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New ML, Amass T, Neumeier A, Huie TJ. Massive Hemoptysis Simulation Curriculum Improves Performance. Chest 2024; 165:645-652. [PMID: 37852435 DOI: 10.1016/j.chest.2023.10.013] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Massive hemoptysis is a rare, high-acuity presentation, which requires the integration of both cognitive and procedural skills. Simulation has been recommended to improve preparation for high-acuity, low-occurrence procedures; however, the effect of a simulation curriculum for massive hemoptysis management has never been investigated. RESEARCH QUESTION Does simulation for hemoptysis management improve competence? STUDY DESIGN AND METHODS Kern's six steps for medical education curriculum design were used iteratively to develop a simulation curriculum for the management of massive hemoptysis. Pulmonary and critical care medicine fellows from the University of Colorado participated in a local needs assessment and a massive hemoptysis simulation curriculum. Using a manikin-based massive hemoptysis simulator developed for this curriculum, the simulation session used repetitive practice, clinical variation, a range of difficulties, and directed feedback in a group practice setting. Time to management and performance were assessed for each management attempt; competence was assessed using a combined metric of management-related priorities and global entrustment. RESULTS During the needs assessment, fellows viewed massive hemoptysis management skills as important, while expressing their current confidence as low. Nineteen fellows participated in a 90-min case-based hemoptysis simulation during which each was exposed to five different cases and acted as the primary manager for two cases. There was significant improvement in performance from the first to final simulation attempts measured by time to successful management (14.24 vs 10.26 min, P = .0067) and entrustment (Global Assessment Scale, 1 [should not perform] to 5 [independent]; 4.11 vs 4.61; P = .015). Fellow self-assessed knowledge and confidence in hemoptysis management and endobronchial blocker placement improved significantly after the simulation. INTERPRETATION Hemoptysis simulation experience improves fellow confidence and skill for management of this high-acuity, low-occurrence presentation.
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Affiliation(s)
- Melissa L New
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; Rocky Mountain Regional VA Medical Center, Aurora, CO.
| | - Timothy Amass
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; Denver Health Medical Center, Denver, CO
| | - Anna Neumeier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; Denver Health Medical Center, Denver, CO
| | - Tristan J Huie
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; National Jewish Health, Denver, CO
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New ML, Amass T, Neumeier A, Jacobson NM, Huie TJ. Creation and Validation of a Massive Hemoptysis Simulator. Chest 2024; 165:636-644. [PMID: 37852436 DOI: 10.1016/j.chest.2023.10.014] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Simulation for the management of massive hemoptysis is limited by the absence of a commercially available simulator to practice procedural skills necessary for management. RESEARCH QUESTION Is it feasible to create and validate a hemoptysis simulator with high functional task alignment? STUDY DESIGN AND METHODS Pulmonary and critical care medicine (PCCM) attending physicians from four academic institutions in the Denver, Colorado, area and internal medicine residents from the University of Colorado participated in this mixed-methods study. A hemoptysis simulator was constructed by connecting a 3-D-printed airway model to a manikin that may be intubated. Attending PCCM physicians evaluated the simulator through surveys and qualitative interviews. Attendings were surveyed to determine simulation content and appropriate assessment criteria for a hemoptysis simulation. Based on these criteria, expert and novice performance on the simulator was assessed. RESULTS The manikin-based hemoptysis simulator demonstrated adequate physical resemblance, high functional alignment, and strong affective fidelity. It was universally preferred over a virtual reality simulator by 10 PCCM attendings. Twenty-seven attendings provided input on assessment criteria and established that assessing management priorities (eg, airway protection) was preferred to a skills checklist for hemoptysis management. Three experts outperformed six novices in hemoptysis management on the manikin-based simulator in all management categories assessed, supporting construct validity of the simulation. INTERPRETATION Creation of a hemoptysis simulator with appropriate content, high functional task alignment, and strong affective fidelity was successful using 3-D-printed airway models and existing manikins. This approach can overcome barriers of cost and availability for simulation of high-acuity, low-occurrence procedures.
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Affiliation(s)
- Melissa L New
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; Rocky Mountain Regional VA Medical Center, Aurora, CO.
| | - Timothy Amass
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; Denver Health Medical Center, Denver, CO
| | - Anna Neumeier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; Denver Health Medical Center, Denver, CO
| | - Nicholas M Jacobson
- College of Engineering, Design and Computing, University of Colorado, Aurora, CO
| | - Tristan J Huie
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO; National Jewish Health, Denver, CO
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Held N, Neumeier A, Amass T, Harry E, Pomponio R, Peterson RA, Huie TJ, Moss M. Extraneous Load, Patient Census, and Patient Acuity Correlate With Cognitive Load During ICU Rounds. Chest 2024:S0012-3692(24)00003-5. [PMID: 38184168 DOI: 10.1016/j.chest.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/29/2023] [Accepted: 12/21/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Cognitive load theory asserts that learning and performance degrade when cognitive load exceeds working memory capacity. This is particularly relevant in the learning environment of ICU rounds, when multidisciplinary providers integrate complex decision-making and teaching in a noisy, high-stress environment prone to cognitive distractions. RESEARCH QUESTION What features of ICU rounds correlate with high provider cognitive load? STUDY DESIGN AND METHODS This was an observational, multisite study of multidisciplinary providers during ICU rounds. Investigators recorded rounding characteristics and hourly extraneous cognitive load events during rounds (defined as distractions, episodes of split-attention or repetition, and deviations from standard communication format). After rounds, investigators measured each provider's cognitive load using the provider task load (PTL), an instrument derived from the National Aeronautics and Space Administration Task Load Index survey that assesses perceived workload associated with complex tasks. Relationships between rounding characteristics, extraneous load, and PTL score were evaluated using mixed-effects modeling. RESULTS A total of 76 providers were observed during 32 rounds from December 2020 to May 2021. The mean rounding census ± SD was 12.5 ± 2.9 patients. The mean rounding time ± SD was 2 h 17 min ± 49 min. The mean extraneous load ± SD was 20.5 ± 4.5 events per hour, or one event every 2 min 51 s. This included 8.6 ± 3.4 distractions, 8.2 ± 4.2 communication deviations, 1.9 ± 1.4 repetitions, and 1.8 ± 1.3 episodes of split-attention per hour. Controlling for covariates, the hourly extraneous load events, number of new patients, and number of higher acuity patients were each associated with increased PTL score (slope, 2.40; 95% CI, 0.76-4.04; slope, 5.23; 95% CI, 2.02-8.43; slope, 3.35; 95% CI, 1.34-5.35, respectively). INTERPRETATION Increased extraneous load, new patients, and patient acuity were associated with higher cognitive load during ICU rounds. These results can help direct how the ICU rounding structure may be modified to reduce workload and optimize provider learning and performance.
