediatrics, Division of Critical Care Medicine , University of California , San Francisco , CA , USA
| | - J R Fineman
- a Benioff Children's Hospital , University of California , San Francisco , CA , USA.,b Department of Pediatrics, Division of Critical Care Medicine , University of California , San Francisco , CA , USA
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Ley B, Newton CA, Arnould I, Elicker BM, Henry TS, Vittinghoff E, Golden JA, Jones KD, Batra K, Torrealba J, Garcia CK, Wolters PJ. The MUC5B promoter polymorphism and telomere length in patients with chronic hypersensitivity pneumonitis: an observational cohort-control study. Lancet Respir Med 2017. [PMID: 28648751 PMCID: PMC5555581 DOI: 10.1016/s2213-2600(17)30216-3] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with hypersensitivity pneumonitis are at risk of developing pulmonary fibrosis, which is associated with reduced survival. In families with multiple affected members, individuals might be diagnosed as having idiopathic pulmonary fibrosis (IPF) or chronic (fibrotic) hypersensitivity pneumonitis, which suggests these disorders share risk factors. We aimed to test whether the genomic risk factors associated with the development and progression of IPF are also associated with the development of fibrosis and reduced survival in people with chronic hypersensitivity pneumonitis. METHODS We did an observational study of two independent cohorts of patients with chronic hypersensitivity pneumonitis, one from the University of California San Francisco, CA, USA (UCSF), and one from the University of Texas Southwestern, TX, USA (UTSW). We measured two common single-nucleotide polymorphisms associated with IPF (MUC5B rs35705950 and TOLLIP rs5743890) and telomere length in peripheral blood leucocytes, and assessed their associations with chronic hypersensitivity pneumonitis risk, survival, and clinical, radiographic, and pathological features. We compared findings with those in patients with IPF from the UCSF and UTSW cohorts, and healthy controls from the European population of the 1000 Genomes Project Phase 3, version 1. FINDINGS The cohorts included 145 patients from UCSF and 72 from UTSW. The minor allele frequency (MAF) was greater for MUC5B rs35705950 in patients with chronic hypersensitivity pneumonitis than in healthy controls (24·4% in UCSF and 32·3% in UTSW vs 10·7%, both p<0·0001), but not for TOLLIP rs5743890. The MAFs were similar to those for IPF (UCSF 33·3%, p=0·09; UTSW 32·0%, p=0·95). In the combined UCSF and UTSW chronic hypersensitivity pneumonitis cohort, we saw associations between extent of radiographic fibrosis and MUC5B rs35705950 minor alleles (adjusted odds ratio [OR] 1·91, 95% CI 1·02-3·59, p=0·045) and short telomere length (adjusted OR per unit change in mean natural logarithm-transformed ratio of telomere repeat copy number to single gene copy number 0·23, 0·09-0·59, p=0·002). Telomere length less than the tenth percentile for age was also significantly associated with reduced survival (log-rank p=0·006). INTERPRETATION The associations between MUC5B rs35705950 and short telomere length with extent of fibrosis, histopathological features of usual interstitial pneumonia, and reduced survival in patients with chronic hypersensitivity pneumonitis suggest shared pathobiology with IPF, and might help to stratify risk. FUNDING National Institutes of Health and Nina Ireland Program for Lung Health.
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Affiliation(s)
- Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Chad A Newton
- Eugene McDermott Centre for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Isabel Arnould
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Kiran Batra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jose Torrealba
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christine Kim Garcia
- Eugene McDermott Centre for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Wolters
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Elicker BM, Kallianos KG, Henry TS. The role of high-resolution computed tomography in the follow-up of diffuse lung disease. Eur Respir Rev 2017; 26:26/144/170008. [PMID: 28615307 PMCID: PMC9488961 DOI: 10.1183/16000617.0008-2017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/18/2017] [Indexed: 01/15/2023] Open
Abstract
High-resolution computed tomography (HRCT) of the lung is a key component of the multidisciplinary approach to diagnosis in diffuse lung disease (DLD). HRCT also plays an important role in the follow-up of patients with established DLD. In this respect, serial HRCT examinations may provide valuable information that cannot be determined from clinical history and other diagnostic tests, such as pulmonary function tests. Important roles of HRCT in this context include assisting in determining prognosis, monitoring for the efficacy of treatment, detecting progression of disease or complications, and evaluating patients with worsening or acute symptoms. Both clinicians and radiologists should be aware of the expected evolution of HRCT changes in a variety of DLDs. The goals of this paper are to discuss: 1) the expected evolution of HRCT findings over time in common DLDs; 2) the role of serial HRCT examinations in formulating an initial diagnosis; and 3) the role of HRCT in the follow-up of patients with known DLD. HRCT plays an important role in the follow-up of patients with diffuse lung diseasehttp://ow.ly/wzY730c2gRO
