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Almulhem M, Ward C, Haq I, Gray RD, Brodlie M. Definitions of pulmonary exacerbation in people with cystic fibrosis: a scoping review. BMJ Open Respir Res 2024; 11:e002456. [PMID: 39147400 PMCID: PMC11331921 DOI: 10.1136/bmjresp-2024-002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/17/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Pulmonary exacerbations (PExs) are clinically important in people with cystic fibrosis (CF). Multiple definitions have been used for PEx, and this scoping review aimed to identify the different definitions reported in the literature and to ascertain which signs and symptoms are commonly used to define them. METHODS A search was performed using Embase, MEDLINE, Cochrane Library, Scopus and CINAHL. All publications reporting clinical trials or prospective observational studies involving definitions of PEx in people with CF published in English from January 1990 to December 2022 were included. Data were then extracted for qualitative thematic analysis. RESULTS A total of 14 039 records were identified, with 7647 titles and abstracts screened once duplicates were removed, 898 reviewed as full text and 377 meeting the inclusion criteria. Pre-existing definitions were used in 148 publications. In 75% of papers, an objective definition was used, while 25% used a subjective definition, which subcategorised into treatment-based definitions (76%) and those involving clinician judgement (24%). Objective definitions were subcategorised into three groups: those based on a combination of signs and symptoms (50%), those based on a predefined combination of signs and symptoms plus the initiation of acute treatment (47%) and scores involving different clinical features each with a specific weighting (3%). The most common signs and symptoms reported in the definitions were, in order, sputum production, cough, lung function, weight/appetite, dyspnoea, chest X-ray changes, chest sounds, fever, fatigue or lethargy and haemoptysis. CONCLUSION We have identified substantial variation in the definitions of PEx in people with CF reported in the literature. There is a requirement for the development of internationally agreed-upon, standardised and validated age-specific definitions. Such definitions would allow comparison between studies and effective meta-analysis to be performed and are especially important in the highly effective modulator therapy era in CF care.
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Affiliation(s)
- Maryam Almulhem
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- College of Applied Medical Sciences, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Christopher Ward
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Iram Haq
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Robert D Gray
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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2
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Cogen JD, Quon BS. Update on the diagnosis and management of cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2024; 23:603-611. [PMID: 38677887 DOI: 10.1016/j.jcf.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024]
Abstract
Pulmonary exacerbations in people with cystic fibrosis are associated with significant morbidity and reduced quality of life. Pulmonary exacerbation treatment guidelines, published by an expert panel assembled by the Cystic Fibrosis Foundation nearly 15 years ago, were primarily consensus-based as there were several gaps in the evidence base. In particular, limited evidence existed regarding optimal pulmonary exacerbation treatment strategies, including duration of antibiotic therapy, treatment location, antibiotic selection, and the role of systemic corticosteroids. Over the last decade, results from observational studies and large multi-center randomized controlled trials have begun to answer important questions related to pulmonary exacerbation treatment. This review focuses on the diagnosis, etiology, and changing epidemiology of pulmonary exacerbations, and also summarizes the most recent and up-to-date studies describing pulmonary exacerbation treatment. Finally, this review provides consideration for future pulmonary exacerbation research priorities, particularly in the current highly effective modulator therapy era.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.
| | - Bradley S Quon
- Division of Respiratory Medicine, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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3
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Bouteleux B, Beaufils F, Fayon M, Bui S. Home-spirometry exacerbation profiles in children with cystic fibrosis. Pediatr Pulmonol 2024; 59:552-561. [PMID: 38014613 DOI: 10.1002/ppul.26781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 11/01/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) are strong predictors of respiratory disease progression in children with cystic fibrosis (CwCF) and may be associated with persistent decreased lung function after acute management. Telemonitoring devices can be used for early detection and monitoring of PEx, but its utility is debated. RESEARCH QUESTION Which symptoms and telemonitoring spirometry characterics are related to outcome dynamics following initial PEx management? METHODS This retrospective study included CwCF followed at Bordeaux University Hospital, France. All severe PEx episodes treated with intravenous (IV) antibiotics (ATB) between 1 January 2017 and 31 December 2021 in CwCF using home telemonitoring were analyzed. Symptoms and home spirometry data were collected 45 days before and up to 60 days after each IV ATB course. We defined three response profiles based on terciles of baseline forced expiratory volume in 1 s (FEV1 ) recovery. RESULTS A total of 346 IV ATB courses for PEx were administered to 65 CwCF during the study period. The drop in FEV1 became significant 8 days before IV ATB initiation. Forty-one percent of IV ATB courses failed to restore baseline FEV1 . The magnitude of FEV1 drop and a greater delay in the initiation of treatment correlated with a low response level. On the 14th day of the IV treatment, a FEV1 recovery less than 94% of baseline was associated with a nonresponder profile. INTERPRETATION Home spirometry may facilitate the early recognition of PEx to implement earlier interventions. This study also provides an outcome lung function threshold which identifies low responders to IV ATB.
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Affiliation(s)
| | - Fabien Beaufils
- CHU Bordeaux, Département de Physiologie, Département de Pédiatrie, Service de Pneumologie Pédiatrique, Centre de Ressources et de Compétences pour la Mucoviscidose, Centre d'Investigation Clinique, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Université de Bordeaux, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Bordeaux, France
| | - Michael Fayon
- CHU Bordeaux, Département de Physiologie, Département de Pédiatrie, Service de Pneumologie Pédiatrique, Centre de Ressources et de Compétences pour la Mucoviscidose, Centre d'Investigation Clinique, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Université de Bordeaux, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Bordeaux, France
| | - Stéphanie Bui
- CHU Bordeaux, Département de Physiologie, Département de Pédiatrie, Service de Pneumologie Pédiatrique, Centre de Ressources et de Compétences pour la Mucoviscidose, Centre d'Investigation Clinique, Bordeaux, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Bordeaux, France
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Steuart R, Pan AY, Woolums A, Benscoter D, Russell CJ, Henningfeld J, Thomson J. Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies. Pediatr Pulmonol 2024; 59:300-313. [PMID: 37937895 DOI: 10.1002/ppul.26746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/22/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown. OBJECTIVE To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies. METHODS This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering. RESULTS Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability. CONCLUSION Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.
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Affiliation(s)
- Rebecca Steuart
- Section of Special Needs, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Henningfeld
- Department of Pediatrics, Section of Pulmonary Medicine, Milwaukee, Wisconsin, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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5
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List R, Solomon G, Bichl S, Horton BJ, Shen S, Corcoran B, Sadeghi H, Britto MT, Ren C, Albon D. Improved recognition of lung function decline as signal of cystic fibrosis pulmonary exacerbation: a Cystic Fibrosis Learning Network Innovation Laboratory quality improvement initiative. BMJ Open Qual 2023; 12:e002466. [PMID: 38154821 PMCID: PMC10759080 DOI: 10.1136/bmjoq-2023-002466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Cystic fibrosis (CF) is a systemic autosomal recessive condition characterised by progressive lung disease. CF pulmonary exacerbations (PEx) are episodes of worsening respiratory status, and frequent PEx are a risk factor for accelerated lung function decline, yet many people with CF (PwCF) go untreated at the time of decline. The goal of this quality improvement (QI) initiative was to improve recognition, treatment and follow-up of PEx in PwCF. METHODS Using the Model for Improvement, the Cystic Fibrosis Learning Network (CFLN) initiated a QI innovation laboratory (iLab) with a global aim to decrease the rate of lung function decline in PwCF. The iLab standardised definitions for signals of PEx using a threshold for decline in forced expiratory volume in one second (FEV1) and/or changes in symptoms. The FEV1 decline signal was termed FIES (FEV1-indicated exacerbation signal). Processes for screening and recognition of FIES and/or symptom changes, a treatment algorithm and follow-up in the presence of a signal were tested concurrently in multiple settings. SPECIFIC AIMS The specific aim is to increase the per cent of PwCF assessed for a PEx signal at ambulatory encounters and to increase the per cent of recommendations to follow-up within 6 weeks for PwCF experiencing a PEx signal. RESULTS FIES recognition increased from 18.6% to 73.4% across all teams during the iLab, and every team showed an improvement. Of PwCF assessed, 15.8% experienced an FIES event (>10% decline in FEV1 per cent predicted (FEV1pp)). Follow-up within 6 weeks was recommended for an average of 70.5% of those assessed for FIES and had an FEV1pp decline greater than 5%. CONCLUSION The CFLN iLab successfully defined and implemented a process to recognise and follow-up PEx signals. This process has the potential to be spread to the larger CF community. Further studies are needed to assess the impact of these processes on PwCF outcomes.
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Affiliation(s)
- Rhonda List
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - George Solomon
- Pulmonary, Allergy, & Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stacy Bichl
- Division of Pulmonary Medicine, Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - Shiyi Shen
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Bean Corcoran
- Connecticut Chapter, Cystic Fibrosis Foundation, Weston, Connecticut, USA
| | - Hossein Sadeghi
- Pediatric Pulmonology and Sleep Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center James M Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Clement Ren
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dana Albon
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Graham BI, Harris JK, Zemanick ET, Wagner BD. Integrating airway microbiome and blood proteomics data to identify multi-omic networks associated with response to pulmonary infection. THE MICROBE 2023; 1:100023. [PMID: 38264413 PMCID: PMC10805068 DOI: 10.1016/j.microb.2023.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Host response to airway infections can vary widely. Cystic fibrosis (CF) pulmonary exacerbations provide an opportunity to better understand the interplay between respiratory microbes and the host. This study aimed to investigate the observed heterogeneity in airway infection recovery by analyzing microbiome and host response (i.e., blood proteome) data collected during the onset of 33 pulmonary infection events. We used sparse multiple canonical correlation network (SmCCNet) analysis to integrate these two types of -omics data along with a clinical measure of recovery. Four microbe-protein SmCCNet subnetworks at infection onset were identified that strongly correlate with recovery. Our findings support existing knowledge regarding CF airway infections. Additionally, we discovered novel microbe-protein subnetworks that are associated with recovery and merit further investigation.
