Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report

Wearable microfluidic patch with integrated capillary valves and pumps for sweat management and multiple biomarker analysis

Wearable sweat sensors are essential for providing insight into human physiological health. The currently developed microfluidic sweat sensors have demonstrated the function of collecting and storing sweat. However, they detect more average concentrations of substances based on time periods, which leads to the fact that in situ real-time measurement for multiple biomarkers remains a grand challenge. Here, we propose a wearable epidermal microfluidic patch with integrated microfluidic pumps and micro-valves for accelerated and continuous collection of the sweat, where the micro-pumps ensure the complete separation of old and new sweat for real-time detection of real concentration of biomarkers in sweat. The biomarker concentration at different time periods is detected by introducing a burst valve, which is used to assist in the analysis of the real-time detection. A quantitative relationship between the minimum burst pressure difference required for sequential collection and the size of the microchannel structure is established to overcome the effects of additional resistance at the gas-liquid interface. Additionally, the sensing modules, including sodium ion, chlorine ion, glucose, and pH level in sweat, are integrated into the patch to realize in situ, real-time detection of multiple biomarkers in the human sweat, decoding the correlation between changes in substance concentrations and physiological conditions. This work provides a unique and simplifying strategy for developing wearable sweat sensors for potential applications in health monitoring and disease diagnostics.

Things come in threes: A new complex allele and a novel deletion within the CFTR gene complicate an accurate diagnosis of cystic fibrosis

Background

Despite consolidated guidelines, the clinical diagnosis and prognosis of cystic fibrosis (CF) is still challenging mainly because of the extensive phenotypic heterogeneity and the high number of CFTR variants, including their combinations as complex alleles.

Results

We report a family with a complicated syndromic phenotype, which led to the suspicion not only of CF, but of a dominantly inherited skeletal dysplasia (SD). Whereas the molecular basis of the SD was not clarified, segregation analysis was central to make a correct molecular diagnosis of CF, as it allowed to identify three CFTR variants encompassing two known maternal mutations and a novel paternal microdeletion.

Conclusion

This case well illustrates possible pitfalls in the clinical and molecular diagnosis of CF; presence of complex phenotypes deflecting clinicians from appropriate CF recognition, and/or identification of two mutations assumed to be in trans but with an unconfirmed status, which underline the importance of an in‐depth molecular CFTR analysis.

The effect of TGF-β1 polymorphisms on pulmonary disease progression in patients with cystic fibrosis

BACKGROUND

Transforming Growth Factor-β1 (TGF-β1) is a genetic modifier in patients with cystic fibrosis (CF). Several single nucleotide polymorphisms (SNPs) of TGF-β1 are associated with neutrophilic inflammation, lung fibrosis and loss of pulmonary function.

AIM

The aim of this study was to assess the relationship between genetic TGF-β1 polymorphisms and pulmonary disease progression in CF patients. Furthermore, the effect of TGF-β1 polymorphisms on inflammatory cytokines in sputum was investigated.

METHODS

56 CF-patients and 62 controls were genotyped for three relevant SNPs in their TGF-β1 sequence using the SNaPshot® technique. Individual "slopes" in forced expiratory volume in 1 s (FEV1) for all patients were calculated by using documented lung function values of the previous five years. The status of Pseudomonas aeruginosa (Pa) infection was determined. Sputum concentrations of the protease elastase, the serine protease inhibitor elafin and the cytokines IL-1β, IL-8, IL-6, TNF-α were measured after a standardized sputum induction and processing.

RESULTS

The homozygous TT genotype at codon 10 was associated with a lower rate of chronic Pa infection (p < 0.05). The heterozygous GC genotype at codon 25 was associated with lower lung function decline (p < 0.05). Patients with homozygous TT genotype at the promotor SNP showed higher levels of TNF-α (p < 0,05). Higher levels of TGF-β1 in plasma were associated with a more rapid FEV1 decline over five years (p < 0.05).

CONCLUSIONS

Our results suggest that polymorphisms in the TGF-β1 gene have an effect on lung function decline, Pa infection as well as levels of inflammatory cytokines. Genotyping these polymorphisms could potentially be used to identify CF patients with higher risk of disease progression. TGF-β1 inhibition could potentially be developed as a new therapeutic option to modulate CF lung disease.

Differing rates of fungi in sinonasal cultures from pediatric sinusitis patients

OBJECTIVES

Pediatric chronic rhinosinusitis (PCRS) is a unique clinical entity and the underlying source of inflammation is unknown. Certain subgroups, such as children with nasal polyps and cystic fibrosis (CF) sinusitis are often recalcitrant to standard medical PCRS treatments that target bacterial inflammation. Fungal infection and allergy to fungal proteins drive inflammation in other airway diseases, resulting in chronic inflammation of both the upper and lower airways. However, there is limited understanding of the role of fungi in the pathophysiology of PCRS. The objective of this study is to define the frequency of fungal infection in pediatric CRS patients, hypothesizing that certain subgroups may have more frequent positive fungal sinus cultures than other subgroups of pediatric sinusitis.

METHODS

Retrospective study of patients undergoing sinus surgery at a tertiary care pediatric hospital to determine the period prevalence of positive fungal cultures in subgroups of patients.

RESULTS

400 children from 2012 to 2019 were included. 265 patients had surgical culture results available. Of the 52 patients with CF 11 (21%) had positive fungal sinus cultures. Similarly, 28% of the 25 patients with non-CF nasal polyps had positive cultures. Only 8.2% of 110 CRS without polyps patients had positive cultures, significantly fewer than other subgroups (X² (1, N = 240) = 17.22, p < 0.01).

CONCLUSION

Children with CF and children with nasal polyps had more frequent positive fungal cultures than children without nasal polyps having sinus surgery. This confirms that pediatric CF and pediatric CRS with polyps represent unique populations to study the impact of fungal infection in CRS. Further research is required to determine if these fungi represent colonization or contribute to the inflammatory environment of the airways.

Vitamins A, D, E status as related to supplementation and lung disease markers in young children with cystic fibrosis

BACKGROUND

The variable response to fat-soluble vitamin supplementation in young children with cystic fibrosis (CF), and factors contributing to this variability, remain under-investigated.

OBJECTIVE

To determine if recommended supplement doses normalize serum vitamins A (retinol), D (25-hydroxy-vitamin D, 25OHD), and E (α-tocopherol), and identify factors predictive of achieving sufficiency, in children with CF in the first 3 years of life.

DESIGN

We studied 144 infants born during 2012-2017 and diagnosed with CF through newborn screening. Serum retinol, 25OHD, α-tocopherol and plasma cytokines interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α were measured in early infancy and yearly thereafter. Vitamin supplement intakes and respiratory microbiology were assessed every 1-2 months in infancy and quarterly thereafter.

RESULTS

The prevalence of vitamin D insufficiency (<30 ng/ml) at all ages combined was significantly higher (22%) compared to vitamin A (<200 ng/ml, 3%) and vitamin E (<5 µg/ml, 5%). All children were vitamin A sufficient by age 2 years. Vitamin E insufficiency was rare. Only 42% were early responders of vitamin D and 17% remain insufficient despite high supplement intakes. IL-6 was positively correlated, while IL-8, IL-10, and TNF-α were negatively correlated, with retinol and 25OHD. Multiple regression analysis revealed that supplement dose, season, α-tocopherol, pancreatic insufficiency, respiratory infections and IL-10 were significant predictors of 25OHD.

CONCLUSION

Diagnosis through newborn screening coupled with supplementation normalized serum retinol and α-tocopherol in almost all infants with CF by age 3 years. However, response to vitamin D supplements in young children with CF occurred later and variably despite early and sustained supplementation.

