Pseudomonas aeruginosa and Burkholderia cepacia infection in cystic fibrosis patients treated in Toronto and Copenhagen

Differences in the course of pulmonary disease in cystic fibrosis (CF) may be altered by different treatment strategies in different CF centers. The Copenhagen clinic uses scheduled, regular and very aggressive treatment of lung infection. The Toronto clinic treats pulmonary infection with oral, inhaled, or intravenous antibiotics, and has emphasized aggressive nutritional therapy. This study compared the clinical status of CF patients treated in the two centers (Toronto, Canada, n=302, and Copenhagen, Denmark, n=214) using a cross-sectional design in terms of Pseudomonas aeruginosa (PA) and Burkholderia cepacia (BC) lung infections, pulmonary function, and levels of PA and BC precipitating antibodies (precipitins). Median ages were similar, but the age distribution was significantly different, with a higher proportion of patients under 10 and > or = 25 years in Toronto, and higher proportion of patients 11-24 years of age in Copenhagen. A higher number of female patients was observed in Copenhagen than in Toronto. Seventy-nine percent of Copenhagen patients, and 52% of Toronto patients were deltaF508 homozygous. Of all the patients, 20.1% of Copenhagen patients and 38% of Toronto patients were deltaF508 heterozygous. Ten percent of Toronto patients had two uncommon mutations. Pulmonary function and nutritional status in both groups were similar despite varying treatment strategies. The prevalence of PA was lower in Danish children and higher in Danish adults than in Canada. These differences are probably due to cohort isolation, which was introduced in Copenhagen in 1981. The prevalence of BC was higher in Toronto than in Copenhagen patients at all ages. In both centers, the number of PA and BC precipitins increased with age in patients chronically infected with PA and BC, respectively, and the number of both PA and BC precipitins rose with declining lung function. This study suggests that the clinic populations had similar pulmonary and nutritional statuses despite differing clinic antibiotic treatment strategies. Microbial colonization seemed to differ, at least in part, because of differences in cohort isolation strategies. Early, aggressive anti-pseudomonal chemotherapy may have reduced pseudomonal colonization among younger patients in Copenhagen. Future studies will be required to assess the impact of this on this cohort's outcome.

The predictive value of early CT and angiography for fatal hemispheric swelling in acute stroke

PURPOSE

Our goal was to analyze the predictive value of early CT and arteriographic morphologic criteria to achieve a more reliable prediction of fatal outcome in patients undergoing fibrinolytic stroke treatment.

METHODS

In 74 patients with acute carotid artery stroke, early signs of cerebral ischemia were determined by CT. The site of vascular occlusion was identified by digital subtraction angiography (DSA). The patients were subsequently treated by intraarterial (n = 68) or intravenous (n = 6) fibrinolysis by means of recombinant tissue plasminogen activator (rt-PA), urokinase, or rt-PA combined with lys-plasminogen and followed-up for a period of 3 months. CT and DSA data were compared with the clinical course, with special emphasis on signs of early fatal deterioration (ie, death by intracranial mass effect) as determined by corresponding CT and clinical observations, occurring within 7 days after stroke.

RESULTS

Seventeen patients died, all of intracranial mass effect, and all within a week after stroke. In nine of these fatalities, DSA revealed carotid "T" occlusion (CTO), which affected 19 patients. In five of the fatalities, a major early sign of ischemia (MESI, referring to cortical hypodensity in more than a third of the territory of the middle cerebral artery, as seen in 14 patients) was recognizable on the initial CT scan. This led to a higher predictive value and sensitivity of CTO relative to MESI for estimating early fatality.

CONCLUSION

CTO as determined by DSA is a substantially better predictor of fatal outcome in patients undergoing intraarterial thrombolytic therapy than is MESI as determined by CT.

Immunohistochemical investigation of the tissue distribution of mannan-binding lectin in non-infected and virus-infected chickens

This paper describes the results of immuno-histochemical staining for chicken mannan-binding lectin (MBL) in formalin-fixed tissue sections from non-infected chickens, and from chickens infected with infectious laryngotracheitis virus (ILTV) or infectious bursal disease virus (IBDV). In the non-infected chickens, MBL was detected in the cytoplasm of a few hepatocytes and in the germinal centres of the caecal tonsils, whereas sections of kidney, heart muscle, spleen, cerebrum, thymus, adrenal gland, bursa of Fabricius, bone marrow and trachea were without staining. In the ILTV-infected chickens, an intense staining reaction for MBL was detected in the cytoplasm of all hepatocytes and on the surface of, and inside, ILTV-infected cells. Also in the IBDV-infected chickens, an intense staining reaction for MBL was detected in the cytoplasm of all hepatocytes. No staining was seen in the follicles of the bursa of Fabricius, but MBL was present in non-identified cells in the interstitium, and in the cytoplasm of macrophage-like cells, located peripheral to the ellipsoid of the spleen. These findings indicate the liver as the primary site of MBL synthesis, and points to up-regulation as a result of the viral infections. The location outside the liver could indicate a role of MBL in the immune defence.

