Cystic fibrosis adult care: consensus conference report

Costs, quality of life and treatment compliance associated with antibiotic therapies in patients with cystic fibrosis: a review of the literature

BACKGROUND

Cystic fibrosis is the most common incurable hereditary disease in the US. Persistent respiratory infection is the leading cause of morbidity and mortality in cystic fibrosis patients.

OBJECTIVE

This study aimed to review the literature on economic and quality of life outcomes and treatment compliance associated with antibiotic therapies for cystic fibrosis patients.

METHODS

A systematic literature review was conducted using keyword searches of the MEDLINE database and selected conference abstracts. The review covered studies published between January 1990 and May 2007.

RESULTS/CONCLUSIONS

Evidence suggests that inhaled tobramycin, a key chronic suppressive therapy, can reduce other healthcare costs. The main determinants of the cost of care include disease severity and respiratory infection. Costs vary widely by country. There is evidence that inhaled tobramycin and oral azithromycin improve quality of life and that treatment setting and patient convenience may also impact on quality of life. Antibiotic treatment compliance varied significantly and depended on the method of measurement, with more subjective measures tending to be higher. This review concludes by offering directions for future research.

Self-reported involvement of family members in the care of adults with CF

BACKGROUND

Few empirical studies have examined the role of family caregivers in the lives of adults with CF.

METHODS

As part of the Project on Adult Care in CF (PAC-CF), an on-going prospective, longitudinal panel study of adults with CF, 119 family members and friends of adults with CF completed a mail survey in which they reported the frequency of help they provide for their family member with CF during routine care, hospitalization, and home IV treatment.

RESULTS

The 119 caregivers were mainly spouses or unmarried partners (56%) and parents (29%). Fifteen percent of caregivers were children, friends, siblings or roommates. Family caregivers for adults with CF report assisting mainly with communication and social support during routine treatment, although one third provide some clinical care on a regular basis. Family caregivers report an increase in assistance during periods of acute illness, such as during a hospitalization and home IV treatment, especially with clinical care tasks.

CONCLUSIONS

The depth of commitment required of families of children with CF has been well documented for decades. Our results suggest that the responsibilities of family members diminish only moderately as those with CF reach adulthood.

Vitamin A intake and elevated serum retinol levels in children and young adults with cystic fibrosis

BACKGROUND

Individuals with cystic fibrosis (CF) and pancreatic insufficiency (PI) are at risk for fat-soluble vitamin deficiency, including vitamin A. Recent evidence suggests current practices of vitamin A intake results in elevated serum retinol.

METHODS

Serum retinol was assessed in 78 subjects (8 to 25 years old) with CF and PI by high performance liquid chromatography, and compared to the U.S. National Health and Nutrition Examination Survey (NHANES) data of subjects of similar age and gender. Vitamin A intake, anthropometry and FEV(1) were measured, and their relationship to serum retinol status was assessed.

RESULTS

Median (range) serum retinol was 80 microg/dL (33 to 208) in subjects with CF; 58% were above the NHANES reference range (30 to 72 microg/dL). Total vitamin A intake from diet and supplements was high (608+431% Recommended Dietary Allowance). Serum retinol was not correlated with vitamin A intake, age or gender, and was inversely correlated with weight and height z scores (r=-0.28, p<0.05) in the subjects with CF.

CONCLUSIONS

Both vitamin A intake and serum retinol were elevated in subjects with CF and PI, corroborating recent evidence of elevated serum retinol in preadolescent children with CF. These findings indicate the need for further study of dosing and monitoring care practices of vitamin A, to ensure adequacy and to avoid toxicity.

[Cystic fibrosis: review]

Cystic Fibrosis (CF) is the recessive autossomic disease more frequent in the caucasian race. The main characteristic is a mutation in CFTR, a trans-membranar protein, responsible for chlorates transportation. This protein has a diffuse epithelial distribution, which gives a multissistemic involvement to this disease, with clinical manifestations with variable degrees of severity. The development of better health care associated with new therapeutic options became responsible for an increase of survival, so CF is no longer a paediatric disease. Lung transplantation also has an important role, bringing new treatment perspectives. So, this pathology has an increased multi-disciplinary involvement in which the pulmonologist have a preponderant role.

Liver transplantation for cystic fibrosis in adults

PURPOSE

To expand our knowledge on liver transplantation for cirrhosis associated with cystic fibrosis in adults.

METHODS

Five patients who underwent a liver transplantation due to cystic fibrosis were reviewed. The outcome of the patients in terms of age, immunosuppression regimen, patient and graft survival, and pre- and post-transplant complications were investigated.

RESULTS

Five adult liver transplant patients had cystic fibrosis (0.2%). These included 4 men and 1 woman with a mean age of 31 +/- 10, ranging from 22 to 52 years old at the time of transplantation. All patients had lung problems. Four patients had exocrine and two had endocrine pancreatic insufficiency. Two are currently alive with a follow-up of 5.8 years and 4 months after transplantation, respectively. There were three deaths from pulmonary embolism at 4.5 years, myocardial infarction with cyclosporine nephrotoxicity at 10.7 years, and lymphoproliferative disorder at 5 months after transplantation. No deaths occurred from lung infection. Only one patient had postoperative pulmonary infectious complications, which were successfully treated with antibiotics and did not result in mortality.

CONCLUSION

Adult liver transplantation for end-stage liver disease associated with cystic fibrosis offers encouraging results with a rapid general improvement after surgery and it is now considered to be a safe and acceptable treatment for this disease population.

