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Abstract
BACKGROUND Clinicians typically select the antibiotics used to treat pulmonary infections in people with cystic fibrosis based on the results of antimicrobial susceptibility testing performed on bacteria traditionally grown in a planktonic mode (grown in a liquid). However, there is considerable evidence to suggest that Pseudomonas aeruginosa actually grows in a biofilm (or slime layer) in the airways of people with cystic fibrosis with chronic pulmonary infections. Therefore, choosing antibiotics based on biofilm rather than conventional antimicrobial susceptibility testing could potentially improve response to treatment of Pseudomonas aeruginosa in people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To compare biofilm antimicrobial susceptibility testing-driven therapy to conventional antimicrobial susceptibility testing-driven therapy in the treatment of Pseudomonas aeruginosa infection in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Most recent search: 07 April 2020. We also searched two ongoing trials registries and the reference lists of relevant articles and reviews. Most recent searches: 07 April 2020 and 05 September 2017. SELECTION CRITERIA Randomized controlled trials (RCTs) of antibiotic therapy based on biofilm antimicrobial susceptibility testing compared to antibiotic therapy based on conventional antimicrobial susceptibility testing in the treatment of Pseudomonas aeruginosa pulmonary infection in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two authors independently selected RCTs, assessed their risk of bias and extracted data from eligible trials. Additionally, the review authors contacted the trial investigators to obtain further information. The quality of the evidence was assessed using the GRADE criteria. MAIN RESULTS The searches identified two multicentre, double-blind RCTs eligible for inclusion in the review with a total of 78 participants (adults and children); one RCT was undertaken in people who were clinically stable, the second was in people experiencing pulmonary exacerbations. Both RCTs prospectively assessed whether the use of biofilm antimicrobial susceptibility testing improved microbiological and clinical outcomes in participants with cystic fibrosis who were infected with Pseudomonas aeruginosa. The primary outcome was the change in sputum Pseudomonas aeruginosa density from the beginning to the end of antibiotic therapy. Although the intervention was shown to be safe, the data from these two RCTs did not provide evidence that biofilm susceptibility testing was superior to conventional susceptibility testing either in terms of microbiological or lung function outcomes. One of the trials also measured risk and time to subsequent exacerbation as well as quality of life measures and did not demonstrate any difference between groups in these outcomes. Both RCTs had an overall low risk of bias and the quality of the evidence using GRADE criteria was deemed to be moderate to high for the outcomes selected. AUTHORS' CONCLUSIONS The current evidence is insufficient to recommend choosing antibiotics based on biofilm antimicrobial susceptibility testing rather than conventional antimicrobial susceptibility testing in the treatment of Pseudomonas aeruginosa pulmonary infections in people with cystic fibrosis. Biofilm antimicrobial susceptibility testing may be more appropriate in the development of newer, more effective formulations of drugs which can then be tested in clinical trials.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Valerie Waters
- Department of Pediatrics, Division of Infectious Diseases, Hospital for Sick Children, Toronto, Canada
| | - Nikki Jahnke
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Felix Ratjen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
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Mayer-Hamblett N, van Koningsbruggen-Rietschel S, Nichols DP, VanDevanter DR, Davies JC, Lee T, Durmowicz AG, Ratjen F, Konstan MW, Pearson K, Bell SC, Clancy JP, Taylor-Cousar JL, De Boeck K, Donaldson SH, Downey DG, Flume PA, Drevinek P, Goss CH, Fajac I, Magaret AS, Quon BS, Singleton SM, VanDalfsen JM, Retsch-Bogart GZ. Building global development strategies for cf therapeutics during a transitional cftr modulator era. J Cyst Fibros 2020; 19:677-687. [PMID: 32522463 DOI: 10.1016/j.jcf.2020.05.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/18/2020] [Accepted: 05/27/2020] [Indexed: 12/30/2022]
Abstract
As CFTR modulator therapy transforms the landscape of cystic fibrosis (CF) care, its lack of uniform access across the globe combined with the shift towards a new standard of care creates unique challenges for the development of future CF therapies. The advancement of a full and promising CF therapeutics pipeline remains a necessary priority to ensure maximal clinical benefits for all people with CF. It is through collaboration across the global CF community that we can optimize the evaluation and approval process of new therapies. To this end, we must identify areas for which harmonization is lacking and for which efficiencies can be gained to promote ethical, feasible, and credible study designs amidst the changing CF care landscape. This article summarizes the counsel from core advisors across multiple international regions and clinical trial networks, developed during a one-day workshop in October 2019. The goal of the workshop was to identify, in consideration of the highly transitional era of CFTR modulator availability, the drug development areas for which global alignment is currently uncertain, and paths forward that will enable advancement of CF therapeutic development.
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Affiliation(s)
- N Mayer-Hamblett
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA.
| | - S van Koningsbruggen-Rietschel
- Cystic Fibrosis Center, Children's Hospital, University of Cologne; Faculty of Medicine and University Hospital Cologne, Cologne Germany
| | - D P Nichols
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - J C Davies
- National Heart & Lung Institute, Imperial College London, London, UK; Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - T Lee
- Leeds Regional Paediatric Cystic Fibrosis Centre, Leeds, UK
| | | | - F Ratjen
- University of Toronto, Toronto, Canada
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH; Rainbow Babies and Children's Hospital, Cleveland, OH
| | - K Pearson
- Seattle Children's Hospital, Seattle, WA
| | - S C Bell
- Children's Health Research Centre, The University of Queensland, Brisbane, Australia
| | - J P Clancy
- Cystic Fibrosis Foundation, Bethesda, MD
| | | | | | - S H Donaldson
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - D G Downey
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - P A Flume
- Medical University of South Carolina, Charleston, SC
| | - P Drevinek
- Charles University, Prague, Czechia, Motol University Hospital, Prague, Czechia
| | - C H Goss
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - I Fajac
- Université de Paris, Paris, France
| | - A S Magaret
- University of Washington, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - B S Quon
- University of British Columbia, Vancouver, British Columbia
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Shaw M, Khan U, Clancy JP, Donaldson SH, Sagel SD, Rowe SM, Ratjen F. Changes in LCI in F508del/F508del patients treated with lumacaftor/ivacaftor: Results from the prospect study. J Cyst Fibros 2020; 19:931-933. [PMID: 32513528 DOI: 10.1016/j.jcf.2020.05.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 11/29/2022]
Abstract
The PROSPECT study, a post-approval observational study in the U.S., showed no significant changes in lung function as measured by spirometry with clinical initiation of lumacaftor/ivacaftor. A sub-study within the PROSPECT study assessed the lung clearance index (LCI), as measured by multiple breath washout (MBW), a measure of lung function demonstrated to be sensitive among people with normal spirometry. Participants performed MBW prior to clinically initiating lumacaftor/ivacaftor therapy and for one year of follow-up. Similar to the whole PROSPECT study, this sub-study cohort (N = 49) had no significant absolute or relative changes in FEV1% predicted at any time point. LCI, however, decreased (improved) by 0.81 units or 5.3% (95% CI -9.7, -0.9%) at 1 month, 0.77 units or 5.9% at 3 months, 0.67 units or 5.9% at 6 months, and 0.55 units or 4.3% at 12 months. These results demonstrate the utility of the LCI in assessing treatment effects of relatively modest size in a heterogenous study population.
