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Roca M, Masip E, Colombo C, Boon M, Hulst JM, Garriga M, de Koning BAE, Bulfamante A, de Boeck K, Ribes-Koninckx C, Calvo-Lerma J. Long-term evaluation of faecal calprotectin levels in a European cohort of children with cystic fibrosis. Arch Dis Child 2024; 109:552-556. [PMID: 38123920 DOI: 10.1136/archdischild-2023-326221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Intestinal inflammation with contradictory data on faecal calprotectin (fCP) levels is documented in patients with cystic fibrosis (CF). The aim of this study was to longitudinally evaluate fCP in a cohort of children with CF and their relationship with clinical variables. DESIGN Prospective observational study to assess evolution of fCP levels, primary aimed at improving fat absorption. Along 1.5 years of follow-up (November 2016-May 2018) with four study visits pertaining to a pilot study (two of four) and to a clinical trial (two of four), the study outcomes were measured. SETTING Six European CF centres in the context of MyCyFAPP Project. SUBJECTS Children with CF and pancreatic insufficiency (2-18 years old). MAIN OUTCOME MEASUREMENTS fCP levels, pulmonary function (percentage of forced expiratory volume in 1 s (FEV1%)) and coefficient of fat absorption (CFA). Additionally, in the last two visits, gastrointestinal (GI) symptoms were evaluated through the PedsQL-GI Questionnaire. Linear mixed regression models were applied to assess association between fCP and FEV1, CFA and GI symptoms. RESULTS Twenty-nine children with CF and pancreatic insufficiency were included. fCP levels were inversely associated with total modified specific PedsQL-GI score (p=0.04) and positively associated with diarrhoea (p=0.03), but not with CFA. Along the four study visits, fCP significantly increased (from 62 to 256 µg/g) and pulmonary function decreased (from 97% to 87%), with a significant inverse association between the two study outcomes (p<0.001). CONCLUSIONS In children with CF, fCP levels are inversely associated with pulmonary function and thus the specificity of fCP as a marker of intestinal inflammation in paediatric patients with CF warrants further investigation.
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Affiliation(s)
- Maria Roca
- Health Research Institute La Fe, Valencia, Spain
| | - Etna Masip
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mieke Boon
- Department of Pediatrics, KU Leuven Hospital, Leuven, Belgium
| | - Jessie M Hulst
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Anna Bulfamante
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Kris de Boeck
- Department of Pediatrics, KU Leuven Hospital, Leuven, Belgium
| | | | - Joaquim Calvo-Lerma
- Health Research Institute La Fe, Valencia, Spain
- Universitat de València, Valencia, Spain
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Al-Beltagi M, Saeed NK, Bediwy AS, Elbeltagi R. Fecal calprotectin in pediatric gastrointestinal diseases: Pros and cons. World J Clin Pediatr 2024; 13:93341. [PMID: 38948001 PMCID: PMC11212754 DOI: 10.5409/wjcp.v13.i2.93341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/28/2024] [Accepted: 05/14/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Fecal calprotectin is a valuable biomarker for assessing intestinal inflammation in pediatric gastrointestinal diseases. However, its role, pros, and cons in various conditions must be comprehensively elucidated. AIM To explore the role of fecal calprotectin in pediatric gastrointestinal diseases, including its advantages and limitations. METHODS A comprehensive search was conducted on PubMed, PubMed Central, Google Scholar, and other scientific research engines until February 24, 2024. The review included 88 research articles, 56 review articles, six meta-analyses, two systematic reviews, two consensus papers, and two letters to the editors. RESULTS Fecal calprotectin is a non-invasive marker for detecting intestinal inflammation and monitoring disease activity in pediatric conditions such as functional gastrointestinal disorders, inflammatory bowel disease, coeliac disease, coronavirus disease 2019-induced gastrointestinal disorders, gastroenteritis, and cystic fibrosis-associated intestinal pathology. However, its lack of specificity and susceptibility to various confounding factors pose challenges in interpretation. Despite these limitations, fecal calprotectin offers significant advantages in diagnosing, monitoring, and managing pediatric gastrointestinal diseases. CONCLUSION Fecal calprotectin holds promise as a valuable tool in pediatric gastroenterology, offering insights into disease activity, treatment response, and prognosis. Standardized protocols and guidelines are needed to optimize its clinical utility and mitigate interpretation challenges. Further research is warranted to address the identified limitations and enhance our understanding of fecal calprotectin in pediatric gastrointestinal diseases.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatric, Faculty of Medicine, Tanta University, Tanta 31511, Alghrabia, Egypt
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama 26671, Manama, Bahrain
- Department of Pediatrics, University Medical Center, Dr. Sulaiman Al Habib Medical Group, Bahrain, Manama 26671, Manama, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 12, Manama, Bahrain
- Medical Microbiology Section, Department of Pathology, Irish Royal College of Surgeon, Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Pulmonology, Faculty of Medicine, Tanta University, Tanta 31527, Alghrabia, Egypt
- Department of Pulmonology, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama 26671, Manama, Bahrain
- Department of Pulmonology, University Medical Center, King Abdulla Medical City, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Manama, Bahrain
| | - Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
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Tindall A, Bass R, Maqbool A, Stallings VA. Impact of lumacaftor/ivacaftor on nutrition and growth in modulator-naïve children over 24 weeks. J Cyst Fibros 2024:S1569-1993(24)00068-7. [PMID: 38789320 DOI: 10.1016/j.jcf.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulators improve nutritional status and are of importance in achieving normal growth among younger children with CF. The study was designed to examine CFTR modulator-associated changes in nutrition status, including bile acids and fatty acids after lumacaftor/ivacaftor therapy for 24 weeks. METHODS Children 2 to 5.9 years were recruited from US and Canadian CF Centers. Eligible children were lumacaftor/ivacaftor naïve and approved to initiate therapy. Anthropometrics, diet, energy expenditure, nutrition biomarkers, pancreatic status, serum and fecal calprotectin, serum bile acids and plasma fatty acids were measured. Changes from baseline at 12 and 24 weeks were examined using mixed effects linear regression modeling. RESULTS Weight-for-age z-score (WAZ) increased at 12 (0.15 ± 0.1, p = 0.01) and 24 weeks (0.23 ± 0.1, p = 0.001) from baseline following modulator therapy. Head circumference-for-age (HCZ) increased at 12 weeks compared to baseline (0.22 ± 0.1, p = 0.03) and subscapular Z score increased from baseline at 24 weeks following therapy (0.33 ± 0.1, p = 0.02). There were no changes in energy expenditure. Serum total bile acids (6.7 ± 2.0, p = 0.001), chenodeoxycholic acid (CDCA) (2.4 ± 1.1, p = 0.001), and cholic acid (CA) (3.5 ± 0.8, p < 0.0001) increased at 24 weeks compared to baseline. Fecal calprotectin decreased at 12 and 24 weeks compared to baseline (-463 ± 310, p = 0.03 and 566 ± 347, p = 0.047). A number of plasma fatty acids changed over the course of 24 weeks of therapy. Noteably, alpha-linolenic acid (ALA) decreased at 12 and 24 weeks (-24 ± 10,p = 0.03 and -18 ± 10, p = 0.02, respectively). CONCLUSIONS Overall, young children experienced favorable changes in nutritional and growth, with the exception of plasma ALA status in the first 24 weeks of lumacaftor/ivacaftor therapy.
