Attention and memory impairments in pediatric patients with cystic fibrosis and inflammatory bowel disease in comparison to healthy controls

Obstructive sleep apnea in children with cystic fibrosis on highly effective modulator therapy

INTRODUCTION

Obstructive sleep apnea (OSA) is common in children with cystic fibrosis (CF). Highly effective modulator therapies (HEMT) have led to improved sinopulmonary disease, but whether this translates to a lower frequency of OSA is unknown.

METHODS

We conducted a single center retrospective review of polysomnographic (PSG) data from 2012 to 2023 in patients aged 0-18 years with CF to assess frequency of OSA. Participants were classified based on HEMT status. Logistic regression was used to quantify the association between HEMT and OSA with p < .05 considered significant.

RESULTS

Forty-nine children underwent PSG during the study period. Ten percent were of non-White race and 24% were of Hispanic ethnicity. Twenty-one children (43%) were on HEMT. These children were older than those not on modulators (11.6 vs. 6.4 years; p = .0001) but no different with respect to gender, race, nutritional status, or lung function. Twenty-eight (57%) children had OSA. Odds of having OSA were higher in the HEMT group (odds ratio [OR] = 4.3; 95% confidence interval [CI]: 1.2-14.9; p = .02). Tonsillar hypertrophy was associated with an increased odds of having OSA independent of modulator status (OR: 6.6; 95% CI: 1.2-37.9; p = .03).

CONCLUSIONS

OSA is frequently diagnosed in the post-HEMT era in this large, racially diverse group of children with CF. Children on HEMT were older and more likely to have OSA as compared to those not on modulators but similar in nutritional status, lung function, and presence of upper airway pathology. Prospective studies are needed to further clarify the relationship between HEMT and OSA in children with CF.

A systematic review of attention-deficit/hyperactivity disorder in people living with cystic fibrosis

There is a lack of research that has focused on attention-deficit hyperactivity disorder (ADHD) in people with cystic fibrosis (pwCF). Given ADHD is associated with executive functioning impairments, exploring ADHD in the context of living with cystic fibrosis (CF) is of great importance. The purpose of the current systematic review was to examine ADHD in pwCF across the lifespan in terms of its prevalence, its impact on various health outcomes, and treatments for managing ADHD. This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Articles reporting studies of any design that focused on ADHD in pwCF were included. Studies were excluded if they did not meet this criterion and if they were written in languages other than English. PsycINFO, MEDLINE, EMBASE, and CINAHL databases were searched. Search items were based on three concepts: (1) terms related to CF, (2) terms related to ADHD, and (3) terms related to age. Ten studies were included in this systematic review. Reported prevalence rates of ADHD in pwCF ranged from 5.26% to 21.9%. The reported relationships between ADHD and CF and other health outcomes is inconsistent. In terms of treatment considerations, pharmacological interventions and behavioural strategies for managing ADHD in the context of living with CF have been reported as being successful. Additional research is needed to further explore ADHD in the CF population and health variables that may be associated with CF prognosis.

Clearing up the smoke: Physical and mental health considerations regarding cannabis use in adolescents with cystic fibrosis

The cannabis plant is the most used federally illegal drug in the United States and is widely used by adolescents. Cannabis has complex effects on the body and mind. All health professionals who take care of adolescents with cystic fibrosis (CF) should be aware of the factors impacting cannabis use in CF. Given limited evidence regarding the benefits of cannabis and the significant risks, clinicians have the responsibility to identify risk of cannabis use early, counsel patients about the risks, provide a safe space for ongoing conversations about cannabis use in the context of CF care, and deliver evidence-based interventions.

Risk factors for obstructive sleep apnea in cystic fibrosis

INTRODUCTION

Despite emerging data that suggest a high frequency and severity of obstructive sleep apnea (OSA) among patients with cystic fibrosis (CF), few of them are referred for polysomnography. Little is known about which patients with CF are at increased risk for OSA and which sleep symptoms merit investigation.

METHODS

A single-center retrospective analysis of clinical and polysomnographic data from 2009, January 1 to October 31, 2020 in referred children and adults with CF.

RESULTS

Among 74 patients (42 children, 32 adults) with CF, 39 (53%) had OSA. No age or sex differences emerged in OSA frequency. Mean apnea-hypopnea index (AHI) was higher among overweight/obese adults (n = 16) as compared with adults of normal weight or underweight (11.4 vs. 6.2; p = 0.005). Adults with (n = 10) versus without a crowded oropharynx had 13.0 times greater odds of OSA (95% confidence interval (CI): 1.4, 121.4; p = 0.02). Children with (n = 24) versus without tonsillar hypertrophy had a higher risk for OSA (OR = 5.2; 95% CI: 1.4, 19.8; p = 0.02), as did children with (n = 10) versus without symptomatic chronic sinusitis (OR = 5.8; 95% CI: 1.1, 32.1; p = 0.04). Neither snoring, excessive daytime sleepiness, nor lung disease severity were associated with OSA.

