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Introduction: Patients with pulmonary fibrosis experience early oxyhemoglobin desaturation under effort, which limits their ability to exercise and their quality of life. Recent studies have shown that in resting normoxaemic patients who become hypoxemic under exertion, administration of outpatient oxygen significantly improves stress dyspnoea and quality of life. It is unclear how this happens, since oxygen administration does not act directly on dyspnoea, and does not appear to have much effect on the heart rate and pulmonary artery pressure. We tested the hypothesis that correcting the hypoxaemia could reduce the increase in respiratory effort during the 6 min walking test, recording the breathing pattern during administration of oxygen or placebo. Methods: We evaluated 20 patients with fibrotic interstitial lung diseases (17 males and 3 females; mean age 72 ± 2 years; M ± SE) with a resting SpO2 ≥92 that fell to ≤88% during the 6 min walk test (6MWT). After first establishing the oxygen flow necessary to prevent desaturation, the patients underwent two further 6MWT, 15–20 min apart, one with administration of medical air and one with oxygen at the same flow, in randomized double-blind order. During the test, SpO2, heart rate, respiratory rate, tidal volume and minute ventilation (VE) were recorded, using a Spiropalm spirometer (Cosmed, Rome, Italy). Results: Oxygen saturation during the 6MWT decreased to a minimum value of 82.3% (95% CI 80.1–84.5%) during placebo and to 92% (90.3–93.7%) during oxygen with an average difference of 9.7% (7.8–11.6%, p < 0.0001). On the contrary, heart rate showed an increasing trend with walking time reaching a significantly higher maximum rate during placebo, with a difference of 5.4 bpm (2.9–8.7, p < 0.005) compared to oxygen. The distance walked was slightly but significantly greater after oxygen by 28 m (2–53, p < 0.05) and end of test dyspnoea after placebo by 0.6 points (0.1–1.1, p < 0.05). Respiratory rate increased over time, without differences between oxygen and placebo in the first minute of walking, then increasing significantly more during placebo (p < 0.0005). With placebo, tidal volume increased rapidly reaching a plateau at about 48% of FVC after 3 min, while with oxygen, the increase was slower, reaching a maximum of about 45% of FVC at the end of the test. Nevertheless, the difference was highly significant (p < 0.0005) at all the time points. Minute ventilation also increased significantly with walking time but remained at a highly significant lower level during oxygen than placebo at all the time points. Mean reduction in VE during the test with oxygen compared to placebo was 4.4 L/min (3.9–4.9, p < 0.0005). Conclusion: In our ILD patients, administration of outpatient oxygen during walking was related to a reduced increase in heart rate, respiratory rate, tidal volume and minute ventilation necessary to meet increased oxygen requirements, resulting in a lower workload on the cardiovascular system and on respiratory muscles and a consequent reduction in dyspnoea.

Background Cytomegalovirus (CMV) is the major and most common opportunistic infection complicating lung transplant (LTX). The aim of this study was to analyse the epidemiological aspects of CMV infection in lung transplant patients subject to a pre-emptive anti-CMV approach and to study the impact of this infection on lung transplant outcome, in terms of onset of chronic lung allograft dysfunction (CLAD). Methods This single-centre retrospective study enrolled 87 LTX patients (median age 55.81 years; 41 females, 23 single LTX, 64 bilateral LTX). All patients were managed with a pre-emptive anti-CMV approach. The incidences of the first episode of CMV infection, 1, 3, 6 and 12 months after LTX, were 12.64%, 44.26%, 50.77% and 56.14%. A median interval of 41 days elapsed between LTX and the first episode of CMV infection. The median blood load of CMV-DNA at diagnosis was 20,385 cp/ml; in 67.64% of cases, it was also the peak value. Patients who had at least one episode had shorter CLAD-free survival. Patients who had three or more episodes of CMV infection had the worst outcome. Results CMV infection was confirmed to be a common event in lung transplant patients, particularly in the first three months after transplant. It had a negative impact on transplant outcome, being a major risk factor for CLAD. The hypothesis that lower viral replication thresholds may increase the risk of CLAD is interesting and deserves further investigation.

Introduction Fibrotic hypersensitivity pneumonitis (fHP) is a frequently misdiagnosed fibrosing interstitial pneumonia, which often remains undiagnosed due to the lack of uniformity of diagnostic criteria. Its features are similar to those of other ILDs, especially idiopathic pulmonary fibrosis (IPF), and biomarkers with potential clinical value have been proposed. Evidence acquisition We reviewed the recent literature on serum and BAL biomarkers, focusing on their clinical role in the diagnosis and management of fHP. We systematically searched Medline/Pubmed results from 2005 until April 2020. Evidence synthesis The manuscripts of interest selected by our search were limited in number and proposed different clinical biomarkers in serum (IgG antibodies, macrophage inflammatory proteins-1, epithelial cell proteins) and BAL (lymphocytes, T cell mediators). This is the first review to summarise all the serum and BAL biomarkers for fHP proposed in the literature. Conclusions This review summarized the main biomarkers investigated in fibrotic hypersesitivity pneumonitis because an urgent aim of subsequent research will be to validate and standardize them for diagnostic purposes.