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Morisset J, Vittinghoff E, Lee BY, Tonelli R, Hu X, Elicker BM, Ryu JH, Jones KD, Cerri S, Manfredi A, Sebastiani M, Gross AJ, Ley B, Wolters PJ, King TE, Kim DS, Collard HR, Lee JS. The performance of the GAP model in patients with rheumatoid arthritis associated interstitial lung disease. Respir Med 2017; 127:51-56. [PMID: 28502419 DOI: 10.1016/j.rmed.2017.04.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is associated with significant morbidity and mortality. Similarities have been observed between patients with idiopathic pulmonary fibrosis (IPF) and the UIP (usual interstitial pneumonia) form of RA-ILD. The GAP (gender, age, physiology) model has been shown to predict mortality in patients with IPF, but its ability to predict mortality in RA-ILD is not known. METHODS We identified 309 patients with RA-ILD at 4 academic centers with ongoing longitudinal cohorts of patients with ILD. The primary endpoint was mortality. To handle missing data (n = 219 subjects with complete dataset), multiple imputation by iterative chained equations was used. Using the GAP model as a baseline, we assessed improvements in mortality risk prediction achieved by incorporating additional variables. Model discrimination was assessed using the c-index, and calibration was checked by comparing observed and expected incidence of death. RESULTS Patients had a mean age of 65 years and were predominantly female (54%). The mean forced vital capacity (FVC) % predicted was 73 and the mean diffusing capacity for carbon monoxide (DLCO) % predicted was 55. Twenty-four percent of the 236 patients with a high-resolution computed tomography scan available for review had a definite UIP pattern. The original GAP model, including gender, age, FVC%, and DLCO%, had a c-index of 0.746 in our cohort. Calibration of this model was satisfactory at 1, 2 and 3 years. Model discrimination was not meaningfully improved by adding other clinical variables. CONCLUSION The GAP model that was derived for IPF performs similarly as a mortality risk prediction tool in RA-ILD.
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Affiliation(s)
- Julie Morisset
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Bo Young Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Roberto Tonelli
- Department of Respiratory Diseases, University of Modena & Reggio Emilia, Modena, Italy
| | - Xiaowen Hu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brett M Elicker
- Department of Radiology, University of California, San Francisco, CA, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Stefania Cerri
- Department of Respiratory Diseases, University of Modena & Reggio Emilia, Modena, Italy
| | - Andreina Manfredi
- Department of Rheumatology, University of Modena & Reggio Emilia, Modena, Italy
| | - Marco Sebastiani
- Department of Rheumatology, University of Modena & Reggio Emilia, Modena, Italy
| | - Andrew J Gross
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Brett Ley
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Paul J Wolters
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Talmadge E King
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Dong Soon Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Harold R Collard
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Joyce S Lee
- Department of Medicine, University of Colorado Denver, CO, USA
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Natalini JG, Swigris JJ, Morisset J, Elicker BM, Jones KD, Fischer A, Collard HR, Lee JS. Understanding the determinants of health-related quality of life in rheumatoid arthritis-associated interstitial lung disease. Respir Med 2017; 127:1-6. [PMID: 28502413 DOI: 10.1016/j.rmed.2017.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/12/2017] [Accepted: 04/03/2017] [Indexed: 12/29/2022]
Abstract
RATIONALE Health-related quality of life (HRQL) is impaired among patients with interstitial lung disease (ILD). Little is understood about HRQL in specific subtypes of ILD. OBJECTIVES The aim of this study was to characterize and identify clinical determinants of HRQL among patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) and compare them to patients with idiopathic pulmonary fibrosis (IPF). METHODS We identified patients with a diagnosis of RA-ILD and IPF from an ongoing longitudinal cohort of ILD patients. HRQL was measured at their baseline visit using the Short Form Health Survey (SF-36), versions 1 and 2. Regression models were used to characterize and understand the relationship between selected baseline clinical covariates, the physical component score (PCS) and mental component score (MCS) of the SF-36. MEASUREMENTS AND MAIN RESULTS RA-ILD patients (n = 50) were more likely to be younger and female compared to IPF patients (n = 50). After controlling for age and pulmonary function, RA-ILD patients had a lower HRQL compared to IPF patients, as measured by the PCS (P = 0.03), with significant differences in two of four PCS domains - bodily pain (P < 0.01) and general health (P = 0.01). Clinical covariates most strongly associated with a lower PCS in RA-ILD patients compared to IPF patients were the presence of joint pain or stiffness and dyspnea severity (P < 0.01). Mental and emotional health, as measured by the MCS, was similar between RA-ILD and IPF patients. CONCLUSION The physical components of HRQL appear worse in RA-ILD patients compared to IPF patients as measured by the PCS of the SF-36. Differences in the PCS of the SF-36 can be explained in part by dyspnea severity and joint symptoms among patients with RA-ILD.
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Affiliation(s)
- Jake G Natalini
- Department of Medicine, University of California, San Francisco, USA
| | - Jeff J Swigris
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Julie Morisset
- Department of Medicine, University of California, San Francisco, USA
| | - Brett M Elicker
- Department of Radiology, University of California, San Francisco, USA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, USA
| | - Aryeh Fischer
- Department of Medicine, University of Colorado Denver, USA
| | - Harold R Collard
- Department of Medicine, University of California, San Francisco, USA
| | - Joyce S Lee
- Department of Medicine, University of Colorado Denver, USA.