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Affiliation(s)
- Natalie Held
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Anna Neumeier
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Timothy Amass
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth Harry
- Department of Medicine, Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Raymond Pomponio
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO
| | - Ryan A Peterson
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO
| | - Tristan J Huie
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO; Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
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4
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Fernández Pérez ER, Crooks JL, Swigris JJ, Solomon JJ, Mohning MP, Huie TJ, Koslow M, Lynch DA, Groshong SD, Fier K. Design and rationale of a randomised, double-blind trial of the efficacy and safety of pirfenidone in patients with fibrotic hypersensitivity pneumonitis. ERJ Open Res 2021; 7:00054-2021. [PMID: 34109243 PMCID: PMC8181708 DOI: 10.1183/23120541.00054-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/12/2021] [Indexed: 01/18/2023] Open
Abstract
Hypersensitivity pneumonitis (HP) is an immunologically mediated form of lung disease resulting from inhalational exposure to any of a large variety of antigens. A subgroup of patients with HP develops pulmonary fibrosis (fibrotic HP; FHP), a significant cause of morbidity and mortality. This study will evaluate the safety and efficacy of the antifibrotic pirfenidone in treating FHP. This single-centre, randomised, double-blind, placebo-controlled trial is enrolling adults with FHP (ClinicalTrials.gov: NCT02958917). Study participants must have fibrotic abnormalities involving ≥5% of the lung parenchyma on high-resolution computed tomography scan, forced vital capacity (FVC) ≥40% and diffusing capacity of the lung for carbon monoxide ≥30% of predicted values. Study participants will be randomised in a 2:1 ratio to receive pirfenidone 2403 mg·day−1 or placebo. The primary efficacy end-point is the mean change in FVC % predicted from baseline to week 52. A number of secondary end-points have been chosen to evaluate the safety and efficacy in different domains. The design of a phase II study of 52 weeks of pirfenidone or placebo on top of standard of care in patients with fibrotic HP (ClinicalTrials.gov NCT02958917)https://bit.ly/32CfeSF
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Affiliation(s)
- Evans R Fernández Pérez
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - James L Crooks
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO, USA
| | - Jeffrey J Swigris
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Joshua J Solomon
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Michael P Mohning
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Tristan J Huie
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Matthew Koslow
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - David A Lynch
- Division of Radiology, National Jewish Health, Denver, CO, USA
| | | | - Kaitlin Fier
- Clinical and Translational Research Unit, National Jewish Health, Denver, CO, USA
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5
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Rahaghi F, Belperio JA, Fitzgerald J, Gulati M, Hallowell R, Highland KB, Huie TJ, Kim HJ, Kolb M, Lasky JA, Southern BD, Swigris JJ, de Andrade JA. Delphi Consensus Recommendations on Management of Dosing, Adverse Events, and Comorbidities in the Treatment of Idiopathic Pulmonary Fibrosis with Nintedanib. Clin Med Insights Circ Respir Pulm Med 2021; 15:11795484211006050. [PMID: 33854398 PMCID: PMC8013629 DOI: 10.1177/11795484211006050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 11/16/2022]
Abstract
Purpose: Nintedanib is an approved treatment for idiopathic pulmonary fibrosis (IPF), which slows disease progression. Management of patients with IPF receiving nintedanib can be complicated by tolerability issues, comorbidities, and concomitant medications. We developed consensus recommendations on the management of dosing, adverse events and comorbidities in patients with IPF treated with nintedanib. Methods: A modified Delphi process using 3 questionnaires was used to survey 14 pulmonologists experienced in using nintedanib. Panelists rated their agreement with statements on a Likert scale from −5 (strongly disagree) to +5 (strongly agree). Consensus was predefined as a mean score of ⩽−2.5 or ⩾+2.5 with a standard deviation not crossing zero. Results: The panelists’ recommendations were largely aligned with clinical trial data, real-world evidence, and the prescribing information, and provided additional guidance regarding minimizing gastrointestinal effects, periodic monitoring for liver dysfunction, caution with respect to concomitant administration of cytochrome P450 3A4 and P-glycoprotein 1 inhibitors and inducers and anticoagulants, and management of comorbidities. The panelists unanimously agreed that adverse event management should be individualized, based on careful consideration of the risks and benefits of each possible intervention and discussion with the patient. Conclusions: These consensus recommendations provide additional guidance on the appropriate management of IPF with nintedanib, for use alongside evidence-based literature and the prescribing information.
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Affiliation(s)
| | | | - John Fitzgerald
- University of Texas (UT) Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | | | - Hyun J Kim
- University of Minnesota, Minneapolis, MN, USA
| | - Martin Kolb
- McMaster University Firestone Institute for Respiratory Health (FIRH), Hamilton, ON, Canada
| | - Joseph A Lasky
- Tulane University School of Medicine, New Orleans, LA, USA
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Mohning MP, Amigues I, Demoruelle MK, Fernández Pérez ER, Huie TJ, Keith RK, Olson AL, Yunt ZX, Chung JH, Hobbs S, Swigris JJ, Solomon JJ. Duration of rheumatoid arthritis and the risk of developing interstitial lung disease. ERJ Open Res 2021; 7:00633-2020. [PMID: 33644223 PMCID: PMC7897845 DOI: 10.1183/23120541.00633-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 07/31/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis is an autoimmune disease that classically presents as a symmetrical inflammatory polyarthritis. Extra-articular manifestations are prevalent, with the lungs being the most common site [1], and interstitial lung disease (ILD) being the most severe form of pulmonary involvement. In some studies, the median survival of patients with rheumatoid arthritis and a usual interstitial pneumonia (UIP) pattern on high-resolution computed tomography (HRCT) is around 3 years (similar to that in idiopathic pulmonary fibrosis (IPF) [2, 3]); however, in other studies, median survival is >7 years [4, 5]. When present, ILD accounts for 10–20% of all deaths in rheumatoid arthritis [6]. Age of ILD onset is similar in patients with RA-UIP and RA-NSIP but duration of RA before ILD onset differshttps://bit.ly/3lgjfDJ
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Affiliation(s)
- Michael P Mohning
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Isabelle Amigues
- Division of Rheumatology, National Jewish Health, Denver, CO, USA
| | - M Kristen Demoruelle
- Division of Rheumatology, National Jewish Health, Denver, CO, USA.,Division of Rheumatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Evans R Fernández Pérez
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Tristan J Huie
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Rebecca K Keith
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Amy L Olson
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Zulma X Yunt
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Stephen Hobbs
- Dept of Radiology, University of Kentucky, Lexington, KY, USA
| | - Jeffrey J Swigris
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
| | - Joshua J Solomon
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, National Jewish Health, Denver, CO, USA
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7
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Channick CL, Garrison G, Huie TJ, Narewski E, Caplan-Shaw C, Cho J, Rafeq S, Alalawi R, Alashram R, Bailey KL, Carmona EM, Habib N, Kapolka R, Krishnan A, Lammi MR, Peck T, Pennington KM, Rali P, Small BL, Swenson C, Witkin A, Hayes MM. ATS Core Curriculum 2020. Adult Pulmonary Medicine. ATS Sch 2020; 1:416-435. [PMID: 33870311 PMCID: PMC8015759 DOI: 10.34197/ats-scholar.2020-0016re] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/03/2020] [Indexed: 01/08/2023] Open
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine in a 3- to 4-year recurring cycle of topics. The topics of the 2020 Pulmonary Core Curriculum include pulmonary vascular disease (submassive pulmonary embolism, chronic thromboembolic pulmonary hypertension, and pulmonary hypertension) and pulmonary infections (community-acquired pneumonia, pulmonary nontuberculous mycobacteria, opportunistic infections in immunocompromised hosts, and coronavirus disease [COVID-19]).
