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Farahbakhsh N, Fatahi S, Shirvani A, Motaharifard MS, Mohkam M, Tabatabaii SA, Khanbabaee G, Yaghoobpoor S, Davoodi SZ, Hosseini AH. Vitamin D deficiency in patients with cystic fibrosis: a systematic review and meta-analysis. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2024; 43:11. [PMID: 38233891 PMCID: PMC10795301 DOI: 10.1186/s41043-024-00499-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/05/2024] [Indexed: 01/19/2024]
Abstract
AIM Vitamin D is a prominent modulator of immunity and respiratory function. It plays a vital role in respiratory diseases such as cystic fibrosis (CF). S. However, there is a dearth of information on patients with CF. The purpose of the meta-analysis is to highlight the importance of following the existing guidelines regarding maintenance of Vitamin D serum levels in patients with CF. METHODS The systematic search was conducted without utilizing any time or language limitations in original database from the beginning until March 2022. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by I2 statistics and Cochrane Q test. RESULTS Pooled analysis using the random-effects model of the 8 case-control studies with 13 effect sizes revealed that the serum 25-OH-vitamin D in participants with cystic fibrosis was significantly lower than controls in pediatrics and adolescences (WMD: - 3.41 ng/ml, 95% CI - 5.02, - 1.80, p = < 0.001) and adults (WMD: - 2.60 ng/ml, 95% CI - 4.32, - 0.89, p = 0.003). Based on data from 12 studies (21 effect sizes) with a total of 1622 participants, the prevalence of vitamin D levels of 20-30 ng/ml in CF patients was 36% among pediatrics/adolescents and 63% among adults. In addition, 27% of pediatric/adolescent CF patients and 35% of adult CF patients had vitamin D levels of below 20 ng/ml. CONCLUSIONS As a result, according to the existing guidelines, our results proved the need to pay attention to the level of vitamin D in these patients.
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Affiliation(s)
- Nazanin Farahbakhsh
- Department of Pediatric Pulmonology, Mofid Pediatrics Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somaye Fatahi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Faculty of Medical Education, Shahid Beheshty University of Medical Sciences, Tehran, Iran
| | - Monireh Sadat Motaharifard
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Mohkam
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Tabatabaii
- Department of Pediatric Pulmonology, Mofid Pediatrics Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghamartaj Khanbabaee
- Department of Pediatric Pulmonology, Mofid Pediatrics Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shirin Yaghoobpoor
- Student Research Committee, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedeh Zahra Davoodi
- Student Research Committee, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Hosseini
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Giacalone VD, Giraldo DM, Silva GL, Hosten J, Peng L, Guglani L, Tirouvanziam R. Pulmonary exacerbations in early cystic fibrosis lung disease are marked by strong modulation of CD3 and PD-1 on luminal T cells. Front Immunol 2023; 14:1194253. [PMID: 37809107 PMCID: PMC10551126 DOI: 10.3389/fimmu.2023.1194253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background In chronic cystic fibrosis (CF) lung disease, neutrophilic inflammation and T-cell inhibition occur concomitantly, partly due to neutrophil-mediated release of the T-cell inhibitory enzyme Arg1. However, the onset of this tonic inhibition of T cells, and the impact of pulmonary exacerbations (PEs) on this process, remain unknown. Methods Children with CF aged 0-5 years were enrolled in a longitudinal, single-center cohort study. Blood (n = 35) and bronchoalveolar lavage (BAL) fluid (n = 18) were collected at stable outpatient clinic visits or inpatient PE hospitalizations and analyzed by flow cytometry (for immune cell presence and phenotype) and 20-plex chemiluminescence assay (for immune mediators). Patients were categorized by PE history into (i) no prior PE, (ii) past history of PE prior to stable visit, or (iii) current PE. Results PEs were associated with increased concentration of both pro- and anti-inflammatory mediators in BAL, and increased neutrophil frequency and G-CSF in circulation. PE BAL samples showed a trend toward an increased frequency of hyperexocytic "GRIM" neutrophils, which we previously identified in chronic CF. Interestingly, expression levels of the T-cell receptor associated molecule CD3 and of the inhibitory programmed death-1 (PD-1) receptor were respectively decreased and increased on T cells from BAL compared to blood in all patients. When categorized by PE status, CD3 and PD-1 expression on blood T cells did not differ among patients, while CD3 expression was decreased, and PD-1 expression was increased on BAL T cells from patients with current PE. Conclusions Our findings suggest that airway T cells are engaged during early-life PEs, prior to the onset of chronic neutrophilic inflammation in CF. In addition, increased blood neutrophil frequency and a trend toward increased BAL frequency of hyperexocytic neutrophils suggest that childhood PEs may progressively shift the balance of CF airway immunity towards neutrophil dominance.
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Affiliation(s)
- Vincent D. Giacalone
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Center for CF and Airways Disease Research, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Diego Moncada Giraldo
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Center for CF and Airways Disease Research, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - George L. Silva
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Center for CF and Airways Disease Research, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Justin Hosten
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Emory University School of Public Health, Atlanta, GA, United States
| | - Lokesh Guglani
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Center for CF and Airways Disease Research, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Rabindra Tirouvanziam
- Department of Pediatrics, Emory University, Atlanta, GA, United States
- Center for CF and Airways Disease Research, Children’s Healthcare of Atlanta, Atlanta, GA, United States
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States
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Milinic T, McElvaney OJ, Goss CH. Diagnosis and Management of Cystic Fibrosis Exacerbations. Semin Respir Crit Care Med 2023; 44:225-241. [PMID: 36746183 PMCID: PMC10131792 DOI: 10.1055/s-0042-1760250] [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] [Indexed: 02/08/2023]
Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is acute pulmonary exacerbation (PEx). Clinical and microbial epidemiology studies of CF PEx continue to provide important insight into the disease course, prognosis, and complications. This work has now led to several large-scale clinical trials designed to clarify the treatment paradigm for CF PEx. The primary goal of this review is to provide a summary and update of the pathophysiology, clinical and microbial epidemiology, outcome and treatment of CF PEx, biomarkers for exacerbation, and the impact of highly effective modulator therapy on these events moving forward.
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Affiliation(s)
- Tijana Milinic
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Oliver J McElvaney
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher H Goss
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Abstract
PURPOSE OF REVIEW The incidence of bacterial respiratory tract infections is growing. In a context of increasing antibiotic resistance and lack of new classes of antibiotics, inhaled antibiotics emerge as a promising therapeutic strategy. Although they are generally used for cystic fibrosis, their use in other conditions is becoming more frequent, including no-cystic fibrosis bronchiectasis, pneumonia and mycobacterial infections. RECENT FINDINGS Inhaled antibiotics exert beneficial microbiological effects in bronchiectasis and chronic bronchial infection. In nosocomial and ventilator-associated pneumonia, aerosolized antibiotics improve cure rates and bacterial eradication. In refractory Mycobacterium avium complex infections, amikacin liposome inhalation suspension is more effective in achieving long-lasting sputum conversion. In relation to biological inhaled antibiotics (antimicrobial peptides, interfering RNA and bacteriophages), currently in development, there is no still enough evidence that support their use in clinical practice. SUMMARY The effective antimicrobiological activity of inhaled antibiotics, added to their potential to overcoming resistances to systemic antibiotics, make inhaled antibiotics a plausible alternative.
