Individualized Assessment of Exercise Capacity in Response to Acute and Long-Term Enzyme Replacement Therapy in Pediatric Pompe Disease

BACKGROUND

Enzyme replacement therapy (ERT) with alglucosidase alfa improves the prospect of patients with infantile-onset Pompe disease (IOPD). However, a progressive decline has been reported. Objective quantification of the response to ERT when assessing newer strategies is warranted.

METHODS

This combined retrospective-prospective study assessed the acute and long-term effects of ERT on exercise in IOPD patients. Evaluation included cardiopulmonary exercise testing (CPET), 6-min walking test (6MWT), spirometry, motor function test (GMFM-88) and enzyme blood levels.

RESULTS

Thirty-four CPETs (17 pre- and 17 two days-post ERT) over variable follow-up periods were performed in four patients. Two days following ERT, blood enzyme levels increased (median, 1.22 and 10.15 μmol/L/h (p = 0.003)). However, FEV1, FVC and GMFM-88, the median 6MWD and the peak VO2 were unchanged. Long-term evaluations showed stabilization in young patients but progressive deterioration in adolescents. Clinical deterioration was associated with more pronounced deterioration in peak VO2 followed in the decreasing order by 6MWD, FVC and GMFM-88.

CONCLUSIONS

The peak VO2 and 6MWD might serve as more sensitive markers to assess clinical deterioration. More studies are needed to clarify the sensitivity of the peak VO2 and 6MWT for quantification of individualized response. This may be important when assessing newer strategies and formulations in IOPD.

Atypical pulmonary metastases in children: the spectrum of radiologic findings

Pulmonary nodules present a diagnostic challenge when they appear as atypical metastases in pediatric oncology patients. Chest computed tomography (CT) is the primary imaging modality for assessing lung nodules. In pediatric populations, Wilms tumor and osteosarcoma are the cancers most likely to produce pulmonary metastasis, both typical and atypical. This pictorial essay provides a thorough description of the specific radiologic features of atypical pediatric pulmonary metastases, and their pathogenesis and differential diagnosis. We also address diagnostic approaches to incidental lung nodules in healthy children found in the literature. Our aim is to help radiologists identify atypical lung metastases on CT, ensuring that children receive prompt, and potentially lifesaving, treatment.

Short- and long-term effects of fluticasone furate/vilaterol in exercising asthmatic adolescents: a randomized and open label trial

PURPOSE

Relvar® (Fluticasone furoate (FF)/Vilanterol (VI)) is a once-daily inhaler with bronchodilator effect lasting 24 hours. Our aim was to investigate the short- and long-term effects of FF/VI on exercise-induced asthma (EIA) in adolescents.

METHODS

Ninety-three adolescent asthmatics aged 12-18 years were referred for evaluation of EIA. Following a positive exercise challenge test (ECT), 22/44 were allocated to a single administration of salbutamol (400 μg) and 22/44 to FF/VI (92/22 μg) in a double-blind method. Thirty-five subjects were reassessed by repeat ECT 30-60 days of FF/VI.

RESULTS

Median FEV1 change post-ECT at baseline was -22.8% predicted (IQR -26.1 and -18.0) for salbutamol and -21.0 (IQR -30.7 and -16.8) for FF/VI. Following bronchodilator, FEV1 improved similarly in both groups. Repeat ECT following 30-60 days of FF/VI resulted in negative exercise challenge test in 33/35 subjects; the median decrease in FEV1 of these 35 subjects was 22.6% predicted (IQR 29-18) before, and 4.6% predicted (IQR 8.7-2.5) after 30-60 days of FF/VI treatment; p<0.0001).

CONCLUSIONS

FF/VI is effective in reversing EIA after 15 minutes in adolescents and in protecting EIA after 30-60 days in adolescents. Larger studies are needed to assess the effect of FF/VI on EIA.

Factors associated with complicated pneumonia in children

INTRODUCTION

Community acquired pneumonia (CAP) is a leading cause of morbidity in children, despite advances in health care and anti-pneumococcal vaccine. Complicated pneumonia accounts for a significant burden with prolonged hospitalization. Finding risk factors for complicated pneumonia may help in tailoring management. We aimed to identify risk factors for developing complicated pneumonia and need for intervention.