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Affiliation(s)
- Michelle Shaw
- Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, US
| | - John P Clancy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, US; Cystic Fibrosis Foundation, Bethesda, MD, US
| | - Scott H Donaldson
- Department of Medicine and the Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, US
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, CO, US
| | - Steven M Rowe
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, US
| | - Felix Ratjen
- Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Hoppe J, Chilvers M, Ratjen F, McNamara J, Owen C, Tian S, Zahigian R, Cornell A, McColley S. WS19.2 Long-term safety of lumacaftor/ivacaftor therapy in persons with cystic fibrosis aged 2–5 years homozygous for the F508del-CFTR mutation (F/F). J Cyst Fibros 2020. [DOI: 10.1016/s1569-1993(20)30265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Smith S, Ratjen F, Remmington T, Waters V. Combination antimicrobial susceptibility testing for acute exacerbations in chronic infection of Pseudomonas aeruginosa in cystic fibrosis. Cochrane Database Syst Rev 2020; 5:CD006961. [PMID: 32412092 PMCID: PMC7387858 DOI: 10.1002/14651858.cd006961.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Antibiotic therapy for acute pulmonary exacerbations in people with cystic fibrosis is usually chosen based on the results of antimicrobial susceptibility testing of individual drugs. Combination antimicrobial susceptibility testing assesses the efficacy of drug combinations including two or three antibiotics in vitro and can often demonstrate antimicrobial efficacy against bacterial isolates even when individual antibiotics have little or no effect. Therefore, choosing antibiotics based on combination antimicrobial susceptibility testing could potentially improve response to treatment in people with cystic fibrosis with acute exacerbations. This is an updated version of a previously published review. OBJECTIVES To compare antibiotic therapy based on conventional antimicrobial susceptibility testing to antibiotic therapy based on combination antimicrobial susceptibility testing in the treatment of acute pulmonary exacerbations in people with cystic fibrosis and chronic infection with Pseudomonas aeruginosa. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Cystic Fibrosis Trials Register which comprises of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of latest search: 19 March 2020. We also searched ongoing trials registries. Date of latest search: 07 April 2020. SELECTION CRITERIA Randomised and quasi-randomised controlled studies of antibiotic therapy based on conventional antimicrobial susceptibility testing compared to antibiotic therapy based on combination antimicrobial susceptibility testing in the treatment of acute pulmonary exacerbations in cystic fibrosis due to chronic infection with Pseudomonas aeruginosa. DATA COLLECTION AND ANALYSIS Both authors independently selected studies, assessed their quality and extracted data from eligible studies. Additionally, the authors contacted the study investigators to obtain further information. MAIN RESULTS The search identified one multicentre study eligible for inclusion in the review. This study prospectively assessed whether the use of multiple combination bactericidal antibiotic testing improved clinical outcomes in participants with acute pulmonary exacerbations of cystic fibrosis who were infected with multiresistant bacteria. A total of 132 participants were randomised in the study. The study investigators provided data specific to the 82 participants who were only infected with Pseudomonas aeruginosa for their primary outcome of time until next pulmonary exacerbation. For participants specifically infected with only Pseudomonas aeruginosa, the hazard ratio of a subsequent exacerbation was 0.82, favouring the control group (95% confidence interval 0.44 to 1.51) (P = 0.52). No further data for any of this review's outcomes specific to participants infected with Pseudomonas aeruginosa were available. The risk of bias for the included study was deemed to be low. The quality of the evidence was moderate for the only outcome providing data solely for individuals with infection due to Pseudomonas aeruginosa. For other outcomes, we were unable to judge the quality of the evidence as no data were available for the relevant subset of participants. AUTHORS' CONCLUSIONS The current evidence, limited to one study, shows that there is insufficient evidence to determine effect of choosing antibiotics based on combination antimicrobial susceptibility testing compared to choosing antibiotics based on conventional antimicrobial susceptibility testing in the treatment of acute pulmonary exacerbations in people with cystic fibrosis with chronic Pseudomonas aeruginosa infection. A large international and multicentre study is needed to further investigate this issue. The only study included in the review was published in 2005, and we have not identified any further relevant studies up to March 2017. We therefore do not plan to update this review until new studies are published.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Felix Ratjen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Valerie Waters
- Department of Pediatrics, Division of Infectious Diseases, Hospital for Sick Children, Toronto, Canada
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106
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Pollak M, Shaw M, Wilson D, Grasemann H, Ratjen F. Bronchodilator responsiveness in children with cystic fibrosis and allergic bronchopulmonary aspergillosis. Eur Respir J 2020; 56:13993003.00175-2020. [DOI: 10.1183/13993003.00175-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/31/2020] [Indexed: 12/26/2022]
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Livingston MH, Mahant S, Connolly B, MacLusky I, Laberge S, Giglia L, Yang C, Roberts A, Shawyer A, Brindle M, Parsons S, Stoian C, Walton JM, Thorpe KE, Chen Y, Zuo F, Mamdani M, Chan C, Loong D, Isaranuwatchai W, Ratjen F, Cohen E. Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema: A Randomized Clinical Trial. JAMA Pediatr 2020; 174:332-340. [PMID: 32011642 PMCID: PMC7042898 DOI: 10.1001/jamapediatrics.2019.5863] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children. OBJECTIVE To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema. DESIGN, SETTING, AND PARTICIPANTS This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children's hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017. INTERVENTIONS Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation. MAIN OUTCOMES AND MEASURES The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost. RESULTS Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, -0.1 days; 95% CI, -2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths. CONCLUSIONS AND RELEVANCE The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01717742.
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Affiliation(s)
- Michael H. Livingston
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada,Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, New York
| | - Sanjay Mahant
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bairbre Connolly
- Image-Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ian MacLusky
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Laberge
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Lucia Giglia
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Connie Yang
- British Columbia’s Children’s Hospital, Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ashley Roberts
- British Columbia’s Children’s Hospital, Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna Shawyer
- Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Mary Brindle
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Simon Parsons
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Cristina Stoian
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - J. Mark Walton
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Kevin E. Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yang Chen
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fei Zuo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carol Chan
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Desmond Loong
- Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, St Michael’s Hospital, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, St Michael’s Hospital, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Felix Ratjen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Grasemann H, Klingel M, Avolio J, Prentice C, Gonska T, Tullis E, Ratjen F. Long-term effect of CFTR modulator therapy on airway nitric oxide. Eur Respir J 2020; 55:13993003.01113-2019. [PMID: 31601715 DOI: 10.1183/13993003.01113-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/18/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Hartmut Grasemann
- Division of Respiratory Medicine, Dept of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada .,Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michelle Klingel
- Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Julie Avolio
- Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carley Prentice
- Division of Respiratory Medicine, Dept of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Tanja Gonska
- Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Division of Gastroenterology, Dept of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Tullis
- Division of Respirology and Keenan Research Centre of Li Ka Shing Knowledge Institute, Dept of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Dept of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Bell SC, Mall MA, Gutierrez H, Macek M, Madge S, Davies JC, Burgel PR, Tullis E, Castaños C, Castellani C, Byrnes CA, Cathcart F, Chotirmall SH, Cosgriff R, Eichler I, Fajac I, Goss CH, Drevinek P, Farrell PM, Gravelle AM, Havermans T, Mayer-Hamblett N, Kashirskaya N, Kerem E, Mathew JL, McKone EF, Naehrlich L, Nasr SZ, Oates GR, O'Neill C, Pypops U, Raraigh KS, Rowe SM, Southern KW, Sivam S, Stephenson AL, Zampoli M, Ratjen F. The future of cystic fibrosis care: a global perspective. The Lancet Respiratory Medicine 2020; 8:65-124. [DOI: 10.1016/s2213-2600(19)30337-6] [Citation(s) in RCA: 351] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/19/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
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Anagnostopoulou P, Latzin P, Jensen R, Stahl M, Harper A, Yammine S, Usemann J, Foong RE, Spycher B, Hall GL, Singer F, Stanojevic S, Mall MA, Ratjen F, Ramsey KA. Normative data for multiple breath washout outcomes in school-aged Caucasian children. Eur Respir J 2019; 55:13993003.01302-2019. [DOI: 10.1183/13993003.01302-2019] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022]
Abstract
BackgroundThe multiple breath nitrogen washout (N2MBW) technique is increasingly used to assess the degree of ventilation inhomogeneity in school-aged children with lung disease. However, reference values for healthy children are currently not available. The aim of this study was to generate reference values for N2MBW outcomes in a cohort of healthy Caucasian school-aged children.MethodsN2MBW data from healthy Caucasian school-age children between 6 and 18 years old were collected from four experienced centres. Measurements were performed using an ultrasonic flowmeter (Exhalyzer D, Eco Medics AG, Duernten, Switzerland) and were analysed with commercial software (Spiroware version 3.2.1, Eco Medics AG). Normative values and upper limits of normal (ULN) were generated for lung clearance index (LCI) at 2.5% (LCI2.5%) and at 5% (LCI5%) of the initial nitrogen concentration and for moment ratios (M1/M0 and M2/M0). A prediction equation was generated for functional residual capacity (FRC).ResultsAnalysis used 485 trials from 180 healthy Caucasian children aged from 6 to 18 years old. While LCI increased with age, this increase was negligible (0.04 units·year–1 for LCI2.5%) and therefore fixed ULN were defined for this age group. These limits were 7.91 for LCI2.5%, 5.73 for LCI5%, 1.75 for M1/M0 and 6.15 for M2/M0, respectively. Height and weight were found to be independent predictors of FRC.ConclusionWe report reference values for N2MBW outcomes measured on a commercially available ultrasonic flowmeter device (Exhalyzer D, Eco Medics AG) in healthy school-aged children to allow accurate interpretation of ventilation distribution outcomes and FRC in children with lung disease.
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Couch MJ, Morgado F, Kanhere N, Kowalik K, Rayment JH, Ratjen F, Santyr G. Assessing the feasibility of hyperpolarized
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Xe multiple‐breath washout MRI in pediatric cystic fibrosis. Magn Reson Med 2019; 84:304-311. [DOI: 10.1002/mrm.28099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/11/2019] [Accepted: 11/05/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Marcus J. Couch
- Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada
- Department of Medical Biophysics University of Toronto Toronto Ontario Canada
| | - Felipe Morgado
- Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada
- Department of Medical Biophysics University of Toronto Toronto Ontario Canada
- Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Nikhil Kanhere
- Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada
| | - Krzysztof Kowalik
- Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada
| | - Jonathan H. Rayment
- Division of Respiratory Medicine British Columbia Children’s Hospital Vancouver British Columbia Canada
| | - Felix Ratjen
- Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada
- Division of Respiratory Medicine The Hospital for Sick Children Toronto Ontario Canada
| | - Giles Santyr
- Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada
- Department of Medical Biophysics University of Toronto Toronto Ontario Canada
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112
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Seidl E, Kiermeier H, Liebisch G, Ballmann M, Hesse S, Paul-Buck K, Ratjen F, Rietschel E, Griese M. Lavage lipidomics signatures in children with cystic fibrosis and protracted bacterial bronchitis. J Cyst Fibros 2019; 18:790-795. [DOI: 10.1016/j.jcf.2019.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/08/2019] [Accepted: 04/12/2019] [Indexed: 12/19/2022]
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113
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Perrem L, Ratjen F. Anti-inflammatories and mucociliary clearance therapies in the age of CFTR modulators. Pediatr Pulmonol 2019; 54 Suppl 3:S46-S55. [PMID: 31715088 DOI: 10.1002/ppul.24364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022]
Abstract
Cystic fibrosis (CF) is a genetic and life-limiting disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. This multi-system disease is characterized by progressive lung disease and pancreatic insufficiency amongst other manifestations. CFTR primarily functions as a chloride channel that transports ions across the apical membrane of epithelial cells but has other functions, including bicarbonate secretion and inhibition of sodium transport. Defective CFTR disrupts these functions, causing viscous and dehydrated mucus to accumulate, compromising the airway lumen and contributing to obstructive pulmonary disease. The combination of CFTR dysfunction, mucus obstruction, and infection drive an exaggerated and dysfunctional inflammatory response, which contributes to irreversible airway destruction and fibrosis. CFTR modulators, an exciting new class of drugs, increase the expression and/or function of CFTR variant protein and improve multiple clinical endpoints, such as lung function, pulmonary exacerbation rates, and nutritional status. However, these genotype-specific drugs are not universally available, the clinical response is variable, and lung function still declines over time when bronchiectasis is established. Consequently, even in the age of CFTR modulators, we must target other important aspects of the CF airway disease, such as inflammation and mucociliary clearance. This review highlights the mechanisms of inflammation and mucus accumulation in the CF lung and discusses anti-inflammatory and mucociliary clearance agents that are currently in development focusing on compounds for which clinical trial data have recently become available.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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Zemanick E, Burgel PR, Taccetti G, Holmes A, Ratjen F, Byrnes CA, Waters VJ, Bell SC, VanDevanter DR, Stuart Elborn J, Flume PA. Antimicrobial resistance in cystic fibrosis: A Delphi approach to defining best practices. J Cyst Fibros 2019; 19:370-375. [PMID: 31680041 DOI: 10.1016/j.jcf.2019.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/10/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Antimicrobial susceptibility testing (AST) is a cornerstone of infection management in cystic fibrosis. However, there is little evidence that AST predicts the clinical outcome of CF antimicrobial treatment. It has been suggested there is a need for careful consideration of current AST use by the CF community. METHODS We engaged a group of experts consisting of pulmonary (adult and pediatric) and infectious disease clinicians, microbiologists, and pharmacists representing a broad international experience. We conducted an iterative systematic survey (Delphi) to determine and quantify consensus regarding key questions facing CF clinicians in the use of respiratory culture results including what tests to order, when to obtain them, and how to act upon the results of the testing. RESULTS Consensus was reached for many questions but there was not universal agreement to the questions that were addressed. There were some differences with respect to cultures obtained for surveillance compared to when there is clinical worsening. Areas of general consensus include when and how respiratory cultures should be performed, what information should be reported, and when AST should be performed. A key finding is that clinical response to treatment is used to guide treatment decisions rather than AST results. CONCLUSIONS Recommendations are presented regarding questions related to microbiology testing for patients with CF. We have also offered recommendations for priority research questions.