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Elborn JS, Blasi F, Burgel PR, Peckham D. Role of inhaled antibiotics in the era of highly effective CFTR modulators. Eur Respir Rev 2023; 32:32/167/220154. [PMID: 36631132 PMCID: PMC9879329 DOI: 10.1183/16000617.0154-2022] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023] Open
Abstract
Recurrent and chronic bacterial infections are common in people with cystic fibrosis (CF) and contribute to lung function decline. Antibiotics are the mainstay in the treatment of exacerbations and chronic bacterial infection in CF. Inhaled antibiotics are effective in treating chronic respiratory bacterial infections and eradicating Pseudomonas aeruginosa from the respiratory tract, with limited systemic adverse effects. In the past decade, highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulators have become a new therapy that partially corrects/opens chloride transport in patients with selected CFTR mutations, restoring mucus hydration and improving mucociliary clearance. The recent triple CFTR modulator combination is approved for ∼80-90% of the CF population and significantly reduces pulmonary exacerbations and improves respiratory symptoms and lung function. CFTR modulators have shifted the focus from symptomatic treatment to personalised/precision medicine by targeting genotype-specific CFTR defects. While these are highly effective, they do not fully normalise lung physiology, stop inflammation or resolve chronic lung damage, such as bronchiectasis. The impact of these new drugs on lung health is likely to change the future management of chronic pulmonary infections in people with CF. This article reviews the role of inhaled antibiotics in the era of CFTR modulators.
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Affiliation(s)
- J. Stuart Elborn
- Faculty of Medicine Health and Life Sciences, Queen's University, Belfast, UK,Corresponding author: J. Stuart Elborn ()
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy,Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pierre-Régis Burgel
- Université Paris Cité, Institut Cochin, Paris, France,Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Daniel Peckham
- Respiratory Medicine, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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Magaret AS, Warden M, Simon N, Heltshe S, Retsch-Bogart GZ, Ramsey BW, Mayer-Hamblett N. A new path for CF clinical trials through the use of historical controls. J Cyst Fibros 2022; 21:293-299. [PMID: 34879997 PMCID: PMC8957493 DOI: 10.1016/j.jcf.2021.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 09/24/2021] [Accepted: 11/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given future challenges in conducting large randomized, placebo controlled trials for future CF therapeutics development, we evaluated the potential for using external historical controls to either enrich or replace traditional concurrent placebo groups in CF trials. METHODS The study included data from sequentially completed, randomized, controlled clinical trials, EPIC and OPTIMIZE respectively, evaluating optimal antibiotic therapy to reduce the risk of pulmonary exacerbation in children with early Pseudomonas aeruginosa infection. The primary treatment effect in OPTIMIZE, the risk of pulmonary exacerbation associated with azithromycin, was re-estimated in alternative designs incorporating varying numbers of participants from the earlier trial (EPIC) as historical controls. Bias and precision of these estimates were characterized. Propensity scores were derived to adjust for baseline differences across study populations, and both Poisson and Cox regression were used to estimate treatment efficacy. RESULTS Replacing 86 OPTIMIZE placebo participants with 304 controls from EPIC to mimic a fully historically controlled trial resulted an 8% reduction in risk of pulmonary exacerbations (Hazard ratio (HR):0.92 95% CI 0.61, 1.34) when not adjusting for key baseline differences between study populations. After adjustment, a 37% decrease in risk of exacerbation (HR:0.63, 95% CI 0.50, 0.80) was estimated, comparable to the estimate from the original trial comparing the 86 placebo participants to 77 azithromycin participants on azithromycin (45%, HR:0.55, 95% CI: 0.34, 0.86). Other adjusted approaches provided similar estimates for the efficacy of azithromycin in reducing exacerbation risk: pooling all controls from both studies provided a HR of 0.60 (95% x`CI 0.46, 0.77) and augmenting half the OPTIMIZE placebo participants with EPIC controls gave a HR 0.63 (95% CI 0.48, 0.82). CONCLUSIONS The potential exists for future CF trials to utilize historical control data. Careful consideration of both the comparability of controls and of optimal methods can reduce the potential for biased estimation of treatment effects.
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Affiliation(s)
- Amalia S. Magaret
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Mark Warden
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Noah Simon
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Sonya Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Bonnie W. Ramsey
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Nicole Mayer-Hamblett
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Hospital, Seattle, WA, USA,Department of Pediatrics, University of Washington, Seattle, WA, USA,Department of Biostatistics, University of Washington, Seattle, WA, USA
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Nayir Buyuksahin H, Yalçın E, Emiralioglu N, Hazırolan G, Ademhan Tural D, Ozsezen B, Sunman B, Guzelkas I, Dogru D, Ozcelik U, Kiper N. The effect of Pseudomonas aeruginosa eradication regimens on chronic colonization and clinical outcomes in pediatric patients with cystic fibrosis. Pediatr Int 2022; 64:e15249. [PMID: 36321341 DOI: 10.1111/ped.15249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Chronic Pseudomonas aeruginosa colonization (Pa-CC) affects cystic fibrosis (CF) progression, including pulmonary exacerbations and pulmonary function tests. There are few studies of the effects of eradication protocols on colonization time. Here, we aimed to evaluate the effect of eradication regimens on chronic colonization and assess the impact of Pa-CC on body mass index, lung functions, and pulmonary exacerbations. METHODS A retrospective review was conducted of medical records, over a period of 11 years, of children aged under 18 years with CF who had Pa-CC in our tertiary care pediatric hospital. RESULTS Pseudomonas aeruginosa was detected in 215 of our patients with CF during the study period. Forty-four patients with Pa-CC were recruited for the study. The eradication treatment for the initial acquisition of P. aeruginosa was inhaled antibiotics in 27 (61.4%) patients; the remainder were given intravenous antibiotics. It was observed that eradication treatment with either IV or inhaled antibiotics did not affect the time between the P. aeruginosa and the time of Pa-CC(P = 0.791). There was a non-significant decrease in the body mass index z-score from the Pa-IA to the last visit(P = 0.27), a significant decline in forced expiratory volume in 1 s (FEV1%) (P = 0.01) over time, and the annual number of exacerbations after colonization was significantly higher than before colonization (P = 0.03). CONCLUSIONS There was no difference between eradication regimens in delaying the age at Pa-CC. Pseudomonas aeruginosa colonization in patients with CF was also associated with poorer lung functions, lower body mass index, and more pulmonary exacerbation regardless of mucoid type. Consequently, to slow the progression of lung disease, we must prevent Pa-CC, which we can achieve with early eradication. Despite conventional eradication protocols, future studies need to evaluate those who fail to clear P. aeruginosa.