METHODS

A retrospective single tertiary center study. Children admitted with a diagnosis of CAP and/or complicated pneumonia (parapneumonic effusion, empyema, necrotizing pneumonia, and lung abscess) on January 2001-March 2020 were included. Demographic, clinical, and laboratory parameters were collected using MDclone, a data acquisition tool. Risk factors for complicated pneumonia (on admission or during hospitalization) and risk for intervention were analyzed.

RESULTS

A total of 6778 children with pneumonia were included; 323 arrived at the Emergency Department with complicated pneumonia while 232 developed a complication during hospitalization. Risk factors for complicated pneumonia (on admission or during hospitalization) were Arab ethnicity, cardiac disease, increased age, and CRP and low O₂ Sat (OR = 2.236 p < .001, OR = 4.376 p < .001, OR = 1.131 p < .001, OR = 1.065 p < .001 and OR = 0.959 p = .029, respectively). O₂ Sat was lower, while fever and CRP were higher in patients with complicated pneumonia requiring intervention.

CONCLUSIONS

Identifying children at risk for complicated pneumonia may help in decision-making in the Emergency Department and during hospitalization. The increased risk of the Arab population for complicated pneumonia requires further understanding. Addressing the underlying socioeconomic and ethnic health inequities may help to decrease the disease burden in this population.

Reverse butterfly pattern image with eosinophilia: Effective treatment with benralizumab-A case report

A 16-year-old adolescent presented with dry cough, fever, weight loss, night sweats, exercise intolerance, and eosinophilia. Computed tomography showed consolidations with "reverse butterfly" pattern. He responded well to corticosteroids but had frequent relapses. He became steroid dependent and developed steroid related morbidity. Benralizumab was prescribed with complete resolution of eosinophilia and lung infiltrates with no adverse effect.

The Association between IgG and Disease Severity Parameters in CF Patients

Assessing disease severity in patients with cystic fibrosis (CF) is essential when directing therapies. Serum immunoglobulin G (IgG) levels increase with disease severity. Lung clearance index (LCI) is recognized as an outcome measure for CF clinical trials. Our aim was to evaluate the correlations between IgG and disease severity markers. This was a single-center retrospective study, evaluating association between IgG and markers of severity in CF patients (including clinical characteristics, lung spirometry, LCI, clinical scores and computed tomography (CT) scores) during stable conditions. There were 69 patients, age 20.5 ± 11.6 years. Nineteen (27.5%) patients had elevated IgG. IgG correlated positively with LCI (r = 0.342, p = 0.005). IgG was higher in pancreatic insufficient (PI) and patients with liver disease (1504.3 ± 625.5 vs. 1229 ± 276.1 mg/dL in PI vs. PS, p = 0.023, and 1702.6 ± 720.3 vs. 1256.2 ± 345.5 mg/dL with vs. without liver disease, p = 0.001, respectively). IgG also correlated positively with CRP, CT score, and days with antibiotics in the previous year (r = 0.38, p = 0.003; r = 0.435, p = 0.001; and r = 0.361, p = 0.002, respectively), and negatively with FEV1% and SK score (r = −0.527, p < 0.001 and r = −0.613, p < 0.001, respectively). IgG correlated with clinical parameters, pulmonary functions, and imaging. However, this is still an auxiliary test, complementing other tests, including lung function and imaging tests. Larger multi-center longitudinal studies are warranted.

The Use of Infant Pulmonary Function Tests in the Diagnosis of Neuroendocrine Cell Hyperplasia of Infancy

BACKGROUND

Infant pulmonary function tests (iPFTs) in subjects with neuroendocrine cell hyperplasia of infancy (NEHI) have demonstrated significant expiratory airflow obstruction and air trapping.

RESEARCH QUESTION

Can indexes from iPFTs be used in the diagnosis of NEHI?

STUDY DESIGN AND METHODS

This is an observational case-control study evaluating iPFT results from a registry of patients assessed at the Hadassah Hebrew University Medical Center between 2008 and 2018. We used the Kruskal-Wallis H test to compare iPFT results in infants with NEHI with those in two infants in a disease control group (infants evaluated for recurrent wheezing and infants evaluated owing to prematurity) and those in a spirometry control group of infants with normal expiratory airflow. Receiver operating characteristic (ROC) curves were used to assess the diagnostic accuracy of the iPFT indexes.