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Affiliation(s)
- Edith Zemanick
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States.
| | - Pierre-Régis Burgel
- Division of Respiratory Medicine and Adult Cystic Fibrosis Center, Assistance Publique Hôpitaux de Paris and University Paris Descartes, Paris, France; ERN-Lung cystic fibrosis network.
| | - Giovanni Taccetti
- Cystic Fibrosis Center, Department of Pediatrics, University of Florence, Italy.
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London. United Kingdom.
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Catherine A Byrnes
- Department of Paediatrics, University of Auckland & Respiratory Department, Starship Children's Health, Auckland, New Zealand
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital and QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - J Stuart Elborn
- Imperial College and Royal Brompton Hospital, London and Queen's University Belfast, United Kingdom.
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
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115
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Ooi CY, Sutherland R, Castellani C, Keenan K, Boland M, Reisman J, Bjornson C, Chilvers MA, van Wylick R, Kent S, Price A, Mateos-Corral D, Hughes D, Solomon M, Zuberbuhler P, Brusky J, Durie PR, Ratjen F, Gonska T. Immunoreactive trypsinogen levels in newborn screened infants with an inconclusive diagnosis of cystic fibrosis. BMC Pediatr 2019; 19:369. [PMID: 31640630 PMCID: PMC6805545 DOI: 10.1186/s12887-019-1756-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/09/2019] [Indexed: 12/18/2022] Open
Abstract
Background Newborn screening (NBS) for cystic fibrosis (CF) not only identifies infants with a diagnosis of CF, but also those with an uncertain diagnosis of cystic fibrosis (CF), i.e. CF transmembrane conductance regulator (CFTR)-related metabolic syndrome (CRMS) or CF screen positive inconclusive diagnosis (CFSPID). These infants have an uncertain long-term outcome and it is currently unclear around time of diagnosis, which infants are at higher risk of later fulfilling a CF diagnosis. In this study, we hypothesised that immunoreactive trypsinogen (IRT) levels, used in NBS as a marker of pancreatic disease and function, may reflect the degree of CFTR dysfunction in each individual and therefore would help to identify those with CRMS/CSPID who are later at risk for meeting the criteria of CF. Methods In this longitudinal, prospective study, infants with CRMS/CFSPID and CF were recruited and followed in 9 CF clinics (Canada and Italy). We compared NBS IRT levels between CF and CRMS/CFSPID, and between children with CRMS/CFSPID→CF and CRMS/CFSPID→CRMS/CFSPID during the period of June 2007 to April 2016. Results Ninety eight CRMS/CFSPID and 120 CF subjects were enrolled. During the study period, 14 (14.3%) CRMS/CFSPID subjects fulfilled the diagnostic criteria for CF (CRMS/CFSPID→CF), while the diagnosis remained uncertain (CRMS/CFSPID→ CRMS/CFSPID) in 84 (85.7%) subjects. Significantly higher NBS IRT concentrations (ng/ml) were present in CF than CRMS/CFPSID (median (interquartile range): 143.8 (99.8–206.2) vs. 75.0 (61.0–105.9); P < 0.0001). Infants with CRMS/CFSPID→CF (n = 14) had significantly higher NBS IRT concentrations (ng/ml) than CRMS/CFSPID→ CRMS/CFSPID (n = 83) (median (interquartile range): 108.9 (72.3–126.8) vs. 73.7(60.0–96.0); P = 0.02). Conclusions Amongst infants who tested positive on NBS for CF, there is a gradation of elevated NBS IRT concentrations. Infants with CF have higher NBS IRT levels than CRMS/CFPSID, and higher NBS IRT concentrations were present in infants with CRMS/CFSPID→CF than CRMS/CFSPID→ CRMS/CFSPID. NBS IRT concentrations, in concert with other factors, may have the potential to predict the likelihood of CF amongst infants with CRMS/CFSPID.
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Affiliation(s)
- Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia. .,miCF Research Centre and Department of Gastroenterology, Sydney Children's Hospital Randwick, High Street, Randwick NSW, Sydney, Australia. .,Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Rosie Sutherland
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Katherine Keenan
- Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Margaret Boland
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Joe Reisman
- Department of Paediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Candice Bjornson
- Department of Pediatrics, Section of Respiratory Medicine, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Mark A Chilvers
- Department of Pediatrics, Division of Pediatric Respiratory Medicine, BC Childrens Hospital, Vancouver, BC, Canada
| | - Richard van Wylick
- Department of Pediatrics, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Steven Kent
- Victoria General Hospital, Victoria, BC, Canada
| | - April Price
- Children's Hospital Of Western Ontario, London, Ontario, Canada
| | | | | | - Melinda Solomon
- Department of Paediatrics, Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | | | - Janna Brusky
- Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Peter R Durie
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Felix Ratjen
- Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Tanja Gonska
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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Klostranec JM, Chen L, Mathur S, McDonald J, Faughnan ME, Ratjen F, Krings T. A theory for polymicrogyria and brain arteriovenous malformations in HHT. Neurology 2019; 92:34-42. [PMID: 30584075 DOI: 10.1212/wnl.0000000000006686] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/14/2018] [Indexed: 01/11/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is generally considered a disorder of endothelial dysfunction, characterized by the development of multiple systemic arteriovenous malformations (AVMs), including within the brain. However, there have recently been a number of reports correlating HHT with malformations of cortical development, of which polymicrogyria is the most common type. Here we present 7 new cases demonstrating polymicrogyria in HHT, 6 of which demonstrate a brain AVM (bAVM) in close spatial proximity, with the aim of providing a common origin for the association. Upon reviewing patient genetics and imaging data and comparing with previously reported findings, we form 2 new conclusions: (1) polymicrogyria in HHT appears exclusively associated with a subset of mutations in the transmembrane protein endoglin that is involved with blood flow-related mechanotransduction signaling during angiogenesis and (2) the polymicrogyria is characteristically unilateral, typically focal, and correlates with vascular regions experiencing low fluid shear stress during corticogenesis in utero. Integrating these with findings in the literature from genetics and molecular biology experiments, we propose a theory suggesting haploinsufficient endoglin mutations, especially those that are dominant-negative, may predispose focal, aberrant hypersprouting angiogenesis during corticogenesis that leads to the production of polymicrogyria. This hypoxic insult may further serve as the revealing trigger for later development of a spatially coincident bAVM. This hypothesis suggests an essential role for endoglin-mediated hemodynamic mechanotransduction in normal corticogenesis.
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Affiliation(s)
- Jesse M Klostranec
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Long Chen
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Shobhit Mathur
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Jamie McDonald
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Marie E Faughnan
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Felix Ratjen
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Timo Krings
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada.
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Ratjen F, Klingel M, Black P, Powers MR, Grasemann H, Solomon M, Sagel SD, Donaldson SH, Rowe SM, Rosenfeld M. Changes in Lung Clearance Index in Preschool-aged Patients with Cystic Fibrosis Treated with Ivacaftor (GOAL): A Clinical Trial. Am J Respir Crit Care Med 2019; 198:526-528. [PMID: 29614238 DOI: 10.1164/rccm.201802-0243le] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Felix Ratjen
- 1 University of Toronto Toronto, Ontario, Canada
| | | | - Philip Black
- 2 Children's Mercy Hospital Kansas City, Missouri
| | | | | | | | - Scott D Sagel
- 4 University of Colorado School of Medicine Aurora, Colorado
| | | | - Steven M Rowe
- 6 University of Alabama at Birmingham Birmingham, Alabama and
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Couch MJ, Thomen R, Kanhere N, Hu R, Ratjen F, Woods J, Santyr G. A two-center analysis of hyperpolarized 129Xe lung MRI in stable pediatric cystic fibrosis: Potential as a biomarker for multi-site trials. J Cyst Fibros 2019; 18:728-733. [PMID: 30922812 PMCID: PMC7054852 DOI: 10.1016/j.jcf.2019.03.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The ventilation defect percent (VDP), measured from hyperpolarized (HP) 129Xe magnetic resonance imaging (MRI), is sensitive to functional changes in cystic fibrosis (CF) lung disease. The purpose of this study was to measure and compare VDP from HP 129Xe MRI acquired at two institutions in stable pediatric CF subjects with preserved lung function. METHODS This retrospective analysis included 26 participants from two institutions (18 CF, 8 healthy, age range 10-17). Pulmonary function tests, N2 multiple breath washout (to measure lung clearance index, LCI), and HP 129Xe MRI were performed. VDP measurements were compared between two trained analysts using mean-anchored linear binning. Correlations were investigated for VDP compared to the forced expiratory volume in one second (FEV1) and LCI. RESULTS VDP measurements agreed for the two analysts with an intraclass correlation coefficient of 0.99. In the combined dataset, VDP measured by Analyst 1 was 5.96 ± 1.82% and 15.96 ± 6.76% for the healthy and CF groups, respectively (p = .0004). Analyst 2 showed similar differences between healthy and CF (p = .0003). VDP measured by either analyst was shown to correlate with FEV1 (R2 = 0.33, p = .003; and R2 = 0.26, p = .009 for Analysts 1 and 2, respectively) and LCI (R2 = 0.76, p < .0001; and R2 = 0.77, p < .0001 for Analysts 1 and 2, respectively). CONCLUSION HP 129Xe MRI provides a robust measurement of ventilation heterogeneity in stable pediatric CF subjects at two sites. Since measurements performed at two sites yielded similar VDP values with near-identical values between different analysts, implementation of the technique in multi-center trials in CF appears feasible.
