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Oates GR, Schechter MS. Aiming to Improve Equity in Pulmonary Health: Cystic Fibrosis. Clin Chest Med 2023; 44:555-573. [PMID: 37517835 PMCID: PMC10458995 DOI: 10.1016/j.ccm.2023.03.011] [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: 08/01/2023]
Abstract
This review summarizes the evidence of health disparities in cystic fibrosis (CF), an autosomal recessive genetic disorder with substantial variation in disease progression and outcomes. We review disparities by race, ethnicity, socioeconomic status, geographic location, gender identity, or sexual orientation documented in the literature. We outline the mechanisms that generate and perpetuate such disparities across levels and domains of influence and assess the implications of this evidence. We then recommend strategies for improving equity in CF outcomes, drawing on recommendations for the general population and considering approaches specific to people living with CF.
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Affiliation(s)
- Gabriela R Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University and Children's Hospital of Richmond at VCU, Richmond, VA, USA
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Abbott J, Hurley MA, Chadwick H, Peckham D. Ways of coping and survival in Cystic Fibrosis: a 20-year longitudinal study. J Cyst Fibros 2023; 22:112-118. [PMID: 35461783 DOI: 10.1016/j.jcf.2022.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/14/2022] [Accepted: 04/11/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The relationship between ways of coping and health outcomes has been a focus of interest for decades. There is increasing recognition that positive psychological functioning can influence health outcomes beneficially. This work investigated the role of coping in predicting survival in CF. METHODS A longitudinal observational cohort study with a 20-year follow-up period was undertaken. At entry to the study, demographic and clinical variables were recorded, and ways of coping were assessed using the Cystic Fibrosis Coping Scale which measures four distinct ways of coping: optimism, hopefulness, distraction and avoidance. Survival outcome was measured as time in days from the date of recruitment to exit from the study, where exit was either death, loss to follow-up or the end of the follow-up period. RESULTS Survival time was modelled using Cox's proportional hazards model. At baseline, 116 people with CF were recruited. By the census date, 54 people had died (14 men had died during 248,565 person-days of observation and 40 women had died during 358,372 person-days of observation). Optimism was the only way of coping that showed any beneficial effect on survival (RR=0.984, p=0.040) after adjustments for age, gender, ppFEV1 and the three other coping variables measured at baseline. CONCLUSION This work suggests that optimistic coping serves as a prognostic measure of survival in CF beyond key clinical and demographic variables. Ways of coping are modifiable, providing a target for clinical intervention; to improve quality of life and clinical outcomes and potentially increase longevity.
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Affiliation(s)
- Janice Abbott
- School of Psychology, University of Central Lancashire, Preston, PR1 2HE, UK.
| | - Margaret A Hurley
- Faculty of Health, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Helen Chadwick
- Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, United Kingdom; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, LS2 9JT, UK
| | - Daniel Peckham
- Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, United Kingdom; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, LS2 9JT, UK
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Oates GR, Schechter MS. Socioeconomic determinants of respiratory health in patients with cystic fibrosis: implications for treatment strategies. Expert Rev Respir Med 2022; 16:637-650. [PMID: 35705523 DOI: 10.1080/17476348.2022.2090928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Great variation exists in the progression and outcomes of cystic fibrosis (CF) lung disease, due to both genetic and environmental influences. Social determinants mediate environmental exposures and treatment success; people with CF from socioeconomically disadvantaged backgrounds have worse health and die younger than those in more advantaged positions. AREAS COVERED This paper reviews the literature on the mechanisms that are responsible for generating and sustaining disparities in CF health, and the ways by which social determinants translate into health advantages or disadvantages in people with CF. The authors make recommendations for addressing social risk factors in CF clinical practice. EXPERT OPINION Socioeconomic factors are not dichotomous and their impact is felt at every step of the social ladder. CF care programs need to adopt a systematic protocol to screen for health-related social risk factors, and then connect patients to available resources to meet individual needs. Considerations such as daycare, schooling options, living and working conditions, and opportunities for physical exercise and recreation as well as promotion of self-efficacy are often overlooked. In addition, advocacy for changes in public policies on health insurance, environmental regulations, social welfare, and education would all help address the root causes of CF health inequities.
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Affiliation(s)
- Gabriela R Oates
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University and Children's Hospital of Richmond at VCU, USA
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Dongarwar D, Garcia BY, Miller K, Salihu HM. Assessment of hospitalization rates, factors associated with hospitalization and in-patient mortality in pediatric patients with cystic fibrosis. J Natl Med Assoc 2021; 113:683-692. [PMID: 34479733 DOI: 10.1016/j.jnma.2021.08.038] [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: 04/26/2021] [Revised: 07/08/2021] [Accepted: 08/09/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF), an inherited autosomal recessive disease that results in the accumulation of mucus and damage primarily to the respiratory and digestive tracts is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. In the United States, it has been estimated that CF occurs in 1 out of 3500 infants. The objective of this study was to explore the patient and hospital characteristics associated with CF hospitalizations and inpatient mortality in pediatric CF patients. METHODS Utilizing the National Inpatient Sample database from 2008 to 2017, a retrospective cohort study was conducted to analyze the hospitalization rates, associated factors, and the inpatient mortality of CF patients 0-17 years of age. Hospitalizations with a diagnosis of CF were identified with ICD-9-CM and ICD-10-CM codes. Adjusted survey logistic regression models were utilized to determine factors associated with CF hospitalizations and in-hospital deaths in CF patients. RESULTS There were a total of 98,660 (about 0.2%) CF hospitalizations in patients 17 years of age or younger during the study period. Non-Hispanic (NH) White CF patients had the highest prevalence of CF (26.30 per 10,000 hospitalizations). The prevalence of inpatient deaths were highest among those identified as NH-Others and NH-Blacks (71.35 and 68.83 per 10,000 CF hospitalizations, respectively. When compared with NH-White category, those belonging to NH-Black, Hispanic and Other racial/ethnic sub-group had reduced odds of being hospitalized with CF. DISCUSSION Despite our finding of an increased likelihood of being hospitalized for CF among NH-White and male pediatric patients, no association between race or sex and CF inpatient death was observed when adjusted for covariates. More research is needed to determine the impact of sex and race on CF mortality rates.
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Affiliation(s)
- Deepa Dongarwar
- Center of Excellence and Health Equity, Training and Research Scholar Program, Baylor College of Medicine, 3701 Kirby Drive, Houston, TX 77098, USA.
| | - Brisa Y Garcia
- Center of Excellence and Health Equity, Training and Research Scholar Program, Baylor College of Medicine, 3701 Kirby Drive, Houston, TX 77098, USA
| | - Kristen Miller
- Department of Pediatrics, Pulmonology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Hamisu M Salihu
- Center of Excellence and Health Equity, Training and Research Scholar Program, Baylor College of Medicine, 3701 Kirby Drive, Houston, TX 77098, USA; Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
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Bustamante AE, Fernández LT, Rivas LC, Mercado-Longoria R. Disparities in cystic fibrosis survival in Mexico: Impact of socioeconomic status. Pediatr Pulmonol 2021; 56:1566-1572. [PMID: 33656284 DOI: 10.1002/ppul.25351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/10/2021] [Accepted: 02/27/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Median survival age in cystic fibrosis (CF) has increased in developed countries. Scarce literature exists about survival in Latin America, especially in Mexico. The aim of our study was to assess the median age of survival in CF patients and the impact of risk factors in Mexico over a 20-year period. METHODS We conducted a retrospective study with all patients registered and followed in the CF Center in Monterrey, Mexico from 2000 to 2020. Median survival age was the primary outcome, assessed with Kaplan-Meier analysis. The influence of clinical, biological, and demographic factors on survival was analyzed with Cox regression model. RESULTS Two-hundred five patients were included. Median survival for the cohort was 21.37 years (95% confidence interval [CI], 17.20-25.55). In the multivariate Cox regression model, low socioeconomic status (hazard ratio [HR], 4.21; 95% CI, 2.43-7.27), chronic Pseudomonas aeruginosa infection at 6 years (HR, 10.45; 95% CI, 5.66-19.28), and pancreatic insufficiency (HR, 3.13; 1.38-7.13) were independent risk factors for mortality. CONCLUSION Median survival in Mexican patients with CF is lower than in high-income countries, and socioeconomic status plays a conspicuous role in the disparity. To increase patient survival for those residing in low-middle income countries, public health authorities must design policies that fully cover diagnosis and treatment strategies for the CF population.
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Affiliation(s)
- Adriana E Bustamante
- Pneumology Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
| | - Lucía T Fernández
- Internal Medicine Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
| | - Lissette C Rivas
- Pneumology Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
| | - Roberto Mercado-Longoria
- Pneumology Department, Hospital Universitario Dr. José E. González, Monterrey, Nuevo León, México
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Abstract
BACKGROUND Male sex is associated with better lung function and survival in people with cystic fibrosis but it is unclear whether the survival benefit is solely due to the sex-effect on lung function. METHODS This study analyzes data between 1996 and 2015 from the longitudinal registry study of the UK Cystic Fibrosis Registry. We jointly analyze repeated measurements and time-to-event outcomes to assess how much of the sex effect on lung function also explains survival. These novel methods allow examination of association between percent of forced expiratory volume in 1 second (%FEV1) and covariates such as sex and genotype, and survival, in the same modeling framework. We estimate the probability of surviving one more year with a probit model. RESULTS The dataset includes 81,129 lung function measurements of %FEV1 on 9,741 patients seen between 1996 and 2015 and captures 1,543 deaths. Males compared with females experienced a more gradual decline in %FEV1 (difference 0.11 per year 95% confidence interval [CI] = 0.08, 0.14). After adjusting for confounders, both overall level of %FEV1 and %FEV1 rate of change are associated with the concurrent hazard for death. There was evidence of a male survival advantage (probit coefficient 0.15; 95% CI = 0.10, 0.19) which changed little after adjustment for %FEV1 using conventional approaches but was attenuated by 37% on adjustment for %FEV1 level and slope in the joint model (0.09; 95% CI = 0.06, 0.12). CONCLUSIONS We estimate that about 37% of the association of sex on survival in cystic fibrosis is mediated through lung function.