CFTR-mediated monocyte/macrophage dysfunction revealed by cystic fibrosis proband-parent comparisons

Cystic fibrosis (CF) is an inherited disorder caused by biallelic mutations of the CF transmembrane conductance regulator (CFTR) gene. Converging evidence suggests that CF carriers with only 1 defective CFTR copy are at increased risk for CF-related conditions and pulmonary infections, but the molecular mechanisms underpinning this effect remain unknown. We performed transcriptomic profiling of peripheral blood mononuclear cells (PBMCs) of CF child-parent trios (proband, father, and mother) and healthy control (HC) PBMCs or THP-1 cells incubated with the plasma of these participants. Transcriptomic analyses revealed suppression of cytokine-enriched immune-related genes (IL-1β, CXCL8, CREM), implicating lipopolysaccharide tolerance in innate immune cells (monocytes) of CF probands and their parents. These data suggest that a homozygous as well as a heterozygous CFTR mutation can modulate the immune/inflammatory system. This conclusion is further supported by the finding of lower numbers of circulating monocytes in CF probands and their parents, compared with HCs, and the abundance of mononuclear phagocyte subsets, which correlated with Pseudomonas aeruginosa infection, lung disease severity, and CF progression in the probands. This study provides insight into demonstrated CFTR-related innate immune dysfunction in individuals with CF and carriers of a CFTR mutation that may serve as a target for personalized therapy.

Chronic cough in cystic fibrosis - the effect of modulator therapy on objective 24-hour cough monitoring

Cystic fibrosis (CF) is an autosomal recessive condition, deletion of phenylalanine at position 508 (F508del) being the most frequent mutation in CF patients. Kaftrio, also called Trikafta in the USA, (Vertex Pharmaceuticals Inc., Germany) is a licensed modulator therapy for CF patients with at least one F508del mutation [1]. Several clinical trials have demonstrated its efficacy [2]. However, the primary outcome measured in these studies was the change in per cent predicted of forced expiratory volume in 1 s (FEV₁), which was in the order of 10%, and thus may have a relatively low sensitivity in predicting efficacy, particularly in more severely affected patients [3].

This is a prospective observation of the effect of Kaftrio initiation in CF. An early and dramatic improvement in the objective measure of 24-h cough monitoring was observed, providing noninvasive, objective evidence of efficacy and compliance in CF.https://bit.ly/3LpnABB

Cystic fibrosis in children: A pediatric anesthesiologist's perspective

Cystic fibrosis is a multi-systemic disease of impaired sodium and chloride transport across epithelial surfaces. Cystic fibrosis is one of the most common autosomal recessive diseases among Caucasian children. However, recent epidemiologic studies suggest that the disease in Hispanic, African American, and Asian American populations may be more common than previously recognized. The phenotypic expression is characterized by the constellation of pulmonary, pancreatic, hepatobiliary, and gastrointestinal dysfunction. Progressive obstructive lung disease is the hallmark of cystic fibrosis, and end-stage respiratory failure is the primary cause of morbidity and mortality. The most significant advance in the care has been the development of cystic fibrosis modulators, a class of drugs that restore cystic fibrosis transmembrane conductance regulator folding, intracellular processing, or function. Improved diagnostic abilities, a multidisciplinary approach to medical management, and the use of cystic fibrosis modulators have led to improvement in the quality of life and life expectancy. These patients undergo range of procedures such as nasal polypectomy, placement of gastrostomy tubes, vascular access device placement, transbronchial lung biopsies, and other thoracic surgeries. The anesthetic care of children with advanced cystic fibrosis disease is complex. Preoperative optimization can help improve postoperative outcomes. Strategies for pain control should rely on non-opiate, multimodal adjuncts, and regional or neuraxial techniques. Unfortunately for some children, a progressive respiratory disease often leads to end-stage respiratory failure and lung transplant surgery remains the only viable treatment option. Widespread use of lung transplant surgery as a treatment option is severely constraint by donor organ availability. Primary graft dysfunction is the most common cause of early death and can be seen within 48 h of surgery. Median long-term survival after lung transplant remains modest. Chronic lung allograft dysfunction, opportunistic infections, and post-transplant lymphoproliferative disorder are the most common causes of morbidity and mortality among long-term survivors.

Increasing life expectancy in cystic fibrosis: Advances and challenges

Since the first description of cystic fibrosis in 1938, there have been significant advances in both quality of life and longevity for people living with this disease. In this article we describe the milestones of the last 80 years and what we perceive to be the remaining barriers to normalcy for this population.

Review article: epidemiology, pathogenesis and management of liver disease in adults with cystic fibrosis

BACKGROUND

Cystic fibrosis-related liver disease (CFLD) is the leading cause of death in cystic fibrosis (CF), after pulmonary disease. To improve identification and management of this condition requires an understanding of the underlying disease mechanism.

AIMS

This review summarises the current understanding of CFLD epidemiology, pathology, diagnosis and management.

METHODS

Relevant reports on cystic fibrosis liver disease were identified using a literature search and summarised.

RESULTS

CFLD is a heterogeneous condition with several different co-existent pathologies, including environmental and genetic factors. Incidence of clinically significant CFLD continues at a linear rate into early adulthood and has been described in up to 25% of CF patients. Diagnosis strategies lack precision and patient risk stratification needs to look beyond Childs-Pugh scoring. Efficacious therapies are lacking and, at present, newer modulator therapies lack data in CFLD and carry an increased risk of hepatotoxicity. Outcomes of liver transplant are comparable to non-CF transplant indications.

CONCLUSIONS

The incidence of CFLD increases with age and hence is increasingly important to adult patients with CF. Effective therapies are lacking. For progress to be made a better understanding of pathogenesis and disease detection are required.

The Correlation of Health-Related Quality of Life with Cystic Fibrosis Severity Markers in Chest CT Scan and 6-Minute Walk Test: A Cross-Sectional Study

OBJECTIVE

To investigate the correlation between severity of lung disease determined by chest computed tomography (CT) and 6-min walk test (6MWT) with health-related quality of life (HRQoL) score in cystic fibrosis (CF) patients.

METHODS

This cross-sectional study evaluated 76 CF patients referred to CF Clinic, aged 7-14 y. Subjects were asked to complete Pediatric quality of life (PedsQL4.0) forms, during their outpatient visits to determine their HRQoL score. Patients' lung disease severity was quantified by Bhalla score determined by the child's chest CT and their 6MWT. These three variables were then analyzed to determine whether there is correlation between HRQoL with severity of lung disease.

RESULTS

The mean distance of patients 6MWT score was 447.4 ± 81.4 m. There was a positive correlation between distance and HRQoL score in total, social, school and emotional function (p < 0.05). However, in physical function the correlation lacked significance (p = 0.07). Patients with a Bhalla score of less than 15 were older than patients with a Bhalla score of more than 15 (p < 0.001). Physical, emotional, social, school, and total function scores were significantly lower in patients with Bhalla score less than 15, compared to those with Bhalla score greater than 15 (p < 0.05).

CONCLUSIONS

The correlation among Bhalla score on CT scan, 6-min walk test, and HRQoL indicates that pulmonary disease has a clear impact on the quality of life of CF patients. HRQoL can be used in the care program of children with CF.

Electrochemical detection of chloride ions using Ag-based electrodes obtained from compact disc

In this work electrochemical sensors fabricated from compact disc material (waste or new) are used to quantify chloride ions in different types of samples. All three electrodes, working, counter, and pseudo-reference electrodes, were fabricated from the compact disc and directly used. Different parameters were studied in order to demonstrate the possibility of using this waste material for efficient and low-cost electrochemical sensors. Chloride sensing performance was evaluated using linear scan voltammetry as the detection technique. A sensitivity of 0.174 mA mM^-1 cm^-2 with a limit of detection of 20 μM and excellent selectivity against many interferents was observed. Selectivity and reproducibility tests were also carried out, showing excellent results. Sensors were also validated with real samples (drinking and sea water, milk, sweat and physiological solutions) with results comparable to conventional techniques. Our results show the applicability and suitability of these low-cost sensors, for detection of those analytes for which, silver, has high sensitivity and selectivity.