The benign course of liver disease in adults with cystic fibrosis and the effect of ursodeoxycholic acid

BACKGROUND AND AIMS

The life expectancy of patients with cystic fibrosis (CF) has been increasing and the associated liver disease has emerged as a significant medical issue. Our aim was to describe the clinical features, course and effect of ursodeoxycholic acid (UDCA) on liver disease in an adult CF population.

STUDY

From 1983 to 2005, 278 patients with CF were followed up at the Alfred Hospital, an adult tertiary referral centre. Twenty-seven patients (9.7%) satisfied the criteria for liver disease and their clinico-pathological features were assessed. The effect of UDCA on hepatobiliary symptoms and biochemical parameters was determined.

RESULTS

The mean age at liver disease diagnosis was 23 years (range 8-47 years). Portal hypertension was present in 18 (67%) patients. During a median follow-up of 7 years (range 1.5-15), variceal haemorrhage occurred in two patients and ascites in three (one spontaneously). Nine (33%) patients died and five (19%) underwent lung transplantation. There was no encephalopathy, liver transplantation or liver-related deaths. UDCA was taken by 22 patients and was associated with a significant improvement in hepatobiliary symptoms [11/22 (50%) in the pre-UDCA period vs 1/22 (4%) in the post-UDCA period; P=0.0003] and a significant reduction in aspartate aminotransferase (P=0.005); alanine aminotransferase (P<0.001); gamma-glutamyltranspeptidase (P=0.021); and alkaline phosphatase (P<0.001).

CONCLUSIONS

Liver disease in adults with CF is commonly complicated by portal hypertension, but morbidity and mortality associated with this in our small patient population were low. UDCA is associated with improvement in hepatobiliary symptoms and liver function tests.

Comparison of High-Frequency Chest Wall Oscillation With Differing Waveforms for Airway Clearance in Cystic Fibrosis

BACKGROUND

High-frequency chest wall oscillation (HFCWO) is commonly used by cystic fibrosis (CF) patients for airway clearance. The primary objective of this study was to determine whether the use of a newer HFCWO device that generates oscillations with a triangular waveform results in greater sputum production than a commonly used device that generates oscillations with a sine waveform.

METHODS

This was a controlled, randomized, double-blind, crossover study. Fifteen clinically stable, adult CF patients participated. Patients performed airway clearance with each device once and at matched oscillation frequencies and pressures. All sputum produced during each session was collected. Patients completed pulmonary function tests before and after each session, and rated the comfort of the two devices.

RESULTS

Mean sputum wet and dry weight produced during sine waveform and triangular waveform HFCWO sessions did not differ (p = 0.11 and p = 0.2, respectively). Mean changes in FEV(1) and FVC following HFCWO therapy were also comparable (p = 0.21 and p = 0.56, respectively). However, there was a significant reduction in air trapping by residual volume/total lung capacity ratio following triangular waveform HFCWO (p = 0.01). In addition, in vitro cough transportability was 10.6% greater following therapy with the triangular waveform device (p = 0.05). Patients perceived the two devices as equally comfortable (p = 0.8).

CONCLUSIONS

Single-session sputum production is comparable with sine and triangular waveform HFCWO devices. Longer term comparisons are needed to determine whether sustained use of the devices results in clinically important differences in outcomes.

A formulation of aerosolized tobramycin (Bramitob) in the treatment of patients with cystic fibrosis and Pseudomonas aeruginosa infection: a double-blind, placebo-controlled, multicenter study

BACKGROUND AND AIM

Chronic infection with Pseudomonas aeruginosa in patients with cystic fibrosis (CF) causes progressive deterioration in lung function. The purpose of this trial was to assess the efficacy and tolerability of a tobramycin highly concentrated solution for inhalation (TSI) [300mg/4mL; Bramitob when added to other antipseudomonal therapies in CF patients with chronic P. aeruginosa infection.

METHODS

In a multinational, double-blind, multicenter study, CF patients with chronic P. aeruginosa infection were randomized to receive nebulized tobramycin or placebo over a 24-week study period in which 4-week treatment periods ('on' cycles) were followed by 4-week periods without treatment ('off' cycles). Forced expiratory volume in 1 second (FEV(1)) percentage of predicted normal was used as the primary efficacy outcome parameter. Forced vital capacity (FVC), forced expiratory flow at 25-75% of FVC (FEF(25)(-)(75%)), P. aeruginosa susceptibility, minimum concentration required to inhibit 90% of strains (MIC(90)), rates of P. aeruginosa-negative culture, P. aeruginosa persistence and superinfection, need for hospitalization and parenteral antipseudomonal antibiotics, loss of school/working days due to the disease, and nutritional status (bodyweight and body mass index) were considered as secondary efficacy outcome parameters. Adverse events reporting, audiometry, and renal function were monitored to evaluate the tolerability and safety of TSI.

RESULTS

A total of 247 patients were randomized in the study. At endpoint time assessment (week 20), FEV(1) was significantly increased in the tobramycin group and the adjusted mean difference between groups (intention-to-treat population) was statistically significant (p < 0.001). At the same time, clinically relevant improvements in FVC and FEF(25-75%) were detected in the TSI group (p = 0.022 and p = 0.001, respectively). The microbiologic outcomes at the end of the last 'on' cycle period were significantly better in the TSI group than the placebo group (p = 0.024), although there was a concomitant trend toward an increase in the MIC of isolated P. aeruginosa strains. The percentage of patients hospitalized as well as the need for parenteral antipseudomonal antibiotics was significantly lower in the TSI group (p = 0.002 and p = 0.009, respectively). Patients treated with TSI had fewer lost school/working days due to the disease (p < 0.001). A favorable effect of tobramycin in terms of an increase in bodyweight and body mass index was also noted, when compared with placebo, at all time points (p < 0.01 and p < 0.001, respectively). No significant changes in serum creatinine and auditory function were detected. The proportion of patients with drug-related adverse events was 15% in both treatment groups.