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36
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Brownell R, Moua T, Henry TS, Elicker BM, White D, Vittinghoff E, Jones KD, Urisman A, Aravena C, Johannson KA, Golden JA, King TE, Wolters PJ, Collard HR, Ley B. The use of pretest probability increases the value of high-resolution CT in diagnosing usual interstitial pneumonia. Thorax 2017; 72:424-429. [PMID: 28082530 DOI: 10.1136/thoraxjnl-2016-209671] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/30/2016] [Accepted: 12/05/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Recent studies have suggested that non-definitive patterns on high-resolution CT (HRCT) scan provide sufficient diagnostic specificity to forgo surgical lung biopsy in the diagnosis of idiopathic pulmonary fibrosis (IPF). The objective of this study was to determine test characteristics of non-definitive HRCT patterns for identifying histopathological usual interstitial pneumonia (UIP). METHODS Patients with biopsy-proven interstitial lung disease (ILD) and non-definitive HRCT scans were identified from two academic ILD centres. Test characteristics for HRCT patterns as predictors of UIP on surgical lung biopsy were derived and validated in independent cohorts. RESULTS In the derivation cohort, 64/385 (17%) had possible UIP pattern on HRCT; 321/385 (83%) had inconsistent with UIP pattern. 113/385 (29%) patients had histopathological UIP pattern in the derivation cohort. Possible UIP pattern had a specificity of 91.2% (95% CI 87.2% to 94.3%) and a positive predictive value (PPV) of 62.5% (95% CI 49.5% to 74.3%) for UIP pattern on surgical lung biopsy. The addition of age, sex and total traction bronchiectasis score improved the PPV. Inconsistent with UIP pattern demonstrated poor PPV (22.7%, 95% CI 18.3% to 27.7%). HRCT pattern specificity was nearly identical in the validation cohort (92.7%, 95% CI 82.4% to 98.0%). The substantially higher prevalence of UIP pattern in the validation cohort improved the PPV of HRCT patterns. CONCLUSIONS A possible UIP pattern on HRCT has high specificity for UIP on surgical lung biopsy, but PPV is highly dependent on underlying prevalence. Adding clinical and radiographic features to possible UIP pattern on HRCT may provide sufficient probability of histopathological UIP across prevalence ranges to change clinical decision-making.
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Affiliation(s)
- Robert Brownell
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Teng Moua
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Darin White
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Anatoly Urisman
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Carlos Aravena
- Respiratory Diseases Department, Pontifical Catholic University, Santiago, Chile
| | | | - Jeffrey A Golden
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Talmadge E King
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Paul J Wolters
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Harold R Collard
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Larsen BT, Smith ML, Elicker BM, Fernandez JM, de Morvil GAAO, Pereira CAC, Leslie KO. Diagnostic Approach to Advanced Fibrotic Interstitial Lung Disease: Bringing Together Clinical, Radiologic, and Histologic Clues. Arch Pathol Lab Med 2016; 141:901-915. [DOI: 10.5858/arpa.2016-0299-sa] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Idiopathic pulmonary fibrosis (IPF) is a distinctive clinicopathologic entity and the most common form of progressive diffuse lung scarring in older adults. Idiopathic pulmonary fibrosis manifests histopathologically as the usual interstitial pneumonia pattern. The usual interstitial pneumonia pattern is distinguished by geographically and temporally heterogeneous fibrosis that is peripherally accentuated, often with honeycombing and traction bronchiectasis. Idiopathic pulmonary fibrosis is not the only disease that leads to end-stage lung fibrosis, however, and several other entities may also cause advanced fibrosis. Surgical lung biopsies often present a diagnostic dilemma when they show clear evidence of advanced fibrosis, but the clinical, imaging, and/or histopathologic subcharacteristics suggest something other than IPF.
Objective.—
To address this dilemma, we review several other fibrotic lung diseases, including connective tissue disease–associated interstitial lung disease, chronic hypersensitivity pneumonitis, advanced pulmonary Langerhans cell histiocytosis, end-stage pulmonary sarcoidosis, Erdheim-Chester disease, Hermansky-Pudlak syndrome, and others, detailing their clinical, radiologic, and histopathologic attributes and emphasizing similarities to and differences from IPF.
Data Sources.—
Data sources comprised published peer-reviewed literature and personal experience of the authors.
Conclusions.—
Often, clues in the lung biopsy may offer the first suggestion of a fibrotic lung disease other than IPF, and accurate classification is important for prognosis, treatment, and the development of future therapies.