The concordance of intraoperative left ventricular wall-motion abnormalities and electrocardiographic S-T segment changes: association with outcome after coronary revascularization. Multicenter Study of Perioperative Ischemia (McSPI) Research Group

BACKGROUND

Transesophageal echocardiography (TEE) and Holter electrocardiography (ECG) are used to detect intraoperative ischemia during coronary artery bypass graft surgery (CABG). Concordance of these modalities and sensitivity as indicators of adverse perioperative cardiac outcomes are poorly defined. The authors tried to determine whether routine use of Holter ECG and TEE in patients with CABGs has clinical value in identifying those patients in whom myocardial infarction (MI) is likely to develop.

METHODS

A total of 351 patients with CABG and both ECG- and TEE-evaluable data were examined for the occurrence of ischemia and infarction. The TEE and five-lead Holter ECGs were performed continuously during cardiac surgery. The incidence of MI (creatine kinase-MB > or = 100 ng/ml) within 12 h of arrival in the intensive care [ICU] unit, new ECG Q wave on ICU admission or on the morning of postoperative day 1, or both, were recorded.

RESULTS

Electrocardiographic or TEE evidence of intraoperative ischemia was present in 126 (36%) patients. The concordance between modalities was poor (positive concordance = 17%; Kappa statistic = 0.13). Myocardial infarction occurred in 62 (17%) patients, and 32 (52%) of them had previous intraoperative ischemia. Of these, 28 (88%) were identified by TEE, whereas 13 (41%) were identified by ECG. Prediction of MI was greater for TEE compared with ECG.

CONCLUSIONS

Wall-motion abnormalities detected by TEE are more common than S-T segment changes detected by ECG, and concordance between the two modalities is low. One half of patients with MI had preceding ECG or TEE ischemia. Logistic regression revealed that TEE is twice as predictive as ECG in identifying patients who have MI.

Decreased antitoxic activities among children with clinical episodes of malaria

Healthy Gambian children, children with clinical Plasmodium falciparum malaria, and children with asymptomatic P. falciparum infections were studied to investigate whether antitoxic activities may contribute to protection against malarial symptoms. Markers of inflammatory reactions, soluble tumor necrosis factor receptor I, and C-reactive protein were found in high concentrations in children with symptomatic P. falciparum malaria compared with levels in children with asymptomatic P. falciparum infections or in healthy children, indicating that inflammatory reactions are induced only in children with clinical symptoms. Concentrations of soluble tumor necrosis factor receptor I and C-reactive protein were associated with levels of parasitemia. We detected antitoxic activities in sera as measured by their capacity to block toxin-induced Limulus amoebocyte lysate (LAL) activation. Symptomatic children had decreased capacity to block induction of LAL activation by P. falciparum exoantigen. The decreased blocking activity was restored in the following dry season, when the children had no clinical malaria. Symptomatic children also had the highest immunoglobulin G (IgG) reactivities to conserved P. falciparum erythrocyte membrane protein 1 and "Pfalhesin" (band #3) peptides, indicating that such IgG antibodies are stimulated by acute disease but are lost rapidly after the disease episode. Half of the children with symptomatic infections had low levels of haptoglobin, suggesting that these children had chronic P. falciparum infections which may have caused symptoms previously. Only a few of the children with asymptomatic P. falciparum infections had high parasite counts, and antitoxic immunity in the absence of antiparasite immunity appears to be rare among children in this community.