CONCLUSIONS

Long-term, intermittent administration of this aerosolized tobramycin formulation (300mg/4mL) in CF patients with P. aeruginosa chronic infection significantly improved pulmonary function and microbiologic outcome, decreased hospitalizations, increased nutritional status, and was well tolerated.

[Pregnancy and lungs]

Respiratory pathology can be relatively frequent during pregnancy. One third of pregnant woman may experience worsening of their asthma condition. Pulmonary tromboembolism is 5 times more frequent in pregnancy. Bacterial, viral and fungal pneumonias are badly tolerated during pregnancy, provoking mother-foetal morbidity, respiratory insufficiency, low born-weight or prematurity. Non-treated tuberculosis may increase maternal mortality and preterm birth by 4 and 9 times respectively. Pregnancy is counter-indicated in women with cystic fibrosis and severe pulmonary function. Despite therapeutic progresses already made, pulmonary hypertension is associated to over 30% of mother-foetal morbidity and mortality. Approximately 1 in 1,000-1,500 pregnancies is affected by mother cancer. High rates of lung cancer morbility in women bring new and important challenges to therapy.

[Analysis of energy expenditure in adults with cystic fibrosis: comparison of indirect calorimetry and prediction equations]

OBJECTIVE

Undernutrition, which implies an imbalance between energy intake and energy requirements, is common in patients with cystic fibrosis. The aim of this study was to compare resting energy expenditure determined by indirect calorimetry with that obtained with commonly used predictive equations in adults with cystic fibrosis and to assess the influence of clinical variables on the values obtained.

PATIENTS AND METHODS

We studied 21 patients with clinically stable cystic fibrosis, obtaining data on anthropometric variables, hand grip dynamometry, electrical bioimpedance, and resting energy expenditure by indirect calorimetry. We used the intraclass correlation coefficient (ICC) and the Bland-Altman method to assess agreement between the values obtained for resting energy expenditure measured by indirect calorimetry and those obtained with the World Health Organization (WHO) and Harris-Benedict prediction equations.

RESULTS

The prediction equations underestimated resting energy expenditure in more than 90% of cases. The agreement between the value obtained by indirect calorimetry and that calculated with the prediction equations was poor (ICC for comparisons with the WHO and Harris-Benedict equations, 0.47 and 0.41, respectively). Bland-Altman analysis revealed a variable bias between the results of indirect calorimetry and those obtained with prediction equations, irrespective of the resting energy expenditure. The difference between the values measured by indirect calorimetry and those obtained with the WHO equation was significantly larger in patients homozygous for the DeltaF508 mutation and in those with exocrine pancreatic insufficiency.

CONCLUSIONS

The WHO and Harris-Benedict prediction equations underestimate resting energy expenditure in adults with cystic fibrosis. There is poor agreement between the values for resting energy expenditure determined by indirect calorimetry and those estimated with prediction equations. Underestimation was greater in patients with exocrine pancreatic insufficiency and patients who were homozygous for DeltaF508.

Transition and transfer of patients who have cystic fibrosis to adult care

Transition to age-appropriate care and transfer of care is a process that best occurs over time. Models to accomplish this are best designed at the local level because local factors weigh heavily on the model a center chooses. Ingredients for the successful transition must include focus on self-care and communication between cystic fibrosis (CF) teams, between pediatric and adult patients who have CF and the teams, and between parents of patients who have CF and the teams. A timeline for transition should begin years before transfer with the realization that one plan may not accommodate all patients' needs.

Current issues in quality improvement in cystic fibrosis

The modern history of cystic fibrosis (CF) is one of continuous improvement. Guidelines and evidence-based medicine provide a general roadmap for directing improvement efforts. Data and measurement are central to quality improvement (QI), a way of keeping score and staying on track. This article describes the history and context of QI in CF, the use of guidelines and data with some examples from the work of one regional consortium, some approaches to developing QI skills with a view to implementing and managing desired changes in CF clinic settings, and the potential benefits and impact of public reporting and data transparency.

Doppler echocardiogram, oxygen saturation and submaximum capacity of exercise in patients with cystic fibrosis

STUDY OBJECTIVES

To determine the relationship between pulmonary arterial systolic pressure (PASP) and submaximum capacity of exercise, using the six-minute walk test (6MWT) in patients with cystic fibrosis (CF), and to investigate the relation between echocardiographic findings and results of 6MWT, clinical scores, chest radiograph scores and lung function tests.

DESIGN

This was a prospective cross-sectional study in patients with CF (16 years and older) with clinical stability, attending the Adult CF Program at the Hospital de Clínicas de Porto Alegre. The patients had Doppler echocardiography and performed a 6MWT. As well as pulmonary function tests and chest roentgenograms, and a clinical score was obtained for all patients.

RESULTS

The study included 39 patients with a mean age of 23.7+/-6.3 years. There were no significant correlation between the distance walked and PASP, diameter of the right ventricle (DRV) and pulmonary acceleration time (p>0.05). We observed a significant correlation among PASP and the SpO(2) at rest (r=-0.73; p<0.001), SpO(2) at the end of the 6MWT (r= -0.45; p=0.006), clinical score (r= -0.55; p=0.001), chest radiograph score (r= -0.33; p=0.049), FEV1 (r= -0.63; p< 0.001), and FVC (r=-0.55; p=0.001). Right ventricular outflow tract flow acceleration time (Ac T) was significantly correlated only with the FEV1 (r=0.32; p=0.047). RVD was significantly correlated with SpO(2) at rest (r= -0.44; p=0.005) and clinical score (r= -0.38; p=0.017). The SpO(2) at rest was the single best predictor of PASP and this effect was independent of the relationship between other independent variables (p=0.001). The declining pulmonary function was significantly associated with PASP (p<0.001), SpO(2) at rest (p=0.001), SpO(2) at the end of the 6MWT (p=0.007) and difference between peripheral oxygen saturation at resting and at the end of the 6MWT (p=0.025).