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Affiliation(s)
| | | | | | | | | | | | - Kevin O. Leslie
- From the Department of Laboratory Medicine & Pathology (Drs Larsen, Smith, and Leslie), Mayo Clinic, Scottsdale, Arizona; the Department of Radiology (Dr Elicker), University of California, San Francisco; Juan Max Boettner Hospital (Drs Fernandez and Arbo-Oze de Morvil), Asunción, Paraguay; and the Department of Medicine (Dr Pereira), Federal University of São Paulo, São Paulo, Brazil
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Kallianos KG, Elicker BM, Henry TS, Ordovas KG, Nguyen J, Naeger DM. Instituting a Low-dose CT-guided Lung Biopsy Protocol. Acad Radiol 2016; 23:1130-6. [PMID: 27317393 DOI: 10.1016/j.acra.2016.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 03/22/2016] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 02/03/2023]
Abstract
RATIONALE AND OBJECTIVES We aimed to evaluate whether implementation of a low-dose computed tomography (CT)-guided lung biopsy protocol, with the support of individual radiologists in the section, would lead to immediate and sustained decreases in radiation dose associated with CT-guided lung biopsies. MATERIALS AND METHODS A low-dose CT-guided lung biopsy protocol was developed with modifications of kilovoltage peak, milliamperes, and scan coverage. Out of 413 CT-guided lung biopsies evaluated over a 3-year period beginning in 2009, 175 performed with a standard protocol before the development of a low-dose protocol, and 238 performed with a low-dose protocol. The dose-length product (DLP) was recorded for each lung biopsy and retrospectively compared between the two protocols. Individual radiologist level DLPs were also compared before and after the protocol change. RESULTS The mean biopsy dose decreased by 64.4% with the low-dose protocol (113.8 milligray centimeters versus 319.7 milligray centimeters; P < 0.001). This decrease in radiation dose persisted throughout the entire 18 months evaluated following the protocol change. After the protocol change, each attending radiologist demonstrated a decrease in administered radiation dose. The diagnostic outcome rate and complication rate were unchanged over the interval. CONCLUSIONS Implementation of a low-dose CT-guided lung biopsy protocol resulted in an immediate reduction in patient radiation dose that was seen with all attending radiologists and persisted for at least 18 months. Such an intervention may be considered at other institutions wishing to reduce patient doses.
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Affiliation(s)
- Kimberly G Kallianos
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, San Francisco, CA 94143-0628
| | - Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, San Francisco, CA 94143-0628
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, San Francisco, CA 94143-0628
| | - Karen G Ordovas
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, San Francisco, CA 94143-0628
| | - Janet Nguyen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, San Francisco, CA 94143-0628
| | - David M Naeger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-391, San Francisco, CA 94143-0628.
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Abstract
Acute lung injury (ALI) is the clinical syndrome associated with histopathologic diffuse alveolar damage. It is a common cause of acute respiratory symptoms and admission to the intensive care unit. Diagnosis of ALI is typically based on clinical and radiographic criteria; however, because these criteria can be nonspecific, diagnostic uncertainty is common. A multidisciplinary approach that synthesizes clinical, imaging, and pathologic data can ensure an accurate diagnosis. Radiologists must be aware of the radiographic and computed tomographic findings of ALI and its mimics. This article discusses the multidisciplinary diagnosis of ALI from the perspective of the imager.
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Affiliation(s)
- Brett M Elicker
- Cardiac and Pulmonary Imaging Section, Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA.
| | - Kirk T Jones
- Department of Pathology, University of California, 505 Parnassus Avenue, Box 0102, San Francisco, CA 94143, USA
| | - David M Naeger
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA
| | - James A Frank
- Division of Pulmonary, Critical Care, Allergy and Sleep, San Francisco VA Medical Center, 4150 Clement Street, Box 111D, San Francisco, CA 94121, USA
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Johannson KA, Elicker BM, Vittinghoff E, Assayag D, de Boer K, Golden JA, Jones KD, King TE, Koth LL, Lee JS, Ley B, Wolters PJ, Collard HR. A diagnostic model for chronic hypersensitivity pneumonitis. Thorax 2016; 71:951-4. [PMID: 27245779 DOI: 10.1136/thoraxjnl-2016-208286] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [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: 01/05/2016] [Accepted: 05/03/2016] [Indexed: 11/04/2022]
Abstract
The objective of this study was to develop a diagnostic model that allows for a highly specific diagnosis of chronic hypersensitivity pneumonitis using clinical and radiological variables alone. Chronic hypersensitivity pneumonitis and other interstitial lung disease cases were retrospectively identified from a longitudinal database. High-resolution CT scans were blindly scored for radiographic features (eg, ground-glass opacity, mosaic perfusion) as well as the radiologist's diagnostic impression. Candidate models were developed then evaluated using clinical and radiographic variables and assessed by the cross-validated C-statistic. Forty-four chronic hypersensitivity pneumonitis and eighty other interstitial lung disease cases were identified. Two models were selected based on their statistical performance, clinical applicability and face validity. Key model variables included age, down feather and/or bird exposure, radiographic presence of ground-glass opacity and mosaic perfusion and moderate or high confidence in the radiographic impression of chronic hypersensitivity pneumonitis. Models were internally validated with good performance, and cut-off values were established that resulted in high specificity for a diagnosis of chronic hypersensitivity pneumonitis.