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Affiliation(s)
- Alyssa Tindall
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Rosara Bass
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Asim Maqbool
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Virginia A Stallings
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Mainz JG, Lester K, Elnazir B, Williamson M, McKone E, Cox D, Linnane B, Zagoya C, Duckstein F, Barucha A, Davies JC, McNally P. Reduction in abdominal symptoms (CFAbd-Score), faecal M2-pyruvate-kinase and Calprotectin over one year of treatment with Elexacaftor-Tezacaftor-Ivacaftor in people with CF aged ≥12 years - The RECOVER study. J Cyst Fibros 2024; 23:474-480. [PMID: 37806792 DOI: 10.1016/j.jcf.2023.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/23/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND RECOVER is a multicentre post-approval study of Elexacaftor/Tezacaftor/Ivacaftor (ETI) in pwCF in Ireland and the UK. The CFAbd-Score is the first validated CF-specific patient reported outcome measure (PROM) focusing on gastrointestinal symptoms; it comprises 28 items in 5 domains. In a preliminary study, we previously reported reductions in abdominal symptoms (AS) in pwCF after 26 weeks of ETI-therapy using the CFAbd-Score. AIM to assess changes in AS in a second, large cohort and explore novel GI-biomarkers of gut inflammation and cell-proliferation in pwCF over one year of ETI-therapy. METHODS Participants were recruited as part of the RECOVER study at 8 sites (Ireland&UK). The CFAbd-Score was administered prior to ETI-initiation, and subsequently at 1,2,6 and 12 months on treatment. Faecal M2-pyruvate kinase (M2-PK) and calprotectin (FC) were quantified in samples collected at baseline, 1 and 6 months. RESULTS 108 CFAbd-Scores and 73 stool samples were collected at baseline. After 12 months of ETI-therapy, total CFAbd-Scores had significantly declined (15.0±1.4→9.8±1.2pts/p<0.001), and so had all its five domains of "pain" (16.9±2.0pts→9.9±1.8pts/p<0.01), "GERD" (14.4±1.8→9.9±1.6/p<0.05), "disorders of bowel movements" (19.2±1.4→14.1±1.5/p<0.01), "appetite" (7.0±1.1→4.6±1.2/p<0.01) and "impaired-QoL" (13.3±1.9→7.5±1.5/p<0.001). Levels of M2-PK and FC significantly decreased during ETI-therapy. DISCUSSION In-depth analysis of AS with the CFAbd-Score reveals a statistically significant, clinically relevant and sustained improvement with ETI. We attribute this to high sensitivity of the implemented CF-specific PROM, developed and validated following FDA-guidelines. Furthermore, for the first time during ETI-therapy a significant decline in faecal M2-PK, a marker of inflammation and cell-proliferation, was found, in parallel to FC.
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Affiliation(s)
- Jochen G Mainz
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.
| | - Karen Lester
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | - Ed McKone
- St Vincent's University Hospital, Dublin, Ireland
| | - Des Cox
- Children's Health Ireland, Dublin, Ireland
| | - Barry Linnane
- University of Limerick School of Medicine, Limerick, Ireland
| | - Carlos Zagoya
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Franziska Duckstein
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Anton Barucha
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany; Department of Gastroenterology, Brandenburg Medical School (MHB) University, Brandenburg an der Havel, Germany
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton Hospital, Guy's & St Thomas' NHS Trust, London, UK
| | - Paul McNally
- RCSI University of Medicine and Health Sciences, Dublin, Ireland; Children's Health Ireland, Dublin, Ireland
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Marsh R, Dos Santos C, Hanson L, Ng C, Major G, Smyth AR, Rivett D, van der Gast C. Tezacaftor/Ivacaftor therapy has negligible effects on the cystic fibrosis gut microbiome. Microbiol Spectr 2023; 11:e0117523. [PMID: 37607068 PMCID: PMC10581179 DOI: 10.1128/spectrum.01175-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/28/2023] [Indexed: 08/24/2023] Open
Abstract
People with cystic fibrosis (pwCF) experience a range of persistent gastrointestinal symptoms throughout life. There is evidence indicating interaction between the microbiota and gut pathophysiology in CF. However, there is a paucity of knowledge on the potential effects of CF transmembrane conductance regulator (CFTR) modulator therapies on the gut microbiome. In a pilot study, we investigated the impact of Tezacaftor/Ivacaftor dual combination CFTR modulator therapy on the gut microbiota and metabolomic functioning in pwCF. Fecal samples from 12 pwCF taken at baseline and following placebo or Tezacaftor/Ivacaftor administration were subjected to microbiota sequencing and to targeted metabolomics to assess the short-chain fatty acid (SCFA) composition. Ten healthy matched controls were included as a comparison. Inflammatory calprotectin levels and patient symptoms were also investigated. No significant differences were observed in overall gut microbiota characteristics between any of the study stages, extended also across intestinal inflammation, gut symptoms, and SCFA-targeted metabolomics. However, microbiota and SCFA metabolomic compositions, in pwCF, were significantly different from controls in all study treatment stages. CFTR modulator therapy with Tezacaftor/Ivacaftor had negligible effects on both the gut microbiota and SCFA composition across the course of the study and did not alter toward compositions observed in healthy controls. Future longitudinal CFTR modulator studies will investigate more effective CFTR modulators and should use prolonged sampling periods, to determine whether longer-term changes occur in the CF gut microbiome. IMPORTANCE People with cystic fibrosis (pwCF) experience persistent gastrointestinal (GI) symptoms throughout life. The research question "how can we relieve gastrointestinal symptoms, such as stomach pain, bloating, and nausea?" remains a top priority for clinical research in CF. While CF transmembrane conductance regulator (CFTR) modulator therapies are understood to correct underlying issues of CF disease and increasing the numbers of pwCF are now receiving some form of CFTR modulator treatment. It is not known how these therapies affect the gut microbiome or GI system. In this pilot study, we investigated, for the first time, effects of the dual combination CFTR modulator medicine, Tezacaftor/Ivacaftor. We found it had negligible effects on patient GI symptoms, intestinal inflammation, or gut microbiome composition and functioning. Our findings are important as they fill important knowledge gaps on the relative effectiveness of these widely used treatments. We are now investigating triple combination CFTR modulators with prolonged sampling periods.