The Exeter Activity Unlimited statement on physical activity and exercise for cystic fibrosis: methodology and results of an international, multidisciplinary, evidence-driven expert consensus

BACKGROUND

The roles of physical activity (PA) and exercise within the management of cystic fibrosis (CF) are recognised by their inclusion in numerous standards of care and treatment guidelines. However, information is brief, and both PA and exercise as multi-faceted behaviours require extensive stakeholder input when developing and promoting such guidelines.

METHOD

On 30th June and 1st July 2021, 39 stakeholders from 11 countries, including researchers, healthcare professionals and patients participated in a virtual conference to agree an evidence-based and informed expert consensus about PA and exercise for people with CF. This consensus presents the agreement across six themes: (i) patient and system centred outcomes, (ii) health benefits, iii) measurement, (iv) prescription, (v) clinical considerations, and (vi) future directions. The consensus was achieved by a stepwise process, involving: (i) written evidence-based synopses; (ii) peer critique of synopses; (iii) oral presentation to consensus group and peer challenge of revised synopses; and (iv) anonymous voting on final proposed synopses for adoption to the consensus statement.

RESULTS

The final consensus document includes 24 statements which surpassed the consensus threshold (>80% agreement) out of 30 proposed statements.

CONCLUSION

This consensus can be used to support health promotion by relevant stakeholders for people with CF.

Five cases of missed cystic fibrosis heterozygous mutations identified after a positive newborn screen on a sibling

In Michigan (MI), NBS for CF was started in October 2007 using the IRT/DNA protocol. In 2016, a component of the Hologic molecular test kit used by the MI NBS lab was recalled (40 CF mutation 2nd tier test). This recall had a major impact on states using the Hologic test kits in their NBS programs. Michigan specimens were sent to another state's NBS Lab for 2nd tier testing using the Luminex 60 mutation test kit until the Luminex kit could be procured and validated in MI. In this report, we present five cases born during this time period. These cases were initially reported out as having normal NBS results for CF but had heterozygous F508 del (c.1521_1523delCTT) mutations later identified. Of the five cases, one was diagnosed with CF (Case1), one with CF related metabolic syndrome (CRMS), and the other three were carriers.

Case report of a Hispanic female with cystic fibrosis and short stature

A 10-year-old female with cystic fibrosis (CF), diagnosed by newborn screen, and pancreatic insufficiency was referred by gastroenterology to endocrinology for short stature (Z-score -3.5 SD). She had poor growth velocity and delayed bone age, although stunting of her growth was evident by age 6 years. Her karyotype was consistent with Turner syndrome (45,X). Growth hormone therapy has improved her growth velocity; she is tolerating it without side effects. At 12 years old, she has delayed puberty due to primary ovarian failure and will initiate estrogen replacement.

Her case highlights the importance of a comprehensive evaluation for short stature in individuals with CF. Poor growth velocity and extreme short stature should not be dismissed as expected comorbidities of CF. The differential for causes of short stature is broad, with some etiologies having significant sequalae and increased morbidity beyond that already seen in CF.

Telemedicine of patients with cystic fibrosis during the COVID-19 pandemic

Objective:

To describe then experience of implementing routine teleconsultations in respiratory physiotherapy at a reference center for Cystic Fibrosis (CF) in Rio de Janeiro / Brazil, during the COVID-19 pandemic.

Methods:

Cross-sectional, descriptive, study with children and adolescents with CF. The sample was divided between participants and those who did not participate in the teleconsultations. The teleconsultations were multidisciplinary and carried out by videoconference or telephone, depending on the patient’s availability. The sequence of care provided by the team was organized together with the professionals, so that everyone could carry out individual and sequential teleconsultations. Physiotherapy appointments were divided into two segments: teleconsultation and telemonitoring. Demographic and clinical data were collected.

Results:

Among the 184 patients assisted in the center, 153 (83.2%) participated in the teleservices and, of these, 33 (21.6%) required telemonitoring; 31 (16.8%) patients did not participate in the teleconsultations for not answering the calls. There was no statistical difference between the group that participated or not in teleservices, nor among those who participated in teleconsultations and telemonitoring. The mean age of the studied population was 7.0±0.4 years. Regarding the CFTR gene mutation, 64.7% had at least one F508del allele and 30.9% of the sample had no pathogens in the sputum test.

Conclusions:

Most participants with CF participated in teleconsultations, highlighting the importance of remote assistance activities during the COVID-19 pandemic period. This strategy was considered as positive, and it may become permanent in the care of patients with CF.

3D Printed Skin-Wash Sampler for Sweat Sampling in Cystic Fibrosis Diagnosis Using Capillary Electrophoretic Ion Ratio Analysis

Sweat chloride analysis is one of the important approaches in cystic fibrosis diagnosis. The commonly used Macroduct method to acquire sweat samples is semi-invasive, time consuming and expensive. Furthermore, this method often fails to collect a sufficient amount of sweat in newborns due to the insufficient sweating rate. In this work, we present a novel, simple, 3D-printed sampling device that is used to collect sweat specimens completely noninvasively in less than one minute. The device has a flow-through channel adjacent to the skin surface, through which 500 µL of deionized water is flushed and the spontaneously formed sweat on the skin in the channel area is washed into a plastic vial. The developed skin-wash procedure is a single step operation, is completely noninvasive and it always produces a sweat specimen. The ions from the skin-wash are subsequently analyzed by capillary electrophoresis with contactless conductivity detection and selected ion ratio (Cl−/K+) or ((Cl− + Na+)/K+) is used as a cut-off value to diagnose cystic fibrosis patients with sensitivity and specificity comparable to the conventional Macroduct method.

The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update

Pseudomonas aeruginosa is a Gram-negative bacterial pathogen that is a common cause of nosocomial infections, particularly pneumonia, infection in immunocompromised hosts, and in those with structural lung disease such as cystic fibrosis. Epidemiological studies have identified increasing trends of antimicrobial resistance, including multi-drug resistant (MDR) isolates in recent years. P. aeruginosa has several virulence mechanisms that increase its ability to cause severe infections, such as secreted toxins, quorum sensing and biofilm formation. Management of P. aeruginosa infections focuses on prevention when possible, obtaining cultures, and prompt initiation of antimicrobial therapy, occasionally with combination therapy depending on the clinical scenario to ensure activity against P. aeruginosa. Newer anti-pseudomonal antibiotics are available and are increasingly being used in the management of MDR P. aeruginosa.

CFTR modulation with elexacaftor-tezacaftor-ivacaftor in people with cystic fibrosis assessed by the β-adrenergic sweat rate assay

BACKGROUND

The cystic fibrosis (CF) sweat gland is defective in β-adrenergically-stimulated sweat secretion in the coil and chloride reabsorption in the duct. Whereas chloride reabsorption is regularly assessed by quantitative pilocarpine iontophoresis (QPIT), the measurement of β-adrenergic sweat secretion is not yet established in clinical practice.

METHODS

A novel sweat bubble imaging protocol was developed that determines sweat secretion rates by automatic recording, processing and quality control of the kinetics of sweat droplet formation.

RESULTS

Treatment of CF patients with the CFTR modulators elexacaftor, tezacaftor and ivacaftor reduced the sweat chloride concentration measured in QPIT in the majority of patients to values in the intermediate or normal range. In contrast, the β-adrenergically-stimulated sweat secretion rate assayed by the automated bubble sweat test was normalized in only 3 patients, slightly increased in 12 patients and remained undetectable in 8 patients.

CONCLUSIONS

β-adrenergic sweat stimulation in the coil is apparently rather stringent in its requirements for a wild type CFTR conformation whereas chloride reabsorption in the duct tolerates residual structural and functional deficits of native or pharmacologically rescued mutant CFTR in the apical membrane.