Background and objective The course of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is highly variable, and accurate prognostic markers are needed. KL-6 is a mucin-like glycoprotein (MUC1) expressed by type II pneumocytes, while CYFRA 21-1 is expressed by alveolar and bronchiolar epithelial cells. Both are released into the blood from cell injury. Methods Serum KL-6 and CYFRA 21-1 levels were measured in a retrospective (n = 189) and a prospective (n = 118) cohort of SSc patients. Genotyping of MUC1 rs4072037 was performed. Linear mixed-effect models were used to evaluate the relationship with change in lung function parameters over time, while association with survival was evaluated with Cox proportional hazard analysis. Results In both cohorts, KL-6 and CYFRA 21-1 were highest in patients with lung involvement, and in patients with extensive rather than limited ILD. KL-6 was higher in patients carrying the MUC1 rs4072037 G allele in both cohorts. In patients with SSc-ILD, serum KL-6, but not CYFRA 21-1, was significantly associated with DLCO decline in both cohorts (P = 0.001 and P = 0.004, respectively), and with FVC decline in the retrospective cohort (P = 0.005), but not the prospective cohort. When combining the cohorts and subgrouping by severity (median CPI = 45.97), KL-6 remained predictive of decline in DLCO in both milder (P = 0.007) and more severe disease (P = 0.02) on multivariable analysis correcting for age, gender, ethnicity, smoking history and MUC1 allele carriage. Conclusion Our results suggest serum KL-6 predicts decline in lung function in SSc, suggesting its clinical utility in risk stratification for progressive SSc-ILD.

Serum amyloid A (SAA) is an apo-lipoprotein produced by the liver in response to proinflammatory cytokines. Few data are available on SAA levels in patients with idiopathic pulmonary fibrosis (IPF), the most common idiopathic form of interstitial pneumonitis (ILD). This study compared SAA concentration in IPF patients to other ILD groups to explore its potential use as a clinical biomarker.

Pulmonary hypertension (PH) is defined as an elevated mean pulmonary artery pressure at rest (mPAP ≥ 25 mmHg), evaluated by right heart catheterization (RHC). The aim of the present study was to evaluate HRCT findings in relation to transthoracic echocardiographic data to better characterize PH in IPF patients and to identify a non-invasive composite index with high predictive value for PH in these patients. 37 IPF patients were enrolled in this retrospective study. All patients underwent a complete assessment for PH, including transthoracic Doppler echocardiography, HRCT scan and right heart catheterization. Right heart catheterization was done in 19 patients (51.3%) as pre-lung transplant assessment and in 18 patients (48.6%) to confirm PH, suspected on the basis of echocardiography. Twenty out of 37 patients (54%) were confirmed to have PH by RHC. Multivariate regression showed that the combination of sPAP, PA area measured by HRCT and the ratio of the diameter of the segmental artery to that of the adjacent bronchus in the apicoposterior segment of the left upper lobe was strongly correlated with mPAP (R2 = 0.53; p = 0.0009). The ROC analysis showed that 931.6 was the ULN for PA area, with 86% sensitivity and 61% specificity (0.839 AUC); 20.34 was the ULN for the ratio of PA area to ascending aorta diameter, with 100% sensitivity and 50% specificity (0.804 AUC). The composite index proposed in the present study could help early detection of IPF patients suspected of PH requiring confirmation by RHC (if deemed clinically necessary). Electronic supplementary material The online version of this article (10.1007/s11739-020-02539-1) contains supplementary material, which is available to authorized users.

Background: New anti-IL-5 antibodies, mepolizumab and benralizumab, have recently been approved for severe asthma, sharing the same inclusion criteria. Objective: To contribute on biomarkers research leading to the personalized choice, we investigated L-selectin, Krebs von den Lungen (KL-6), and lymphocyte subsets as bioindicators of airway hyper-responsiveness and remodeling. Materials and Methods: A cohort of 28 patients affected by severe eosinophilic asthma were treated with anti-IL-5 drugs. According to clinical parameters, patients were subdivided into early and partial responders. Lymphocytes subsets were analyzed through flow cytometry, while KL-6 and sL-selectin were analyzed on serum samples. Clinical, functional, and immunological data at baseline (T0), after 1 month (T1), and 6 months of therapy were collected in a database. Results: All treated patients showed an increase in the percentage of forced expiratory volume in the first second (FEV1) and FEV1/forced vital capacity ratio and a decrease of peripheral eosinophils for both drugs after 1 month of treatment. Mepolizumab-treated patients also showed decreased CD8+ and NKT-like cell percentages and a significant increase in sL-selectin concentrations between T0 and T1. Stratifying the cohort of our patients in early and partial responders at T0, they showed a reduction of peripheral eosinophils, sL-selectin and KL-6, while no differences were found at T0 between early and partial responders patients treated with benralizumab. Conclusions: This real-life study provides new insights for the personalized approach to severe asthma therapy. Although preliminary, the results indicate that besides eosinophils, KL-6 and sL-selectin are useful as biomarkers of early response that can also involve in the pathogenesis of severe asthma.