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Triage for Malnutrition Risk among Pediatric and Adolescent Outpatients with Cystic Fibrosis, Using a Disease-Specific Tool. CHILDREN 2020; 7:children7120269. [PMID: 33291524 PMCID: PMC7761802 DOI: 10.3390/children7120269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 01/01/2023]
Abstract
Malnutrition prevails in considerable proportions of children with Cystic Fibrosis (CF), and is often associated with adverse outcomes. For this, routine screening for malnutrition is pivotal. In the present cross-sectional study, we aimed to assess the risk for malnutrition in pediatric outpatients with CF. A total of 76 outpatients (44 girls, 11.9 ± 3.9 years old, 39.5% adolescents) were recruited and anthropometric, clinical, dietary and respiratory measures were collected. All outpatients were screened for malnutrition risk with a validated disease-specific instrument. Most children exhibited a low risk for malnutrition (78.9%), whereas none of the participants were characterized as having a high malnutrition risk. In the total sample, malnutrition risk was positively associated with age (r = 0.369, p = 0.001), and inversely related to the body mass index (r = −0.684, p < 0.001), height z-score (r = −0.264, p = 0.021), and forced expiratory volume (FEV1%, r = −0.616, p < 0.001). Those classified as having a low malnutrition risk were younger (p = 0.004), heavier (p < 0.001) and taller (p = 0.009) than their counterparts with a moderate risk. On the other hand, patients in the moderate risk group were more likely pubertal (p = 0.034), with a reduced mid-upper arm fat area (p = 0.011), and worse pulmonary function (p < 0.001). Interestingly, none of the children attaining ideal body weight were classified as having a moderate malnutrition. risk, whereas 37.5% of the patients allocated at the moderate risk group exhibited physiological lung function. In this cohort of outpatients with CF that were predominantly well-nourished and attained physiological lung function, malnutrition risk was identified only in small proportions of the sample. Our data support that patients that are older, pubertal, or have diminished fat mass are at greater risk for malnutrition.
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Managing Cystic Fibrosis in Polish Healthcare. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207630. [PMID: 33092012 PMCID: PMC7589707 DOI: 10.3390/ijerph17207630] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/05/2020] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
The quality and length of life of patients with cystic fibrosis (CF) are determined by a number of factors including the quality of healthcare received by patients, as well as access to drug programs dedicated to this particular disease. The purpose of this paper is to present an overview of changes in the average life expectancy and mortality rate of the CF population in Poland between 2000 and 2018. Furthermore, we would like to evaluate access to healthcare services, including the drug program, guaranteed by public healthcare system, and funded by National Health Fund (NHF). The average life expectancy of patients with CF increased in the period in question from ca. 14.5 ± 7.6–24.5 ± 8.9 years (mean ± SD, p = 0.0001). We have observed a drop in the number of deaths in paediatric age during that period. Despite the increase in life expectancy, the use of health resources in patients with CF, especially the drug program, is dramatically low. Considering the fact that in Poland there was no active countrywide CF registry, now it is possible to estimate the frequency of use of CF healthcare services in various provinces exclusively on the basis of database maintained by the Polish NHF.
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Somayaji R, Nichols DP, Bell SC. Cystic fibrosis - Ten promising therapeutic approaches in the current era of care. Expert Opin Investig Drugs 2020; 29:1107-1124. [PMID: 32744089 DOI: 10.1080/13543784.2020.1805733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease affecting multiple organ systems. Research and innovations in novel therapeutic agents and health care delivery have resulted in dramatic improvements in quality of life and survival for people with CF. Despite this, significant disease burden persists for many and this is compounded by disparities in treatment access and care which globally necessitates further work to improve outcomes. Because of the advent of numerous therapies which include gene-targeted modulators in parallel with specialized care delivery models, innovative efforts continue. AREAS COVERED In this review, we discuss the available data on investigational agents in clinical development and currently available treatments for CF. We also evaluate approaches to care delivery, consider treatment gaps, and propose future directions for advancement. EXPERT OPINION Since the discovery of the CF gene, CFTR modulators have provided a hallmark of success, even though it was thought not previously possible. This has led to reinvigorated efforts and innovations in treatment approaches and care delivery. Numerous challenges remain because of genetic and phenotypic heterogeneity, access issues, and therapeutic costs, but the collaborative approach between stakeholders for continued innovation fuels optimism. Abbreviations: CF cystic fibrosis; CFF Cystic Fibrosis Foundation (USA); CFTR cystic fibrosis transmembrane regulator; CRISPR clustered regularly interspaced short palindromic repeats; COX cyclo oxygenase; FDA US Food and Drug Administration; FEV1% forced expiratory volume in one second % predicted; F508del deletion of phenylalanine (F) in the 508th position (most common mutation); G551D substitution of the amino acid glycine by aspartate at position 551 in the nucleotide binding domain-1 of the CFTR gene; LMIC low- and middle-income country; LTB4 leukotriene B4; MDT multi-disciplinary care team; NO nitric oxide; NSAIDs non-steroidal anti-inflammatory drugs; SLPI secretory leukocyte protease inhibitor.
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Affiliation(s)
- Ranjani Somayaji
- Departments of Medicine; Microbiology, Immunology & Infectious Disease; Community Health Sciences, University of Calgary , Calgary, AB, Canada.,Snyder Institute for Chronic Diseases , Calgary, AB, Canada.,O'Brien Institute for Public Health , Calgary, AB, Canada
| | - Dave P Nichols
- Department of Pediatrics, Seattle Children's Hospital , Seattle, WA, USA.,Department of Pediatrics, University of Washington , Seattle, WA, USA.,Seattle Children's Research Institute , Seattle, WA, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital , Brisbane, QLD, Australia.,Children's Health Research Centre, Faculty of Medicine, The University of Queensland , Brisbane, QLD, Australia.,Translational Research Institute , Brisbane, QLD, Australia
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Tobacco smoke exposure and socioeconomic factors are independent predictors of pulmonary decline in pediatric cystic fibrosis. J Cyst Fibros 2020; 19:783-790. [PMID: 32081643 DOI: 10.1016/j.jcf.2020.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/07/2020] [Accepted: 02/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary decline in CF is heterogeneous, with socio-environmental factors contributing to this variability. Few studies have attempted to disentangle the effects of tobacco smoke exposure and socioeconomic factors on lung function deterioration in pediatric CF. The current study evaluates their contributions longitudinally across the entire U.S. CF care network population. METHODS Data from the CF Foundation Patient Registry were obtained on all individuals who at the end of 2016 were 6-18 years old. Lung function measures (ppFEV1) for each person were calculated at each attained age. Multivariable analyses used mixed modeling to assess the impact of smoke exposure and socioeconomic factors on initial lung function and change over time. RESULTS The sample included 10,895 individuals contributing 65,581 person years. At age 6, ppFEV1 of smoke-exposed children was 4.7% lower than among unexposed. The deficit persisted through age 18. In adjusted mixed models, smoke exposure and socioeconomic factors had independent, additive associations with lung function. Median ppFEV1 declined 2.4% with smoke exposure, 4.9% with lower paternal education, 0.3% with public insurance, and increased 0.2% with each $10,000 annual household income. The effect of smoke exposure on ppFEV1 was larger in disadvantaged children compared to privileged counterparts (3.2% vs 1.2%). CONCLUSIONS Smoke exposure and socioeconomic factors are independent risk factors for decreased ppFEV1 in pediatric CF. Smoking cessation strategies should be emphasized at the time of CF diagnosis and reiterated during infancy and early childhood. Interventions may be prioritized in disadvantaged families, where the exposure has a disproportionately large effect.
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11
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Health Disparities. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_3] [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: 10/24/2022]
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Schlüter DK, Southern KW, Dryden C, Diggle P, Taylor-Robinson D. Impact of newborn screening on outcomes and social inequalities in cystic fibrosis: a UK CF registry-based study. Thorax 2019; 75:123-131. [PMID: 31771956 PMCID: PMC7029232 DOI: 10.1136/thoraxjnl-2019-213179] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 10/07/2019] [Accepted: 10/31/2019] [Indexed: 12/30/2022]
Abstract
Background Newborn bloodspot screening (NBS) for cystic fibrosis (CF) was introduced across the UK in 2007 but the impact on clinical outcomes and health inequalities for children with CF is unclear. Methods We undertook longitudinal analyses of UK CF registry data on over 3000 children with CF born between 2000 and 2015. Clinical outcomes were the trajectories of percent predicted forced expiratory volume in one second (%FEV1) from age 5, weight for age and body mass index (BMI) SD-scores from age one, and time to chronic Pseudomonas aeruginosa (cPA) infection. Using mixed effects and time-to-event models we assessed the association of NBS with outcomes and potential interactions with childhood socioeconomic conditions, while adjusting for confounders. Results NBS was associated with higher average lung function trajectory (+1.56 FEV1 percentage points 95% CI 0.1 to 3.02, n=2216), delayed onset of cPA, and higher average weight trajectory intercept at age one (+0.16 SD; 95% CI 0.07 to 0.26, n=3267) but negative rate of weight change thereafter (−0.02 SD per year; 95% CI −0.03 to −0.00). We found no significant association of NBS with BMI or rate of change of lung function. There was no clear evidence of an impact of NBS on health inequalities early in life. Conclusions Children diagnosed with CF by NBS in the UK have better lung function and increased early weight but NBS does not appear to have narrowed early health inequalities.