CONCLUSION

Key risk factors for OSA may differ between children and adults with CF: upper airway pathology appears important in children and overweight/obesity or a crowded oropharynx in adults. Given the lack of sensitivity of snoring, daytime sleepiness, and lung disease severity, detection of OSA may require a low threshold for polysomnographic assessment in this vulnerable population.

Intensive pulmonary rehabilitation in a pediatric lung transplantation patient: A case report

BACKGROUND

The pediatric lung transplant is a very important treatment for patients with end-stage lung diseae, and pulmonary rehabilitation (PR) is also an important factor in determining the prognosis. However, there is no much literature available on pulmonary rehabilitation in pediatric patients' post lung transplant. Through this case report, we would like to present our intensive PR program for pediatric patients' post-lung transplant.

PATIENT CONCERNS

The 10-year-old boy's breathing before receiving a lung transplant continued to deteriorate and he eventually became dependent on a wheelchair.

DIAGNOSIS

He was diagnosed with infantile acute lymphoblastic leukemia at 6 months of age. At the age of one year, he underwent allogeneic bone marrow transplantation, but was diagnosed with post-transplantation bronchiolitis obliterans (PTBO) two months later. He had a lung transplant at the age of 10.

INTERVENTIONS

He was hospitalized and received an initial assessment. This assessment included functional, cognitive, and psychological evaluations. He additionally completed PR exercises twice daily for two weeks. After discharge, he continued to participate in an outpatient-based PR program for three months. During the outpatient phase, PR exercises were performed once weekly, in addition to home-based cognitive training.

OUTCOMES

Our intensive post-lung PR program improved our patient's exercise capacity, lung function, and quality of life. As a comprehensive rehabilitation service, our program also included a cognitive training component.

CONCLUSION

We describe an intensive PR program tailored to pediatric patients' post-lung transplant. The program was feasible and resulted in improvements in functional exercise capacity, lung function, and quality of life. Future research into our method is necessary for continued improvement of this novel program.

Promoting emotional wellness in children with CF, part II: Mental health assessment and intervention

This is the second of two companion papers that examine the emotional wellness of children with cystic fibrosis (CF) during the early years of life, defined here as the period between birth and age 12. Both papers promote optimal mental health and well-being, with an emphasis on early identification and intervention. The first paper explores child and family resilience. Here, we discuss strategies for pediatric CF teams to provide routine, systematic mental health assessment, anticipatory guidance, brief intervention, and triage to evidence-based treatment when needed, while addressing barriers to accessing care. Many mental health conditions emerge before the age of 12, with the potential for lifelong effects on individuals, their families, and society. Living with a chronic illness such as CF can further increase the risk of mental health concerns and, in a bidirectional manner, their consequences for the quality of life, sustaining daily care, and health outcomes. There has been a significant focus in recent years on the mental health and wellness of adolescents and adults with CF, but less attention to specifics of depression and anxiety in younger children, or to other common pediatric comorbidities including trauma, developmental disorders such as attention-deficit/hyperactivity disorder or autism spectrum disorder, and oppositional behavior. Given the availability of psychometrically sound screening instruments and effective interventions, routinely addressing the mental health of children with CF and their families is feasible to integrate within multidisciplinary CF care, allowing for a personalized approach respecting individual needs, values, and goals.

Visuomotor reaction time and dynamic balance in children with cystic fibrosis and non-cystic fibrosis bronchiectasis: A case-control study

OBJECTIVE

Extrapulmonary involvement such as balance and reaction time is unclear in cystic fibrosis (CF) patients. The aim of this study was to evaluate visuomotor reaction time (VMRT) and dynamic balance in children with CF and non-CF bronchiectasis compared to healthy children.

DESIGN/METHODS

Demographic and clinical characteristics were recorded. All children were evaluated with pulmonary function test (PFT) using a spirometer, incremental shuttle walk test (ISWT) for exercise capacity, Fitlight Trainer for VMRT, and functional reach test (FRT) for dynamic balance.

RESULTS

Fourteen children with CF (10.71 ± 2.94 years, 7 females), 17 children with non-CF bronchiectasis (12.75 ± 2.81 years, 8 females), and 21 healthy children (11.36 ± 3.28 years, 11 females) were included. Children with CF had longer total VMRT (P = .027), poorer FRT performance (P = .001), and shorter ISWT distances (P = .03) compared to the children with non-CF bronchiectasis and controls. Although total VMRT was longest in the CF group, there was no significant difference in mean VMRT among the CF, non-CF bronchiectasis, and control groups (P > .05).

