Assessing Differences in Mortality Rates and Risk Factors Between Hispanic and Non-Hispanic Patients With Cystic Fibrosis in California

Minorities Are Underrepresented in Clinical Trials of Pharmaceutical Agents for Cystic Fibrosis

RATIONALE

Members of racial or ethnic minorities make up an appreciable proportion of patients with cystic fibrosis (CF) and have worse outcomes than non-Latino white individuals. Between 1,999 and 2014, the CF Foundation Patient Registry reported an increase in minorities from 5 to 8.2% for Latinos, from 3 to 4.6% for black individuals and from 1.4 to 3.1% for "Other."

OBJECTIVES

To evaluate the representation of racial and ethnic minorities in pharmacology clinical trials for CF.

METHODS

We analyzed pharmacology clinical trials in CF published between 1999 and 2015 by searching PubMed and published study reference lists for qualifying study reports. We examined whether the race and ethnicity of study subjects were reported and, if so, what percentage of subjects represented major minority groups.

MEASUREMENTS AND MAIN RESULTS

Among 147 pharmacology clinical trials, only 19.7% reported the race or ethnicity of study subjects. Latinos were verified as included in 7.5% of clinical trials, black individuals in 6.8%, and Asians in 2.0%. Inclusion of subjects described as "Other race" was reported in 7.5% of trials. In 29 clinical trials that reported race and ethnicity, the percentage of minorities included as subjects was 2.0% for Latinos, 1.0% for black individuals, and 0.1% for Asians.

CONCLUSIONS

Although CF disproportionately affects non-Latino white individuals, members of other racial or ethnic groups are proportionally underrepresented in CF pharmacology clinical trials. Inadequate inclusion of minorities and failure to report the racial or ethnic background of study subjects limits information about factors influencing drug response and may contribute to health disparities for minorities with CF.

Cystic fibrosis: Priorities and progress for future therapies

Significant improvement in the survival of patients with CF has been achieved in the last decades. The improved clinical status of the patients is mainly the result of a better understanding of the natural course of infection and inflammation in CF that has led to the implementation of strategies that increase the life expectancy and quality of life of the patients. These strategies include prompt diagnosis, timely and aggressive nutritional support, augmentation of MCC and improved mucous drainage, initiation of antimicrobial and anti-inflammatory therapy as soon as possible, early treatment of acute exacerbations, implementation of effective hygienic measures in and outside CF centers and prompt identification and treatment of CF-related complications. Treatment at a specialized CF center by a multidisciplinary dedicated team, including frequent visits, and periodic routine tests are essential to detect and treat early changes. Adherence to these therapies is challenging. Maintaining patients in optimal status will allow them to benefit from future treatments designed to correct or modify the basic genetic defect associated with CFTR by gene replacement therapy or pharmacological interventions currently under development. These new therapies are expected to further increase life expectancy of the patients.

Pseudomonas aeruginosa and post-tracheotomy bacterial respiratory tract infection readmissions

OBJECTIVE

Identify risk factors for readmission due to a bacterial tracheostomy-associated respiratory tract infection (bTARTI) within 12 months of discharge after tracheotomy.

DESIGN/METHODS

We performed a retrospective cohort study of 240 children who underwent tracheotomy and were discharged with tracheotsomy in place between January 1, 2005 and June 30, 2013. Children with prolonged total or post-tracheotomy length of stay (LOS), less than 12 months of follow-up, or who died during the index hospitalization were excluded. Readmission for a bTARTI (eg, pneumonia, tracheitis) treated with antibiotics, as ascertained by manual chart review, was the outcome variable. We used multivariate logistic regression to identify the independent association between risk factors and hospital readmission for bTARTI within 12 months.

RESULTS

At index hospitalizations for tracheotomy, the median admission age was 5 months (interquartile range [IQR] 2-43 months) and median LOS was 73 days (IQR 43-121 days). Most patients were of Hispanic ethnicity (n = 162, 68%) and were publicly insured (n = 213, 89%). Nearly half (n = 112, 47%) were discharged on positive pressure mechanical ventilation. Many (n = 103, 43%) were admitted for bTARTI within 12 months of discharge. Only Hispanic ethnicity (adjusted odds ratio [AOR] 2.0; 95% confidence interval [CI]: 1.1-3.9; P = 0.03) and acquisition of Pseudomonas aeruginosa between tracheotomy and discharge from index hospitalization (AOR 3.2; 95%CI: 1.2-8.3; P = 0.02) were independently associated with increased odds of bTARTI readmission, while discharge on gastrointestinal pro-motility agents was associated with decreased risk (AOR = 0.4; 95%CI: 0.2-0.8; P = 0.01).