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Affiliation(s)
- Kerri A Johannson
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brett M Elicker
- Department of Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | | | - Kaïssa de Boer
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jeffrey A Golden
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, San Francisco, California, USA
| | - Talmadge E King
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Laura L Koth
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joyce S Lee
- University of Colorado Denver, Aurora, Colorado, USA
| | - Brett Ley
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Paul J Wolters
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Harold R Collard
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Assayag D, Vittinghoff E, Ryerson CJ, Cocconcelli E, Tonelli R, Hu X, Elicker BM, Golden JA, Jones KD, King TE, Koth LL, Lee JS, Ley B, Shum AK, Wolters PJ, Ryu JH, Collard HR. The effect of bronchodilators on forced vital capacity measurement in patients with idiopathic pulmonary fibrosis. Respir Med 2015; 109:1058-62. [PMID: 26140806 DOI: 10.1016/j.rmed.2015.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/29/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Forced vital capacity (FVC) is a key measure of disease severity in patients with idiopathic pulmonary fibrosis (IPF) and is an important clinical trial endpoint. We hypothesize that reversible airflow limitation co-exists in a subgroup of patients with IPF, and that bronchodilator use will improve the performance characteristics of FVC. METHODS IPF patients with pre and post-bronchodilator spirometry testing performed were identified from two tertiary referral cohorts. The difference between pre and post-bronchodilator FVC (intra-test difference) was calculated. The test characteristics of pre and post-bronchodilator FVC change over time (inter-test difference) were assessed in patients with sequential spirometry, and were used to generate sample size estimates for hypothetical clinical trials using change in FVC as the primary endpoint. RESULTS There were 551 patients, contributing 967 unique spirometry tests. The mean intra-test increase in FVC with bronchodilator use was 0.04 L (2.71 vs. 2.75 L, p < 0.001). Reversible airflow limitation (increase in FEV1 or FVC of ≥12% and ≥200 mL) occurred in 9.1% of patients. The inter-test difference in change in FVC over time were equivalent for pre and post-bronchodilator (p = 0.65), leading to similar sample size estimates in a hypothetical clinical trial using change in FVC as the primary endpoint. CONCLUSION Approximately one in ten patients with IPF has physiological evidence of reversible airflow limitation, and bronchodilator use in these patients may improve the assessment of disease progression based on FVC change over time. Bronchodilator use does not appear to meaningfully impact the precision of FVC as an endpoint in clinical trials.
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Affiliation(s)
- Deborah Assayag
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | | | | | | | - Xiaowen Hu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Brett M Elicker
- Department of Radiology, University of California San Francisco, San Francisco, CA, United States
| | - Jeffrey A Golden
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, CA, United States
| | - Talmadge E King
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Laura L Koth
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Joyce S Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Anthony K Shum
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Paul J Wolters
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Harold R Collard
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
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Wolters PJ, Elicker BM. Subacute onset of pulmonary langerhans cell histiocytosis with resolution after smoking cessation. Am J Respir Crit Care Med 2015; 190:e64. [PMID: 25436789 DOI: 10.1164/rccm.201405-0974im] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Stuart BD, Lee JS, Kozlitina J, Noth I, Devine MS, Glazer CS, Torres F, Kaza V, Girod CE, Jones KD, Elicker BM, Ma SF, Vij R, Collard HR, Wolters PJ, Garcia CK. Effect of telomere length on survival in patients with idiopathic pulmonary fibrosis: an observational cohort study with independent validation. Lancet Respir Med 2014; 2:557-65. [PMID: 24948432 DOI: 10.1016/s2213-2600(14)70124-9] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Short telomere lengths are found in a subset of patients with idiopathic pulmonary fibrosis, but their clinical significance is unknown. Our aim was to investigate whether patients with various blood leucocyte telomere lengths had different overall survival. METHODS In this observational cohort study, we enrolled patients with interstitial lung disease from Dallas, TX (primary cohort), and from Chicago, IL, and San Francisco, CA (replication cohorts). We obtained genomic DNA samples from unrelated healthy controls in Dallas, TX, and spouses of patients were also enrolled as an independent control group. Telomere lengths were measured in genomic DNA samples isolated from peripheral blood obtained at the time of the initial enrolment assessment. The primary endpoint was transplant-free survival (ie, time to death or lung transplantation) in the Dallas cohort. Findings were validated in the two independent idiopathic pulmonary fibrosis cohorts (Chicago and San Francisco). FINDINGS 370 patients were enrolled into the Dallas cohort between June 17, 2003, and Aug 25, 2011. The 149 patients with idiopathic pulmonary fibrosis had shorter telomere lengths than did the 195 healthy controls (mean age-adjusted log-transformed ratio of telomere to single copy gene was -0.16 [SD 0.23] vs 0.00 [0.18]; p<0.0001); however, telomere lengths of the Dallas patients with idiopathic pulmonary fibrosis (1.33 [SD 0.25]) were similar to the 221 patients with other interstitial lung disease diagnoses (1.46 [0.24]) after adjusting for age, sex, and ethnicity (p=0.47). Telomere length was independently associated with transplant-free survival time for patients with idiopathic pulmonary fibrosis (HR 0.22 [95% CI 0.08-0.63]; p=0.0048), but not for patients with interstitial lung disease diagnoses other than idiopathic pulmonary fibrosis (HR 0.73 [0.16-3.41]; p=0.69). The association between telomere length and survival in patients with idiopathic pulmonary fibrosis was independent of age, sex, forced vital capacity, or diffusing capacity of carbon monoxide, and was replicated in the two independent idiopathic pulmonary fibrosis replication cohorts (Chicago cohort, HR 0.11 [0.03-0.39], p=0.00066; San Francisco cohort, HR 0.25 [0.07-0.87], p=0.029). INTERPRETATION Shorter leucocyte telomere lengths are associated with worse survival in idiopathic pulmonary fibrosis. Additional studies will be needed to establish clinically relevant thresholds for telomere length and how this biomarker might affect risk stratification of patients with idiopathic pulmonary fibrosis. FUNDING US National Heart, Lung, and Blood Institute, National Center for Advancing Translational Sciences, Harroun Family Foundation, and Nina Ireland Lung Disease Program.