RESULTS

We evaluated iPFT data in 481 infants (15, NEHI; 292, wheezing; 128, premature; and 46, control group). Infants with NEHI had significantly increased trapped air volumes (median functional residual capacity measured with baby-body plethysmograph [FRC_pleth] was 199% predicted; median ratio of residual volume to total lung capacity was 59% predicted) when compared with results in all evaluated groups of infants (P < .001), including multiple pairwise comparisons. Airflow limitation was demonstrated in infants with NEHI when compared with the infants in the spirometry control group but was similar to that in the two infants in the disease control group. FRC_pleth had the best discriminatory ability for NEHI diagnosis, with an FRC_pleth ≥ 150% predicted demonstrating a ROC of 0.91 (95% CI, 0.82-1.00), sensitivity of 86.7% (95% CI, 59.5%-98.3%), and specificity of 95.5% (95% CI, 93.2%-97.3%).

INTERPRETATION

Findings on iPFTs of markedly increased air trapping, out of proportion to the degree of airflow limitation, are characteristic of infants with NEHI. iPFT results demonstrating an FRC_pleth ≥ 150% predicted are highly specific for NEHI and may aid in early diagnosis. Further research is required to confirm these findings in a prospective cohort and to understand the pathophysiologic explanation for these findings.

Atypical cardiopulmonary manifestations in pediatric Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem autoinflammatory disease of unknown etiology. Cardiopulmonary involvement is rare, especially in young patients, and carries high morbidity and mortality rates.

AIM

Of 26 patients with pediatric BD enlisted in our center, we encountered three patients with severe atypical cardiorespiratory presentations. Our aim was to describe the manifestations and the course that led to the diagnosis of BD.

RESULTS

Three adolescents presented with intracardiac thrombi and left anterior descending obstruction causing myocardial infarction, pulmonary artery aneurysm with pulmonary embolism in situ, and suspected epiglottitis. Two patients had a delayed diagnosis of BD, and all had a good response to anti-inflammatory agents.

CONCLUSIONS

This study demonstrated that pediatric BD is associated with atypical cardiopulmonary manifestations which maybe life threatening. Since diagnosis maybe challenging, a high index of suspicion is needed especially in young patients, to promptly diagnose and treat these complications. Cardiopulmonary signs and symptoms, though uncommon, maybe the first manifestation and a clue to the diagnosis of this rare disease.

Understanding the interplay between factors that influence bone mineral density in CF

BACKGROUND AND OBJECTIVES

Multiple factors affect bone mineral density (BMD) in cystic fibrosis (CF). Our aim was to perform comprehensive analyses of parameters potentially contributing to BMD.

METHODS

A prospective single-center study assessing BMD, and correlations with multiple parameters including pancreatic status, lung functions, 6-minute walk test (6MWT), clinical score (modified Shwachman-Kulczycki [SK] score), vitamin D, nutritional intake, hand grip strength (HGS), habitual physical activity (smart watches), and quality of life (SF-36 questionnaire).

RESULTS

Forty CF patients, mean age 18.3 ± 8.1 years, forced expiratory volume in 1 second 74.7% ± 17.9% predicted. Fifteen (37.5%) and 11 (27.5%) had osteopenia and osteoporosis, respectively. BMD was similar in pancreatic sufficient (pancreatic sufficient [PS], n = 15) and insufficient (pancreatic insufficient [PI], n = 25); median hip z score -1.5 ((-2.7)-(+0.2)) vs -1.5 ((-3.5)-(+0.7)), P = .79; spine -0.8 ((-2.2)-(+2)) vs -1.2 ((-4.4)-(+1.5)), P = .39 in PS vs PI, respectively. BMD correlated with HGS (r = .72, P < .001 hip; r = .52, P = .001 spine) and fat-free mass index (r = .81, P < .001 hip; r = .63, P < .001 spine). BMD z score correlated weakly with SK score and moderately with SF-36 general health. Data from smart watches, nutrition questionnaires, and 6MWT did not correlate with BMD. In a multivariate model, age and SK score predicted spine z score BMD.

CONCLUSIONS

A substantial number of CF patients have low BMD. Similar rates in PS and PI suggest that other factors, such as disease severity, may contribute to low BMD. SK and age, which can easily be obtained even with limited resources, were the best predictors of low BMD. Further larger multicenter studies are warranted to evaluate the contribution of multifactorial etiologies to low BMD in CF.