Probabilistic Boolean Modeling of Pre-clinical Tumor Models for Biomarker Identification in Cancer Drug Development

As high-throughput sequencing experiments become more widely used in pre-clinical and clinical settings, pharmacogenetic and pharmacogenomic biomarker development plays an increasingly important role in oncology drug development pipelines and programs. Consequently, computer-based learning approaches have entered into use at multiple stages in pre-clinical and clinical pipelines. However, few approaches are available to identify interpretable and implementable biomarkers of response early in the drug development process when only small pre-clinical data packages are available. To address the need for early-stage biomarker development using pre-clinical tumor models, we have adapted the previously published Probabilistic Target Inhibitor Map (PTIM) platform to the challenge of biomarker hypothesis development, and denoted this approach the Probabilistic Target Map-Biomarker (PTM-Biomarker). In this article, we detail the history and design philosophy of PTM-Biomarker, and present two case studies using the biomarker discovery tool to illustrate its utility in guiding cancer drug development. © 2021 Wiley Periodicals LLC.

Evaluation of anthropometry as an alternative to DXA as predictor of low bone mineral density in children and adolescents with cystic fibrosis

BACKGROUND & AIMS

Low bone mineral density (BMD) for age in people with Cystic Fibrosis (CF) is associated with worse nutritional status. The aim of this study is to assess body composition by anthropometry as a predictor of BMD in people with CF.

METHODS

Multicenter cross-sectional study with 39 people aged 5 and 20 years with CF. BMD was assessed by dual energy x-ray emission (DXA) in the incidence of the total body less head (TBLH) and the TBLH Z-score (Z-TBLH) was calculated, adjusted by sex, age, height and ethnicity. Anthropometry was assessed by weight, height, mid-upper arm circumference (MUAC) and triceps skinfold (TSF). Arm muscle area (AMA) and Body Mass Index (BMI) were calculated. Lean mass (LM), fat mass (FM) and free-fat mass (FFM) were identified by DXA. The molecular analysis method by sequencing was used to identify and classify the participants regarding the presence of the F508del pathogenic variant of the CFTR gene. Statistical models of simple and multiple linear regression were created to establish the predictive power of Z-TBLH in the variables.

RESULTS

Average age of the participants was 13.31 ± 3.86 years, 59% of whom were male. They showed more LM (30.97 Kg ± 11.29) than females (23 Kg ± 6.73). 20 of 30 participants (66.7%) had at least copy of F508del. Among the multiple models, adjusted by height, age and sex, it found BMI (R² = 0.367), Weight (R² = 0.220), AMA (R² = 0.338) as significant predictors of Z-TBLH. The final model composed of AMA, TSF and Age (p = 0.001; R² = 0.381) had AMA and Age as significant predictors. AMA was associated with an increase in the BMD Z-score in the participants studied. 66.7% of genetically tested participants had the F508del pathogenic variant. The presence of the F508del variant was associated with worse nutritional status.

CONCLUSION

A statistical model composed of the values of AMA, TSF and Age can predict Z-TBLH, as well as anthropometric variables Weight, or BMI, or AMA associated with height, age and sex, in children and adolescents aged 5-20 years old, of both sexes. Anthropometric markers, as they are easy and relatively inexpensive to obtain, it is a promising alternative to the use of DXA in predicting BMD in these people with CF.

Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis

BACKGROUND

Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review.

OBJECTIVES

To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis 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. We also searched the reference lists of relevant articles and reviews. Last search: 09 September 2021. We searched two ongoing trial registries (Clinicaltrials.gov and the WHO trials platform). Date of latest search: 16 August 2021.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager.

MAIN RESULTS

Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively.

AUTHORS' CONCLUSIONS

There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.

Colonic Transit Time and Fecal Impaction in Children and Adolescents With Cystic Fibrosis-associated Constipation

BACKGROUND

Constipation is prevalent in pediatric cystic fibrosis (CF) patients and colonic motility has not been studied in this population. In this study, we aimed to evaluate the total and segmental colonic transit time in children and adolescents with CF based on the presence of constipation and radiological fecal impaction.

METHODS

In this case series, all patients aged 3 to 20 years of a CF reference center were invited to participate. CF-associated constipation was diagnosed based on the European Society for Paediatric Gastroenterology Hepatology and Nutrition criteria. Total and segmental colonic transit time was determined using radiopaque markers. Fecal impaction on plain abdominal radiography was assessed based on the Barr score.

RESULTS

Of the 43 eligible patients, 34 (79%) agreed to participate. Constipation was found in 44.1% of children and adolescents, predominantly in girls. The total colonic transit time (medians of 42 and 24 hours, respectively, P = 0.028) and the segmental right colon transit time (medians of 8 and 2 hours, respectively, P = 0.012) were significantly longer in CF-associated constipation group than in the group of patients without constipation. The frequency of radiological fecal impaction was similar in patients with (50.0%) and without (64.2%) CF-associated constipation (P = 0.70). There was no relationship between radiological fecal impaction and the total and segmental colonic transit time.

CONCLUSIONS

Children and adolescents with CF-associated constipation had a longer total and segmental right colon transit time. Colonic transit time was similar in patients with and without radiological fecal impaction.

Assessment of hospitalization rates, factors associated with hospitalization and in-patient mortality in pediatric patients with cystic fibrosis

INTRODUCTION

Cystic fibrosis (CF), an inherited autosomal recessive disease that results in the accumulation of mucus and damage primarily to the respiratory and digestive tracts is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. In the United States, it has been estimated that CF occurs in 1 out of 3500 infants. The objective of this study was to explore the patient and hospital characteristics associated with CF hospitalizations and inpatient mortality in pediatric CF patients.

METHODS

Utilizing the National Inpatient Sample database from 2008 to 2017, a retrospective cohort study was conducted to analyze the hospitalization rates, associated factors, and the inpatient mortality of CF patients 0-17 years of age. Hospitalizations with a diagnosis of CF were identified with ICD-9-CM and ICD-10-CM codes. Adjusted survey logistic regression models were utilized to determine factors associated with CF hospitalizations and in-hospital deaths in CF patients.

RESULTS

There were a total of 98,660 (about 0.2%) CF hospitalizations in patients 17 years of age or younger during the study period. Non-Hispanic (NH) White CF patients had the highest prevalence of CF (26.30 per 10,000 hospitalizations). The prevalence of inpatient deaths were highest among those identified as NH-Others and NH-Blacks (71.35 and 68.83 per 10,000 CF hospitalizations, respectively. When compared with NH-White category, those belonging to NH-Black, Hispanic and Other racial/ethnic sub-group had reduced odds of being hospitalized with CF.

DISCUSSION

Despite our finding of an increased likelihood of being hospitalized for CF among NH-White and male pediatric patients, no association between race or sex and CF inpatient death was observed when adjusted for covariates. More research is needed to determine the impact of sex and race on CF mortality rates.