CONCLUSION

The PASP was not significantly correlated with the distance walked during the 6MWT in patients with CF. The PASP was strongly correlated with oxygen status at rest. The SpO(2) at rest was the best predictor of PASP. Also, PASP was strongly correlated with Shwachman-Kulczycki score, FEV(1), and FVC in this population.

Infection Control Practice in Cystic Fibrosis Centers

In this article, the authors outline some of the major historical events that signaled the need to better understand mechanisms of infection in cystic fibrosis (CF). The authors discuss general principles of infection control, focusing on issues of particular importance to patients who have CF. The authors also describe the major pathogens associated with the CF airway, provide a review of findings from inpatient and outpatient studies of infection control, and provide an outline of future directions for investigation.

Nutrition and Lung Disease in Cystic Fibrosis

Among patients who have cystic fibrosis (CF), lung disease is a significant contributor to morbidity. From a clinical perspective, the link between malnutrition and lung dysfunction in CF is well established; however, the causal relationship remains unclear. Nutritional intervention for CF patients is predicated on the hypothesis that improved nutritional status improves pulmonary function. Which interventions will be of most value and have sustained gains is not completely clear from the available data. Taking into account that several factors condition the deficits that lead to malnutrition in CF, multidisciplinary interventions are likely to give the best results. More research is needed to better dissect the nutritional factors involved in lung disease and to identify effective and safe interventions through systematic controlled trials.

Mucoviscidose : du bon usage des explorations fonctionnelles respiratoires

INTRODUCTION

Neonatal screening for cystic fibrosis (CF) leads to early dedicated specialist care for all patients.

BACKGROUND

Pulmonary function tests (PFT) are mandatory for routine monitoring of CF patients. The aim of this article is to review the current guidelines for PFTs in CF, particularly the type of test, the age and the clinical status of the patient.

VIEWPOINT

The regular use of spirometry is generally accepted. Many other tests are used but their clinical value in the routine follow-up of CF patients remains to be established.

CONCLUSION

Further efforts should be made to evaluate the value of PFTs in CF, particularly in very young children.

Update on enteral nutrition support for cystic fibrosis

Cystic fibrosis (CF) is an inherited disease affecting the respiratory, gastrointestinal, hepatobiliary, and reproductive systems. Nutrition status in persons with CF is often compromised due to increased energy needs, frequent infections, pancreatic insufficiency, lung disease, or CF-related diabetes. Maintaining good nutrition status has been associated with better pulmonary function, reduced hospitalizations, and increased longevity. Nutrition support as oral supplementation (used in >37% of the CF population) or tube feeding (used in >13% of the CF population) is often required for children and adults with CF. The purpose of this update is to describe current consensus and evidence for enteral nutrition support guidelines, reported complications of enteral feeding in the CF population, evidence of expected outcomes, and to discuss related areas requiring further research. A case report is provided to illustrate potential outcomes of aggressive enteral support.

The epidemiology, pathogenesis and treatment of Pseudomonas aeruginosa infections

Pseudomonas aeruginosa is an important bacterial pathogen, particularly as a cause of infections in hospitalised patients, immunocompromised hosts and patients with cystic fibrosis. Surveillance of nosocomial P. aeruginosa infections has revealed trends of increasing antimicrobial resistance, including carbapenem resistance and multidrug resistance. Mechanisms of antimicrobial resistance include multidrug efflux pumps, ss-lactamases and downregulation of outer membrane porins. Mechanisms of virulence include secreted toxins and the ability to form biofilms. The effective treatment of infections caused by P. aeruginosa includes prevention when possible, source control measures as necessary and prompt administration of appropriate antibacterial agents. Antibacterial de-escalation should be pursued in patients with an appropriate clinical response, especially when antibacterial susceptibilities are known. Multidrug-resistant P. aeruginosa may require treatment with less commonly used antibacterials (e.g. colistin), but newer anti-pseudomonal antibacterials are expected to be available in the near future.

Adults with cystic fibrosis report important and unmet needs for disease information

BACKGROUND

The informational needs of the growing population of adults with cystic fibrosis (CF) have not been previously assessed.

METHODS

Adults with CF enrolled in the Project on Adult Care in CF (PAC-CF) completed a survey including 22 items in which information topics were rated on the importance of receiving more information and the satisfaction with sources of information. Unmet needs were defined as those topics rated with both high importance and low satisfaction with information sources.

RESULTS

The median age of the 233 respondents was 34 years, median FEV(1) was 68% predicted, and 59% were female. The information topics with the highest mean importance ratings were on CF treatments and managing infection. The percentage of respondents rating an individual information need as unmet ranged from 2-32%. Information on "ways to deal with decreased energy, "new CF therapies," and "ways to deal with the unpredictability of the future" were reported as unmet by almost one-third of respondents. For all but four of the information topics assessed, clinical and socio-demographic factors were not significantly associated with increased likelihood of reporting unmet informational needs.

CONCLUSIONS

Adults with CF rated information on treatment topics as most important. In contrast, patients were more likely to report information needs on disease self-management and future planning as unmet. Clinical and socio-demographic patient characteristics were not systematically associated with unmet informational needs. Clinicians caring for adult CF patients should not solely rely socio-demographic factors or markers of disease severity as signals for providing comprehensive information on disease self-management and future planning.