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Affiliation(s)
- Halime Nayir Buyuksahin
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ebru Yalçın
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Gulsen Hazırolan
- Department of Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilber Ademhan Tural
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Birce Sunman
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ismail Guzelkas
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ugur Ozcelik
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
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Abstract
BACKGROUND Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual but it has previously been shown to be an effective treatment option for those who are seeking techniques to support and promote independence. However, at a time where the trajectory and demographics of the disease are changing, it is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis. OBJECTIVES To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews, as well as two ongoing trials registers (02 February 2021). Date of most recent search of the Cochrane Cystic Fibrosis Trials Register: 06 July 2021. SELECTION CRITERIA We identified randomised and quasi-randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions. DATA COLLECTION AND ANALYSIS Data extraction and assessments of risk of bias were independently performed by three authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted seven teams of investigators for further information pertinent to their published studies. MAIN RESULTS Searches retrieved 64 references to 37 individual studies, of which eight (n = 212) were eligible for inclusion. One study was of parallel design with the remaining seven being cross-over in design; participant numbers ranged from 4 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in two studies received treatment whilst hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage. The certainty of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross-over design, outcome reporting bias and the inability to blind participants. The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all eight studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Seven of the eight included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions, intravenous antibiotics and pseudomonas gene expression. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion. AUTHORS' CONCLUSIONS Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis, particularly in an era where treatment options are changing rapidly. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non-inferiority. The varied length and design of the studies made the analysis of pooled data challenging.
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Affiliation(s)
- Paul Burnham
- Servicio de Medicina Fisica y Rehabilitacion, Hospital La Paz, Madrid, Spain
| | - Gemma Stanford
- Department of Cystic Fibrosis, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Insititute, Imperial College London, London, UK
| | - Ruth Stewart
- Royal Hospital for Children and Young People, Edinburgh, UK
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Bresnick K, Arteaga-Solis E, Millar SJ, Laird G, LeCamus C. Burden of cystic fibrosis in children <12 years of age prior to the introduction of CFTR modulator therapies. BMJ Open Respir Res 2021; 8:8/1/e000998. [PMID: 34857524 PMCID: PMC8640656 DOI: 10.1136/bmjresp-2021-000998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Cystic fibrosis (CF) is a genetic, multisystemic, progressive and life-shortening disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. Different genotypes have been linked to variations in disease progression among people with CF. The burden of illness (BOI) in children with CF is incompletely characterised, particularly as it relates to CFTR genotypes prior to the availability of the first CFTR modulators. This retrospective, cross-sectional, descriptive study evaluated the BOI in US children with CF <12 years of age prior to the first approval of CFTR modulators. Methods Data from the US Cystic Fibrosis Foundation Patient Registry from 2011 were used to summarise key patient and disease characteristics using descriptive statistics, overall and grouped by age (0 to <2 years, 2 to <6 years and 6 to <12 years) and genotype (F508del/F508del, F508del/minimal function (MF), MF/MF, gating mutation on ≥1 allele, residual function mutation on ≥1 allele and R117H on ≥1 allele) group. Results The analysis included 9185 children. Among 6-year-olds to <12-year-olds, mean (SD) per cent predicted FEV1 in 1 s was 92.6% (17.5%). Among all children <12 years of age, the mean (SD) all-cause hospitalisation and pulmonary exacerbation rates in 2011 were 0.4 (1.0) and 0.3 (0.8), respectively. Most (93.6%) had ≥1 positive lung microbiology culture. CF-related medication and nutritional supplementation use was common across all ages and genotypes. More than half (54.7%) had ≥1 CF-related complication. Evidence of disease burden was observed across the age and genotype groups studied. Conclusions Prior to the approval of the first CFTR modulator therapies in children <12 years of age, CF was associated with substantial BOI from an early age—including respiratory infections, hospitalisations/pulmonary exacerbations, need for supplemental nutrition and pharmacological treatments—irrespective of genotype.
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Affiliation(s)
- Kathryn Bresnick
- Real World Evidence, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Emilio Arteaga-Solis
- Global Medical Affairs, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Stefanie J Millar
- Biostatistics & Medical Writing, ICON PLC, North Wales, Pennsylvania, USA
| | - Glen Laird
- Biostatistics, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Cecile LeCamus
- Global Medical Affairs, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
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Walicka-Serzysko K, Postek M, Jeneralska N, Cichocka A, Milczewska J, Sands D. The effects of the addition of a new airway clearance device to chest physiotherapy in children with cystic fibrosis pulmonary exacerbations. JOURNAL OF MOTHER AND CHILD 2021; 24:16-24. [PMID: 33544556 PMCID: PMC8258837 DOI: 10.34763/jmotherandchild.20202403.2013.d-20-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chest physiotherapy plays a crucial role in managing cystic fibrosis, especially during pulmonary exacerbations. This study evaluated the effects of adding a new airway clearance device to chest physiotherapy in subjects with cystic fibrosis hospitalised due to pulmonary exacerbations. METHODS This prospective open-label study was carried out at the Pediatric Cystic Fibrosis Centre in Poland between October 2017 and August 2018. Cystic fibrosis patients aged 10 to 18 years who were admitted to the hospital and required intravenous antibiotic therapy due to pulmonary exacerbations were consecutively allocated (1:1) to either chest physiotherapy alone or chest physiotherapy with a new airway clearance device (Simeox; PhysioAssist). Patients performed spirometry and multiple-breath nitrogen washout for lung clearance index assessment upon admission and prior to discharge. RESULTS Forty-eight cystic fibrosis patients were included (24 in each group). Spirometry parameters in both groups improved significantly after intravenous antibiotic therapy. A significant improvement in the maximum expiratory flow at 25% of forced vital capacity was observed only in the group with a new airway clearance device (p < 0.01 vs. baseline). Trends towards a lower lung clearance index ratio were similar in both groups. No adverse events were observed in either group. CONCLUSIONS Spirometry parameters increased significantly in cystic fibrosis patients treated for pulmonary exacerbations with intravenous antibiotic therapy and intensive chest physiotherapy. The new airway clearance device was safe and well tolerated when added to chest physiotherapy and may be another option for the treatment of pulmonary exacerbation in cystic fibrosis.
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Affiliation(s)
- Katarzyna Walicka-Serzysko
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland, E-mail:
| | - Magdalena Postek
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland
| | | | | | - Justyna Milczewska
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland
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11
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The modified shuttle test as a predictor of risk for hospitalization in youths with cystic fibrosis: A two-year follow-up study: Modified shuttle test as a predictor of hospitalization. J Cyst Fibros 2021; 20:648-654. [PMID: 33422453 DOI: 10.1016/j.jcf.2020.12.014] [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: 09/30/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) present exercise intolerance and episodes of pulmonary exacerbations. This study aimed to evaluate the association of the distance covered on the modified shuttle test (MST), as well as other clinical variables (anthropometry, chronic colonization by Pseudomonas aeruginosa, lung function), with the risk of hospitalization for pulmonary exacerbation. METHODS Cohort study including CF patients older than 6 years, from two specialized CF centers. All patients underwent a MST and a lung function test at the time of inclusion. Demographic, anthropometric and clinical data were collected. Free time until the first hospitalization, total days of hospitalization and use of antibiotics during the two years of follow-up were recorded. RESULTS Sixty-seven patients with a mean (SD) age of 12.4 (5.2) years and forced expiratory volume in the first second (FEV1) of 78.7% (22.4) were included. The mean distance covered (m) in the MST was 775.6 (255.7) (73.4 ± 19.5% of predicted). The distance achieved (MST) was considered as the main independent variable to predict the risk of hospitalization (Cox HR 0.97, p = 0.029). Patients who walked a distance of less than 80% of predicted in the MST showed an increase of 3.9 (95%CI 1.0-15.3) in the relative risk for hospitalization and significantly higher total number of days of hospitalization (p = 0.022). CONCLUSION There is an association between the distance covered in the MST and the risk of hospitalization in youths with CF. Patients with reduced exercise capacity presented a 3.9 times increase in the relative risk for hospitalization due to pulmonary exacerbation.