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Affiliation(s)
- Colleen L. Channick
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Garth Garrison
- Division of Pulmonary Disease and Critical Care Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Tristan J. Huie
- Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Erin Narewski
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Caralee Caplan-Shaw
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, New York University, New York, New York
| | - Josalyn Cho
- Division of Pulmonary, Critical Care, and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Samaan Rafeq
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, New York University, New York, New York
| | - Raed Alalawi
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Arizona, Phoenix, Phoenix, Arizona
| | - Rami Alashram
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Kristina L. Bailey
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Nebraska Medical Center, University of Nebraska, Omaha, Nebraska
| | - Eva M. Carmona
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Naomi Habib
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Arizona, Phoenix, Phoenix, Arizona
| | - Rebecca Kapolka
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, Georgia
| | - Amita Krishnan
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, Louisiana State University, New Orleans, Louisiana
| | - Matthew R. Lammi
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, Louisiana State University, New Orleans, Louisiana
| | - Tyler Peck
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Kelly M. Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Bronwyn L. Small
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Nebraska Medical Center, University of Nebraska, Omaha, Nebraska
| | - Colin Swenson
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, Georgia
| | - Alison Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
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8
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Fernández Pérez ER, Sprunger D, Ratanawatkul P, Maier LA, Huie TJ, Swigris JJ, Solomon JJ, Mohning M, Keith RC, Brown KK. Reply to Hall et al.: Hypersensitivity Pneumonitis Mortality by Industry and Occupation. Am J Respir Crit Care Med 2019; 200:518-519. [PMID: 31051089 PMCID: PMC6701030 DOI: 10.1164/rccm.201904-0876le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Lisa A. Maier
- University of Colorado at BoulderBoulder, Coloradoand
| | | | | | | | - Michael Mohning
- National Jewish HealthDenver, Colorado,University of Colorado at BoulderBoulder, Coloradoand
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9
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Culver DA, Behr J, Belperio JA, Corte TJ, de Andrade JA, Flaherty KR, Gulati M, Huie TJ, Lancaster LH, Roman J, Ryerson CJ, Kim HJ. Patient Registries in Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med 2019; 200:160-167. [PMID: 31034241 PMCID: PMC6635784 DOI: 10.1164/rccm.201902-0431ci] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/24/2019] [Indexed: 01/06/2023] Open
Abstract
Over the past decade, several large registries of patients with idiopathic pulmonary fibrosis (IPF) have been established. These registries are collecting a wealth of longitudinal data on thousands of patients with this rare disease. The data collected in these registries will be complementary to data collected in clinical trials because the patient populations studied in registries have a broader spectrum of disease severity and comorbidities and can be followed for a longer period of time. Maintaining the quality and completeness of registry databases presents administrative and resourcing challenges, but it is important to ensuring the robustness of the analyses. Data from patient registries have already helped improve understanding of the clinical characteristics of patients with IPF, the impact that the disease has on their quality of life and survival, and current practices in diagnosis and management. In the future, analyses of biospecimens linked to detailed patient profiles will provide the opportunity to identify biomarkers linked to disease progression, facilitating the development of precision medicine approaches for prognosis and therapy in patients with IPF.
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Affiliation(s)
| | - Jürgen Behr
- Department of Internal Medicine V, Ludwig-Maximilians University of Munich, Munich, Germany
- Asklepios Clinic Gauting, Member of the German Center for Lung Research, Gauting, Germany
| | - John A. Belperio
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Tamera J. Corte
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | | | - Kevin R. Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mridu Gulati
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Jesse Roman
- Jane and Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Hyun J. Kim
- University of Minnesota, Minneapolis, Minnesota
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10
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Fernández Pérez ER, Sprunger DB, Ratanawatkul P, Maier LA, Huie TJ, Swigris JJ, Solomon JJ, Mohning MP, Keith RC, Brown KK. Increasing Hypersensitivity Pneumonitis–related Mortality in the United States from 1988 to 2016. Am J Respir Crit Care Med 2019; 199:1284-1287. [DOI: 10.1164/rccm.201807-1258le] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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11
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Abstract
Radiologists have a critical role in the evaluation and diagnosis of suspected idiopathic pulmonary fibrosis (IPF). Accurate pattern identification on imaging is key in the multidisciplinary diagnostic process and frequently obviates the need for a surgical lung biopsy. In this review, we describe the clinical and imaging features of IPF in the context of recently revised international guidelines; contrast findings in other diseases that may inform differential diagnosis of fibrotic lung disease; and highlight common complications associated with pulmonary fibrosis.
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12
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Blumhagen RZ, Hedin BR, Malcolm KC, Burnham EL, Moss M, Abraham E, Huie TJ, Nick JA, Fingerlin TE, Alper S. Alternative pre-mRNA splicing of Toll-like receptor signaling components in peripheral blood mononuclear cells from patients with ARDS. Am J Physiol Lung Cell Mol Physiol 2017; 313:L930-L939. [PMID: 28775099 DOI: 10.1152/ajplung.00247.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 06/08/2017] [Revised: 07/28/2017] [Accepted: 07/30/2017] [Indexed: 12/14/2022] Open
Abstract
A key physiological feature of acute respiratory distress syndrome (ARDS) is inflammation. Toll-like receptor (TLR) signaling is required to combat the infection that underlies many ARDS cases but also contributes to pathological inflammation. Several TLR signaling pathway genes encoding positive effectors of inflammation also produce alternatively spliced mRNAs encoding negative regulators of inflammation. An imbalance between these isoforms could contribute to pathological inflammation and disease severity. To determine whether splicing in TLR pathways is altered in patients with ARDS, we monitored alternative splicing of MyD88 and IRAK1, two genes that function in multiple TLR pathways. The MyD88 and IRAK1 genes produce long proinflammatory mRNAs (MyD88L and IRAK1) and shorter anti-inflammatory mRNAs (MyD88S and IRAK1c). We quantified mRNA encoding inflammatory cytokines and MyD88 and IRAK1 isoforms in peripheral blood mononuclear cells (PBMCs) from 104 patients with ARDS and 30 healthy control subjects. We found that MyD88 pre-mRNA splicing is altered in patients with ARDS in a proinflammatory direction. We also observed altered MyD88 isoform levels in a second critically ill patient cohort, suggesting that these changes may not be unique to ARDS. Early in ARDS, PBMC IRAK1c levels were associated with patient survival. Despite the similarities in MyD88 and IRAK1 alternative splicing observed in previous in vitro studies, there were differences in how MyD88 and IRAK1 alternative splicing was altered in patients with ARDS. We conclude that pre-mRNA splicing of TLR signaling genes is altered in patients with ARDS, and further investigation of altered splicing may lead to novel prognostic and therapeutic approaches.