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Affiliation(s)
- Daniela K Schlüter
- Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Carol Dryden
- Department of Paediatrics, Wishaw General Hospital, Wishaw, UK
| | - Peter Diggle
- Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
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McGarry ME, Williams WA, McColley SA. The demographics of adverse outcomes in cystic fibrosis. Pediatr Pulmonol 2019; 54 Suppl 3:S74-S83. [PMID: 31715087 PMCID: PMC6857719 DOI: 10.1002/ppul.24434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/16/2019] [Indexed: 01/08/2023]
Abstract
Understanding variability in cystic fibrosis (CF) health outcomes requires an understanding of factors that go far beyond Cystic Fibrosis Transmembrane Receptor (CFTR) function caused by different gene mutations. Social and environmental factors that influence health have a significant influence on the trajectory of health in CF and in other chronic diseases. In this article, we review demographic factors associated with poorer health outcomes in CF, known and postulated biological mechanisms of these outcomes, and interventions that healthcare teams can implement that may reduce outcome disparities.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Wadsworth A Williams
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois
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Denford S, Mackintosh KA, McNarry MA, Barker AR, Williams CA. Enhancing intrinsic motivation for physical activity among adolescents with cystic fibrosis: a qualitative study of the views of healthcare professionals. BMJ Open 2019; 9:e028996. [PMID: 31201192 PMCID: PMC6575634 DOI: 10.1136/bmjopen-2019-028996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the views of healthcare professionals from cystic fibrosis (CF) multidisciplinary teams (MDT) on physical activity for adolescents with CF, the specific strategies used for physical activity promotion and associated challenges. DESIGN In this exploratory study, in-depth qualitative interviews were conducted with 15 healthcare professionals from CF MDTs to explore their views surrounding physical activity promotion for adolescents with CF. PARTICIPANTS Eleven physiotherapists (nine female), two consultants (both male) and two dieticians (both female) provided written informed consent and participated in the study. SETTING CF clinics in the UK. RESULTS While healthcare professionals highlighted the importance of physical activity in the management of CF, they noted that very few patients were motivated solely by (CF or general) health reasons. Healthcare professionals discussed the need for physical activity to be an enjoyable and routine part of their life, undertaken with significant others, outside the clinic whenever possible. Adopted approaches for physical activity promotion focused on providing individualised recommendations that suit the patients' individual needs and goals and enhance intrinsic motivation for physical activity. CONCLUSION Our research offers valuable information for those seeking to develop interventions to promote physical activity among adolescents with CF. Specifically, intervention developers should focus on developing individualised interventions that focus on enhancing intrinsic motivation and support the integration of physical activity into everyday life.
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Affiliation(s)
- Sarah Denford
- Children's Health & Exercise Research Centre, Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Kelly A Mackintosh
- Applied Sports Science, Technology, Exercise and Medicine Research Centre, College of Engineering, Swansea University, Swansea, UK
| | - Melitta A McNarry
- Applied Sports Science, Technology, Exercise and Medicine Research Centre, College of Engineering, Swansea University, Swansea, UK
| | - Alan R Barker
- Children's Health & Exercise Research Centre, Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Craig Anthony Williams
- Children's Health & Exercise Research Centre, Sport and Health Sciences, University of Exeter, Exeter, UK
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MacNeill SJ, Pierotti L, Mohammed MA, Wildman M, Boote J, Harrison S, Carr SB, Cullinan P, Elston C, Bilton D. Identifying exceptional cystic fibrosis care services: combining statistical process control with focus groups. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The Cystic Fibrosis (CF) Registry collects clinical data on all patients attending specialist CF centres in the UK. These data have been used to make comparisons between centres on key outcomes such as forced expiratory volume in 1 second (FEV1) using simple rankings, which promote the assumption that those with the highest measures provide ‘better’ care.
Objectives
To explore whether or not using statistical ‘process control’ charts that move away from league tables and adjusting for case mix (age, where appropriate; sex; CF genotype; pancreatic sufficiency; and socioeconomic status) could identify exceptional CF care services in terms of clinically meaningful outcomes. Then, using insight from patients and clinicians on what structures, processes and policies are necessary for delivering good CF care, to explore whether or not care is associated with observed differences in outcomes.
Design
Cross-sectional analyses.
Setting
Specialist CF centres in the UK.
Participants
Patients aged ≥ 6 years attending specialist CF centres and clinicians at these centres.
Main outcome measures
FEV1% predicted.
Data sources
Annual reviews taken from the UK CF Registry (2007–15).
Results
We studied FEV1 in many different ways and in different periods. In our analyses of both adult and paediatric centres, we observed that some centres showed repeated evidence of ‘special-cause variation’, with mean FEV1 being greater than the mean in some cases and lower than the mean in others. Some of these differences were explained by statistical adjustment for different measures of case mix, such as age, socioeconomic status, genotype and pancreatic sufficiency. After adjustment, there was some remaining evidence of special-cause variation for some centres. Our data at these centres suggest that there may be an association with the use of intravenous antibiotics. Workshops and focus groups with clinicians at paediatric and adult centres identified a number of structures, processes and policies that were felt to be associated with good care. From these, questionnaires for CF centre directors were developed and disseminated. However, the response rate was low, limiting the questionnaires’ use. Focus groups with patients to gain their insights into what is necessary for the delivery of good care identified themes similar to those identified by clinicians, and a patient questionnaire was developed based on these insights.
Limitations
Our data analyses suggest that differences in intravenous antibiotic usage may be associated with centre-level outcomes; this needs to be explored further in partnership with the centres. Our survey of centre directors yielded a low response, making it difficult to gain useful knowledge to inform further discussions with sites.
Conclusions
Our findings confirm that the CF Registry can be used to identify differences in clinical outcomes between centres and that case mix might explain some of these differences. As such, adjustment for case mix is essential when trying to understand how and why centres differ from the mean.
Future work
Future work will involve exploring with clinicians how care is delivered so that we can understand associations between care and outcomes. Patients will also be asked for their perspectives on the care they receive.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Stephanie J MacNeill
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Livia Pierotti
- Department of Occupational and Environmental Medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Martin Wildman
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jonathan Boote
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steve Harrison
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Siobhán B Carr
- Department of Paediatrics, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Paul Cullinan
- Department of Occupational and Environmental Medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Diana Bilton
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Mortality Due to Cystic Fibrosis over a 36-Year Period in Spain: Time Trends and Geographic Variations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16010119. [PMID: 30621191 PMCID: PMC6338987 DOI: 10.3390/ijerph16010119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/21/2018] [Accepted: 12/23/2018] [Indexed: 01/27/2023]
Abstract
The aim of this study is to analyze population-based mortality attributed to cystic fibrosis (CF) over 36 years in Spain. CF deaths were obtained from the National Statistics Institute, using codes 277.0 from the International Classification of Diseases (ICD) ninth revision (ICD9-CM) and E84 from the tenth revision (ICD10) to determine the underlying cause of death. We calculated age-specific and age-adjusted mortality rates, and time trends were assessed using joinpoint regression. The geographic analysis by district was performed by standardized mortality ratios (SMRs) and smoothed-SMRs. A total of 1002 deaths due to CF were identified (50.5% women). Age-adjusted mortality rates fell by −0.95% per year between 1981 and 2016. The average age of death from CF increased due to the annual fall in the mortality of under-25s (−3.77% males, −2.37% females) and an increase in over-75s (3.49%). We identified districts with higher than expected death risks in the south (Andalusia), the Mediterranean coast (Murcia, Valencia, Catalonia), the West (Extremadura), and the Canary Islands. In conclusion, in this study we monitored the population-based mortality attributed to CF over a long period and found geographic differences in the risk of dying from this disease. These findings complement the information provided in other studies and registries and will be useful for health planning.
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17
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Beswick DM, Mace JC, Rudmik L, Soler ZM, Alt JA, Smith KA, Detwiller KY, Smith TL. Socioeconomic factors impact quality of life outcomes and olfactory measures in chronic rhinosinusitis. Int Forum Allergy Rhinol 2018; 9:231-239. [PMID: 30548212 DOI: 10.1002/alr.22256] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/31/2018] [Accepted: 11/13/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Healthcare disparities related to socioeconomic factors may adversely impact disease states and treatment outcomes. Among patients with chronic rhinosinusitis (CRS), the impact of socioeconomic factors on outcomes following endoscopic sinus surgery (ESS) remains uncertain. METHODS Adult patients with refractory CRS were prospectively enrolled into an observational, multi-institutional cohort study between March 2011 and June 2015. Socioeconomic factors analyzed included household income, insurance status, years of education completed, race, age, and ethnicity. Income was stratified according to the Thompson and Hickey model. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Brief Smell Identification Test (BSIT) were completed preoperatively and postoperatively. RESULTS A total of 392 patients met inclusion criteria. Higher age and male gender were associated with better mean preoperative SNOT-22 scores (both p < 0.02), whereas Medicare insurance status and male gender were associated with worse preoperative mean BSIT scores (both p < 0.02). Postoperatively, higher household income ($100,001+/year) and lower age were associated with a greater likelihood of improving at least 1 minimal clinically important difference (MCID) on SNOT-22 scores (OR = 2.40 and 1.03, respectively, both p < 0.05), while no factors were associated with increased odds of achieving a MCID on BSIT scores. CONCLUSIONS Preoperative olfactory function and postoperative quality of life (QOL) improvement were associated with metrics of socioeconomic status in patients with CRS electing ESS. The odds of experiencing a clinically meaningful QOL improvement were more than twice as likely for patients with the highest household income level compared to other income tiers. Further investigation is warranted to identify barriers to postoperative improvement.