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Affiliation(s)
- Brenton I.M. Graham
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - J. Kirk Harris
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Edith T. Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brandie D. Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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7
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Palla JB, Laguna TA. Health inequities in the modulator era. Curr Opin Pulm Med 2023; 29:626-633. [PMID: 37611037 DOI: 10.1097/mcp.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE OF REVIEW To discuss the existing health inequities in people with cystic fibrosis (CF) and how the recent development of cystic fibrosis transmembrane regulator (CFTR) modulators may impact these inequities. RECENT FINDINGS People with CF (pwCF) from low socioeconomic status (SES) have more pulmonary exacerbations, worse nutritional status, lower pulmonary function, and an increased mortality rate with less access to lung transplantation. pwCF who identify as racial and ethnic minorities have earlier mortality, lower lung function, are less likely to be detected on newborn screening resulting in a delayed diagnosis, are underrepresented in clinic trials, and less likely to be eligible for a CFTR modulator. Female sex is associated with more pulmonary exacerbations and earlier mortality. Sexual gender minorities are a vulnerable population with worse health outcomes, and more research is needed in CF. CFTR modulators are inaccessible to low to middle-income countries due to significant cost burden. SUMMARY People with CF from low SES, racial and ethnic minorities, female sex, and sexual gender minorities face health inequities. CFTR modulator use will further widen existing health inequities given the unequal access to modulators based on nonqualifying genetics and exorbitant cost restricting use both on an individual and global level.
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Affiliation(s)
- John B Palla
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Theresa A Laguna
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
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Gatt D, Shaw M, Waters V, Kritzinger F, Solomon M, Dell S, Ratjen F. Treatment response to pulmonary exacerbation in primary ciliary dyskinesia. Pediatr Pulmonol 2023; 58:2857-2864. [PMID: 37449771 DOI: 10.1002/ppul.26599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/19/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Pulmonary exacerbation (Pex) are common in pediatric primary ciliary dyskinesia (PCD), however changes in forced expiratory volume in 1 s precent predicted (FEV1pp) during Pex are not well described. AIM To assess the evolution of FEV1pp during Pex and to define factors associated with failure to return to baseline lung function. METHOD This was a retrospective study of patients with PCD between 2010 and 2022. Pex were defined as the presence of increased respiratory symptoms treated with intravenous (IV) antibiotics. The main outcomes were the changes in FEV1 during therapy and the proportion of patients (responders) achieving ≥90% of baseline FEV1pp values at the end of admission. RESULTS The study included 52 Pex events in 28 children with PCD. The rate of responders was 32/41 (78%) at the end of admission. Nonresponse was associated with lower median body mass index (BMI) Z-score (-2.4 vs. -0.4, p < .01) and with a history of IV treated Pex in the previous year (p = .06). For the 22 Pex with available FEV1pp measurements at mid admission, the median relative and absolute improvement from admission to Day 7 was 9.1% and 6.2%, respectively (p- .001), and from Days 7 to 14 was 4.4% and 2.8%, respectively (p = .08). CONCLUSION In children with PCD treated with IV antibiotics, the majority of lung function recovery happens during the first week of IV therapy. Lower BMI was associated with nonresponse to therapy.
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Affiliation(s)
- Dvir Gatt
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie Waters
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Fiona Kritzinger
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Dell
- Department of Pediatrics, Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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Walicka-Serzysko K, Postek M, Borawska-Kowalczyk U, Milczewska J, Sands D. Pulmonary Function Tests in the Evaluation of Early Lung Disease in Cystic Fibrosis. J Clin Med 2023; 12:4735. [PMID: 37510850 PMCID: PMC10380830 DOI: 10.3390/jcm12144735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Properly evaluating respiratory system dysfunction is essential in children with cystic fibrosis (CF). This prospective study aimed to assess the course of early lung disease based on multiple breath nitrogen washout (MBNW), impulse oscillometry (IOS), and conventional techniques, such as spirometry and body plethysmography. METHODS Over a 2 year recruitment period, subjects with CF aged 7-18 performed pulmonary function tests (PFTs). Moreover, the nutritional and microbiological status, frequency of pulmonary exacerbations (PExs), and patients' health-related quality of life (HRQoL) were assessed. RESULTS The mean age of the children (n = 69) was 14.09 ± 3.26 years; F/M 37/32. Spirometry-based diagnoses of normal lung function (forced expiratory volume in 1 s, FEV1 ≥ 90%pred), mild (FEV1 70-89%pred) and moderate (FEV1 40-69%pred) lung diseases were established in 34 (49.3%), 25 (36.2%), and 10 (14.5%) patients, respectively. An elevated lung clearance index (LCI > 6.98) was observed in 85% of the subjects with normal FEV1. The presence of Pseudomonas aeruginosa infection (n = 16) and the number of PExs treated with IV antibiotics were associated with significantly worse PFT results. CONCLUSIONS MBNW and IOS are more helpful tools than conventional techniques in assessing early lung disease in CF. LCI is a more useful parameter for detecting functional abnormalities than FEV1 in school-age children.
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Affiliation(s)
- Katarzyna Walicka-Serzysko
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Magdalena Postek
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Urszula Borawska-Kowalczyk
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Justyna Milczewska
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
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10
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Palla JB. Disparities and therapeutic advances in cystic fibrosis. Pediatr Pulmonol 2023. [PMID: 37133222 DOI: 10.1002/ppul.26445] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/20/2023] [Indexed: 05/04/2023]
Abstract
Cystic fibrosis (CF) has seen a multitude of therapeutic advances targeting its downstream effects. This has led to a steady increase in survival over the past few decades. The recent development of disease-modifying drugs targeting the underlying CFTR mutation has revolutionized treatment for CF. Despite these advances, individuals with CF who are racial and ethnic minorities, from low socioeconomic status, or female sex have worse clinical outcomes. The inequitable access to CFTR modulators from cost and/or genetic eligibility has the potential to further worsen the existing health disparities seen within the CF community.
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Affiliation(s)
- John B Palla
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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11
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Perrem L, Stanojevic S, Solomon M, Grasemann H, Sweezey N, Waters V, Sanders DB, Davis SD, Ratjen F. Evaluation of clinically relevant changes in the lung clearance index in children with cystic fibrosis and healthy controls. Thorax 2023; 78:362-367. [PMID: 35428702 DOI: 10.1136/thoraxjnl-2021-218347] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The limits of reproducibility of the lung clearance index (LCI) are higher in children with cystic fibrosis (CF) compared with healthy children, and it is currently unclear what defines a clinically meaningful change. METHODS In a prospective multisite observational study of children with CF and healthy controls (HCs), we measured LCI, FEV1% predicted and symptom scores at quarterly visits over 2 years. Two reviewers performed a detailed review of visits to evaluate the frequency that between visit LCI changes outside ±10%, ±15%, ±20% represented a clinically relevant signal. In the setting of acute respiratory symptoms, we used a generalised estimating equation model, with a logit link function to determine the ability of LCI worsening at different thresholds to predict failure of lung function recovery at follow-up. RESULTS Clinically relevant LCI changes outside ±10%, ±15% and ±20% were observed at 25.7%, 15.0% and 8.3% of CF visits (n=744), respectively. The proportions of LCI changes categorised as noise, reflecting biological variability, were comparable between CF and HC at the 10% (CF 9.9% vs HC 13.0%), 15% (CF 4.3% vs HC 3.1%) and 20% (CF 2.4% vs HC 1.0%) thresholds. Compared with symptomatic CF visits without a worsening in LCI, events with ≥10% LCI increase were more likely to fail to recover baseline LCI at follow-up. CONCLUSION The limits of reproducibility of the LCI in healthy children can be used to detect clinically relevant changes and thus inform clinical care in children with CF.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada .,Postgraduate Medical Education, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Valerie Waters
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Stephanie D Davis
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
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12
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Elmassry MM, Colmer-Hamood JA, Kopel J, San Francisco MJ, Hamood AN. Anti- Pseudomonas aeruginosa Vaccines and Therapies: An Assessment of Clinical Trials. Microorganisms 2023; 11:916. [PMID: 37110338 PMCID: PMC10144840 DOI: 10.3390/microorganisms11040916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Pseudomonas aeruginosa is a Gram-negative opportunistic pathogen that causes high morbidity and mortality in cystic fibrosis (CF) and immunocompromised patients, including patients with ventilator-associated pneumonia (VAP), severely burned patients, and patients with surgical wounds. Due to the intrinsic and extrinsic antibiotic resistance mechanisms, the ability to produce several cell-associated and extracellular virulence factors, and the capacity to adapt to several environmental conditions, eradicating P. aeruginosa within infected patients is difficult. Pseudomonas aeruginosa is one of the six multi-drug-resistant pathogens (ESKAPE) considered by the World Health Organization (WHO) as an entire group for which the development of novel antibiotics is urgently needed. In the United States (US) and within the last several years, P. aeruginosa caused 27% of deaths and approximately USD 767 million annually in health-care costs. Several P. aeruginosa therapies, including new antimicrobial agents, derivatives of existing antibiotics, novel antimicrobial agents such as bacteriophages and their chelators, potential vaccines targeting specific virulence factors, and immunotherapies have been developed. Within the last 2-3 decades, the efficacy of these different treatments was tested in clinical and preclinical trials. Despite these trials, no P. aeruginosa treatment is currently approved or available. In this review, we examined several of these clinicals, specifically those designed to combat P. aeruginosa infections in CF patients, patients with P. aeruginosa VAP, and P. aeruginosa-infected burn patients.
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Affiliation(s)
- Moamen M. Elmassry
- Department of Biological Sciences, Texas Tech University, Lubbock, TX 79409, USA
| | - Jane A. Colmer-Hamood
- Department of Medical Education, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Department of Immunology and Molecular Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jonathan Kopel
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Michael J. San Francisco
- Department of Biological Sciences, Texas Tech University, Lubbock, TX 79409, USA
- Honors College, Texas Tech University, Lubbock, TX 79409, USA
| | - Abdul N. Hamood
- Department of Immunology and Molecular Microbiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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13
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Montemayor K, Jain R. Cystic Fibrosis: Highly Effective Targeted Therapeutics and the Impact on Sex and Racial Disparities. Med Clin North Am 2022; 106:1001-1012. [PMID: 36280328 DOI: 10.1016/j.mcna.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
People with Cystic Fibrosis (CF) are living longer and healthier lives due in part to new therapies, called Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulators. However, disparities in outcomes still exist, with females demonstrating a shorter life expectancy than males; this is opposed to the typical female versus male life expectancy in the general United States population. In addition, minority populations such as those of Hispanic ethnicity and African Americans are less frequently eligible for these new CFTR modulators. The mechanisms driving this difference and the relative contribution of CFTR to the etiology are not yet elucidated.
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Affiliation(s)
- Kristina Montemayor
- Department of Medicine, Johns Hopkins University, 1830 E. Monument Street 5th Floor, Baltimore, MD 21205, USA
| | - Raksha Jain
- Department of Medicine, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-8558, USA.