Two Years of Newborn Screening for Cystic Fibrosis in North Macedonia: First Experience

There is a widely accepted consensus on the benefits of newborn screening (NBS) for cystic fibrosis (CF) in terms of reduced disease severity, improved quality of life, lower treatment burden, and reduced costs. More and more countries in the world are introducing NBS for CF as a national preventive health program. Newborn screening for CF was introduced in the Republic of North Macedonia (RNM) in April, 2019, after a pilot study of 6 months in 2018. A two-step immunoreactive trysinogen (IRT-IRT) algorithm is performed, and then a sweat test for confirmation/exclusion of the CF diagnosis when the IRT values were both over the cutoff (70.0 and 45.0 ng/mL, respectively). In cases with confirmed diagnosis of CF (a sweat chloride concentration >60.0 mmol/L) or with intermediate sweat test results (a sweat chloride concentration of between 30.0 and 59.0 mmol/L), CF transmembrane conductance regulator (CFTR) mutation analysis is performed. By the end of 2020, over a period of 27 months, including the pilot study period, a total number of 43,139 newborns were screened for CF. Seventeen (0.039%) newborns were diagnosed with CF. In all newly discovered CF cases by screening, the diagnosis was confirmed by determination of the CFTR mutations. The most common CFTR mutation, F508del, was found with an overall incidence of 70.6%. Other more frequent mutations were G542X (11.8%) and N1303K (5.9%). Four mutations were found in one CFTR allele each: G1349D, G126D, 457TAT>G and CFTRdupexon22, with the last one being newly discovered with unknown consequences. An incredibly large difference was found in the incidence of the disease between the Macedonian and Albanian neonatal population, with almost four time higher prevalence among Albanians (1:4530 vs. 1:1284).

Effect of Sitagliptin on Islet Function in Pancreatic Insufficient Cystic Fibrosis With Abnormal Glucose Tolerance

PURPOSE

Impaired incretin secretion may contribute to the defective insulin secretion and abnormal glucose tolerance (AGT) that associate with worse clinical outcomes in pancreatic insufficient cystic fibrosis (PI-CF). The study objective was to test the hypothesis that dipeptidyl peptidase-4 (DPP-4) inhibitor-induced increases in intact incretin hormone [glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP)] concentrations augment insulin secretion and glucagon suppression and lower postprandial glycemia in PI-CF with AGT.

METHODS

26 adults from Children's Hospital of Philadelphia and University of Pennsylvania CF Center with PI-CF and AGT [defined by oral glucose tolerance test glucose (mg/dL): early glucose intolerance (1-h ≥ 155 and 2-h < 140), impaired glucose tolerance (2-h ≥ 140 and < 200 mg/dL), or diabetes (2-h ≥ 200)] were randomized to a 6-month double-blind trial of DPP-4 inhibitor sitagliptin 100 mg daily or matched placebo; 24 completed the trial (n = 12 sitagliptin; n = 12 placebo). Main outcome measures were mixed-meal tolerance test (MMTT) responses for intact GLP-1 and GIP, insulin secretory rates (ISRs), glucagon suppression, and glycemia and glucose-potentiated arginine (GPA) test-derived measures of β- and α-cell function.

RESULTS

Following 6-months of sitagliptin vs placebo, MMTT intact GLP-1 and GIP responses increased (P < 0.001), ISR dynamics improved (P < 0.05), and glucagon suppression was modestly enhanced (P < 0.05) while GPA test responses for glucagon were lower. No improvements in glucose tolerance or β-cell sensitivity to glucose, including for second-phase insulin response, were found.

CONCLUSIONS

In glucose intolerant PI-CF, sitagliptin intervention augmented meal-related incretin responses with improved early insulin secretion and glucagon suppression without affecting postprandial glycemia.

Reduced neutrophil elastase inhibitor elafin and elevated transforming growth factor-β1 are linked to inflammatory response in sputum of cystic fibrosis patients with Pseudomonas aeruginosa

Research question

Pulmonary disease progression in patients with cystic fibrosis (CF) is characterised by inflammation and fibrosis and aggravated by Pseudomonas aeruginosa (Pa). We investigated the impact of Pa specifically on: 1) protease/antiprotease balance; 2) inflammation; and 3) the link of both parameters to clinical parameters of CF patients.

Methods

Transforming growth factor-β₁ (TGF-β₁), interleukin (IL)-1β, IL-8, neutrophil elastase (NE) and elastase inhibitor elafin were measured (ELISA assays), and gene expression of the NF-κB pathway was assessed (reverse transcriptase PCR) in the sputum of 60 CF patients with a minimum age of 5 years. Spirometry was assessed according to American Thoracic Society guidelines.

Results

Our results demonstrated the following: 1) NE was markedly increased in Pa-positive sputum, whereas elafin was significantly decreased; 2) increased IL-1β/IL-8 levels were associated with both Pa infection and reduced forced expiratory volume in 1 s, and sputum TGF-β₁ was elevated in Pa-infected CF patients and linked to an impaired lung function; and 3) gene expression of NF-κB signalling components was increased in sputum of Pa-infected patients, and these findings were positively correlated with IL-8.

Conclusion

Our study links Pa infection to an imbalance of NE and NE inhibitor elafin and increased inflammatory mediators. Moreover, our data demonstrate an association between high TGF-β₁ sputum levels and a progress in chronic lung inflammation and pulmonary fibrosis in CF. Controlling the excessive airway inflammation by inhibition of NE and TGF-β₁ might be promising therapeutic strategies in future CF therapy and a possible complement to cystic fibrosis transmembrane conductance regulator (CFTR) modulators.

Preclinical atherosclerosis in cystic fibrosis: Two distinct presentations are related to pancreatic status

BACKGROUND

Patients with cystic fibrosis (CF) are exposed to overlapping cardiovascular risk factors. We hypothesized that CF is characterized by increased arterial stiffness and greater intima-media thickness (IMT).

METHODS

This cross-sectional study assessed the digital volume pulse arterial stiffness index (SI_DVP) using photopletysmography, measured intima-media complex thickness (IMT) at the common carotid artery, and obtained an extended set of clinical and atherosclerosis-related laboratory parameters.

RESULTS

Fifty-five patients with moderate-to-severe CF (mean age 26.3±8.6 years, BMI 20.3±3.1 kg/m2, FEV1 62±26%) and 51 healthy controls (25.1±4.4 years, BMI 21.7±3.0 kg/m2) entered the study. SI_DVP was greater in pancreatic insufficient (PI), but not pancreatic sufficient (PS) CF patients compared with control (7.3±1.8 m/s vs 6.0±1.2 m/s; p=7.1 × 10^-5). IMT was increased in PS (but not PI) participants relative to control (552±69 µm vs 456±95 µm, p=0.0011). SI_DVP was also greater in PI than in PS patients (7.3±1.8 m/s vs 6.3±1.7 m/s, p=0.0232) and IMT was higher in PS compared with PI (552±69 µm vs 453±82 µm, p=0.0002). SI_DVP independently associated with age, PI, the lack of liver cirrhosis, and with Pseudomonas aeruginosa colonization. PS was the only independent correlate of IMT in CF.

CONCLUSIONS

PI patients are at risk of developing general arterial stiffness. PS may relate to carotid IMT thickening, which underscores the need for further study that could lead to reconsideration of dietary guidance in PS CF.

Stretchable and Superwettable Colorimetric Sensing Patch for Epidermal Collection and Analysis of Sweat

Stretchable and wearable sensors allow intimate integration with the human body for health and fitness monitoring. In addition to the acquisition of various physical parameters, quantitative analysis of chemical biomarkers present in sweat may provide vital insights into the physiological state of an individual. A widely investigated system utilizes electrochemical techniques for continuous monitoring of these biomarkers. The required supporting electronics and batteries are often challenging to form a deformable system. In this study, an intrinsically stretchable sensing patch is developed with compliant mechanical properties for conformal attachment to the skin and reliable collection of sweat. In these patches, superhydrophilic colorimetric assays consisting of thermoplastic polyurethane nanofiber textiles decorated with silica nanoparticles are assembled over a styrene-ethylene-butylene-styrene-based superhydrophobic substrate, thereby generating a large wettability contrast to efficiently concentrate the sweat. The system supports multiplexed colorimetric analysis of sweat to quantify pH and ion concentrations with images acquired using smartphones, in which the influence of ambient lighting conditions is largely compensated with a set of reference color markers. Successful demonstrations of in situ analysis of sweat after physical exercises effectively illustrate the practical suitability of the sensing patch, which is attractive for advanced health monitoring, clinical diagnostics, and competitive sports.