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Affiliation(s)
- Rachel Z Blumhagen
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado.,Department of Biomedical Research, National Jewish Health, Denver, Colorado
| | - Brenna R Hedin
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado.,Department of Biomedical Research, National Jewish Health, Denver, Colorado
| | - Kenneth C Malcolm
- Department of Medicine, National Jewish Health, Denver, Colorado.,Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Ellen L Burnham
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Marc Moss
- Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Edward Abraham
- Office of the Dean, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tristan J Huie
- Department of Medicine, National Jewish Health, Denver, Colorado.,Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, Colorado.,Division of Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Tasha E Fingerlin
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado.,Department of Biomedical Research, National Jewish Health, Denver, Colorado.,Department of Biostatistics and Bioinformatics, Colorado School of Public Health, Aurora, Colorado
| | - Scott Alper
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado; .,Department of Biomedical Research, National Jewish Health, Denver, Colorado.,Program in Mucosal Inflammation and Immunity, National Jewish Health, Denver, Colorado; and.,Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado
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13
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Yunt ZX, Chung JH, Hobbs S, Fernandez-Perez ER, Olson AL, Huie TJ, Keith RC, Janssen WJ, Goldstein BL, Lynch DA, Brown KK, Swigris JJ, Solomon JJ. High resolution computed tomography pattern of usual interstitial pneumonia in rheumatoid arthritis-associated interstitial lung disease: Relationship to survival. Respir Med 2017; 126:100-104. [PMID: 28427540 DOI: 10.1016/j.rmed.2017.03.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/24/2017] [Accepted: 03/28/2017] [Indexed: 01/27/2023]
Abstract
PURPOSE Interstitial lung disease is a common extra-articular manifestation of rheumatoid arthritis (RA-ILD) and is associated with significant morbidity and mortality. However, limited data exist regarding predictors of mortality. We sought to examine the prognostic value of the high-resolution computed tomography (HRCT) patterns in patients with RA-ILD. MATERIALS AND METHODS RA-ILD patients with HRCT patterns of usual interstitial pneumonia (UIP) or nonspecific interstitial pneumonia (NSIP) were identified among a longitudinal cohort of individuals evaluated at National Jewish Health. A total of 158 subjects were included in the study. For each subject, the earliest available HRCT was reviewed independently by two expert thoracic radiologists blinded to clinical data. HRCT patterns were classified as demonstrating definite UIP, possible UIP, or NSIP. Kaplan-Meier curves were generated and survival was compared among the three patterns using a log rank test for trend. RESULTS One hundred subjects (63%) had HRCT findings classified as definite UIP, 23 (15%) as possible UIP and 35 (22%) as NSIP. No difference in survival was seen between subjects with definite UIP versus those with possible UIP. The combined group of subjects with either definite- or possible UIP had significantly worse survival than those with NSIP (log-rank p = 0.03). CONCLUSIONS In patients with RA-ILD, patients with either definite UIP or possible UIP have equally poor survival when compared to those with an NSIP pattern.
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Affiliation(s)
- Zulma X Yunt
- National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Jonathan H Chung
- University of Chicago, 5841 South Maryland Ave, Chicago, IL 60637, USA
| | - Stephen Hobbs
- University of Kentucky, 740 South Limestone St, Lexington, KY 40536, USA
| | | | - Amy L Olson
- National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Tristan J Huie
- National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Rebecca C Keith
- National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | | | | | - David A Lynch
- National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
| | - Kevin K Brown
- National Jewish Health, 1400 Jackson St, Denver, CO 80206, USA
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14
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Solomon JJ, Chung JH, Cosgrove GP, Demoruelle MK, Fernandez-Perez ER, Fischer A, Frankel SK, Hobbs SB, Huie TJ, Ketzer J, Mannina A, Olson AL, Russell G, Tsuchiya Y, Yunt ZX, Zelarney PT, Brown KK, Swigris JJ. Predictors of mortality in rheumatoid arthritis-associated interstitial lung disease. Eur Respir J 2015; 47:588-96. [DOI: 10.1183/13993003.00357-2015] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 09/20/2015] [Indexed: 11/05/2022]
Abstract
Interstitial lung disease (ILD) is a common pulmonary manifestation of rheumatoid arthritis. There is lack of clarity around predictors of mortality and disease behaviour over time in these patients.We identified rheumatoid arthritis-related interstitial lung disease (RA-ILD) patients evaluated at National Jewish Health (Denver, CO, USA) from 1995 to 2013 whose baseline high-resolution computed tomography (HRCT) scans showed either a nonspecific interstitial pneumonia (NSIP) or a “definite” or “possible” usual interstitial pneumonia (UIP) pattern. We used univariate, multivariate and longitudinal analytical methods to identify clinical predictors of mortality and to model disease behaviour over time.The cohort included 137 subjects; 108 had UIP on HRCT (RA-UIP) and 29 had NSIP on HRCT (RA-NSIP). Those with RA-UIP had a shorter survival time than those with RA-NSIP (log rank p=0.02). In a model controlling for age, sex, smoking and HRCT pattern, a lower baseline % predicted forced vital capacity (FVC % pred) (HR 1.46; p<0.0001) and a 10% decline in FVC % pred from baseline to any time during follow up (HR 2.57; p<0.0001) were independently associated with an increased risk of death.Data from this study suggest that in RA-ILD, disease progression and survival differ between subgroups defined by HRCT pattern; however, when controlling for potentially influential variables, pulmonary physiology, but not HRCT pattern, independently predicts mortality.
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15
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Huie TJ, Brown KK. Definitions of disease: should possible and probable idiopathic pulmonary fibrosis be enrolled in treatment trials? Respir Investig 2015; 53:88-92. [PMID: 25951093 DOI: 10.1016/j.resinv.2014.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 09/26/2014] [Revised: 12/15/2014] [Accepted: 12/17/2014] [Indexed: 10/23/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic, fibrosing interstitial lung disease of unknown etiology characterized by progressive lung scarring and a median survival of 3-5 years from the time of diagnosis. The most recent consensus guidelines adopt a diagnostic process that characterizes patients as having a final diagnosis of IPF, probable IPF, or possible IPF determined from a combination of the clinical context and specific chest imaging and histologic disease patterns. Based on currently available data, the enrollment criteria for treatment trials could be expanded to include not only patients with IPF but also those with probable and possible IPF without adversely affecting trial design or outcomes.
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Affiliation(s)
- Tristan J Huie
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
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16
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Strand MJ, Sprunger D, Cosgrove GP, Fernandez-Perez ER, Frankel SK, Huie TJ, Olson AL, Solomon J, Brown KK, Swigris JJ. Pulmonary function and survival in idiopathic vs secondary usual interstitial pneumonia. Chest 2015; 146:775-785. [PMID: 24700149 DOI: 10.1378/chest.13-2388] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [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] Open
Abstract
BACKGROUND The usual interstitial pneumonia (UIP) pattern of lung injury may occur in the setting of connective tissue disease (CTD), but it is most commonly found in the absence of a known cause, in the clinical context of idiopathic pulmonary fibrosis (IPF). Our objective was to observe and compare longitudinal changes in pulmonary function and survival between patients with biopsy-proven UIP found in the clinical context of either CTD or IPF. METHODS We used longitudinal data analytic models to compare groups (IPF [n = 321] and CTD-UIP [n = 56]) on % predicted FVC (FVC %) or % predicted diffusing capacity of the lung for carbon monoxide (Dlco %), and we used both unadjusted and multivariable techniques to compare survival between these groups. RESULTS There were no significant differences between groups in longitudinal changes in FVC % or Dlco % up to diagnosis, or from diagnosis to 10 years beyond (over which time, the mean decrease in FVC % per year [95% CI] was 4.1 [3.4, 4.9] for IPF and 3.5 [1.8, 5.1] for CTD-UIP, P = .49 for difference; and the mean decrease in Dlco % per year was 4.7 [4.0, 5.3] for IPF and 4.3 [3.0, 5.6] for CTD-UIP, P = .60 for difference). Despite the lack of differences in pulmonary function, subjects with IPF had worse survival in unadjusted (log-rank P = .003) and certain multivariable analyses. CONCLUSIONS Despite no significant differences in changes in pulmonary function over time, patients with CTD-UIP (at least those with certain classifiable CTDs) live longer than patients with IPF--an observation that we suspect is due to an increased rate of mortal acute exacerbations in patients with IPF.