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14
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Bouzek DC, Ren CL, Thompson M, Slaven JE, Sanders DB. Evaluating FEV1 decline in diagnosis and management of pulmonary exacerbations in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:1709-1716. [PMID: 35429154 PMCID: PMC9321873 DOI: 10.1002/ppul.25925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/22/2022] [Accepted: 04/10/2022] [Indexed: 11/25/2022]
Abstract
RATIONALE Forced expiratory volume in 1 s (FEV1) decline (ΔFEV1) is associated with pulmonary exacerbation (PEx) diagnosis in cystic fibrosis (CF). Spirometry may not be available during telehealth visits and could impair clinician ability to diagnose PEx. This study aims to (1) identify the associations between degrees of ΔFEV1 (decrease of <5% predicted vs. 5%-9% predicted vs. ≥10% predicted from baseline), clinical symptoms, and clinician-diagnosed PEx and (2) evaluate the correlation between respiratory symptoms, ΔFEV1, and antibiotic treatment. METHODS Retrospective, descriptive study of PEx diagnosis and management in 628 outpatient clinical encounters with spirometry in 178 patients with CF ages 6-17 years at Riley Hospital for Children during 2019. Odds ratios (OR) of symptoms associated with clinician-defined PEx diagnosis and antibiotic management stratified by ΔFEV1 decline were determined. RESULTS Clinician-diagnosed PEx occurred at 199 (31.7%) visits; increased cough (77.4%) and sputum/wet cough (57.8%) were the most frequently reported symptoms. Compared to no ΔFEV1, the odds of a clinician-diagnosed PEx were increased when ΔFEV15%-9% and ΔFEV1≥10% was present with increased cough (OR 1.56, 95% confidence interval [CI] 1.25-1.94 and OR 1.82, 95% CI 1.52-2.19, respectively), increased sputum (OR 1.59, 95% CI 1.20-2.12 and OR 1.78, 95% CI 1.37-2.32, respectively), and increased cough and sputum together (OR 1.51, 95% CI 1.08-2.13 and OR 1.68, 95% CI 1.22-2.31, respectively). CONCLUSIONS ΔFEV1 is associated with increased likelihood that cough and sputum are diagnosed as a PEx. Spirometry is essential for PEx diagnosis and treatment and is a necessary component of all clinical encounters.
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Affiliation(s)
- Drake C Bouzek
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Misty Thompson
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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15
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Woollam M, Siegel A, Grocki P, Saunders JL, Sanders DB, Agarwal M, Davis MD. Preliminary method for profiling volatile organic compounds in breath that correlate with pulmonary function and other clinical traits of subjects diagnosed with cystic fibrosis: a pilot study. J Breath Res 2022; 16. [PMID: 35120338 DOI: 10.1088/1752-7163/ac522f] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/04/2022] [Indexed: 11/12/2022]
Abstract
Cystic fibrosis (CF) is characterized by chronic respiratory infections which progressively decrease lung function over time. Affected individuals experience episodes of intensified respiratory symptoms called pulmonary exacerbations (PEx) which accelerate pulmonary function decline and decrease survival. There is no standard classification for PEx, which results in treatments that are heterogeneous. Improving PEx classification and management is a significant priority for people with CF. Previous studies have shown volatile organic compounds (VOCs) in exhaled breath can be used as biomarkers because they are products of metabolic pathways dysregulated by different diseases. To provide insights on PEx classification and other clinical factors, exhaled breath was collected from subjects with CF, with some experiencing PEx and others at baseline. Exhaled breath was collected in Tedlar bags during tidal breathing for VOC analysis by solid phase microextraction coupled to gas chromatography-mass spectrometry. Statistical significance testing between quantitative and categorical clinical variables displayed percent-predicted forced expiratory volume in one second (FEV1pp) was decreased in subjects experiencing PEx. VOCs correlating with other clinical variables (body mass index, age, use of highly effective modulator therapies, and need for antibiotics) were also explored. VOCs correlating to potential confounding variables were removed and analyzed by regression for correlations with FEV1pp measurements. The VOC with the highest correlation with FEV1pp (3,7-dimethyldecane) also gave the lowest p-value when comparing subjects at baseline and during PEx. Receiver operator characteristic curves showed 3,7-dimethyldecane had a higher ability to classify PEx (area under the curve (AUC) = 0.91) relative to FEV1pp values at collection (AUC = 0.83). However, normalized ΔFEV1pp values had the highest capability to distinguish PEx (AUC = 0.93). These results show that exhaled VOCs may be a source of biomarkers for various clinical traits of CF, including PEx, that should be explored in larger sample cohorts and validation studies.
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Affiliation(s)
- Mark Woollam
- Chemistry and Chemical Biology, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Amanda Siegel
- Department of Chemistry and Chemical Biology, Indiana University Purdue University Indianapolis, 402 N Blackford St., LD326, Indianapolis, Indiana, 46202, UNITED STATES
| | - Paul Grocki
- Chemistry and Chemical Biology, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Jessica L Saunders
- Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, 46202, UNITED STATES
| | - Don B Sanders
- Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, 46202, UNITED STATES
| | - Mangilal Agarwal
- Mechanical and Energy Engineering, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Michael D Davis
- Pulmonary Medicine, Herman B Wells Center for Pediatric Research, 1044 W. Walnut St., Indianapolis, Indiana, 46202, UNITED STATES
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16
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Henderson AG, Davis JM, Keith JD, Green ME, Oden AM, Rowe SM, Birket SE. Static mucus impairs bacterial clearance and allows chronic infection with Pseudomonas aeruginosa in the cystic fibrosis rat. Eur Respir J 2022; 60:2101032. [PMID: 35115338 PMCID: PMC9944330 DOI: 10.1183/13993003.01032-2021] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
Cystic fibrosis (CF) airway disease is characterised by chronic Pseudomonas aeruginosa infection. Successful eradication strategies have been hampered by a poor understanding of the mechanisms underlying conversion to chronicity. The CFTR-knockout (KO) rat harbors a progressive defect in mucociliary transport and viscosity. KO rats were infected before and after the appearance of the mucus defect, using a clinical, mucoid-isolate of P. aeruginosa embedded in agarose beads. Young KO rats that were exposed to bacteria before the development of mucociliary transport defects resolved the infection and subsequent tissue damage. However, older KO rats that were infected in the presence of hyperviscous and static mucus were unable to eradicate bacteria, but instead had bacterial persistence through 28 days post-infection that was accompanied by airway mucus occlusion and lingering inflammation. Normal rats responded to infection with increased mucociliary transport to supernormal rates, which reduced the severity of a second bacterial exposure. We therefore conclude that the aberrant mucus present in the CF airway permits persistence of P. aeruginosa in the lung.
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Affiliation(s)
- Alexander G Henderson
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joy M Davis
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Johnathan D Keith
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Morgan E Green
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley M Oden
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Steven M Rowe
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Susan E Birket
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
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17
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Franz N, Rapp H, Hansen RN, Gold LS, Goss CH, Lechtzin N, Kessler L. Health care costs related to home spirometry in the eICE randomized trial. J Cyst Fibros 2022; 21:61-69. [PMID: 33715993 PMCID: PMC8433261 DOI: 10.1016/j.jcf.2021.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/02/2021] [Accepted: 02/26/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Home spirometry with regular symptom assessment is one strategy to track lung health to intervene early in episodes of pulmonary exacerbations (PE). In a multi-center randomized controlled trial home spirometry and symptom tracking demonstrated no significant differences regarding the primary clinical endpoint, FEV1, compared to usual care, but did identify differences in healthcare utilization. We used data from the Early Intervention in Cystic Fibrosis Exacerbation (eICE) study to evaluate whether home monitoring of PE is a cost-minimizing intervention in the context of this randomized trial. METHODS We reviewed healthcare resource utilization of all 267 eICE participants, including outpatient visits, antibiotics and hospitalizations. Prices were identified in the IBM/Watson MarketScanⓇ Commercial Claims and Encounters Databases and averaged over the 2014-2017 period. Using total healthcare utilization costs, we generated summary statistics by intervention and protocol arm (total cost, mean cost, standard deviation). We performed Welch Two Sample t-tests to determine if total costs and cost by type of utilization differed significantly between groups. RESULTS Outpatient visit costs were significantly higher by 13% in the Early Intervention (EI) than in the usual care (UC) arm ($3,345 vs. $2,966). We found no significant differences in outpatient antibiotic, hospitalization, or total health care costs between the arms. CONCLUSIONS Within the context of the eICE trial, outpatient visits were significantly higher in those with experimental home spirometry care, but that did not translate into statistically significant differences of overall health care costs between the two arms.
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Affiliation(s)
- Natalie Franz
- Department of Health Services, University of Washington, Seattle, Washington, United States
| | - Hannah Rapp
- Department of Health Services, University of Washington, Seattle, Washington, United States
| | - Ryan N. Hansen
- School of Pharmacy, University of Washington, Seattle, Washington, United States
| | - Laura S. Gold
- Department of Radiology, University of Washington, Seattle, Washington, United States
| | - Christopher H. Goss
- Department of Medicine, University of Washington, Seattle, Washington, United States;,Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Noah Lechtzin
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, Washington, United States
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18
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Duration of intravenous antibiotic treatment for acute exacerbations of cystic fibrosis: A systematic review: Duration of treatment for acute exacerbations of cystic fibrosis. J Cyst Fibros 2021; 21:562-573. [PMID: 34588142 DOI: 10.1016/j.jcf.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/07/2021] [Accepted: 08/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute exacerbations of Cystic Fibrosis (AECF) are associated with significant morbidity. Recommendations are to treat for 2-3 weeks despite limited data. Spirometry is a measure of clinical response yet appears to plateau at 7-10 days. While durations <9 days have been associated with poorer outcomes, a duration of 10 days may be as effective as 14 days, potentially conferring advantages in terms of cost and adverse events. A 2019 Cochrane review by Abbott et al. did not identify any randomised controlled trials (RCT) comparing durations of treatment. Utilising data from non-randomised studies (NRS), we report a systematic review of intravenous antibiotic treatment, exploring changes in FEV1 (Forced Expiratory Volume in 1 second), CRP (C-reactive protein) and peripheral WBC (white blood cell) count in studies with different treatment durations. STUDY DESIGN AND METHODS Systematic review of published literature following a search of MEDLINE, Embase, CINAHL and the Cochrane Clinical Trials register. Guidelines from the Preferred Reporting items for Systematic reviews and Meta-Analysis (PRISMA) and reporting Meta-analysis of Observational studies (MOOSE) statement were followed. RESULTS No randomised controlled trials were identified that specifically examined duration of treatment during AECF. This study included all relevant RCTs and also NRS, grouping according to study characteristics, such as length of treatment, location, year, and also characteristics of the patient population. 52 studies, comprising 79 subgroups, and 1,597 patients, were identified. Mean change (95%CI) in ppFEV1 was 10.13 (9.21-11.05). There was no significant difference in change in ppFEV1 for studies treating for 10-12 days; 8.85 (7.47-10.23), vs 13-15 days; 10.68 (9.53-11.82). Similar changes in CRP and WBC were seen irrespective of treatment duration. CONCLUSION This systematic review provides evidence that shorter durations of treatment may be associated with similar changes in FEV1, CRP and WBC compared with longer durations.