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Affiliation(s)
- Daniel M Beswick
- Department of Otolaryngology, University of Colorado, Aurora, CO
| | - Jess C Mace
- Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Jeremiah A Alt
- Sinus and Skull Base Surgery Program, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Kristine A Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kara Y Detwiller
- Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Timothy L Smith
- Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
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18
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Froux L, Billet A, Becq F. Modulating the cystic fibrosis transmembrane regulator and the development of new precision drugs. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1547109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Lionel Froux
- Laboratoire Signalisation et Transports Ioniques Membranaires, Université de Poitiers, Poitiers, France
| | - Arnaud Billet
- Laboratoire Signalisation et Transports Ioniques Membranaires, Université de Poitiers, Poitiers, France
| | - Frédéric Becq
- Laboratoire Signalisation et Transports Ioniques Membranaires, Université de Poitiers, Poitiers, France
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19
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Freese J, Baer-Bositis L. Networks of problems: social, psychological, and genetic influences on health. Curr Opin Psychol 2018; 27:88-92. [PMID: 30553192 DOI: 10.1016/j.copsyc.2018.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/21/2018] [Accepted: 11/28/2018] [Indexed: 01/21/2023]
Abstract
An emerging idea in psychopathology conceives of disorders as networks of mutually-reinforcing symptoms that constitute the disorder rather than simply reflect it. This is similar to how social scientists already view socioeconomic status, and has affinities to how physical health problems compound in later life. Social, psychological, and physical conditions might therefore be thought of as networks of problems with 'causal bridges' that span different levels and bring low SES, mental health challenges, and physical health problems into pervasive relationships with one another. The network view suggests a more heterogeneous and less reductive view on genetic causes which accords with the highly diffuse causal architecture now known to be the hallmark of complex behaviors and traits.
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Affiliation(s)
- Jeremy Freese
- Department of Sociology, Stanford University, United States.
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20
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Ullah S, Ali N, Khan A, Ali S, Nazish HR. The Epidemiological Characteristics of Epilepsy in the Province of Khyber Pakhtunkhwa, Pakistan. Front Neurol 2018; 9:845. [PMID: 30459698 PMCID: PMC6232227 DOI: 10.3389/fneur.2018.00845] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/20/2018] [Indexed: 02/05/2023] Open
Abstract
Previous studies have shown that Khyber Pakhtunkhwa, Pakistan has a high incidence of epilepsy and a high proportion of low socioeconomic background and high treatment gap. Considering the changes over the past 20 years little is known about the current epidemiological characteristics of epilepsy in Khyber Pakhtunkhwa, Pakistan. The current study was focused to find the impact of various contributing factors on the clinical response to anti-epileptic drugs in the KP population, Pakistan. A total of 315 participants aged 19.1 ± 8.6 years were examined. Mean age of the patients was 18 ± 8.1 year. Epilepsy was high in male patients (64.39%) and urban areas (60.1%). Mostly, 88.6% of patients were belonging to low socioeconomic status background. 42.4% patients have positive family history for epilepsy and 42.8% patients had consanguineous marriages. Middle SES class patients (OR, 2.22 [CI, 0.54-9.1]) were slightly associated with controlled response to CBZ and VPA therapy. Absence seizure (OR, 1.16 [CI, 0.59-2.3]), and Complex partial seizure (OR, 1.29 [CI, 0.58-6.3]) showed good response to CBZ therapy while, Myoclonic seizure (OR, 2.23 [CI, 0.05-8.8]) was responsive to VPA therapy. However, non-compliance (R 2 0.82, P < 0.0001) and nature of seizures (R 2 0.83, P < 0.0001) were associated with the high risk for poor response to both CBZ and VPA therapy. Epilepsy was high in male patients and in urban areas. Most patients were belonging to low socioeconomic status. Non-compliance, low socioeconomic and nature of seizures strongly predict poor clinical response of anti-epileptic drugs therapy.
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Affiliation(s)
- Shakir Ullah
- Pharmacology/Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
- Center for Neuroscience, Shantou University Medical College, Shantou, China
| | - Niaz Ali
- Pharmacology/Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Adnan Khan
- Neurology Departments, Lady Reading Hospital Peshawar, Peshawar, Pakistan
| | - Saad Ali
- Neurology Departments, Lady Reading Hospital Peshawar, Peshawar, Pakistan
| | - Haleema Rehana Nazish
- Pharmacology/Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
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21
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Rodríguez-Calá F, Suárez-Medina R, Venero-Fernández SJ, Smyth A, Carr SB, Fogarty AW. The prevalence, clinical status and genotype of cystic fibrosis patients living in Cuba using national registry data. J Cyst Fibros 2018; 18:522-524. [PMID: 30366848 DOI: 10.1016/j.jcf.2018.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND We aimed to establish a national cystic fibrosis (CF) registry for Cuba, a developing country. METHODS Regional centres that deliver care for all CF patients provided information for a national database. FINDINGS The prevalence of CF in Cuba is 26.3 cases per 1,000,000 population. The median age at diagnosis is 2 years, and the median age of the total population was 15 years. Of those aged 16 years or older, the prevalence of Pseudomonas aeruginosa infection was 46%, the prevalence of Staphylococcus aureus infection was 36%, and 80% of individuals were receiving oral azithromycin. The commonest gene mutation was F508del which was observed in 50% of patients. INTERPRETATION These data demonstrate that it is possible to establish a national CF registry in a developing country such as Cuba. This provides baseline data to permit evaluation of health care delivery enable the spread of good clinical practice nationally.
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Affiliation(s)
- Fidel Rodríguez-Calá
- Hospital Universitario "General Calixto García", Avenida Universidad y J, Plaza, Código Postal, 10400 La Habana, Cuba.
| | - Ramón Suárez-Medina
- Instituto Nacional de Higiene, Epidemiología y Microbiología, Infanta No 1158 e/ Llinas y Clavel, Código Postal, 10300 La Habana, Cuba
| | - Silvia Josefina Venero-Fernández
- Instituto Nacional de Higiene, Epidemiología y Microbiología, Infanta No 1158 e/ Llinas y Clavel, Código Postal, 10300 La Habana, Cuba
| | - Alan Smyth
- Division of Child Health, University of Nottingham, Queens Medical Centre, Nottingham, UK
| | - Siobhán B Carr
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Andrew W Fogarty
- Division of Epidemiology and Public Health, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
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22
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Buu MC, Milla CE. Tear Down This Wall: Diversity and Disparities in Cystic Fibrosis. Am J Respir Crit Care Med 2018; 198:983-984. [DOI: 10.1164/rccm.201806-1076ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- MyMy C. Buu
- Center for Excellence in Pulmonary BiologyStanford University School of MedicineStanford, California
| | - Carlos E. Milla
- Center for Excellence in Pulmonary BiologyStanford University School of MedicineStanford, California
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23
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Stephenson AL, Stanojevic S, Sykes J, Burgel PR. The changing epidemiology and demography of cystic fibrosis. Presse Med 2017; 46:e87-e95. [PMID: 28554720 DOI: 10.1016/j.lpm.2017.04.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/05/2017] [Indexed: 01/26/2023] Open
Abstract
Once considered a pediatric disease with a poor prognosis, individuals born with cystic fibrosis (CF) today can expect to live well into adulthood. The implementation of multidisciplinary care, novel treatments and newborn screening has resulted in the rapid evolution in the demographics of the CF population. The purpose of this review is to highlight the evolving epidemiology and demographics of the CF population internationally.
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Affiliation(s)
- Anne L Stephenson
- University of Toronto, St-Michael's hospital, Li Ka Shing knowledge institute, Keenan research centre, department of medicine, adult CF program, 30, Bond street, 6th floor, Bond Wing, M5B 1W8 Toronto, ON, Canada; University of Toronto, institute of health policy, management and evaluation, Toronto, ON, Canada.
| | - Sanja Stanojevic
- The hospital for sick children, division of respiratory medicine, Toronto, ON, Canada; University of Toronto, institute of health policy, management and evaluation, Toronto, ON, Canada
| | - Jenna Sykes
- University of Toronto, St-Michael's hospital, Li Ka Shing knowledge institute, Keenan research centre, department of medicine, adult CF program, 30, Bond street, 6th floor, Bond Wing, M5B 1W8 Toronto, ON, Canada
| | - Pierre-Regis Burgel
- Sorbonne Paris Cité, université Paris Descartes, 75014 Paris, France; Assistance publique-Hôpitaux de Paris, hôpital Cochin, 75014 Paris, France
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24
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Ong T, Schechter M, Yang J, Peng L, Emerson J, Gibson RL, Morgan W, Rosenfeld M. Socioeconomic Status, Smoke Exposure, and Health Outcomes in Young Children With Cystic Fibrosis. Pediatrics 2017; 139:peds.2016-2730. [PMID: 28093464 PMCID: PMC5260155 DOI: 10.1542/peds.2016-2730] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Lower socioeconomic status (SES) and environmental tobacco smoke (ETS) exposure are both associated with poorer disease outcomes in cystic fibrosis (CF), and children with low SES are disproportionately exposed to ETS. We analyzed a large cohort of young children with CF to distinguish the impact of SES and ETS on clinical outcomes. METHODS The Early Pseudomonas Infection Control Observational study enrolled Pseudomonas-negative young children with CF <13 years of age. An enrollment survey assessed SES and ETS exposures. Forced expiratory volume in 1 second (FEV1), crackles and wheezes, and weight-for-age percentile were assessed at each clinical encounter over at least 4 years. Repeated measures analyses estimated the association of SES and ETS exposures with longitudinal clinical outcomes, adjusting for confounders. RESULTS Of 1797 participants, 1375 were eligible for analysis. Maternal education was high school or less in 28.1%, 26.8% had household income <$40 000, and 43.8% had Medicaid or no insurance. Maternal smoking after birth was present in 24.8%, more prevalent in household with low SES. In separate models, lower SES and ETS exposure were significantly associated with lower FEV1% predicted, presence of crackles or wheezes, and lower weight percentile. In combined models, effect estimates for SES changed minimally after adjustment for ETS exposures, whereas estimates for ETS exposures were attenuated after adjusting for SES. CONCLUSIONS ETS exposure was disproportionately high in low SES families in this cohort of children with CF. Lower SES and ETS exposure had independent adverse effects on pulmonary and nutritional outcomes. Estimated effect of SES on FEV1 decreased minimally after ETS adjustment, suggesting health disparity risks independent of ETS exposure.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington;
| | - Michael Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University, Children’s Hospital of Richmond at VCU, Richmond, Virginia
| | - Jing Yang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia; and
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia; and
| | - Julia Emerson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ronald L. Gibson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Wayne Morgan
- Departments of Pediatrics and Physiology, Pediatric Pulmonary Center, University of Arizona, Tucson, Arizona
| | - Margaret Rosenfeld
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
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25
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Isa HM, Al-Ali LF, Mohamed AM. Growth assessment and risk factors of malnutrition in children with cystic fibrosis. Saudi Med J 2017; 37:293-8. [PMID: 26905352 PMCID: PMC4800894 DOI: 10.15537/smj.2016.3.13476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives: To evaluate the nutritional status, to screen for the presence of malnutrition, and to study the possible risk factors associated with malnutrition in patients with cystic fibrosis (CF). Methods: A retrospective cross-sectional review of medical records of all diagnosed CF patients in the Pediatric Department, Salmaniya Medical Complex, Manama, Kingdom of Bahrain, between January 1984 and May 2015 was conducted. Demographic and anthropometric data were collected from records of last visit to CF clinic. Nutritional status and risk factors of malnutrition were assessed. Results: All records of 109 CF patients were reviewed. Forty-seven pediatric patients were included in the study. All included patients were on pancreatic enzyme replacement and 42 (89%) received high-calorie supplementation. Growth failure was noted in 34 (72%) patients, 19 (56%) were wasted and stunted, 8 (23.5%) were wasted only, and 7 (20.5%) were stunted. Low birth weight (p=0.032), and the presence of gastroesophageal reflux disease (GERD) (p=0.039) were the significant risk factors for malnutrition. Conclusion: Most CF patients in Bahrain (72%) are malnourished. Low birth weight and the presence of GERD are risk factors.