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Affiliation(s)
- Bridget D Stuart
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joyce S Lee
- University of California San Francisco, San Francisco, CA, USA
| | - Julia Kozlitina
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Imre Noth
- University of Chicago, Chicago, IL, USA
| | - Megan S Devine
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Craig S Glazer
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fernando Torres
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vaidehi Kaza
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos E Girod
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kirk D Jones
- University of California San Francisco, San Francisco, CA, USA
| | - Brett M Elicker
- University of California San Francisco, San Francisco, CA, USA
| | | | - Rekha Vij
- University of Chicago, Chicago, IL, USA
| | | | - Paul J Wolters
- University of California San Francisco, San Francisco, CA, USA
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Ley B, Elicker BM, Hartman TE, Ryerson CJ, Vittinghoff E, Ryu JH, Lee JS, Jones KD, Richeldi L, King TE, Collard HR. Idiopathic pulmonary fibrosis: CT and risk of death. Radiology 2014; 273:570-9. [PMID: 24927326 DOI: 10.1148/radiol.14130216] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To investigate the prognostic value of quantitative computed tomographic (CT) scoring for the extent of fibrosis or emphysema in the context of a clinical model that includes the gender, age, and physiology ( GAP gender, age, and physiology model) of the patient. MATERIALS AND METHODS Study cohorts were approved by local institutional review boards, and all patients provided written consent. This was a retrospective cohort study that included 348 patients (246 men, 102 women; mean age, 69 years ± 9) with idiopathic pulmonary fibrosis from two institutions. Fibrosis and emphysema visual scores were independently determined by two radiologists. Models were based on competing risks regression for death and were evaluated by using the C index and reclassification improvement. RESULTS The CT- GAP gender, age, and physiology model (a modification of the original GAP gender, age, and physiology model that replaces diffusion capacity of carbon monoxide with CT fibrosis score) had accuracy comparable to that of the original GAP gender, age, and physiology model, with a C index of 70.3 (95% confidence interval: 66.4, 74.0); difference in C index compared with the GAP gender, age, and physiology model of -0.4 (95% confidence interval: -2.2, 3.4). The performance of the original GAP gender, age, and physiology model did not change significantly with the simple addition of fibrosis score, with a change in C index of 0.0 (95% confidence interval: -1.8, 0.5) or of emphysema score, with a change in C index of 0.0 [95% confidence interval: -1.3, 0.4]). CONCLUSION CT fibrosis score can replace diffusion capacity of carbon monoxide test results in a modified GAP gender, age, and physiology model (the CT- GAP gender, age, and physiology model) with comparable performance. This may be a useful alternative model in situations where CT scoring is more reliable and available than diffusion capacity of carbon monoxide.
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Affiliation(s)
- Brett Ley
- From the Departments of Medicine (B.L., J.S.L., T.E.K., H.R.C.), Radiology (B.M.E.), Epidemiology and Biostatistics (E.V.), and Pathology (K.D.J.), University of California-San Francisco, 505 Parnassus Ave, Box 0111, San Francisco, CA 94143; Departments of Radiology (T.E.H.) and Medicine (J.H.R.), Mayo Clinic, Rochester, Minn; Department of Medicine, University of British Columbia, Vancouver, BC, Canada (C.J.R.); and Department of Respiratory Medicine, University of Southampton, Southampton, England (L.R.)