Cystic Fibrosis in Adults

The aim of this cross-sectional retrospective study was to describe clinical and functional characteristics and the microbiological profile of an adult population with cystic fibrosis. The study was performed at the Pulmonary Diseases Service of the Hospital of the Medical School of the State University of Campinas. The charts of 54 adults (27 males, 27 females) with cystic fibrosis were reviewed. Demographic, clinical, and microbiological data were collected. Clinical and functional characteristics of patients with chronic Pseudomonas infection were compared with those without it. The mean age of the patients was 41.8 years and the mean sweat chloride concentration was 106.4 mEq/L. Forty-nine percent had chronic respiratory symptoms only after 18 years of age, and 85% reported chronic production of purulent sputum. Six percent had diarrhea or fat in stools, and no patient suffered from diabetes mellitus. Pseudomonas was present in 48%, and 73% of them had the mucoid strain. Others agents found were Staphylococcus aureus (28%), Hemophylus sp. (34%), Aspergillus sp. (22%), Stenotrophomonas maltophilia (9%), Acinetobacter sp. (7%), and Burkholderia cepacia (2%). Nontuberculous mycobacteria were found in sputum from 9 patients (11%); 34 patients (67%) had obstructive ventilatory defect; and 47% had obstruction and restriction. Concerning the groups with and without Pseudomonas colonization, only the values of sweat chloride were significantly higher in chronic colonized patients. Less severe phenotypes of cystic fibrosis may be found among patients previously diagnosed as having bronchiectasis. Chronic colonization with Pseudomonas aeruginosa in this study was not associated with worse clinical status but colonized patients did show significantly higher levels of chloride in sweat.

Adherence to chest physiotherapy in adults with cystic fibrosis

Chest physiotherapy (CP) is seen as a cornerstone of Cystic Fibrosis (CF) treatment. However, previous studies have suggested that adherence to CP is low. This study of adults with CF (N = 563) investigated CP adherence and associated factors. Only 29.5 per cent reported undertaking daily CP. Predictors of adherence included problems with fitting CP into lifestyle, a perception that CP does not help, physical consequences of CP, doing exercises instead and doing CP as and when necessary. These variables accounted for 45 per cent of the variance in adherence. Content analysis revealed a number of themes related to adherence to CP. Future studies should explore the benefits of daily CP and attempt to devise simple interventions to maximize adherence to CP.

Evaluation of glucose tolerance in cystic fibrosis: comparison of 50-g and 75-g tests

BACKGROUND

The recommended tests for evaluation of glucose tolerance in cystic fibrosis are the fasting blood glucose (FBG) and the 75-g, fasting, 2-h oral glucose tolerance test (OGTT). We compared a 50 g, non-fasting, 1-h glucose challenge test (GCT) to the standard OGTT.

METHODS

During their regularly scheduled visit to the cystic fibrosis clinic, patients underwent a 50-g, non-fasting 1-h GCT and were asked to complete a standard 75-g, fasting, 2-h OGTT within one week of their clinic visit.

RESULTS

Fifty-seven patients underwent glucose tolerance testing. Of these, 31/57 (54%) completed both tests. Hyperglycemia was detected on both tests in 9/31 (29%) patients, 11/31 (35%) tested positive only on the GCT, while all those with positive OGTTs had positive GCTs (p<0.01).

CONCLUSIONS

In this study, the GCT identified all patients who meet the criteria for abnormal glucose tolerance on an OGTT. There was a large subgroup that was positive for glucose intolerance only on the GCT. These individuals represent a distinct biochemical subgroup of uncertain significance that warrants closer evaluation. Although the GCT can be completed in a non-fasting state and in conjunction with regular blood work or clinic visits, the anticipated greater compliance was not seen.

Advances in cystic fibrosis therapies

PURPOSE OF REVIEW

Over the past four decades, outcomes for patients with cystic fibrosis have improved dramatically. Major contributors to this improvement are a better understanding of disease pathogenesis and the systematic conduct of clinical trials evaluating new therapies designed to address these defects. This review describes recent developments in cystic fibrosis pulmonary therapies intended to treat various facets of the disease, including several treatments currently in development.

RECENT FINDINGS

The mainstays of therapy for cystic fibrosis, such as nutritional support and mechanical mucus clearance, are now supplemented with aggressive antibiotic regimens intended to suppress or eradicate bacterial colonization, anti-inflammatory agents, and new approaches that improve mucociliary clearance. Therapies in development address the underlying ion transport defect found in cystic fibrosis airways and also include small-molecule agents that restore function to the mutant cystic fibrosis transmembrane conductance regulator.

SUMMARY

Recent advances in therapies for cystic fibrosis offer the promise of improved outcomes and longer lives for patients with cystic fibrosis.

Classification of nutritional status in cystic fibrosis

PURPOSE OF REVIEW

Nutritional status impacts on the progression of cystic fibrosis. Current guidelines recommend the use of anthropometric indicators to classify nutritional status and identify malnutrition. However, the current nutrition-classification systems are problematic. I summarize these problems and review recent progress in the development of evidence-based anthropometric criteria for classifying nutritional status in cystic fibrosis patients.

RECENT FINDINGS

Percentage of ideal body weight as a malnutrition index is flawed. In children with cystic fibrosis, this index underestimates the severity of underweight in short patients and overestimates it in tall patients. In adults with cystic fibrosis, percentage of ideal body weight based on the Metropolitan Life Insurance reference weights for medium/large frames overestimates the severity of underweight. Body-mass-index percentile for children and body mass index for adults as underweight indices have been proven to be valid. Strong associations between body mass index and lung function are also observed, but cutoff values to maintain a desirable level of lung function can vary.