Severe acute respiratory syndrome caused by coronavirus 2 emerged in Wuhan (China) in December 2019 and has severely challenged the human population. NK and T cells are involved in the progression of COVID-19 infection through the ability of NK cells to modulate T-cell responses, and by the stimulation of cytokine release. No detailed investigation of the NK cell landscape in clinical SARS-CoV-2 infection has yet been reported. A total of 35 COVID-19 hospitalised patients were stratified for clinical severity and 17 healthy subjects were enrolled. NK cell subsets and T cell subsets were analysed with flow cytometry. Serum cytokines were detected with a bead-based multiplex assay. Fewer CD56dimCD16brightNKG2A+NK cells and a parallel increase in the CD56+CD69+NK, CD56+PD-1+NK, CD56+NKp44+NK subset were reported in COVID-19 than HC. A significantly higher adaptive/memory-like NK cell frequency in patients with severe disease than in those with mild and moderate phenotypes were reported. Moreover, adaptive/memory-like NK cell frequencies were significantly higher in patients who died than in survivors. Severe COVID-19 patients showed higher serum concentrations of IL-6 than mild and control groups. Direct correlation emerged for IL-6 and adaptive/memory-like NK. All these findings provide new insights into the immune response of patients with COVID-19. In particular, they demonstrate activation of NK through overexpression of CD69 and CD25 and show that PD-1 inhibitory signalling maintains an exhausted phenotype in NK cells. These results suggest that adaptive/memory-like NK cells could be the basis of promising targeted therapy for future viral infections.

BAL cellularity and lymphocyte immunophenotyping offer insights into lung inflammatory status. Natural killer (NK) cells are efficient effector cells, producing pro-inflammatory cytokines. A better understanding of the biology of NK cells in BAL in the lungs is necessary to improve the pathogenesis of fibrotic ILD and develop prospective targeted treatments. Our aim was to analyse NK and NKT-like cell percentages in BAL from 159 patients with different ILD: f-HP, f-NSIP, IPF and CTD-ILD, to evaluate their potential diagnostic/prognostic role. BAL NK cell percentages showed significantly higher values in IPF than in f-HP and f-NSIP, while BAL NKT-like cells showed significantly lower values in the f-NSIP than the f-HP and IPF. A cut-off of 4%NK cells in BAL of IPF showed a significant difference in survival rate. It suggests a possible new marker of survival and raises the possibility of new targeted approach in treatment and management of IPF.

Background: The immune mechanisms occurring during acute rejection (AR) and chronic lung allograft dysfunction are a challenge for research and the balance between effector and regulatory cells has not been defined completely. In this study, we aimed to elucidate the interaction of effector cells, mainly Th17, Th1 and Th2, and regulatory cells including (CD4+CD25+CD127low/−) T reg cells and phenotypes of B regs, CD19+CD24hiCD38hi, CD19+CD24hiCD27hi and CD19+CD5+CD1d+. Methods: Bronchoalveolar lavage cells (BAL) and peripheral blood mononuclear cells (PBMCs) from stable lung transplanted (LTx )subjects (n = 4), AR patients (n = 6) and bronchiolitis obliterans syndrome (BOS) (n = 6) were collected at the same time. Cellular subsets were detected through flow cytometry. Results: A predominance of Th17 cells subtypes in the PBMCs and BAL and a depletion of Tregs, that resulted in decrease Treg/Th17 ratio, was observed in the AR group. CD19+CD24hiCD38hi Bregs resulted increased in BAL of AR patients. Th1 cells predominance and a reduction of Tregs cells was observed in BAL from AR patients. Moreover, multivariate analysis showed interdependences within studied variables revealing that effector cells and regulatory cells can effectively discriminate patients’ immunological status. Conclusions: In AR, BOS and stable lung transplant, regulatory and effector cells clearly demonstrated different pathways of activation. Understanding of the balance of T cells and T and B regulatory cells can offers insights into rejection.

Background Severe allergic asthma (SAA) is based on type 2 (T2-high) immune responses to allergens promoting type 2 T helper (Th2) cell cytokine responses and production of IgE antibodies. Omalizumab was the first biological drug licensed for clinical use in the management of IgE-mediated SAA. Despite, emerging evidence supporting the prominent role of follicular T cells (Tfh), Breg and Treg subsets, in the development and progression of SAA, no data is available on the impact omalizumab therapy. Methods Ten SAA patients monitored at the Respiratory Diseases Unit of Siena University Hospital and 10 healthy sex- and age-matched controls were enrolled in the study. Clinical and functional parameters were collected at baseline (T0) and after 6 months of therapy (T6). Cellular population analysis were determined through multi-color flow cytometry. Results SAA patients showed higher percentages of Th17.1, Tfh and Tfh2 while CD24 hi CD27 hi Breg cell, Treg and Tfr percentages were significantly lower than controls. Higher percentages of Tfh2 in patients with nasal polyps than in those without and in controls were observed. At T6, significant decreases of Tfh and Tfh2 than T0 were observed. A slightly significant increase in Teff was reported at T6 with respect to T0. ΔIgE levels in serum were correlated with ΔCD19 + CD24 + CD27 + Breg cell percentages (r=-0.86, p=0.0022). Conclusions Our data explored the changes of Tfh cells, Tregs and Bregs in severe asthma. The restoration of immunological imbalance in SAA patients after omalizumab is surely intriguing and represents a glimpse of light in the comprehension of immunological effects of treatment.