[Congestive myelopathy caused by spinal dural arteriovenous fistulas. Anamnesis, clinical aspects, diagnosis, therapy and prognosis]

Congestive myelopathy, formerly referred to as varicosis spinalis or Foix-Alajouanine syndrome, is caused by a spinal dural arteriovenous fistula (SDAVF). So far, the blood supply from the meningeal arteries draining through the fistula into the medullary venous system can only be verified by spinal angiography. Patients predominantly male and over the age of 60 are afflicted. Initially reversible functional disorders caused by the congestion of the spinal cord veins eventually become irreversible, the most common symptom being an increasingly paretic gait disorder, the signs of which generally begin symmetrically and progress from distal to proximal signs. Simultaneously, predominantly transverse sensory dysfunctions develop, as well as bladder and bowel dysfunctions, most often leading to incontinence. MRI typically shows a central medullary signal enhancement with slight swelling of the afflicted region, initially indicative of a reversible congestive edema and later of an irreversible infarction, and extended perimedullar vessels. Thus, if the clinical course and the characteristic MRI findings suggest the possibility of disease related to congestive myelopathy, spinal angiography becomes indispensable. Since ensuing the success of therapy and prognosis depends on rapid determination of the extent of the illness, a speedy diagnostic reaction is mandatory to institute the treatment necessary to prevent paraplegia.

A human T-cell leukemia virus Tax variant incapable of activating NF-kappaB retains its immortalizing potential for primary T-lymphocytes

The human T-cell leukemia virus type 1 (HTLV-1) transactivator (Tax) has been shown to interfere with regulated cellular proliferation. Many studies have focused on the ability of Tax to transform rodent fibroblasts; however, none has defined the molecular requirements for Tax transformation of human lymphoid cells. We show here that tax induces permanent growth of human primary T-lymphocytes by using a transformation/immortalization defective rhadinovirus vector. The cells phenotypically resemble HTLV-immortalized lymphocytes and contain episomally persisting recombinant rhadinoviral sequences, which stably express functional Tax protein. As Tax can activate major cellular signal transducing pathways including NF-kappaB and cAMP-responsive element binding protein (CREB), we asked for the relevance of these routes in the immortalization of human lymphocytes. By using Tax mutants that either activate exclusively CREB/activating transcription factor or are defective in activating this signaling pathway, we delineated that Tax can induce immortalization of primary human T-lymphocytes through a mechanism independent of NF-kappaB activation.

Feature extraction by burst-like spike patterns in multiple sensory maps

In most sensory systems, higher order central neurons extract those stimulus features from the sensory periphery that are behaviorally relevant (e.g.,Marr, 1982; Heiligenberg, 1991). Recent studies have quantified the time-varying information carried by spike trains of sensory neurons in various systems using stimulus estimation methods (Bialek et al., 1991; Wessel et al., 1996). Here, we address the question of how this information is transferred from the sensory neuron level to higher order neurons across multiple sensory maps by using the electrosensory system in weakly electric fish as a model. To determine how electric field amplitude modulations are temporally encoded and processed at two subsequent stages of the amplitude coding pathway, we recorded the responses of P-type afferents and E- and I-type pyramidal cells in the electrosensory lateral line lobe (ELL) to random distortions of a mimic of the fish's own electric field. Cells in two of the three somatotopically organized ELL maps were studied (centromedial and lateral) (Maler, 1979; Carr and Maler, 1986). Linear and second order nonlinear stimulus estimation methods indicated that in contrast to P-receptor afferents, pyramidal cells did not reliably encode time-varying information about any function of the stimulus obtained by linear filtering and half-wave rectification. Two pattern classifiers were applied to discriminate stimulus waveforms preceding the occurrence or nonoccurrence of pyramidal cell spikes in response to the stimulus. These signal-detection methods revealed that pyramidal cells reliably encoded the presence of upstrokes and downstrokes in random amplitude modulations by short bursts of spikes. Furthermore, among the different cell types in the ELL, I-type pyramidal cells in the centromedial map performed a better pattern-recognition task than those in the lateral map and than E-type pyramidal cells in either map.

Constraints on cortical and thalamic projections: the no-strong-loops hypothesis

The many distinct cortical areas of the macaque monkey visual system can be arranged hierarchically, but not in a unique way. We suggest that the connections between these cortical areas never form strong, directed loops. For connections between the visual cortex and particular thalamic nuclei, we predict that certain types of connections will not be found. If strong, directed loops were to exist, we suggest that the cortex would go into uncontrolled oscillations.