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Ryerson CJ, Vittinghoff E, Ley B, Lee JS, Mooney JJ, Jones KD, Elicker BM, Wolters PJ, Koth LL, King TE, Collard HR. Predicting Survival Across Chronic Interstitial Lung Disease. Chest 2014; 145:723-728. [DOI: 10.1378/chest.13-1474] [Citation(s) in RCA: 266] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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46
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Mooney JJ, Elicker BM, Urbania TH, Agarwal MR, Ryerson CJ, Nguyen MLT, Woodruff PG, Jones KD, Collard HR, King TE, Koth LL. Radiographic fibrosis score predicts survival in hypersensitivity pneumonitis. Chest 2014; 144:586-592. [PMID: 23392130 DOI: 10.1378/chest.12-2623] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is unknown if the radiographic fibrosis score predicts mortality in persistent hypersensitivity pneumonitis (HP) and if survival is similar to that observed in idiopathic pulmonary fibrosis (IPF) when adjusting for the extent of radiographic fibrosis. METHODS We reviewed records from 177 patients with HP and 224 patients with IPF whose diagnoses were established by multidisciplinary consensus. Two thoracic radiologists scored high-resolution CT (HRCT) scan lung images. Independent predictors of transplant-free survival were determined using a Cox proportional hazards analysis. Kaplan-Meier survival curves were constructed, stratified by disease as well as fibrosis score. RESULTS HRCT scan fibrosis score and radiographic reticulation independently predicted time to death or lung transplantation. Clinical predictors included a history of cigarette smoking, auscultatory crackles on lung examination, baseline FVC, and FEV1/FVC ratio. The majority of HP deaths occurred in patients with both radiographic reticulation and auscultatory crackles on examination, compared with patients with only one of these manifestations (P < .0001). Patients with IPF had worse survival than those with HP at any given degree of radiographic fibrosis (hazard ratio 2.31; P < .01). CONCLUSIONS Survival in patients with HP was superior to that of those with IPF with similar degrees of radiographic fibrosis. The combination of auscultatory crackles and radiographic reticulation identified patients with HP who had a particularly poor outcome.
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Affiliation(s)
- Joshua J Mooney
- Department of Medicine, University of California, San Francisco, CA
| | - Brett M Elicker
- Department of Radiology, University of California, San Francisco, CA
| | - Thomas H Urbania
- Department of Radiology, University of California, San Francisco, CA
| | - Misha R Agarwal
- Department of Medicine, University of California, San Francisco, CA
| | | | | | | | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, CA
| | - Harold R Collard
- Department of Medicine, University of California, San Francisco, CA
| | - Talmadge E King
- Department of Medicine, University of California, San Francisco, CA
| | - Laura L Koth
- Department of Medicine, University of California, San Francisco, CA.
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Assayag D, Elicker BM, Urbania TH, Colby TV, Kang BH, Ryu JH, King TE, Collard HR, Kim DS, Lee JS. Rheumatoid arthritis-associated interstitial lung disease: radiologic identification of usual interstitial pneumonia pattern. Radiology 2013; 270:583-8. [PMID: 24126367 DOI: 10.1148/radiol.13130187] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the accuracy of computed tomography (CT) in identifying the histopathologic usual interstitial pneumonia (UIP) pattern in rheumatoid arthritis-associated interstitial lung disease (RA-ILD). MATERIALS AND METHODS All patients were enrolled into institutional review board-approved longitudinal cohorts at their respective institution, and informed consent was obtained at the time of enrollment. Images of patients with surgical lung biopsy-proved RA-ILD (n = 69) were collected from three tertiary care centers. Two experienced thoracic radiologists independently reviewed the CT scans. The CT pattern was categorized as definite UIP, possible UIP, or inconsistent with UIP in accordance with published criteria. Findings of biopsies were reviewed by an experienced lung pathologist. The sensitivity and specificity of definite CT UIP pattern to histopathologic UIP pattern were determined. The agreement between radiologists was assessed by calculating a κ score. RESULTS The histopathologic UIP pattern was present in 42 of 69 (61%) patients. Men were more likely than women to have a histopathologic UIP pattern (P = .02). Twenty patients (29%, 20 of 69) had a definite UIP pattern on CT scans. The specificity of CT UIP pattern was 96% (26 of 27; 95% confidence interval [CI]: 81%, 100%), with a negative predictive value of 53% (26 of 49). The sensitivity of CT UIP pattern was 45% (19 of 42; 95% CI: 30%, 61%), with a positive predictive value of 95% (19 of 20). The agreement between radiologists for definite UIP pattern versus not was 87% (κ = 0.67, P < .0001). CONCLUSION Definite UIP pattern on a CT scan in RA-ILD is highly specific and moderately sensitive for histopathologic UIP pattern. CT can therefore help accurately identify the UIP pattern in RA-ILD.
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Affiliation(s)
- Deborah Assayag
- From the Departments of Medicine (D.A., T.E.K., H.R.C., J.S.L.) and Radiology (B.M.E., T.H.U.), University of California, San Francisco, Calif; Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Ariz (T.V.C.); Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, 388-1 Pungnap-2dong, Songpa-gu, Seoul 138-736, Korea (B.H.K., D.S.K.); and Department of Medicine, Mayo Clinic, Rochester, Minn (J.H.R.)
