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Barth S, Edwards C, Saini G, Haider Y, Williams NP, Storrar W, Jenkins G, Stewart I, Wickremasinghe M. Feasibility and acceptability of remotely monitoring spirometry and pulse oximetry as part of interstitial lung disease clinical care: a single arm observational study. Respir Res 2024; 25:162. [PMID: 38622608 PMCID: PMC11020645 DOI: 10.1186/s12931-024-02787-1] [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: 08/16/2023] [Accepted: 03/23/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Remote monitoring of patient-recorded spirometry and pulse oximetry offers an alternative approach to traditional hospital-based monitoring of interstitial lung disease (ILD). Remote spirometry has been observed to reasonably reflect clinic spirometry in participants with ILD but remote monitoring has not been widely incorporated into clinical practice. We assessed the feasibility of remotely monitoring patients within a clinical ILD service. METHODS Prospective, single-arm, open-label observational multi-centre study (NCT04850521). Inclusion criteria included ILD diagnosis, age ≥ 18 years, FVC ≥ 50% predicted. 60 participants were asked to record a single spirometry and oximetry measurement at least once daily, monitored weekly by their local clinical team. Feasibility was defined as ≥ 68% of participants with ≥ 70% adherence to study measurements and recording measurements ≥ 3 times/week throughout. RESULTS A total of 60 participants were included in the analysis. 42/60 (70%) were male; mean age 67.8 years (± 11.2); 34/60 (56.7%) had idiopathic pulmonary fibrosis (IPF), Median ILD-GAP score was 3 (IQR 1-4.75). Spirometry adherence was achieved for ≥ 70% of study days in 46/60 participants (77%) and pulse oximetry adherence in 50/60 participants (83%). Recording ≥ 3 times/week every week was provided for spirometry in 41/60 participants (68%) and pulse oximetry in 43/60 participants (72%). Mean difference between recent clinic and baseline home spirometry was 0.31 L (± 0.72). 85.7% (IQR 63.9-92.6%) home spirometry attempts/patient were acceptable or usable according to ERS/ATS spirometry criteria. Positive correlation was observed between ILD-GAP score and adherence to spirometry and oximetry (rho 0.24 and 0.38 respectively). Adherence of weekly monitoring by clinical teams was 80.95% (IQR 64.19-95.79). All participants who responded to an experience questionnaire (n = 33) found remote measurements easy to perform and 75% wished to continue monitoring their spirometry at the conclusion of the study. CONCLUSION Feasibility of remote monitoring within an ILD clinical service was demonstrated over 3 months for both daily home spirometry and pulse oximetry of patients. Remote monitoring may be more acceptable to participants who are older or have more advanced disease. TRIAL REGISTRATION clinicaltrials.gov NCT04850521 registered 20th April 2021.
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Affiliation(s)
- Sarah Barth
- Imperial College Healthcare NHS Trust, ILD Service, Mint Wing, St Mary?s Hospital, Praed Street, London, W2 1NY, UK.
| | | | - Gauri Saini
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Yussef Haider
- Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | | | - Will Storrar
- Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Gisli Jenkins
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Iain Stewart
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Melissa Wickremasinghe
- Imperial College Healthcare NHS Trust, ILD Service, Mint Wing, St Mary?s Hospital, Praed Street, London, W2 1NY, UK
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Barth S, Edwards C, Borton R, Beever D, Adams W, Jenkins G, Pizzo E, Stewart I, Wickremasinghe M. REMOTE-ILD study: Description of the protocol for a multicentre, 12-month randomised controlled trial to assess the clinical and cost-effectiveness of remote monitoring of spirometry and pulse oximetry in patients with interstitial lung disease. BMJ Open Respir Res 2024; 11:e002067. [PMID: 38418384 PMCID: PMC10910426 DOI: 10.1136/bmjresp-2023-002067] [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: 09/12/2023] [Accepted: 11/14/2023] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Remote monitoring of home physiological measurements has been proposed as a solution to support patients with chronic diseases as well as facilitating virtual consultations and pandemic preparedness for the future. Daily home spirometry and pulse oximetry have been demonstrated to be safe and acceptable to patients with interstitial lung disease (ILD) but there is currently limited evidence to support its integration into clinical practice. AIM Our aim is to understand the clinical utility of frequent remote physiological measurements in ILD and the impact of integrating these into clinical practice from a patient, clinical and health economic perspective. METHODS AND ANALYSIS 132 patients with fibrotic ILD will be recruited and randomised to receive either usual care with remote digital monitoring of home spirometry and pulse oximetry or usual care alone for 12 months. All participants will complete health-related quality of life and experience questionnaires.The primary outcome compares the availability of spirometry measurements within the 2 weeks preceding planned clinic appointments. Secondary outcomes will explore other aspects of clinical and cost-effectiveness of the remote monitoring programme. ETHICS AND DISSEMINATION The study has been approved by the Camden and Kings Cross Research Ethics Committee (22/LO/0309). All participants will provide informed consent.This study is registered with www. CLINICALTRIALS gov (NCT05662124).The results of the study will be submitted for presentation at regional and national conferences and submitted for peer-reviewed publication. Reports will be prepared for study participants with the support from our public involvement representatives through the charity Action for Pulmonary Fibrosis.
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Affiliation(s)
- Sarah Barth
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Dan Beever
- Action For Pulmonary Fibrosis, Peterborough, UK
| | - Wendy Adams
- Action For Pulmonary Fibrosis, Peterborough, UK
| | - Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Iain Stewart
- National Heart and Lung Institute, Imperial College London, London, UK
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3
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Dixon G, Hague S, Mulholland S, Adamali H, Khin AMN, Thould H, Connon R, Minnis P, Murtagh E, Khan F, Toor S, Lawrence A, Naqvi M, West A, Coker RK, Ward K, Yazbeck L, Hart S, Garfoot T, Newman K, Rivera-Ortega P, Stranks L, Beirne P, Bradley J, Rowan C, Agnew S, Ahmad M, Spencer LG, Aigbirior J, Fahim A, Wilson AM, Butcher E, Chong SG, Saini G, Zulfikar S, Chua F, George PM, Kokosi M, Kouranos V, Molyneaux P, Renzoni E, Vitri B, Wells AU, Nicol LM, Bianchi S, Kular R, Liu H, John A, Barth S, Wickremasinghe M, Forrest IA, Grimes I, Simpson AJ, Fletcher SV, Jones MG, Kinsella E, Naftel J, Wood N, Chalmers J, Crawshaw A, Crowley LE, Dosanjh D, Huntley CC, Walters GI, Gatheral T, Plum C, Bikmalla S, Muthusami R, Stone H, Rodrigues JC, Tsaneva-Atanasova K, Scotton CJ, Gibbons MA, Barratt SL. Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK. ERJ Open Res 2024; 10:00529-2023. [PMID: 38226064 PMCID: PMC10789269 DOI: 10.1183/23120541.00529-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/17/2023] [Indexed: 01/17/2024] Open
Abstract
Background Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting. Methods 26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey. Results 24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD. Conclusion We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.