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12
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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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13
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Addy C, Caskey S, Downey D. Gram negative infections in cystic fibrosis: a review of preventative and treatment options. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1713748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Charlotte Addy
- Centre for Medical Education, Queen’s University Belfast, Belfast, UK
- Northern Ireland Regional Adult CF Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Steven Caskey
- Northern Ireland Regional Adult CF Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Damian Downey
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
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14
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Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is an acute pulmonary exacerbation. Clinical and microbial epidemiology studies of CF pulmonary exacerbations continue to provide important insight into the disease course, prognosis, and complications. This work has now led to a number of large scale clinical trials with the goal of improving the treatment paradigm for CF pulmonary exacerbation. The primary goal of this review is to provide a summary of the pathophysiology, the clinical epidemiology, microbial epidemiology, outcome and the treatment of CF pulmonary exacerbation.
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Affiliation(s)
- Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Pediatrics, University of Washington School of Medicine, Seattle, Washington
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15
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Tesell MA, Alper CJ, Bacon R, Greenwood BC, Lenz K, Jeffrey PL, Stevens K. Effect of Lumacaftor/Ivacaftor on Pulmonary Exacerbation Rates in Members with Cystic Fibrosis in a Medicaid Population. J Manag Care Spec Pharm 2019; 25:1021-1025. [PMID: 31456498 PMCID: PMC10401991 DOI: 10.18553/jmcp.2019.25.9.1021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Lumacaftor/ivacaftor (LUM/IVA) is indicated for patients with cystic fibrosis (CF) homozygous for the F508del mutation in the CFTR gene. In clinical trials, LUM/IVA decreased pulmonary exacerbation rates. To our knowledge, there is no published data evaluating real-world outcomes for Medicaid patients receiving LUM/IVA. OBJECTIVE To compare CF pulmonary exacerbation rates before and after initiation of LUM/IVA in 1 state's Medicaid program. METHODS This pre-post claims analysis screened fee-for-service and managed Medicaid members who had ≥ 1 pharmacy claim for LUM/IVA between July 2, 2015, and September 30, 2016. Members were included if they were aged ≥ 6 years with a CF diagnosis and homozygous for the F508del mutation, consistent with the indication at study initiation. Exclusion criteria included Medicaid as a secondary payer or any break in coverage during the study. The index date was defined as the first claim for LUM/IVA. Demographics and outcomes were derived from pharmacy and medical claims. Outcomes included overall rate of pulmonary exacerbations (reported as the total events for the study population 6 months before and after the index date and average annualized rate). Pulmonary exacerbation was defined as any combination of medical claims for an emergency room (ER) visit or inpatient hospitalization with a CF pulmonary exacerbation or respiratory infection (ICD-9/10-CM codes) or pharmacy claims for an oral or intravenous antibiotic (excluding macrolides). A gap of > 7 days was considered a new pulmonary exacerbation. Paired t-test was used to test significance. RESULTS 21 patients met inclusion criteria with an average age at treatment initiation of 20.1 years. Average proportion of days covered (SD) was 0.62 (0.29). The number of pulmonary exacerbations increased from 45 to 48 during the 6 months before and after the index date, respectively, and the annualized rate increased from 4.37 to 4.66 (P = 0.69). While the number of pulmonary exacerbations associated with antibiotics alone increased (23 to 33; P = 0.08), those associated with at least 1 ER visit or inpatient hospitalization decreased (22 to 15; P = 0.08). CONCLUSIONS This analysis did not find a decrease in pulmonary exacerbation rate for Medicaid members receiving LUM/IVA; however, adherence was low. Further study of similar populations is needed to better understand the long-term effect of treatment. DISCLOSURES No outside funding supported this study. The authors have nothing to disclose. A poster of this project was presented at the Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting 2018 in Boston, MA, on April 23-26, 2018.
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Affiliation(s)
- Mark A. Tesell
- Clinical Pharmacy Services, UMass Medical School, Shrewsbury, Massachusetts
| | - Caroline J. Alper
- Clinical Pharmacy Services, UMass Medical School, Shrewsbury, Massachusetts
| | - Rachel Bacon
- Clinical Pharmacy Services, UMass Medical School, Shrewsbury, Massachusetts
| | | | | | | | - Karen Stevens
- Clinical Pharmacy Services, UMass Medical School, Shrewsbury, Massachusetts
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16
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Tangpricha V, Lukemire J, Chen Y, Binongo JNG, Judd SE, Michalski ES, Lee MJ, Walker S, Ziegler TR, Tirouvanziam R, Zughaier SM, Chesdachai S, Hermes WA, Chmiel JF, Grossmann RE, Gaggar A, Joseph PM, Alvarez JA. Vitamin D for the Immune System in Cystic Fibrosis (DISC): a double-blind, multicenter, randomized, placebo-controlled clinical trial. Am J Clin Nutr 2019; 109:544-553. [PMID: 30793177 PMCID: PMC6408205 DOI: 10.1093/ajcn/nqy291] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/30/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with cystic fibrosis (CF) have increased risk of vitamin D deficiency owing to fat malabsorption and other factors. Vitamin D deficiency has been associated with increased risk of pulmonary exacerbations of CF. OBJECTIVES The primary objective of this study was to examine the impact of a single high-dose bolus of vitamin D3 followed by maintenance treatment given to adults with CF during an acute pulmonary exacerbation on future recurrence of pulmonary exacerbations. METHODS This was a multicenter, double-blind, placebo-controlled, intent-to-treat clinical trial. Subjects with CF were randomly assigned to oral vitamin D3 given as a single dose of 250,000 International Units (IU) or to placebo within 72 h of hospital admission for an acute pulmonary exacerbation, followed by 50,000 IU of vitamin D3 or an identically matched placebo pill taken orally every other week starting at 3 mo after random assignment. The primary outcome was the composite endpoint of the time to next pulmonary exacerbation or death within 1 y. The secondary outcomes included circulating concentrations of the antimicrobial peptide cathelicidin and recovery of lung function as assessed by the percentage of predicted forced expiratory volume in 1 s (FEV1%). RESULTS A total of 91 subjects were enrolled in the study. There were no differences between the vitamin D3 and placebo groups in time to next pulmonary exacerbation or death at 1 y. In addition, there were no differences in serial recovery of lung function after pulmonary exacerbation by FEV1% or in serial concentrations of plasma cathelicidin. CONCLUSIONS Vitamin D3 initially given at the time of pulmonary exacerbation of CF did not alter the time to the next pulmonary exacerbation, 12-mo mortality, serial lung function, or serial plasma cathelicidin concentrations. This trial was registered at clinicaltrials.gov as NCT01426256.
