Background: This American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Asociaci on Latinoamericana de T orax guideline updates prior idiopathic pulmonary fibrosis (IPF) guidelines and addresses the progression of pulmonary fibrosis in patients with interstitial lung diseases (ILDs) other than IPF.Methods: A committee was composed of multidisciplinary experts in ILD, methodologists, and patient representatives. 1) Update of IPF: Radiological and histopathological criteria for IPF were updated by consensus. Questions about transbronchial lung cryobiopsy, genomic classifier testing, antacid medication, and antireflux surgery were informed by systematic reviews and answered with evidence-based recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.2) Progressive pulmonary fibrosis (PPF): PPF was defined, and then radiological and physiological criteria for PPF were determined by consensus. Questions about pirfenidone and nintedanib were informed by systematic reviews and answered with evidence-based recommendations using the GRADE approach.Results: 1) Update of IPF: A conditional recommendation was made to regard transbronchial lung cryobiopsy as an acceptable alternative to surgical lung biopsy in centers with appropriate expertise. No recommendation was made for or against genomic classifier testing. Conditional recommendations were made against antacid medication and antireflux surgery for the treatment of IPF. 2) PPF: PPF was defined as at least two of three criteria (worsening symptoms, radiological progression, and physiological progression) occurring within the past year with no alternative explanation in a patient with an ILD other than IPF. A conditional recommendation was made for nintedanib, and additional research into pirfenidone was recommended.Conclusions: The conditional recommendations in this guideline are intended to provide the basis for rational, informed decisions by clinicians.

Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax. Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions. Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.

Protein synthesis rates were measured in liver and gastrointestinal tract (GIT) sections of fattening sheep offered lucerne (Medicago sativa) pellets a t either 1.25 or 2 times energy maintenance. The measurement technique involved a large dose of [l-'3C]valine over 60 min. Animals on the higher intake had a larger mass of liver protein (143 v. 100 g, P = 0.02), similar fractional synthesis rates (ks; 22.5 v. 22.1 %/d, not significant) and greater absolute amounts of protein synthesis (32 v. 23 g/d; P = 0.016) compared with those on the smaller amount of ration. The k," values and RNA:protein in the GJT sections also tended to increase with food intake. Estimated total GIT protein synthesis was approximately three-fold that in liver and probably constituted 25-35 YO of whole body synthesis. All splanchnic tissues measured had lower translational efficiencies (g protein synthesized/d per g total RNA) than reported for milk-fed and newly-weaned lambs and this may relate to the decline in the rate of protein deposition as lambs progress to the fattening condition. The intense metabolic activity of the gastrointestinal tract (GIT) and liver are well recognized. In ruminants, for example, the splanchnic tissues comprise less than 10% of body mass but account for approximately 50 YO of total energy expenditure (e.g. Reynolds et al. 1991). Whether a similar contribution is made to protein turnover, a major contributor to cell metabolism, is less certain. This is due to the lack of reliable values for protein synthesis in ruminant splanchnic tissues, with the few data that are available usually obtained by continuous infusion of tracers (e

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