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Affiliation(s)
- Giles Dixon
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Samuel Hague
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Sarah Mulholland
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
| | - Aye Myat Noe Khin
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Hannah Thould
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Roisin Connon
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Paul Minnis
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Eoin Murtagh
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Fasihul Khan
- Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sameen Toor
- Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Marium Naqvi
- Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Alex West
- Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Robina K. Coker
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katie Ward
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Leda Yazbeck
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Simon Hart
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Theresa Garfoot
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kate Newman
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Pilar Rivera-Ortega
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lachlan Stranks
- Interstitial Lung Disease Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paul Beirne
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Sarah Agnew
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospital NHS FT, Liverpool, UK
| | - Mahin Ahmad
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospital NHS FT, Liverpool, UK
| | - Lisa G. Spencer
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospital NHS FT, Liverpool, UK
| | - Joshua Aigbirior
- New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ahmed Fahim
- New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Andrew M. Wilson
- Norfolk and Norwich University Hospital NHS Foundation Trust, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Sy Giin Chong
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gauri Saini
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Felix Chua
- Royal Brompton and Harefield Hospitals, London, UK
| | | | - Maria Kokosi
- Royal Brompton and Harefield Hospitals, London, UK
| | | | | | | | | | | | | | - Stephen Bianchi
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Raman Kular
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - HuaJian Liu
- Southern Health and Social Care Trust, Portadown, UK
| | | | - Sarah Barth
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian A. Forrest
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ian Grimes
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - A. John Simpson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Sophie V. Fletcher
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Respiratory Biomedical Research Centre and School of Clinical and Experimental Sciences, Faulty of Medicine, University of Southampton, Southampton, UK
| | - Mark G. Jones
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Respiratory Biomedical Research Centre and School of Clinical and Experimental Sciences, Faulty of Medicine, University of Southampton, Southampton, UK
| | - Emma Kinsella
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Jennifer Naftel
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Nicola Wood
- University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Jodie Chalmers
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anjali Crawshaw
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Louise E. Crowley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Davinder Dosanjh
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christopher C. Huntley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gareth I. Walters
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Gatheral
- University Hospitals of Morecambe Bay NHS Foundation Trust, Lancashire and South Cumbria ILD Service, Lancaster, UK
| | - Catherine Plum
- University Hospitals of Morecambe Bay NHS Foundation Trust, Lancashire and South Cumbria ILD Service, Lancaster, UK
| | - Shiva Bikmalla
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Raja Muthusami
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Helen Stone
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Jonathan C.L. Rodrigues
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department of Health, University of Bath, Bath, UK
| | - Krasimira Tsaneva-Atanasova
- Department of Mathematics and Statistics, Faculty of Environment, Science and Economy, University of Exeter, Exeter, UK
- EPSRC Hub for Quantitative Modelling in Healthcare, University of Exeter, Exeter, UK
- Living Systems Institute, University of Exeter, Exeter, UK
| | - Chris J. Scotton
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Michael A. Gibbons
- South West Peninsula ILD Network, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
- These authors contributed equally
| | - Shaney L. Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust, Bristol, UK
- These authors contributed equally
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Smith DJF, Meghji J, Moonim M, Ross C, Viola P, Wickremasinghe M, Gleeson LE. Sarcoidosis following COVID infection: A case series. Respirol Case Rep 2023; 11:e01231. [PMID: 37840600 PMCID: PMC10570663 DOI: 10.1002/rcr2.1231] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 04/10/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023] Open
Abstract
Here we describe three cases of sarcoidosis which were diagnosed following COVID infection. Treating clinicians should consider post-COVID-19 sarcoidosis in their differential, as it represents a potentially treatable cause of persistent symptomatology.
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Affiliation(s)
- David J. F. Smith
- Department of Inflammation Repair & Development, National Heart & Lung InstituteImperial College LondonLondonUK
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Jamilah Meghji
- Department of Respiratory MedicineCambridge University Hospitals NHS TrustCambridgeUK
| | - Mufaddal Moonim
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
- North West London PathologyLondonUK
| | - Clare Ross
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Patrizia Viola
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
- North West London PathologyLondonUK
| | - Melissa Wickremasinghe
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
| | - Laura E. Gleeson
- Department of Respiratory MedicineSt Mary's Hospital, Imperial College Healthcare NHS TrustLondonUK
- Department of Respiratory MedicineTrinity College DublinDublinRepublic of Ireland
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Kumar K, Ratnakumar R, Collin SM, Berrocal-Almanza LC, Ricci P, Al-Zubaidy M, Coker RK, Coleman M, Elkin SL, Mallia P, Meghji J, Ross C, Russell GK, Ward K, Wickremasinghe M, Sheard S, Copley SJ, Kon OM. Chest CT features and functional correlates of COVID-19 at 3 months and 12 months follow-up. Clin Med (Lond) 2023; 23:467-477. [PMID: 37775167 PMCID: PMC10541283 DOI: 10.7861/clinmed.2023-0059] [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] [Indexed: 10/01/2023]
Abstract
Long-term pulmonary sequelae of Coronavirus 2019 (COVID-19) remain unclear. Thus, we aimed to establish post-COVID-19 temporal changes in chest computed tomography (CT) features of pulmonary fibrosis and to investigate associations with respiratory symptoms and physiological parameters at 3 and 12 months' follow-up. Adult patients who attended our initial COVID-19 follow-up service and developed chest CT features of interstitial lung disease, in addition to cases identified using British Society of Thoracic Imaging codes, were evaluated retrospectively. Clinical data were gathered on respiratory symptoms and physiological parameters at baseline, 3 months, and 12 months. Corresponding chest CT scans were reviewed by two thoracic radiologists. Associations between CT features and functional correlates were estimated using random effects logistic or linear regression adjusted for age, sex and body mass index. In total, 58 patients were assessed. No changes in reticular pattern, honeycombing, traction bronchiectasis/bronchiolectasis index or pulmonary distortion were observed. Subpleural curvilinear lines were associated with lower odds of breathlessness over time. Parenchymal bands were not associated with breathlessness or impaired lung function overall. Based on our results, we conclude that post-COVID-19 chest CT features of irreversible pulmonary fibrosis remain static over time; other features either resolve or remain unchanged. Subpleural curvilinear lines do not correlate with breathlessness. Parenchymal bands are not functionally significant. An awareness of the different potential functional implications of post-COVID-19 chest CT changes is important in the assessment of patients who present with multi-systemic sequelae of COVID-19 infection.
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Affiliation(s)
- Kartik Kumar
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and NIHR Imperial BRC clinical research fellow in respiratory medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ratnaprashanthika Ratnakumar
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and clinical research fellow in respiratory medicine and lung cancer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Simon M Collin
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Luis C Berrocal-Almanza
- NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London, UK
| | - Piera Ricci
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mustafa Al-Zubaidy
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Robina K Coker
- National Heart and Lung Institute, Imperial College London, London, UK, and honorary clinical senior lecturer, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Meg Coleman
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah L Elkin
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Patrick Mallia
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jamilah Meghji
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Clare Ross
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Katie Ward
- National Heart and Lung Institute, Imperial College London, London, UK, and honorary clinical senior lecturer, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Melissa Wickremasinghe
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK, and honorary clinical senior lecturer, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sarah Sheard
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Susan J Copley
- National Heart and Lung Institute, Imperial College London, London, UK, and professor of practice (radiology), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Joint senior authors
| | - Onn Min Kon
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK and professor of respiratory medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Joint senior authors
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Drake TM, Docherty AB, Harrison EM, Quint JK, Adamali H, Agnew S, Babu S, Barber CM, Barratt S, Bendstrup E, Bianchi S, Villegas DC, Chaudhuri N, Chua F, Coker R, Chang W, Crawshaw A, Crowley LE, Dosanjh D, Fiddler CA, Forrest IA, George PM, Gibbons MA, Groom K, Haney S, Hart SP, Heiden E, Henry M, Ho LP, Hoyles RK, Hutchinson J, Hurley K, Jones M, Jones S, Kokosi M, Kreuter M, MacKay LS, Mahendran S, Margaritopoulos G, Molina-Molina M, Molyneaux PL, O'Brien A, O'Reilly K, Packham A, Parfrey H, Poletti V, Porter JC, Renzoni E, Rivera-Ortega P, Russell AM, Saini G, Spencer LG, Stella GM, Stone H, Sturney S, Thickett D, Thillai M, Wallis T, Ward K, Wells AU, West A, Wickremasinghe M, Woodhead F, Hearson G, Howard L, Baillie JK, Openshaw PJM, Semple MG, Stewart I, Jenkins RG. Outcome of Hospitalization for COVID-19 in Patients with Interstitial Lung Disease. An International Multicenter Study. Am J Respir Crit Care Med 2020; 202:1656-1665. [PMID: 33007173 PMCID: PMC7737581 DOI: 10.1164/rccm.202007-2794oc] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Rationale: The impact of coronavirus disease (COVID-19) on patients with interstitial lung disease (ILD) has not been established.Objectives: To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age-, sex-, and comorbidity-matched population.Methods: An international multicenter audit of patients with a prior diagnosis of ILD admitted to the hospital with COVID-19 between March 1 and May 1, 2020, was undertaken and compared with patients without ILD, obtained from the ISARIC4C (International Severe Acute Respiratory and Emerging Infection Consortium Coronavirus Clinical Characterisation Consortium) cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished idiopathic pulmonary fibrosis from non-idiopathic pulmonary fibrosis ILD and used lung function to determine the greatest risks of death.Measurements and Main Results: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to the hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching, patients with ILD with COVID-19 had significantly poorer survival (hazard ratio [HR], 1.60; confidence interval, 1.17-2.18; P = 0.003) than age-, sex-, and comorbidity-matched controls without ILD. Patients with an FVC of <80% had an increased risk of death versus patients with FVC ≥80% (HR, 1.72; 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR, 2.27; 1.39-3.71).Conclusions: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD.
