Establishing a Diagnosis of Pulmonary Sarcoidosis

Pulmonary sarcoidosis is the most prevalent manifestation of sarcoidosis and the commonest diagnosis in clinics for ILD. Due to the lack of a simple and reliable test, making the diagnosis is often challenging. There are three criteria that must always be considered: (1) compatible clinical presentation; (2) evidence of granuloma formation (usually non-caseating); and (3) exclusion of alternative causes of granulomatous disease. There are various tools available for diagnosis, amongst which serum biomarkers like sACE and sIL-2R, HRCT, BAL, EBUS/EUS and sometimes bronchoscopic or surgical lung biopsy are most contributive. However, the degree of invasiveness of the applied test and associated risk to the patient must be weighed against management consequences. In specific situations (e.g., presentation as Löfgren's syndrome) or when there is high suspicion based on HRCT in the context of supportive clinical findings, it might be justifiable to decide on a "working diagnosis of sarcoidosis" and to refrain from further invasive procedures for the patient. This should, however, preferably be agreed upon after discussion in an experienced multidisciplinary team and requires close follow-up of the patient. In general, it is advisable to always maintain a healthy dose of skepticism when making the diagnosis of sarcoidosis, especially when the clinical course of disease gives rise to this

Clustering of lung diseases in the family of interstitial lung disease patients

Background: The presence of familial interstitial lung disease (ILD) has been found to predict development of progressive pulmonary fibrosis. However, the role of non-ILD lung diseases in ILD patients’ families has not yet been investigated. We aimed to identify associations between ILDs and non-ILD lung diseases from ILD patients’ self-reported family health history. Methods: We analysed questionnaires on family health history of 1164 ILD patients for the occurrence of ILD and non-ILD lung disease in relatives. Logistic regression analysis was used to study associations with diagnosis groups. Results: Familial pulmonary fibrosis was reported by 20% of patients with idiopathic pulmonary fibrosis (IPF; OR 9.2, 95% CI 4.7–17.9), and 15% of patients with unclassifiable pulmonary fibrosis (OR 4.1, 95% CI 2.0–8.2). Familial occurrence was reported by 14% of patients with sarcoidosis (OR 3.3, 95% CI 1.9–5.8). Regarding non-ILD lung disease, significantly more patients with IPF (36%) reported lung cancer in their family (OR 2.3, 95% CI 1.4–3.5), and patients with hypersensitivity pneumonitis (18%) mostly reported COPD (OR 2.3, 95% CI 1.3–4.2). Comparison of sporadic and familial ILD patients’ reports showed that emphysema (OR 4.6, 95% CI 1.8–11.6), and lung cancer (OR 2.4, 95% CI 1.2–4.9) were predictive for familial pulmonary fibrosis, particularly when reported both in a family (OR 16.7, 95% CI 3.2–86.6; p < 0.001). Conclusions: Our findings provide evidence for clustering of ILD and non-ILD lung diseases in families and show that self-reported emphysema and lung cancer of relatives in this population predicts familial pulmonary fibrosis

Соціальний капітал у формуванні екстерналій освітньої сфери

У статті аналізується передавальний механізм імпульсу, який одержує економіка від зміни рівня освіти. Виходячи із припущення про прискорення (уповільнення) економічного зростання як одну із можливих екстерналій освіти, автори досліджують опосередкований вплив соціального капіталу на формування цієї екстерналії.В статье анализируется передаточный механизм импульса, полученного экономикой от изменения уровня образования. Исходя из предположения об ускорении (замедлении) экономического роста как о возможной экстерналии образования, авторы исследуют опосредованное влияние социального капитала на формирование этой экстерналии.The article under consideration analyzes the intermediary mechanism of impulse which results in economics due to education level change. In terms of assumption as regards economic growth acceleration (impairment) as one of possible education externalities the authors are researching the indirect social capital influence upon this externality formation

Microbial aetiology, outcomes, and costs of hospitalisation for community-acquired pneumonia; an observational analysis