Background Galectins are proteins that bind β-galactosides such as N-acetyllactosamine present in N-linked and O-linked glycoproteins and that seem to be implicated in inflammatory and immune responses as well as fibrotic mechanisms. This preliminary study investigated serum galectins as clinical biomarkers in lung transplant patients with chronic lung allograft dysfunction (CLAD), phenotype bronchiolitis obliterans syndrome (BOS). Materials and Methods Nineteen lung transplant patients [median age (IQR), 55 (45–62) years; 53% males] were enrolled in the study. Peripheral blood concentrations of galectins-1, 3 and 9 were determined with commercial ELISA kits. Results Galectin-1 concentrations were higher in BOS than in stable LTX patients (p = 0.0394). In logistic regression analysis, testing BOS group as dependent variable with Gal-1 and 3 as independent variables, area under the receiver operating characteristics (AUROC) curve was 98.9% (NPV 90% and PPV 88.9%, p = 0.0003). With the stable LTX group as dependent variable and Gal-1, 3 and 9 as independent variables, AUROC was 92.6% (NPV 100% and PPV 90%, p = 0.0023). In stable patients were observed an inverse correlation of Gal-3 with DLCO% and KCO%, and between Gal-9 and KCO%. Conclusion Galectins-1, 3 and 9 are possible clinical biomarkers in lung transplant patients with diagnostic and prognostic meaning. These molecules may be directly implicated in the pathological mechanisms of BOS. The hypothesis that they could be new therapeutic targets in BOS patients is intriguing and also worth exploring.

Severe eosinophilic asthma (SEA) has been associated with T-helper type 2 (Th2) inflammatory response. A good understanding of T cell functions in asthma is important for therapy, especially in the choice of biological treatments for severe cases. Mepolizumab, an IL-5 antagonist, is indicated for the treatment of severe asthma. Regulatory T cells (Tregs) suppress inflammation by secreting cytokines that inhibit Th2 cell proliferation. We investigated peripheral Treg, CD4, CD8, CD19 and NK cell percentages and their relationship to clinical and functional parameters, including peripheral eosinophils, before and after anti-IL5 treatment. Subjects were 14 adult SEA patients (9 male, 54.1 ± 11.6 years), treated with mepolizumab, and 10 controls. T cells (CD4 and CD8), CD19, NK and Tregs were evaluated by flow cytometry. Comparison of lung function parameters before and after treatment with mepolizumab (T0 and T1) showed an increase in FEV1, FEV1/FVC ratio and a reduction in blood eosinophil percentages. CD8 and CD16/56+ CD3+ were significantly higher in SEA patients than controls (P = .04 and P = .03, respectively). A decrease in CD45+, CD8 + and CD16/56+ CD3+ cell percentages was observed between T0 and T1 (P = .02, P = .04, P = .03, respectively). A significant increase in Treg percentages (P = .0001) was recorded between T0 and T1. Mepolizumab therapy was found to modulate immune response, restoring immune balance in patients with SEA.

Sarcoidosis is a multi‐systemic granulomatous disease of unknown origin. Recent research has focused upon the role of autoimmunity in its development and progression. This study aimed to determine and define the disturbance and distribution of T and B cell subsets in the alveolar and peripheral compartments. Thirteen patients were selected for the study [median age, interquartile range (IQR) = 57 years (48–59); 23% were male]. Twelve healthy controls [median age, IQR = 53 years (52–65); 16% male] were also enrolled into the study. Cellular and cytokine patterns were measured using the cytofluorimetric approach. Peripheral CD8 percentages were higher in sarcoidosis patients (SP) than healthy controls (HC) (p = 0.0293), while CD4 percentages were lower (p = 0.0305). SP showed low bronchoalveolar lavage (BAL) percentages of CD19 (p = 0.0004) and CD8 (p = 0.0035), while CD19+CD5+CD27− percentages were higher (p = 0.0213); the same was found for CD4 (p = 0.0396), follicular regulatory T cells (Treg) (p = 0.0078) and Treg (p, Sarcoidosis is a systemic granulomatous disease and recent research has focused on the role of autoimmunity in its development and progression. This is the first study to demonstrate a link between an imbalance in circulating and alveolar Tfh cells, especially CCR4‐, CXCR3‐, and CXCR5‐expressing Tfh subsets, in the development of sarcoidosis. These findings raise questions about the pathogenesis of sarcoidosis and may provide new directions for future clinical studies and treatment strategies.