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Affiliation(s)
- Thomas M Drake
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Annemarie B Docherty
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Ewen M Harrison
- Centre for Medical Informatics, The Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust and.,Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Sarah Agnew
- Liverpool Interstitial Lung Disease Service, Aintree site, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Suresh Babu
- Queen Alexandra Hospital, Portsmouth, United Kingdom
| | | | - Shaney Barratt
- Bristol Interstitial Lung Disease Service, North Bristol NHS Trust and.,Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Elisabeth Bendstrup
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Diego Castillo Villegas
- Interstitial Lung Disease (ILD) Unit, Respiratory Medicine Department, Hospital of the Holy Cross and Saint Paul, Barcelona, Spain
| | - Nazia Chaudhuri
- ILD Unit, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, United Kingdom.,University of Manchester, Manchester, United Kingdom
| | - Felix Chua
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Robina Coker
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - William Chang
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Anjali Crawshaw
- Birmingham Interstitial Lung Disease Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Davinder Dosanjh
- Birmingham Interstitial Lung Disease Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Christine A Fiddler
- Cambridge Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ian A Forrest
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Peter M George
- National Heart and Lung Institute, Imperial College, London, United Kingdom.,Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Michael A Gibbons
- South West Peninsula ILD Network, Royal Devon & Exeter Foundation NHS Trust, Exeter, United Kingdom
| | - Katherine Groom
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sarah Haney
- Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, United Kingdom
| | - Emily Heiden
- University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | - Ling-Pei Ho
- Oxford Interstitial Lung Disease Service, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Rachel K Hoyles
- Oxford Interstitial Lung Disease Service, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Killian Hurley
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.,Beaumont Hospital, Dublin, Ireland
| | - Mark Jones
- University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre & Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - Steve Jones
- Action for Pulmonary Fibrosis, Stuart House, Peterborough, United Kingdom
| | - Maria Kokosi
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.,Guys and St. Thomas' NHS Trust, London, United Kingdom
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology, Thoraxklinik, University of Heidelberg and German Center for Lung Research, Heidelberg, Germany
| | - Laura S MacKay
- Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom
| | - Siva Mahendran
- Kingston Hospital NHS Foundation Trust, Surrey, United Kingdom
| | - George Margaritopoulos
- ILD Unit, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, United Kingdom
| | - Maria Molina-Molina
- ILD Unit, Respiratory Department, University Hospital of Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Philip L Molyneaux
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Katherine O'Reilly
- Department of Respiratory Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Alice Packham
- Birmingham Interstitial Lung Disease Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Helen Parfrey
- Cambridge Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Venerino Poletti
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark.,Department of Diseases of the Thorax, Morgagni Hospital, Forli, Italy
| | - Joanna C Porter
- UCL Respiratory, University College London and ILD Service, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Elisabetta Renzoni
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Pilar Rivera-Ortega
- ILD Unit, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, United Kingdom
| | - Anne-Marie Russell
- National Heart and Lung Institute, Imperial College, London, United Kingdom.,Imperial Healthcare NHS Trust, St. Mary's Hospital, The Bays, London, United Kingdom
| | - Gauri Saini
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Lisa G Spencer
- Liverpool Interstitial Lung Disease Service, Aintree site, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Giulia M Stella
- Laboratory of Biochemistry and Genetics, Pneumology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Helen Stone
- University Hospital North Midlands NHS Trust, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Sharon Sturney
- Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
| | - David Thickett
- Birmingham Interstitial Lung Disease Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,University of Birmingham, Birmingham, United Kingdom
| | - Muhunthan Thillai
- Cambridge Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Tim Wallis
- University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre & Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| | - Katie Ward
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Athol U Wells
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Alex West
- Guys and St. Thomas' NHS Trust, London, United Kingdom
| | | | - Felix Woodhead
- Institute of Lung Health, Interstitial Lung Disease Unit, Glenfield Hospital, Leicester, United Kingdom
| | - Glenn Hearson
- NIHR Biomedical Research Centre, Respiratory Research Unit, University of Nottingham, Nottingham, United Kingdom
| | - Lucy Howard
- NIHR Biomedical Research Centre, Respiratory Research Unit, University of Nottingham, Nottingham, United Kingdom
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom.,Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, United Kingdom
| | - Peter J M Openshaw
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Malcolm G Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom; and.,Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Iain Stewart
- NIHR Biomedical Research Centre, Respiratory Research Unit, University of Nottingham, Nottingham, United Kingdom
| | - R Gisli Jenkins
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,NIHR Biomedical Research Centre, Respiratory Research Unit, University of Nottingham, Nottingham, United Kingdom
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Birnie D, Beanlands RSB, Nery P, Aaron SD, Culver DA, DeKemp RA, Gula L, Ha A, Healey JS, Inoue Y, Judson MA, Juneau D, Kusano K, Quinn R, Rivard L, Toma M, Varnava A, Wells G, Wickremasinghe M, Kron J. Cardiac Sarcoidosis multi-center randomized controlled trial (CHASM CS- RCT). Am Heart J 2020; 220:246-252. [PMID: 31911261 DOI: 10.1016/j.ahj.2019.10.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [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: 03/20/2019] [Accepted: 10/06/2019] [Indexed: 12/23/2022]
Abstract
Approximately 5% of patients with sarcoidosis have clinically manifest cardiac involvement. Clinical features of Cardiac Sarcoidosis are dependent on the location, extent, and activity of the disease. First line therapy is usually with prednisone and this is recommended based on clinician experience, expert opinion and small observational cohorts. There are no published clinical trials in cardiac sarcoidosis and multiple experts in the field have called for randomized clinical trials to answer important patient care questions. Corticosteroid are associated with multiple adverse effects including hypertension, diabetes, weight gain, osteoporosis, and increased risk of infections. In contrast Methotrexate is generally well tolerated and is increasingly used in other forms of sarcoidosis. OBJECTIVES The Cardiac Sarcoidosis Multi-Center Randomized Controlled Trial (CHASM CS-RCT; NCT03593759) is a multicenter randomized controlled trial designed to evaluate the optimal initial treatment strategy for patients with active cardiac sarcoidosis. We hypothesize that (1) a low dose prednisone/methotrexate combination will have non-inferior efficacy to standard dose prednisone and that (2) the low dose prednisone/ methotrexate combination will result in significantly better quality of life than standard dose prednisone, as a result of reduced burden of side effects. METHODS/DESIGN Eligible study subjects will have active clinically manifest cardiac sarcoidosis presenting with one or more of the following clinical findings: advanced conduction system disease, significant sinus node dysfunction, non-sustained or sustained ventricular arrhythmia, left ventricular dysfunction or right ventricular dysfunction. Subjects will be randomized in a 1:1 ratio to prednisone 0.5 mg/kg/day for 6 months (maximum dose 30 mg daily) OR to prednisone 20 mg daily for 1 month, then 10 mg daily for 1 month, then 5 mg daily for one month then stop AND methotrexate 15-20 mg once weekly for 6 months. The primary endpoint is summed perfusion rest score on 6-month PET (blinded core-lab review). The summed perfusion rest score is measure of myocardial fibrosis/scar. The design is non-inferiority with a sample size of 97 per group. DISCUSSION Given the multiorgan system potential adverse side effects of prednisone, proving noninferiority of an alternate regimen would be sufficient to make the alternative compare favorably to standard dose steroids. This is the first ever clinical trial in cardiac sarcoidosis and thus in addition to the listed goals of the trial, we will also establish a multi-center, multinational cardiac sarcoidosis clinical trials network. Such a collaborative infrastructure will enable a new era of high quality data to guide physicians when treating cardiac sarcoidosis patients.