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19
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Perrem L, Stanojevic S, Shaw M, Jensen R, McDonald N, Isaac SM, Davis M, Clem C, Guido J, Jara S, France L, Solomon M, Grasemann H, Waters V, Sweezey N, Sanders DB, Davis SD, Ratjen F. Lung Clearance Index to Track Acute Respiratory Events in School-Age Children with Cystic Fibrosis. Am J Respir Crit Care Med 2021; 203:977-986. [PMID: 33030967 DOI: 10.1164/rccm.202006-2433oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: The lung clearance index (LCI) is responsive to acute respiratory events in preschool children with cystic fibrosis (CF), but its utility to identify and manage these events in school-age children with CF is not well defined.Objectives: To describe changes in LCI with acute respiratory events in school-age children with CF.Methods: In a multisite prospective observational study, the LCI and FEV1 were measured quarterly and during acute respiratory events. Linear regression was used to compare relative changes in LCI and FEV1% predicted at acute respiratory events. Logistic regression was used to compare the odds of a significant worsening in LCI and FEV1% predicted at acute respiratory events. Generalized estimating equation models were used to account for repeated events in the same subject.Measurements and Main Results: A total of 98 children with CF were followed for 2 years. There were 265 acute respiratory events. Relative to a stable baseline measure, LCI (+8.9%; 95% confidence interval, 6.5 to 11.3) and FEV1% predicted (-6.6%; 95% confidence interval, -8.3 to -5.0) worsened with acute respiratory events. A greater proportion of events had a worsening in LCI compared with a decline in FEV1% predicted (41.7% vs. 30.0%; P = 0.012); 53.9% of events were associated with worsening in LCI or FEV1. Neither LCI nor FEV1 recovered to baseline values at the next follow-up visit.Conclusions: In school-age children with CF, the LCI is a sensitive measure to assess lung function worsening with acute respiratory events and incomplete recovery at follow-up. In combination, the LCI and FEV1 capture a higher proportion of events with functional impairment.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada.,Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Sanja Stanojevic
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Renee Jensen
- Division of Respiratory Medicine and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Nancy McDonald
- Division of Respiratory Medicine and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sarah M Isaac
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Miriam Davis
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Charles Clem
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Julia Guido
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sylvia Jara
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Lisa France
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Melinda Solomon
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Valerie Waters
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Felix Ratjen
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
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20
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Khanal S, Webster M, Niu N, Zielonka J, Nunez M, Chupp G, Slade MD, Cohn L, Sauler M, Gomez JL, Tarran R, Sharma L, Dela Cruz CS, Egan M, Laguna T, Britto CJ. SPLUNC1: a novel marker of cystic fibrosis exacerbations. Eur Respir J 2021; 58:13993003.00507-2020. [PMID: 33958427 DOI: 10.1183/13993003.00507-2020] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/29/2021] [Indexed: 11/05/2022]
Abstract
Acute pulmonary Exacerbations (AE) are episodes of clinical worsening in cystic fibrosis (CF), often precipitated by infection. Timely detection is critical to minimise morbidity and lung function declines associated with acute inflammation during AE. Based on our previous observations that airway protein Short Palate Lung Nasal epithelium Clone 1 (SPLUNC1) is regulated by inflammatory signals, we investigated the use of SPLUNC1 fluctuations to diagnose and predict AE in CF.We enrolled CF participants from two independent cohorts to measure AE markers of inflammation in sputum and recorded clinical outcomes for a 1-year follow-up period.SPLUNC1 levels were high in healthy controls (n=9, 10.7 μg mL-1), and significantly decreased in CF participants without AE (n=30, 5.7 μg mL-1, p=0.016). SPLUNC1 levels were 71.9% lower during AE (n=14, 1.6 μg mL-1, p=0.0034) regardless of age, sex, CF-causing mutation, or microbiology findings. Cytokines Il-1β and TNFα were also increased in AE, whereas lung function did not consistently decrease. Stable CF participants with lower SPLUNC1 levels were much more likely to have an AE at 60 days (HR: 11.49, Standard Error: 0.83, p=0.0033). Low-SPLUNC1 stable participants remained at higher AE risk even one year after sputum collection (HR: 3.21, Standard Error: 0.47, p=0.0125). SPLUNC1 was downregulated by inflammatory cytokines and proteases increased in sputum during AE.In acute CF care, low SPLUNC1 levels could support a decision to increase airway clearance or to initiate pharmacological interventions. In asymptomatic, stable patients, low SPLUNC1 levels could inform changes in clinical management to improve long-term disease control and clinical outcomes in CF.
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Affiliation(s)
- Sara Khanal
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan Webster
- Department of Cell Biology & Physiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Naiqian Niu
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jana Zielonka
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Myra Nunez
- Division of Pediatric Respiratory Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Geoffrey Chupp
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Martin D Slade
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lauren Cohn
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maor Sauler
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jose L Gomez
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Robert Tarran
- Department of Cell Biology & Physiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lokesh Sharma
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles S Dela Cruz
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marie Egan
- Division of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Theresa Laguna
- Division of Pediatric Respiratory Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Clemente J Britto
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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21
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Muirhead CA, Lanocha N, Markwardt S, MacDonald KD. Evaluation of rescue oral glucocorticoid therapy during inpatient cystic fibrosis exacerbations. Pediatr Pulmonol 2021; 56:891-900. [PMID: 33289316 DOI: 10.1002/ppul.25204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/13/2020] [Accepted: 11/30/2020] [Indexed: 11/07/2022]
Abstract
An acute pulmonary exacerbation (APE) in cystic fibrosis (CF) is characterized by increased pulmonary symptoms attributed to bacterial colonization, neutrophil recruitment, and inflammation. Antimicrobials, airway clearance, and nutrition are the mainstay of therapy. However, when patients fail to improve, corticosteroids have been added to therapy. We retrospectively examined the use of rescue steroids in a children's hospital from 2013 to 2017 during CF APE treatment following at least 1 week of inpatient therapy without expected clinical improvement. In total, 106 encounters of 53 unique patients, aged 6-20 years, who had FEV1 percent predicted (FEV1pp) data at baseline, admission, midpoint, and discharge, and had admission duration of at least 12 days were studied. Encounters treated with steroids had less improvement at midpoint percent change from admission in FEV1pp (4.9 ± 11.3) than nonsteroid group change in FEV1pp (20.1 ± 24.6; p < .001). Failure to improve as expected was the rationale for steroid use. At discharge, there was no difference in mean FEV1pp (p = .76). Delays in steroid therapy by waiting until the end of the second week increased the total length of stay (LOS). Propensity matching, comparing outcomes in patients without midpoint improvement in FEV1pp, was also evaluated. There was no difference in admission or discharge FEV1pp between groups. Equally, no difference in FEV1pp at follow-up visit or in time until the next APE was detected. Secondary analysis for associations including gender, genotype, fungal colonization, or inhaled antimicrobials was nonsignificant. These data suggest rescue use of corticosteroids during APE does not predictably impact important outcome measures during CF APE treatment.
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Affiliation(s)
- Corinne A Muirhead
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Natalie Lanocha
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Sheila Markwardt
- Department of Biostatistics, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelvin D MacDonald
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
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Ishak A, Stick SM, Turkovic L, Ranganathan SC, King L, Harrison J, Sly PD, Caudri D, Schultz A. BAL Inflammatory Markers Can Predict Pulmonary Exacerbations in Children With Cystic Fibrosis. Chest 2020; 158:2314-2322. [DOI: 10.1016/j.chest.2020.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022] Open
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Houston CJ, Taggart CC, Downey DG. The role of inflammation in cystic fibrosis pulmonary exacerbations. Expert Rev Respir Med 2020; 14:889-903. [PMID: 32544353 DOI: 10.1080/17476348.2020.1778469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cystic Fibrosis pulmonary exacerbations are critical events in the lives of people with CF that have deleterious effects on lung function, quality of life, and life expectancy. There are significant unmet needs in the management of exacerbations. We review here the associated inflammatory changes that underlie these events and are of interest for the development of biomarkers of exacerbation. AREAS COVERED Inflammatory responses in CF are abnormal and contribute to a sustained proinflammatory lung microenvironment, abundant in proinflammatory mediators and deficient in counter-regulatory mediators that terminate and resolve inflammation. There is increasing interest in these inflammatory pathways to discover novel biomarkers for pulmonary exacerbation management. In this review, we explore the inflammatory changes occurring during intravenous antibiotic therapy for exacerbation and how they may be applied as biomarkers to guide exacerbation therapy. A literature search was conducted using the PubMed database in February 2020. EXPERT OPINION Heterogeneity in inflammatory responses to treatment of a pulmonary exacerbation, a disease process with complex pathophysiology, limits the clinical utility of individual biomarkers. Biomarker panels may be a more successful strategy to capture informative changes within the CF population to improve pulmonary exacerbation management and outcomes.
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Affiliation(s)
- Claire J Houston
- Airway Innate Immunity Group (Aiir), Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Northern Ireland
| | - Clifford C Taggart
- Airway Innate Immunity Group (Aiir), Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Northern Ireland
| | - Damian G Downey
- Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Northern Ireland.,Northern Ireland Regional Adult CF Centre, Belfast Health and Social Care Trust , Belfast, UK
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Bush A. Azithromycin is the answer in paediatric respiratory medicine, but what was the question? Paediatr Respir Rev 2020; 34:67-74. [PMID: 31629643 DOI: 10.1016/j.prrv.2019.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023]
Abstract
The first clinical indication of non-antibiotic benefits of macrolides was in the Far East, in adults with diffuse panbronchiolitis. This condition is characterised by chronic airway infection, often with Pseudomonas aeruginosa, airway inflammation, bronchiectasis and a high mortality. Low dose erythromycin, and subsequently other macrolides, led in many cases to complete remission of the condition, and abrogated the neutrophilic airway inflammation characteristic of the disease. This dramatic finding sparked a flurry of interest in the many hundreds of macrolides in nature, especially their anti-inflammatory and immunomodulatory effects. The biggest subsequent trials of azithromycin were in cystic fibrosis, which has obvious similarities to diffuse panbronchiolitis. There were unquestionable improvements in lung function and pulmonary exacerbations, but compared to diffuse panbronchiolitis, the results were disappointing. Case reports, case series and some randomised controlled trials followed in other conditions. Three trials of azithromycin in preschool wheeze gave contradictory results; a trial in pauci-inflammatory adult asthma, and a trial in non-cystic fibrosis bronchiectasis both showed a significant reduction in exacerbations, but none matched the dramatic results in diffuse panbronchiolitis. There is clearly a huge risk of antibacterial resistance if macrolides are used widely and uncritically in the community. In summary, Azithromycin is not the answer to anything in paediatric respiratory medicine; the paediatric respiratory community needs to refocus on the dramatic benefits of macrolides in diffuse panbronchiolitis, use modern - omics technologies to determine the endotypes of inflammatory diseases and discover in nature or synthesise designer macrolides to replicate the diffuse panbronchiolitis results. We must now find out how to do better!