CONCLUSION

Dynamic balance and VMRT show greater impairment in children with CF than in children with non-CF bronchiectasis compared to healthy controls. Our findings suggest that VMRT and dynamic balance should be taken into consideration for assessments and exercise programs in pulmonary rehabilitation.

Impaired cognitive function in Crohn's disease: Relationship to disease activity

Background & aims

Impaired attention and response inhibition have been reported in patients with Crohn’s disease (CD) in clinical remission. Prospective studies are needed to determine whether this is a stable feature of CD and whether a similar impairment is evident in ulcerative colitis (UC). Thus, our aims were to examine whether patients with CD and UC exhibited a persistent impairment in attentional performance, and if this impairment was related to key biological indices of relevance to cognition.

Methods

A prospective observational study was conducted on fifteen patients with CD and 7 with UC in clinical remission recruited from a specialty clinic and 30 healthy matched control participants. A neuropsychological assessment was carried out at baseline (visit 1) and at a 6 month follow-up (visit 2). Plasma proinflammatory cytokines, the plasma kynurenine:tryptophan (Kyn:Trp) ratio and the salivary cortisol awakening response (CAR) were also determined at each visit.

Results

Across visits, patients with CD exhibited impaired attentional performance (p ​= 0.023). Plasma IL-6 (P ​= ​0.001) and the Kyn:Trp ratio (P ​= ​0.03) were consistently elevated and the CAR significantly blunted (P ​< ​0.05) in patients with CD. No significant relationships were identified between any biochemical parameter and altered cognitive performance.

Conclusions

Impaired cognitive function is a stable feature of patients with CD. These data suggest that even where remission has been achieved, the functional impact of an organic gastrointestinal disorder on cognition is still evident. However, it is unclear at present if physiological changes due to disease activity play a role in cognitive impairment in CD.

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Crohn’s disease (CD) patients previously associated with impaired cognition.

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CD patients consistently exhibited impaired attentional performance at multiple visits.

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Functional impact of organic gastrointestinal disorder on cognition still evident in remission.

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Increased IL-6, kynurenine pathway activation and blunted cortisol awakening response in CD.

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Biochemical parameters not associated with altered cognitive performance.

Sleep-disordered breathing in cystic fibrosis

INTRODUCTION

Cystic fibrosis (CF) is a life-shortening, genetic disease that affects approximately 30,000 Americans. Although patients frequently report snoring, mouth breathing, and insomnia, the extent to which sleep-disordered breathing (SDB) may underlie these complaints remains unknown.

METHODS

Single-center retrospective review of polysomnography results from referred patients with and without CF individually-matched (1:2) for age, gender, race, and body mass index (BMI).

RESULTS

Mean ages were 8.0 ± 5.2 (sd) and 35.9 ± 12.9 years, among 29 children and 23 adults with CF respectively. The CF and non-CF groups were well-matched in age and BMI. Subjects with vs. without CF had three times greater odds of moderate-severe SDB (apnea-hypopnea index (AHI) ≥ 5 in children, ≥ 15 in adults) (p = 0.01). Nocturnal oxygen saturation nadir (Minimum SpO₂) was lower among CF vs. non-CF groups (p = 0.002). For every 1-unit increase in AHI, the decline in Minimum SpO₂ was larger for subjects with vs. without CF (p = 0.05). In subjects with CF, forced expiratory volume in 1 s percent predicted (FEV1 PPD) was associated with Minimum SpO₂ (Pearson r = 0.68, p < 0.0001) but not AHI (r = -0.19, p = 0.27). For every 1-unit increase in AHI, magnitude of decline in Minimum SpO₂ was larger for those with low vs. normal FEV1 PPD (p = 0.01).

CONCLUSION

Severity of SDB may be worse among referred patients with vs. without CF. The SDB may modify the relationship between CF lung disease and nocturnal hypoxemia. Markers of lung disease severity including lung function do not predict SDB severity, suggesting the need for routine polysomnography to screen for this sleep disorder.