Phenotypes of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a complex heterogeneous disease with different phenotypes and endotypes. Recent advances in our understanding of the pathogenetic mechanisms of CRS endotypes have led to the introduction of effective biologic agents for CRS management. Traditionally, CRS phenotypes have been divided into with or without nasal polyps depending on the presence of polyps. Although this classification does not reflect the various endotypes that are recently emerging, it is simple and easily recognized by clinicians. Other phenotypes of CRS are fungal rhinosinusitis (including invasive and noninvasive subtypes), infectious rhinosinusitis, aspirin-exacerbated respiratory disease, cystic fibrosis, pediatric CRS, and CRS associated with systemic diseases. This article reviews the diagnostic approaches and up-to-date treatment strategies for each CRS phenotype with the hope that a better understanding of endotypes will result in a more scientific understanding of phenotypes and precise, personalized treatments.

Bone Cells Differentiation: How CFTR Mutations May Rule the Game of Stem Cells Commitment?

Cystic fibrosis (CF)-related bone disease has emerged as a significant comorbidity of CF and is characterized by decreased bone formation and increased bone resorption. Both osteoblast and osteoclast differentiations are impacted by cystic fibrosis transmembrane conductance regulator (CFTR) mutations. The defect of CFTR chloride channel or the loss of CFTRs ability to interact with other proteins affect several signaling pathways involved in stem cell differentiation and the commitment of these cells toward bone lineages. Specifically, TGF-, nuclear factor-kappa B (NF-B), PI3K/AKT, and MAPK/ERK signaling are disturbed by CFTR mutations, thus perturbing stem cell differentiation. High inflammation in patients changes myeloid lineage secretion, affecting both myeloid and mesenchymal differentiation. In osteoblast, Wnt signaling is impacted, resulting in consequences for both bone formation and resorption. Finally, CFTR could also have a direct role in osteoclasts resorptive function. In this review, we summarize the existing literature on the role of CFTR mutations on the commitment of induced pluripotent stem cells to bone cells.

Sweat Testing and Recent Advances

Cystic fibrosis (CF) is the most common fatal genetic disease of the Caucasian population. Sweat testing is the principal diagnostic test for CF, and it is used for the evaluation of infants with positive CF newborn screening (NBS) and in patients with clinical findings suggesting CF. This article describes the classical sweat test method in detail and also provides an overwiew of recent advances.

A Novel Cystic Fibrosis Gene Mutation C.4242+1G>C in an Omani Patient: A Case Report

Cystic fibrosis (CF) is a genetic disease caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene that affects multisystems in the body, particularly the lungs and digestive system. We report a case of an Omani newborn who presented with meconium ileus and high suspicion of CF. Thus, full CFTR gene sequencing was performed, which revealed a homozygous unreported C.4242+1G>C novel gene mutation. Both parents were found to be heterozygous for this mutation. This case sheds light on the importance of the extensive genetic testing of typical CF cases in the absence of family history or during neonatal presentations, especially when the sweat test cannot be performed and the diagnosis can be challenging.

Self-Powered Point-of-Care Device for Galvanic Cell-Based Sample Concentration Measurement

A novel self-powered point-of-care low-power electronics approach for galvanic cell-based sample concentration measurement is presented. The electronic system harvests and senses at the same time from the single cell. The system implements a solution that is suitable in those scenarios where extreme low power is generated from the fuel cell. The proposed approach implements a capacitive-based method to perform a non-linear sweep voltammetry to the cell, but without the need to implement a potentiostat amplifier for that purpose. It provides a digital-user readable result without the need for external non-self-powered devices or instruments compared with other solutions. The system conception was validated for a particular case. The scenario consisted of the measurement of a NaCl solution as the electrolyte, which was related to the conductivity of the sample. The electronic reader continuously measured the current with a transfer function gain of 1.012VmA⁻¹. The overall system exhibited a maximum coefficient of variation of 6.1%, which was an improvement compared with the state-of-the-art. The proof of concept of this electronics system was validated with a maximum power consumption of 5.8μW using commercial-off-the-self parts.

Motor repertoire is age-inadequate in infants with cystic fibrosis

BACKGROUND

General movements (GMs) in infants occur as fidgety movements (FMs) between postterm 9 and 20 weeks. We aimed to evaluate FMs and motor repertoire in infants with cystic fibrosis (CF) and their relation with clinical findings.

METHODS

Demographic and clinical characteristics were recorded. FMs and motor repertoire were analyzed from a 5-min video recording of each infant. Videos were rated based on the Prechtl General Movement Assessment and motor optimality score (MOS) was calculated.

RESULTS

The analysis included 18 infants with CF and 20 healthy infants at postterm age of 3-5 months. MOS was significantly lower in the infants with CF compared to controls (p < 0.05). Fifty percent of the infants with CF had abnormal or absent/sporadic FMs. MOS was negatively associated with hospitalization duration (r = -0.378, p = 0.036); and positively associated with vitamin A level in CF infants (r = 0.665, p = 0.026).

CONCLUSIONS

Infants with genetically anticipated severe CF phenotype tended to have lower MOS. MOS may be used in addition to genetic testing to predict disease severity in infants with CF. Infants with CF, absent/sporadic FMs, and lower MOS could be considered for planning specific age-adequate early intervention programs.

IMPACT

Motor repertoire was age-inadequate in infants with cystic fibrosis (CF). 50% of infants with CF had abnormal or absent/sporadic fidgety movements (FMs). Motor optimality score (MOS) was positively associated with vitamin A level and negatively correlated with hospitalization duration in infants with CF. MOS tended to decrease as genetically anticipated disease severity increased; thus, MOS might enable us to predict disease severity in CF. The relationship between motor repertoire and phenotype and genotype is unclear and warrants further study. CF infants with absent/sporadic FMs, and lower MOS could be considered for planning early intervention.

The correlation between 6-min walk test and respiratory parameters in children with cystic fibrosis

BACKGROUND

The 6-min walk test (6MWT) is a sub-maximal exercise test and has been widely used for evaluating of exercise capacity of patients with cystic fibrosis (CF) in recent years. Few studies have examined the relationship between 6MWT and parameters used to assess the severity of the disease in children with CF. In this study, we have examined this relationship to find out if 6MWT can be a marker of the severity of cystic fibrosis.

METHODS

A cross-sectional study was done to analyze the correlations among spirometry parameters, body mass index (BMI), chest tomography (CT), and 6MWT. CF patients, aged 7-14 years, were involved.

RESULTS

Seventy-six patients, 32F/44M, mean age 10.49 ± 3.18 years, were studied. The mean distance in 6MWT was 447 ± 84.1. The following correlations versus distance were found: FEV1 (r = 0.255, p = 0.026), FVC(r = 0.285, p = 0.013), FEF25-75% (r = 0.546, p < 0.001), BMI (r = 0.163, p = 0.160), and CT (r = 0.075, p = 0.520).The following correlations versus O₂ saturation (SpO₂) decline were found: FEV1 (r = -0.393, p < 0.001), FVC (r = -0.431, p < 0.001), FEF25-75% (r = -0.296, p = 0.010), BMI (r = 0.042, p = 0.721), and CT (r = -0.196, p = 0.090). There was a significant correlation between 6MWT (distance and SpO₂ decline) and pulmonary function test. There was no significant correlation between BMI, chest CT, and 6MWT.

CONCLUSIONS

6MWT can be applied beside spirometry and chest CT for CF patients follow up.