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Affiliation(s)
- Andrew Bush
- Professor of Paediatrics and Paediatric Respirology, Imperial College Consultant Paediatric Chest Physician, Royal Brompton & Harefield NHS Foundation Trust, National Heart and Lung Institute, UK; Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust, UK.
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Wagener JS, VanDevanter DR, Konstan MW, Pasta DJ, Millar SJ, Morgan WJ. Lung function changes before and after pulmonary exacerbation antimicrobial treatment in cystic fibrosis. Pediatr Pulmonol 2020; 55:828-834. [PMID: 31746561 DOI: 10.1002/ppul.24577] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/09/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND In cystic fibrosis, observation of a lung function drop (as percent predicted forced expiratory volume in 1 s [FEV1 ]; ppFEV1 ) frequently precedes pulmonary exacerbation (PEx) diagnosis. Recovery of ppFEV1 to a previous "baseline" is commonly used to assess antimicrobial treatment response. However, not all diagnosed PEx are associated with a ppFEV1 drop, and it is unclear whether these are a different type of PEx from those associated with a ppFEV1 drop. METHODS We analyzed pre- and posttreatment ppFEV1 for PEx recorded in the Epidemiologic Study of Cystic Fibrosis from 2003 through 2005. Baseline, pretreatment, and follow-up ppFEV1 were the best recorded within 12-months pre-PEx, the lowest recorded -30 to +3 days of treatment, and the best recorded during 6-month follow-up, respectively. Logistic regression models for return of ppFEV1 to baseline during follow-up were developed separately for PEx with ≥10%, <10%, and no ppFEV1 drop before treatment. RESULTS Of 15 147 PEx, 10 166 (67.1%), 3479 (23.0%), and 1502 (9.9%) presented with a ≥10%, <10%, or no ppFEV1 drop at diagnosis, respectively. 19.5%, 35.2%, and 65.6% of PEx, respectively, had follow-up ppFEV1 equal to or exceeding baseline; overall 27.7% of all PEx treatments resulted in complete recovery of baseline ppFEV1 . Significant predictors of ppFEV1 recovery at follow-up were younger patient age, absence of Aspergillus, lower baseline ppFEV1 , fewer visits during the baseline, lower frequency of prior-year PEx, shorter elapsed time from baseline measure to treatment, smaller relative ppFEV1 drop before treatment, and non intravenous (ie, oral or inhaled antibiotic) treatment. PEx with ≥10%, <10%, and no ppFEV1 drop before treatment had only modest differences in covariate odds ratios associated with complete ppFEV1 recovery. CONCLUSIONS Among the 10% of PEx presenting with no apparent ppFEV1 drop, more than one-third resulted in a decreased ppFEV1 during follow-up. Risk factors for this outcome were the same as those associated with lack of ppFEV1 recovery among PEx with pretreatment ppFEV1 drops. These results suggest that inherent FEV1 variability, baseline and follow-up sampling methodologies, ppFEV1 regression to the mean, and underlying lung disease progression complicate this approach for assessing effects of PEx and treatment response.
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Affiliation(s)
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - David J Pasta
- Department of Outcomes, ICON Clinical Research, San Francisco, California
| | - Stefanie J Millar
- Department of Outcomes, ICON Clinical Research, San Francisco, California
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona
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Vitamin D status correlates with the markers of cystic fibrosis-related pulmonary disease. Pediatr Neonatol 2019; 60:210-215. [PMID: 30093293 DOI: 10.1016/j.pedneo.2018.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 03/01/2018] [Accepted: 07/05/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The prevalence of Vitamin D deficiency remains high in cystic fibrosis despite daily supplementation. Vitamin D as an immunomodulator has been related to lower respiratory tract infections in children. The present study was undertaken to examine the association between vitamin D status and markers of cystic fibrosis-related pulmonary disease including exacerbations, bacterial colonization and pulmonary function. METHODS The study includes review of records of 51 cystic fibrosis patients. Baseline patient variables and serum vitamin D levels were recorded. Based on vitamin D levels study patients were divided into three groups: vitamin-D sufficient (≥20 ng/mL), vitamin-D insufficient (12 to 20 ng/mL), and vitamin D-deficient (≤12 ng/ml). RESULTS The proportion of children with deficient, insufficient and sufficient vitamin D levels were 47.1%, 15.7%, and 37.2%, respectively. Female sex, bacterial colonization and a greater number of exacerbations were associated with highest odds of developing vitamin D deficiency in patients with CF with 1.77 (0.22-4.61) (p = 0.002), 2.9(0.57-14.82) (p = 0.011), and 5.12 (1.28-20.50) (p = 0.021) respectively. The comparison of vitamin-D levels taken during exacerbations, colonization and during routine follow-up were significant [16.04 (7.42-27.91), 24.3 (15.5-32.4) and 48.54 (18.37-78.7) ng/ml, p < 0.001]. The FEV1 was determined in 24 patients; the comparison was significant between vitamin D-deficient and -sufficient groups [0.75 (0.717-0.777) vs. 0.82 (0.74-0.92) p < 0.05]. CONCLUSION We concluded that vitamin D deficiency was highly prevalent in children with CF, despite daily supplementation of the vitamin in diet. Further, vitamin D deficiency was associated with a higher rate of pulmonary exacerbations and higher incidence of pulmonary bacterial colonization. In addition, in younger patients, low vitamin D levels were associated with reduced pulmonary function.
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Juarez-Colunga E, Rosenfeld M, Zemanick ET, Wagner B. Application of multiple event analysis as an alternative approach to studying pulmonary exacerbations as an outcome measure. J Cyst Fibros 2019; 19:114-118. [PMID: 30642785 DOI: 10.1016/j.jcf.2018.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/30/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) are important contributors to morbidity and mortality in cystic fibrosis (CF). Understanding risk factors for PEx is critical to improve treatment; pulmonary exacerbations also serve as an important outcome in CF clinical trials. Current risk estimates generally only evaluate time to the first PEx. Methods accounting for multiple exacerbations during the observation period could provide more power to detect significant risk factors. METHODS The Early Pseudomonas Infection Control (EPIC) Observational Study enrolled participants between 2004 and 2006 who were ≤ 12 years of age and negative for Pseudomonas aeruginosa. First and multiple event analyses were used to investigate risk factors for pulmonary exacerbations. RESULTS We evaluated a total of 5129 PEx from 1734 CF patients in the EPIC study. Multiple event analysis identified 2 more factors associated with occurrence of PEx compared to first event analysis. After adjusting for multiple factors, the following were associated with higher occurrence of PExs: female gender, older age at enrollment, household cigarette smoke exposure, increased cough at the most recent encounter, having used antibiotics since the previous encounter, a positive culture for any CF organism at the most recent encounter, and having had a PEx in the last 30 days. CONCLUSIONS Multiple event analyses use all PEx events and may identify more risk factors for PEx than analysis of time to first PEx. We have provided an example of how to apply this type of analysis and how to interpret estimates in the context of the EPIC study.
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Affiliation(s)
- Elizabeth Juarez-Colunga
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, USA; Adult and Child Consortium for Health Outcomes Research and Delivery Science, USA.
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE Seattle, WA 98105, USA
| | - Edith T Zemanick
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Brandie Wagner
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, USA; Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Center, Aurora, CO, USA
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Flume PA, Suthoff ED, Kosinski M, Marigowda G, Quittner AL. Measuring recovery in health-related quality of life during and after pulmonary exacerbations in patients with cystic fibrosis. J Cyst Fibros 2018; 18:737-742. [PMID: 30587335 DOI: 10.1016/j.jcf.2018.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 11/30/2018] [Accepted: 12/08/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND We explored the time-dependent impact of pulmonary exacerbations (PEx) on health-related quality of life (HRQoL) using Cystic Fibrosis Questionnaire-Revised (CFQ-R) data from 2 large cystic fibrosis (CF) trials. METHODS This exploratory post-hoc analysis evaluated the impact of PEx on CFQ-R domains of functioning in 80 patients with CF (homozygous for F508del-CFTR), aged ≥14 years randomized to placebo in the TRAFFIC and TRANSPORT trials who experienced 1 PEx. RESULTS Scores on the CFQ-R were significantly lower within 1 week of PEx start in 8 out of 12 domains (Respiratory Symptoms, Physical Functioning, Emotional Functioning, Health Perceptions, Role Functioning, Social Functioning, Eating, and Vitality). Patients whose PEx was treated with hospitalization or intravenous antibiotics had greater reductions in some domains of HRQoL compared with those treated with oral antibiotics. In the immediate weeks post-PEx, improvement was seen on Emotional Functioning, Respiratory Symptoms, and Health Perceptions, while further decline was seen for Eating, Physical Functioning, Role Functioning, Vitality, and Weight. For some measures (Physical Functioning, Vitality), full recovery to pre-PEx levels took several weeks. CONCLUSIONS Pulmonary exacerbations have significant effects on multiple domains of HRQoL, and recovery across multiple domains post-PEx can take several weeks. These findings provide insight into the impact of PEx on patient HRQoL and recovery post-PEx. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifiers, NCT01807923 and NCT01807949.
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Affiliation(s)
- Patrick A Flume
- Medical University of South Carolina, 96 Jonathan Lucas Street, 812-CSB, Charleston, SC 29425, USA.
| | - Ellison D Suthoff
- Formerly of Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - Mark Kosinski
- Quality Metric Incorporated, Now Part of Optum Insight, 1301 Atwood Avenue, Johnston, RI 02919, USA.
| | - Gautham Marigowda
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - Alexandra L Quittner
- Nicklaus Children's Research Institute, 3100 SW 62nd Avenue, Miami, FL 33155, USA.