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Affiliation(s)
- David Birnie
- University of Ottawa Heart Institute, ON, Canada.
| | | | - Pablo Nery
- University of Ottawa Heart Institute, ON, Canada
| | | | | | | | - Lorne Gula
- London Health Sciences Centre, On, Canada
| | - Andrew Ha
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Yuko Inoue
- National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Daniel Juneau
- Centre Hospitalier de l'Université de Montréal, Department of Radiology and Nuclear Medicine, Montréal, QC, Canada
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Suita, Japan; Libin Cardiovascular Institute of Alberta, Alberta, Canada
| | | | - Lena Rivard
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Mustafa Toma
- Imperial College Healthcare NHS Trust, London, UK
| | | | - George Wells
- University of Ottawa Heart Institute, ON, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, VA, USA
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Trevelyan G, Kumar K, Russell GK, Wickremasinghe M. Secondary syphilis presenting with acute unilateral vision loss and a widespread maculopapular rash. BMJ Case Rep 2019; 12:12/9/e230341. [PMID: 31537590 DOI: 10.1136/bcr-2019-230341] [Citation(s) in RCA: 2] [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] [Indexed: 11/04/2022] Open
Abstract
Syphilis infection has shown a marked resurgence over the past several years. Ocular involvement is a rare complication of syphilis, occurring in approximately 1% of cases. We present the case of a man in his 50s who presented to hospital with acute unilateral vision loss and a widespread maculopapular rash. Ophthalmological examination showed unilateral optic disc swelling and bilateral vitritis. Intracranial imaging revealed no acute pathology. Initial blood tests were normal apart from mildly elevated inflammatory markers. A comprehensive autoimmune and infection screen revealed positive syphilis serology. The patient was subsequently treated for syphilis with ocular involvement with a course of intravenous benzylpenicillin, resulting in rapid symptomatic improvement. This case highlighted the importance of considering syphilis infection as part of the differential diagnosis for unexplained multisystemic symptoms, such as loss of vision in combination with dermatological involvement.
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Affiliation(s)
- Gareth Trevelyan
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kartik Kumar
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Georgina K Russell
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Melissa Wickremasinghe
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Saketkoo LA, Karpinski A, Young J, Adell R, Walker M, Hennebury T, Wickremasinghe M, Russell AM. Feasibility, utility and symptom impact of modified mindfulness training in sarcoidosis. ERJ Open Res 2018; 4:00085-2017. [PMID: 29750143 PMCID: PMC5938490 DOI: 10.1183/23120541.00085-2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 03/17/2018] [Indexed: 01/28/2023] Open
Abstract
Sarcoidosis is a multisystem disorder characterised by noncaseating granulomatous inflammation of unknown aetiology. It may resolve spontaneously, but ∼30% of patients have progressive disease with significant organ damage [1]. Although any organ is vulnerable, the lungs are frequently involved resulting in shortness of breath and dry cough. Fatigue is an overarching symptom in sarcoidosis, originating from multiple and combined causes of mental fatigue and physical fatigue [2]. This is also true of the psychosocial impact of sarcoidosis, which may include depression, anxiety, isolation and feelings of uncertainty. The prevalence of these factors remains high even for those who achieve clinical remission, resulting in psychological distress and reduced health status [3]. A modified mindfulness-based exercise intervention has beneficial impact on people living with sarcoidosishttp://ow.ly/XYTO30jtmms
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Affiliation(s)
- Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, University Medical Center Comprehensive Pulmonary Hypertension Center and Tulane University School of Medicine, New Orleans, LA, USA
| | - Aryn Karpinski
- Evaluation and Measurement, School of Foundations, Leadership and Administration, Kent State University, Kent, OH, USA
| | - Jessica Young
- Louisiana State University, School of Medicine, Baton Rouge, LA, USA
| | - Ryan Adell
- Louisiana State University, School of Medicine, Baton Rouge, LA, USA
| | - McCall Walker
- University of Virginia, School of Medicine, Charlottesville, VA, USA
| | | | | | - Anne-Marie Russell
- National Heart and Lung Institute Imperial College, London, UK.,Royal Brompton Hospital, London, UK
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Singanayagam A, Manalan K, Connell DW, Chalmers JD, Sridhar S, Ritchie AI, Lalvani A, Wickremasinghe M, Kon OM. Evaluation of serum inflammatory biomarkers as predictors of treatment outcome in pulmonary tuberculosis. Int J Tuberc Lung Dis 2018; 20:1653-1660. [PMID: 27931342 DOI: 10.5588/ijtld.16.0159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] Open
Abstract
OBJECTIVE To evaluate C-reactive protein (CRP), globulin and white blood cell (WBC) count as predictors of treatment outcome in pulmonary tuberculosis (PTB). METHODS An observational study of patients with active PTB was conducted at a tertiary centre. All patients had serum CRP, globulin and WBC measured at baseline and at 2 months following commencement of treatment. The outcome of interest was requirement for extension of treatment beyond 6 months. RESULTS There were 226 patients included in the study. Serum globulin 45 g/l was the only baseline biomarker evaluated that independently predicted requirement for treatment extension (OR 3.42, 95%CI 1.597.32, P 0.001). An elevated globulin level that failed to normalise at 2 months was also associated with increased requirement for treatment extension (63.9% vs. 5.1%, P 0.001), and had a low negative likelihood ratio (0.07) for exclusion of requirement for treatment extension. On multivariable analysis, an elevated globulin that failed to normalise at 2 months was independently associated with requirement for treatment extension (OR 6.13, 95%CI 2.2316.80, P 0.001). CONCLUSIONS Serum globulin independently predicts requirement for treatment extension in PTB and outperforms CRP and WBC as a predictive biomarker. Normalisation of globulin at 2 months following treatment commencement is associated with low risk of requirement for treatment extension.