Baseline Cystic fibrosis disease severity has an adverse impact on pregnancy and infant outcomes, but does not impact disease progression

BACKGROUND

With increasing longevity and quality of life in adults with Cystic fibrosis (CF), growing maternity rates are reported. Women with severe CF are becoming pregnant, with unpredictable maternal and fetal outcomes.

AIM

To determine how baseline disease severity, pancreatic insufficiency (PI) and Pseudomonas aeruginosa (PA) infection affect fertility, the pregnancy course, delivery, neonatal outcome, and subsequent disease progression.

METHODS

A multicenter-retrospective cohort study. Data on patients that had been pregnant between 1986-2018 was collected from ten CF centers worldwide. Disease severity [mild or moderate-severe (mod-sev)] was defined according to forced expiratory volume % predicted in 1 second (FEV₁) and body mass index (BMI). Three time periods were compared, 12 months prior to conception, the pregnancy itself and the 12 months thereafter.

RESULTS

Data was available on 171 pregnancies in 128 patients aged 18-45 years; 55.1% with mod-sev disease, 43.1% with PI and 40.3% with PA. Women with mod-sev disease had more CF-related complications during and after pregnancy and delivered more preterm newborns. However, FEV₁ and BMI decline were no different between the mild and mod-sev groups. A more rapid decline in FEV₁ was observed during pregnancy in PI and PA infected patients, though stabilizing thereafter. PI was associated with increased risk for small for gestational age infants.

CONCLUSION

Baseline disease severity, PA infection and PI have an adverse impact on infant outcomes, but do not impact significantly on disease progression during and after pregnancy. Consequently, pregnancies in severe CF patients can have a good prognosis.

Comprehensive cardiopulmonary assessment in α mannosidosis

INTRODUCTION

α Mannosidosis is an extremely rare, progressive, and complex lysosomal storage disease, characterized by mental retardation, hearing impairment, coarse facial features, skeletal abnormalities, and pulmonary involvement. While bone marrow transplantation has been the only therapeutic option to date, nowadays new treatment options are being explored, which may affect pulmonary and exercise capacity.

AIM AND METHODS

To assess cardiopulmonary involvement in patients with α mannosidosis by pulmonary function tests, cardiopulmonary exercise testing, and low irradiation chest computed tomography (CT).

RESULTS

Five patients aged 11 to 28 years were followed in our Respiratory-Metabolic Clinic. All five had pulmonary symptoms and received inhaled therapy. Three patients underwent bone marrow transplantation. Parenchymal lung disease was evident in 3/5 chest CT tests. Pulmonary function tests were abnormal in all patients and showed obstructive/restrictive impairment with air trapping. All five patients showed reduced peak oxygen uptake (median 23.1; range 20.4-32.2 mL/minute/kg, median %predicted 62; range %predicted 59-79).

CONCLUSIONS

Pulmonary involvement is a known complication in this rare disease. Comprehensive cardiopulmonary evaluation is feasible among these patients and may help in assessing disease progression and response to new treatment modalities.

Incidence of congenital thoracic malformations detected by prenatal ultrasound

BACKGROUND

The increased and earlier use of prenatal ultrasound has facilitated the detection of congenital thoracic malformations (CTMs). Our Pediatric Pulmonology Institute follows an increasing number of patients with CTMs. Thus, we aimed to evaluate and describe prenatal sonographic findings of CTM, and to estimate changes in detection rates of CTMs over a period of 16 years.

METHODS

A retrospective, cross-section analysis of prenatal ultrasound (US) screening tests carried out in a large community-based clinic, comparing two periods: 2001-2007 and 2007-2017.

RESULTS

A total of 34 716 prenatal US were performed at a median gestational age of 15.4 weeks (range, 11.6-23.9) and 15.7 weeks (range, 12-33.6) in 2001-2007 and 2007-2017, respectively. In 2001-2007, 12 016 prenatal US tests detected 19 CTMs, compared to 30 CTMs in 22 700 tests in 2007-2017. Detection rates did not change (1.58/1,000 in 2001-2007 versus 1.32/1,000 in 2007-2017, P = 0.64). The most common abnormality was congenital pleural effusion (CPE) (17 cases, 34.7%), followed by congenital pulmonary airway malformation) and congenital diaphragmatic hernia; 13 cases each, 26.5%. Twenty CTMs, mainly congenital diaphragmatic hernia and CPE, were associated with other fetal lesions.