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Schechter MS. Reevaluating approaches to cystic fibrosis pulmonary exacerbations. Pediatr Pulmonol 2018; 53:S51-S63. [PMID: 29979495 DOI: 10.1002/ppul.24125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/20/2018] [Indexed: 11/10/2022]
Abstract
Cystic Fibrosis (CF) lung disease is characterized by intermittent acute episodes of worsening signs, symptoms, and pulmonary function; these so-called pulmonary exacerbations (PEx) appear to be important drivers of long-term declines in lung function, quality of life, and life expectancy. Surveillance for development of PEx and their treatment is a fundamental component of chronic CF management, and the merits of novel CF therapies are often judged based on their ability to reduce the frequency of PEx. Given the central role that they play, it is surprising how poorly PEx are understood, how thin is the evidence base for their treatment and how often they are left unrecognized and untreated in clinical practice. This paper reviews what is known and what is unknown regarding the nature of PEx, and discusses the impact of missed recognition and treatment of these episodes as well as the apparent variation in practice across CF care centers. The arguments supporting a liberal, highly sensitive approach to the diagnosis of PEx are presented, as well as recommendation for how care programs can achieve consistency in their early recognition and treatment. A stepwise approach to personalized treatment supported by close follow-up to ensure the successful resolution of all signs and symptoms will lead to the stabilization of patients' lung function and quality of life. Recommendations are made regarding important priorities for research into evidence-based approaches to improving the care of PEx.
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Affiliation(s)
- Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University, Children's Hospital of Richmond at VCU, Richmond, Virginia
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McColley SA, Konstan MW, Ramsey BW, Stuart Elborn J, Boyle MP, Wainwright CE, Waltz D, Vera-Llonch M, Marigowda G, Jiang JG, Rubin JL. Lumacaftor/Ivacaftor reduces pulmonary exacerbations in patients irrespective of initial changes in FEV 1. J Cyst Fibros 2018; 18:94-101. [PMID: 30146268 DOI: 10.1016/j.jcf.2018.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Improved lung function and fewer pulmonary exacerbations (PEx) were observed with lumacaftor/ivacaftor (LUM/IVA) in patients with cystic fibrosis homozygous for F508del. It is unknown whether PEx reduction extends to patients without early lung function improvement. METHODS Post hoc analyses of pooled phase 3 data (NCT01807923, NCT01807949) categorized LUM/IVA-treated patients by percent predicted forced expiratory volume in 1 s (ppFEV1) change from baseline to day 15 into threshold categories (absolute change ≤0 vs >0; relative change <5% vs ≥5%) and compared PEx rates vs placebo. RESULTS LUM (400 mg q12h)/IVA (250 mg q12h)-treated patients (n = 369) experienced significantly fewer PEx vs placebo, regardless of threshold category. With LUM/IVA, PEx rate per patient per year was 0.60 for those with absolute change in ppFEV1 > 0 and 0.85 for those with absolute change ≤0 (respective rate ratios vs placebo [95% CI]: 0.53 [0.40-0.69; P < .0001], 0.74 [0.55-0.99; P = .04]). CONCLUSIONS LUM/IVA significantly reduced PEx, even in patients without early lung function improvement.
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Affiliation(s)
- Susanna A McColley
- Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue #43, Chicago, IL 60611, USA.
| | - Michael W Konstan
- Case Western Reserve University School of Medicine and Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Bonnie W Ramsey
- Seattle Children's Hospital and University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - J Stuart Elborn
- Imperial College and Royal Brompton Hospital, London and Queens University Belfast, 97 Lisburn Road, Belfast BT9 7AE, UK.
| | - Michael P Boyle
- Johns Hopkins Medical Institution, 600 North Wolfe Street, Baltimore, MD 21287, USA.
| | - Claire E Wainwright
- Lady Cilento Children's Hospital and Child Health Research Centre, University of Queensland, 62 Graham Street, South Brisbane, Queensland 4104, Australia.
| | - David Waltz
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | | | - Gautham Marigowda
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - John G Jiang
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA
| | - Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
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Abstract
INTRODUCTION Cystic fibrosis (CF) outcomes and survival have improved over the last century primarily due to advancements in antibiotics, nutritional, and pulmonary therapies. Reviewed here are the significant unmet needs that exist for individuals with CF. Areas covered: With the recent development of medications that address the underlying defect in the CF protein, there is hope that there will be continued improvement in CF outcomes. However, there remains a need to prevent or stop progression of CF-related complications, as the CF protein is important to several body systems. As end stage lung disease is the primary cause of mortality in CF, a need exists for advancements in pulmonary therapies to reduce time burden, identification of best practices for the treatment of pulmonary exacerbations, further development of anti-infective and anti-inflammatory therapies, and appropriately timed referral for lung transplantation at end-stage lung disease. Extra-pulmonary complications are increasingly recognized and better understanding of such problems as CF related liver disease is needed. Expert commentary: While CFTR modulators are available for the majority of CF patients, there remains a need for effective therapies to address infection, inflammation, irreversible lung disease, and extrapulmonary complications of CF.
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Affiliation(s)
- Natalie E West
- a Department of Medicine, Division of Pulmonary and Critical Care Medicine , Johns Hopkins University , Baltimore , USA
| | - Patrick A Flume
- b Departments of Medicine and Pediatrics , Medical University of South Carolina , Charleston , SC , USA
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Pulmonary exacerbations and acute declines in lung function in patients with cystic fibrosis. J Cyst Fibros 2018; 17:496-502. [DOI: 10.1016/j.jcf.2018.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/30/2017] [Accepted: 02/05/2018] [Indexed: 11/17/2022]
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Characteristics and outcomes of oral antibiotic treated pulmonary exacerbations in children with cystic fibrosis. J Cyst Fibros 2018; 17:760-768. [PMID: 29921503 PMCID: PMC7105204 DOI: 10.1016/j.jcf.2018.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 11/24/2022]
Abstract
Background Pulmonary exacerbations (PEx) in children with cystic fibrosis (CF) are frequently treated in the outpatient setting with oral antibiotics. However, little is known about the characteristics of PEx managed on an outpatient basis and the effectiveness of oral antibiotic therapy. We sought to prospectively evaluate clinical and laboratory changes associated with oral antibiotic treatment for PEx. Methods Children with CF between 8 and 18 years of age prescribed two weeks of oral antibiotics for a PEx were eligible to enroll. The study consisted of a visit within 48 h of starting antibiotics and a second visit within one week of antibiotic completion. Twenty-eight participants were evaluated by exacerbation score, quality of life measurements, lung function, sputum microbiology and inflammation. Results Oral antibiotic treatment was associated with a significant improvement in exacerbation score and quality of life measured by the CF Questionnaire-Revised (CFQ-R) respiratory domain. Following treatment, forced expiratory volume in 1 s (FEV1) % predicted increased [median (range)] 9% (−8%, 31%), and 22 (81%) subjects returned to 90% or higher of baseline FEV1. Bacterial density of the primary organism identified on sputum culture decreased significantly with a median (range) decrease of 0.8 log10 cfu/mL (−8 log10, 2 log10, p = 0.03). Sputum neutrophil elastase [−37 μg/mL (−464, 272), p = 0.02] and IL-1β [−2.8 × 103μg/mL (−6.9 × 104, 3.3 × 104), p = 0.03] decreased significantly following treatment in this cohort. Conclusions Treatment of PEx with oral antibiotics was associated with measurable improvements in patient reported outcomes, lung function, bacterial density and sputum inflammatory markers.
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Whole Blood Gene Expression Profiling Predicts Severe Morbidity and Mortality in Cystic Fibrosis: A 5-Year Follow-Up Study. Ann Am Thorac Soc 2018; 15:589-598. [DOI: 10.1513/annalsats.201707-527oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Constrictive Bronchiolitis in Cystic Fibrosis Adolescents with Refractory Pulmonary Decline. Ann Am Thorac Soc 2018; 13:2174-2183. [PMID: 27684511 DOI: 10.1513/annalsats.201412-594oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Refractory lung function decline in association with recurrent pulmonary exacerbations is a common, yet poorly explained finding in cystic fibrosis (CF). To investigate the histopathologic mechanisms of pulmonary deterioration during adolescence and early adulthood, we reviewed clinically-indicated lung biopsy specimens obtained during a period of persistent decline. OBJECTIVES To determine if peribronchiolar remodeling is prominent in lung biopsy specimens obtained in adolescents with CF refractory to conventional therapy. METHODS Six adolescents with CF (mean age, 16.2 y; mean FEV1, 52% predicted at biopsy) with significant pulmonary deterioration over 12-24 months (mean FEV1 decline of 14% predicted/year) despite aggressive intervention underwent computed tomography imaging and ultimately lung biopsy to aid clinical management. In addition to routine clinical evaluation, histopathologic investigation included staining for transforming growth factor-β (TGF-β, a genetic modifier of CF lung disease), collagen deposition (a marker of fibrosis), elastin (to evaluate for bronchiectasis), and α-smooth muscle actin (to identify myofibroblasts). MEASUREMENTS AND MAIN RESULTS All computed tomography scans demonstrated a mix of bronchiectasis and hyperinflation that was variable across lung regions and within patients. Lung biopsy revealed significant peribronchiolar remodeling, particularly in patients with more advanced disease, with near complete obliteration of the peribronchiolar lumen (constrictive bronchiolitis). Myofibroblast differentiation (a TGF-β-dependent process) was prominent in specimens with significant airway remodeling. CONCLUSIONS Constrictive bronchiolitis is widely present in the lung tissue of adolescents with CF with advanced disease and may contribute to impaired lung function that is refractory to conventional therapy (antibiotics, antiinflammatories, and mucolytics). TGF-β-dependent myofibroblast differentiation is prominent in areas of active fibrogenesis and may foster small airway remodeling in CF lung disease.
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Epidemiology of CF: How registries can be used to advance our understanding of the CF population. J Cyst Fibros 2017; 17:297-305. [PMID: 29275954 DOI: 10.1016/j.jcf.2017.11.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 02/08/2023]
Abstract
Cystic fibrosis (CF) registries work by bringing patient data together from specialist CF centres and accumulating data on a relatively rare condition over patients' lifetimes. In this review, we examine the origin of national CF registries, the use of registries for monitoring the health of the population, the power of conducting longitudinal analysis of registry data, knowledge gleaned from changing demographics, the evolving area of international comparisons of registries, strategies for sustaining registries and CF registries of the future. Examples of research undertaken using registry data and routinely reported CF registry statistics from across the world are provided. The application, utility and challenges facing CF registries in the future are discussed.