Simple Summary Evaluation of the prognostic significance of serial measurements of serum concentrations of Krebs von den Lungen-6 (KL-6) showed that an annual increment in KL-6 exceeding a threshold amount was an independent risk factor for progressive disease and poor prognosis. No literature data are available on long-term KL-6 measurements in the follow-up of IPF patients treated with Nintedanib. The aim of this study is to serially analyze KL-6 in idiopathic pulmonary fibrosis (IPF) patients after 24 months of Nintedanib and to investigate its biomarker potential in patients with IPF and lung cancer with respect to fibrotic hypersensitivity pneumonitis patients, pulmonary fibrosis associated with autoimmune diseases group and healthy controls. Abstract Background: Krebs von den Lungen-6 (KL-6) was suggested as ILD biomarker including idiopathic pulmonary fibrosis (IPF). Lung cancer is one of the most severe comorbidity of IPF patients. This study aims to serially analyze KL-6 in IPF patients after 24 months of Nintedanib and to first investigate the biomarker behavior in IPF associated with adenocarcinoma. Materials and methods: One hundred and forty-two ILD patients (median (IQR), 69 (63–75) years; 86 males) were retrospectively enrolled. Serial serum samples were collected from IPF patients before starting antifibrotic therapy and after 12 months. Serum KL-6 levels were measured by KL-6 reagent assay (Fujirebio Europe, UK). Results: Increased KL-6 concentrations were identified in IPF-LC patients than IPF, fibrotic hypersensitivity pneumonitis, and pulmonary fibrosis associated with autoimmune disease groups. A cut-off value was calculated to distinguish IPF and IPF-LC patients. IPF patients monitored for 24 months with Nintedanib showed persisted increased levels of KL-6 with a progressive decline of FVC percentages. Conclusion: This preliminary study offers a first demonstration that very high serum concentrations of KL-6 in IPF-LC patients are associated with poor prognosis. Moreover, serial evaluation of serum KL-6 in IPF patients over 24 months of Nintedanib treatment revealed that most patients experienced a stabilization of lung function parameters and of serum concentrations of KL-6.

Background Broncho-alveolar lavage (BAL) is a safe diagnostic procedure, useful for differentiating fibrotic lung disorders and for excluding malignancy and infection. A recent multicenter study demonstrated a new, relatively sensitive, and specific index called Bronchoalveolar Cytology Threshold (BCT), useful for distinguishing healthy individuals from patients with lung diseases. Objectives In our study, BCT was applied for the first time to the analysis of interstitial lung diseases (ILDs), investigating its potential for differential diagnosis. Combinations of BAL cells that improve diagnostic accuracy for ILDs were studied and are proposed. Methods A retrospective analysis of BAL samples was performed. We considered more than 1000 BAL samples from patients investigated for ILD, performed at Siena University Hospital. The samples enrolled for the study included 468 patients: 413 with and 55 without ILD. BAL was performed for diagnostic purposes in line with international guidelines. BCT were calculated according to available literature. Results Among ILDs, patients with fibrotic hypersensitivity pneumonitis, idiopathic pulmonary fibrosis (IPF) and sarcoidosis showed significantly lower BCTs than unclassified ILD. Asbestosis patients showed significantly lower BCTs than nonspecific interstitial pneumonia (NSIP), cryptogenic organizing pneumonia (COP), connective tissue disease related ILD (CTD-ILD), sarcoidosis and unclassified ILD patients. COP patients showed significantly higher BCT than IPF, f-HP and sarcoidosis. Moreover, COP patients were best distinguished by BCT. Conclusion The analysis of BAL features is currently included in the diagnostic algorithm of ILDs. BAL cell patterns and BCT index can provide useful information for distinguishing ILDs, reducing the need for invasive procedures. Integrated approaches to BAL analysis can improve the interpretation of results without further cost or loss of time.

Since SARS-CoV-2 emerged in 2019, strict monitoring of post-COVID-19 patients in order to ensure the early detection of sequelae and/or chronic organ damage that could been associated with the infection has been essential. Potential involvement of the NO pathway in the development of post-COVID-19 lung fibrotic alterations is feasible, since the majority of respiratory cells can produce NO, and fractional exhaled NO (FeNO) represents a biomarker of airway inflammation. The aim of this study was to investigate the potential utility of multiple-flow FeNO parameters in a post-COVID-19 population and to compare it with other indicators of lung damage proposed in the literature. We enrolled 20 patients hospitalized for COVID-19, who underwent clinical, respiratory functional (including PFTs and FeNO) and radiological follow-up after discharge. Compared with age- and sex-matched healthy controls, post-COVID-19 patients showed significantly higher FeNO 350 mL/s and CaNO levels. Moreover, among the parameters included in the follow-up, CaNO showed the best accuracy in indicating predominant fibrotic changes and GGO at CT scan. To our knowledge, this preliminary study has investigated for the first time multiple-flow FeNO parameters in a post-COVID-19 population. The evidence of increased CaNO values may imply the persistence of alveolar and bronchiolar inflammation and/or a mild impairment of the alveolar-capillary membrane in these patients.