Double-monoclonal immunofluorometric assays for pregnancy-associated plasma protein A/proeosinophil major basic protein (PAPP-A/proMBP) complex in first-trimester maternal serum screening for Down syndrome

Four double-monoclonal time-resolved immunofluorometric assays (TrIFMAs) have been developed for the specific determination of pregnancy-associated plasma protein A/proeosinophil major basic protein (PAPP-A/ proMBP) complex in first-trimester maternal serum samples. The assays have a functional sensitivity of < 4 mIU/L and a working range from 4 to 1000 mIU/L. These 4 assays, together with a polyclonal sandwich TrIFMA, were compared for their ability to discriminate between normal pregnancies (n = 149) and pregnancies carrying a Down syndrome fetus (n = 36) in maternal serum screening samples from gestational weeks 4-13. In 26 Down syndrome pregnancies from gestational weeks 7-12, the median PAPP-A multiples of the median concentration in controls (MoMs) determined by monoclonal antibody combinations 234-3/234-2*, 234-4/234-2*, 234-4/234-5*, and 234-5/234-6* were 0.35, 0.37, 0.42, and 0.44, respectively, whereas the median MoM determined by the polyclonal assay was 0.56. ROC curve analysis also showed that better overall diagnostic accuracy and detection rates were achieved by the monoclonal TrIFMAs than by the polyclonal TrIFMA. This report is the first to describe assays that specifically measure PAPP-A/proMBP complex without possible interference from other proMBP-containing complexes.

Immunopurified extracellular Bartonella henselae antigen for detecting specific antibodies by enzyme immunoassay

Protein antigens of Bartonella henselae bacterial sonicate supernatant and concentrated cell-free culture filtrate were examined by SDS-PAGE. The sonicate supernatant gave 38 bands and the culture filtrate at least 21, of which 18 were of bacterial origin. Immunoblotting against 13 monoclonal antibodies obtained from mice infected with live B. henselae showed that 10 of these antibodies reacted with a narrow 225 kDa band and varying smears of bands ranging from 36 to 240 kDa in the sonicate, but only with a single 200 kDa band in the culture filtrate. Testing of pre- and post-infection rabbit sera in immunoblotting against culture filtrate demonstrated that the 200 kDa component gave the most prominent specific reaction with post-infection sera. The 200 kDa antigen was isolated by immunoaffinity chromatography of concentrated culture filtrate, and its molecular size determined by size-exclusion chromatography as > 1000 kDa. The immunopurified antigen was compared with bacterial sonicate as coating antigen in EIA for determining humoral immune responses in rabbits inoculated with live B. henselae. The two antigens gave almost identical results for IgM and IgG responses. The specificity of the immunopurified antigen was tested in EIA against hyperimmune rabbit sera and sera of rabbits inoculated with live B. henselae, B. quintana and Afipia felis. Only the hyperimmune serum against B. henselae and the sera of the rabbits inoculated with live B. henselae reacted with the immunopurified antigen, whereas the B. henselae sonicate cross-reacted with hyperimmune and post-infection sera of rabbits inoculated with B. quintana and A. felis.

Soluble haemoglobin is a marker of recent Plasmodium falciparum infections

Monoclonal antibodies (Mab) were raised against haemoglobin (Hb) associated with Plasmodium falciparum protein and used to develop an ELISA, measuring circulating levels of released Hb. This assay was evaluated in different malaria patients in parallel with ELISA assays for C-reactive protein (CRP) and haptoglobin. Levels of Hb were negatively associated with levels of haptoglobin. Increased levels of serum Hb and CRP and decreased levels of haptoglobin were seen in Danish malaria patients. Consecutive studies showed that increased Hb levels were detectable 3-7 days after initiation of treatment probably because of drug induced destruction of infected erythrocytes. Increased levels of CRP were measured 0-3 days after initiation of treatment. The Hb assay was used in an epidemiological study of malaria in an area of Sudan with unstable malaria transmission. The proportion of Sudanese adults with detectable soluble Hb was higher in the rainy season with malaria transmission compared to the dry season. Hb levels in the rainy season were negatively associated with levels of haptoglobin. Most adults had increased levels of soluble Hb and decreased levels of haptoglobin 7 and 30 days after their treatment of P. falciparum malaria compared to the levels during acute disease. Thus, both soluble Hb and haptoglobin appear to be markers of recent P. falciparum infections. Very high levels of CRP protein were measured in some of the malaria patients at the day of treatment while lower levels were recorded 7 and 30 days after treatment. Soluble Hb levels were associated with malariometric parameters in a similar fashion to haptoglobin. The new Mab-based assay for measuring soluble Hb in the peripheral blood of malaria patients may be useful for future epidemiological studies of malaria.