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Affiliation(s)
- Hasan M Isa
- Pediatric Department, Salmaniya Medical Complex, Manama, Kingdom of Bahrain. E-mail.
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26
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Cystic Fibrosis. Respir Med 2017. [DOI: 10.1007/978-3-319-43447-6_9] [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: 10/20/2022]
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27
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Weber HC, Robinson PF, Saxby N, Beggs SA, Els I, Ehrlich RI. Do children with cystic fibrosis receiving outreach care have poorer clinical outcomes than those treated at a specialist cystic fibrosis centre? Aust J Rural Health 2016; 25:34-41. [PMID: 27859825 PMCID: PMC5347938 DOI: 10.1111/ajr.12334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/27/2022] Open
Abstract
Introduction Although cystic fibrosis (CF) centre care is generally considered ideal, children living in regional Australia receive outreach care supported by the academic CF centres. Methods This is a retrospective database review of children with CF treated at the Royal Children's Hospital in Melbourne and its outreach clinics in Albury (Victoria), and Tasmania. The aim was to compare the outcomes of children with CF managed at an academic centre with that of outreach care, using lung function, nutritional status and Pseudomonas aeruginosa colonisation. Three models of care, namely CF centre care, Shared care and predominantly Local care, were compared, based on the level of involvement of CF centre multidisciplinary team. In our analyses, we controlled for potential confounders, such as socio‐economic status and the degree of remoteness, to determine its effect on the outcome measures. Results There was no difference in lung function, i.e. forced expiratory volume in 1 s (FEV1), the prevalence of Pseudomonas aeruginosa colonisation or nutritional status (body mass index (BMI)) between those receiving CF centre care and various modes of outreach care. Neither socio‐economic status, measured by the Socio‐Economic Index for Area (SEIFA) for disadvantage, nor distance from an urban centre (Australian Standard for Geographical Classification (ASGC)) were associated with lung function and nutritional outcome measures. There was however an association between increased Pseudomonas aeruginosa colonisation and poorer socio‐economic status. Conclusion Outcomes in children with CF in regional and remote areas receiving outreach care supported by an academic CF centre were no different from children receiving CF centre care.
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Affiliation(s)
- Heinrich C Weber
- Faculty of Health, University of Tasmania, Rural Clinical School, Burnie, Tasmania, Australia
| | - Philip F Robinson
- Paediatrics - Respiratory Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nicole Saxby
- Dietetics/Cystic Fibrosis, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Sean A Beggs
- Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Ingrid Els
- Paediatrics, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Rodney I Ehrlich
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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28
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Veit G, Avramescu RG, Chiang AN, Houck SA, Cai Z, Peters KW, Hong JS, Pollard HB, Guggino WB, Balch WE, Skach WR, Cutting GR, Frizzell RA, Sheppard DN, Cyr DM, Sorscher EJ, Brodsky JL, Lukacs GL. From CFTR biology toward combinatorial pharmacotherapy: expanded classification of cystic fibrosis mutations. Mol Biol Cell 2016; 27:424-33. [PMID: 26823392 PMCID: PMC4751594 DOI: 10.1091/mbc.e14-04-0935] [Citation(s) in RCA: 371] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
More than 2000 mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) have been described that confer a range of molecular cell biological and functional phenotypes. Most of these mutations lead to compromised anion conductance at the apical plasma membrane of secretory epithelia and cause cystic fibrosis (CF) with variable disease severity. Based on the molecular phenotypic complexity of CFTR mutants and their susceptibility to pharmacotherapy, it has been recognized that mutations may impose combinatorial defects in CFTR channel biology. This notion led to the conclusion that the combination of pharmacotherapies addressing single defects (e.g., transcription, translation, folding, and/or gating) may show improved clinical benefit over available low-efficacy monotherapies. Indeed, recent phase 3 clinical trials combining ivacaftor (a gating potentiator) and lumacaftor (a folding corrector) have proven efficacious in CF patients harboring the most common mutation (deletion of residue F508, ΔF508, or Phe508del). This drug combination was recently approved by the U.S. Food and Drug Administration for patients homozygous for ΔF508. Emerging studies of the structural, cell biological, and functional defects caused by rare mutations provide a new framework that reveals a mixture of deficiencies in different CFTR alleles. Establishment of a set of combinatorial categories of the previously defined basic defects in CF alleles will aid the design of even more efficacious therapeutic interventions for CF patients.
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Affiliation(s)
- Gudio Veit
- Department of Physiology, McGill University, Montréal, QC H3G 1Y6, Canada
| | - Radu G Avramescu
- Department of Physiology, McGill University, Montréal, QC H3G 1Y6, Canada
| | - Annette N Chiang
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA 15260
| | - Scott A Houck
- Marsico Lung Institute, School of Medicine, University of North Carolina, Chapel Hill, NC 27514
| | - Zhiwei Cai
- School of Physiology & Pharmacology, University of Bristol, Bristol BS8 1TD, United Kingdom
| | - Kathryn W Peters
- Department of Cell Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | - Jeong S Hong
- Department of Cellular, Developmental, and Integrative Biology, University of Alabama, Birmingham, AL 35294
| | - Harvey B Pollard
- Department of Anatomy, Physiology and Genetics and Center for Medical Proteomics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - William B Guggino
- Department of Physiology, Johns Hopkins University, Baltimore, MD 21205
| | - William E Balch
- Department of Chemical Physiology, Skaggs Institute of Chemical Physiology, Scripps Research Institute, La Jolla, CA 92037
| | - William R Skach
- Department of Biochemistry and Molecular Biology, Oregon Health and Science University, Portland, OR 97239
| | - Garry R Cutting
- McKusick-Nathans Institute of Genetic Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21205
| | - Raymond A Frizzell
- Department of Cell Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | - David N Sheppard
- School of Physiology & Pharmacology, University of Bristol, Bristol BS8 1TD, United Kingdom
| | - Douglas M Cyr
- Marsico Lung Institute, School of Medicine, University of North Carolina, Chapel Hill, NC 27514
| | - Eric J Sorscher
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322
| | - Jeffrey L Brodsky
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA 15260
| | - Gergely L Lukacs
- Department of Physiology, McGill University, Montréal, QC H3G 1Y6, Canada Department of Biochemistry, McGill University, Montréal, QC H3G 1Y6, Canada GRASP, McGill University, Montréal, QC H3G 1Y6, Canada
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29
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Somayaji R, Lam JC, Surette MG, Waddell B, Rabin HR, Sibley CD, Purighalla S, Parkins MD. Long-term clinical outcomes of 'Prairie Epidemic Strain' Pseudomonas aeruginosa infection in adults with cystic fibrosis. Thorax 2016; 72:333-339. [PMID: 27682327 DOI: 10.1136/thoraxjnl-2015-208083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 08/10/2016] [Accepted: 08/31/2016] [Indexed: 01/21/2023]
Abstract
RATIONALE Epidemic Pseudomonas aeruginosa (PA) plays an important role in cystic fibrosis (CF) lung disease. A novel strain, the 'Prairie Epidemic Strain' (PES), has been identified in up to 30% of patients in Prairie-based Canadian CF centres. OBJECTIVE To determine the incidence, prevalence and long-term clinical impact of PES infection. METHODS A cohort of adults with CF was followed from 1980 to 2014 where bacteria isolated from clinical encounters were prospectively collected. Strain typing was performed using pulse-field gel electrophoresis and multilocus sequence typing. Patients were divided into one of four cohorts: no PA, transient PA, chronic PA with unique strains and chronic PES. Proportional Cox hazard and linear mixed models were used to assess for CF-associated respiratory death or transplantation, and rates of %FEV1 and body mass index (BMI) decline. RESULTS 274 patients (51.7% male) were analysed: 44--no PA, 29--transient PA, 137--unique PA, 64--PES. A total of 92 patients (33.6%) died or underwent lung transplantation (2423.0 patient-years). PES infection was associated with greater risk of respiratory death or lung transplant compared with the no PA group (aHR, 3.94 (95% CI 1.18 to 13.1); p=0.03) and unique PA group (aHR, 1.75 (95% CI 1.05 to 2.92) p=0.03). Rate of lung function decline (%FEV1 predicted) was greatest in the PES group (1.73%/year (95% CI 1.63% to 1.82%); p<0.001). BMI improved over time but at an attenuated rate in the PES group (p=0.001). CONCLUSIONS Infection with PES was associated with increased patient morbidity through three decades and manifested in an increased risk of respiratory death and/or lung transplantation.