Simple Summary This paper is a review of the literature on the clinical role of oncomarkers in idiopathic pulmonary fibrosis (IPF) progression, and a description of the routine oncomarker trend in IPF patients over the longest follow-up yet reported. This is the first meta-analysis to review the results of studies evaluating the predictive prognostic value of circulating oncomarkers (CEA, Ca15.3, Ca19.9, Ca125, and KL-6) for IPF. The study focused on the discovery of multiple biomarker signatures, such as combinations of oncomarkers, that are widely and routinely available in biochemistry laboratories. The combination of clinical parameters and biological markers could help achieve more accurate results regarding prognosis and response to treatment in IPF. Our results could pave the way for a more “personalized” medical approach to patients affected by IPF. Abstract Background: Idiopathic pulmonary fibrosis (IPF) is a severe progressive interstitial lung disease. At 5-year follow-up, 15% of IPF patients develop lung cancer, which significantly reduces the survival rate. Here we review the literature on the clinical role of oncomarkers in IPF progression, and describe the trend of routine oncomarkers in IPF patients over the longest follow-up yet reported. Materials and methods: A systematic search of the literature in PubMed was performed to find relevant studies published up to 24 September 2020. The most common oncomarkers were chosen to select papers related to pulmonary fibrosis. Then, 24 IPF patients and 25 non-IPF patients, followed at Careggi ILD Referral Centre and Siena Regional Referral Centre for ILD, were enrolled consecutively. Results: A few studies reported an association between serum oncomarkers and severity of IPF. NSE, CEA, Ca19.9, and Ca125 were higher in the IPF, than in the non-IPF, group at every follow-up (p < 0.05). Ca15.3 concentrations were higher in the IPF, than the non-IPF, group at t3 (p = 0.0080) and t4 (p = 0.0168). To improve the specificity and sensitivity of Ca15.3, a panel of biomarkers was analyzed, with the IPF group as dependent variable, and chitotriosidase, Cyfra 21.1, Ca15.3, Ca125, and Ca19.9 as independent variables. Conclusions: This study focused on the discovery of multiple biomarker signatures, such as combinations of oncomarkers, that are widely and routinely available in biochemistry laboratories. The combination of clinical parameters and biological markers could help achieve more accurate results regarding prognosis and response to treatment in IPF. Our results could pave the way for a more “personalized” medical approach to patients affected by IPF.

Background Idiopathic pulmonary fibrosis (IPF) is a chronic progressive interstitial lung disease limited to the lungs. Immunological dysregulation may significantly participate in the pathophysiology of IPF. The immunological responses to nintedanib therapy in IPF patients were investigated for the first time in this study. Materials and methods Fifty IPF patients (median age (IQR) 69 (65–75) years; 38 males), were selected retrospectively. Flowcytometry analysis were performed to phenotype immunological biomarkers in peripheral blood from IPF patients after 1 year of antifibrotic therapy and a group of healthy volunteers. Results Before starting antifibrotic treatment, IPF patients showed increased CD1d+CD5+ (p = 0.0460), Treg (p = 0.0354), T effector (CD25highCD127high) (p = 0.0336), central cells (CD4+CD45RA−) (p = 0.0354), effector cells (CD4+CD45RA+) (p = 0.0249) and follicular cell percentages (p = 0.0006), notably Tfh1 (p = 0.0412) and Tfh17 (p = 0.0051) cell percentages, in respect with healthy controls (HC). After nintedanib therapy, Breg (p = 0.0302), T effector (p = 0.0468), Th17.1 (p = 0.0146) and follicular cells (p = 0.0006), notably Tfh1 (p = 0.0006) and Tfh17 (p = 0.0182) cell percentages, were significantly decreased. In the logistic regression, Tfh panel showed a significant area under the receiver operating characteristics curve (AUROC) to distinguish IPF than HC (90.5%), as well as t0 and t1 (99.3%). Conclusion In conclusion, the immunological results obtained in this study demonstrate that nintedanib significantly helps to restore immunological responses in IPF patients. These findings will be useful in the search for biomarkers predictive of response to antifibrotic treatment.

Introduction: Severe eosinophilic asthma (SEA) is characterized by uncontrolled symptoms and poor response to drug. Mepolizumab therapy (MT) is a IL-5 antagonist approved for SEA. Leukocytes migration plays a role in the pathogenesis of the disease. L-selectin (CD62L) has a key role in leukocyte adhesion. Regulatory T cells (Treg) is a population of T belongs to tolerance system that regulate immune response. Aim and Objectives: To analyse T cell immunophenotyping and serum L-selectin (sL-selectin) levels in patients with SEA before and after administration of MT. Methods: 14 patients affected by SEA and 10 healthy controls (HC) were enrolled. Flow cytometric analysis of T cells was performed at baseline (T0) and after one month of MT (T1). Multiplex assay was performed to evaluate sL-selectin levels. Results: Increased FEV1 values were observed at T1 than T0 (p=0.014 and p=0.045, respectively). CD4+CD62L+ cells’ expression were increased in SEA patients than HC (p=0.004) and in T0 than T1 (p=0.024). ΔCD4+CD62L+ cell percentages revealed an indirect correlation with Δblood eosinophilis (r=-0.61, p=0.047). sL-Selectin levels were decreased in T1 than T0 (p=0.007). Treg cells showed increased in T1 than T0 (p Conclusions: Mepolizumab was confirmed a modulatory therapy, restoring the homeostasis immune cells in SEA. L-Selectin and Treg cells may represent future potential biomarkers to evaluate the answer to MT.