BACKGROUND: The aim of this study was to investigate the clinical outcome and especially costs of hospitalisation for community-acquired pneumonia (CAP) in relation to microbial aetiology. This knowledge is indispensable to estimate cost-effectiveness of new strategies aiming to prevent and/or improve clinical outcome of CAP. METHODS: We performed our observational analysis in a cohort of 505 patients hospitalised with confirmed CAP between 2004 and 2010. Hospital administrative databases were extracted for all resource utilisation on a patient level. Resource items were grouped in seven categories: general ward nursing, nursing on ICU, clinical chemistry laboratory tests, microbiology exams, radiology exams, medication drugs, and other.linear regression analyses were conducted to identify variables predicting costs of hospitalisation for CAP. RESULTS: Streptococcus pneumoniae was the most identified causative pathogen (25%), followed by Coxiella burnetii (6%) and Haemophilus influenzae (5%). Overall median length of hospital stay was 8.5 days, in-hospital mortality rate was 4.8%. Total median hospital costs per patient were €3,899 (IQR 2,911-5,684). General ward nursing costs represented the largest share (57%), followed by nursing on the intensive care unit (16%) and diagnostic microbiological tests (9%). In multivariate regression analysis, class IV-V Pneumonia Severity Index (indicative for severe disease), Staphylococcus aureus, or Streptococcus pneumonia as causative pathogen, were independent cost driving factors. Coxiella burnetii was a cost-limiting factor. CONCLUSIONS: Median costs of hospitalisation for CAP are almost €4,000 per patient. Nursing costs are the main cause of these costs.. Apart from prevention, low-cost interventions aimed at reducing length of hospital stay therefore will most likely be cost-effective

Presence of propionibacterium acnes in granulomas associates with a chronic disease course in dutch sarcoidosis patients

Several studies demonstrated that Propionibacterium acnes may be involved in sarcoidosis pathogenesis. Presence of P. acnes was found in granulomas of the majority of Japanese sarcoidosis patients. However, presence of P. acnes in tissue has never been related to sarcoidosis phenotypes and clinical outcome. Therefore, the aims of our study were to demonstrate whether P. acnes can be detected in granulomas of Dutch sarcoidosis patients and to investigate whether its presence is related to a clinical phenotype and/or course of disease. Sections of formalin-fixed paraffin-embedded tissue blocks of 76 sarcoidosis patients were examined by immunostaining with a P. acnes-specific monoclonal antibody (PAB antibody) using a Ventana BenchMark ULTRA. Clinical outcome status (COS) was determined and classified into two phenotype groups: A: resolved, minimal or persistent disease without treatment (COS 1–6) and B: persistent disease with need for treatment (COS 7–9). P. acnes was detected in samples of 31 patients (41%) and located within granulomas in samples of 13 patients (17%). The frequency of P. acnes detected in granulomas at diagnosis was significantly higher in patients with phenotype B compared to patients with phenotype A (29% versus 0%, p=0.021). Presence of P. acnes in granulomas can be confirmed in Dutch sarcoidosis patients. It is intriguing that presence of P. acnes in granulomas is more frequently found in patients with chronic disease requiring treatment. This adds to the rationale that a subgroup of sarcoidosis patients might benefit from antibiotic therapy

Genetic disorders of the surfactant system: Focus on adult disease

Genes involved in the production of pulmonary surfactant are crucial for the development and maintenance of healthy lungs. Germline mutations in surfactant-related genes cause a spectrum of severe monogenic pulmonary diseases in patients of all ages. The majority of affected patients present at a very young age, however, a considerable portion of patients have adult-onset disease. Mutations in surfactant-related genes are present in up to 8% of adult patients with familial interstitial lung disease (ILD) and associate with the development of pulmonary fibrosis and lung cancer. High disease penetrance and variable expressivity underscore the potential value of genetic analysis for diagnostic purposes. However, scarce genotype–phenotype correlations and insufficient knowledge of mutation-specific pathogenic processes hamper the development of mutation-specific treatment options. This article describes the genetic origin of surfactant-related lung disease and presents spectra for gene, age, sex and pulmonary phenotype of adult carriers of germline mutations in surfactant-related genes

The use of online visual analogue scales in idiopathic pulmonary fibrosis

The visual analogue scale is a valid and reliable tool to assess symptoms over time in IPF. Because of their simplicity, visual analogue scales have the potential to be used for systematic evaluation of disease course in trials and daily practice. https://bit.ly/3BuxJs

Elevated serum amyloid a levels are not specific for sarcoidosis but associate with a fibrotic pulmonary phenotype