SUMMARY

Body mass index should replace the use of percentage of ideal body weight for classifying underweight in cystic fibrosis patients. More research is needed to identify appropriate indicators to classify short stature in children with cystic fibrosis.

Report of a Korean patient with cystic fibrosis, carrying Q98R and Q220X mutations in the CFTR gene

Although cystic fibrosis (CF) is one of the most frequently seen autosomal-recessive disorders in Caucasians, it is extremely rare in the Korean population. Recently, a 15-yr-old Korean boy was admitted to our hospital complaining of coughing, sputum, and exertional dyspnea. Chest radiographs and computed tomographic chest and paranasal sinus scans revealed diffuse bronchiectasis and pansinusitis. Pulmonary function tests revealed severe obstructive impairment. The average sweat chloride concentrations on both of the patients' forearms were 63.0 mM/L (reference limit: < 40 mM/L). Upon mutation analysis, two different mutations (Q98R and Q220X) were identified in the cystic fibrosis transmembrane conductance regulator gene, both of which had been previously detected in CF patients, one from France and the other from England. As CF is quite rare in Korea, the diagnosis of CF in this patient might be delayed. Therefore, we recommend that a diagnosis of CF should be suspected in patients exhibiting unexplained chronic respiratory symptoms.

An adult cystic fibrosis patient presenting with persistent dyspnea: case report

BACKGROUND

Persistent dyspnea is a common finding in the cystic fibrosis patient that typically leads to further work up of an alternative pulmonary etiology. Adult cystic fibrosis patients; however, are growing in numbers and they are living into the ages in which coronary artery disease becomes prevalent. Coronary disease should be included in the consideration of diagnostic possibilities.

CASE PRESENTATION

A 52-year-old white male with cystic fibrosis was evaluated for exertional dyspnea associated with vague chest discomfort. Diagnostic testing revealed normal white blood cell, hemoglobin and platelet count, basic metabolic panel, fasting lipid profile, HbA1c, with chest radiograph confirming chronic cystic findings unchanged from prior radiographs and an electrocardiogram that revealed sinus rhythm with left anterior fascicular block. Stress thallium testing demonstrated a reversible anteroseptal perfusion defect with a 55% left ventricular ejection fraction. Heart catheterization found a 99% occlusion of the left anterior descending artery extending into the two diagonal branches, with 100% obstruction of the left anterior descending artery at the trifurcation and 70% lesion affecting the first posterior lateral branch of the circumflex artery.

CONCLUSION

This case report represents the first description in the medical literature of a cystic fibrosis patient diagnosed with symptomatic coronary artery disease. Applying a standard clinical practice guide proved useful toward evaluating a differential diagnosis for a cystic fibrosis patient presenting with dyspnea and chest discomfort.

[Digestive complications in adults with cystic fibrosis]

In France the median life expectancy of patients with cystic fibrosis (CF) is 36 years and one third of patients are adults. Respiratory disorders are the main determinants of survival during adulthood, although gastrointestinal complications can also have a major impact on quality of life and nutritional status. We reviewed gastro-intestinal and pancreatic manifestations of CF in adults. Some complications (diabetes, distal intestinal obstruction syndrome and acute pancreatitis) are more frequent in adulthood than in childhood. Clinical and therapeutic aspects of specific conditions (such as distal intestinal obstruction syndrome) or atypical presentations (including appendicular complications) are presented herein.

Cardiopulmonary Rehabilitation and Cancer Rehabilitation. 2. Pulmonary Rehabilitation Review

Pulmonary rehabilitation includes the rehabilitation of not only patients with respiratory failure in need of ventilatory support but also patients with primary pulmonary disease. New advances in medical management now offer treatment to patients with end-stage emphysema, pulmonary hypertension, and interstitial disease, and the principles of rehabilitation can add both function and quality to the lives of these patients. New surgical approaches and better transplantation outcomes that restore pulmonary function have also been introduced. Rehabilitation professionals need to be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine.

OVERALL ARTICLE OBJECTIVES

(a) To identify major categories of pulmonary disease seen in pulmonary rehabilitation, (b) to know appropriate interventions and support for patients with respiratory failure, (c) to describe the new interventions available for end-stage lung disease, and (d) to describe the appropriate pulmonary rehabilitation for people with pulmonary disease.

Outcomes of Adults with Cystic Fibrosis Infected with Antibiotic-Resistant Pseudomonas aeruginosa

BACKGROUND

Although Pseudomonas aeruginosa is the most common bacterial infection in adults with cystic fibrosis and frequently develops resistance to multiple classes of antibiotics, it has not been determined whether patients with multiple antibiotic-resistant Pseudomonas aeruginosa have worse clinical outcomes than patients with more susceptible strains.

OBJECTIVES

This study assessed the impact of multiply-resistant P. aeruginosa on lung function, hospitalizations, antibiotic use, lung transplantation and survival in adults with cystic fibrosis.

METHODS

In a cohort study at a university-based adult cystic fibrosis program, 75 consecutive adult cystic fibrosis patients who had P. aeruginosa isolated from sputum cultures were studied over a 4-year period. Outcomes included decline in FEV1, clinic visits, hospitalizations, courses and days of intravenous antibiotics, and lung transplantation. Multiple linear and Poisson regression for repeated measures were used to assess the outcomes.

RESULTS

In comparison to patients with susceptible strains, patients with resistant P. aeruginosa had more severe baseline lung disease, more rapid decline in FEV1 (160 ml/year, p = 0.003) and were significantly more likely to undergo lung transplantation (17.6 vs. 0%, p = 0.005).