Introduction: Idiopathic pulmonary fibrosis (IPF) is a severe interstitial lung disease (ILD). Bronchoalveolar lavage (BAL) is useful for differential diagnosis of ILD and as a source of ILD biomarkers. BAL neutrophilia has been associated with rapid progression of disease while BAL lymphocytosis with less severe fibrotic involvement. Peripheral neutrophil-to-lymphocyte ratio (N/L) was proposed as a prognostic factor in several types of neoplastic and non-neoplastic lung disease but no data is available on ILD. Aim and Objectives: BAL N/L ratio has been evaluated in sarcoidosis (SA) and chronic Hypersensitivity Pneumonitis (cHP) compared with IPF patients. Methods: BAL samples from the 167 ILD patients were retrospectively enrolled and clustered into three diagnostic categories: IPF, cHP and SA. A decision-tree statistical algorithm was performed. Results: N/L was significantly higher in IPF than SA and cHP patients (fig.1a). Receiver operating curve (ROC) analysis discriminated between IPF and other ILD, according to DLco percentages and N/L ratio (fig.1b,c). A decision-tree statistical analysis to combine the prognostic biomarkers has been added (fig.1d). Conclusions: IPF showed the highest N/L ratio in BAL than SA and cHP. A relationship between BAL N/L and DLco was demonstrated in patients with IPF. This ratio can contribute to clinical management of IPF patients allowing to improve follow-up and outcome.

Ultrasound imaging of the lung (LUS) and associated tissues has demonstrated clinical utility in coronavirus disease 2019 (COVID-19) patients. The aim of the present study was to evaluate the possibilities of a portable pocket-sized ultrasound scanner in the evaluation of lung involvement in patients with COVID-19 pneumonia. We conducted 437 paired readings in 34 LUS evaluations of hospitalized individuals with COVID-19. The LUS scans were performed on the same day with a standard high-end ultrasound scanner (Venue GO, GE Healthcare, Chicago, IL, USA) and a pocket-sized ultrasound scanner (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). Fourteen scans were performed on individuals with severe cases, 11 on individuals with moderate cases and nine on individuals with mild cases. No difference was observed between groups in days since onset of symptoms (23.29 ± 10.07, 22.91 ± 8.91 and 28.56 ± 11.13 d, respectively; p = 0.38). No significant differences were found between LUS scores obtained with the high-end and the portable pocket-sized ultrasound scanner. LUS scores in individuals with mild respiratory impairment were significantly lower than in those with moderate and severe cases. Our study confirms the possibilities of portable pocket-sized ultrasound imaging of the lung in COVID-19 patients. Portable pocket-sized ultrasound scanners are cheap, easy to handle and equivalent to standard scanners for non-invasive assessment of severity and dynamic observation of lung lesions in COVID-19 patients.

Background The risk of COVID‐19 is expected to be higher among solid organ transplant. The aim of the present study was to evaluate the incidence of COVID‐19 and the impact of the SARS‐CoV‐2 outbreak on the personal hygiene and expectations in heart and lung transplant recipients. Methods A telephone survey of heart (n = 69) and lung (n = 41) transplant patients and a group of controls (n = 41) was conducted concerning personal hygiene before and after the outbreak; the impact on subjective expectations regarding graft outcome; symptoms possibly associated with SARS‐CoV‐2 infection; and diagnosis of COVID‐19. Results Seventy nine percent of the patients declared they increased the use of face masks and handwash. Behavior at home regarding self‐isolation did not change. About half the patients said they were afraid of the virus. A higher percentage of Lung transplant (LTX) were convinced that SARS‐CoV‐2 could have a negative impact on the outcome of their graft. 28% declared that they were afraid to come to the hospital for routine examinations and asked to postpone. Nine LTX and five Heart transplant (HTX) patients experienced symptoms that could have been associated with SARS‐CoV‐2 infection, but none of them underwent a nasopharyngeal swab. Only one LTX was diagnosed with the infection. Conclusions In our study, we observed a low incidence of COVID‐19 in heart and lung transplant patients (0.9%), similar to that of the general population of our Region. Isolation measures were already observed before the pandemic and were further strengthened in most cases. Particular attention should also be paid to new psychological and physical complications indirectly linked to the COVID‐19 pandemic.

Fractional exhaled nitric oxide (FeNO) is a well-known and widely accepted biomarker of airways inflammation that can be useful in the therapeutic management, and adherence to inhalation therapy control, in asthmatic patients. However, the multiple-flows assessment of FeNO can provide a reliable measurement of bronchial and alveolar production of NO, supporting its potential value as biomarker also in peripheral lung diseases, such as interstitial lung diseases (ILD). In this review, we first discuss the role of NO in the pathobiology of lung fibrosis and the technique currently approved for the measurement of maximum bronchial flux of NO (J’awNO) and alveolar concentration of NO (CaNO). We systematically report the published evidence regarding extended FeNO analysis in the management of patients with different ILDs, focusing on its potential role in differential diagnosis, prognostic evaluation and severity assessment of disease. The few available data concerning extended FeNO analysis, and the most common comorbidities of ILD, are explored too. In conclusion, multiple-flows FeNO analysis, and CaNO in particular, appears to be a promising tool to be implemented in the diagnostic and prognostic pathways of patients affected with ILDs.