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Affiliation(s)
- A Singanayagam
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London
| | - K Manalan
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London
| | - D W Connell
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London, Tuberculosis Immunology Group, Imperial College London, London
| | - J D Chalmers
- Tayside Respiratory Research Group, University of Dundee, Dundee, UK
| | - S Sridhar
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London, Tuberculosis Immunology Group, Imperial College London, London
| | - A I Ritchie
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London
| | - A Lalvani
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London, Tuberculosis Immunology Group, Imperial College London, London
| | - M Wickremasinghe
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London
| | - O M Kon
- Chest and Allergy Department, St Marys Hospital, Imperial College NHS Trust, London
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Ritchie A, Singanayagam A, Manalan K, Connell D, Chalmers J, Sridhar S, Lalvani A, Wickremasinghe M, Kon OM. P112 Serum inflammatory biomarkers as predictors of treatment outcome in pulmonary tuberculosis. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.255] [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: 11/03/2022]
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Russell AM, Sonecha S, Datta A, Hewitt R, Howell I, Elliott A, Wickremasinghe M. P276 Development of patient reported experience measure (PREM) for idiopathic pulmonary fibrosis (IPF). Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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13
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Hewitt RJ, Singanayagam A, Sridhar S, Wickremasinghe M, Min Kon O. Screening for latent tuberculosis before tumour necrosis factor antagonist therapy. Eur Respir J 2015; 45:1510-2. [DOI: 10.1183/09031936.00194314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kow K, Connell D, Singanayagam A, Dafydd DA, Jarvis H, O'Donoghue M, Wickremasinghe M, Lalvani A, Kon O. P186 Intrathoracic Lymph Node Tuberculosis - A Comprehensive Clinical Description. Thorax 2014. [DOI: 10.1136/thoraxjnl-2014-206260.315] [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: 11/04/2022]
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16
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Hill C, Nasr R, Fisher M, Maher T, Spiteri M, Allen M, Birring S, Parfrey H, Hoyles R, Gibbons M, Burge G, Scullion J, Adams E, Wickremasinghe M. M272 Estimated Cost And Payment By Results (pbr) Tariff Reimbursement For Idiopathic Pulmonary Fibrosis Services Across 14 Specialist Providers In England. Thorax 2014. [DOI: 10.1136/thoraxjnl-2014-206260.453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ross CL, Anwar M, Wickremasinghe M, Cooke G, Rebec M, Fahy E, Jepson A, Kon OM. P25 Sensitivity of the Xpert ®MTB/RIF assay in bronchoalveolar lavage samples in a North West London Hospital: a useful adjunct to current diagnostic modalities. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.175] [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: 11/04/2022]
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Keir GJ, Maher TM, Ming D, Abdullah R, de Lauretis A, Wickremasinghe M, Nicholson AG, Hansell DM, Wells AU, Renzoni EA. Rituximab in severe, treatment-refractory interstitial lung disease. Respirology 2013; 19:353-9. [PMID: 24286447 DOI: 10.1111/resp.12214] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [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: 06/12/2013] [Revised: 08/25/2013] [Accepted: 10/07/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE In patients with severe interstitial lung disease (ILD) progressing despite conventional immunosuppression, rituximab, a B-lymphocyte depleting monoclonal antibody, may offer an effective rescue therapy. METHODS Retrospective assessment of 50 patients with severe, progressive ILD (of varying aetiologies, excluding idiopathic pulmonary fibrosis (IPF)) treated with rituximab between 2010 and 2012. Change in pulmonary function tests compared with pre-rituximab levels was assessed at 6-12 months post-treatment. RESULTS ILD was associated with connective tissue disease in 33 patients, hypersensitivity pneumonitis in 6 patients and miscellaneous conditions in 11 patients. At the time of rituximab administration, patients had severe physiologic impairment with a median forced vital capacity (FVC) of 44.0% (24.0-99.0%) and diffusing capacity of carbon monoxide (DLCO ) of 24.5% (11.4-67.0%). In contrast with a median decline in FVC of 14.3% and DLCO of 18.8% in the 6-12 months prior to rituximab, analysis of paired pulmonary function data revealed a median improvement in FVC of 6.7% (P < 0.01) and stability of DLCO (0% change; P < 0.01) in the 6-12 months following rituximab treatment. Two patients developed serious infections (pneumonia) requiring hospitalization following rituximab, and 10 patients died from progression of underlying ILD, a median of 5.1 (1.2-24.5) months after treatment. CONCLUSIONS In patients with severe, progressive non-IPF ILD unresponsive to conventional immunosuppression, rituximab may offer an effective therapeutic intervention. Future prospective, controlled trials are warranted to validate these findings, and to assess safety outcomes.
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Affiliation(s)
- Gregory J Keir
- Royal Brompton Hospital, London, UK; Princess Alexandra Hospital, Brisbane, Queensland, Australia
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19
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Honor Craig CE, Wickremasinghe M, Finney L, Wright CB, Berry M, Kon OM. Importance of onsite cytopathology at endobronchial ultrasound. Am J Respir Crit Care Med 2013; 188:1164. [PMID: 24180447 DOI: 10.1164/rccm.201302-0378le] [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] [Indexed: 11/16/2022] Open
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20
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Singanayagam A, Manalan K, Sridhar S, Molyneaux PL, Connell DW, George PM, Kindelerer A, Seneviratne S, Lalvani A, Wickremasinghe M, Kon OM. Evaluation of screening methods for identification of patients with chronic rheumatological disease requiring tuberculosis chemoprophylaxis prior to commencement of TNF-α antagonist therapy. Thorax 2013; 68:955-61. [PMID: 23976779 DOI: 10.1136/thoraxjnl-2013-203436] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients undergoing tumour necrosis factor (TNF)-α antagonist therapy are at increased risk of latent tuberculosis infection (LTBI) reactivation. The aim of this study was to determine the optimum available screening strategy for identifying patients for tuberculosis (TB) chemoprophylaxis. METHODS We conducted a prospective observational study of consecutive adults with chronic rheumatological disease referred for LTBI screening prior to commencement of TNF-α antagonist therapy. All patients included had calculation of TB risk according to age, ethnicity and year of UK entry, as described in the 2005 British Thoracic Society (BTS) guidelines and measurement of tuberculin skin test (TST) and T.Spot.TB. RESULTS There were 187 patients included in the study, with 157 patients (84%) taking immunosuppressants. 137 patients would require further risk stratification according to the BTS algorithm, with 110 (80.3%) classified as being at low risk of having LTBI. There were 39 patients (35.5%) who were categorised as low risk but were either TST and/or T.Spot positive and would not have received chemoprophylaxis according to the BTS algorithm. Combination of all three methods (risk stratification and/or positive T.Spot and/or positive TST) identified 66 patients out of 137 who would potentially be offered chemoprophylaxis, which was greater than any single test or two-test combination. CONCLUSION Performing both a TST and T.Spot in patients on immunosuppressants prior to commencement of TNF-α antagonist therapy gives an additional yield of potential LTBI compared with use of risk stratification tables alone. Our results suggest that use of all three screening modalities gives the highest yield of patients potentially requiring chemoprophylaxis.