CONCLUSIONS

Infection with multiple-antibiotic-resistant P. aeruginosa is associated with accelerated progression of cystic fibrosis, and has important implications for infection control strategies, antibiotic use and lung transplantation.

Evidence for physical therapies (airway clearance and physical training) in cystic fibrosis: An overview of five Cochrane systematic reviews

BACKGROUND

A range of physical therapies (including airway clearance and physical training) are used in cystic fibrosis (CF). The aim of this paper is to summarise the main findings from Cochrane systematic reviews that have considered the evidence for physical therapies in CF.

METHODS

All outcomes reported in relevant Cochrane systematic reviews are summarised.

RESULTS

Review 1 provides some evidence from short-term trials of the benefit of airway clearance over no airway clearance in improved mucus transport but no definitive evidence from long-term trials to support the efficacy of airway clearance over no airway clearance; review 2 provides some evidence that conventional chest physiotherapy (CCPT) is at least as effective as other forms of airway clearance, but that patients may have a preference for self-administered treatments over CCPT; review 3 provides some evidence that positive expiratory pressure (PEP) is at least as effective as other forms of airway clearance; review 4 provides some evidence to support the use of non-invasive ventilation during airway clearance in patients with moderate to severe disease who have difficulty clearing sputum; review 5 provides some evidence of the benefits of different types of physical training.

CONCLUSION

The Cochrane systematic reviews summarised in this paper provide some evidence to support the inclusion of physical therapies in the care-management plan of CF. They also provide information to steer the direction and focus of future research in this area.

Incidence and prevalence of diabetes mellitus in patients with cystic fibrosis undergoing lung transplantation before and after lung transplantation

Cystic fibrosis (CF) related diabetes mellitus (DM) occurs in 15% of adult pancreatic insufficient CF patients. Lung transplantation is a treatment option for end-stage CF. We hypothesized that the prevalence of DM increases after lung transplantation. The study population included adult patients undergoing lung transplantation from March 1988 to March 2002 for end-stage CF at the University of Toronto. Demographic data, exocrine pancreatic function, presence of DM before and after transplant, as well as timing of its development after transplant were collected. Eighty-six patients met the study criteria; 77 of 86 (89.5%) of patients were pancreatic insufficient and were further analyzed. Median follow-up post-transplant was 3.3 yr (interquartile range: 1.2-7.2). Their mean age was 29.7 +/- 8.1 yr and 46 of 77 (59.7%) were male. The prevalence of DM increased from 22 of 77 (28.6%) before transplant to 38 of 77 (49.4%) after transplant (p = 0.008). The median time of DM development after transplant was 80 d (range: 13-4352). Sixteen of 55 (29.1%) of pancreatic insufficient patients who were non-diabetic prior to transplant, developed DM after transplant. DM is common in CF patients undergoing lung transplantation and the prevalence increases after transplant.

Determinants of mortality for adults with cystic fibrosis admitted in Intensive Care Unit: a multicenter study

BACKGROUND

Intensive care unit (ICU) admission of adults with cystic fibrosis (CF) is controversial because of poor outcome. This appraisal needs re-evaluation following recent changes in both CF management and ICU daily practice. Objectives were to determine long-term outcome of adults with CF admitted in ICU and to identify prognostic factors.

METHODS

Retrospective multicenter study of 60 ICU hospitalizations for 42 adult CF patients admitted between 2000 and 2003. Reason for ICU admission, ventilatory support provided and one-year survival were recorded. Multiple logistic analysis was used to determine predictors of mortality.

RESULTS

Prior to ICU admission, all patients (mean age 28.1 +/- 8 yr) had a severe lung disease (mean FEV1 28 +/- 12% predicted; mean PaCO2 47 +/- 9 mmHg). Main reason for ICU hospitalization was pulmonary infective exacerbation (40/60). At admission, noninvasive ventilation was used in 57% of cases and was successful in 67% of patients. Endotracheal intubation was implemented in 19 episodes. Overall ICU mortality rate was 14%. One year after ICU discharge, 10 of the 28 survivors have been lung transplanted. Among recognized markers of CF disease severity, only the annual FEV1 loss was associated with a poor outcome (HR = 1.47 [1.18-1.85], p = 0.001). SAPSII (HR = 1.08 [1.03-1.12], p < 0.001) and endotracheal intubation (HR = 16.60 [4.35-63.34], p < 0.001) were identified as strong independent predictors of mortality.

CONCLUSION

Despite advanced lung disease, adult patients with CF admitted in ICU have high survival rate. Endotracheal intubation is associated with a poor prognosis and should be used as the last alternative. Although efforts have to be made in selecting patients with CF likely to benefit from ICU resources, ICU admission of these patients should be considered.

Differential diagnosis of adult asthma

Although the term "all that wheezes is not asthma" is not new, and the long list of asthma masqueraders has remained essentially the same for several decades, the importance of knowing when to question the accuracy ofa diagnosis of asthma has remained critical for physicians who care for patients with respiratory symptoms. The concepts of "asthma control" and"asthma severity" are currently evolving, although the fundamental hall-marks that define the syndrome of asthma endure and should be mastered by asthma specialists. Asthma masqueraders, including several that may confound a correct diagnosis of asthma, are important to consider when either the presentation of asthma is atypical or the response of the patient to treatment is suboptimal. COPD and VCD head the list of diagnoses most likely to be confused with asthma in everyday practice. Correctly identifying the diagnosis of COPD enables implementation of an up-to-date treatment plan that differs from asthma management. VCD is a vastly under recognized syndrome whose existence is widely accepted but whose pathophysiology is poorly understood, and correctly identifying a VCD component to asthma symptoms enables both a reduction in costly and potentially harmful asthma medications and focus on specific VCD treatment, such as speech therapy. For less common and uncommon asthma masqueraders, it is important to be familiar with their typical clinical presentation and basic diagnostic approaches.