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Affiliation(s)
- Ryan Marsh
- Department of Applied Sciences, Northumbria University, Newcastle, United Kingdom
| | - Claudio Dos Santos
- Department of Natural Sciences, Manchester Metropolitan University, Manchester, United Kingdom
| | - Liam Hanson
- Department of Natural Sciences, Manchester Metropolitan University, Manchester, United Kingdom
- Department of Life Sciences, Manchester Metropolitan University, Manchester, United Kingdom
| | - Christabella Ng
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
- NIHR Nottingham Biomedical Research Centre, Nottingham, United Kingdom
| | - Giles Major
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Nestlé Institute of Health Sciences, Société des Produits Nestlé, Lausanne, Switzerland
| | - Alan R. Smyth
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
- NIHR Nottingham Biomedical Research Centre, Nottingham, United Kingdom
| | - Damian Rivett
- Department of Natural Sciences, Manchester Metropolitan University, Manchester, United Kingdom
| | - Christopher van der Gast
- Department of Applied Sciences, Northumbria University, Newcastle, United Kingdom
- Department of Respiratory Medicine, Salford Royal NHS Foundation Trust, Salford, United Kingdom
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Yule A, Sills D, Smith S, Spiller R, Smyth AR. Thinking outside the box: a review of gastrointestinal symptoms and complications in cystic fibrosis. Expert Rev Respir Med 2023; 17:547-561. [PMID: 37345513 DOI: 10.1080/17476348.2023.2228194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Gastrointestinal (GI)-related symptoms, complications, and comorbidities in cystic fibrosis (CF) are common and research to reduce their burden is a priority for the CF community. To enable future research, this review aimed to summarize the range of GI symptoms, complications and comorbidities seen in CF, the underlying pathophysiology, and treatments. AREAS COVERED This was a rapid systematic review undertaken using the recommendations from the Cochrane Rapid Reviews Methods Group. We searched databases including PubMed, Embase, Medline and the Cochrane database and identified those studies reporting GI-related symptoms, complications, or comorbidities in CF or their treatment. Our searches identified 2,930 studies and a total 119 studies met our inclusion criteria. Where a prevalence could be determined, GI symptoms were reported in 33.7% of study participants. The range of symptoms reported was broad and the highest median prevalence included flatulence (43.5%), bloating and abdominal distension (36%), and fatty stool (36%). Meconium ileus was reported in 12% and distal intestinal obstruction syndrome in 8.5. EXPERT OPINION GI-related symptoms, complications, and comorbidities in CF are common. More consistent characterization and recording of these symptoms in clinical studies may help achieve the priority of reducing the burden of GI disease in CF.
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Affiliation(s)
- Alexander Yule
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
| | - Darren Sills
- Nutrition and Dietetics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sherie Smith
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robin Spiller
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
- Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan R Smyth
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
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Lazzarotto ES, Vasco JFDM, Führ F, Riedi CA, Filho NAR. Systematic review on fecal calprotectin in cystic fibrosis. J Pediatr (Rio J) 2023; 99:4-10. [PMID: 35523321 PMCID: PMC9875247 DOI: 10.1016/j.jped.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Fecal calprotectin is an inflammatory marker used for monitoring intestinal diseases. It has been studied as a marker of intestinal inflammation in cystic fibrosis (CF), a multi-systemic genetic disease caused by alterations to the CFTR gene. Manifestations of the disease favor a systemic inflammation not limited to the respiratory tract, therefore, calprotectin is a non-invasive and effective diagnostic method. The aim of the study was to perform a systematic review of the literature with a qualitative synthesis of studies. SOURCES The articles were selected from PubMed, Web of Science, Scielo and Lilacs. SUMMARY OF THE FINDINGS Nine studies were selected for that qualitative synthesis, one was a randomized clinical trial, and eight were case-control or cohort designs. Most studies have indicated that calprotectin is a marker of systemic inflammation in CF and not just intestinal inflammation. Calprotectin is an aid in monitoring inflammatory bowel conditions in patients with cystic fibrosis. CONCLUSION Further studies should be conducted to investigate the role of this marker in the systemic inflammation of CF.
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Affiliation(s)
| | | | - Fabiane Führ
- Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Carlos Antônio Riedi
- Universidade Federal do Paraná, Curitiba, PR, Brazil; Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brazil
| | - Nelson Augusto Rosário Filho
- Universidade Federal do Paraná, Curitiba, PR, Brazil; Universidade Federal do Paraná, Hospital de Clínicas, Curitiba, PR, Brazil
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Wilschanski M, Peckham D. Nutritional and metabolic management for cystic fibrosis in a post-cystic fibrosis transmembrane conductance modulator era. Curr Opin Pulm Med 2022; 28:577-583. [PMID: 36102602 DOI: 10.1097/mcp.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The introduction of highly effective cystic fibrosis transmembrane conductance regulator modulators has resulted in a paradigm shift towards treating underlying cause of cystic fibrosis (CF) rather than the ensuing complications. In this review, we will describe the impact of these small molecules on growth, nutrition, and metabolic status in people with CF (pwCF). RECENT FINDING Results of clinical trials and real world data demonstrate that these small molecules are having a significant impact of on augmenting body weight, improving nutritional status and reducing gastrointestinal symptom burden. Early treatment can also positively impact on pancreatic endocrine and exocrine function. SUMMARY Nutritional and metabolic management of pwCF needs to change in order to maximize long term health and avoid future complications relating to obesity and increased cardiovascular risk. Longitudinal registry studies will be key to improve our understanding of the longer-term outcome of these new therapies.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Daniel Peckham
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Wrigley-Carr HE, van Dorst JM, Ooi CY. Intestinal dysbiosis and inflammation in cystic fibrosis impacts gut and multi-organ axes. MEDICINE IN MICROECOLOGY 2022. [DOI: 10.1016/j.medmic.2022.100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Niedermayr K, Gasser V, Rueckes-Nilges C, Appelt D, Eder J, Fuchs T, Naehrlich L, Ellemunter H. Personalized medicine with drugs targeting the underlying protein defect in cystic fibrosis: is monitoring of treatment response necessary? Ther Adv Chronic Dis 2022; 13:20406223221108627. [PMID: 35959505 PMCID: PMC9358561 DOI: 10.1177/20406223221108627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 06/01/2022] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is caused by two mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. In the last years, drugs targeting the underlying protein defect like lumacaftor/ivacaftor (LUM/IVA) or tezacaftor/ivacaftor (TEZ/IVA) and more recently elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) were admitted. Outcome parameters evaluating therapy response like forced expiratory pressure in 1 s (FEV1), body mass index (BMI) or the efficacy of CFTR function in sweat glands showed improvement in several cases. Other, CFTR biomarkers were analysed rarely. This prospective observational study was aimed at evaluating CFTR function in patients treated with different CFTR modulators together with common valid clinical outcome parameters at standardized appointments (day 0, week 2, 4, 16). We followed four patients with the same mutation (F508del-CFTR), sex, age and disease severity. Monitoring focused on lung function, gastrointestinal aspects and CFTR function of sweat glands, nasal and intestinal epithelium. Sweat tests were performed by pilocarpine iontophoresis. Nasal potential difference (NPD) measured transepithelial voltage in vivo and potential increased when CFTR function improved. Rectal biopsies were obtained for intestinal current measurements (ICM) ex vivo. Intestinal CFTR function was assessed by stimulating chloride secretion with different reagents. Response to CFTR modulators regarding clinical outcome parameters was rather variable. A sweat chloride reduction of 35.3 mmol/L, nasal CFTR rescue of 4.4% and fivefold higher CFTR function in the intestine was seen at week 16 post-LUM/IVA. Due to our monitoring, we identified a non-responder to LUM/IVA and TEZ/IVA. In case of ELX/TEZ/IVA, clinical parameters and CFTR bioassays improved and were concordant. Although our cohort is small, results emphasize that non-responders exist and conclusions could not be drawn if patients were not monitored. Data on CFTR function can confirm or disprove ongoing CFTR dysfunction and might be helpful selectively. Non-responders need other alternative therapy options as demonstrated with ELX/TEZ/IVA.