Elevated Serum Amyloid A (SAA) levels have been found in several inflammatory diseases, including sarcoidosis. SAA is suggested to be involved in sarcoidosis pathogenesis by involvement in granuloma formation and maintenance. We hypothesized that SAA serum levels would be higher in sarcoidosis compared to other non-infectious granulomatous and non-granulomatous diseases. SAA levels were measured in serum from sarcoidosis, Hypersensitivity pneumonitis (HP), and (eosinophilic) granulomatosis with polyangiitis ((E)GPA) patients. Idiopathic pulmonary fibrosis (IPF) patients were included as non-granulomatous disease group. SAA levels of patients with sarcoidosis (31.0 µg/mL), HP (23.4 µg/mL), (E)GPA (36.9 µg/mL), and IPF (22.1 µg/mL) were all higher than SAA levels of healthy controls (10.1 µg/mL). SAA levels did not differ between the diagnostic groups. When SAA serum levels were analyzed in sarcoidosis subgroups, fibrotic sarcoidosis patients showed higher SAA levels than sarcoidosis patients without fibrosis (47.8 µg/mL vs. 29.4 µg/mL, p = 0.005). To conclude, the observation that fibrotic sarcoidosis patients have higher SAA levels, together with our finding that SAA levels were also increased in IPF patients, suggests that SAA may next to granulomatous processes also reflect the process of fibrogenesis. Further studies should clarify the exact role of SAA in fibrosis and the underlying mechanisms involved

Activation of downstream mTORC1 target ribosomal protein S6 kinase (S6K) can be found in a subgroup of Dutch patients with granulomatous pulmonary disease

Mechanistic target of rapamycin complex 1 (mTORC1) has been linked to different diseases. The mTORC1 signaling pathway is suggested to play a role in the granuloma formation of sarcoidosis. Recent studies demonstrated conflicting data on mTORC1 activation in patients with sarcoidosis by measuring activation of its downstream target S6 kinase (S6K) with either 33% or 100% of patients. Therefore, the aim of our study was to reevaluate the percentage of S6K activation in sarcoidosis patients in a Dutch cohort. To investigate whether this activation is specific for sarcoid granulomas, we also included Dutch patients with other granulomatous diseases of the lung. The activation of the S6K signaling pathway was evaluated by immunohistochemical staining of its downstream effector phospho-S6 in tissue sections. Active S6K signaling was detected in 32 (43%) of the sarcoidosis patients. Twelve (31%) of the patients with another granulomatous disorder also showed activated S6K signaling, demonstrating that the mTORC1 pathway may be activated in a range for different granulomatous diseases (p = 0.628). Activation of S6K can only be found in a subgroup of patients with sarcoidosis, as well as in patients with other granulomatous pulmonary diseases, such as hypersensitivity pneumonitis or vasculitis. No association between different clinical phenotypes and S6K activation can be found in sarcoidosis

Randomised, placebo-controlled trial of dexamethasone for quality of life in pulmonary sarcoidosis

Background: Many patients with pulmonary sarcoidosis experience reduced quality of life. Although oral corticosteroids are the most common agents used in sarcoidosis, very little is known on the effects on quality of life. Methods: In this double-blind, placebo-controlled trial, newly diagnosed patients without an indication for high dose immunosuppressive therapy were randomised to once-daily dexamethasone 1 mg (6.5 mg prednisone equivalent) or placebo for 6 months. The primary study parameter was the subscale physical functioning of the 36-item Short Form health survey (SF-36). Secondary parameters included five other patient reported outcome measures, disease activity markers and plasma cytokine profiles. Results: A total of 16 patients was randomised to dexamethasone (n = 7) and placebo (n = 9). During follow-up no significant difference for physical functioning was measured (p = 0.18). Dexamethasone treated patients showed a decrease in fatigue score (Checklist Individual Strength) from 106 (baseline) to 88 (3 months; p = 0.03); 86 (6 months; p = 0.05); 79 (9 months; p = 0.04); 90 (12 months; p = 0.03). Placebo treated patients showed no change: 96 (baseline) to 105 (3 months; p = 0.16); 91 (6 months; p = 0.48); 92 (9 months; p = 0.61); 95 (12 months; p = 0.90). During treatment with dexamethasone significant improvements in the SF-36 subscales vitality and pain, and a significant reduction in serum angiotensin-converting enzyme, soluble interleukin 2 receptor levels and serum cytokines and chemokines were measured. Conclusions: Low-dose dexamethasone results in a reduction of the inflammatory profile and has the potential to improve quality of life parameters and fatigue