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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0010" class="elsevierStylePara elsevierViewall">Given the variable prevalence of Hypersensitivity Pneumonitis &#40;HP&#41; across the world and the absence of widely accepted criteria for the definition of acute&#44; subacute and chronic forms&#44; characterization of different HP phenotypes is serious and a better classification of the disease stages is desirable&#44; together with a better correlation of radiological and pathological features&#44; to provide an adequate implementation of diagnostic and therapeutic approach&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Santos et al&#46; retrospectively assessed clinical and diagnostic data of a cohort of HP patients from the North of Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> 73&#44;7&#37; of patients had chronic form&#44; agreeing with the literature data&#59; in fact&#44; the majority of patients with hypersensitivity pneumonitis who present to specialist centers have the chronic fibrotic form of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Chronic HP is characterized by a varied outcome and an accelerated rate of progression may be observed in a proportion of patients&#44; similar to Idiopathic Pulmonary Fibrosis &#40;IPF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> 12&#44;9&#37; of patients observed by Santos et al&#46; had undetermined exposure and there was a significant association between chronic presentation and those patients with undetermined exposure&#46; When a specific exposure cannot be clearly identified&#44; differentiation of chronic HP can become more challenging&#59; on the other hand&#44; specific IgG signal merely reflects antigen exposure and a multidisciplinary diagnosis of chronic HP may not be associated with an improved outcome over patients diagnosed with IPF&#44; as if they were the same disease&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Furthermore&#44; in chronic HP sub-group&#44; patients had most frequently ground glass&#44; reticulation and honey combing patterns&#44; while no differences were found regarding mosaic pattern and emphysema&#46; It is worth pointing out this result as we know from the literature that computed tomography &#40;CT&#41; predictors of mortality in chronic HP includes reticular pattern&#44; honeycombing and traction bronchiectasis&#59; whereas mosaic attenuation &#40;although the headcheese sign may be highly specific and moderately sensitive for a high-confidence diagnosis of fibrotic HP&#41; is usually not predictive of outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Chronic HP patients with more extensive fibrosis may progress to death with an IPF-like disease course&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; in an era in which the multidisciplinary team diagnosis is the accepted diagnostic standard&#44; the number of patients with diffuse parenchymal lung diseases &#40;DPLDs&#41; undergoing lung biopsy is inevitably reduced as invasive complementary diagnostic tests are reserved only for cases in which the multidisciplinary evaluation is not enough to conclude a definitive diagnosis&#46; In Santos&#8217;s series&#44; 29&#44;2&#37; of patients needed to perform histological analysis and a significant number of patients undergoing lung biopsy had chronic HP &#40;for which differential diagnosis is considerably more challenging&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> More than a third of lung biopsies were obtained by transbronchial lung cryobiopsy &#40;TBLC&#41;&#59; although additional research is needed to enhance knowledge regarding the role of TBLC in the diagnostic algorithm of chronic HP&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the recent Chest guidelines have further confirmed that TBLC contribution to the diagnosis of DPLDs obtained via multidisciplinary discussion appears to be good at least in experienced centers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; Santos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> confirms the need for a more precise and complex diagnostic evaluation for hypersensitivity pneumonitis&#44; especially the chronic fibrotic form&#44; due to the differential diagnosis between this form and other fibrotic interstitial pneumonias with poor prognosis&#46;</p></span>"
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EDITORIAL
Hypersensitivity pneumonitis: Need for a better diagnostic evaluation
Claudia Ravaglia
Department of Thoracic Diseases, GB Morgagni Hospital, Forlì, Italy
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    "titulo" => "Hypersensitivity pneumonitis&#58; Need for a better diagnostic evaluation"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0010" class="elsevierStylePara elsevierViewall">Given the variable prevalence of Hypersensitivity Pneumonitis &#40;HP&#41; across the world and the absence of widely accepted criteria for the definition of acute&#44; subacute and chronic forms&#44; characterization of different HP phenotypes is serious and a better classification of the disease stages is desirable&#44; together with a better correlation of radiological and pathological features&#44; to provide an adequate implementation of diagnostic and therapeutic approach&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Santos et al&#46; retrospectively assessed clinical and diagnostic data of a cohort of HP patients from the North of Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> 73&#44;7&#37; of patients had chronic form&#44; agreeing with the literature data&#59; in fact&#44; the majority of patients with hypersensitivity pneumonitis who present to specialist centers have the chronic fibrotic form of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Chronic HP is characterized by a varied outcome and an accelerated rate of progression may be observed in a proportion of patients&#44; similar to Idiopathic Pulmonary Fibrosis &#40;IPF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> 12&#44;9&#37; of patients observed by Santos et al&#46; had undetermined exposure and there was a significant association between chronic presentation and those patients with undetermined exposure&#46; When a specific exposure cannot be clearly identified&#44; differentiation of chronic HP can become more challenging&#59; on the other hand&#44; specific IgG signal merely reflects antigen exposure and a multidisciplinary diagnosis of chronic HP may not be associated with an improved outcome over patients diagnosed with IPF&#44; as if they were the same disease&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Furthermore&#44; in chronic HP sub-group&#44; patients had most frequently ground glass&#44; reticulation and honey combing patterns&#44; while no differences were found regarding mosaic pattern and emphysema&#46; It is worth pointing out this result as we know from the literature that computed tomography &#40;CT&#41; predictors of mortality in chronic HP includes reticular pattern&#44; honeycombing and traction bronchiectasis&#59; whereas mosaic attenuation &#40;although the headcheese sign may be highly specific and moderately sensitive for a high-confidence diagnosis of fibrotic HP&#41; is usually not predictive of outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Chronic HP patients with more extensive fibrosis may progress to death with an IPF-like disease course&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; in an era in which the multidisciplinary team diagnosis is the accepted diagnostic standard&#44; the number of patients with diffuse parenchymal lung diseases &#40;DPLDs&#41; undergoing lung biopsy is inevitably reduced as invasive complementary diagnostic tests are reserved only for cases in which the multidisciplinary evaluation is not enough to conclude a definitive diagnosis&#46; In Santos&#8217;s series&#44; 29&#44;2&#37; of patients needed to perform histological analysis and a significant number of patients undergoing lung biopsy had chronic HP &#40;for which differential diagnosis is considerably more challenging&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> More than a third of lung biopsies were obtained by transbronchial lung cryobiopsy &#40;TBLC&#41;&#59; although additional research is needed to enhance knowledge regarding the role of TBLC in the diagnostic algorithm of chronic HP&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the recent Chest guidelines have further confirmed that TBLC contribution to the diagnosis of DPLDs obtained via multidisciplinary discussion appears to be good at least in experienced centers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; Santos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> confirms the need for a more precise and complex diagnostic evaluation for hypersensitivity pneumonitis&#44; especially the chronic fibrotic form&#44; due to the differential diagnosis between this form and other fibrotic interstitial pneumonias with poor prognosis&#46;</p></span>"
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