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Affiliation(s)
- Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John C Lam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael G Surette
- Departments of Medicine, and Biochemistry and Biomedical Sciences, The Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Waddell
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Harvey R Rabin
- Departments of Medicine, and Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | | | - Swathi Purighalla
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Parkins
- Departments of Medicine, and Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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Quality of Reporting Nutritional Randomized Controlled Trials in Patients With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2016; 63:265-9. [PMID: 26881412 DOI: 10.1097/mpg.0000000000001164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Randomized controlled trials (RCTs) have a major role in the making of evidence-based guidelines. The aim of the present study was to critically appraise the RCTs that addressed nutritional interventions in patients with cystic fibrosis. METHODS Embase, PubMed, and the Cochrane Library were systematically searched until July 2015. Methodology and reporting of nutritional RCTs were evaluated by the Consolidated Standards of Reporting Trials (CONSORT) checklist and additional dimensions relevant to patients with CF. RESULTS Fifty-one RCTs were included. Full details on methods were provided in a minority of studies. The mean duration of intervention was <6 months. 56.9% of the RCTs did not define a primary outcome; 70.6% of studies did not provide details on sample size calculation; and only 31.4% reported on the subgroup or separated between important subgroups. CONCLUSIONS The examined RCTs were characterized by a weak methodology, a small number of patients with no sample size calculations, a relatively short intervention, and many times did not examine the outcomes that are important to the patient. Improvement over the years has been minor.
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Oates GR, Schechter MS. Socioeconomic status and health outcomes: cystic fibrosis as a model. Expert Rev Respir Med 2016; 10:967-77. [DOI: 10.1080/17476348.2016.1196140] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Forrester DL, Knox AJ, Smyth AR, Barr HL, Simms R, Pacey SJ, Pavord ID, Honeybourne D, Dewar J, Clayton A, Fogarty AW. Glutamine supplementation in cystic fibrosis: A randomized placebo-controlled trial. Pediatr Pulmonol 2016; 51:253-7. [PMID: 26709241 DOI: 10.1002/ppul.23370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 10/02/2015] [Accepted: 10/26/2015] [Indexed: 01/04/2023]
Abstract
RATIONALE Pulmonary infection and malnutrition in cystic fibrosis are associated with decreased survival. Glutamine has a possible anti-microbial effect, with a specific impact against Pseudomonas aeruginosa. We aimed to test the hypothesis that oral glutamine supplementation (21 g/day) for 8 weeks in adults with cystic fibrosis would decrease pulmonary inflammation and improve clinical status. METHODS The study design was a randomized double-blind placebo-controlled study design with an iso-nitrogenous placebo. The primary analysis was intention to treat, and the primary outcome was change in induced sputum neutrophils. RESULTS Thirty-nine individuals were recruited and thirty-six completed the study. Glutamine supplementation had no impact on any of the outcome measures in the intention-to-treat analysis. In the per protocol analysis, glutamine supplementation was associated with an increase in induced sputum neutrophils (P = 0.046), total cells (P = 0.03), and in Pseudomonas isolation agar colony forming units (P = 0.04) compared to placebo. CONCLUSIONS There was no effect of glutamine supplementation on markers of pulmonary inflammation in the intention-to-treat analysis.
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Affiliation(s)
- Doug L Forrester
- Division of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Alan J Knox
- Division of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Alan R Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, United Kingdom
| | - Helen L Barr
- Division of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Rebecca Simms
- Division of Respiratory Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Sarah J Pacey
- Department of Pharmacy, NUH NHS Trust, Nottingham, United Kingdom
| | - Ian D Pavord
- Division of Respiratory Medicine, Oxford University, United Kingdom
| | - David Honeybourne
- Department of Respiratory Medicine, Heartlands Hospital, Birmingham, United Kingdom
| | - Jane Dewar
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, United Kingdom
| | - Andy Clayton
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, United Kingdom
| | - Andrew W Fogarty
- Division of Public Health and Epidemiology, University of Nottingham, Nottingham, United Kingdom
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Kerem E, Cohen-Cymberknoh M. Disparities in Cystic Fibrosis Care and Outcome. Chest 2016; 149:298-300. [DOI: 10.1016/j.chest.2015.08.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 08/17/2015] [Accepted: 08/17/2015] [Indexed: 11/29/2022] Open
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Quintana-Gallego E, Ruiz-Ramos M, Delgado-Pecellin I, Calero C, Soriano JB, Lopez-Campos JL. Mortality from cystic fibrosis in Europe: 1994-2010. Pediatr Pulmonol 2016; 51:133-42. [PMID: 26584153 DOI: 10.1002/ppul.23337] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 07/14/2015] [Accepted: 07/23/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To date, available mortality trends due to cystic fibrosis (CF) have been limited to the analysis of certain countries in different parts of the world showing that mortality trends have been constantly decreasing. However, no studies have examined Europe as a whole. The present study aims to analyze CF mortality trends by gender within the European Union (EU) and to quantify potential years of life lost (PYLL). DESIGN Deaths from the 27 EU countries were obtained from the statistical office of the EU from the years 1994-2010. Crude and age-standardized mortality rates (ASR) were estimated for women and men using the standard European population, expressed in deaths per 1,000,000 persons. The PYLL from ages 0 up to 30 years were estimated. Trends were studied by a joinpoint regression analysis. RESULTS During the study period, 5,130 deaths (2,443 in males and 2,687 in females) were identified. Females had a slightly higher mortality rate than males, with a downward trend observed for both genders. In males, the ASR changed from 1.34 in 1994 to 1.03 in 2010. In females, the ASR changed from 1.42 in 1994 to 0.92 in 2010. The mean age at death and PYLL increased for both genders. The joinpoint analysis did not identify any significant joinpoint for either gender for ASR or PYLL. CONCLUSIONS Our data suggest a continued downward trend of CF mortality throughout the EU, with differences by country and gender.
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Affiliation(s)
- Esther Quintana-Gallego
- Unidad de Fibrosis Quística, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Ruiz-Ramos
- Consejería de Igualdad, Salud y Políticas Sociales de Andalucía, Seville, Spain
| | - Isabel Delgado-Pecellin
- Unidad de Fibrosis Quística, Servicio de Pediatría, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Carmen Calero
- Unidad de Fibrosis Quística, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Joan B Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Cátedra UAM-Linde, Madrid, Spain
| | - Jose Luis Lopez-Campos
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Sevilla, Spain
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Buu MC, Sanders LM, Mayo JA, Milla CE, Wise PH. Assessing Differences in Mortality Rates and Risk Factors Between Hispanic and Non-Hispanic Patients With Cystic Fibrosis in California. Chest 2016; 149:380-389. [PMID: 26086984 DOI: 10.1378/chest.14-2189] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Over the past 30 years, therapeutic advances have extended the median lifespan of patients with cystic fibrosis (CF). Hispanic patients are a vulnerable subpopulation with a high prevalence of risk factors for worse health outcomes. The consequences of these differences on health outcomes have not been well described. The objective of this study was to characterize the difference in health outcomes, including mortality rate, between Hispanic and non-Hispanic patients with CF. METHODS This study is a retrospective analysis of CF Foundation Patient Registry data of California residents with CF, diagnosed during or after 1991, from 1991 to 2010. Ethnicity was self-reported. The primary outcome was mortality. Hazard ratios were estimated from a Cox regression model, stratified by sex, and adjusted for socioeconomic status, clinical risk factors, and year of diagnosis. RESULTS Of 1,719 patients, 485 (28.2%) self-identified as Hispanic. Eighty-five deaths occurred, with an overall mortality rate of 4.9%. The unadjusted mortality rate was higher among Hispanic patients than among non-Hispanic patients (9.1% vs 3.3%, P < .0001). Compared with non-Hispanic patients, Hispanic patients had a lower survival rate 18 years after diagnosis (75.9% vs 91.5%, P < .0001). Adjusted for socioeconomic status and clinical risk factors, Hispanic patients had an increased rate of death compared with non-Hispanic patients (hazard ratio, 2.81; 95% CI, 1.70-4.63). CONCLUSIONS Hispanic patients with CF have a higher mortality rate than do non-Hispanic patients, even after adjusting for socioeconomic status and clinical severity. Further investigation into the mechanism for the measured difference in lung function will help inform interventions and improve the health of all patients with CF.