Controlled trial of inhaled budesonide in patients with cystic fibrosis and chronic bronchopulmonary Psuedomonas aeruginosa infection

The efficacy and safety of anti-inflammatory treatment with inhaled glucocorticosteroids in patients with cystic fibrosis (CF) and complicating chronic Pseudomonas aeruginosa (P.a.) lung infection was studied in a placebo-controlled, parallel, double-blind single center trial. Active treatment consisted of budesonide dry powder, 800 microg twice daily, delivered from a Turbuhaler. The study period covered two successive 3-mo intervals between elective courses of intravenous anti-Pseudomonas antibiotics. Fifty-five patients entered the study, with a mean age of 20 yr and a mean FEV1 of 63% of predicted. Analysis of all patients entered, irrespective of trial adherence ("intention to treat"), showed a decrease in FEV1 in the first period of -0.032 L in patients on budesonide versus -0.187 L in patients on placebo (p = 0.08). The corresponding figures for the patients adhering to the protocol during the first period were -0.017 L versus -0.198 L (p < 0.05, confidence interval of the difference: -0.035 to +0.327 L). For all patients entered, as well as for patients adhering to the trial, there was always a trend in favor of budesonide, as judged by changes in FEV1 and FVC in both 3-mo periods. None of the patients had asthma, but the patients on budesonide had a mean improvement in histamine reactivity of +1.15 dose steps over the entire 6-mo period, as opposed to +0.017 dose steps in patients on placebo (p < 0.05). There was also a significant (p = 0.01) correlation between pre-trial histamine reactivity and the change in FEV1 in the first period in patients on budesonide. We conclude that inhaled glucocorticosteroids can be of short-term benefit in patients with CF and chronic P.a. infection and that those patients most likely to benefit from this treatment are patients with hyperreactive airways. Prolonged studies in larger number of patients are necessary to determine the long-term efficacy of this treatment.

[Improved prognosis for patients with cystic fibrosis. A result of aggressive center-based treatment]

We report survival data for Danish centre-treated cystic fibrosis (CF) patients, covering the period 1974-1993 using cross-sectional cumulative survival probability based on annual age-specific mortality rates. No significant differences were noted in the survival probability when patients were grouped according to sex or absence/presence of meconium ileus. The annual mortality rate for 1989-1993 was 0-1.2%. Using the age-specific mortality rate for 1989-1993, we were unable to calculate the median survival probability because the curve did not fall below 50% (age up to 45 years). It was, however, possible to show that the survival probability for a CF child born after 1989 to reach his or hers 45th birthday was 80.4% (95% confidence interval 76.5-84.6%). The probability of surviving 40 years after the diagnosis of CF is made was 83.3% (95% confidence interval 80.1%-86.6%). This is considerably higher than any other published survival probability. An aggressive anti-Pseudomonas aeruginosa treatment regimen seemed important in achieving the observed improved survival.

[Differential therapy of cerebral angiomas]

Patients with cerebral arteriovenous malformations (cAVMs) are usually young at the time of diagnosis with a mean age of 32 years. These patients are in a crucial phase of their lives, starting a family and establishing a professional position. Facing a relative annual risk of 2 to 3% for a severe hemorrhage which cumulates to a 50% risk of hemorrhage over the next four decades of their lives, these patients have to make the decision about possible treatment of their cAVM. Advice can only be given to the patients on an individual basis because there are almost no two identical lesions. Nevertheless, based on a grading system and within established treatment regimens, risk estimations are possible and particularly with close neuroradiological/neurosurgical cooperation these risks can be defined and minimized. In this context we report a series of 184 patients with cAVMs which were taken care of at the Departments of Neurosurgery and Neuroradiology at the University of Hamburg between February 1988 and July 1996 and who were treated according to a standardized joint protocol with interventional and microsurgical options.

[Cranial dural arteriovenous fistulas--current status of therapy]

Spontaneous dural arteriovenous fistulas (DAVF) are abnormal arteriovenous shunts with a nidus within the dura mater. The exact etiology of the spontaneous DAVFs remains uncertain. Arterial inflow is from the meningeal branches in the region, which can be from an extracranial or an intracranial source. The venous drainage is through the dural sinuses, although cortical or deep venous drainage may be recruited. The critical symptoms are highly dependent on the venous drainage. Computed tomography and/or magnetic resonance imaging demonstrates the epiphenomena rather than the DAVF itself. Angiography is the most important modality in evaluating a DAVF. Based on the patterns of the venous drainage, a classification of the DAVF is possible. This classification enables decision-making about the appropriate therapy. Also the risk of each DAVF may be determined.