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Exercise performance and quality of life in children with cystic fibrosis and mildly impaired lung function: relation with antibiotic treatments and hospitalization. Eur J Pediatr 2017; 176:1689-1696. [PMID: 28965267 DOI: 10.1007/s00431-017-3024-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
UNLABELLED This study evaluates the impact of antibiotic treatments and hospitalization on exercise performance and health-related quality of life (QOL) in children with mild cystic fibrosis (CF) lung disease. Forty-seven children between 7 and 17 years with mild CF underwent a maximal exercise test including spiro-ergometry and filled out a QOL-questionnaire (PedsQL™). Amount of antibiotic treatments (AB) and hospitalization days in the last 3 years were reviewed. FEV1% was mildly decreased (91.7 ± 17.9 L/min, p = 0.02). Maximal oxygen consumption (VO2max), test duration and anaerobic threshold were lower compared to a control population (VO2max% 94 ± 15 vs 103 ± 13, p = 0.009). FEV1% correlated with AB and hospitalization episodes in the last year and 3 years before testing, VO2max% only correlated with AB in the last 3 years. Domains of school functioning and emotional functioning were low. Children with higher VO2max% and less AB in the last 3 years had better physical health. Physical health and school functioning were negatively correlated with hospitalization days in the last year. CONCLUSION Patients with mild CF lung disease have good exercise performance although still lower than the normal population. VO2max% is affected by number of antibiotic treatments over a longer period. There is an impact of hospitalization days on quality of life. What is Known: • Children with CF have lower exercise performance; there is an association between hospitalization frequency and exercise performance • Quality of life is diminished in children with CF and influenced by respiratory infections What is New: • Even patients with mild CF lung disease have lower maximal exercise performance (VO 2 max) and a lower anaerobic threshold; VO 2 max is lower in children who had more antibiotic treatments in the last 3 years • School and emotional functioning are diminished in children with mild CF lung disease; hospitalization is negatively correlated with school functioning and physical functioning.
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Roberts JM, Dai DLY, Hollander Z, Ng RT, Tebbutt SJ, Wilcox PG, Sin DD, Quon BS. Multiple reaction monitoring mass spectrometry to identify novel plasma protein biomarkers of treatment response in cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2017; 17:333-340. [PMID: 29174082 DOI: 10.1016/j.jcf.2017.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systemic inflammation decreases with IV antibiotics during the treatment of CF pulmonary exacerbations (PEx). We used multiple reaction monitoring mass spectrometry and immunoassays to monitor blood proteins during PEx treatment to determine if early changes could be used to predict PEx outcomes following treatment. METHODS Blood samples from 25 PEx (22 unique adults) were collected within 24h of admission, day 5, day 10, and at IV antibiotic completion. Ninety-two blood proteins involved in host immunity and inflammation were measured. RESULTS Levels of several blood proteins changed from admission to end of IV antibiotics, most increasing with treatment. Early changes (admission to day 5) in fibrinogen levels had the strongest correlation with overall improvement in CFRSD-CRISS and FEV1% predicted by the end of treatment. CONCLUSIONS Several plasma proteins changed significantly with IV antibiotics. Future studies will evaluate fibrinogen as an early biomarker of PEx treatment response in CF.
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Affiliation(s)
- James M Roberts
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada
| | - Darlene L Y Dai
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada
| | - Zsuzsanna Hollander
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada
| | - Raymond T Ng
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada
| | - Scott J Tebbutt
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pearce G Wilcox
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Sanders DB, Zhao Q, Li Z, Farrell PM. Poor recovery from cystic fibrosis pulmonary exacerbations is associated with poor long-term outcomes. Pediatr Pulmonol 2017; 52:1268-1275. [PMID: 28881091 PMCID: PMC5639928 DOI: 10.1002/ppul.23765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 06/20/2017] [Indexed: 02/02/2023]
Abstract
RATIONALE People with CF treated with IV antibiotics for a pulmonary exacerbation (PEx) frequently fail to recover to baseline FEV1 . The long-term impact of these events has not been studied. OBJECTIVES To determine if a patient's spirometric recovery after a PEx is associated with time to next PEx within 1 year, the spirometric recovery after the next PEx, and/or the number of PEx episodes in the next 3 years. METHODS We used data from the CF Foundation Patient Registry from 2004 to 2011. We randomly selected one PEx per patient that met inclusion/exclusion criteria. Patients were defined as Non-Responders if their best FEV1 (in liters) recorded in the 3 months after the PEx was <90% of the best FEV1 (in liters) in the 6 months before the PEx. We compared Responders and Non-Responders using multivariable regression models. RESULTS We randomly chose 13 954 PEx episodes that met inclusion/exclusion criteria. A total of 2 762 (19.8%) patients were classified as Non-Responders. Non-Responders had a shorter median time to the next PEx, 235 (95%CI 218, 252) days, versus >365 days for Responders. Thirty-four percent of Non-Responders at the initial PEx were also Non-Reponders at the next PEx, versus 20% of Responders at the initial PEx. Non-Responders had more PEx episodes over the next 3 years, 4.99 (95%CI 4.84, 5.13), than Responders, 3.46 (95%CI 3.41, 3.51). CONCLUSIONS Poor recovery after a PEx is associated with a shorter time to the next PEx, increased risk of poor recovery at a second PEx, and more frequent subsequent PEx treatments.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.,Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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Sanders DB, Li Z, Zhao Q, Farrell PM. Poor recovery from a pulmonary exacerbation does not lead to accelerated FEV 1 decline. J Cyst Fibros 2017; 17:S1569-1993(17)30818-4. [PMID: 28765072 PMCID: PMC5788732 DOI: 10.1016/j.jcf.2017.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with CF treated for pulmonary exacerbations (PEx) may experience faster subsequent declines in FEV1. Additionally, incomplete recovery to baseline FEV1 occurs frequently following PEx treatment. Whether accelerated declines in FEV1 are preceded by poor PEx recovery has not been studied. METHODS Using 2004 to 2011 CF Foundation Patient Registry data, we randomly selected one PEx among patients ≥6years of age with no organ transplantations, ≥12months of data before and after the PEx, and ≥1 FEV1 recorded within the 6months before and 3months after the PEx. We defined poor PEx recovery as the best FEV1 in the 3months after the PEx <90% of the best FEV1 in the 6months before the PEx. We calculated mean (95% CI) hazard ratios (HR) of having >5% predicted/year FEV1 decline and poor PEx recovery using multi-state Markov models. RESULTS From 13,954 PEx, FEV1 declines of >5% predicted/year were more likely to precede poor spirometric recovery, HR 1.17 (1.08, 1.26), in Markov models adjusted for age and sex. Non-Responders were less likely to have a subsequent fast FEV1 decline, HR 0.41 (0.37, 0.46), than patients who recovered to >90% of baseline FEV1 following PEx treatment. CONCLUSIONS Accelerated declines in FEV1 are more likely to precede a PEx with poor recovery than to occur in the following year. Preventing or halting declines in FEV1 may also have the benefit of preventing PEx episodes.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN, USA.
| | - Zhanhai Li
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Qianqian Zhao
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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Flume PA, Wainwright CE, Elizabeth Tullis D, Rodriguez S, Niknian M, Higgins M, Davies JC, Wagener JS. Recovery of lung function following a pulmonary exacerbation in patients with cystic fibrosis and the G551D-CFTR mutation treated with ivacaftor. J Cyst Fibros 2017; 17:83-88. [PMID: 28651844 DOI: 10.1016/j.jcf.2017.06.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) are associated with acute loss of lung function that is often not recovered after treatment. We investigated lung function recovery following PEx for ivacaftor- and placebo-treated subjects. METHODS Short- and long-term pulmonary function recovery data after PEx were summarized from a placebo-controlled trial in 161 cystic fibrosis patients≥12years old with the G551D-CFTR mutation (NCT00909532). Short-term recovery was measured 2 to 8weeks after treatment, and long-term recovery was determined at the end-of-study, both compared with baseline measured just prior to the PEx. RESULTS Fewer patients receiving ivacaftor experienced a PEx than patients receiving placebo (33.7% vs. 56.4%; P=0.004) and had a lower adjusted incidence rate of PEx (0.589 vs. 1.382; P<0.001). The proportion of PEx followed by full short-term recovery of percent predicted forced expiratory volume in 1s was similar (ivacaftor vs. placebo, 57.1% vs. 53.7), as was the proportion of patients having long-term recovery (46.4% vs. 47.7%). CONCLUSIONS Ivacaftor treatment reduces the frequency of PEx but does not improve on the rate of complete lung function recovery after PEx when compared with placebo.
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Affiliation(s)
- Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, 96 Jonathan Lucas St, Room 812-CSB, MSC 630, Charleston, SC 29425, USA.
| | - Claire E Wainwright
- University of Queensland, Level 7, Centre for Child Health Research, Graham St, South Brisbane, Queensland 4101, Australia; Lady Cilento Children's Hospital, 501 Stanley St, South Brisbane 4101, Australia.
| | - D Elizabeth Tullis
- Division of Respirology, Keenan Research Centre of Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, 1 King's College Circle, 6263 Medical Sciences Building, Toronto, ON M5S 1A8, Canada.
| | - Sally Rodriguez
- Johnson & Johnson Medical Devices, 325 Paramount Dr, Raynham, MA 02767, USA.
| | - Minoo Niknian
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, MA 02210, USA.
| | - Mark Higgins
- Vertex Pharmaceuticals (Europe) Limited, 86-88 Jubilee Avenue, Milton Park, Abingdon, Oxfordshire OX14 4RW, UK.
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College, London, UK; Department of Pediatric Respiratory Medicine, Royal Brompton and Harefield National Health Service Foundation Trust, Sydney Street, London SW3 6NP, UK.
| | - Jeffrey S Wagener
- Department of Pediatrics, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO 80045, USA.