Behavioral adaptations in a relapsing mouse model of colitis

Inflammatory bowel disease (IBD) is characterized by relapsing periods of gut inflammation, and is comorbid with depression, anxiety, and cognitive deficits. Animal models of IBD that explore the behavioral consequences almost exclusively use acute models of gut inflammation, which fails to recapitulate the cyclic, chronic nature of IBD. This study sought to identify behavioral differences in digging, memory, and stress-coping strategies in mice exposed to one (acute) or three (chronic) cycles of gut inflammation, using the dextran sodium sulfate (DSS) model of colitis. Similar levels of gut pathology were observed between acute and chronically exposed mice, although mice in the chronic treatment had significantly shorter colons, suggesting more severe disease. Behavioral measures revealed an unexpected pattern in which chronic treatment evoked fewer deficits than acute treatment. Specifically, acutely-treated mice showed alterations in measures of object burying, novel object recognition, object location memory, and stress-coping (forced swim task). Chronically-treated animals, however, showed similar alterations in object burying, but not the other measures. These data suggest an adaptive or tolerizing effect of repeated cycles of peripheral gut inflammation on mnemonic function and stress-coping, whereas some other behaviors continue to be affected by gut inflammation. We speculate that the normalization of some functions may involve the reversion to the baseline state of the hypothalamic-pituitary-adrenal axis and/or levels of neuroinflammation, which are both activated by the first exposure to the colitic agent.

Selective effects of acute low-grade inflammation on human visual attention

Illness is often accompanied by perceived cognitive sluggishness, a symptom that may stem from immune system activation. The current study used electroencephalography (EEG) to assess how inflammation affected three different distinct attentional processes: alerting, orienting and executive control. In a double-blinded placebo-controlled within-subjects design (20 healthy males, mean age = 24.5, SD = 3.4), Salmonella typhoid vaccination (0.025 mg; Typhim Vi, Sanofi Pasteur) was used to induce transient mild inflammation, while a saline injection served as a placebo-control. Participants completed the Attention Network Test with concurrent EEG recorded 6 h post-injection. Analyses focused on behavioral task performance and on modulation of oscillatory EEG activity in the alpha band (9-12 Hz) for alerting as well as orienting attention and frontal theta band (4-8 Hz) for executive control. Vaccination induced mild systemic inflammation, as assessed by interleukin-6 (IL-6) levels. While no behavioral task performance differences between the inflammation and placebo condition were evident, inflammation caused significant alterations to task-related brain activity. Specifically, inflammation produced greater cue-induced suppression of alpha power in the alerting aspect of attention and individual variation in the inflammatory response was significantly correlated with the degree of alpha power suppression. Notably, inflammation did not affect orienting (i.e., alpha lateralization) or executive control (i.e., frontal theta activity). These results reveal a unique neurophysiological sensitivity to acute mild inflammation of the neural network that underpins attentional alerting functions. Observed in the absence of performance decrements, these novel findings suggest that acute inflammation requires individuals to exert greater cognitive effort when preparing for a task in order to maintain adequate behavioral performance.

Changes in Heart Rate Variability in Patients with Spleen-Qi Deficiency Syndrome

Many functional diseases are related to dysautonomia, and heart rate variability has been used to assess dysautonomia. However, heart rate variability has not been studied in Spleen-Qi deficiency syndrome (SQDS). Healthy volunteers (n = 37) and patients with SQDS (n = 67), recruited from the Clinic of the State University of Ecatepec Valley were included in the study. Outcome measures were average heart rate, standard deviation of the normal-to-normal heartbeat intervals, low frequency (LF), high frequency (HF) power, and the LF/HF ratio. Also, intestinal peristalsis, gastrointestinal symptoms (GSs), fatigue, and level of attention were measured. Standard deviation of the normal-to-normal heartbeat intervals (17 ± 2.3%) and HF (14 ± 3.1%) were lower in SQDS patients (17 ± 1.3%) than in healthy volunteers. SQDS patients had higher heart rate, LF power, LF/HF ratio, and fatigue scores (9.6 ± 1.12%, 16 ± 2.1%, 22 ± 3.8%, and 21 ± 4.1%). The fatigue correlated positively with the LF/HF ratio and negatively with HF power. The SQDS group had lower concentration performance (16.2 ± 1.9%) in the d2 test. The intestinal peristalsis showed a reduction (15 ± 1.3%) as compared with control. GS score and peristalsis correlated negatively with HF. Our results suggest that the pathology of SDQS could be associated with a low vagal tone which causes a decrease in peristalsis, increased fatigue, reduced attention, and appearance of GSs.

Sleep disturbances and their impact in pediatric cystic fibrosis

Cystic fibrosis is a chronic, life-shortening illness that affects multiple systems and results in frequent respiratory infections, chronic cough, fat malabsorption and malnutrition. Poor sleep is often reported by patients with cystic fibrosis. Although objective data to explain these complaints have been limited, they do show poor sleep efficiency and frequent arousals. Abnormalities in gas exchange are also observed during sleep in patients with cystic fibrosis. The potential impact of these abnormalities in sleep on health and quality of life remains largely unstudied. This review summarizes what is known about sleep in children with cystic fibrosis, and implications for clinical practice. This report also highlights new evidence on the impact of sleep problems on disease-specific outcomes such as lung function, and identifies areas that need further exploration.