RESUMO Objetivo A fibrose pulmonar familiar (FPF) é definida como uma doença pulmonar intersticial idiopática que afeta dois ou mais membros da mesma família. Nesses pacientes, os resultados têm sido insatisfatórios, apresentando alto risco de morte e disfunção crônica do enxerto pulmonar (CLAD) após o transplante de pulmão. O objetivo do presente estudo foi comparar o resultado de curto e longo prazo do transplante de pulmão em pacientes com FPF e pacientes transplantados por outras doenças pulmonares intersticiais. Métodos Foram coletados retrospectivamente dados clínicos pré e pós-transplante de 83 pacientes com fibrose pulmonar submetidos a transplante de pulmão. Os pacientes foram divididos em aqueles com fibrose pulmonar familiar (n = 9, grupo FPF) e aqueles com fibrose pulmonar não familiar (n = 74, grupo controle). Resultados O grupo FPF foi composto de quatro mulheres e cinco homens, sendo 44,5% ex-fumantes. A maioria apresentou tomografia computadorizada e evidência patológica de pneumonia intersticial usual. Os pacientes com FPF tiveram níveis significativamente menores de hemoglobina e hematócrito. Não foram observadas outras diferenças nas características pré e pós-transplante em relação ao grupo controle. A evolução clínica pós-operatória foi semelhante nos dois grupos. Não foi constatada diferença significativa na sobrevida de um ano livre de CLAD e na sobrevida em geral. Conclusão A evolução pós-transplante de pacientes com FPF foi semelhante à dos pacientes com fibrose pulmonar não familiar, embora mais pacientes com FPF tivessem anemia pré-transplante. O resultado a curto e longo prazo foi comparável em ambos os grupos. O transplante de pulmão provou ser uma opção válida para pacientes com FPF, assim como para pacientes com outros tipos de fibrose pulmonar. ABSTRACT Objective Familial pulmonary fibrosis (FPF) is defined as an idiopathic interstitial lung disease affecting two or more members of the same family; poor outcome with high risk of death and chronic lung allograft dysfunction (CLAD) after lung transplant has been reported in these patients. The present study aimed to compare the short- and long-term outcome of lung transplants in patients with FPF and patients transplanted because of other interstitial lung diseases. Method Clinical pre- and post-transplant data from 83 consecutive patients with pulmonary fibrosis who underwent lung transplant at our centre were collected retrospectively. Patients were divided into those with familial (n=9 FPF group) and those with non-familial pulmonary fibrosis (n=74 controls). Results The FPF group was composed of 4 females and 5 males; 44.5% were ex-smokers. The majority presented their CT scan and pathology evidence of usual interstitial pneumonia. Patients with FPF had significantly lower pre-transplant levels of haemoglobin and haematocrit. No other differences in pre- and post-transplant characteristics were observed concerning controls. The clinical post-operative course was similar in the two groups. No significant difference in one-year CLAD-free survival and overall survival was observed. Conclusion The post-transplant course of patients with FPF was similar to patients with non-familial pulmonary fibrosis, although more patients with FPF had pre-transplant anaemia. Short- and long-term outcome was comparable in both groups. Lung transplant proved to be a valid option for patients with FPF as it was for patients with other types of pulmonary fibrosis.

Aim: Interstitial lung diseases (ILD) are a group of lung disorders characterized by interstitial lung thickening. Krebs von den Lungen-6 (KL-6) is a molecule that is predominantly expressed by damaged alveolar type II cells and it has been proposed as a potential biomarker of different ILD. Materials & methods: A growing literature about KL-6 has been reviewed and selected to evaluate its role in the clinical management of ILD to predict disease diagnosis, activity, prognosis and treatment response. Results: KL-6 concentrations have been evaluated in fibrotic and granulomatous lung diseases and it was demonstrated to be a biomarker of disease severity useful for clinical follow-up of ILD patients. KL-6 levels differentiated between fibrotic ILD, such as idiopathic pulmonary fibrosis and chronic hypersensitivity pneumonitis, and nonfibrotic lung disorders, including sarcoidosis and pulmonary alveolar proteinosis. Conclusion: KL-6 is predictive biomarker useful in the clinical management of ILD patients, in particular in patients with severe fibrotic lung disorders.

Background Chronic lung allograft dysfunction (CLAD) is still the principal long-term cause of mortality after lung transplant. Animal studies and small case series have proposed pirfenidone, a potent antifibrotic agent registered for idiopathic pulmonary fibrosis (IPF), for treatment of CLAD. The aim of this study was to evaluate the safety profile and potential efficacy of pirfenidone in patients with CLAD. Methods The present study concerns a cohort of nine CLAD patients treated with pirfenidone. Pulmonary function tests were performed before and after beginning treatment. Side effects were recorded and survival was analyzed. All data were retrospectively collected. Results The duration of treatment was 408.5±534.8 days. Significant side effects occurred in one case. FEV1 decline reduced from -44.5±40.7 mL/month in the 6 months before therapy to -12.8±34.3 mL/month in the following 6 months. However, data was only available for three patients (three patients died before 6 months of therapy, two patients lacked lung function parameters, one discontinued therapy and one was still in the early months of therapy). Median survival was 686 days. No significant survival differences were observed in relation to CLAD phenotype (BOS, RAS and BOS/RAS). Median survival from the start of pirfenidone therapy was 221 days. Conclusions Our CLAD patients treated with pirfenidone showed a good safety profile, similarly to that reported for IPF patients. The drug showed potential for stabilizing decline in respiratory function. Further studies are needed in order to draw conclusions about the effectiveness of this therapy.