CONCLUSIONS

Congenital diaphragmatic hernia and CPE tend to appear with multiple lesions and warrant further attention. The incidence rates stayed stable when comparing the last decade to previous years. Thus, the increased referral of CTM can be attributed to an increase in the number of prenatal screening studies performed, rather than a true higher incidence.

Effect of late preterm birth on lung clearance index and respiratory physiology in school-age children

BACKGROUND

We hypothesized that former late preterm (LP) children have abnormal pulmonary physiology parameters, including uneven ventilation distribution, due to premature disruption of normal lung development.

METHODS

A cross-sectional study evaluating former LP children at the age of 6 to 12 years as compared to term controls. Demographics and child's and family history of asthma/atopy/smoking were recorded. The outcome parameters were spirometry, multiple breath washout (MBW) measurement by lung clearance index (LCI), 6-minute walk test (6MWT), symptoms related to asthma and allergy, and Godin Leisure-Time Exercise Questionnaire.

RESULTS

Twenty-nine former LP were compared to 30 term-control children (mean age, 8.2 ± 1.7 and 8.8 ± 1.8 years, respectively). LP had reduced forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) compared to term controls (FEV1 1.59 ± 0.48 vs 1.80 ± 0.39 L, P = 0.005 and FVC 1.73 ± 0.45 vs 1.99 ± 0.49 L, P = 0.009). There were no differences between the two groups regarding FEV1/FVC, forced expiratory flow between 25 and 75 (FEF25-75), LCI (7.10 ± 0.79 vs 6.96 ± 0.75, P = 0.50), 6MW distance, and weekly leisure-activity score. Former LP children had more episodes of wheezing and greater use of asthma medication.

CONCLUSIONS

This pilot study suggests that LP have lower pulmonary function tests (PFTs) but not ventilation inhomogeneity measured by LCI or functional disturbance. It is unclear if the differences in PFTs are due to late prematurity by itself or are the consequence of maternal and neonatal factors associated with LP. Further larger studies are required to assess the long-term respiratory consequences of LP birth.

The Effect of a 30-Min Water-Pipe Smoking Session on Cognitive Measures and Cardio-Pulmonary Parameters

Introduction

One session of water-pipe tobacco smoking (WPS) can increase carboxyhemoglobin (COHb) to levels comparable to those reported in carbon monoxide poisoning, which may cause memory impairment and confusion.

Methods

A prospective study evaluating healthy volunteers pre- and post-30 min of WPS session. Primary outcome parameters were executive cognitive measures [digit span test and Paced Auditory Serial Addition Test (PASAT)]. The effect of repeated cognitive testing 30 min apart without WPS was evaluated in age- and sex-matched healthy volunteers. Secondary outcome parameters included cardio-pulmonary, COHb, serum nicotine, and cytokine changes.

Results

Thirty-five subjects aged 25.6 ± 4.5 years smoked water-pipe for a 30-min session. Control group included 20 subjects aged 25.2 ± 5.1 years. Digit span test median score decreased after WPS (16 and 15, respectively, p = .003), insignificant decrease in controls. Median PASAT score increased after WPS (49 and 52, respectively, p = .009); however, a much larger significant increase was observed in controls (p ≤ .001). One WPS session resulted in significant increases in heart and respiratory rates and significant decrease in FEF25–75%. Post WPS, median COHb levels increased (from 2.2% to 10.7%, p &lt; .0001) as did median serum nicotine levels (from 1.2 to 26.8 ng/mL, p &lt; .0001). Serum cytokines levels: IL-2 and IL-6 increased (p &lt; .0001 for each), and IL-10 and IL-5 decreased (p &lt; .0001 and p = .04, respectively).

Conclusions

One session of WPS resulted in significant negative effects on cognitive executive measures, significant increases in COHb and serum nicotine levels, and significant changes in serum cytokines. Our findings call for increasing awareness towards the possible consequences of cognitive alterations following a 30-min session of WPS.

Implications

One 30-min session of water-pipe smoking resulted in negative effects on executive cognitive measures, increased carboxyhemoglobin and serum nicotine, and significant changes in serum cytokine levels. This study adds to the accumulating evidence on the harmful effects of water-pipe smoking, a growing epidemic, and calls for awareness of its possible consequences of acute cognitive alterations.