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Affiliation(s)
| | - David Sprunger
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Gregory P Cosgrove
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Evans R Fernandez-Perez
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Stephen K Frankel
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Tristan J Huie
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Amy L Olson
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Joshua Solomon
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Jeffrey J Swigris
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO.
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17
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Fernández Pérez ER, Swigris JJ, Forssén AV, Tourin O, Solomon JJ, Huie TJ, Olson AL, Brown KK. Identifying an inciting antigen is associated with improved survival in patients with chronic hypersensitivity pneumonitis. Chest 2014; 144:1644-1651. [PMID: 23828161 DOI: 10.1378/chest.12-2685] [Citation(s) in RCA: 230] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The cornerstone of hypersensitivity pneumonitis (HP) management is having patients avoid the inciting antigen (IA). Often, despite an exhaustive search, an IA cannot be found. The objective of this study was to examine whether identifying the IA impacts survival in patients with chronic HP. METHODS We used the Kaplan-Meier method to display, and the log-rank test to compare, survival curves of patients with well-characterized chronic HP stratified on identification of an IA exposure. A Cox proportional hazards (PH) model was used to identify independent predictors in time-to-death analysis. RESULTS Of 142 patients, 67 (47%) had an identified IA, and 75 (53%) had an unidentified IA. Compared with survivors, patients who died (n = 80, 56%) were older, more likely to have smoked, had lower total lung capacity % predicted and FVC % predicted, had higher severity of dyspnea, were more likely to have pulmonary fibrosis, and were less likely to have an identifiable IA. In a Cox PH model, the inability to identify an IA (hazard ratio [HR], 1.76; 95% CI, 1.01-3.07), older age (HR, 1.04; 95% CI, 1.01-1.07), the presences of pulmonary fibrosis (HR, 2.43; 95% CI, 1.36-4.35), a lower FVC% (HR, 1.36; 95% CI, 1.10-1.68), and a history of smoking (HR, 2.01; 95% C1, 1.15-3.50) were independent predictors of shorter survival. After adjusting for mean age, presence of fibrosis, mean FVC%, mean diffusing capacity of the lung for carbon monoxide (%), and history of smoking, survival was longer for patients with an identified IA exposure than those with an unidentified IA exposure (median, 8.75 years vs 4.88 years; P = .047). CONCLUSIONS Among patients with chronic HP, when adjusting for a number of potentially influential predictors, including the presence of fibrosis, the inability to identify an IA was independently associated with shortened survival.
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Affiliation(s)
- Evans R Fernández Pérez
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO.
| | - Jeffrey J Swigris
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Anna V Forssén
- Division of Pulmonary and Critical Care Medicine, and the Department of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO
| | | | - Joshua J Solomon
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Tristan J Huie
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Amy L Olson
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Interstitial Lung Disease Program and Autoimmune Lung Center, National Jewish Health, Denver, CO
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18
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Fernández Pérez ER, Krishnamoorthy M, Brown KK, Huie TJ, Fischer A, Solomon JJ, Meehan RT, Olson AL, Achcar RD, Swigris JJ. FEV1 over time in patients with connective tissue disease-related bronchiolitis. Respir Med 2013; 107:883-9. [PMID: 23582575 DOI: 10.1016/j.rmed.2013.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 02/25/2013] [Accepted: 02/28/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fibrosis or inflammation of the bronchioles is a well-known manifestation of connective tissue disease (CTD). However, the natural history of CTD-related bronchiolitis is largely unknown. METHODS We analyzed consecutive patients evaluated at National Jewish Health (Denver, CO) from 1998 to 2008 with CTD and surgical lung biopsy-confirmed bronchiolitis. Linear mixed effects models were used to estimate the longitudinal postbronchodilator FEV1 %predicted (%pred) course and differences between subjects with or without constrictive bronchiolitis (CB). RESULTS Of 28 subjects with a mean age of 53 ± 9 years, fourteen (50%) had CB. The most common CTD diagnosis was rheumatoid arthritis (n = 14; 50%). There were no significant differences in demographics, smoking status, underlying CTD diagnoses, 6-min walk distance, dyspnea score or drug therapy between subjects with CB and those with cellular bronchiolitis. Three subjects with CB (11%) and four with cellular bronchiolitis (14%) died. Compared with subjects with CB, those with cellular bronchiolitis had higher mean FEV1 %pred at all times. There were no significant differences in FEV1 %pred slope within- or between-groups (CB vs. cellular bronchiolitis) preceding surgical lung biopsy or afterward. CONCLUSION Subjects with CTD-related CB had lower FEV1 %pred values than those with CTD-related cellular bronchiolitis at all time points, but FEV1 %pred remained stable over time in both groups regardless of therapy received.
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Affiliation(s)
- Evans R Fernández Pérez
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO 80206, USA.
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19
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Lara AR, Cosgrove GP, Janssen WJ, Huie TJ, Burnham EL, Heinz DE, Curran-Everett D, Sahin H, Schwarz MI, Cool CD, Groshong SD, Geraci MW, Tuder RM, Hyde DM, Henson PM. Increased lymphatic vessel length is associated with the fibroblast reticulum and disease severity in usual interstitial pneumonia and nonspecific interstitial pneumonia. Chest 2013; 142:1569-1576. [PMID: 22797508 DOI: 10.1378/chest.12-0029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Lymphangiogenesis responds to tissue injury as a key component of normal wound healing. The development of fibrosis in the idiopathic interstitial pneumonias may result from abnormal wound healing in response to injury. We hypothesize that increased lymphatic vessel (LV) length, a marker of lymphangiogenesis, is associated with parenchymal components of the fibroblast reticulum (organizing collagen, fibrotic collagen, and fibroblast foci), and its extent correlates with disease severity. METHODS We assessed stereologically the parenchymal structure of fibrotic lungs and its associated lymphatic network, which was highlighted immunohistochemically in age-matched samples of usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP) with FVC < 80%, COPD with a Global Initiative for Obstructive Lung Disease stage 0, and normal control lungs. RESULTS LV length density, as opposed to vessel volume density, was found to be associated with organizing and fibrotic collagen density (P < .0001). Length density of LVs and the volume density of organizing and fibrotic collagen were significantly associated with severity of both % FVC (P < .001) and diffusing capacity of the lung for carbon monoxide (P < .001). CONCLUSIONS Severity of disease in UIP and NSIP is associated with increased LV length and is strongly associated with components of the fibroblast reticulum, namely organizing and fibrotic collagen, which supports a pathogenic role of LVs in these two diseases. Furthermore, the absence of definable differences between UIP and NSIP suggests that LVs are a unifying mechanism for the development of fibrosis in these fibrotic lung diseases.