CONCLUSIONS

Hispanic ethnicity and post-tracheotomy acquisition of P. aeruginosa during initial hospitalization are associated with bTARTI readmission.

Phenotypes of Rapid Cystic Fibrosis Lung Disease Progression during Adolescence and Young Adulthood

RATIONALE

Individuals with cystic fibrosis are at risk for prolonged drops in lung function, clinically termed rapid decline, during discreet periods of the disease.

OBJECTIVES

To identify phenotypes of rapid pulmonary decline and determine how these phenotypes are related to patient characteristics.

METHODS

A longitudinal cohort study of patients with cystic fibrosis aged 6-21 years was conducted using the Cystic Fibrosis Foundation Patient Registry. A statistical approach for clustering longitudinal profiles, sparse functional principal components analysis, was used to classify patients into distinct phenotypes by evaluating trajectories of FEV1 decline. Phenotypes were compared with respect to baseline and mortality characteristics.

MEASUREMENTS AND MAIN RESULTS

Three distinct phenotypes of rapid decline were identified, corresponding to early, middle, and late timing of maximal FEV1 loss, in the overall cohort (n = 18,387). The majority of variation (first functional principal component, 94%) among patient profiles was characterized by differences in mean longitudinal FEV1 trajectories. Average degree of rapid decline was similar among phenotypes (roughly -3% predicted/yr); however, average timing differed, with early, middle, and late phenotypes experiencing rapid decline at 12.9, 16.3, and 18.5 years of age, respectively. Individuals with the late phenotype had the highest initial FEV1 but experienced the greatest loss of lung function. The early phenotype was more likely to have respiratory infections and acute exacerbations at baseline or to develop them subsequently, compared with other phenotypes.

CONCLUSIONS

By identifying phenotypes and associated risk factors, timing of interventions may be more precisely targeted for subgroups at highest risk of lung function loss.

Cystic fibrosis year in review 2016

In this article, we highlight cystic fibrosis (CF) research and case reports published in Pediatric Pulmonology during 2016. We also include articles from a variety of journals that are thematically related to these articles, or are of special interest to clinicians.

A rare CFTR mutation associated with severe disease progression in a 10-year-old Hispanic patient

Cystic fibrosis is a life‐shortening multisystem genetic disease. While readily tested, few tests analyze rare gene mutations prevalent among ethnic minorities. This case of a Hispanic child with a rare CF‐causing c.233dupT mutation and severe disease emphasizes the need for broad CFTR mutation analyses and genotyping particularly in minority populations.

Respiratory System Disease

Respiratory system involvement in cystic fibrosis is the leading cause of morbidity and mortality. Defects in the cystic fibrosis transmembrane regulator (CFTR) gene throughout the sinopulmonary tract result in recurrent infections with a variety of organisms including Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and nontuberculous mycobacteria. Lung disease occurs earlier in life than once thought and ideal methods of monitoring lung function, decline, or improvement with therapy are debated. Treatment of sinopulmonary disease may include physiotherapy, mucus-modifying and antiinflammatory agents, antimicrobials, and surgery. In the new era of personalized medicine, CFTR correctors and potentiators may change the course of disease.

Background and Epidemiology

Cystic fibrosis (CF) is the most common autosomal-recessive disease in white persons. Significant advances in therapies and outcomes have occurred for people with CF over the past 30 years. Many of these improvements have come about through the concerted efforts of the CF Foundation and international CF societies; networks of CF care centers; and the worldwide community of care providers, researchers, and patients and families. There are still hurdles to overcome to continue to improve the quality of life, reduce CF complications, prolong survival, and ultimately cure CF. This article reviews the epidemiology of CF, including trends in incidence and prevalence, clinical characteristics, common complications, and survival.