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Affiliation(s)
- Aran Singanayagam
- Chest and Allergy Department, St Mary's Hospital, Imperial College NHS trust, , London, UK
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Bloom CI, Graham CM, Berry MPR, Rozakeas F, Redford PS, Wang Y, Xu Z, Wilkinson KA, Wilkinson RJ, Kendrick Y, Devouassoux G, Ferry T, Miyara M, Bouvry D, Valeyre D, Dominique V, Gorochov G, Blankenship D, Saadatian M, Vanhems P, Beynon H, Vancheeswaran R, Wickremasinghe M, Chaussabel D, Banchereau J, Pascual V, Ho LP, Lipman M, O'Garra A. Transcriptional blood signatures distinguish pulmonary tuberculosis, pulmonary sarcoidosis, pneumonias and lung cancers. PLoS One 2013; 8:e70630. [PMID: 23940611 PMCID: PMC3734176 DOI: 10.1371/journal.pone.0070630] [Citation(s) in RCA: 206] [Impact Index Per Article: 18.7] [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: 03/23/2013] [Accepted: 06/20/2013] [Indexed: 01/08/2023] Open
Abstract
RATIONALE New approaches to define factors underlying the immunopathogenesis of pulmonary diseases including sarcoidosis and tuberculosis are needed to develop new treatments and biomarkers. Comparing the blood transcriptional response of tuberculosis to other similar pulmonary diseases will advance knowledge of disease pathways and help distinguish diseases with similar clinical presentations. OBJECTIVES To determine the factors underlying the immunopathogenesis of the granulomatous diseases, sarcoidosis and tuberculosis, by comparing the blood transcriptional responses in these and other pulmonary diseases. METHODS We compared whole blood genome-wide transcriptional profiles in pulmonary sarcoidosis, pulmonary tuberculosis, to community acquired pneumonia and primary lung cancer and healthy controls, before and after treatment, and in purified leucocyte populations. MEASUREMENTS AND MAIN RESULTS An Interferon-inducible neutrophil-driven blood transcriptional signature was present in both sarcoidosis and tuberculosis, with a higher abundance and expression in tuberculosis. Heterogeneity of the sarcoidosis signature correlated significantly with disease activity. Transcriptional profiles in pneumonia and lung cancer revealed an over-abundance of inflammatory transcripts. After successful treatment the transcriptional activity in tuberculosis and pneumonia patients was significantly reduced. However the glucocorticoid-responsive sarcoidosis patients showed a significant increase in transcriptional activity. 144-blood transcripts were able to distinguish tuberculosis from other lung diseases and controls. CONCLUSIONS Tuberculosis and sarcoidosis revealed similar blood transcriptional profiles, dominated by interferon-inducible transcripts, while pneumonia and lung cancer showed distinct signatures, dominated by inflammatory genes. There were also significant differences between tuberculosis and sarcoidosis in the degree of their transcriptional activity, the heterogeneity of their profiles and their transcriptional response to treatment.
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Affiliation(s)
- Chloe I Bloom
- Division of Immunoregulation, MRC National Institute for Medical Research, London, United Kingdom.
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Manalan K, Singanayagam A, Molyneaux PL, George PM, Connell DW, Lalvani A, Wickremasinghe M, Kon OM. P56 Use of the Tuberculin Skin Test and Tspot For Screening Prior to TNF Antagonist Therapy Identifies Additional Patients Eligible For Chemoprophylaxis Compared to Use of Risk Assessment Strategies Alone. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.197] [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: 11/04/2022]
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Singanayagam A, Burroughs AK, Min Kon O, Wickremasinghe M. Reply: Adaptation and Antituberculosis Drug–induced Liver Injury. Am J Respir Crit Care Med 2012. [DOI: 10.1164/ajrccm.186.4.388] [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] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Andrew K. Burroughs
- The Royal Free HospitalLondon, United KingdomandUniversity College LondonLondon, United Kingdom
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Thillai M, Eberhardt C, Lewin AM, Potiphar L, Hingley-Wilson S, Sridhar S, Macintyre J, Kon OM, Wickremasinghe M, Wells A, Weeks ME, Mitchell D, Lalvani A. Sarcoidosis and tuberculosis cytokine profiles: indistinguishable in bronchoalveolar lavage but different in blood. PLoS One 2012; 7:e38083. [PMID: 22815689 PMCID: PMC3398021 DOI: 10.1371/journal.pone.0038083] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [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: 02/15/2012] [Accepted: 04/30/2012] [Indexed: 01/22/2023] Open
Abstract
Background The clinical, radiological and pathological similarities between sarcoidosis and tuberculosis can make disease differentiation challenging. A complicating factor is that some cases of sarcoidosis may be initiated by mycobacteria. We hypothesised that immunological profiling might provide insight into a possible relationship between the diseases or allow us to distinguish between them. Methods We analysed bronchoalveolar lavage (BAL) fluid in sarcoidosis (n = 18), tuberculosis (n = 12) and healthy volunteers (n = 16). We further investigated serum samples in the same groups; sarcoidosis (n = 40), tuberculosis (n = 15) and healthy volunteers (n = 40). A cross-sectional analysis of multiple cytokine profiles was performed and data used to discriminate between samples. Results We found that BAL profiles were indistinguishable between both diseases and significantly different from healthy volunteers. In sera, tuberculosis patients had significantly lower levels of the Th2 cytokine interleukin-4 (IL-4) than those with sarcoidosis (p = 0.004). Additional serum differences allowed us to create a linear regression model for disease differentiation (within-sample accuracy 91%, cross-validation accuracy 73%). Conclusions These data warrant replication in independent cohorts to further develop and validate a serum cytokine signature that may be able to distinguish sarcoidosis from tuberculosis. Systemic Th2 cytokine differences between sarcoidosis and tuberculosis may also underly different disease outcomes to similar respiratory stimuli.
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Affiliation(s)
- Muhunthan Thillai
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Christian Eberhardt
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alex M. Lewin
- Biostatistics Group, Department of Epidemiology and Public Health, Imperial College London, London, United Kingdom
| | - Lee Potiphar
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Suzie Hingley-Wilson
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Saranya Sridhar
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jonathan Macintyre
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Onn Min Kon
- Department of Respiratory Medicine, St. Mary’s Hospital, London, United Kingdom
| | | | - Athol Wells
- Interstitial Lung Unit, Royal Brompton Hospital, Imperial College London NHS Healthcare Trust, London, United Kingdom
| | - Mark E. Weeks
- Molecular Haematology and Cancer Biology Unit, UCL Institute of Child Health, London, United Kingdom
| | - Donald Mitchell
- Interstitial Lung Unit, Royal Brompton Hospital, Imperial College London NHS Healthcare Trust, London, United Kingdom
| | - Ajit Lalvani
- Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- * E-mail:
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Thillai M, Potiphar L, Eberhardt C, Pareek M, Dhawan R, Kon OM, Wickremasinghe M, Wells A, Mitchell D, Lalvani A. Obstructive lung function in sarcoidosis may be missed, especially in older white patients. Eur Respir J 2012; 39:775-7. [DOI: 10.1183/09031936.00103811] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Singanayagam A, Sridhar S, Dhariwal J, Abdel-Aziz D, Munro K, Connell DW, George PM, Molyneaux PL, Cooke GS, Burroughs AK, Lalvani A, Wickremasinghe M, Kon OM. A comparison between two strategies for monitoring hepatic function during antituberculous therapy. Am J Respir Crit Care Med 2011; 185:653-9. [PMID: 22198973 DOI: 10.1164/rccm.201105-0850oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE The optimum strategy for monitoring liver function during antituberculous therapy is unclear. OBJECTIVES To assess the value of the American Thoracic Society risk-factor approach for predicting drug-induced liver injury and to compare with a uniform policy of liver function testing in all patients at 2 weeks. METHODS We conducted an observational study of adult patients undergoing therapy for active tuberculosis at a tertiary center. All patients had alanine transferase measurement at baseline and 2 weeks following commencement of therapy. Sensitivity, specificity, and positive and negative predictive values were used to assess strategies. MEASUREMENTS AND MAIN RESULTS There were 288 patients included, and 21 (7.3%) developed drug-induced liver injury (57.1% "early" at 2 wk and 42.9% "late," after 2 wk). There were increased rates of individuals with HIV infection in the early drug-induced liver injury group compared with no drug-induced liver injury and late drug-induced liver injury groups (33% vs. 7.1% vs. 0%; P = 0.004). The American Thoracic Society algorithm had a sensitivity and specificity of 66.7 and 65.6%, respectively, for prediction of early and 22.2% and 63.7% for late drug-induced liver injury. The uniform monitoring policy had poor sensitivity but better specificity (22.2 and 82.1%) for prediction of late drug-induced liver injury. CONCLUSIONS In our urban, ethnically diverse population, a risk-factor approach is neither sensitive nor specific for prediction of drug-induced liver injury. A uniform policy of liver function testing at 2 weeks is useful for prompt identification of a subgroup who develop early drug-induced liver injury and may offer better specificity in ruling out late drug-induced liver injury.