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Affiliation(s)
- Abigail R Lara
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO.
| | - Gregory P Cosgrove
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO; Division of Pulmonary and Critical Care Medicine, National Jewish Health, Denver, CO
| | - William J Janssen
- Division of Pulmonary and Critical Care Medicine, National Jewish Health, Denver, CO
| | - Tristan J Huie
- Division of Pulmonary and Critical Care Medicine, National Jewish Health, Denver, CO
| | - Ellen L Burnham
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - David E Heinz
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - Douglas Curran-Everett
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO; Department of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO
| | - Hakan Sahin
- Department of Radiology, University of Colorado Denver, Aurora, CO
| | - Marvin I Schwarz
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - Carlyne D Cool
- Department of Pathology, University of Colorado Denver, Aurora, CO
| | | | - Mark W Geraci
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - Rubin M Tuder
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Aurora, CO
| | - Dallas M Hyde
- Department of Anatomy, Physiology and Cell Biology, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Peter M Henson
- Division of Immunology, National Jewish Health, Denver, CO
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20
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Fischer A, Brown KK, Du Bois RM, Frankel SK, Cosgrove GP, Fernandez-Perez ER, Huie TJ, Krishnamoorthy M, Meehan RT, Olson AL, Solomon JJ, Swigris JJ. Mycophenolate mofetil improves lung function in connective tissue disease-associated interstitial lung disease. J Rheumatol 2013; 40:640-6. [PMID: 23457378 DOI: 10.3899/jrheum.121043] [Citation(s) in RCA: 241] [Impact Index Per Article: 21.9] [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: 11/22/2022]
Abstract
OBJECTIVE Small series suggest mycophenolate mofetil (MMF) is well tolerated and may be an effective therapy for connective tissue disease-associated interstitial lung disease (CTD-ILD). We examined the tolerability and longitudinal changes in pulmonary physiology in a large and diverse cohort of patients with CTD-ILD treated with MMF. METHODS We identified consecutive patients evaluated at our center between January 2008 and January 2011 and prescribed MMF for CTD-ILD. We assessed safety and tolerability of MMF and used longitudinal data analyses to examine changes in pulmonary physiology over time, before and after initiation of MMF. RESULTS We identified 125 subjects treated with MMF for a median 897 days. MMF was discontinued in 13 subjects. MMF was associated with significant improvements in estimated percentage of predicted forced vital capacity (FVC%) from MMF initiation to 52, 104, and 156 weeks (4.9% ± 1.9%, p = 0.01; 6.1% ± 1.8%, p = 0.0008; and 7.3% ± 2.6%, p = 0.004, respectively); and in estimated percentage predicted diffusing capacity (DLCO%) from MMF initiation to 52 and 104 weeks (6.3% ± 2.8%, p = 0.02; 7.1% ± 2.8%, p = 0.01). In the subgroup without usual interstitial pneumonia (UIP)-pattern injury, MMF significantly improved FVC% and DLCO%, and in the subgroup with UIP-pattern injury, MMF was associated with stability in FVC% and DLCO%. CONCLUSION In a large diverse cohort of CTD-ILD, MMF was well tolerated and had a low rate of discontinuation. Treatment with MMF was associated with either stable or improved pulmonary physiology over a median 2.5 years of followup. MMF appears to be a promising therapy for the spectrum of CTD-ILD.
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Affiliation(s)
- Aryeh Fischer
- Autoimmune and Interstitial Lung Disease Program, National Jewish Health, Denver, Colorado 80206, USA.
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21
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Pillai M, Olson AL, Huie TJ, Solomon JJ, Fernandez-Perez ER, Brown KK, Hanna P, Lee-Chiong T, Swigris JJ. Obstructive sleep apnea does not promote esophageal reflux in fibrosing interstitial lung disease. Respir Med 2012; 106:1033-9. [PMID: 22521226 DOI: 10.1016/j.rmed.2012.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 01/13/2012] [Accepted: 03/23/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with fibrosing interstitial lung disease (fILD), gastroesophageal reflux (GER) is highly prevalent, perhaps because of the effects of lung fibrosis on altering intrathoracic pressure, diaphragm morphology and lower esophageal sphincter (LES) function. For unclear reasons, obstructive sleep apnea (OSA) is also highly prevalent among patients with fILD. We conducted this study to test our hypothesis that, in patients with fILD, OSA would exacerbate diaphragm/LES dysfunction and increase the propensity for-and severity of - GER. METHODS We identified patients with fILD who underwent screening polysomnogram and pH or pH/impedence probe at our center during the same week. We examined the association between OSA and GER and used logistic regression to determine independent predictors of OSA or GER. RESULTS In 54 included subjects, neither OSA (dichotomous) nor apnea hypopnea index (continuous) predicted the presence of GER. Regardless of body position (upright, recumbent), GER was no more frequent or severe among subjects with OSA vs. those without OSA. Subjects with idiopathic pulmonary fibrosis (IPF) had an odds of GER nearly seven-fold greater than subjects with other forms of fILD (odds ratio = 6.84, 95% confidence interval 1.36-34.43, p = 0.02). For the entire cohort and the subgroup with IPF, there was no correlation between pulmonary physiology and GER. CONCLUSIONS In fILD, OSA does not appear to promote GER. Research is needed to determine if compensatory mechanisms emanating from the crural diaphragm prevent GER in fILD patients with OSA and to sort out whether GER has a role in the pathogenesis of certain forms of fILD.
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Affiliation(s)
- Manju Pillai
- Sleep Medicine Program, National Jewish Health, Denver, CO, USA
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22
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Fischer A, Solomon JJ, du Bois RM, Deane KD, Olson AL, Fernandez-Perez ER, Huie TJ, Stevens AD, Gill MB, Rabinovitch AM, Lynch DA, Burns DA, Pineiro IS, Groshong SD, Duarte Achcar RD, Brown KK, Martin RJ, Swigris JJ. Lung disease with anti-CCP antibodies but not rheumatoid arthritis or connective tissue disease. Respir Med 2012; 106:1040-7. [PMID: 22503074 DOI: 10.1016/j.rmed.2012.03.006] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 03/07/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to characterize a novel cohort of patients with lung disease, anti-cyclic citrullinated peptide (CCP) antibody positivity, without rheumatoid arthritis (RA) or other connective tissue disease (CTD). METHODS The study sample included 74 subjects with respiratory symptoms, evaluated January 2008-January 2010 and found to have a positive anti-CCP antibody but no evidence for RA or other CTD. Each underwent serologic testing, pulmonary physiology testing, and thoracic high-resolution computed tomography (HRCT) scan as part of routine clinical evaluation. RESULTS The majority of subjects were women, and most were former cigarette smokers. Four distinct radiographic phenotypes were identified: isolated airways disease (54%), isolated interstitial lung disease (ILD) (14%), mixed airways disease and ILD (26%), and combined pulmonary fibrosis with emphysema (7%). This cohort had a predominance of airways disease, either in isolation or along with a usual interstitial pneumonia-pattern of ILD. Among subjects with high-titer anti-CCP positivity (n=33), three developed the articular manifestations of RA during a median follow-up of 449 days. CONCLUSION We have described a unique cohort of patients with anti-CCP antibody positivity and lung disease in the absence of existing RA or other CTD. The lung phenotypic characteristics of this cohort resemble those of established RA and a few of these patients have developed articular RA within a short period of follow-up. The implications of a positive anti-CCP antibody among patients with lung disease but not RA are not yet known, but we believe requires further investigation.