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Affiliation(s)
- Katharina Niedermayr
- Department for Child and Adolescent Health, University Clinic for Paediatrics III, Cystic Fibrosis Centre, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Tyrol, Austria
| | - Verena Gasser
- Department for Child and Adolescent Health, University Clinic for Paediatrics III, Cystic Fibrosis Centre, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Rueckes-Nilges
- Department of General Pediatrics and Neonatology, University Hospital of Giessen and Marburg, Campus Giessen, Giessen, Germany
| | - Dorothea Appelt
- Department for Child and Adolescent Health, University Clinic for Paediatrics III, Cystic Fibrosis Centre, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Eder
- Department for Child and Adolescent Health, University Clinic for Paediatrics III, Cystic Fibrosis Centre, Medical University of Innsbruck, Innsbruck, Austria
| | - Teresa Fuchs
- Department for Child and Adolescent Health, University Clinic for Paediatrics III, Cystic Fibrosis Centre, Medical University of Innsbruck, Innsbruck, Austria
| | - Lutz Naehrlich
- Department of General Pediatrics and Neonatology, University Hospital of Giessen and Marburg, Campus Giessen, Giessen, Germany
| | - Helmut Ellemunter
- Department for Child and Adolescent Health, University Clinic for Paediatrics III, Cystic Fibrosis Centre, Medical University of Innsbruck, Innsbruck, Austria
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Probiotics Administration in Cystic Fibrosis: What Is the Evidence? Nutrients 2022; 14:nu14153160. [PMID: 35956335 PMCID: PMC9370594 DOI: 10.3390/nu14153160] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
In the last 20 years, gut microbiota in patients with cystic fibrosis (CF) has become an object of interest. It was shown that these patients had gut dysbiosis and this could explain not only the intestinal manifestations of the disease but also part of those involving the respiratory tract. The acquisition of previously unknown information about the importance of some bacteria, i.e., those partially or totally disappeared in the gut of CF patients, in the regulation of the activity and function of the gut and the lung was the base to suggest the use of probiotics in CF patients. The main aim of this paper is to discuss the biological basis for probiotic administration to CF patients and which results could be expected. Literature analysis showed that CF intestinal dysbiosis depends on the same genetic mutations that condition the clinical picture of the diseases and is aggravated by a series of therapeutic interventions, such as dietary modifications, the use of antibiotics, and the administration of antacids. All this translates into a significant worsening of the structure and function of organs, including the lung and intestine, already deeply penalized by the genetic alterations of CF. Probiotics can intervene on dysbiosis, reducing the negative effects derived from it. However, the available data cannot be considered sufficient to indicate that these bacteria are essential elements of CF therapy. Further studies that take into account the still unsolved aspects on how to use probiotics are absolutely necessary.
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12
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Jaudszus A, Pfeifer E, Lorenz M, Beiersdorf N, Hipler UC, Zagoya C, Mainz JG. Abdominal Symptoms Assessed With the CFAbd-Score are Associated With Intestinal Inflammation in Patients With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2022; 74:355-360. [PMID: 34789668 DOI: 10.1097/mpg.0000000000003357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES This prospective study evaluated the relationship between fecal markers of intestinal inflammation and cystic fibrosis (CF)-associated abdominal symptoms. These were assessed using the CFAbd-Score, a CF-specific patient-related outcome measure developed and validated, following FDA guidelines. METHODS In feces from patients with CF (n = 41) and healthy volunteers (n = 27), concentrations of fecal calprotectin (FC), M2-pyruvate kinase (M2-PK), interleukins IL-1β, IL-6, IL-8, and neutrophilic elastase (NE) were measured. Abdominal symptoms during the 2 preceding weeks were recorded using the CFAbd-Score. This patient-reported outcome measure (PROM) for assessment of the multi-organic abdominal involvement in CF includes 28 items in five domains. RESULTS Inflammatory parameters FC, IL-1β, M2-PK, and NE in feces, as well as CFAbd-Scores resulted significantly higher in CF patients than in healthy controls (all P < 0.01). Furthermore, significant differences between both groups were found for pain-symptoms, disorders of bowel movement, impaired quality of life, as well as disorders of eating and appetite. With 83% sensitivity and 74% specificity, FC was the most reliable measure for CF-related intestinal inflammation, which, in the CFAbd-Score, was associated to significantly higher rates of abdominal pain, as well as to general quality of life items such as gastrointestinal-related impaired sleep and frustration. CONCLUSION Using the CFAbd-Score as a CF-specific PROM for identification and quantification of abdominal symptoms revealed that abdominal pain and impaired quality of life are associated with intestinal inflammation in CF.