Assessment of hypoxia in children with cystic fibrosis

Hypoxia during sleep and exercise may occur in an important number of patients with cystic fibrosis (CF). Despite its recognition, no clear definition for hypoxia in CF exists, and nor do guidelines for commencing oxygen therapy. CF patients with hypoxia may have increased pulmonary artery pressure, reduced exercise ability, and skeletal muscle strength, and most importantly of all worse sleep quality, and a worse quality of life. Laboratory and rodent evidence exists to suggest that hypoxia may contribute to the decline in lung function in CF by upregulating lung inflammation, and encouraging growth of Pseudomonas aeruginosa, the most important pathogen associated with CF lung disease. The effects of hypoxia in childhood CF need to be fully studied, and a potential expanded role for oxygen as therapy in CF may be worthy of exploration.

Exacerbation of underlying pulmonary disease in pregnancy

OBJECTIVE

The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis.

DESIGN

Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants.

METHODS

A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases.

CONCLUSIONS

Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.

The physical, psychological, and social implications of caring for the pregnant patient and newborn with cystic fibrosis

Cystic fibrosis (CF) involves the exocrine glands and epithelial tissues of the pancreas, sweat glands, and mucus glands in the respiratory, digestive, and reproductive tracts. Significant pulmonary disease, poor nutritional status, and pulmonary hypertension are results of chronic infections. When the woman with CF becomes pregnant, her body may find it difficult to adjust to the normal physiological changes of pregnancy, with the pulmonary, cardiovascular, and nutritional status being particularly stressed. Both the mother and the fetus are at a significant risk for increased morbidity and mortality. The woman whose life and pregnancy are compromised by CF and/or the newborn who is diagnosed with CF offer the nurse an extremely challenging situation--one in which physical and psychological care are proportional in importance. As part of the healthcare team, which includes a perinatologist, a pulmonary medicine specialist, a neonatologist, an anesthesiologist, a geneticist, a dietitian, a respiratory therapist, a social worker, an ethicist, and perhaps a clergyman, the nurse helps to coordinate and carry out the care needed for a successful outcome.

Breakpoints for predicting Pseudomonas aeruginosa susceptibility to inhaled tobramycin in cystic fibrosis patients: use of high-range Etest strips

Inhaled administration of tobramycin assures high concentrations in cystic fibrotic lungs, improving the therapeutic ratio over that of parenteral tobramycin levels, particularly against Pseudomonas aeruginosa. Conventional Clinical and Laboratory Standards Institute (CLSI; formerly National Committee for Clinical Laboratory Standards) breakpoints only consider parenteral levels and do not take into account these high antimicrobial concentrations. The Spanish Antibiogram Committee (The MENSURA Group) has tentatively defined specific breakpoint values for inhaled tobramycin when testing P. aeruginosa isolates from cystic fibrosis (CF) patients (susceptible, < or =64 microg/ml; resistant, > or =128 microg/ml). The antimicrobial susceptibilities of 206 prospectively collected CF P. aeruginosa isolates were determined by the reference agar dilution method. For tobramycin, the performance of high range tobramycin Etest strips (AB Biodisk, Solna, Sweden) and conventional tobramycin disks were assessed with the same collection. Applying MENSURA proposed breakpoints, 95.1% of the strains were categorized as susceptible to tobramycin, either using agar dilution or Etest high-range strips (99% categorical agreement between both methods). With CLSI breakpoints, susceptibility rates decreased to 79.1 and 81.1% for agar dilution and Etest strips, respectively (83.5% categorical agreement). Minor, major, and very major errors for Etest strips (CLSI criteria) were 13.6, 1.2, and 14.8%, respectively. Upon applying the new proposed criteria for inhaled tobramycin, only one major and one very major error were observed with Etest strips. Whenever inhaled tobramycin is considered for therapy, we suggest that P. aeruginosa strains from CF patients categorized as intermediate or resistant to tobramycin according to the CLSI criteria should be retested with high-range Etest strips and recategorized using MENSURA interpretive criteria. CLSI breakpoints should still be followed when intravenous tobramycin is used in CF patients, particularly during the course of exacerbations.

Diabetes: a major co-morbidity of cystic fibrosis

Cystic fibrosis-related diabetes (CFRD) is a frequent complication of cystic fibrosis, its prevalence increases with age of patient and is close to 30% at the age of 30 years. As life expectancy greatly increases, the number of cystic fibrosis patients developing diabetes will increase too. CFRD shares some features with type 1 and type 2 diabetes, initial phase is characterised by postprandial hyperglycaemia followed by a progression toward insulin deficiency. Insulin deficiency is an essential factor in the development of diabetes with an additional contribution of insulin resistance. Systematic screening with an oral glucose tolerance test is recommended from the age of 14 years because clinical signs of CFRD are often confused with signs of pulmonary infection and CFRD occurrence is associated with weight and pulmonary function deterioration. In observational studies CFRD diagnosis is associated with a significant increase in mortality, while treatment allow correction of weight and lung deterioration suggesting that CFRD has a significant impact on CF evolution. Microvascular complications are recognised, although paucity of data does not permit a clear description of their natural history. Annual screening for microvascular complication is recommended. There is no evidence by now that CF patients develop macrovascular complications. The only recommended pharmacological treatment is insulin therapy.