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Affiliation(s)
- Aryeh Fischer
- Autoimmune Lung Center, National Jewish Health, Denver, CO 80206, USA.
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23
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Swigris JJ, Olson AL, Huie TJ, Fernandez-Perez ER, Solomon J, Sprunger D, Brown KK. Ethnic and racial differences in the presence of idiopathic pulmonary fibrosis at death. Respir Med 2012; 106:588-93. [PMID: 22296740 PMCID: PMC3294009 DOI: 10.1016/j.rmed.2012.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [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: 06/20/2011] [Revised: 11/08/2011] [Accepted: 01/09/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND In studies of idiopathic pulmonary fibrosis (IPF), whites makeup the vast majority of subjects. Whether ethnic/racial differences in idiopathic pulmonary fibrosis occur in the general population is unknown. METHODS To compare the presence of IPF between ethnic/racial groups of U.S. decedents from 1989 to 2007 by using the National Center for Health Statistics database. RESULTS There were 251,058 U.S. decedents with IPF; 87.2% were non-Hispanic whites (White), 5.1% were non-Hispanic African American (black), 5.4% were Hispanic, and 2.2% were from other ethnic/racial groups (other). Whites coded with IPF died older than those in the other groups (77.9 years vs. 72.1 years for blacks, 75.3 years for Hispanics, and 75.6 years for others; p < 0.0001 for all pairwise comparisons). When controlling for age and for sex, compared with whites, both Hispanics and Others were more likely to be coded with IPF (OR = 1.47, 95% CI 1.44-1.49, p < 0.0001 and OR = 1.29, 95% CI 1.26-1.36, p < 0.0001 respectively), while blacks were significantly less likely to be coded with IPF (OR = 0.48, 95% CI 0.47-0.49, p < 0.0001). Among decedents with IPF, Hispanics were more likely, and blacks were less likely, than whites to die from IPF (OR = 1.24, 95% CI 1.20-1.29, p < 0.0001 and OR = 0.91, 95% CI 0.87-0.94, p < 0.0001). CONCLUSION From 1989 to 2007, black decedents were less-and Hispanics were more-likely than whites to die of/with IPF. Research is needed to determine if genetic differences between ethnic/racial groups explain these findings.
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Affiliation(s)
- Jeffrey J Swigris
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO 80206, USA.
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Sprunger DB, Olson AL, Huie TJ, Fernandez-Perez ER, Fischer A, Solomon JJ, Brown KK, Swigris JJ. Pulmonary fibrosis is associated with an elevated risk of thromboembolic disease. Eur Respir J 2011; 39:125-32. [PMID: 21737559 DOI: 10.1183/09031936.00041411] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Recent epidemiological studies have suggested an increased risk of venous thromboembolism (VTE) in lung fibrosis. Large-scale epidemiological data regarding the risk of VTE in pulmonary fibrosis-associated mortality have not been published. Using data from the National Center for Health Statistics from 1988-2007, we determined the risk of VTE in decedents with pulmonary fibrosis in the USA. We analysed 46,450,489 records, of which 218,991 met our criteria for idiopathic pulmonary fibrosis. Among these, 3,815 (1.74%) records also contained a diagnostic code for VTE. The risk of VTE in pulmonary fibrosis decedents was 34% higher than in the background population, and 44% and 54% greater than among decedents with chronic obstructive pulmonary disease and lung cancer, respectively. Those with VTE and pulmonary fibrosis died at a younger age than those with pulmonary fibrosis alone (females: 74.3 versus 77.4 yrs (p<0.0001); males: 72.0 versus 74.4 yrs (p<0.0001)). Decedents with pulmonary fibrosis had a significantly greater risk of VTE. Those with VTE and pulmonary fibrosis died at a younger age than those with pulmonary fibrosis alone. These data suggest a link between a pro-fibrotic and a pro-coagulant state.
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Affiliation(s)
- D B Sprunger
- Interstitial Lung Disease Program and Autoimmune Lung Center, Division of Pulmonary and Critical Care Medicine, National Jewish Health, Denver, CO 80220, USA
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Swigris JJ, Olson AL, Huie TJ, Fernandez-Perez ER, Solomon J, Sprunger D, Brown KK. Sarcoidosis-related mortality in the United States from 1988 to 2007. Am J Respir Crit Care Med 2011; 183:1524-30. [PMID: 21330454 PMCID: PMC3137141 DOI: 10.1164/rccm.201010-1679oc] [Citation(s) in RCA: 213] [Impact Index Per Article: 16.4] [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: 10/18/2010] [Accepted: 02/17/2011] [Indexed: 12/21/2022] Open
Abstract
RATIONALE It has been nearly 20 years since sarcoidosis mortality was examined at the population level in the United States. OBJECTIVES To examine mortality rates and underlying causes of death among United States decedents with sarcoidosis from 1988-2007. METHODS We used data from the National Center for Health Statistics to (1) calculate age-adjusted sarcoidosis-associated mortality rates; (2) examine how those rates differ by age, sex, and race and ethnicity; and (3) determine underlying causes of death among sarcoidosis decedents. MEASUREMENTS AND MAIN RESULTS From 1988-2007, there were 46,450,489 deaths in the United States and 23,679 decedents with sarcoidosis mentioned on their death certificates. Over this time, the age-adjusted, sarcoidosis-related mortality rate increased 50.5% in women and 30.1% in men. The greatest absolute increase in death rates was among non-Hispanic black females. Regardless of sex or race, mortality rates climbed most in decedents 55 years or older. The most common cause of death was sarcoidosis itself. Younger sarcoidosis decedents with pulmonary fibrosis were more likely to be black than white, and younger sarcoidosis decedents were more likely than similarly aged decedents in the general population to have a cardiac cause contribute to death. CONCLUSIONS From 1988-2007, sarcoidosis-related mortality rates increased significantly, particularly in non-Hispanic black females aged 55 years or older. The underlying cause of death in most patients with sarcoidosis was the disease itself. Among young sarcoidosis decedents, those with pulmonary fibrosis or a cardiac cause contributing to death were more likely to be black than white.
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Affiliation(s)
- Jeffrey J Swigris
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO 80206, USA.