[CT-angiography for diagnostic assessment of intracranial vascular aneurysms]

Intracranial aneurysms bear a high risk of morbidity and mortality especially when they have become symptomatic due to rupture or represent a space occupying lesion. Therefore operative treatment is aimed at the obliteration of the aneurysm to eliminate the risk of hemorrhage. Planning of treatment requires a diagnostic resolution capable of showing aneurysms and their anatomic relationship to the adjacent structures. Due to technical advances computed tomography has reached a diagnostic accuracy sufficient to plan aneurysm treatment. This report describes the present state of three-dimensional spiral-CT angiography (3D-spiral-CTA) and our protocol to examine the arteries of the Circle of Willis for the presence and microanatomy of aneurysms. The experience of 46 patients with 64 aneurysms is reported and the diagnostic value of the method in comparison to conventional angiography is evaluated.

Spatial vision thresholds in the near absence of attention

It is well known that attention increases the discriminability of some types of spatial information. To ascertain more specifically which types of spatial information benefit from attention, we have measured spatial vision thresholds both in the presence and in the near absence of attention. To obtain near absence of attention, we induce subjects to focus attention elsewhere in the display by means of a suitably demanding concurrent visual task. We measure contrast and orientation thresholds for sine-wave gratings, as well uni- and bidirectional offset thresholds for vernier targets. The results suggest that attention selectively lowers some thresholds but not others: orientation thresholds are far more affected than contrast thresholds, and bidirectional vernier thresholds are far more affected than unidirectional thresholds.

[The pharmacologic basis of postoperative pain therapy. Epidural opioid administration]

The administration of epidural opioids is alternatively used in the management of postoperative analgesia. However, the administration is associated with side effects, including respiratory depression, somnolence and pruritus. A rational opioid selection between the hydrophilic and lipophilic opioids morphine, hydromorphone, alfentanil, fentanyl and sufentanil is discussed in this mini-review. Thus, the administration of the lipophilic opioid sufentanil might has some advantages. Notwithstanding, epidural opioid administration alone offers no marked clinical advantages compared to the intravenous route. In future, reduced doses of lipophilic opioids and local anaesthetics like bupivacaine 0.05-0.1% may provide benefits over the use of either drug alone and may offer marked clinical advantages over the intravenous route of opioids alone. The same holds true for alpha 2-adrenoceptor agonists as adjuvants. However, multicenter dose-ranging studies are necessary to determine both the ideal concentrations of the drug combinations and the general outcome. Moreover, we must also determine cost effectiveness for our postoperative analgesic techniques.

Conjugation to preadsorbed preactivated proteins and efficient generation of anti peptide antibodies

A solid phase conjugation method is described based on the preadsorption of proteins to aluminium hydroxide adjuvant followed by activation of the adsorbed carrier proteins with iodoacetic acid N-hydroxysuccinimidester or other conjugation reagents. Cysteine-containing peptides were coupled to the iodoacetic acid-activated carrier-adjuvant particles through their SH groups. No dialysis is required since the reaction product is isolated at each step of the procedure by a simple centrifugation and can easily be extensively washed between individual manipulations. The method generates peptide-carrier-adjuvant particles with sterically defined presentation of the peptides at the surface of the particles. When used for immunization of mice and rabbits the conjugates elicited high-titered specific anti-peptide sera, which reacted well with the parent protein in ELISA. The strongest reactions were with the denatured form of the parent protein. On immunoblots antisera to the N- and C-terminus of calreticulin recognized the same M, 52,000 protein.

International practice patterns by age and severity of lung disease in cystic fibrosis: data from the Epidemiologic Registry of Cystic Fibrosis (ERCF)

The Epidemiologic Registry of Cystic Fibrosis provides clinical profiles for more than 6,800 patients and descriptions of practice patterns across eight European countries. Preliminary cross-sectional analysis has been performed by age and pulmonary function as an assessment of disease severity. In general, pulmonary treatments including inhaled bronchodilators and rhDNase increased as lung disease became more severe. Use of a number of treatments, including mucolytic agents and inhaled corticosteroids, varied markedly from country to country. Several widely used therapies are not yet supported by controlled clinical trials, particularly in patients under 6 years of age. Nutritional intervention was more common in patients with advanced lung disease regardless of age. Patients with nasal polyps had less severe lung disease at each age than patients without polyps. It is clear that studies of early interventions are needed to determine the optimal types of treatments and the ages at which to begin treatment.