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Affiliation(s)
- Aran Singanayagam
- Department of Respiratory Medicine, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Asgheddi M, Connell DW, Nooredinvand HA, Abdullah M, O'Donoghue M, Campbell L, Lalvani A, Wickremasinghe M, Khan S, Kon OM. P63 The prevalence of viral hepatitis in patients undergoing anti-tuberculous therapy. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054c.63] [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: 11/03/2022]
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Almond MH, O'Donoghue M, Drey N, Seneviratne S, Lalvani A, Wickremasinghe M, Kon OM. P13 Interferon-gamma release assay (IGRA) conversion, reversion and implications for the diagnosis of latent tuberculosis infection using a multimodality approach: a retrospective, observational study within a central London TB centre. Thorax 2011. [DOI: 10.1136/thoraxjnl-2011-201054c.13] [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: 11/04/2022]
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Iskander D, Wickremasinghe M, Bain BJ. Thrombotic microangiopathy complicating pegylated interferon treatment of hepatitis C infection. Am J Hematol 2011; 86:859. [PMID: 21630311 DOI: 10.1002/ajh.22057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 04/13/2011] [Indexed: 11/06/2022]
Affiliation(s)
- Deena Iskander
- Department of Haematology, London W2 1NY, United Kingdom
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George PM, Mehta M, Dhariwal J, Singanayagam A, Raphael CE, Salmasi M, Connell DW, Molyneaux P, Wickremasinghe M, Jepson A, Kon OM. Post-bronchoscopy sputum: improving the diagnostic yield in smear negative pulmonary TB. Respir Med 2011; 105:1726-31. [PMID: 21840695 DOI: 10.1016/j.rmed.2011.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [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: 03/06/2011] [Revised: 07/21/2011] [Accepted: 07/23/2011] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patients with suspected active Pulmonary Tuberculosis (PTB) who are Acid-Fast Bacilli (AFB) smear negative or non-productive of sputum may undergo bronchoalveolar lavage. However, post-bronchoscopy sputum (PBS) sampling is not routine. The aim of this study was to establish the potential diagnostic value of PBS sampling. METHODS A retrospective study of patients attending a London University hospital with microbiologically confirmed PTB between January 2004 and December 2010. Patients who were AFB smear negative or non-productive of sputum were eligible if sputum sampling was performed within 7 days of bronchoscopy. RESULTS Over the study period, 236 patients had microbiologically confirmed smear negative PTB of which 57 patients were eligible for the study. 15 patients (26.3%) were infected with HIV. 19 patients (33.3%) converted to AFB sputum smear positivity post-bronchoscopy and 5 patients (8.8%) were exclusively AFB sputum smear positive on PBS microscopy. Mycobacterium tuberculosis was cultured from the PBS of 43 patients (75.4%) and of these, 4 (7.0%) were exclusively PBS culture positive. CONCLUSION PBS analysis can provide a simple method of rapidly diagnosing pulmonary tuberculosis. In this cohort, M. tuberculosis culture yield was increased by 7% through PBS sampling. This study has important infection control implications with nearly one third of patients becoming more infectious after bronchoscopy.
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Affiliation(s)
- Peter M George
- Chest and Allergy Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK.
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Navani N, Molyneaux PL, Breen RA, Connell DW, Jepson A, Nankivell M, Brown JM, Morris-Jones S, Ng B, Wickremasinghe M, Lalvani A, Rintoul RC, Santis G, Kon OM, Janes SM. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study. Thorax 2011; 66:889-93. [PMID: 21813622 DOI: 10.1136/thoraxjnl-2011-200063] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as an important tool for the diagnosis and staging of lung cancer but its role in the diagnosis of tuberculous intrathoracic lymphadenopathy has not been established. The aim of this study was to describe the diagnostic utility of EBUS-TBNA in patients with intrathoracic lymphadenopathy due to tuberculosis (TB). METHODS 156 consecutive patients with isolated intrathoracic TB lymphadenitis were studied across four centres over a 2-year period. Only patients with a confirmed diagnosis or unequivocal clinical and radiological response to antituberculous treatment during follow-up for a minimum of 6 months were included. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, HIV status, pathological findings and microbiological results were recorded. RESULTS EBUS-TBNA was diagnostic of TB in 146 patients (94%; 95% CI 88% to 97%). Pathological findings were consistent with TB in 134 patients (86%). Microbiological investigations yielded a positive culture of TB in 74 patients (47%) with a median time to positive culture of 16 days (range 3-84) and identified eight drug-resistant cases (5%). Ten patients (6%) did not have a specific diagnosis following EBUS; four underwent mediastinoscopy which confirmed the diagnosis of TB while six responded to empirical antituberculous therapy. There was one complication requiring an inpatient admission. CONCLUSIONS EBUS-TBNA is a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy.
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Affiliation(s)
- Neal Navani
- Centre for Respiratory Research, University College London, 5 University Street, London WC1E 6JJ, UK
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Bloch S, Wickremasinghe M, Wright A, Rice A, Thompson M, Kon OM. Paradoxical reactions in non-HIV tuberculosis presenting as endobronchial obstruction. Eur Respir Rev 2011; 18:295-9. [PMID: 20956154 DOI: 10.1183/09059180.00003709] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [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] Open
Abstract
Paradoxical reaction (PR) in tuberculosis (TB) is common and may affect up to 25% of patients. PR has the potential to cause significant morbidity and, on occasion, death. Although PR has been recognised for some time, the pathophysiology, especially in HIV-negative patients, is not well understood. We present two cases of PR in HIV-negative patients with TB presenting as significant airway obstruction secondary to a florid endobronchial component. These cases demonstrate that PR should be considered in all patients presenting with airway symptoms who have started TB treatment. The outcomes of the cases illustrate the need for wider recognition of this condition and more research to characterise patients who may be at risk, in order to gain a greater understanding of the mechanisms involved and to make or predict this diagnosis earlier.
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Affiliation(s)
- S Bloch
- Dept of Respiratory Medicine, Hammersmith Hospital NHS Trust, Depts of #Radiology, ¶Histopathology, †Respiratory Medicine, St. Mary's Hospital, London, UK.
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Casey R, Blumenkrantz D, Millington K, Montamat-Sicotte D, Kon OM, Wickremasinghe M, Bremang S, Magtoto M, Sridhar S, Connell D, Lalvani A. Enumeration of functional T-cell subsets by fluorescence-immunospot defines signatures of pathogen burden in tuberculosis. PLoS One 2010; 5:e15619. [PMID: 21179481 PMCID: PMC3001879 DOI: 10.1371/journal.pone.0015619] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [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: 09/14/2010] [Accepted: 11/15/2010] [Indexed: 01/11/2023] Open
Abstract
Background IFN-γ and IL-2 cytokine-profiles define three functional T-cell subsets which may correlate with pathogen load in chronic intracellular infections. We therefore investigated the feasibility of the immunospot platform to rapidly enumerate T-cell subsets by single-cell IFN-γ/IL-2 cytokine-profiling and establish whether immunospot-based T-cell signatures distinguish different clinical stages of human tuberculosis infection. Methods We used fluorophore-labelled anti-IFN-γ and anti-IL-2 antibodies with digital overlay of spatially-mapped colour-filtered images to enumerate dual and single cytokine-secreting M. tuberculosis antigen-specific T-cells in tuberculosis patients and in latent tuberculosis infection (LTBI). We validated results against established measures of cytokine-secreting T-cells. Results Fluorescence-immunospot correlated closely with single-cytokine enzyme-linked-immunospot for IFN-γ-secreting T-cells and IL-2-secreting T-cells and flow-cytometry-based detection of dual IFN-γ/IL-2-secreting T-cells. The untreated tuberculosis signature was dominated by IFN-γ-only-secreting T-cells which shifted consistently in longitudinally-followed patients during treatment to a signature dominated by dual IFN-γ/IL-2-secreting T-cells in treated patients. The LTBI signature differed from active tuberculosis, with higher proportions of IL-2-only and IFN-γ/IL-2-secreting T-cells and lower proportions of IFN-γ-only-secreting T-cells. Conclusions Fluorescence-immunospot is a quantitative, accurate measure of functional T-cell subsets; identification of cytokine-signatures of pathogen burden, distinct clinical stages of M. tuberculosis infection and long-term immune containment suggests application for treatment monitoring and vaccine evaluation.