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Affiliation(s)
- Anke Jaudszus
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Elena Pfeifer
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Michael Lorenz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Nathalie Beiersdorf
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | | | - Carlos Zagoya
- Brandenburg Medical School/Medizinische Hochschule Brandenburg (MHB), University, Pediatric Pulmonology/Cystic Fibrosis, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Jochen G Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany.,Brandenburg Medical School/Medizinische Hochschule Brandenburg (MHB), University, Pediatric Pulmonology/Cystic Fibrosis, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.,Faculty of Health Sciences, joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, the Brandenburg Medical School Theodor Fontane and the University of Potsdam, Germany
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Tam RY, van Dorst JM, McKay I, Coffey M, Ooi CY. Intestinal Inflammation and Alterations in the Gut Microbiota in Cystic Fibrosis: A Review of the Current Evidence, Pathophysiology and Future Directions. J Clin Med 2022; 11:jcm11030649. [PMID: 35160099 PMCID: PMC8836727 DOI: 10.3390/jcm11030649] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting autosomal recessive multisystem disease. While its burden of morbidity and mortality is classically associated with pulmonary disease, CF also profoundly affects the gastrointestinal (GI) tract. Chronic low-grade inflammation and alterations to the gut microbiota are hallmarks of the CF intestine. The etiology of these manifestations is likely multifactorial, resulting from cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, a high-fat CF diet, and the use of antibiotics. There may also be a bidirectional pathophysiological link between intestinal inflammation and changes to the gut microbiome. Additionally, a growing body of evidence suggests that these GI manifestations may have significant clinical associations with growth and nutrition, quality of life, and respiratory function in CF. As such, the potential utility of GI therapies and long-term GI outcomes are areas of interest in CF. Further research involving microbial modulation and multi-omics techniques may reveal novel insights. This article provides an overview of the current evidence, pathophysiology, and future research and therapeutic considerations pertaining to intestinal inflammation and alterations in the gut microbiota in CF.
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Affiliation(s)
- Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
| | - Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
| | - Isabelle McKay
- Wagga Wagga Base Hospital, Wagga Wagga, NSW 2650, Australia;
| | - Michael Coffey
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, NSW 2031, Australia
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, NSW 2031, Australia
- Correspondence:
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van Dorst JM, Tam RY, Ooi CY. What Do We Know about the Microbiome in Cystic Fibrosis? Is There a Role for Probiotics and Prebiotics? Nutrients 2022; 14:nu14030480. [PMID: 35276841 PMCID: PMC8840103 DOI: 10.3390/nu14030480] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-shortening genetic disorder that affects the cystic fibrosis transmembrane conductance regulator (CFTR) protein. In the gastrointestinal (GI) tract, CFTR dysfunction results in low intestinal pH, thick and inspissated mucus, a lack of endogenous pancreatic enzymes, and reduced motility. These mechanisms, combined with antibiotic therapies, drive GI inflammation and significant alteration of the GI microbiota (dysbiosis). Dysbiosis and inflammation are key factors in systemic inflammation and GI complications including malignancy. The following review examines the potential for probiotic and prebiotic therapies to provide clinical benefits through modulation of the microbiome. Evidence from randomised control trials suggest probiotics are likely to improve GI inflammation and reduce the incidence of CF pulmonary exacerbations. However, the highly variable, low-quality data is a barrier to the implementation of probiotics into routine CF care. Epidemiological studies and clinical trials support the potential of dietary fibre and prebiotic supplements to beneficially modulate the microbiome in gastrointestinal conditions. To date, limited evidence is available on their safety and efficacy in CF. Variable responses to probiotics and prebiotics highlight the need for personalised approaches that consider an individual’s underlying microbiota, diet, and existing medications against the backdrop of the complex nutritional needs in CF.
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Affiliation(s)
- Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
- Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney 2031, Australia
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney 2031, Australia
- Correspondence:
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Talebi S, Day AS, Khadem Rezaiyan M, Ranjbar G, Zarei M, Safarian M, Kianifar HR. Fecal Calprotectin and Phenotype Severity in Patients with Cystic Fibrosis: A Systematic Review and Meta-Analysis. Pediatr Gastroenterol Hepatol Nutr 2022; 25:1-12. [PMID: 35087728 PMCID: PMC8762598 DOI: 10.5223/pghn.2022.25.1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/11/2021] [Indexed: 12/27/2022] Open
Abstract
Inflammation plays an important role in the outcome of patients with cystic fibrosis (CF). It may develop due to cystic fibrosis transmembrane conductance regulator protein dysfunction, pancreatic insufficiency, or prolonged pulmonary infection. Fecal calprotectin (FC) has been used as a noninvasive method to detect inflammation. Therefore, the aim of the current meta-analysis was to investigate the relationship between FC and phenotype severity in patients with CF. In this study, searches were conducted in PubMed, Science Direct, Scopus, and Embase databases up to August 2021 using terms such as "cystic fibrosis," "intestine," "calprotectin," and "inflammation." Only articles published in English and human studies were selected. The primary outcome was the level of FC in patients with CF. The secondary outcome was the relationship between FC and clinical severity. Statistical analysis was performed using Comprehensive Meta-Analysis software. Of the initial 303 references, only six articles met the inclusion criteria. The mean (95% confidence interval [CI]) level of FC was 256.5 mg/dL (114.1-398.9). FC levels were significantly associated with pancreatic insufficiency (mean, 243.02; 95% CI, 74.3 to 411.6; p=0.005; I2=0), pulmonary function (r=-0.39; 95% CI, -0.58 to -0.15; p=0.002; I2=60%), body mass index (r=-0.514; 95% CI, 0.26 to 0.69; p<0.001; I2=0%), and Pseudomonas colonization (mean, 174.77; 95% CI, 12.5 to 337.02; p=0.035; I2=71%). While FC is a reliable noninvasive marker for detecting gastrointestinal inflammation, it is also correlated with the severity of the disease in patients with CF.