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Affiliation(s)
- Marcus J Couch
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Robert Thomen
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - Nikhil Kanhere
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Raymond Hu
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jason Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Giles Santyr
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada..
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Ratjen F, Davis SD, Stanojevic S, Kronmal RA, Hinckley Stukovsky KD, Jorgensen N, Rosenfeld M, Kerby G, Kopecky C, Anthony M, Mogayzel P, Walker D, Zeglin B, Hoover W, Hathorne H, Slaten K, Dorkin H(H, Fowler R, Fenton C(N, Ulles M, Goetz D, Caci N, Cahill B, Roach C, Retsch-Bogart G, Johnson R, Cunnion R, McColley S, Ward S, Bell E, McPhail G, Keller K, Thornton K, Parsons A, Chmiel J, Schaefer C, Tribout M, Consiglio B, Tribout H, McCoy K, Johnson T, Olson P, Raterman L, Hiatt P, Walker B, Schaap N, Davis M, Davis S, Clem C, Bendy L, Starner T, Lux C, Carver T, Thompson R, Williams A, Schmoll C, Hastings PM, Noe J, Roth L, Kump T, McNamara J, Franck Thompson E, Yousef S, Wezel G(G, Oquendo O, Darling A, Valencia W, Milla C, Zirbes J, Rubenstein R, Donnelly E, Malpass J, Weiner D, Agostini B, Hartigan E, Cornell A, Klein B, Bucher J, Nusbaum P, Rosenfeld M, McNamara S, Genatossio A, Pittman J, Hicks T, Bauer I, Siegel M, Isaac S, Jensen R, Au J, Stanojevic S, Ratjen F, McDonald N, Prentice C, Chilvers M, Richmond M. Inhaled hypertonic saline in preschool children with cystic fibrosis (SHIP): a multicentre, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine 2019; 7:802-809. [DOI: 10.1016/s2213-2600(19)30187-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023]
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Robinson PD, Latzin P, Ramsey KA, Stanojevic S, Aurora P, Davis SD, Gappa M, Hall GL, Horsley A, Jensen R, Lum S, Milla C, Nielsen KG, Pittman JE, Rosenfeld M, Singer F, Subbarao P, Gustafsson PM, Ratjen F. Preschool Multiple-Breath Washout Testing. An Official American Thoracic Society Technical Statement. Am J Respir Crit Care Med 2019; 197:e1-e19. [PMID: 29493315 DOI: 10.1164/rccm.201801-0074st] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Obstructive airway disease is nonuniformly distributed throughout the bronchial tree, although the extent to which this occurs can vary among conditions. The multiple-breath washout (MBW) test offers important insights into pediatric lung disease, not available through spirometry or resistance measurements. The European Respiratory Society/American Thoracic Society inert gas washout consensus statement led to the emergence of validated commercial equipment for the age group 6 years and above; specific recommendations for preschool children were beyond the scope of the document. Subsequently, the focus has shifted to MBW applications within preschool subjects (aged 2-6 yr), where a "window of opportunity" exists for early diagnosis of obstructive lung disease and intervention. METHODS This preschool-specific technical standards document was developed by an international group of experts, with expertise in both custom-built and commercial MBW equipment. A comprehensive review of published evidence was performed. RESULTS Recommendations were devised across areas that place specific age-related demands on MBW systems. Citing evidence where available in the literature, recommendations are made regarding procedures that should be used to achieve robust MBW results in the preschool age range. The present work also highlights the important unanswered questions that need to be addressed in future work. CONCLUSIONS Consensus recommendations are outlined to direct interested groups of manufacturers, researchers, and clinicians in preschool device design, test performance, and data analysis for the MBW technique.
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Ratjen F, Jensen R, Klingel M, McDonald R, Moore C, Benseler N, Wilson D, Stanojevic S. Effect of changes in tidal volume on multiple breath washout outcomes. PLoS One 2019; 14:e0219309. [PMID: 31269068 PMCID: PMC6608950 DOI: 10.1371/journal.pone.0219309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/20/2019] [Indexed: 01/03/2023] Open
Abstract
The lung clearance index (LCI), measured by multiple breath washout (MBW), reflects global ventilation inhomogeneity and is a sensitive marker of early obstructive airway disease. For the MBW test to accurately reflect a subject's gas mixing within the lungs, the breathing pattern should represent physiologically appropriate tidal volumes (VT) and respiratory rate (RR). We aimed to assess whether changes in VT impact MBW outcome measures with a series of prospective and retrospective studies. MBW testing was performed using the Exhalyzer ® D (EcoMedics AG, Switzerland). Healthy adult subjects performed MBW with uninstructed tidal breathing and a series of instructed tidal breathing tests, designed to isolate specific features of the breathing pattern. In addition, we retrospectively analyzed MBW data from two pediatric multi-centre interventional studies of cystic fibrosis (CF) subjects to determine the range of VT observed during uninstructed breathing, and whether breathing outside this range impacted results. The LCI was lower, but not significantly different between deep breathing at 20 ml/kg body weight and uninstructed tidal breathing; whereas LCI was significantly higher during shallow breathing compared with normal tidal breathing. For the majority of subjects with CF (80%), VT ranged from 9-15mL/kg. Within the observed VT range, LCI was similar in trials with mean VT /kg below this range compared to trials with VT /kg within the range. If subjects breathe naturally and are not instructed to use specific targets, the range of VT is within physiologically appropriate limits and normal variations observed do not impact MBW outcomes.
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Affiliation(s)
- Felix Ratjen
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
- * E-mail:
| | - Renee Jensen
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Michelle Klingel
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Reginald McDonald
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Courtney Moore
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Nick Benseler
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - David Wilson
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Sanja Stanojevic
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
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Affiliation(s)
- Lucy Perrem
- 1 Division of Respiratory Medicine The Hospital for Sick Children Toronto, Ontario, Canada
| | - Felix Ratjen
- 1 Division of Respiratory Medicine The Hospital for Sick Children Toronto, Ontario, Canada.,2 Department of Pediatrics University of Toronto Toronto, Ontario, Canada.,3 Translational Medicine and.,4 Research Institute The Hospital for Sick Children Toronto, Ontario, Canada
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Matenchuk BA, Tamana SK, Lou WY, Lefebvre DL, Sears MR, Becker AB, Azad MB, Moraes TJ, Turvey SE, Subbarao P, Kozyrskyj AL, Mandhane PJ, Subbarao P, Turvey S, Anand S, Azad M, Becker A, Befus A, Brauer M, Brook J, Chen E, Cyr M, Daley D, Dell S, Denburg J, Duan Q, Eiwegger T, Grasemann H, HayGlass K, Hegele R, Holness D, Hystad P, Kobor M, Kollmann T, Kozyrskyj A, Laprise C, Lou W, Macri J, Mandhane P, Miller G, Moraes T, Paré P, Ramsey C, Ratjen F, Sandford A, Scott J, Scott J, Sears M, Silverman F, Simons E, Takaro T, Tebbutt S, To T. Prenatal depression and birth mode sequentially mediate maternal education's influence on infant sleep duration. Sleep Med 2019; 59:24-32. [DOI: 10.1016/j.sleep.2019.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 11/15/2018] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
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124
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Reix P, Klingel M, Davis S, Retsch-Bogart G, Stanojevic S, Ratjen F. WS07-3 Effect of cumulative bacterial infection on the Lung Clearance Index in preschool children with cystic fibrosis. J Cyst Fibros 2019. [DOI: 10.1016/s1569-1993(19)30156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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125
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Perrem L, Stanojevic S, Solomon M, Carpenter S, Ratjen F. Incidence and risk factors of paediatric cystic fibrosis-related diabetes. J Cyst Fibros 2019; 18:874-878. [PMID: 31072797 DOI: 10.1016/j.jcf.2019.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis (CF) directly linked to increased morbidity and mortality. Both the incidence of type I and type II diabetes has been shown to increase in the general population. In this study, we investigated the incidence and risk factors of CFRD in a paediatric CF population. METHODS Prospectively collected data from the Canadian CF Registry (CCFR) from 2000 to 2016 for patients ages 10 to 18 years was used to determine the incidence of CFRD. Risk factors for CFRD in the Canadian population were investigated using a nested case-control design. Conditional logistic regression analysis with a 4:1 control: case matching was used. RESULTS From 2000 to 2016, 2326 patients with CF aged between 10 through 18 years were included in the CCFR, during this time the overall incidence rate of CFRD was 2.1 cases per 100 patient-years (95% confidence interval 1.8 to 2.3). Incidence rates were stable in the Canadian cohort over three consecutive time periods 2000-2005, 2006-2010; 2011-2016. Worse lung function, female gender, history of allergic bronchopulmonary aspergillosis, Gastrostomy tube insertion and liver disease were statistically significant risk factors for CFRD. CONCLUSION The incidence of CFRD in the Canadian paediatric population has been stable over time, in contrast to the rising rates of Type 1 and Type 2 diabetes in the general paediatric population. The risk factor for CFRD in this contemporary population were consistent with previous studies.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Susan Carpenter
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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126
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Hebestreit H, Hulzebos EHJ, Schneiderman JE, Karila C, Boas SR, Kriemler S, Dwyer T, Sahlberg M, Urquhart DS, Lands LC, Ratjen F, Takken T, Varanistkaya L, Rücker V, Hebestreit A, Usemann J, Radtke T, Junge S, Smaczny C, Rand S, Dawson C. Cardiopulmonary Exercise Testing Provides Additional Prognostic Information in Cystic Fibrosis. Am J Respir Crit Care Med 2019; 199:987-995. [DOI: 10.1164/rccm.201806-1110oc] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Erik H. J. Hulzebos
- Child Development & Exercise Center, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jane E. Schneiderman
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chantal Karila
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et Compétences dans la Mucoviscidose, Hôpital Necker Enfants Malades, Université Paris V – Descartes, Paris, France
| | - Steven R. Boas
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susi Kriemler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Tiffany Dwyer
- Discipline of Physiotherapy, Faculty of Health Sciences and
- Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Margareta Sahlberg
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
| | - Don S. Urquhart
- Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Larry C. Lands
- Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Takken
- Child Development & Exercise Center, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Viktoria Rücker
- Institute for Clinical Epidemiology and Biometry, Wuerzburg, Germany; and
| | | | - Jakob Usemann
- University Children’s Hospital Basel, Basel, Switzerland
| | - Thomas Radtke
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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127
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Gould MJ, Ratjen F, Gonska T. A184 PANCREATITIS IN A PREVIOUSLY PANCREATIC INSUFFICIENT PATIENT WITH CYSTIC FIBROSIS AFTER TREATMENT WITH LUMACAFTOR/IVACAFTOR COMBINATION THERAPY. J Can Assoc Gastroenterol 2019. [DOI: 10.1093/jcag/gwz006.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M J Gould
- Hospital for Sick Children, Toronto, ON, Canada
| | - F Ratjen
- Hospital for Sick Children, Toronto, ON, Canada
| | - T Gonska
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
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128
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Santyr G, Kanhere N, Morgado F, Rayment JH, Ratjen F, Couch MJ. Hyperpolarized Gas Magnetic Resonance Imaging of Pediatric Cystic Fibrosis Lung Disease. Acad Radiol 2019; 26:344-354. [PMID: 30087066 DOI: 10.1016/j.acra.2018.04.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/14/2018] [Accepted: 04/05/2018] [Indexed: 12/26/2022]
Abstract
Conventional pulmonary function tests appear normal in early cystic fibrosis (CF) lung disease. Therefore, new diagnostic approaches are required that can detect CF lung disease in children and monitor treatment response. Hyperpolarized (HP) gas (129Xe and 3He) magnetic resonance imaging (MRI) is a powerful, emergent tool for mapping regional lung function and may be well suited for studying pediatric CF. HP gas MRI is well tolerated, reproducible, and it can be performed longitudinally without the need for ionizing radiation. In particular, quantification of the distribution of ventilation, or ventilation defect percent (VDP), has been shown to be a sensitive indicator of CF lung disease and correlates well with pulmonary function tests. This article presents the current state of CF diagnosis and treatment and describes the potential role of HP gas MRI for detection of early CF lung disease and following the effects of interventions. The typical HP gas imaging workflow is described, along with a discussion of image analysis to calculate VDP, dosing considerations, and the reproducibility of VDP. The potential use of VDP as an outcome measure in CF is discussed, by considering the correlation with pulmonary function measures, preliminary interventional studies, and case studies involving longitudinal imaging and pulmonary exacerbations. Finally, emerging HP gas imaging techniques such as multiple breath washout imaging are introduced, followed by a discussion of future directions. Overall, HP gas MRI biomarkers are expected to provide sensitive outcome measures that can be used in disease surveillance as well as interventional studies involving novel CF therapies.
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Affiliation(s)
- Giles Santyr
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
| | - Nikhil Kanhere
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Felipe Morgado
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Jonathan H Rayment
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Marcus J Couch
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
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129
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Rayment JH, Couch MJ, McDonald N, Kanhere N, Manson D, Santyr G, Ratjen F. Hyperpolarised 129Xe magnetic resonance imaging to monitor treatment response in children with cystic fibrosis. Eur Respir J 2019; 53:13993003.02188-2018. [DOI: 10.1183/13993003.02188-2018] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/02/2019] [Indexed: 01/01/2023]
Abstract
Pulmonary magnetic resonance imaging using hyperpolarised 129Xe gas (XeMRI) can quantify ventilation inhomogeneity by measuring the percentage of unventilated lung volume (ventilation defect per cent (VDP)). While previous studies have demonstrated its sensitivity for detecting early cystic fibrosis (CF) lung disease, the utility of XeMRI to monitor response to therapy in CF is unknown. The aim of this study was to assess the ability of XeMRI to capture treatment response in paediatric CF patients undergoing inpatient antibiotic treatment for a pulmonary exacerbation.15 CF patients aged 8–18 years underwent XeMRI, spirometry, plethysmography and multiple-breath nitrogen washout at the beginning and end of inpatient treatment of a pulmonary exacerbation. VDP was calculated from XeMRI images obtained during a static breath hold using semi-automated k-means clustering and linear binning approaches.XeMRI was well tolerated. VDP, lung clearance index and the forced expiratory volume in 1 s all improved with treatment; however, response was not uniform in individual patients. Of all outcome measures, VDP showed the largest relative improvement (−42.1%, 95% CI −52.1–−31.9%, p<0.0001).These data support further investigation of XeMRI as a tool to capture treatment response in CF lung disease.
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130
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Au JWY, McDonald R, Stanojevic S, Ratjen F. Does the multiple-breath washout test need to be measured before spirometry? ERJ Open Res 2019; 5:00230-2018. [PMID: 30740459 PMCID: PMC6360208 DOI: 10.1183/23120541.00230-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/18/2018] [Indexed: 11/05/2022] Open
Abstract
Spirometry does not have a short-term effect on multiple-breath washout outcomes, thus allowing greater flexibility for implementation into clinical practice http://ow.ly/2Tg330ngXk4.
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Affiliation(s)
- Jacky W Y Au
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Reginald McDonald
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
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131
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Miliku K, Robertson B, Sharma AK, Subbarao P, Becker AB, Mandhane PJ, Turvey SE, Lefebvre DL, Sears MR, Bode L, Azad MB, Anand SS, Azad M, Becker AB, Befus AD, Brauer M, Brook JR, Chen E, Cyr M, Daley D, Dell SD, Denburg JA, Duan Q, Eiwegger T, Grasemann H, HayGlass K, Hegele RG, Holness DL, Hystad P, Kobor M, Kollman TR, Kozyrskyj AL, Laprise C, Lou WYW, Macri J, Miller G, Moraes TJ, Ramsey C, Ratjen F, Sandford A, Scott JA, Scott J, Silverman F, Simons E, Takaro T, Tebbutt S, To T. Human milk oligosaccharide profiles and food sensitization among infants in the CHILD Study. Allergy 2018; 73:2070-2073. [PMID: 29775217 DOI: 10.1111/all.13476] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- K. Miliku
- Manitoba Developmental Origins of Chronic Diseases in Children Network (DEVOTION) Children's Hospital Research Institute of Manitoba Winnipeg MB Canada
- Department of Pediatrics and Child Health University of Manitoba Winnipeg MB Canada
- The Generation R Study Group Departments of Pediatrics and Epidemiology Erasmus University Medical Center Rotterdam Rotterdam The Netherlands
| | - B. Robertson
- Department of Pediatrics and Larsson‐Rosenquist Foundation Mother‐Milk‐Infant Center of Research Excellence University of California San Diego La Jolla CA USA
| | - A. K. Sharma
- George & Fay Yee Centre for Healthcare Innovation University of Manitoba Winnipeg MB Canada
| | - P. Subbarao
- Departments of Pediatrics & Physiology University of Toronto Toronto ON Canada
| | - A. B. Becker
- Manitoba Developmental Origins of Chronic Diseases in Children Network (DEVOTION) Children's Hospital Research Institute of Manitoba Winnipeg MB Canada
- Department of Pediatrics and Child Health University of Manitoba Winnipeg MB Canada
| | - P. J. Mandhane
- Department of Pediatrics University of Alberta Edmonton AB Canada
| | - S. E. Turvey
- Department of Pediatrics University of British Columbia Vancouver BC Canada
| | - D. L. Lefebvre
- Department of Medicine McMaster University Hamilton ON Canada
| | - M. R. Sears
- Department of Medicine McMaster University Hamilton ON Canada
| | - L. Bode
- Department of Pediatrics and Larsson‐Rosenquist Foundation Mother‐Milk‐Infant Center of Research Excellence University of California San Diego La Jolla CA USA
| | - M. B. Azad
- Manitoba Developmental Origins of Chronic Diseases in Children Network (DEVOTION) Children's Hospital Research Institute of Manitoba Winnipeg MB Canada
- Department of Pediatrics and Child Health University of Manitoba Winnipeg MB Canada
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132
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Racette C, Lu Z, Kowalik K, Cheng O, Bendiak G, Amin R, Dubeau A, Jensen R, Balkovec S, Gustafsson P, Ratjen F, Subbarao P. Lung clearance index is elevated in young children with symptom-controlled asthma. Health Sci Rep 2018; 1:e58. [PMID: 30623093 PMCID: PMC6266588 DOI: 10.1002/hsr2.58] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/11/2018] [Accepted: 05/18/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Pulmonary function testing has been recommended as an adjunct to symptom monitoring for assessment of asthma control. Lung clearance index (LCI) measures ventilation inhomogeneity and is thought to represent changes in the small airways. It has been proposed as a useful early marker of airway disease in asthmatic subjects, and determining it is feasible in preschool children. This study aims to assess whether LCI remains elevated in symptomatically controlled asthmatic children with a history of severe asthma, compared with healthy controls. A secondary aim was to determine whether the results were consistent across the preschool and school-aged populations. METHODS Using a case-control design, we compared 33 children with currently well-controlled symptoms who had a history of severe asthma, to 45 healthy controls (age 3-15 years) matched by age, height, and sex. We performed multiple breath washout tests using sulfur hexafluoride as a tracer gas, to determine their LCI and Scond values. RESULTS In the overall study, LCI z-score values were on average 0.86 units (95% confidence interval: 0.24-1.47, P = 0.01, t-test) higher in children with a history of severe asthma with current well-controlled symptoms compared with healthy controls. In addition, within the subgroup of preschool children (age ≤ 6), the asthmatic had significantly higher LCI z-score values than their healthy controls peers (mean (SD), 0.57 (2.18) vs -1.10 (1.00), P = 0.03, t-test). Twenty-seven percent (27%; 9/33) of subjects had an LCI value greater than the upper limit of our healthy controls despite being symptom controlled. Amongst preschool children, 5 (42%; 5/12) of the asthmatic children had abnormal LCI at the individual level. CONCLUSIONS LCI is elevated in children with asthma, which may be driven by differences in the preschool population. LCI may be useful in defining preschool asthma endotypes with persistent ventilation inhomogeneity despite symptomatic control.