Exercise capacity in patients with cystic fibrosis vs. non-cystic fibrosis bronchiectasis

Background

Bronchiectasis is associated with morbidity, low exercise capacity and poor quality of life. There is a paucity of data on exercise capacity using cardiopulmonary exercise test (CPET) in non-cystic fibrosis (CF) bronchiectasis. Our aim was to compare exercise capacity using CPET in CF and non-CF bronchiectasis patients.

Methods

Cross-sectional retrospective/prospective controlled study assessing CPET using cycle ergometer. Exercise parameters and computed tomography (CT) findings were compared. Results: Hundred two patients with bronchiectasis and 88 controls were evaluated; 49 CF (age 19.7 ± 9.7 y/o, FEV₁%predicted 70.9 ± 20.5%) and 53 non-CF (18.6 ± 10.6 y/o, FEV₁%predicted 68.7 ± 21.5%). Peak oxygen uptake (peak V˙O2) was similar and relatively preserved in both groups (CF 1915.5±702.0; non-CF 1740±568; control 2111.0±748.3 mL/min). Breathing limitation was found in the two groups vs. control; low breathing reserve (49% in CF; 43% non-CF; 5% control) and increased V˙E/V˙CO2 (CF 31.4±4.1, non-CF 31.7±4.1 and control 27.2 ± 2.8). Oxygen pulse was lower in the non-CF; whereas a linear relationship between peak V˙O2 vs. FEV₁ and vs. FVC was found only for CF. CT score correlated with V˙E/V˙CO2 and negatively correlated with V˙O2/kg and post exercise oxygen saturation (SpO₂).

Conclusions

CPET parameters may differ between CF and non-CF bronchiectasis. However, normal exercise capacity may be found unrelated to the etiology of the bronchiectasis. Anatomical changes in CT are associated with functional finding of increased V˙E/V˙CO2 and decreased SpO₂. Larger longitudinal studies including cardiac assessment are needed to better study exercise capacity in different etiologies of non-CF bronchiectasis.

Trial registration

ClinicalTrials.gov, registration number: NCT03147651.

Pilot study to test inhaled nitric oxide in cystic fibrosis patients with refractory Mycobacterium abscessus lung infection

BACKGROUND

Airways of Cystic Fibrosis (CF) patients are Nitric Oxide (NO) deficient which may contribute to impaired lung function and infection clearance. Mycobacterium abscessus (M. abscessus) infection prevalence is increasing in CF patients and is associated with increased morbidity and mortality. Here, we assess the safety and efficacy of intermittent inhaled NO (iNO) as adjuvant therapy in CF patients with refractory M. abscessus lung infection.

METHODS

A prospective, open-label pilot study of iNO (160 ppm) administered five times/day during hospitalization (14 days), and three times/day during ambulatory treatment (7 days) was conducted. The primary outcome was safety measured by NO-related adverse events (AEs). Secondary outcomes were six-minute walk distance (6MWD), forced expiratory volume in 1 s (FEV₁), and M. abscessus burden in airways.

RESULTS

Nine subjects were recruited. INO at 160 ppm was well-tolerated and no iNO-related SAEs were observed during the study. Mean FEV1 and 6WMD were increased relative to baseline during NO treatment. M. abscessus culture conversion was not achieved, but 3/9 patients experienced at least one negative culture during the study. Mean time to positivity in M. abscessus culture, and qPCR analysis showed reductions in sputum bacterial load. The study was not powered to achieve statistical significance in FEV1, 6WMD, and bacterial load.

CONCLUSIONS

Intermittent iNO at 160 ppm is well tolerated and safe and led to increases in mean 6MWD and FEV1. INO exhibited potential antibacterial activity against M. abscessus. Further evaluation of secondary endpoints in a larger cohort of CF patients is warranted to demonstrate statistical significance.

Six-minute walk, lung clearance index, and QOL in bronchiolitis obliterans and cystic fibrosis

INTRODUCTION

The 6-min walk test (6MWT) predicts outcome in pulmonary hypertension. Recently, its use was reported in both cystic fibrosis (CF) and bronchiolitis obliterans (BO). While the 6MWT is a simple, non-invasive and inexpensive tool, lung clearance index (LCI) measurement requires expensive equipment and expertise. We aimed to evaluate 6MWT in BO and CF, and to compare to MBW (multiple breath washout), pulmonary function tests and quality of life (QOL).

METHODS

A prospective single center study assessing 6MWT, MBW, spirometry, whole-body plethysmography and QOL (SF-36 questionnaire) in BO and CF patients and correlations between them.