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Affiliation(s)
- Saeedeh Talebi
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Andrew S Day
- Department of Pediatrics, University of Otago (Christchurch), Christchurch, New Zealand
| | - Majid Khadem Rezaiyan
- Department of Community Medicine, Clinical Research Development Unit of Akbar Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Golnaz Ranjbar
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mitra Zarei
- Department of Knowledge and Information Science, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahammad Safarian
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Reza Kianifar
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Gastrointestinal Factors Associated With Hospitalization in Infants With Cystic Fibrosis: Results From the Baby Observational and Nutrition Study. J Pediatr Gastroenterol Nutr 2021; 73:395-402. [PMID: 34016873 PMCID: PMC8780884 DOI: 10.1097/mpg.0000000000003173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To identify factors that increase the risk of gastrointestinal-related (GI-related) hospitalization of infants with cystic fibrosis (CF) during the first year of life. METHODS The Baby Observational and Nutrition Study was a longitudinal, observational cohort of 231 infants diagnosed with CF by newborn screening. We performed a post-hoc assessment of the frequency and indications for GI-related admissions during the first year of life. RESULTS Sixty-five participants had at least one admission in the first 12 months of life. High pancreatic enzyme replacement therapy (PERT) dosing (>2000 lipase units/kg per meal; hazard ratio [HR] = 14.75, P = 0.0005) and use of acid suppressive medications (HR = 4.94, P = 0.01) during the study period were positively associated with subsequent GI-related admissions. High levels of fecal calprotectin (fCP) (>200 μg/g) and higher relative abundance of fecal Klebsiella pneumoniae were also positively associated with subsequent GI-related admissions (HR = 2.64, P = 0.033 and HR = 4.49, P = 0.002, respectively). During the first 12 months of life, participants with any admission had lower weight-for-length z scores (WLZ) (P = 0.01). The impact of admission on WLZ was particularly evident in participants with a GI-related admission (P < 0.0001). CONCLUSIONS Factors associated with a higher risk for GI-related admission during the first 12 months include high PERT dosing, exposure to acid suppressive medications, higher fCP levels, and/or relative abundance of fecal K pneumoniae early in life. Infants with CF requiring GI-related hospitalization had lower WLZ at 12 months of age than those not admitted as well as those admitted for non-GI-related indications.
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The Intestinal Microbiome and Cystic Fibrosis Transmembrane Conductance Regulator Modulators: Emerging Themes in the Management of Gastrointestinal Manifestations of Cystic Fibrosis. Curr Gastroenterol Rep 2021; 23:17. [PMID: 34448955 DOI: 10.1007/s11894-021-00817-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW While commonly associated with pulmonary manifestations, cystic fibrosis (CF) is a systemic disease with wide-ranging effects on the gastrointestinal (GI) tract. This article reviews major recent updates in gastroenterological CF care and research. RECENT FINDINGS The high burden of GI symptoms in CF has led to recent studies assessing GI-specific symptom questionnaires and scoring systems. Intestinal dysbiosis potentially contributes to gastrointestinal symptoms in patients with CF and an increased risk of gastrointestinal cancers in CF. An increased incidence of colorectal cancer (CRC) has led to CF-specific CRC screening and surveillance recommendations. Pharmacologic therapies targeting specific cystic fibrosis transmembrane conductance regulator (CFTR) mutations have shown promise in treating GI manifestations of CF. New research has highlighted the importance of intestinal dysbiosis in CF. Future studies should assess whether CFTR modulators affect the gut microbiome and whether altering the gut microbiome will impact GI symptoms and GI cancer risk.
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18
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Westerink F, Huibregtse I, De Hoog M, Bruin S, Meesters E, Brandjes D, Gerdes V. Faecal Inflammatory Biomarkers and Gastrointestinal Symptoms after Bariatric Surgery: A Longitudinal Study. Inflamm Intest Dis 2021; 6:109-116. [PMID: 34124182 DOI: 10.1159/000514576] [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: 08/19/2020] [Accepted: 12/29/2020] [Indexed: 11/19/2022] Open
Abstract
Background Bariatric surgery induces various gastrointestinal (GI) modifications. We performed the first study longitudinally assessing the effect of bariatric surgery on faecal inflammatory biomarker levels and its relation with GI complaints. Method Faecal calprotectin, lactoferrin, and calgranulin-C levels were determined in 41 patients (34 Roux-en-Y [RYGB], 7 sleeves) before and at 6-16 weeks, 6 months, and 1 year after surgery. Changes in biomarker levels and percentage of patients above reference value were determined. Gastrointestinal symptom rating scale (GSRS) was used to assess GI complaints at corresponding time points. The postoperative relation between GSRS score and biomarker levels above reference value was investigated. Results After RYGB, median calprotectin levels are significantly higher (>188, 104-415 μg/g) than before surgery (40, 19-78 μg/g; p < 0.001), and over 90% of patients have levels above reference value 1 year after surgery. Median lactoferrin was 0.4 (0.2-1.6) μg/g before, and >5.9 (1.8-13.6) μg/g after surgery (p < 0.001). Median calgranulin-C levels remained far below the reference value and were 0.13 (0.05-0.24) μg/g before and <0.23 (0.06-0.33) μg/g after surgery. Similar results were found after sleeve gastrectomy. No difference was seen in GSRS score for patients with calprotectin and lactoferrin levels above reference values. Conclusion Faecal inflammatory biomarkers calprotectin and lactoferrin, but not calgranulin-C, rise above reference values shortly after bariatric surgery and remain elevated in the majority of patients. The discrepancy between calprotectin and calgranulin-C levels suggests no GI inflammation. Furthermore, patients after RYGB with biomarkers above the population reference value do not seem to have more GI complaints.
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Affiliation(s)
- Floris Westerink
- Department of internal medicine, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Inge Huibregtse
- Department of gastroenterology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - Sjoerd Bruin
- Department of surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Eelco Meesters
- Department of internal medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Desiderius Brandjes
- Department of internal medicine, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Victor Gerdes
- Department of internal medicine, Amsterdam University Medical Centre, Amsterdam, The Netherlands.,Department of internal medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
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The Use of Fecal Calprotectin Testing in Paediatric Disorders: A Position Paper of the European Society for Paediatric Gastroenterology and Nutrition Gastroenterology Committee. J Pediatr Gastroenterol Nutr 2021; 72:617-640. [PMID: 33716293 DOI: 10.1097/mpg.0000000000003046] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the study was to review the evidence regarding the clinical use and value of fecal calprotectin (FC) measurements in different gastrointestinal disorders in children. METHODS A literature search was conducted in the PubMed, MEDLINE, EMBASE, and Cochrane databases until October 31, 2019. Subtopics were identified and each assigned to individual authors. RESULTS A total of 28 recommendations were voted on using the nominal voting technique. Recommendations are given related to sampling, measurement methods, and results interpretation. The 14 authors anonymously voted on each recommendation using a 9-point scale (1 strongly disagree to 9 fully agree). Consensus was considered achieved if at least 75% of the authors voted 6, 7, 8, or 9. CONCLUSIONS Consensus was reached for all recommendations. Limitations for the use of FC in clinical practice include variability in extraction methodology, performance of test kits as well as the need to establish local reference ranges because of the influence of individual factors, such as age, diet, microbiota, and drugs. The main utility of FC measurement at present is in the diagnosis and monitoring of inflammatory bowel disease (IBD) as well as to differentiate it from functional gastrointestinal disorders (FAPDs). FC, however, has neither utility in the diagnosis of infantile colic nor to differentiate between functional and organic constipation. A rise in FC concentration, may alert to the risk of developing necrotizing enterocolitis and help identifying gastrointestinal involvement in children with Henoch-Schönlein purpura. FC measurement is of little value in Cow's Milk Protein Allergy, coeliac disease (CD), and cystic fibrosis. FC does neither help to distinguish bacterial from viral acute gastroenteritis (AGE), nor to diagnose Helicobacter Pylori infection, small intestinal bacterial overgrowth (SIBO), acute appendicitis (AA), or intestinal polyps.