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Affiliation(s)
- Christine Racette
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | - Zihang Lu
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Krzysztof Kowalik
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
| | - Olivia Cheng
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | - Glenda Bendiak
- Department of PediatricsUniversity of CalgaryCalgaryAlbertaCanada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | - Aimee Dubeau
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | - Renée Jensen
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | - Susan Balkovec
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | | | - Felix Ratjen
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
| | - Padmaja Subbarao
- Division of Respiratory Medicine, Department of PediatricsHospital for Sick Children and Research InstituteTorontoOntarioCanada
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
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133
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Lu Z, Foong RE, Kowalik K, Moraes TJ, Dubeau A, Lefebvre D, Davis SD, Balkovec S, Becker A, Mandhane P, Turvey SE, Lou W, Sears MR, Ratjen F, Subbarao P. Reference equations for the interpretation of forced expiratory and plethysmographic measurements in infants. Pediatr Pulmonol 2018; 53:907-916. [PMID: 29790670 DOI: 10.1002/ppul.24063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/08/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pulmonary function testing is commonly performed for diagnosis and clinical management of respiratory diseases. It is important to use appropriate reference equations from healthy subjects for interpretation of data from infants with lung disease. This study aimed to determine if published reference equations were similar to forced flow measures and plethysmographic infant pulmonary function testing data collected in the Canadian Healthy Infant Longitudinal Development (CHILD) Study. METHODS Reference equations for five pulmonary function variables (FEV0.5 , FVC, FEF25-75 , FEV0.5 /FVC ratio and plethysmography (FRCpleth )) were developed using data from the nSpire system. New reference equations developed using healthy data from the CHILD Study were compared to previously published reference equations for forced flow and plethysmographic measures. RESULTS The current analysis included 131 infants (on 181 test occasions) with forced flow measures and 161 infants (on 246 test occasions) with plethysmography measures, aged 3-24 months. Age and length were major determinants of both forced flow and plethysmography measures. In addition, ethnicity (Caucasian vs non-Caucasian) was significantly associated with FEV0.5 /FVC and FEF25-75 measures. We found that the published reference equations based on custom-built equipment or commercially available systems provided poor fit to our current pulmonary function testing data, resulting in placing a large proportion of our healthy population outside the normal ranges. CONCLUSIONS Our current data support the need for population and device specific reference data for infant pulmonary function studies. By deriving new equipment-specific reference equations for our healthy population, we provide normative data to other centers utilizing this equipment.
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Affiliation(s)
- Zihang Lu
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Rachel E Foong
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Curtin University of Technology, Perth, Western Australia
| | - Krzysztof Kowalik
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Aimee Dubeau
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Diana Lefebvre
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine; Department of Pediatrics; Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Susan Balkovec
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Allan Becker
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Piush Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart E Turvey
- Department of Pediatrics, Child & Family Research Institute, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Malcolm R Sears
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Padmaja Subbarao
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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134
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Lu Z, Foong RE, Kowalik K, Moraes TJ, Boyce A, Dubeau A, Balkovec S, Gustafsson PM, Becker AB, Mandhane PJ, Turvey SE, Lou W, Ratjen F, Sears M, Subbarao P. Ventilation inhomogeneity in infants with recurrent wheezing. Thorax 2018; 73:936-941. [PMID: 29907664 DOI: 10.1136/thoraxjnl-2017-211351] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/10/2018] [Accepted: 05/21/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The care of infants with recurrent wheezing relies largely on clinical assessment. The lung clearance index (LCI), a measure of ventilation inhomogeneity, is a sensitive marker of early airway disease in children with cystic fibrosis, but its utility has not been explored in infants with recurrent wheezing. OBJECTIVE To assess ventilation inhomogeneity using LCI among infants with a history of recurrent wheezing compared with healthy controls. METHODS This is a case-control study, including 37 infants with recurrent wheezing recruited from outpatient clinics, and 113 healthy infants from a longitudinal birth cohort, the Canadian Healthy Infant Longitudinal Development study. All infants, at a time of clinical stability, underwent functional assessment including multiple breath washout, forced expiratory flows and body plethysmography. RESULTS LCI z-score values among infants with recurrent wheeze were 0.84 units (95% CI 0.41 to 1.26) higher than healthy infants (mean (95% CI): 0.26 (-0.11 to 0.63) vs -0.58 (-0.79 to 0.36), p<0.001)). Nineteen percent of recurrently wheezing infants had LCI values that were above the upper limit of normal (>1.64 z-scores). Elevated exhaled nitric oxide, but not symptoms, was associated with abnormal LCI values in infants with recurrent wheeze (p=0.05). CONCLUSIONS Ventilation inhomogeneity is present in clinically stable infants with recurrent wheezing.
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Affiliation(s)
- Zihang Lu
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rachel E Foong
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada.,School of Physiotherapy and Exercise Science, Curtin University, Bentley, Western Australia, Australia
| | - Krzysztof Kowalik
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| | - Ayanna Boyce
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| | - Aimee Dubeau
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| | - Susan Balkovec
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| | | | - Allan B Becker
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Piush J Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart E Turvey
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
| | - Malcolm Sears
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Padmaja Subbarao
- Division of Respiratory Medicine and Translational Medicine, Department of Pediatrics & Physiology, Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
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135
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Molinski SV, Ahmadi S, Ip W, Ouyang H, Villella A, Miller JP, Lee PS, Kulleperuma K, Du K, Di Paola M, Eckford PD, Laselva O, Huan LJ, Wellhauser L, Li E, Ray PN, Pomès R, Moraes TJ, Gonska T, Ratjen F, Bear CE. Orkambi® and amplifier co-therapy improves function from a rare CFTR mutation in gene-edited cells and patient tissue. EMBO Mol Med 2018; 9:1224-1243. [PMID: 28667089 PMCID: PMC5582412 DOI: 10.15252/emmm.201607137] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The combination therapy of lumacaftor and ivacaftor (Orkambi®) is approved for patients bearing the major cystic fibrosis (CF) mutation: ΔF508. It has been predicted that Orkambi® could treat patients with rarer mutations of similar “theratype”; however, a standardized approach confirming efficacy in these cohorts has not been reported. Here, we demonstrate that patients bearing the rare mutation: c.3700 A>G, causing protein misprocessing and altered channel function—similar to ΔF508‐CFTR, are unlikely to yield a robust Orkambi® response. While in silico and biochemical studies confirmed that this mutation could be corrected and potentiated by lumacaftor and ivacaftor, respectively, this combination led to a minor in vitro response in patient‐derived tissue. A CRISPR/Cas9‐edited bronchial epithelial cell line bearing this mutation enabled studies showing that an “amplifier” compound, effective in increasing the levels of immature CFTR protein, augmented the Orkambi® response. Importantly, this “amplifier” effect was recapitulated in patient‐derived nasal cultures—providing the first evidence for its efficacy in augmenting Orkambi® in tissues harboring a rare CF‐causing mutation. We propose that this multi‐disciplinary approach, including creation of CRISPR/Cas9‐edited cells to profile modulators together with validation using primary tissue, will facilitate therapy development for patients with rare CF mutations.
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Affiliation(s)
- Steven V Molinski
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada.,Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Saumel Ahmadi
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Wan Ip
- Programme in Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Hong Ouyang
- Programme in Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | | | | | - Po-Shun Lee
- Proteostasis Therapeutics, Cambridge, MA, USA
| | - Kethika Kulleperuma
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada.,Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Kai Du
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Di Paola
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada.,Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Paul Dw Eckford
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Onofrio Laselva
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Ling Jun Huan
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Leigh Wellhauser
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Ellen Li
- Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter N Ray
- Division of Molecular Genetics, Hospital for Sick Children, Toronto, ON, Canada
| | - Régis Pomès
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada.,Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Theo J Moraes
- Programme in Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Tanja Gonska
- Programme in Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Christine E Bear
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada .,Programme in Molecular Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada
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136
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Taylor-Cousar J, Tullis E, Derichs N, Davies J, Nazareth D, Downey D, Rosenbluth D, Fajac I, Malfroot A, Saunders C, Short C, Jensen R, Solomon G, Vermeulen F, Willmann S, Saleh S, Langer S, Kaiser A, Hoffmann A, Rowe S, Ratjen F. P028 Riociguat for the treatment of adult Phe508del homozygous cystic fibrosis: efficacy data from the Phase II Rio-CF study. J Cyst Fibros 2018. [DOI: 10.1016/s1569-1993(18)30325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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137
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Ratjen F, Moeller A, McKinney ML, Asherova I, Alon N, Maykut R, Angyalosi G. Eradication of early P. aeruginosa infection in children <7 years of age with cystic fibrosis: The early study. J Cyst Fibros 2018; 18:78-85. [PMID: 29685813 DOI: 10.1016/j.jcf.2018.04.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/19/2018] [Accepted: 04/04/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Antibiotic eradication treatment is the standard-of-care for cystic fibrosis (CF) patients with early Pseudomonas aeruginosa (Pa)-infection; however, evidence from placebo-controlled trials is limited. METHODS This double-blind, placebo-controlled trial randomised CF patients <7 years (N = 51) with early Pa-infection to tobramycin inhalation solution (TOBI 300 mg) or placebo (twice daily) for 28 days with an optional cross-over on Day 35. Primary endpoint was proportion of patients having throat swabs/sputum free of Pa on Day 29. RESULTS On Day 29, 84.6% patients in the TOBI versus 24.0% in the placebo group were Pa-free (p < 0.001). At the end of the cross-over period, 76.0% patients receiving TOBI in the initial 28 days were Pa-free compared to 47.8% receiving placebo initially. Adverse events were consistent with the TOBI safety profile with no differences between TOBI and placebo. CONCLUSION TOBI was effective in eradicating early Pa-infection with a favourable safety profile in young CF patients. TRIAL REGISTRATION NUMBER NCT01082367.