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Affiliation(s)
- MyMy C Buu
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, Center for Excellence in Pulmonary Biology, Stanford University School of Medicine, Stanford, CA.
| | - Lee M Sanders
- Department of Pediatrics, Division of General Pediatrics, Center for Policy, Outcomes and Prevention, Stanford University School of Medicine, Stanford, CA
| | - Jonathan A Mayo
- Department of Pediatrics, Division of General Pediatrics, Center for Policy, Outcomes and Prevention, Stanford University School of Medicine, Stanford, CA
| | - Carlos E Milla
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, Center for Excellence in Pulmonary Biology, Stanford University School of Medicine, Stanford, CA
| | - Paul H Wise
- Department of Pediatrics, Division of General Pediatrics, Center for Policy, Outcomes and Prevention, Stanford University School of Medicine, Stanford, CA
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Vahedi L, Jabarpoor-Bonyadi M, Ghojazadeh M, Hazrati H, Rafeey M. Association Between Outcomes and Demographic Factors in an Azeri Turkish Population With Cystic Fibrosis: A Cross-Sectional Study in Iran From 2001 Through 2014. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e29615. [PMID: 27275400 PMCID: PMC4893412 DOI: 10.5812/ircmj.29615] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/08/2015] [Accepted: 07/02/2015] [Indexed: 12/03/2022]
Abstract
Background Outcomesforcystic fibrosis patients are improving rapidly. The demographic factors are notable variables inoutcomes, which can be evaluated and modified. Objectives This study was designed to investigate the association between outcome and demographic factors in patients with cystic fibrosis. Patients and Methods This was a cross-sectional study and data were gathered for 331 patients using the census method, from March 2001 to September 2014 in Iran. Data was analyzed using logistic regression analysis, chi-square test, and independent sample t test using SPSS 18. Odds ratio with confidence intervals of 95% and P < 0.05 were considered significant. Results There were 85 (25.7%) deceased patients and 246 (74.3%) living patients at the time of the study. Of the 246 living CF patients, 202 (82.2%) were less than nine years of age, and 77 (90.6%) out of the 85 deceased CF patients had died younger than four years of age. There was a significant difference between outcome and location of residence. The risk of mortality was 50% less in urban patients than in rural patients (P = 0.03). The risk of mortality was approximately two times higher in patients with a positive family history than in those with a negative family history (P = 0.02). The proportion of mortality was approximately two times, or 94%, higher for those in a consanguineous marriage than for those in a non-consanguineous marriage (P = 0.01). Conclusions The results demonstrated that the mortality rate was higher in CF patients with a positive family history, a consanguineous marriage, and residence in a rural area. Therefore, demographic factors play an important role in the outcome of cystic fibrosis. Unfortunately, these parameters, which can be managed easily and with low cost, have been overlooked.
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Affiliation(s)
- Leila Vahedi
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Morteza Jabarpoor-Bonyadi
- Faculty of Natural Sciences, Center of Excellence for Biodiversity, University of Tabriz, Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Morteza Ghojazadeh
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Hakimeh Hazrati
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Mandana Rafeey
- Tabriz Children’s Hospital, Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding Author: Mandana Rafeey, Tabriz Children’s Hospital, Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel: +98-9141146982, Fax: +41-33373741, E-mail:
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Survival in Cystic Fibrosis: Trends, Clinical Factors, and Prediction Models. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2015; 28:244-249. [DOI: 10.1089/ped.2015.0531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Oates GR, Stepanikova I, Gamble S, Gutierrez HH, Harris WT. Adherence to airway clearance therapy in pediatric cystic fibrosis: Socioeconomic factors and respiratory outcomes. Pediatr Pulmonol 2015; 50:1244-52. [PMID: 26436321 PMCID: PMC4871693 DOI: 10.1002/ppul.23317] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/08/2015] [Accepted: 09/14/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The evidence linking socioeconomic status (SES) and adherence in cystic fibrosis (CF) is inconclusive and focused on medication uptake. We examined associations between SES, adherence to airway clearance therapy (ACT), and CF respiratory outcomes. STUDY DESIGN Socioeconomic, clinical, and adherence data of CF patients (N = 110) at a single CF Center were evaluated in this cross-sectional observational study. SES was operationalized as maternal and paternal education and household income. Adherence to ACT was measured with utilization data from the high-frequency chest wall oscillation (HFCWO) device over 4-6 weeks. Statistical modeling was used to test three hypotheses: (H1) Higher SES is associated with higher ACT adherence; (H2) Higher SES is associated with better respiratory outcomes; and (H3) ACT adherence mediates the relationship between SES and respiratory outcomes. RESULTS In multinomial logistic regression, maternal college education, annual income >$50,000, and more adults in the household were independently related to better adherence (P < 0.05). Paternal college education, income >$100,000, and lack of exposure to smoking were independently related to higher lung function (P < 0.05). Current adherence to ACT with HFCWO was not associated with lung function over 12 months. CONCLUSIONS SES is associated both with ACT adherence and respiratory outcomes in pediatric CF patients. However, the link between SES and respiratory outcomes in this study was not mediated by adherence to ACT with HFCWO. These data emphasize the importance of socioeconomic resources and household environment for CF health. Family socio-demographic profiles can help identify patients at increased risk for ACT nonadherence.
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Affiliation(s)
- Gabriela R Oates
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Irena Stepanikova
- Department of Sociology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Hector H Gutierrez
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - William T Harris
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
Cystic fibrosis is the most common genetically determined, life-limiting disorder in populations of European ancestry. The genetic basis of cystic fibrosis is well established to be mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene that codes for an apical membrane chloride channel principally expressed by epithelial cells. Conventional approaches to cystic fibrosis care involve a heavy daily burden of supportive treatments to combat lung infection, help clear airway secretions and maintain nutritional status. In 2012, a new era of precision medicine in cystic fibrosis therapeutics began with the licensing of a small molecule, ivacaftor, which successfully targets the underlying defect and improves CFTR function in a subgroup of patients in a genotype-specific manner. Here, we review the three main targeted approaches that have been adopted to improve CFTR function: potentiators, which recover the function of CFTR at the apical surface of epithelial cells that is disrupted in class III and IV genetic mutations; correctors, which improve intracellular processing of CFTR, increasing surface expression, in class II mutations; and production correctors or read-through agents, which promote transcription of CFTR in class I mutations. The further development of such approaches offers great promise for future therapeutic strategies in cystic fibrosis.
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Nie S, Zhang H, Mayer KM, Oppenheim FG, Little FF, Greenberg J, Uluer AZ, Walt DR. Correlations of salivary biomarkers with clinical assessments in patients with cystic fibrosis. PLoS One 2015; 10:e0135237. [PMID: 26258476 PMCID: PMC4530931 DOI: 10.1371/journal.pone.0135237] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/20/2015] [Indexed: 01/17/2023] Open
Abstract
RATIONALE Monitoring clinical disease status in cystic fibrosis frequently requires invasive collection of clinical samples. Due to its noninvasive collection process and direct anatomic relationship with the lower airway, saliva shows great potential as a biological fluid for cystic fibrosis monitoring. OBJECTIVES To measure the levels of multiple protein markers in human saliva supernatants and investigate the possibility of utilizing them to provide a more quantitative measure of disease state for use in research and monitoring of patients with cystic fibrosis clinically. METHODS Whole saliva samples were collected and processed from cystic fibrosis patients at two distinct time points (2010 and 2013) and measured by two separate platforms. In this cross sectional study, a convenience sample of 71 participants were recruited with samples measured by multiplexed fluorescence microarray (fiber microarray) and another 117 participant samples were measured by an automated, point-of-care, analyzer (SDReader) using a microsphere-based array via fluorescence sandwich immunoassay. For comparison, saliva from 56 and 50 healthy subjects were collected, respectively. The levels of six target proteins were quantified. Various demographic and clinical data, including spirometry, medical history, and clinicians' assessments were also collected from patients with cystic fibrosis on the day of saliva collection. MEASUREMENTS AND MAIN RESULTS Similar trends were observed with both platforms and compared with healthy subjects, cystic fibrosis patients had significantly elevated levels of VEGF, IP-10, IL-8, and EGF as well as lower levels of MMP-9 (P ≤ 0.005) using fiber microarray and significantly elevated levels of IP-10, IL-8 with lower levels of MMP-9 and IL-1β (P ≤ 0.02) using the SDReader. The levels of the six proteins correlated with each other significantly, and in some cases, biomarker levels could be used to differentiate between subgroups of patients with different clinical presentations. For example, IP-10 levels significantly correlated with FEV1 and disease severity (as evaluated by clinicians) with both platforms (P < 0.05). CONCLUSIONS Significant variations of the levels of six proteins in saliva supernatants, and the correlations of these levels with clinical assessments, demonstrated the potential of saliva for cystic fibrosis research and monitoring.
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Affiliation(s)
- Shuai Nie
- Department of Chemistry, Tufts University, Medford, Massachusetts, United States of America
| | - Huaibin Zhang
- Department of Chemistry, Tufts University, Medford, Massachusetts, United States of America
| | - Kathryn M. Mayer
- Department of Chemistry, Tufts University, Medford, Massachusetts, United States of America
| | - Frank G. Oppenheim
- Goldman School of Dental Medicine, Boston University, Boston, Massachusetts, United States of America
| | - Frédéric F. Little
- School of Medicine, Boston University, Boston, Massachusetts, United States of America
| | - Jonathan Greenberg
- Division of Respiratory Diseases, Boston Children’s Hospital and Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ahmet Z. Uluer
- Division of Respiratory Diseases, Boston Children’s Hospital and Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David R. Walt
- Department of Chemistry, Tufts University, Medford, Massachusetts, United States of America
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Alicandro G, Frova L, Di Fraia G, Colombo C. Cystic fibrosis mortality trend in Italy from 1970 to 2011. J Cyst Fibros 2015; 14:267-74. [DOI: 10.1016/j.jcf.2014.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 07/28/2014] [Accepted: 07/28/2014] [Indexed: 11/29/2022]
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Health Trajectories in People with Cystic Fibrosis in the UK: Exploring the Effect of Social Deprivation. A LIFE COURSE PERSPECTIVE ON HEALTH TRAJECTORIES AND TRANSITIONS 2015. [DOI: 10.1007/978-3-319-20484-0_5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Loch Macdonald R. Vasospasm: my first 25 years-what worked? what didn't? what next? ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:1-10. [PMID: 25366591 DOI: 10.1007/978-3-319-04981-6_1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Angiographic vasospasm as a complication of aneurysmal and other types of subarachnoid hemorrhage (SAH) was identified about 62 years ago. It is now hypothesized that angiographic vasospasm contributes to delayed cerebral ischemia (DCI) by multiple pathways, including reduced blood flow from angiographic vasospasm as well as microcirculatory constriction, microthrombosis, cortical spreading ischemia, and delayed effects of early brain injury. It is likely that other factors, such as systemic complications, effects of the subarachnoid blood, brain collateral and anastomotic blood flow, and the genetic and epigenetic makeup of the patient, contribute to the individual's response to SAH. Treatment of aneurysmal SAH and DCI includes neurocritical care management, early aneurysm repair, prophylactic administration of nimodipine, and rescue therapies (induced hypertension and balloon or pharmacologic angioplasty) if the patient develops DCI. Well-designed clinical trials of tirilazad, clasozentan, antiplatelet drugs, and magnesium have been conducted using more than a 1,000 patients each. Some of these drugs have almost purely vascular effects; other drugs are theoretically neuroprotective as well, but they share in common the ability to reduce angiographic vasospasm and, in many cases, DCI, but have no effect on clinical outcome. Experimental research in SAH continues to identify new targets for therapy. Challenges for the future will be to identify the most promising drugs to advance from preclinical studies and to understand why clinical trials have so frequently failed to show drug benefit on clinical outcome. Similar issues with treatment of ischemic stroke are being addressed by suggestions for improving the quality of experimental studies, collaborative preclinical trials, and multinational, multicenter clinical studies that can rapidly include many patients and be large enough to account for numerous factors that conspire to disrupt clinical trials.