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Beaufils F, Mas E, Mittaine M, Addra M, Fayon M, Delhaes L, Clouzeau H, Galode F, Lamireau T, Bui S, Enaud R. Increased Fecal Calprotectin Is Associated with Worse Gastrointestinal Symptoms and Quality of Life Scores in Children with Cystic Fibrosis. J Clin Med 2020; 9:jcm9124080. [PMID: 33348735 PMCID: PMC7766355 DOI: 10.3390/jcm9124080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 02/06/2023] Open
Abstract
In cystic fibrosis (CF), cystic fibrosis transmembrane regulator (CFTR) dysfunction leads to digestive disorders that promote intestinal inflammation and dysbiosis enhancing gastrointestinal symptoms. In pancreatic insufficiency CF patients, both intestinal inflammation and dysbiosis, are associated with an increase in the fecal calprotectin (FC) level. However, associations between the FC level, gastrointestinal symptoms, and quality of life (QoL) remain poorly studied. We aimed to assess such associations in pancreatic insufficiency CF children. The FC level was measured in pancreatic insufficiency CF children’s stool samples. Children and their parents completed two questionnaires: The Gastrointestinal Symptoms Scales 3.0-PedsQLTM and the Quality of Life Pediatric Inventory 4.0-PedsQLTM. Lower scores indicated worse symptomatology or QoL. Thirty-seven CF children were included. A FC level above 250 µg/g was associated with worse gastrointestinal symptoms and QoL scores. The FC level was inversely correlated with several gastrointestinal scores assessed by children (i.e., Total, “Heart Burn Reflux”, “Nausea and Vomiting”, and “Gas and Bloating”). Several QoL scores were correlated with gastrointestinal scores. The FC level was weakly associated with clinical parameters. Some gastrointestinal and QoL scores were related to disease severity associated parameters. In CF, the FC level, biomarker previously related to intestinal inflammation and dysbiosis, was associated with worse digestive symptoms and QoL scores.
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Affiliation(s)
- Fabien Beaufils
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-5-56-79-98-24
| | - Emmanuel Mas
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
- INSERM, INRA, ENVT, Université de Toulouse, UPS, F-31000 Toulouse, France
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, F-31300 Toulouse, France
| | - Marie Mittaine
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
| | - Martin Addra
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
| | - Michael Fayon
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Laurence Delhaes
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
- CHU Bordeaux, Service de Parasitologie-Mycologie, F-33000 Bordeaux, France
| | - Haude Clouzeau
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - François Galode
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Thierry Lamireau
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Stéphanie Bui
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Raphaël Enaud
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
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Reduced Intestinal Inflammation With Lumacaftor/Ivacaftor in Adolescents With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2020; 71:778-781. [PMID: 32740537 DOI: 10.1097/mpg.0000000000002864] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A chronic intestinal inflammation may occur in patients with cystic fibrosis (CF), while no therapeutic management is proposed. Although Lumacaftor/Ivacaftor is well-known to modulate the defective cystic fibrosis transmembrane conductance regulator (CFTR) protein in lungs, no data are available on the impact of this treatment on CF intestinal disorders. We, therefore, investigated the evolution of intestinal inflammation after initiation of Lumacaftor/Ivacaftor in CF adolescents (median of follow-up: 336 days [IQR: 278;435]). Median fecal calprotectin concentrations decreased significantly after Lumacaftor/Ivacaftor initiation (102 μg/g [IQR: 69-210]) compared with the baseline (713 μg/g (IQR:148-852), P = 0.001). To our knowledge, this study showed for the first time that CF-related intestinal inflammation is improved by Lumacaftor/Ivacaftor treatment.
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22
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CisarÒ F, Pizzol A, Rigazio C, Calvo PL. Fecal calprotectin in the pediatric population: a 2020 update. Minerva Pediatr 2020; 72:514-522. [PMID: 32731735 DOI: 10.23736/s0026-4946.20.06002-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Calprotectin is a calcium and zinc-binding protein, formed by a hetero complex of S100A8 and S100A9 proteins, which belong to the S-100 protein family consisting in more than 20 different proteins with a tissue-specific expression pattern. This protein is secreted extracellularly from stimulated neutrophils or released by cell disruption or death. The presence of calprotectin in feces quantitatively relates to neutrophil migration toward the gastrointestinal (GI) tract; thus, it represents a useful marker of intestinal inflammation. Fecal calprotectin (FC) has been proven largely useful for determining the inflammatory origin of GI symptoms differentiating between organic and non-organic diseases. Indeed, increased FC levels are also seen in gastroenteritis, microscopic colitis, polyps, malignancies and cystic fibrosis. To date, there are many evidences regarding usefulness in the detection of fecal calprotectin for the management of gastrointestinal disorders, both in children and adults but, especially in the pediatric population, still clear indications for its use are lacking. Its incorporation in primary care reduces the risk of missing an organic disease and facilitates the indication for expensive and invasive investigations as colonoscopy. We herein review and discuss the last evidence on the usefulness of FC in children, with its current indications and future prospective.
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Affiliation(s)
- Fabio CisarÒ
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy -
| | - Antonio Pizzol
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Caterina Rigazio
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
| | - Pier L Calvo
- Unit of Pediatric Gastroenterology, Department of Pediatrics, Città della Salute e della Scienza, Turin, Italy
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23
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Enaud R, Hooks KB, Barre A, Barnetche T, Hubert C, Massot M, Bazin T, Clouzeau H, Bui S, Fayon M, Berger P, Lehours P, Bébéar C, Nikolski M, Lamireau T, Delhaes L, Schaeverbeke T. Intestinal Inflammation in Children with Cystic Fibrosis Is Associated with Crohn's-Like Microbiota Disturbances. J Clin Med 2019; 8:jcm8050645. [PMID: 31083321 PMCID: PMC6572243 DOI: 10.3390/jcm8050645] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 02/07/2023] Open
Abstract
Cystic fibrosis (CF) is a systemic genetic disease that leads to pulmonary and digestive disorders. In the majority of CF patients, the intestine is the site of chronic inflammation and microbiota disturbances. The link between gut inflammation and microbiota dysbiosis is still poorly understood. The main objective of this study was to assess gut microbiota composition in CF children depending on their intestinal inflammation. We collected fecal samples from 20 children with CF. Fecal calprotectin levels were measured and fecal microbiota was analyzed by 16S rRNA sequencing. We observed intestinal inflammation was associated with microbiota disturbances characterized mainly by increased abundances of Staphylococcus, Streptococcus, and Veillonella dispar, along with decreased abundances of Bacteroides, Bifidobacterium adolescentis, and Faecalibacterium prausnitzii. Those changes exhibited similarities with that of Crohn's disease (CD), as evidenced by the elevated CD Microbial-Dysbiosis index that we applied for the first time in CF. Furthermore, the significant over-representation of Streptococcus in children with intestinal inflammation appears to be specific to CF and raises the issue of gut-lung axis involvement. Taken together, our results provide new arguments to link gut microbiota and intestinal inflammation in CF and suggest the key role of the gut-lung axis in the CF evolution.