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Affiliation(s)
- Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Irina Asherova
- Yaroslavl's Children's Clinical Hospital, Yaroslavl, Russia
| | - Nipa Alon
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
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138
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Fernandopulle N, Mertens L, Klingel M, Manson D, Ratjen F. Echocardiography Grading for Pulmonary Arteriovenous Malformation Screening in Children with Hereditary Hemorrhagic Telangiectasia. J Pediatr 2018; 195:288-291.e1. [PMID: 29274888 DOI: 10.1016/j.jpeds.2017.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/12/2017] [Accepted: 11/17/2017] [Indexed: 01/09/2023]
Abstract
Transthoracic contrast echocardiography (TTCE) has high sensitivity but low specificity in screening for pulmonary arteriovenous malformations (pAVMs) in children with hereditary hemorrhagic telangiectasia (HHT). Here we describe characteristics of TTCE that might be used to reduce the need for confirmatory computed tomography scans in children with HHT.
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Affiliation(s)
- Nigel Fernandopulle
- University of Toronto, Toronto, Ontario, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Klingel
- Department of Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Manson
- University of Toronto, Toronto, Ontario, Canada; Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Felix Ratjen
- University of Toronto, Toronto, Ontario, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
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139
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Castellani C, Duff AJA, Bell SC, Heijerman HGM, Munck A, Ratjen F, Sermet-Gaudelus I, Southern KW, Barben J, Flume PA, Hodková P, Kashirskaya N, Kirszenbaum MN, Madge S, Oxley H, Plant B, Schwarzenberg SJ, Smyth AR, Taccetti G, Wagner TOF, Wolfe SP, Drevinek P. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros 2018; 17:153-178. [PMID: 29506920 DOI: 10.1016/j.jcf.2018.02.006] [Citation(s) in RCA: 426] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/26/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata Verona, Italy; Cystic Fibrosis Centre, Gaslini Institute, Genoa, Italy
| | - Alistair J A Duff
- Regional Paediatric CF Unit, Leeds General Infirmary Leeds, UK; Department of Clinical & Health Psychology, St James' University Hospital, Leeds, UK.
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Harry G M Heijerman
- Dept of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Munck
- Hopital Robert Debré Assistante publique-Hôpitaux de Paris, Université Paris 7, Pediatric CF Centre, Paris, France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Isabelle Sermet-Gaudelus
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151 Hôpital Necker Enfants Malades, P, France
| | - Kevin W Southern
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jurg Barben
- Ostschweizer Kinderspital Sankt Gallen, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Patrick A Flume
- Division of Pulmonary and Critical Care, Medical University of South Carolina, USA
| | - Pavla Hodková
- Department of Clinical Psychology, University Hospital, Prague, Czech Republic
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis Group), Federal State Budgetary Institution, Research Centre for Medical Genetics, Moscow, Russia
| | - Maya N Kirszenbaum
- Department of Pediatric Pulmunology, CRCM, Hôpital Necker-Enfants Malades, Paris, France
| | - Sue Madge
- Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
| | - Helen Oxley
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Barry Plant
- Cork Adult CF Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Sarah Jane Schwarzenberg
- Divison of Pediatric Gastroenterology Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), University of Nottingham, Nottingham, UK
| | - Giovanni Taccetti
- Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Thomas O F Wagner
- Frankfurter Referenzzentrum für Seltene Erkrankungen (FRZSE), Universitätsklinikum Frankfurt am Main, Wolfgang von Goethe-Universität, Frankfurt am Main, Germany
| | - Susan P Wolfe
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Leeds Teaching Hospitals, Belmont Grove, Leeds, UK
| | - Pavel Drevinek
- Department of Medical Microbiology, Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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140
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Robinson PD, Lum S, Moore C, Hardaker KM, Benseler N, Aurora P, Cooper P, Fitzgerald D, Jensen R, McDonald R, Selvadurai H, Ratjen F, Stanojevic S. Comparison of facemask and mouthpiece interfaces for multiple breath washout measurements. J Cyst Fibros 2018; 17:511-517. [PMID: 29483003 DOI: 10.1016/j.jcf.2018.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/17/2017] [Accepted: 01/07/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Different interfaces (mouthpiece/nose clip vs. facemask) are used during multiple breath washout (MBW) tests in young children. METHODS We investigated the effect of interface choice and breathing modalities on MBW outcomes in healthy adults and preschool children. RESULTS In adults (n = 26) facemask breathing significantly increased LCI, compared to mouthpiece use (mean difference (95% CI) 0.4 (0.2; 0.6)), with results generalizable across sites and different equipment. Exclusively nasal breathing within the facemask increased LCI, as compared to oral breathing. In preschoolers (2-6 years, n = 46), no significant inter-test difference was observed across interfaces for LCI or FRC. Feasibility and breathing stability were significantly greater with facemask (incorporating dead space volume minimization), vs. mouthpiece. This was more pronounced in subjects <4 years of age. CONCLUSION Both nasal vs. oral breathing and mouthpiece vs. facemask affect LCI measurements in adults. This effect was minimal in preschool children, where switching between interfaces is most likely to occur.
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Affiliation(s)
- Paul D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Westmead, Australia.
| | - Sooky Lum
- Respiratory, Critical Care & Anaesthesia section, UCL, Institute of Child Health, London, United Kingdom
| | - Courtney Moore
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - Kate M Hardaker
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Westmead, Australia
| | - Nick Benseler
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - Paul Aurora
- Respiratory, Critical Care & Anaesthesia section, UCL, Institute of Child Health, London, United Kingdom; Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Peter Cooper
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Australia
| | - Dominic Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Westmead, Australia
| | - Renee Jensen
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom; Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Reginald McDonald
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hiran Selvadurai
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Westmead, Australia
| | - Felix Ratjen
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom; Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Sanja Stanojevic
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom; Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
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141
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Rayment JH, Stanojevic S, Davis SD, Retsch-Bogart G, Ratjen F. Lung clearance index to monitor treatment response in pulmonary exacerbations in preschool children with cystic fibrosis. Thorax 2018; 73:451-458. [DOI: 10.1136/thoraxjnl-2017-210979] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/04/2017] [Accepted: 01/22/2018] [Indexed: 11/03/2022]
Abstract
BackgroundAntibiotic treatment for pulmonary symptoms in preschool children with cystic fibrosis (CF) varies among clinicians. The lung clearance index (LCI) is sensitive to early CF lung disease, but its utility to monitor pulmonary exacerbations in young children has not been assessed.ObjectiveWe aim to (1) understand how LCI changes during lower respiratory tract symptoms relative to a recent clinically stable measurement, (2) determine whether LCI can identify antibiotic treatment response and (3) compare LCI changes to changes in spirometric indices.MethodsLCI and spirometry were measured at quarterly clinic visits over a 12-month period in preschool children with CF. Symptomatic visits were identified and classified as treated or untreated. Treatment response was estimated using propensity score matching methods.Results104 symptomatic visits were identified in 78 participants. LCI increased from baseline in both treated (mean relative change +23.8% (95% CI 16.2 to 31.4)) and untreated symptomatic visits (mean relative change +11.2% (95% CI 2.4 to 19.9)). A significant antibiotic treatment effect was observed when LCI was used as the outcome measure (average treatment effect −15.5% (95% CI −25.4 to −5.6)) but not for z-score FEV1.ConclusionLCI significantly deteriorated with pulmonary symptoms relative to baseline and improved with antibiotic treatment. These data suggest that LCI may have a role in the routine clinical care of preschool children with CF.