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Ryerson CJ, Hartman T, Elicker BM, Ley B, Lee JS, Abbritti M, Jones KD, King TE, Ryu J, Collard HR. Clinical features and outcomes in combined pulmonary fibrosis and emphysema in idiopathic pulmonary fibrosis. Chest 2013; 144:234-240. [PMID: 23370641 DOI: 10.1378/chest.12-2403] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [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 Combined pulmonary fibrosis and emphysema (CPFE) is increasingly recognized, but its prevalence and prognosis remain unclear. We sought to determine the prevalence, clinical features, and prognosis of CPFE in idiopathic pulmonary fibrosis (IPF), using a standardized and reproducible definition. METHODS Patients with IPF were identified from two ongoing cohorts. Two radiologists scored emphysema and fibrosis severity on high-resolution CT (HRCT) scans. CPFE was defined as ≥10% emphysema on HRCT scan. Clinical characteristics and outcomes of patients with CPFE and IPF and those with non-CPFE IPF were compared with unadjusted analysis and then analysis after adjustment for HRCT fibrosis score. Mortality was compared using competing risks regression to handle lung transplantation. Sensitivity analyses were performed using Cox proportional hazards, including time to death (transplantation censored) and time to death or transplant. RESULTS CPFE criteria were met in 29 of 365 patients with IPF (8%), with high agreement between radiologists (κ=0.74). Patients with CPFE had less fibrosis on HRCT scans and higher FVC, but greater oxygen requirements (P≤.01 for all comparisons). Findings were maintained with adjustment for fibrosis severity. Inhaled therapies for COPD were used by 53% of patients with CPFE. There was no significant difference in mortality comparing patients with CPFE and IPF to those with non-CPFE IPF (hazard ratio, 1.14; 95% CI, 0.61-2.13; P=.69). CONCLUSIONS CPFE was identified in 8% of patients with IPF and is a distinct, clinical phenotype with potential therapies that remain underutilized. Patients with CPFE and IPF and those with non-CPFE IPF have similar mortality.
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Affiliation(s)
| | | | - Brett M Elicker
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - Brett Ley
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Joyce S Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Marta Abbritti
- Pulmonary Institute and Respiratory Intensive Care Unit, S. Maria della Misericordia Hospital, Perugia, Italy
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco, CA
| | - Talmadge E King
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jay Ryu
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Harold R Collard
- Department of Medicine, University of California San Francisco, San Francisco, CA
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Urisman A, Leard LE, Nathan M, Elicker BM, Hoopes C, Kukreja J, Jones KD. Rapidly progressive pulmonary venoocclusive disease in young women taking oral contraceptives. J Heart Lung Transplant 2013; 31:1031-6. [PMID: 22884388 DOI: 10.1016/j.healun.2012.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 03/03/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022] Open
Abstract
Pulmonary venoocclusive disease (PVOD) is a rare cause of pulmonary hypertension characterized by a progressive clinical course and poor outcomes if not treated by early lung transplantation. The pathogenesis of PVOD remains poorly understood. We report PVOD that developed in 2 young women soon after the initiation of oral contraceptives (OCs). The first patient is a 14-year-old girl, with no medical history, who started taking an OC 3 weeks before the onset of symptoms. The second patient is an 18-year-old girl, diagnosed 2 years previously with systemic lupus erythematosus and lupus anticoagulant, who started taking an OC 4 months before the onset of symptoms. Both patients required lung transplantation. Radiographic and histopathologic findings in both patients showed features of PVOD. Only 1 prior patient with PVOD and a handful of unclassified patients with pulmonary hypertension in association with OCs have been documented. The importance of PVOD as the basis of pulmonary hypertension in patients with connective tissue disease has been recently proposed, as well as the role of thrombogenesis, in the development of PVOD. The temporal sequence in these 2 patients suggests the thrombogenic action of OCs may contribute to the development of PVOD, with or without underlying connective tissue disease.
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Affiliation(s)
- Anatoly Urisman
- Department of Pathology, University of California San Francisco, San Francisco, CA 94143-0102, USA.
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Ryerson CJ, Urbania TH, Richeldi L, Mooney JJ, Lee JS, Jones KD, Elicker BM, Koth LL, King TE, Wolters PJ, Collard HR. Prevalence and prognosis of unclassifiable interstitial lung disease. Eur Respir J 2012; 42:750-7. [PMID: 23222877 DOI: 10.1183/09031936.00131912] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to determine the prevalence, characteristics and outcomes of patients with unclassifiable interstitial lung disease (ILD) and to develop a simple method of predicting disease behaviour. Unclassifiable ILD patients were identified from an ongoing longitudinal cohort. Unclassifiable ILD was diagnosed after a multidisciplinary review did not secure a specific ILD diagnosis. Clinical characteristics and outcomes were compared with idiopathic pulmonary fibrosis (IPF) and non-IPF ILDs. Independent predictors of mortality were determined using Cox proportional-hazards analysis to identify subgroups with distinct disease behaviour. Unclassifiable ILD was diagnosed in 10% of the ILD cohort (132 out of 1370 patients). The most common reason for being unclassifiable was missing histopathological assessment due to a high risk of surgical lung biopsy. Demographic and physiological features of unclassifiable ILD were intermediate between IPF and non-IPF disease controls. Unclassifiable ILD had longer survival rates when compared to IPF on adjusted analysis (hazard ratio 0.62, p = 0.04) and similar survival compared to non-IPF ILDs (hazard ratio 1.54, p = 0.12). Independent predictors of survival in unclassifiable ILD included diffusion capacity of the lung for carbon monoxide (p = 0.001) and a radiological fibrosis score (p = 0.02). Unclassifiable ILD represents approximately 10% of ILD cases and has a heterogeneous clinical course, which can be predicted using clinical and radiological variables.
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