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Affiliation(s)
- Raphaël Enaud
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France.
- CRCM Pédiatrique, CHU Bordeaux, CIC 1401, F-33000 Bordeaux, France.
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
| | - Katarzyna B Hooks
- Bordeaux Bioinformatics Center, University Bordeaux, F-33000 Bordeaux, France.
- Laboratoire Bordelais de Recherche en Informatique, CNRS, University Bordeaux, UMR 5800, F-33400 Talence, France.
| | - Aurélien Barre
- Bordeaux Bioinformatics Center, University Bordeaux, F-33000 Bordeaux, France.
- Laboratoire Bordelais de Recherche en Informatique, CNRS, University Bordeaux, UMR 5800, F-33400 Talence, France.
| | - Thomas Barnetche
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
- Service de Rhumatologie, CHU Bordeaux, F-33000 Bordeaux, France.
| | - Christophe Hubert
- INSERM, MRGM, University Bordeaux, U1211, F-33000 Bordeaux, France.
- PGTB, University Bordeaux, F-33000 Bordeaux, France.
| | - Marie Massot
- BIOGECO, INRA, University Bordeaux, F-33610 Cestas, France.
| | - Thomas Bazin
- INRA-Bordeaux Aquitaine Centre, University Bordeaux, USC EA 3671, Infections Humaines à Mycoplasmes et à Chlamydiae, CHU Bordeaux, F-33000 Bordeaux, France.
| | - Haude Clouzeau
- CRCM Pédiatrique, CHU Bordeaux, CIC 1401, F-33000 Bordeaux, France.
| | - Stéphanie Bui
- CRCM Pédiatrique, CHU Bordeaux, CIC 1401, F-33000 Bordeaux, France.
| | - Michael Fayon
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France.
- CRCM Pédiatrique, CHU Bordeaux, CIC 1401, F-33000 Bordeaux, France.
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
| | - Patrick Berger
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France.
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
| | - Philippe Lehours
- BaRITOn, INSERM, University Bordeaux, UMR1053, CHU Bordeaux, F-33000 Bordeaux, France.
| | - Cécile Bébéar
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
- INRA-Bordeaux Aquitaine Centre, University Bordeaux, USC EA 3671, Infections Humaines à Mycoplasmes et à Chlamydiae, CHU Bordeaux, F-33000 Bordeaux, France.
| | - Macha Nikolski
- Bordeaux Bioinformatics Center, University Bordeaux, F-33000 Bordeaux, France.
- Laboratoire Bordelais de Recherche en Informatique, CNRS, University Bordeaux, UMR 5800, F-33400 Talence, France.
| | - Thierry Lamireau
- CRCM Pédiatrique, CHU Bordeaux, CIC 1401, F-33000 Bordeaux, France.
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
| | - Laurence Delhaes
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France.
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
| | - Thierry Schaeverbeke
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France.
- Service de Rhumatologie, CHU Bordeaux, F-33000 Bordeaux, France.
- INRA-Bordeaux Aquitaine Centre, University Bordeaux, USC EA 3671, Infections Humaines à Mycoplasmes et à Chlamydiae, CHU Bordeaux, F-33000 Bordeaux, France.
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24
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Abstract
Calprotectin is a 36kDa member of the S100 family of proteins. It is derived predominantly from neutrophils and has direct antimicrobial effects and a role within the innate immune response. Calprotectin is found in various body fluids in proportion to the degree of any existing inflammation and its concentration in feces is about six times that of plasma. Measurement of fecal calprotectin is a useful surrogate marker of gastrointestinal inflammation. It has a high negative predictive value in ruling out inflammatory bowel disease (IBD) in undiagnosed, symptomatic patients and a high sensitivity for diagnosing the disease making it useful as a tool for prioritising endoscopy. In patients with known IBD, fecal calprotectin can be a useful tool to assist management, providing evidence of relapse or mucosal healing to enable therapy to be intensified or reduced. There are a number of commercial calprotectin assays with marked difference in performance as judged by external quality assessment and at present no standardised reference material exists. Various factors may affect results including age, medication and day to day variation. Laboratories should therefore be mindful of the characteristics of their own assay and factors that may affect results.
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Affiliation(s)
- Ruth M Ayling
- FRCPath Consultant Chemical Pathologist, Clinical Biochemistry, Pathology and Pharmacy Building, Royal London Hospital, London, United Kingdom
| | - Klaartje Kok
- MRCP Consultant Gastroenterologist, Barts Health NHS Trust, London, United Kingdom
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25
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Garg M, Leach ST, Day AS, Ooi CY. Fecal calprotectin concentrations in young children with cystic fibrosis: Authors response. J Cyst Fibros 2017; 17:e10-e11. [PMID: 29128316 DOI: 10.1016/j.jcf.2017.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/16/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Millie Garg
- School of Women's and Children's Health, Medicine, The University of New South Wales, High Street, Randwick 2031, New South Wales, Australia.
| | - Steven T Leach
- School of Women's and Children's Health, Medicine, The University of New South Wales, High Street, Randwick 2031, New South Wales, Australia
| | - Andrew S Day
- Department of Pediatrics, University of Otago, Riccarton Ave, Christchurch 8011, Canterbury, New Zealand
| | - Chee Y Ooi
- School of Women's and Children's Health, Medicine, The University of New South Wales, High Street, Randwick 2031, New South Wales, Australia; miCF Research Centre and Department of Gastroenterology, Sydney Children's Hospital, High Street, Randwick 2031, New South Wales, Australia.
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26
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Ellemunter H, Schüller K, Steinkamp G. Faecal calprotectin concentrations in young children with cystic fibrosis. J Cyst Fibros 2017; 17:e8-e9. [PMID: 29107599 DOI: 10.1016/j.jcf.2017.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Helmut Ellemunter
- Cystic Fibrosis (CF) Centre at the Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria.
| | | | - Gratiana Steinkamp
- Cystic Fibrosis (CF) Centre at the Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria; Clinical Research and Medical Scientific Writing, Schwerin, Germany
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