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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Standardized Treatment of Pulmonary Exacerbations (STOP) study: Physician treatment practices and outcomes for individuals with cystic fibrosis with pulmonary Exacerbations. J Cyst Fibros 2017; 16:600-606. [PMID: 28457954 DOI: 10.1016/j.jcf.2017.04.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/07/2017] [Accepted: 04/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pulmonary Exacerbations (PEx) are associated with increased morbidity and mortality in individuals with CF. PEx management practices vary widely, and optimization through interventional trials could potentially improve outcomes. The object of this analysis was to evaluate current physician treatment practices and patient outcomes for PEx. METHODS The Standardized Treatment of Pulmonary Exacerbations (STOP) observational study enrolled 220 participants ≥12years old admitted to the hospital for PEx at 11 U.S. CF centers. Spirometry and daily symptom scores were collected during the study. Physicians were surveyed on treatment goals and their management practices were observed. Treatment outcomes were compared to stated goals. RESULTS The mean (SD) duration of IV antibiotic treatment was 15.9 (6.0) days. Those individuals with more severe lung disease (<50% FEV1) were treated nearly two days longer than those with >50% FEV1. Physician-reported FEV1 improvement goals were 10% (95% CI: 5%, 14%) lower for patients with 6-month baseline FEV1 ≤50% predicted compared with those with 6-month baseline FEV1 >50% predicted. There were clinically and statistically significant improvements in symptoms from the start of IV antibiotic treatment to the end of IV antibiotic treatment and 28days after the start of treatment. The mean absolute increase in FEV1 from admission was 9% predicted at end of IV antibiotic treatment, and 7% predicted at day 28. Only 39% fully recovered lost lung function, and only 65% recovered at least 90% of lost lung function. Treatment was deemed successful by 84% of clinicians, although 6-month baseline FEV1 was only recovered in 39% of PEx. CONCLUSIONS In this prospective observational study of PEx, treatment regimens and durations showed substantial variation. A significant proportion of patients did not reach physician's treatment goals, yet treatment was deemed successful.
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Sharma A, Kirkpatrick G, Chen V, Skolnik K, Hollander Z, Wilcox P, Quon BS. Clinical utility of C-reactive protein to predict treatment response during cystic fibrosis pulmonary exacerbations. PLoS One 2017; 12:e0171229. [PMID: 28178305 PMCID: PMC5298271 DOI: 10.1371/journal.pone.0171229] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/17/2017] [Indexed: 11/29/2022] Open
Abstract
Rationale C-reactive protein (CRP) is a systemic marker of inflammation that correlates with disease status in cystic fibrosis (CF). The clinical utility of CRP measurement to guide pulmonary exacerbation (PEx) treatment decisions remains uncertain. Objectives To determine whether monitoring CRP during PEx treatment can be used to predict treatment response. We hypothesized that early changes in CRP can be used to predict treatment response. Methods We reviewed all PEx events requiring hospitalization for intravenous (IV) antibiotics over 2 years at our institution. 83 PEx events met our eligibility criteria. CRP levels from admission to day 5 were evaluated to predict treatment non-response, using a modified version of a prior published composite definition. CRP was also evaluated to predict time until next exacerbation (TUNE). Measurements and main results 53% of 83 PEx events were classified as treatment non-response. Paradoxically, 24% of PEx events were characterized by a ≥ 50% increase in CRP levels within the first five days of treatment. Absolute change in CRP from admission to day 5 was not associated with treatment non-response (p = 0.58). Adjusted for FEV1% predicted, admission log10 CRP was associated with treatment non-response (OR: 2.39; 95% CI: 1.14 to 5.91; p = 0.03) and shorter TUNE (HR: 1.60; 95% CI: 1.13 to 2.27; p = 0.008). The area under the receiver operating characteristics (ROC) curve of admission CRP to predict treatment non-response was 0.72 (95% CI 0.61–0.83; p<0.001). 23% of PEx events were characterized by an admission CRP of > 75 mg/L with a specificity of 90% for treatment non-response. Conclusions Admission CRP predicts treatment non-response and time until next exacerbation. A very elevated admission CRP (>75mg/L) is highly specific for treatment non-response and might be used to target high-risk patients for future interventional studies aimed at improving exacerbation outcomes.
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Affiliation(s)
- Ashutosh Sharma
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Gordon Kirkpatrick
- Department of Medicine, Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Virginia Chen
- Prevention Of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Kate Skolnik
- Department of Medicine, Division of Respiratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zsuzsanna Hollander
- Prevention Of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Pearce Wilcox
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bradley S. Quon
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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Sullivan A, Hunt E, MacSharry J, Murphy DM. 'The Microbiome and the Pathophysiology of Asthma'. Respir Res 2016; 17:163. [PMID: 27919249 PMCID: PMC5139145 DOI: 10.1186/s12931-016-0479-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/26/2016] [Indexed: 02/06/2023] Open
Abstract
Asthma is a chronic respiratory disease whose prevalence is increasing in the western world. Recently research has begun to focus on the role the microbiome plays in asthma pathogenesis in the hope of further understanding this respiratory disorder. Considered sterile until recently, the lungs have revealed themselves to contain a unique microbiota. A shift towards molecular methods for the quantification and sequencing of microbial DNA has revealed that the airways harbour a unique microbiota with apparent, reproducible differences present between healthy and diseased lungs. There is a hope that in classifying the microbial load of the asthmatic airway an insight may be afforded as to the possible role pulmonary microbes may have in propagating an asthmatic airway response. This could potentially pave the way for new therapeutic strategies for the treatment of chronic lung conditions such as asthma.
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Affiliation(s)
- Ashley Sullivan
- APC Microbiome Institute, School of Medicine, University College Cork, Cork, Ireland
| | - Eoin Hunt
- The Department of Respiratory Medicine, Cork University Hospital, Wilton, Cork, Ireland.,Health Research Board Clinical Research Facility, University College Cork, Cork, Ireland
| | - John MacSharry
- APC Microbiome Institute, School of Medicine, University College Cork, Cork, Ireland.,School of Microbiology, University College Cork, Cork, Ireland
| | - Desmond M Murphy
- The Department of Respiratory Medicine, Cork University Hospital, Wilton, Cork, Ireland. .,Health Research Board Clinical Research Facility, University College Cork, Cork, Ireland.
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Sunther M, Bush A, Hogg C, McCann L, Carr SB. Recovery of baseline lung function after pulmonary exacerbation in children with primary ciliary dyskinesia. Pediatr Pulmonol 2016; 51:1362-1366. [PMID: 27273679 DOI: 10.1002/ppul.23479] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 03/15/2016] [Accepted: 04/18/2016] [Indexed: 01/11/2023]
Abstract
RATIONALE Spirometry in children with cystic fibrosis (CF) frequently fails to return to baseline after treatment for a pulmonary exacerbation. It is unclear whether the same is true for children with primary ciliary dyskinesia (PCD). OBJECTIVES To determine in children with PCD treated with intravenous antibiotics for a pulmonary exacerbation: (1) the proportion who recover to baseline forced expiratory volume at 1 sec (FEV1 ) within 3 months after treatment and (2) to try to identify factors which are associated with failure to regain pre-exacerbation FEV1 . METHODS Cohort study using the PCD database for children at the Royal Brompton Hospital, 2003-2013. We selected the first pulmonary exacerbation treated with intravenous antibiotics. The best FEV1 within 3 months after treatment was compared to the best FEV1 in the 12 months before treatment (baseline). Recovery to baseline was defined as any FEV1 after treatment that was greater than or equal to 90% of the baseline FEV1 . RESULTS 32/150 children (21%) had at least one pulmonary exacerbation. 23/30 (77%) regained baseline spirometry within 3 months of treatment. There was no difference between responders and non-responders in any baseline characteristics. CONCLUSIONS Around 25% of children with PCD fail to recover to baseline lung function within 3 months following treatment for a pulmonary exacerbation, similar to CF. Better treatment strategies are needed, and the results also suggest that prevention of exacerbations would be a useful end-point in clinical trials. Pediatr Pulmonol. 2016;51:1362-1366. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Meera Sunther
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Claire Hogg
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Lauren McCann
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Siobhán B Carr
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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Treatment of Pulmonary Exacerbations Improves Short But Not Long-Term Growth Trajectory in Children With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2016; 63:e54-e57. [PMID: 27668654 DOI: 10.1097/mpg.0000000000001311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The present study sought to determine the long-term growth consequences after a pulmonary exacerbation in children with cystic fibrosis (CF). METHODS Retrospective cohort study of pediatric patients with CF with a hospital admission for a pulmonary exacerbation. Logistic regression used to determine risk factors for failure to recover baseline body mass index (BMI) percentile. RESULTS Of 72 patients, 43% failed to recover their baseline BMI percentile 12 months after discharge and these patients also had a lower forced expiratory volume in 1 second at follow-up. A greater decrease in weight percentile from baseline to admission was the only risk factor identified (odds ratio 0.83, P = 0.0015). CONCLUSIONS Greater decrease in weight percentile from baseline to admission predicts failure to recover BMI percentile 1 year after a pulmonary exacerbation. Children with CF with poor growth preceding a pulmonary exacerbation continue to be at risk for long-term nutritional failure despite treatment for pulmonary exacerbation.
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Abstract
Numerous individuals with chronic disease age into adulthood each year, necessitating transition from a pediatric to an adult medical care team. Transition should start early in adolescence and occur gradually over years, preparing the individual for the transfer to the adult team. Cystic fibrosis (CF) has a growing population of adults, as survival over the past several decades has increased. The CF Foundation has implemented guidelines for the transition process. The transition process for individuals with CF provides an example that could be adapted into other chronic disease populations, to provide a successful and meaningful transition into adult care.
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Abstract
BACKGROUND Invasive pneumococcal disease is associated with significant mortality and many countries have introduced routine pneumococcal vaccination into their childhood immunisation programmes. Whilst pneumococcal disease in cystic fibrosis is uncommon, pneumococcal immunisation may offer some protection against pulmonary exacerbations caused by this pathogen. In the USA and UK pneumococcal vaccination is currently recommended for all children and adults with cystic fibrosis. This is an update of a previously published review. OBJECTIVES To assess the efficacy of pneumococcal vaccines in reducing morbidity in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Cystic Fibrosis Trials Register, which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. In addition, the pharmaceutical manufacturers of the polysaccharide and conjugate pneumococcal vaccines were approached.Date of the most recent search: 27 June 2016. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing pneumococcal vaccination (with either a polysaccharide or conjugate pneumococcal vaccine) with non-vaccination or placebo in children or adults with cystic fibrosis were eligible for inclusion. DATA COLLECTION AND ANALYSIS No relevant trials were identified. MAIN RESULTS There are no trials included in this review. AUTHORS' CONCLUSIONS As no trials were identified we cannot draw conclusions on the efficacy of routine pneumococcal immunisation in people with cystic fibrosis in reducing their morbidity or mortality. As many countries now include pneumococcal immunisation in their routine childhood vaccination schedule it is unlikely that future randomised controlled trials will be initiated. Rigorously conducted epidemiological studies may offer the opportunity to evaluate the efficacy of pneumococcal vaccination in reducing morbidity and mortality in people with cystic fibrosis.
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Affiliation(s)
- Laura Burgess
- Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK, L12 2AP
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