A pilot study of cystic fibrosis exacerbation response phenotypes reveals contrasting serum and sputum iron trends

The cystic fibrosis (CF) community seeks to explain heterogeneous outcomes of pulmonary exacerbation (PEX) treatment. Serum and sputum inflammatory mediators may identify people with CF (PwCF) at risk for suboptimal responses. However, lack of an established association between response phenotypes and these mediators limits clinical application. In this pilot study, we prospectively characterized treatment response phenotypes by assessing health-related quality-of-life (HRQoL) during PEX. We also measured lung function and iron-related biochemical parameters in serum and sputum. We classified subjects as sustained symptom-responders (SRs) or non-sustained symptom-responders (NSRs) based on the absence or presence, respectively, of worsened symptom scores after initial improvement. We used linear mixed models (LMMs) to determine whether trends in lung function, hematologic, serum, and sputum indices of inflammation differed between response cohorts. In 20 PwCF, we identified 10 SRs and 10 NSRs with no significant differences in lung function at PEX onset and treatment durations. SRs had better model-predicted trends in lung function than NSRs during PEX. Non-linear trends in serum and sputum iron levels significantly differed between SRs and NSRs. In adults with cystic fibrosis, PEX treatment response phenotypes may be correlated with distinctive trends in serum and sputum iron concentrations.

Fighting diagnostic confirmation bias: Cystic fibrosis, allergic bronchopulmonary aspergillus, or both?

As diagnostic algorithms for cystic fibrosis (CF) continue to evolve, education of general practitioners is essential to prevent delayed diagnosis of CF and allow prompt referral to CF centers. For patients suffering from allergic bronchopulmonary aspergillosis (ABPA), CF should be at the top of the differential diagnosis.

Severe Genotype, Pancreatic Insufficiency and Low Dose of Pancreatic Enzymes Associate with Abnormal Serum Sterol Profile in Cystic Fibrosis

BACKGROUND

Several factors could lead to lipid disturbances observed in cystic fibrosis (CF). This study aimed to assess sterol homeostasis in CF and define potential exogenous and endogenous determinants of lipid dysregulation.

METHODS

The study involved 55 CF patients and 45 healthy subjects (HS). Sterol concentrations (μg/dL) were measured by gas chromatography/mass spectrometry. CF was characterised by lung function, pancreatic status, liver disease and diabetes coexistence, Pseudomonas aeruginosa colonisation and BMI. CFTR genotypes were classified as severe or other.

RESULTS

Campesterol and β-sitosterol concentrations were lower (p = 0.0028 and p < 0.0001, respectively) and lathosterol levels (reflecting endogenous cholesterol biosynthesis) were higher (p = 0.0016) in CF patients than in HS. Campesterol and β-sitosterol concentrations were lower in patients with a severe CFTR genotype, pancreatic insufficiency and lower pancreatic enzyme dose (lipase units/gram of fat). In multiple regression analyses, β-sitosterol and campesterol concentrations were predicted by genotype and pancreatic insufficiency, whereas cholesterol and its fractions were predicted by phytosterol concentrations, age, dose of pancreatic enzymes, nutritional status and genotype.

CONCLUSIONS

Independent determinants of lipid status suggest that malabsorption and pancreatic enzyme supplementation play a significant role in sterol abnormalities. The measurement of campesterol and β-sitosterol concentrations in CF patients may serve for the assessment of the effectiveness of pancreatic enzyme replacement therapy and/or compliance, but further research is required.

Clinical Characteristics Associated With Lung Function Decline in Individuals With Adult-Diagnosed Cystic Fibrosis: Contemporary Analysis of the Canadian CF Registry

BACKGROUND

Individuals with cystic fibrosis (CF) diagnosed as adults represent a rare but growing subset of the CF population. Limited studies have described their lung function trajectories.

RESEARCH QUESTION

What is the overall trajectory of lung function and clinical characteristics associated with lung function decline in people who receive a diagnosis of CF as adults?

STUDY DESIGN AND METHODS

The Canadian CF Patient Registry (CCFR) was used to identify patients with CF who were ≥ 18 years of age at diagnosis and received a diagnosis between 2000 and 2017. Linear mixed-effects models were used to quantify the change in lung function over age and to examine clinical characteristics associated with lung function decline.

RESULTS

Lung function was stable in early adulthood, with a decline in middle adulthood (age 30-50 years) and a greater decline after 50 years of age. Individuals who receive a diagnosis at older ages (> 50 years: slope, -0.71%/y; 41-50 years: -0.68%/y; 31-40 years: -0.29%/y; 18-30 years: -0.28%/y) and those demonstrating pulmonary symptoms (slope, -0.41%/y) compared with no pulmonary symptoms at baseline were associated with faster rate of lung function decline.

INTERPRETATION

The lung function of who receive a diagnosis of CF as adults in the CCFR declines slowly compared with estimates from the overall adult CF population. Individuals with adult-diagnosed CF who are older and demonstrate pulmonary symptoms at diagnosis experience a faster rate of lung function decline and should be monitored more closely.

Prognosis-Based Early Intervention Strategies to Resolve Exacerbation and Progressive Lung Function Decline in Cystic Fibrosis

Cystic fibrosis (CF) is a genetic disease caused by a mutation(s) in the CF transmembrane regulator (CFTR), where progressive decline in lung function due to recurring exacerbations is a major cause of mortality. The initiation of chronic obstructive lung disease in CF involves inflammation and exacerbations, leading to mucus obstruction and lung function decline. Even though clinical management of CF lung disease has prolonged survival, exacerbation and age-related lung function decline remain a challenge for controlling the progressive lung disease. The key to the resolution of progressive lung disease is prognosis-based early therapeutic intervention; thus, the development of novel diagnostics and prognostic biomarkers for predicting exacerbation and lung function decline will allow optimal management of the lung disease. Hence, the development of real-time lung function diagnostics such as forced oscillation technique (FOT), impulse oscillometry system (IOS), and electrical impedance tomography (EIT), and novel prognosis-based intervention strategies for controlling the progression of chronic obstructive lung disease will fulfill a significant unmet need for CF patients. Early detection of CF lung inflammation and exacerbations with the timely resolution will not only prolong survival and reduce mortality but also improve quality of life while reducing significant health care costs due to recurring hospitalizations.

Cystic Fibrosis

Cystic fibrosis (CF) is one of the most commonly diagnosed genetic disorders. Clinical characteristics include progressive obstructive lung disease, sinusitis, exocrine pancreatic insufficiency leading to malabsorption and malnutrition, liver and pancreatic dysfunction, and male infertility. Although CF is a life-shortening disease, survival has continued to improve to a median age of 46.2 years due to earlier diagnosis through routine newborn screening, promulgation of evidence-based guidelines to optimize nutritional and pulmonary health, and the development of CF-specific interdisciplinary care centers. Future improvements in health and quality of life for individuals with CF are likely with the recent development of mutation-specific modulator therapies. In this review, we will cover the current understanding of the disease manifestations, diagnosis, and management as well as common complications seen in individuals with CF.

The effects of the addition of a new airway clearance device to chest physiotherapy in children with cystic fibrosis pulmonary exacerbations

BACKGROUND

Chest physiotherapy plays a crucial role in managing cystic fibrosis, especially during pulmonary exacerbations. This study evaluated the effects of adding a new airway clearance device to chest physiotherapy in subjects with cystic fibrosis hospitalised due to pulmonary exacerbations.

METHODS

This prospective open-label study was carried out at the Pediatric Cystic Fibrosis Centre in Poland between October 2017 and August 2018. Cystic fibrosis patients aged 10 to 18 years who were admitted to the hospital and required intravenous antibiotic therapy due to pulmonary exacerbations were consecutively allocated (1:1) to either chest physiotherapy alone or chest physiotherapy with a new airway clearance device (Simeox; PhysioAssist). Patients performed spirometry and multiple-breath nitrogen washout for lung clearance index assessment upon admission and prior to discharge.

RESULTS

Forty-eight cystic fibrosis patients were included (24 in each group). Spirometry parameters in both groups improved significantly after intravenous antibiotic therapy. A significant improvement in the maximum expiratory flow at 25% of forced vital capacity was observed only in the group with a new airway clearance device (p < 0.01 vs. baseline). Trends towards a lower lung clearance index ratio were similar in both groups. No adverse events were observed in either group.