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Affiliation(s)
- Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA,Nutrition Health Sciences Program, Emory University School of Public Health, Atlanta, GA,Emory Cystic Fibrosis Center, Atlanta, GA,Atlanta VA Medical Center, Atlanta, GA,Address correspondence to VT (e-mail: )
| | | | | | | | - Suzanne E Judd
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL
| | - Ellen S Michalski
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA,Nutrition Health Sciences Program, Emory University School of Public Health, Atlanta, GA
| | - Moon J Lee
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA,Nutrition Health Sciences Program, Emory University School of Public Health, Atlanta, GA,Emory Cystic Fibrosis Center, Atlanta, GA,Atlanta VA Medical Center, Atlanta, GA
| | - Rabin Tirouvanziam
- Emory Cystic Fibrosis Center, Atlanta, GA,Division of Pulmonary, Allergy & Immunology, Cystic Fibrosis, and Sleep, Department of Pediatrics, Emory University, Atlanta, GA
| | | | - Supavit Chesdachai
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Wendy A Hermes
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - James F Chmiel
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | | | - Amit Gaggar
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, The University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL
| | - Patricia M Joseph
- Division of Pulmonary, Critical Care & Sleep, Department of Medicine, University of Cincinnati, Cincinnati, OH
| | - Jessica A Alvarez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA,Nutrition Health Sciences Program, Emory University School of Public Health, Atlanta, GA,Emory Cystic Fibrosis Center, Atlanta, GA
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17
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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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18
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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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19
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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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20
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van Horck M, van de Kant K, Winkens B, Wesseling G, Gulmans V, Hendriks H, van der Grinten C, Jöbsis Q, Dompeling E. Risk factors for lung disease progression in children with cystic fibrosis. Eur Respir J 2018; 51:13993003.02509-2017. [PMID: 29773689 DOI: 10.1183/13993003.02509-2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 04/16/2018] [Indexed: 12/15/2022]
Abstract
To identify potential risk factors for lung disease progression in children with cystic fibrosis (CF), we studied the longitudinal data of all children with CF (aged ≥5 years) registered in the Dutch CF Registry (2009-2014).Lung disease progression was expressed as a decline in lung function (forced expiratory volume in 1 s (FEV1) % pred) and pulmonary exacerbation rate. Potential risk factors at baseline included sex, age, best FEV1 % pred, best forced vital capacity % pred, genotype, body mass index z-score, pancreatic insufficiency, medication use (proton pump inhibitors (PPIs), prophylactic antibiotics and inhaled corticosteroids), CF-related diabetes, allergic bronchopulmonary aspergillosis and colonisation with Pseudomonas aeruginosaThe data of 545 children were analysed. PPI use was associated with both annual decline of FEV1 % pred (p=0.017) and future pulmonary exacerbation rate (p=0.006). Moreover, lower FEV1 % pred at baseline (p=0.007), prophylactic inhaled antibiotic use (p=0.006) and pulmonary exacerbations in the baseline year (p=0.002) were related to pulmonary exacerbations in subsequent years.In a cohort of Dutch children with CF followed for 5 years, we were able to identify several risk factors for future exacerbations. In particular, the association between PPI use and lung disease progression definitely requires further investigation.
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Affiliation(s)
- Marieke van Horck
- Dept of Paediatric Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Dept of Paediatrics, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Kim van de Kant
- Dept of Paediatric Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Dept of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Bjorn Winkens
- Dept of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Geertjan Wesseling
- Dept of Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Han Hendriks
- Dept of Paediatric Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Dept of Paediatrics, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Chris van der Grinten
- Dept of Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Quirijn Jöbsis
- Dept of Paediatric Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Edward Dompeling
- Dept of Paediatric Respiratory Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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21
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Kirkham HS, Staskon F, Hira N, McLane D, Kilgore KM, Parente A, Kim S, Sawicki GS. Outcome evaluation of a pharmacy-based therapy management program for patients with cystic fibrosis. Pediatr Pulmonol 2018; 53. [PMID: 29512893 PMCID: PMC6001460 DOI: 10.1002/ppul.23978] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To compare medication adherence, pulmonary exacerbations, healthcare utilization, and costs for patients with cystic fibrosis (CF) who utilized a pharmacy-based therapy management program to a matched control group. We hypothesized that patient management services would be associated with better medication adherence, and thus require fewer visits to the emergency room or hospitalizations. METHODS This retrospective, observational cohort study used claims data from the MORE2 claims Registry®. The sample consisted of CF patients, aged 6+, who had ≥1 pharmacy claim for inhaled tobramycin, inhaled aztreonam, ivacaftor, or dornase alfa from 6/2/2014-5/31/2015. Adherence was measured as proportion of days covered (PDC). Propensity score matching and multivariable regression techniques were used to compare outcomes in program participants to matched controls. RESULTS Of the 236 intervention and 724 control patients meeting selection criteria, 202 were propensity-matched from each cohort. Relative to the control cohort, program patients had 23% higher mean PDC for tobramycin (IRR = 1.23, P = 0.01) and were twice as likely to be adherent to tobramycin (PDC ≥ 80%) than matched controls (OR = 2.14, P = 0.04). Program patients had fewer ER visits (IRR = 0.52, P < 0.01) and slightly lower ER costs (IRR = 0.66, P = 0.06) than the control patients. CONCLUSION A pharmacy-based therapy management program for CF patients was associated with higher adherence to inhaled tobramycin and lower ER rates. Pharmacies that provide therapy management can support effective CF care management.
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Affiliation(s)
| | | | - Nishita Hira
- AllianceRx Walgreens Prime, Pittsburgh, Pennsylvania
| | - Darren McLane
- AllianceRx Walgreens Prime, Pittsburgh, Pennsylvania
| | | | | | - Seung Kim
- Avalere Health-an Inovalon Company, Bowie, Maryland
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22
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Taylor-Cousar JL, Jain M, Barto TL, Haddad T, Atkinson J, Tian S, Tang R, Marigowda G, Waltz D, Pilewski J. Lumacaftor/ivacaftor in patients with cystic fibrosis and advanced lung disease homozygous for F508del-CFTR. J Cyst Fibros 2018; 17:228-235. [DOI: 10.1016/j.jcf.2017.09.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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23
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Espel JC, Palac HL, Cullina JF, Clarke AP, McColley SA, Prickett MH, Jain M. Antibiotic duration and changes in FEV 1 are not associated with time until next exacerbation in adult cystic fibrosis: a single center study. BMC Pulm Med 2017; 17:160. [PMID: 29187171 PMCID: PMC5707785 DOI: 10.1186/s12890-017-0503-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 11/16/2017] [Indexed: 11/24/2022] Open
Abstract
Background Pulmonary exacerbations (PEx) are a major driver of morbidity and mortality in cystic fibrosis and reducing their frequency by extending the time between them is an important therapeutic goal. Although treatment decisions for exacerbations are often made based on dynamic changes in lung function, it is not clear if these changes truly impact future exacerbation risk. We analyzed adults with chronic Pseudomonas aeruginosa infection to determine whether changes in FEV1 or duration of intravenous antibiotic therapy were associated with time to the next pulmonary exacerbation. Methods Medical records and Cystic Fibrosis Foundation Patient Registry data were examined retrospectively to assess whether various patient-specific demographic factors and exacerbation-specific characteristics were associated with time until next exacerbation using the Andersen-Gill model in order to control for previous exacerbation frequency history. Results We examined 59 patients with 221 CF pulmonary exacerbations over a 3-year study period. Mean age was 28.2 years and mean baseline FEV1 was 62% predicted. In our univariable model, fall in FEV1 at onset of exacerbation (median absolute −3% predicted change), recovery of FEV1 with treatment (median absolute +3% predicted change) and duration of IV antibiotics (median 16 days) were not associated with time to next exacerbation (median 93.5 days). Paradoxically each one-year increase in age was associated with a reduction in hazard of PEx by 3% (HR 0.97, P = 0.03, 95% CI 0.95–1.00). Conclusions FEV1 drop and recovery associated with onset and treatment of a CF pulmonary exacerbation or duration of intravenous antibiotics were not predictive of time until next exacerbation. Our finding that older age may be associated with decreased hazard of exacerbation is likely due to a healthy survivor effect and should be controlled for in clinical trials of pulmonary exacerbations.