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Swigris JJ, Olson AL, Huie TJ, Fernandez-Perez ER, Solomon JJ, Sprunger D, Brown KK. Increased risk of pulmonary embolism among US decedents with sarcoidosis from 1988 to 2007. Chest 2011; 140:1261-1266. [PMID: 21565969 DOI: 10.1378/chest.11-0324] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A recently published report from the United Kingdom suggested an association between sarcoidosis and pulmonary embolism (PE). We sought to examine whether this association was present among US decedents with sarcoidosis. METHODS We used data from the National Center for Health Statistics to investigate the association between sarcoidosis and PE among US decedents from 1988 to 2007. RESULTS From 1988 to 2007, there were 46,450,489 deaths in the United States and 23,679 decedents with sarcoidosis mentioned on their death certificates. Among these, 602 (2.54%) had PE mentioned on their death certificates, compared with only 1.13% of the background population (P < .0001 for comparison). The association between sarcoidosis and PE was significant regardless of gender (OR, 2.07; 95% CI, 1.80-2.39; P < .0001 for men and OR, 1.76; 95% CI, 1.59-1.96; P ≤ .0001 for women) or race (OR, 1.57; 95% CI, 1.41-1.76; P < .0001 for blacks and OR, 1.87; 95% CI, 1.63-2.14; P < .0001 for whites). Among decedents with sarcoidosis, there was no difference in risk of PE between men and women (2.30% vs 2.54%, χ(2) = 1.32, P = .25) or between blacks and whites (2.60% vs 2.23%, χ(2) = 3.09, P = .08). The association between sarcoidosis and PE held regardless of age. CONCLUSIONS Using death certificate data from 1988 to 2007, we detected an association between sarcoidosis and PE regardless of gender, race, or age. Further investigation is needed to decipher the mechanisms of this apparent association.
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Affiliation(s)
- Jeffrey J Swigris
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO.
| | - Amy L Olson
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Tristan J Huie
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Evans R Fernandez-Perez
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Joshua J Solomon
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - David Sprunger
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
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Huie TJ, Moss M, Frankel SK. What can biomarkers tell us about the pathogenesis of acute exacerbations of idiopathic pulmonary fibrosis? Am J Physiol Lung Cell Mol Physiol 2010; 299:L1-2. [DOI: 10.1152/ajplung.00155.2010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tristan J. Huie
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora; and
- Interstitial Lung Disease Program, National Jewish Health, Denver, Colorado
| | - Marc Moss
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora; and
| | - Stephen K. Frankel
- Division of Pulmonary Science and Critical Care Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora; and
- Interstitial Lung Disease Program, National Jewish Health, Denver, Colorado
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Huie TJ, Olson AL, Cosgrove GP, Janssen WJ, Lara AR, Lynch DA, Groshong SD, Moss M, Schwarz MI, Brown KK, Frankel SK. A detailed evaluation of acute respiratory decline in patients with fibrotic lung disease: aetiology and outcomes. Respirology 2010; 15:909-17. [PMID: 20546190 DOI: 10.1111/j.1440-1843.2010.01774.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVE A comprehensive diagnostic evaluation is recommended for all patients with fibrotic lung disease and acute respiratory decompensation. However, the effect on clinical outcomes of this evaluation remains unknown. METHODS We evaluated 27 consecutive patients with fibrotic lung disease who were hospitalized for an acute respiratory decline between June 2006 and April 2009. An interstitial lung disease expert assisted with the acute care of each patient. A retrospective review of the patient charts was performed to obtain demographic and clinical data, and to assess outcomes. RESULTS Using a strict definition of acute exacerbation (AE) of fibrotic lung disease derived from the IPF Network Pulmonary Perspective statement, 10 of the 27 patients were classified as definite AE and nine as suspected AE. In eight patients, infectious agents were identified as potential explanations for the respiratory decline. No patients with congestive heart failure or pulmonary embolism were identified. Overall survival to discharge was 37.0%. One-year survival was 14.8%. There were no differences in outcomes for patients with AE compared with those for whom potential infectious aetiologies were identified (log rank, P = 0.932). Patients with IPF showed a decreased rate of survival compared with patients with non-IPF fibrotic disease (1-year survival 0% vs 28.6%, log rank, P = 0.045). CONCLUSIONS In patients with fibrotic lung disease and an acute respiratory decline, a detailed diagnostic evaluation revealed a potential infectious aetiology in up to one-third of cases. However, there was no association between this finding and outcomes in these patients. One-year survival was dismal in patients who suffered an acute respiratory decompensation.
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Affiliation(s)
- Tristan J Huie
- University of Colorado Denver, Division of Pulmonary Sciences and Critical Care Medicine, Aurora, Colorado 80045, USA.
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Olson AL, Huie TJ, Groshong SD, Cosgrove GP, Janssen WJ, Schwarz MI, Brown KK, Frankel SK. Acute exacerbations of fibrotic hypersensitivity pneumonitis: a case series. Chest 2008; 134:844-850. [PMID: 18842917 DOI: 10.1378/chest.08-0428] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [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 It is now recognized that a significant portion of patients with idiopathic pulmonary fibrosis (IPF) can have sudden and rapid deteriorations in disease course that cannot be explained by infection, heart failure, or thromboembolic disease. These events are often fatal and have been termed acute exacerbations (AEs) of underlying disease. While best described in patients with IPF, they have also been reported in patients with other forms of interstitial lung disease. We sought to determine if this same phenomenon occurs in patients with hypersensitivity pneumonitis (HP). METHODS We retrospectively reviewed our clinical experience at National Jewish Medical and Research Center for patients with surgical lung biopsy-proven fibrotic HP who had an acute decline in respiratory status and met criteria similar to those proposed for the diagnosis of an AE of IPF. RESULTS Over a 2-year period, we identified four patients with an AE of fibrotic HP. All patients had a clinical course similar to that most frequently described in AEs of IPF: respiratory failure requiring assisted ventilation, lack of clinical response to high-dose corticosteroid therapy, and a poor prognosis (all cases resulted in death or emergent lung transplantation). Lung biopsy at the time of the AE, explant, or autopsy revealed organizing diffuse alveolar damage superimposed on fibrotic lung disease. CONCLUSIONS Fibrotic HP, like other forms of fibrotic lung disease, can be associated with AEs of disease. Further investigation into similarities and pathways common in AEs of various fibrotic lung diseases may yield additional insight into this recently recognized syndrome.
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Affiliation(s)
- Amy L Olson
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO.
| | - Tristan J Huie
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Steve D Groshong
- Interstitial Lung Disease Program, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Gregory P Cosgrove
- Interstitial Lung Disease Program, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
| | - William J Janssen
- Interstitial Lung Disease Program, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Marvin I Schwarz
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Kevin K Brown
- Interstitial Lung Disease Program, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
| | - Stephen K Frankel
- Interstitial Lung Disease Program, Section of Critical Care and Hospital Medicine, National Jewish Medical and Research Center, Denver, CO
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Huie TJ, Lyn-Kew K, Roberts A. REDUCED NEUROMUSCULAR BLOCKADE REQUIREMENTS IN PATIENTS RECEIVING AIRWAY PRESSURE RELEASE VENTILATION. Chest 2005. [DOI: 10.1378/chest.128.4_meetingabstracts.197s] [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: 11/01/2022] Open
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