CONCLUSIONS

Spirometry parameters increased significantly in cystic fibrosis patients treated for pulmonary exacerbations with intravenous antibiotic therapy and intensive chest physiotherapy. The new airway clearance device was safe and well tolerated when added to chest physiotherapy and may be another option for the treatment of pulmonary exacerbation in cystic fibrosis.

Dialogs in the assessment of neonatal cholestatic liver disease

Neonatal cholestatic liver disease is rarely encountered by pathologists outside of specialized pediatric centers and navigating the long list of potential diseases can be daunting. However, the differential diagnosis can be rapidly narrowed through open conversations between the pathologist and pediatric gastroenterologist. The dialog should ideally begin before obtaining the liver biopsy and continue through the rendering of the final pathologic diagnosis. Such dialogs are necessary to first ensure the proper handling of the precious sample and then to allow for synthesis of the clinical, laboratory, imaging, and genetic data in the context of the histologic features seen in the liver biopsy. In this review, we aim to provide a broad template on which such dialogs may be based and pitfalls that may be encountered on both the clinical and pathologic sides. This review will focus on non-biliary atresia etiologies of neonatal cholestasis, including select infectious, genetic, and metabolic entities.

Implementing a tracking system for confirmatory diagnostic results after positive newborn screening for cystic fibrosis-implications for process quality and patient care

Newborn screening for cystic fibrosis (CF-NBS) was introduced in Germany in 2016. Currently, systematic follow-up of positive CF-NBS results is not implemented or reimbursed in the NBS program. We investigated results of confirmatory testing over 24 months after implementation of CF-NBS for a large German NBS center before and after introduction of an active tracking system and performed a cost calculation for tracking. Results are compared with the federal state of Bavaria, where a centralized tracking system has been in place for many years. At the NBS center, 244 of 281,907 children had a positive CF-NBS result requiring diagnostic confirmation. Before implementation of a telephone tracking system, only 43% of confirmatory results were returned despite repeated written requests. The consecutive strategy including telephone tracking led to an increase of resolved cases to 84%. However, the centralized tracking system in Bavaria, assigning children with positive CF-NBS directly to a responsible CF-center, resolved 99% of cases. The calculated additional cost for a tracking system in Germany including telephone tracking is 1.20€ per newborn screened.Conclusion: The implementation of a tracking system achieves a distinct improvement in CF-NBS with justifiable costs. The effect can be limited by absence of centralized organization of confirmatory testing. What is Known: • Newborn screening for cystic fibrosis (CF-NBS) has been performed for many years in several countries worldwide • While many studies have focused on different CF-NBS strategies, the organization of confirmatory testing and process quality concerning returned information to the NBS center has so far received less attention. What is New: • The implementation of an active tracking system achieves a distinct improvement of clarified cases after positive CF-NBS with justifiable costs. • The effect of a tracking system can be limited by the absence of a centralized organization of confirmatory testing.

What Is Most Suitable for Children With Cystic Fibrosis-The Relationship Between Spirometry, Oscillometry, and Multiple Breath Nitrogen Washout

INTRODUCTION

In cystic fibrosis (CF), pathological lung changes begin early in life. The technological progress currently gives many diagnostic possibilities. However, pulmonary function testing in children remains problematic.

OBJECTIVES

Our study aimed to correlate the results of impulse oscillometry (IOS) with those of multiple breath nitrogen washout (MBNW) in our pediatric CF population. We also compared those parameters between the groups with and without spirometric features of obturation.

METHODS

We collected 150 pulmonary function test sets, including spirometry, IOS, and MBNW in patients with CF aged 12.08 ± 3.85 years [6-18]. The study group was divided into two subgroups: IA (without obturation) and IB (with obturation). We also compared Sacin, Scond, and oscillometry parameters of 20 patients aged 14-18 years who reached the appropriate tidal volume (VT) during MBNW.

RESULTS

Statistical analysis showed a negative correlation between lung clearance index (LCI) and spimoetric parameters. Comparison of subgroups IA (n = 102) and IB (n = 48) indicated a statistically significant difference in LCI (p < 0.001) and FEV1z-score (p < 0.001), FEV1% pred (p < 0.001), MEF25z-score (p < 0.001), MEF50 z-score (p < 0.001), MEF75 z-score (p < 0.001), R5% pred (p < 0.05), and R20% pred (p < 0.01). LCI higher than 7.91 was found in 75.33% of the study group, in subgroup IB-91.67%, and IA-67.6%.

CONCLUSIONS

LCI derived from MBNW may be a better tool than IOS for assessing pulmonary function in patients with CF, particularly those who cannot perform spirometry.

Case Report: White Colored Stool: An Early Sign of Cystic Fibrosis in Infants

A 2-month-old male infant presented with white colored stools 1 month after birth. There was no jaundice of the skin, mucous membrane, or sclera; his liver was enlarged (4 cm below the ribs), and his liver function tests showed slightly elevated total bilirubin (TB), direct bilirubin (DB), and total bile acid (TBA). An abdominal doppler ultrasound showed no signs of biliary atresia. Genetic testing revealed a CFTR hemizygous mutation site (c.223C>T) in exon 3 and exon 2-3 heterozygous deletion mutation. The infant's stool turned yellow after oral administration of pancreatic tablets. Finally, the infant was diagnosed with cystic fibrosis (CF). Review of literature revealed five children (including the infant in this case study) with CF who presented with white stool. All five children had anemia, four had edema and hypoproteinemia, five had changes in stool color (it was pistachio-green color in two patients, pale colored in one, acholic stool in one, and white stool in one), two had cholestasis, one infant had delayed meconium discharge, and three children had delayed growth and hepatomegaly. Two children had an abnormal sweat test, one had a F508del compound heterozygous mutation, and one had three mutation sites (C.214G>G/A, P.A72T; C.650A>A/G, P.E217G, and C.3406G>G/A, P. A1136T), which was a compound heterozygous mutation. So, CF could be included in the differential diagnosis of infants with white stool. Genetic testing could confirm an early diagnosis of CF. Pancreatic replacement therapy has been shown to be beneficial for improving the digestive function.

Assessment of Distinct Electrophysiological Parameters in Rectal Biopsies for the Choice of the Best Diagnosis/Prognosis Biomarkers for Cystic Fibrosis

Most cases of Cystic Fibrosis (CF) are diagnosed early in life. However, people with atypical CF forms pose diagnosis dilemmas, requiring laboratory support for diagnosis confirmation/exclusion. Ex vivo analysis of fresh rectal biopsies by Ussing chamber has been the best discriminant biomarker for CF diagnosis/prognosis so far. Here we aimed to evaluate different electrophysiological parameters from Ussing chamber analysis of rectal biopsies from people with CF (PwCF) to establish the one with highest correlations with clinical features as the best CF diagnosis/prognosis biomarker. We analyzed measurements of CFTR-mediated Cl- secretion in rectal biopsies from 143 individuals (∼592 biopsies), the largest cohort so far analyzed by this approach. New parameters were analyzed and compared with the previous biomarker, i.e., the IBMX (I)/Forskolin (F)/Carbachol (C)-stimulated short-circuit current (I'sc-I/F/C). Correlations with clinical features showed that the best parameter corresponded to voltage measurements of the I/F + (I/F/CCH) response (VI/F+I/F/C), with higher correlations vs. I'sc-I/F/C for: sweat chloride (59 vs. 52%), fecal elastase (69 vs. 55%) and lung function, measured by FEV1 (27 vs. 20%). Altogether data show that VI/F+I/F/C is the most sensitive, reproducible, and robust predictive biomarker for CF diagnosis/prognosis effectively discriminating classical, atypical CF and non-CF groups.