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Affiliation(s)
- Rosalyn Casey
- Tuberculosis Research Unit, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, St Mary's Hospital, London, United Kingdom
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George PM, Mehta M, Dhariwal J, Singanayagam A, Raphael CE, Salmasi M, Connell DW, Molyneaux P, Wickremasinghe M, Jepson A, Kon OM. P55 Post-bronchoscopy sputum: increasing the diagnostic yield in smear negative pulmonary tuberculosis. Thorax 2010. [DOI: 10.1136/thx.2010.150979.6] [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: 11/04/2022]
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Abstract
The aim of the present study was to determine whether patients with bronchiectasis and nontuberculous mycobacteria (NTM) have a higher prevalence of Aspergillus-related lung disease. A series of 30 consecutive patients with bronchiectasis and NTM (cases) were compared with 61 patients with bronchiectasis and no evidence of NTM (controls). Aspergillus serology and computerised tomography of the thorax were used to identify Aspergillus-related lung diseases, including aspergilloma, allergic bronchopulmonary aspergillosis and chronic necrotising pulmonary aspergillosis. The rate of positive Aspergillus serology was higher in cases with NTM disease compared with controls (10 out of 30 versus six out of 61). The radiological features of Aspergillus-related lung disease were also more common among patients with NTM disease than controls (six out of 30 versus none out of 61). This association between NTM disease and Aspergillus-related lung disease remained significant after adjustment for confounding effects of age and lung function (adjusted odds ratio 5.1, 95% confidence interval 1.5-17.0). Patients with bronchiectasis and nontuberculous mycobacterial disease have a higher prevalence of coexisting Aspergillus-related lung disease than patients with bronchiectasis and without nontuberculous mycobacteria. Identification of Aspergillus-related lung disease is important as prognosis amongst undetected cases is invariably poor.
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MESH Headings
- Aged
- Aspergillosis, Allergic Bronchopulmonary/complications
- Aspergillosis, Allergic Bronchopulmonary/diagnosis
- Aspergillosis, Allergic Bronchopulmonary/diagnostic imaging
- Aspergillosis, Allergic Bronchopulmonary/epidemiology
- Bronchiectasis/complications
- Bronchiectasis/diagnosis
- Bronchiectasis/diagnostic imaging
- Bronchiectasis/epidemiology
- Female
- Humans
- Male
- Middle Aged
- Mycobacterium Infections, Nontuberculous/complications
- Mycobacterium Infections, Nontuberculous/diagnosis
- Mycobacterium Infections, Nontuberculous/diagnostic imaging
- Mycobacterium Infections, Nontuberculous/epidemiology
- Pneumonia, Bacterial/complications
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/diagnostic imaging
- Pneumonia, Bacterial/epidemiology
- Prevalence
- Prognosis
- Radiography
- Retrospective Studies
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Affiliation(s)
- H Kunst
- Department of Respiratory Medicine, Heartlands Hospital, Birmingham, UK
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Wickremasinghe M, Ozerovitch LJ, Davies G, Wodehouse T, Chadwick MV, Abdallah S, Shah P, Wilson R. Non-tuberculous mycobacteria in patients with bronchiectasis. Thorax 2005; 60:1045-51. [PMID: 16227333 PMCID: PMC1747265 DOI: 10.1136/thx.2005.046631] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Non-tuberculous mycobacteria (NTM) are ubiquitous environmental organisms. Patients with pre-existing lung damage are susceptible to NTM, but their prevalence in bronchiectasis is unknown. Distinguishing between lung colonisation and disease can be difficult. METHODS A prospective study of 100 patients with bronchiectasis was undertaken to evaluate the prevalence of NTM in sputum, and a retrospective analysis of clinical, microbiological, lung function and radiology data of our clinic patients with NTM sputum isolates over 11 years was performed. RESULTS The prevalence of NTM in this population of patients with bronchiectasis was 2%. Patients in the retrospective study were divided into three groups: bronchiectasis+multiple NTM isolates (n=25), bronchiectasis+single isolates (n=23), and non-bronchiectasis+multiple isolates (n=22). Mycobacterium avium complex (MAC) species predominated in patients with bronchiectasis compared with non-bronchiectasis lung disease (72% v 9%, p<0.0001). Single isolates were also frequently MAC (45.5%). Multiple isolates in bronchiectasis were more often smear positive on first sample than single isolates (p<0.0001). NTM were identified on routine screening samples or because of suggestive radiology. No particular bronchiectasis aetiology was associated with an NTM. Pseudomonas aeruginosa and Staphylococcus aureus were frequently co-cultured. Six (25%) of multiple NTM patients had cavities of which five were due to MAC. Half the patients with multiple isolates were treated, mostly due to progressive radiology. CONCLUSIONS NTM are uncommon in non-cystic fibrosis bronchiectasis. Routine screening identifies otherwise unsuspected patients. MAC is the most frequent NTM isolated.
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Affiliation(s)
- M Wickremasinghe
- Host Defence Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Abstract
BACKGROUND Inhaled propranolol causes bronchoconstriction in asthmatic subjects by an indirect mechanism which remains unclear. Inhaled frusemide has been shown to attenuate a number of indirectly acting bronchoconstrictor challenges. The aim of this study was to investigate whether frusemide could protect against propranolol-induced bronchoconstriction in patients with stable mild asthma. METHODS Twelve asthmatic subjects were studied on three separate days. At the first visit subjects inhaled increasing doubling concentrations of propranolol (0.25-32 mg/ml), breathing tidally from a jet nebuliser. The provocative concentration of propranolol causing a 20% reduction in FEV1 (PC20FEV1 propranolol) was determined from the log concentration-response curve for each subject. At the following visits nebulised frusemide (4 ml x 10 mg/ml) or placebo (isotonic saline) was administered in a randomised, double blind, crossover fashion. FEV1 was measured immediately before and five minutes after drug administration. Individual PC20FEV1 propranolol was then administered and FEV1 was recorded at five minute intervals for 15 minutes. Residual bronchoconstriction was reversed with nebulised salbutamol. RESULTS Frusemide had no acute bronchodilator effect but significantly reduced the maximum fall in FEV1 due to propranolol: mean fall 18.2% after placebo and 11.8% after frusemide. The median difference in maximum % fall in FEV1 within individuals between study days was 3.6% (95% CI 1.2 to 11.7). CONCLUSIONS Frusemide attenuates propranolol-induced bronchoconstriction, a property shared with sodium cromoglycate. Both drugs block other indirect challenges and the present study lends further support to the suggestion that frusemide and cromoglycate share a similar mechanism of action in the airways.
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Affiliation(s)
- J D Myers
- Department of Medicine (Respiratory Division), Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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Wickremasinghe M. Mycobacterium tuberculosis stimulates transcription-dependent chemokine secretion from human respiratory epithelial cells. Immunol Lett 1997. [DOI: 10.1016/s0165-2478(97)88637-3] [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: 10/18/2022]
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Wickremasinghe M, Friedland JS. Mycobacterium tuberculosis stimulates transcription-dependent chemokine secretion from human respiratory epithelial cells. Immunol Lett 1997. [DOI: 10.1016/s0165-2478(97)86797-1] [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: 11/25/2022]
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Wickremasinghe M. Commentary. Ecstasy and crack cocaine. Thorax 1996; 51:962-3. [PMID: 8984714 PMCID: PMC472626 DOI: 10.1136/thx.51.9.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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