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Affiliation(s)
- Julia C Espel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, 240 E. Huron Ave., McGaw Mezzanine, Chicago, IL, 60611, USA
| | - Hannah L Palac
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | | | - Alexandria P Clarke
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, 240 E. Huron Ave., McGaw Mezzanine, Chicago, IL, 60611, USA
| | | | - Michelle H Prickett
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, 240 E. Huron Ave., McGaw Mezzanine, Chicago, IL, 60611, USA
| | - Manu Jain
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, 240 E. Huron Ave., McGaw Mezzanine, Chicago, IL, 60611, USA.
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Abstract
BACKGROUND Autogenic drainage is an airway clearance technique that was developed by Jean Chevaillier in 1967. The technique is characterised by breathing control using expiratory airflow to mobilise secretions from smaller to larger airways. Secretions are cleared independently by adjusting the depth and speed of respiration in a sequence of controlled breathing techniques during exhalation. The technique requires training, concentration and effort from the individual. It is important to systematically review the evidence demonstrating that autogenic drainage is an effective intervention for people with cystic fibrosis. OBJECTIVES To compare the clinical effectiveness of autogenic drainage in people with cystic fibrosis with other physiotherapy airway clearance techniques. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews, as well as two trials registers (31 August 2017).Dtae of most recent search of the Cochrane Cystic Fibrosis Trials Register: 25 September 2017. SELECTION CRITERIA We identified randomised and quasi-randomised controlled studies comparing autogenic drainage to another airway clearance technique or no therapy in people with cystic fibrosis for at least two treatment sessions. DATA COLLECTION AND ANALYSIS Data extraction and assessments of risk of bias were independently performed by two authors. The authors assessed the quality of the evidence using the GRADE system. The authors contacted two investigators for further information pertinent to their published studies. MAIN RESULTS Searches retrieved 35 references to 21 individual studies, of which seven (n = 208) were eligible for inclusion. One study was of parallel design with the remaining six being cross-over in design; participant numbers ranged from 17 to 75. The total study duration varied between four days and two years. The age of participants ranged between seven and 63 years with a wide range of disease severity reported. Six studies enrolled participants who were clinically stable, whilst participants in one study had been hospitalised with an infective exacerbation. All studies compared autogenic drainage to one (or more) other recognised airway clearance technique. Exercise is commonly used as an alternative therapy by people with cystic fibrosis; however, there were no studies identified comparing exercise with autogenic drainage.The quality of the evidence was generally low or very low. The main reasons for downgrading the level of evidence were the frequent use of a cross-over design, outcome reporting bias and the inability to blind participants.The review's primary outcome, forced expiratory volume in one second, was the most common outcome measured and was reported by all seven studies; only three studies reported on quality of life (also a primary outcome of the review). One study reported on adverse events and described a decrease in oxygen saturation levels whilst performing active cycle of breathing techniques, but not with autogenic drainage. Six of the seven included studies measured forced vital capacity and three of the studies used mid peak expiratory flow (per cent predicted) as an outcome. Six studies reported sputum weight. Less commonly used outcomes included oxygen saturation levels, personal preference, hospital admissions or intravenous antibiotics. There were no statistically significant differences found between any of the techniques used with respect to the outcomes measured except when autogenic drainage was described as being the preferred technique of the participants in one study over postural drainage and percussion. AUTHORS' CONCLUSIONS Autogenic drainage is a challenging technique that requires commitment from the individual. As such, this intervention merits systematic review to ensure its effectiveness for people with cystic fibrosis. From the studies assessed, autogenic drainage was not found to be superior to any other form of airway clearance technique. Larger studies are required to better evaluate autogenic drainage in comparison to other airway clearance techniques in view of the relatively small number of participants in this review and the complex study designs. The studies recruited a range of participants and were not powered to assess non-inferiority. The varied length and design of the studies made the analysis of pooled data challenging.
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Affiliation(s)
- Pamela McCormack
- Alder Hey Children's NHS Foundation TrustDepartment of Respiratory PhysiotherapyEaton RoadLiverpoolUKL12 2AP
| | - Paul Burnham
- Hospital La PazServicio de Medicina Fisica y RehabilitacionMadridSpain
| | - Kevin W Southern
- University of LiverpoolDepartment of Women's and Children's HealthAlder Hey Children's NHS Foundation TrustEaton RoadLiverpoolMerseysideUKL12 2AP
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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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Rubin JL, Thayer S, Watkins A, Wagener JS, Hodgkins PS, Schechter MS. Frequency and costs of pulmonary exacerbations in patients with cystic fibrosis in the United States. Curr Med Res Opin 2017; 33:667-674. [PMID: 28058864 DOI: 10.1080/03007995.2016.1277196] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Information is limited regarding the cost of pulmonary exacerbations (PEx) among patients with cystic fibrosis in the United States. METHODS To examine PEx costs, medical chart data were linked to insurance claims for patients aged ≥6 years who had commercial coverage from a large US health insurer affiliated with Optum during 2008-2013. A PEx was categorized as an episode requiring newly started (1) oral antibiotics (PEx-O) or (2) intravenous (IV) antibiotics and/or inpatient stay (PEx-IV). RESULTS Among 241 patients, 88.0% had ≥1 PEx (2.9/year) of any type, and 48.1% had ≥1 PEx-IV. Prior PEx-IV was the strongest risk factor for subsequent PEx-IV. The mean cost per episode was $12,784 for PEx of any type and $36,319 for PEx-IV. Patients with worse lung function were more likely to experience a PEx and incurred higher annual PEx-related costs. LIMITATIONS This was an observational study using a convenience sample of patients with commercial coverage from a large US health insurer whose medical charts were available for abstraction. Results of the study may not be generalizable to individuals with Medicaid coverage and other types of insurance, or to the uninsured. CONCLUSIONS Most patients experience ≥1 PEx annually, and nearly half require IV antibiotics and/or inpatient stay at considerable cost.