RESULTS

Thirty-three BO patients and 37 CF patients. LCI was significantly higher in BO (12.4 ± 4.2 vs 10.5 ± 3.4, P = 0.044) while FEF 25-75% was significantly lower in BO (43.9 ± 24.4 vs 60.8 ± 30.8, P = 0.014). 6MWD was 474.8 ± 76.3 in BO and 506.6 ± 70 in CF (P > 0.05). There was no correlation between 6MWD and LCI in these small study groups There were few correlation between spirometry prameters and 6MWD. In CF, SF-36 scores correlated with pulmonary functions.

CONCLUSIONS

The 6MWT is an easy-to-perform test that may be helpful in chronic lung diseases in regions with limited resources. However,with the current limited data, 6MWT cannot replace LCI or spirometry as a marker of disease progression. Is is suggested that, together with QOL, the 6MWT may provide a global estimation of the physiological and general well-being of these patients. Further larger multi-center studies are warranted to evaluate the correlations of 6MWT with pulmonary physiology parameters in various chronic diseases.

Long term follow-up of Palivizumab administration in children born at 29-32 weeks of gestation

BACKGROUND

Severe respiratory syncytial virus (RSV) bronchiolitis requiring hospitalization induces long term immunological and respiratory abnormalities. The long-term immunomodulation effect of Palivizumab (RSV monoclonal antibody) prophylaxis and its impact on the development of asthma remain controversial. Our aim was to evaluate airway hyper-reactivity, systemic inflammatory markers, allergic parameters and respiratory morbidity, 5-7 years following Palivizumab administration to children born at 29-32 weeks of gestation (WGA).

METHODS

Children born at 29-32 WGA were evaluated at age 5-7 years. Methacholine challenge test (MCT), serum inflammatory cytokines, fractional exhaled nitric oxide (FeNO), blood tests for eosinophil count, IgE and assessment of respiratory morbidity by questionnaire were compared between those born before Palivizumab prophylaxis was extended to 29-32 WGA and those who received Palivizumab prophylaxis.

RESULTS

Of 42 children recruited, 27 received Palivizumab and 15 did not. The mean gestational age and weight were lower in the Palivizumab group. Similar values of spirometry, MCT, FeNO and allergic parameters were observed in the two groups. The Palivizumab group had higher IL4, IL5 and IL13 (Th2 cytokines), IL6, IL17α, and G-CSF (Th17 activation), and lower IL12 and higher INF-γ (Th1 cytokines).

CONCLUSION

Compared to children who did not receive immunoprophylaxis, among children who received Palivizumab, no beneficial effects on long-term respiratory morbidity, airway reactivity or allergic parameters were observed, and levels of Th2 and Th17 cytokines implicated in the pathogenesis of asthma were higher. These findings cast doubt on the potential long-term beneficial effect of Palivizumab on asthma inception.

Factors Associated with Recurrence of Tracheoesophageal Fistula

BACKGROUND

Recurrence of tracheoesophageal fistula (TEF) is reported in 8-20% patients. Factors that may influence recurrence of fistula beyond the postoperative period are not clear.

OBJECTIVES

To evaluate possible factors associated with recurrence of TEF beyond the immediate postoperative period.

METHODS

A single center, retrospective comparison of patients with and without recurrence of TEF was conducted. Medical records of patients previously operated for TEF who were followed in our pediatric pulmonary institute between January 2007 and December 2016 were reviewed.

RESULTS

The medical records of 74/77 patients previously operated for TEF were evaluated. Nine patients (12%) had a recurrence of TEF and 65 did not. These groups had similar age and gender distribution and similar prevalence of VACTERL association. In addition, they had similar length of atretic gap, rates of thoracoscopic surgery, rates of prolonged need for respiratory assistance post-surgery, and frequency of gastrointestinal symptoms. Notably, the patients who had recurrent TEF had significantly more hospitalizations for respiratory symptoms (P = 0.011) and significantly more episodes of clinical bronchiolitis per patient (P < 0.0001). In addition, the patients with recurrent TEF had significantly more episodes of positive polymerase chain reaction for viruses (P = 0.009).

CONCLUSIONS

Hospitalizations for respiratory symptoms as well as clinical and/or viral bronchiolitis are associated with recurrence of TEF. Even though cause and effect cannot be established, these patients should undergo meticulous evaluation for the possibility of recurrence of TEF.