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada,
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Taylor-Robinson DC, Thielen K, Pressler T, Olesen HV, Diderichsen F, Diggle PJ, Smyth R, Whitehead M. Low socioeconomic status is associated with worse lung function in the Danish cystic fibrosis population. Eur Respir J 2014; 44:1363-6. [PMID: 25186272 PMCID: PMC4216452 DOI: 10.1183/09031936.00063714] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Karsten Thielen
- Dept of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tania Pressler
- Cystic Fibrosis Center, Rigshospitalet, Copenhagen, Denmark
| | - Hanne V Olesen
- Paediatric Dept A, Cystic Fibrosis Center, Aarhus University Hospital, Aarhus, Denmark
| | - Finn Diderichsen
- Dept of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter J Diggle
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | | | - Margaret Whitehead
- Dept of Public Health and Policy, Whelan Building, University of Liverpool, Liverpool, UK
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MacKenzie T, Gifford AH, Sabadosa KA, Quinton HB, Knapp EA, Goss CH, Marshall BC. Longevity of patients with cystic fibrosis in 2000 to 2010 and beyond: survival analysis of the Cystic Fibrosis Foundation patient registry. Ann Intern Med 2014; 161:233-41. [PMID: 25133359 PMCID: PMC4687404 DOI: 10.7326/m13-0636] [Citation(s) in RCA: 235] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Advances in treatments for cystic fibrosis (CF) continue to extend survival. An updated estimate of survival is needed for better prognostication and to anticipate evolving adult care needs. OBJECTIVE To characterize trends in CF survival between 2000 and 2010 and to project survival for children born and diagnosed with the disease in 2010. DESIGN Registry-based study. SETTING 110 Cystic Fibrosis Foundation-accredited care centers in the United States. PATIENTS All patients represented in the Cystic Fibrosis Foundation Patient Registry (CFFPR) between 2000 and 2010. MEASUREMENTS Survival was modeled with respect to age, age at diagnosis, gender, race or ethnicity, F508del mutation status, and symptoms at diagnosis. RESULTS Between 2000 and 2010, the number of patients in the CFFPR increased from 21,000 to 26,000, median age increased from 14.3 to 16.7 years, and adjusted mortality decreased by 1.8% per year (95% CI, 0.5% to 2.7%). Males had a 19% (CI, 13% to 24%) lower adjusted risk for death than females. Median survival of children born and diagnosed with CF in 2010 is projected to be 37 years (CI, 35 to 39 years) for females and 40 years (CI, 39 to 42 years) for males if mortality remains at 2010 levels and more than 50 years if mortality continues to decrease at the rate observed between 2000 and 2010. LIMITATIONS The CFFPR does not include all patients with CF in the United States, and loss to follow-up and missing data were observed. Additional analyses to address these limitations suggest that the survival projections are conservative. CONCLUSION Children born and diagnosed with CF in the United States in 2010 are expected to live longer than those born earlier. This has important implications for prognostic discussions and suggests that the health care system should anticipate greater numbers of adults with CF. PRIMARY FUNDING SOURCE Cystic Fibrosis Foundation.
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Hoo Z, Wildman M, Teare M. Exploration of the impact of ‘mild phenotypes’ ON median age at death IN the UK CF registry. Respir Med 2014; 108:716-21. [DOI: 10.1016/j.rmed.2014.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 02/16/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
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Hurley MN, McKeever TM, Prayle AP, Fogarty AW, Smyth AR. Rate of improvement of CF life expectancy exceeds that of general population--observational death registration study. J Cyst Fibros 2014; 13:410-5. [PMID: 24418187 PMCID: PMC4074348 DOI: 10.1016/j.jcf.2013.12.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 09/20/2013] [Accepted: 12/04/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is unclear why cystic fibrosis (CF) survival has improved. We wished to quantify increases in CF median age of death in the context of general population survival improvement. METHOD Death registration data analysis (US, England & Wales (E&W)-1972-2009). RESULTS CF median age of death is higher in US than E&W and greater for males, opposite to that of death from all causes. CF median age of death has increased by 0.543 life years per year (E&W, US combined (95% confidence interval 0.506, 0.582)). The difference in median age at death between those dying from all causes and CF decreased in both territories. CF median age of death for males is greater than for females in both territories. This gap has not narrowed. CONCLUSION The median age of death of people with CF is improving more rapidly than that of the general population in US and E&W.
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Affiliation(s)
- Matthew N Hurley
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, E Floor East Block, Queens Medical Centre, Nottingham, NG7 2UH, United Kingdom.
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Andrew P Prayle
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, E Floor East Block, Queens Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | - Andrew W Fogarty
- Division of Epidemiology and Public Health, School of Medicine, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, United Kingdom
| | - Alan R Smyth
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, E Floor East Block, Queens Medical Centre, Nottingham, NG7 2UH, United Kingdom
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Taylor-Robinson DC, Smyth R, Diggle PJ, Whitehead M. A longitudinal study of the impact of social deprivation and disease severity on employment status in the UK cystic fibrosis population. PLoS One 2013; 8:e73322. [PMID: 24009747 PMCID: PMC3751887 DOI: 10.1371/journal.pone.0073322] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/18/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND People with Cystic Fibrosis (CF) in the UK and elsewhere are increasingly surviving into adulthood, yet there is little research on the employment consequences of having CF. We investigated, for the first time in a UK-wide cohort, longitudinal employment status, and its association with deprivation, disease severity, and time in hospital. METHODS We did a longitudinal registry study of adults with CF in the UK aged 20 to 40 (3458 people with 15,572 observations between 1996 and 2010), using mixed effects models. RESULTS Around 50% of adults with CF were in employment. Male sex, higher lung function and body mass index, and less time in hospital were associated with improved employment chances. All other things being equal, being in the most deprived quintile was associated with a reduction of employment prevalence of 17.6 percentage points compared to the prevalence in the least deprived quintile. Having poor lung function was associated with a reduced employment prevalence of 7.2 percentage points compared to the prevalence for people with relatively good lung function. Acting synergistically, deprivation modifies the effect of lung function on employment chances - poor lung function in the least deprived group was associated with a 3 percentage point reduction in employment chances, while poor lung function in the most deprived quintile was associated with a 7.7 point reduction in employment chances. CONCLUSIONS Greater deprivation, disease severity, and time in hospital are all associated with employment chances in adults with CF. Furthermore, our analysis suggests that deprivation amplifies the harmful association of disease severity on employment. Future studies should focus on understanding and mitigating the barriers to employment faced by people with CF.
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McCartney G, Collins C, Mackenzie M. What (or who) causes health inequalities: theories, evidence and implications? Health Policy 2013; 113:221-7. [PMID: 23810172 DOI: 10.1016/j.healthpol.2013.05.021] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/29/2013] [Accepted: 05/29/2013] [Indexed: 11/16/2022]
Abstract
Health inequalities are the unjust differences in health between groups of people occupying different positions in society. Since the Black Report of 1980 there has been considerable effort to understand what causes them, so as to be able to identify actions to reduce them. This paper revisits and updates the proposed theories, evaluates the evidence in light of subsequent epidemiological research, and underlines the political and policy ramifications. The Black Report suggested four theories (artefact, selection, behavioural/cultural and structural) as to the root causes of health inequalities and suggested that structural theory provided the best explanation. These theories have since been elaborated to include intelligence and meritocracy as part of selection theory. However, the epidemiological evidence relating to the proposed causal pathways does not support these newer elaborations. They may provide partial explanations or insights into the mechanisms between cause and effect, but structural theory remains the best explanation as to the fundamental causes of health inequalities. The paper draws out the vitally important political and policy implications of this assessment. Health inequalities cannot be expected to reduce substantially as a result of policy aimed at changing health behaviours, particularly in the face of wider public policy that militates against reducing underlying social inequalities. Furthermore, political rhetoric about the need for 'cultural change', without the required changes in the distribution of power, income, wealth, or in the regulatory frameworks in society, is likely to divert from necessary action.
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Affiliation(s)
- Gerry McCartney
- Public Health Observatory Division, NHS Health Scotland, Elphinstone House, 65 West Regent Street, Glasgow G2 2AF, Scotland, United Kingdom.
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