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Affiliation(s)
- Jaime L Rubin
- a Vertex Pharmaceuticals, Incorporated , Boston , MA , USA
| | | | | | | | | | - Michael S Schechter
- e Children's Hospital of Richmond at Virginia Commonwealth University , VA , USA
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Continuous alternating inhaled antibiotics for chronic pseudomonal infection in cystic fibrosis. J Cyst Fibros 2016; 15:809-815. [DOI: 10.1016/j.jcf.2016.05.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/03/2016] [Accepted: 05/03/2016] [Indexed: 01/07/2023]
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Abstract
Cystic fibrosis (CF) is the most common autosomal-recessive disease in white persons. Significant advances in therapies and outcomes have occurred for people with CF over the past 30 years. Many of these improvements have come about through the concerted efforts of the CF Foundation and international CF societies; networks of CF care centers; and the worldwide community of care providers, researchers, and patients and families. There are still hurdles to overcome to continue to improve the quality of life, reduce CF complications, prolong survival, and ultimately cure CF. This article reviews the epidemiology of CF, including trends in incidence and prevalence, clinical characteristics, common complications, and survival.
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Affiliation(s)
- Don B. Sanders
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Aliza Fink
- Epidemiology, Cystic Fibrosis Foundation, Bethesda, Maryland
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Savant AP, McColley SA. Pediatric Pulmonology year in review 2015: Part 4. Pediatr Pulmonol 2016; 51:754-65. [PMID: 27171478 DOI: 10.1002/ppul.23470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 11/06/2022]
Abstract
In this article, we highlight cystic fibrosis (CF) research published in Pediatric Pulmonology during 2015. Articles from other journals that reflect similar themes, and those of special importance, are also included. Pediatr Pulmonol. 2016;51:754-765. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Adrienne P Savant
- Division of Pulmonary Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susanna A McColley
- Division of Pulmonary Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois
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Flume PA, VanDevanter DR, Morgan EE, Dudley MN, Loutit JS, Bell SC, Kerem E, Fischer R, Smyth AR, Aaron SD, Conrad D, Geller DE, Elborn JS. A phase 3, multi-center, multinational, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of levofloxacin inhalation solution (APT-1026) in stable cystic fibrosis patients. J Cyst Fibros 2016; 15:495-502. [DOI: 10.1016/j.jcf.2015.12.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/01/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
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VanDevanter DR, Flume PA, Morris N, Konstan MW. Probability of IV antibiotic retreatment within thirty days is associated with duration and location of IV antibiotic treatment for pulmonary exacerbation in cystic fibrosis. J Cyst Fibros 2016; 15:783-790. [PMID: 27139161 DOI: 10.1016/j.jcf.2016.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are few objective data to guide management of cystic fibrosis (CF) pulmonary exacerbations. We studied intravenous (IV) antibiotic treatment failure as defined by a need to retreat patients with IV antibiotics within 30days of completion of a prior IV antibiotic treatment for pulmonary exacerbation. METHODS The first IV-treated exacerbation on or after Jan. 1, 2010 among US CF Foundation Patient Registry patients was studied, combining treatments separated by <7days into single treatments. IV treatment duration categories were: 1-4, 5-8, 9-12, 13-16, 17-22, and ≥23days (inclusive). Logistic regressions for IV retreatment in ≤30days were adjusted with 12 categorical covariates, including age, sex, lung function, prior-year exacerbations, CF complications, CF Care Program, and ever/never treated in hospital. RESULTS 777 of 13,579 patients (5.7%) were retreated within 30days, with incidence varying by treatment duration: 1-4days, 8.7%; 5-8days; 6.6%; 9-12days, 3.2%; 13-16days, 4.5%; 17-22days, 6.2%; ≥23days, 10.3% and hospitalization: ever, 5.0%; never 8.5%. Adjusted odds ratios (OR) for retreatment (compared to 13-16days treatment) were: 1-4days, 1.94 [95%CI 1.49, 2.54] P<.001; 5-8days, 1.55 [1.18, 2.04] P=.002; 9-12days, 0.78 [0.58, 1.04] P=.09; 17-22days, 1.12 [0.88, 1.42] P=.37; ≥23days, 1.46 [1.12, 1.91] P=.005. Adjusted retreatment OR for never/ever hospitalized was 1.57 [1.29, 1.90] P<.001. Prior-year exacerbation number, oxygen therapy, non-invasive ventilation, and female sex were significantly associated with retreatment. Modeling hazard rate time-dependence showed that treatment duration and location-associated hazard rates attenuated within a few months after treatment. CONCLUSION After adjustment for covariates known to be associated with increased risk of IV treatment for exacerbation, IV antibiotic treatments of <9 and ≥23days and those without hospitalization were significant risk factors for IV retreatment within 30days of completion of an exacerbation treatment.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - P A Flume
- Medical University of South Carolina, Charleston, SC, USA
| | - N Morris
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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Matouk E, Nguyen D, Benedetti A, Bernier J, Gruber J, Landry J, Rousseau S, Ahlgren HG, Lands LC, Wojewodka G, Radzioch D. C-Reactive Protein in Stable Cystic Fibrosis: An Additional Indicator of Clinical Disease Activity and Risk of Future Pulmonary Exacerbations. ACTA ACUST UNITED AC 2016; 6:1000375. [PMID: 28066689 PMCID: PMC5218840 DOI: 10.4172/2161-105x.1000375] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In stable adult cystic fibrosis (CF) patients, we assessed the role of baseline high sensitivity C-reactive protein (hs-CRP) on CF clinical variables and frequency of intravenous (IV) treated pulmonary exacerbations (PExs) 1-year post-baseline. METHODS We recruited 51 clinically stable CF patients from our Adult CF Center. We incorporated collected parameters into Matouk CF clinical score and CF questionnaire-revised quality of life score (QOL). We used the clinical minus complications subscores as a clinical disease activity score (CDAS). We dichotomized our patients according to the cohort median baseline hs-CRP of 5.2 mg/L. RESULTS Patients in the high hs-CRP group (≥ 5.2 mg/L) demonstrated worse CDAS (r=0.67, p=0.0001) and QOL scores (r=0.57, p=0.0017) at a given FEV1% predicted. In both hs-CRP groups, prior-year IV-treated PExs and baseline CDASs were significant predictors of future IV-treated PExs. Interestingly, the association between baseline CDAS and future PExs frequency was more robust in the high compared to the low hs-CRP group (r=-0.88, p<0.0001, r=-0.48, p=0.017, respectively) with a steeper regression slope (p=0.001). In addition, a significant interaction was demonstrated between elevated baseline hs-CRP levels and CDASs for the prediction of increased risk of future PExs (p=0.02). This interaction provided an additional indicator of clinical disease activity and added another dimension to the prior year PExs frequency phenotype to identify patients at increased risk for future PExs. CONCLUSION Stable CF patients with elevated baseline hs-CRP (≥ 5.2 mg/L) demonstrated worse clinical disease activity and QOL scores at a given level of disease severity (FEV1% predicted). Elevated baseline hs-CRP values combined with clinical disease activity scores are associated with increased risk for future IV-treated PExs even in those with mild clinical disease activity scores.