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142
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Kanhere N, Couch MJ, Rayment JH, Ratjen F, Santyr G. Reply to Verbanck and Vanderhelst: The Respective Roles of Lung Clearance Index and Magnetic Resonance Imaging in the Clinical Management of Patients with Cystic Fibrosis. Am J Respir Crit Care Med 2018; 197:411-412. [DOI: 10.1164/rccm.201707-1392le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nikhil Kanhere
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
| | | | | | - Felix Ratjen
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
| | - Giles Santyr
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
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143
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Moore C, Horton E, Benseler N, Jensen R, Ratjen F. The effects of 100% oxygen on breathing pattern are not limited to young children. Eur Respir J 2018; 51:51/1/1702055. [DOI: 10.1183/13993003.02055-2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 11/05/2022]
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144
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Ramsey K, Ratjen F, Latzin P. Elucidating progression of early cystic fibrosis lung disease. Eur Respir J 2017; 50:50/5/1701916. [DOI: 10.1183/13993003.01916-2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 11/05/2022]
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145
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Hayeems RZ, Miller FA, Vermeulen M, Potter BK, Chakraborty P, Davies C, Carroll JC, Ratjen F, Guttmann A. False-Positive Newborn Screening for Cystic Fibrosis and Health Care Use. Pediatrics 2017; 140:peds.2017-0604. [PMID: 29025964 DOI: 10.1542/peds.2017-0604] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Evidence is mixed regarding the impact of false-positive (FP) newborn bloodspot screening (NBS) results on health care use. Using cystic fibrosis (CF) as an example, we determined the association of FP NBS results with health care use in infants and their mothers in Ontario, Canada. METHODS We conducted a population-based cohort study of all infants with FP CF results (N = 1564) and screen-negative matched controls (N = 6256) born between April 2008 and November 2012 using linked health administrative data. Outcomes included maternal and infant physician and emergency visits and inpatient hospitalizations from the infant's third to 15th month of age. Negative binomial regression tested associations of NBS status with outcomes, adjusting for infant and maternal characteristics. RESULTS A greater proportion of infants with FP results had >2 outpatient visits (16.2% vs 13.2%) and >2 hospital admissions (1.5% vs 0.7%) compared with controls; CF-related admissions and emergency department visits were not different from controls. Differences persisted after adjustment, with higher rates of outpatient visits (relative risk 1.39; 95% confidence interval 1.20-1.60) and hospital admissions (relative risk 1.67; 95% confidence interval 1.21-2.31) for FP infants. Stratified models indicated the effect of FP status was greater among those whose primary care provider was a pediatrician. No differences in health care use among mothers were detected. CONCLUSIONS Higher use of outpatient services among FP infants may relate to a lengthy confirmatory testing process or follow-up carrier testing. However, increased rates of hospitalization might signal heightened perceptions of vulnerability among healthy infants.
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Affiliation(s)
- Robin Z Hayeems
- Child Health Evaluative Sciences Program and .,Institute of Health Policy, Management and Evaluation
| | | | | | - Beth K Potter
- School of Epidemiology, Public Health and Preventive Medicine and
| | - Pranesh Chakraborty
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Canada; and.,Newborn Screening Ontario, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Christine Davies
- Newborn Screening Ontario, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - June C Carroll
- Department of Family and Community Medicine and Sinai Health System, and
| | - Felix Ratjen
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences Program and.,Institute of Health Policy, Management and Evaluation.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
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146
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Kanhere N, Couch MJ, Kowalik K, Zanette B, Rayment JH, Manson D, Subbarao P, Ratjen F, Santyr G. Correlation of Lung Clearance Index with Hyperpolarized 129Xe Magnetic Resonance Imaging in Pediatric Subjects with Cystic Fibrosis. Am J Respir Crit Care Med 2017; 196:1073-1075. [DOI: 10.1164/rccm.201611-2228le] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nikhil Kanhere
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
| | | | | | - Brandon Zanette
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
| | | | - David Manson
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
| | - Padma Subbarao
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
| | - Felix Ratjen
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
| | - Giles Santyr
- The Hospital for Sick ChildrenToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
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147
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Kane M, Rayment JH, Jensen R, McDonald R, Stanojevic S, Ratjen F. Correcting for tissue nitrogen excretion in multiple breath washout measurements. PLoS One 2017; 12:e0185553. [PMID: 29020072 PMCID: PMC5636099 DOI: 10.1371/journal.pone.0185553] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/14/2017] [Indexed: 11/18/2022] Open
Abstract
Nitrogen excreted from body tissues impacts the calculation of multiple breath nitrogen washout (MBWN2) outcomes. The aim of this study was to determine the effect of tissue N2 on MBWN2 outcomes in both healthy subjects and patients with CF and to assess whether it is possible to correct for tissue N2. The contribution of tissue N2 to MBWN2 outcomes was estimated by comparing MBWN2-derived functional residual capacity (FRCN2) to FRC measured by body plethysmography (FRCpleth) and by comparing MBW outcome measures derived from MBWN2 and sulfur hexafluoride MBW (MBWSF6). Compared to plethysmography and MBWSF6, MBWN2 overestimated FRC and lung clearance index (LCI). Application of mathematical tissue N2 corrections reduced FRCN2 values closer to FRCpleth in health and reduced LCIN2 in both health and CF, but did not explain all of the differences observed between N2-dependent and -independent techniques. Use of earlier washout cut-offs could reduce the influence of tissue N2. Applying tissue N2 corrections to LCIN2 measurements did not significantly affect the interpretation of treatment effects reported in a previously published interventional trial. While tissue N2 excretion likely has an impact on MBWN2 outcomes, better understanding of the nature of this phenomenon is required before routine correction can be implemented into current MBWN2 protocols.
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Affiliation(s)
- Mica Kane
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Jonathan H. Rayment
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Renee Jensen
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Reginald McDonald
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sanja Stanojevic
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Translational Medicine, The Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- * E-mail:
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148
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Oude Engberink E, Ratjen F, Davis SD, Retsch-Bogart G, Amin R, Stanojevic S. Inter-test reproducibility of the lung clearance index measured by multiple breath washout. Eur Respir J 2017; 50:50/4/1700433. [PMID: 28982773 PMCID: PMC5898949 DOI: 10.1183/13993003.00433-2017] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/06/2017] [Indexed: 01/15/2023]
Abstract
The lung clearance index (LCI) has strong intra-test repeatability; however, the inter-test reproducibility of the LCI is poorly defined. The aim of the present study was to define a physiologically meaningful change in LCI in preschool children, which discriminates changes associated with disease progression from biological variability. Repeated LCI measurements from a longitudinal cohort study of children with cystic fibrosis and age-matched controls were collected to define the inter-visit reproducibility of the LCI. Absolute change, the coefficient of variation, Bland–Altman limits of agreement, the coefficient of repeatability, intra-class correlation coefficient, and percentage changes were calculated. LCI measurements (n=505) from 71 healthy and 77 cystic fibrosis participants (aged 2.6–6 years) were analysed. LCI variability was proportional to its magnitude, such that reproducibility defined by absolute changes is biased. A physiologically relevant change for quarterly LCI measurements in health was defined as exceeding ±15%. In clinically stable cystic fibrosis participants, the threshold was higher (±25%); however, for measurements made 24 h apart, the threshold was similar to that observed in health (±17%). A percentage change in LCI greater than ±15% in preschool children can be considered physiologically relevant and greater than the biological variability of the test. Biological variability of lung clearance index is dependent on magnitude; % change is better for tracking patientshttp://ow.ly/tgbX30dBbCX
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Affiliation(s)
- Esther Oude Engberink
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Division of Respiratory Medicine and Allergy, Dept of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Felix Ratjen
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie D Davis
- Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Reshma Amin
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sanja Stanojevic
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada .,Dept of Medicine, University of Toronto, Toronto, ON, Canada
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149
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Abstract
BACKGROUND The antibiotics used to treat pulmonary infections in people with cystic fibrosis are typically chosen based on the results of antimicrobial susceptibility testing performed on bacteria traditionally grown in a planktonic mode (grown in a liquid). However, there is considerable evidence to suggest that Pseudomonas aeruginosa actually grows in a biofilm (or slime layer) in the airways of people with cystic fibrosis with chronic pulmonary infections. Therefore, choosing antibiotics based on biofilm rather than conventional antimicrobial susceptibility testing could potentially improve response to treatment of Pseudomonas aeruginosa in people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To compare biofilm antimicrobial susceptibility testing-driven therapy to conventional antimicrobial susceptibility testing-driven therapy in the treatment of Pseudomonas aeruginosa infection in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Most recent search: 19 June 2017.We also searched two ongoing trials registries and the reference lists of relevant articles and reviews. Most recent searches: 24 August 2017 and 05 September 2017. SELECTION CRITERIA Randomized controlled trials of antibiotic therapy based on biofilm antimicrobial susceptibility testing compared to antibiotic therapy based on conventional antimicrobial susceptibility testing in the treatment of Pseudomonas aeruginosa pulmonary infection in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed their risk of bias and extracted data from eligible trials. Additionally, the review authors contacted the trial investigators to obtain further information. The quality of the evidence was assessed using the GRADE criteria. MAIN RESULTS The searches identified two multicentre, randomized, double-blind controlled clinical trials eligible for inclusion in the review with a total of 78 participants (adults and children); one trial was done in people who were clinically stable, the other in people experiencing pulmonary exacerbations. These trials prospectively assessed whether the use of biofilm antimicrobial susceptibility testing improved microbiological and clinical outcomes in participants with cystic fibrosis who were infected with Pseudomonas aeruginosa. The primary outcome was the change in sputum Pseudomonas aeruginosa density from the beginning to the end of antibiotic therapy.Although the intervention was shown to be safe, the data from these two trials did not provide evidence that biofilm susceptibility testing was superior to conventional susceptibility testing either in terms of microbiological or lung function outcomes. One of the trials also measured risk and time to subsequent exacerbation as well as quality of life measures and did not demonstrate any difference between groups in these outcomes. Both trials had an overall low risk of bias and the quality of the evidence using GRADE criteria was deemed to be moderate to high for the outcomes selected. AUTHORS' CONCLUSIONS The current evidence is insufficient to recommend choosing antibiotics based on biofilm antimicrobial susceptibility testing rather than conventional antimicrobial susceptibility testing in the treatment of Pseudomonas aeruginosa pulmonary infections in people with cystic fibrosis. Biofilm antimicrobial susceptibility testing may be more appropriate in the development of newer, more effective formulations of drugs which can then be tested in clinical trials.
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Affiliation(s)
- Valerie Waters
- Hospital for Sick ChildrenDepartment of Pediatrics, Division of Infectious Diseases555 University AvenueTorontoONCanadaM5G 1X8
| | - Felix Ratjen
- The Hospital for Sick ChildrenDepartment of Pediatrics555 University AvenueTorontoONCanadaM5G 1XB
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150
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Grasemann H, Ciet P, Amin R, McDonald N, Klingel M, Tiddens H, Ratjen F, Grosse-Wortmann L. Changes in magnetic resonance imaging scores and ventilation inhomogeneity in children with cystic fibrosis pulmonary exacerbations. Eur Respir J 2017; 50:50/2/1700244. [DOI: 10.1183/13993003.00244-2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/29/2017] [Indexed: 11/05/2022]
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