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Affiliation(s)
- Elias Matouk
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Canada; McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada
| | - Dao Nguyen
- McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada; Meakins-Christie Laboratories, Montreal Chest Institute, McGill University Health Centre, Canada
| | - Andrea Benedetti
- McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada; Department of Epidemiology, Biostatistics and Occupational Health, Montreal Chest Institute, McGill University Health Center, Canada
| | - Joanie Bernier
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Canada
| | - James Gruber
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Canada; Department of Medicine, McGill University, Canada
| | - Jennifer Landry
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Canada; McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada
| | - Simon Rousseau
- Department of Medicine, McGill University, Canada; Meakins-Christie Laboratories, Montreal Chest Institute, McGill University Health Centre, Canada
| | - Heather G Ahlgren
- McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada
| | - Larry C Lands
- McGill University Health Center Research Institute, Canada; Meakins-Christie Laboratories, Montreal Chest Institute, McGill University Health Centre, Canada; Division of Pediatric Respiratory Medicine, Montreal Children's Hospital, Canada
| | - Gabriella Wojewodka
- Department of Human Genetics, Respiratory Division, McGill University, Canada; McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada
| | - Danuta Radzioch
- Department of Human Genetics, Respiratory Division, McGill University, Canada; McGill University Health Center Research Institute, Canada; Department of Medicine, McGill University, Canada
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Hoo ZH, Curley R, Campbell MJ, Walters SJ, Hind D, Wildman MJ. Accurate reporting of adherence to inhaled therapies in adults with cystic fibrosis: methods to calculate "normative adherence". Patient Prefer Adherence 2016; 10:887-900. [PMID: 27284242 PMCID: PMC4883819 DOI: 10.2147/ppa.s105530] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Preventative inhaled treatments in cystic fibrosis will only be effective in maintaining lung health if used appropriately. An accurate adherence index should therefore reflect treatment effectiveness, but the standard method of reporting adherence, that is, as a percentage of the agreed regimen between clinicians and people with cystic fibrosis, does not account for the appropriateness of the treatment regimen. We describe two different indices of inhaled therapy adherence for adults with cystic fibrosis which take into account effectiveness, that is, "simple" and "sophisticated" normative adherence. METHODS TO CALCULATE NORMATIVE ADHERENCE Denominator adjustment involves fixing a minimum appropriate value based on the recommended therapy given a person's characteristics. For simple normative adherence, the denominator is determined by the person's Pseudomonas status. For sophisticated normative adherence, the denominator is determined by the person's Pseudomonas status and history of pulmonary exacerbations over the previous year. Numerator adjustment involves capping the daily maximum inhaled therapy use at 100% so that medication overuse does not artificially inflate the adherence level. THREE ILLUSTRATIVE CASES Case A is an example of inhaled therapy under prescription based on Pseudomonas status resulting in lower simple normative adherence compared to unadjusted adherence. Case B is an example of inhaled therapy under-prescription based on previous exacerbation history resulting in lower sophisticated normative adherence compared to unadjusted adherence and simple normative adherence. Case C is an example of nebulizer overuse exaggerating the magnitude of unadjusted adherence. CONCLUSION Different methods of reporting adherence can result in different magnitudes of adherence. We have proposed two methods of standardizing the calculation of adherence which should better reflect treatment effectiveness. The value of these indices can be tested empirically in clinical trials in which there is careful definition of treatment regimens related to key patient characteristics, alongside accurate measurement of health outcomes.
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Affiliation(s)
- Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, University of Sheffield, Sheffield, UK
| | - Rachael Curley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, University of Sheffield, Sheffield, UK
| | - Michael J Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, University of Sheffield, Sheffield, UK
- Correspondence: Martin J Wildman, Sheffield Adult Cystic Fibrosis Centre, Brearley Outpatient, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK, Tel +44 114 271 5212, Fax +44 114 226 6280, Email
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Maliniak ML, Stecenko AA, McCarty NA. A longitudinal analysis of chronic MRSA and Pseudomonas aeruginosa co-infection in cystic fibrosis: A single-center study. J Cyst Fibros 2015; 15:350-6. [PMID: 26610860 DOI: 10.1016/j.jcf.2015.10.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/23/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Few studies have examined the association between chronic methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PA) co-infection and health outcomes despite evidence that these pathogens alone contribute to higher morbidity and mortality in cystic fibrosis (CF). This study examines outcomes among CF patients with chronic MRSA and PA co-infection compared with patients with either or neither of these organisms. METHODS CF patients attending the care center in Atlanta, GA from 2007-2013 comprised the study cohort. Chronic co-infection was defined as >50% PA+ cultures and >50% MRSA+ cultures and modeled as time-varying. The rate of decline in lung function (FEV1) and the rate of IV treatments were the main outcomes. RESULTS Among all patients (N=354), chronic co-infection was associated with a significantly more rapid rate of FEV1 decline compared with patients with chronic PA alone [adjusted difference: -0.60% predicted/year (-1.13, -0.08)] and chronic MRSA alone [adjusted difference: -0.89% predicted/year (-1.56, -0.22)]. Rate of IV treatments was significantly higher among patients with chronic co-infection compared with patients with chronic PA alone [adjusted IRR: 1.24 (1.01, 1.52)] and chronic MRSA alone [adjusted IRR: 1.34 (1.03, 1.74)]. CONCLUSIONS Data from the Atlanta Care Center suggest that chronic MRSA and PA co-infection may be associated with increased rate of lung function decline and rate of intravenous antibiotics compared with patients with either pathogen alone.
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Affiliation(s)
- Maret L Maliniak
- Department of Pediatrics, Emory University, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Emory+Children's Center for CF and Airways Disease Research, 2015 Uppergate Drive, Atlanta, GA 30322, USA.
| | - Arlene A Stecenko
- Department of Pediatrics, Emory University, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Emory+Children's Center for CF and Airways Disease Research, 2015 Uppergate Drive, Atlanta, GA 30322, USA.
| | - Nael A McCarty
- Department of Pediatrics, Emory University, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Emory+Children's Center for CF and Airways Disease Research, 2015 Uppergate Drive, Atlanta, GA 30322, USA.
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IV-treated pulmonary exacerbations in the prior year: An important independent risk factor for future pulmonary exacerbation in cystic fibrosis. J Cyst Fibros 2015; 15:372-9. [PMID: 26603642 DOI: 10.1016/j.jcf.2015.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/25/2015] [Accepted: 10/12/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Single-center analyses have suggested that the number of CF pulmonary exacerbations (PEx) treated with intravenous antibiotics an individual has experienced in the prior year is significantly associated with their future PEx hazard. METHODS We studied Prior-year PEx association with future PEx hazard by Cox proportional hazards regression among CF Foundation Patient Registry patients who experienced PEx after Jan 1, 2010. RESULTS Among 13,579 patients, those with 1, 2, 3, or ≥4 Prior-year PEx treated with intravenous antibiotics were at 1.8, 2.9, 4.8, and 8.7 higher PEx hazard vs those without (P<.0001). Adjustment with significant demographic and clinical covariates (univariate P≤.0001) reduced Prior-year PEx hazard ratios to 1.6, 2.4, 3.6, and 6.0 (P<.0001). No other covariates had adjusted hazard ratios of >1.7. CONCLUSIONS Prior-year PEx strongly associate with future PEx hazard and should be accounted for in prospective trials where treatment-associated change in PEx hazard is an efficacy outcome.
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Affiliation(s)
- Don B Sanders
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, University of Wisconsin, 600 Highland Avenue, K4/920, Madison, WI 53792-9988, United States.
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