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Tung NWH, Edmondson C, Westrupp N, Rosenthal M, Davies JC. Neutrophil-to-lymphocyte ratio as a biomarker of acute pulmonary exacerbations in children with cystic fibrosis: a retrospective cohort study. Arch Dis Child 2024:archdischild-2024-327056. [PMID: 38876505 DOI: 10.1136/archdischild-2024-327056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/30/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Neutrophils are key contributors to chronic airway inflammation in cystic fibrosis (CF) lung disease, although airway and blood-based neutrophil markers are seldom used. The neutrophil-to-lymphocyte ratio (NLR) is an accessible biomarker, the clinical utility of which has not been adequately studied. OBJECTIVE This study aimed to investigate the characteristics of the NLR in children with CF and its correlations with acute pulmonary exacerbations and spirometry. DESIGN A previous study had collected clinical data from children with CF for a 3-year period between 2016 and 2021. Retrospectively, NLR values were categorised according to patients' clinical status during blood sample collection as 'stable', 'acute pulmonary exacerbation' or 'elective admission for chronic clinical concern'. MAIN OUTCOME MEASURES Demographic characteristics associated with the NLR; changes in NLR values in relation to clinical status; relationship between NLR and lung function. RESULTS 141 children with CF were included. NLR values during clinical stability were higher in females and increased with age. For children admitted for intravenous antibiotics, NLR values significantly increased from clinical stability (median (IQR)=1.13 (0.75-1.51)) to acute pulmonary exacerbations (median (IQR)=1.50 (0.96-2.65), p=0.001), but similar changes were not observed in elective admissions. The NLR was not associated with lung function. CONCLUSIONS The NLR demonstrated associations with clinical status in children with CF with significant elevations during acute pulmonary exacerbations. While its utility as a single-marker measure is limited, monitoring the NLR over time may help identify periods of increased inflammation.
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Affiliation(s)
| | - Claire Edmondson
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Nicole Westrupp
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark Rosenthal
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jane C Davies
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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Houston CJ, Alkhatib A, Einarsson GG, Tunney MM, Taggart CC, Downey DG. Diminished airway host innate response in people with cystic fibrosis who experience frequent pulmonary exacerbations. Eur Respir J 2024; 63:2301228. [PMID: 38135443 PMCID: PMC10882324 DOI: 10.1183/13993003.01228-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023]
Abstract
RATIONALE Pulmonary exacerbations are clinically impactful events that accelerate cystic fibrosis (CF) lung disease progression. The pathophysiological mechanisms underlying an increased frequency of pulmonary exacerbations have not been explored. OBJECTIVES To compare host immune response during intravenous antibiotic treatment of pulmonary exacerbations in people with CF who have a history of frequent versus infrequent exacerbations. METHODS Adults with CF were recruited at onset of antibiotic treatment of a pulmonary exacerbation and were categorised as infrequent or frequent exacerbators based on their pulmonary exacerbation frequency in the previous 12 months. Clinical parameters, sputum bacterial load and sputum inflammatory markers were measured on day 0, day 5 and at the end of treatment. Shotgun proteomic analysis was performed on sputum using liquid chromatography-mass spectrometry. MEASUREMENTS AND MAIN RESULTS Many sputum proteins were differentially enriched between infrequent and frequent exacerbators (day 0 n=23 and day 5 n=31). The majority of these proteins had a higher abundance in infrequent exacerbators and were secreted innate host defence proteins with antimicrobial, antiprotease and immunomodulatory functions. Several differentially enriched proteins were validated using ELISA and Western blot including secretory leukocyte protease inhibitor (SLPI), lipocalin-1 and cystatin SA. Sputum from frequent exacerbators demonstrated potent ability to cleave exogenous recombinant SLPI in a neutrophil elastase dependent manner. Frequent exacerbators had increased sputum inflammatory markers (interleukin (IL)-1β and IL-8) and total bacterial load compared to infrequent exacerbators. CONCLUSIONS A diminished innate host protein defence may play a role in the pathophysiological mechanisms of frequent CF pulmonary exacerbations. Frequent exacerbators may benefit from therapies targeting this dysregulated host immune response.
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Affiliation(s)
- Claire J Houston
- Airway Innate Immunity Research Group, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Aya Alkhatib
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | | | - Clifford C Taggart
- Airway Innate Immunity Research Group, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Joint senior authors
| | - Damian G Downey
- Belfast Health and Social Care Trust, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Joint senior authors
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3
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Milinic T, McElvaney OJ, Goss CH. Diagnosis and Management of Cystic Fibrosis Exacerbations. Semin Respir Crit Care Med 2023; 44:225-241. [PMID: 36746183 PMCID: PMC10131792 DOI: 10.1055/s-0042-1760250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is acute pulmonary exacerbation (PEx). Clinical and microbial epidemiology studies of CF PEx continue to provide important insight into the disease course, prognosis, and complications. This work has now led to several large-scale clinical trials designed to clarify the treatment paradigm for CF PEx. The primary goal of this review is to provide a summary and update of the pathophysiology, clinical and microbial epidemiology, outcome and treatment of CF PEx, biomarkers for exacerbation, and the impact of highly effective modulator therapy on these events moving forward.
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Affiliation(s)
- Tijana Milinic
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Oliver J McElvaney
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher H Goss
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Al-Keilani MS, Awad S, Hammouri HM, Al Shalakhti T, Almomani BA, Dahabreh MM, Ajlony MJ. Evaluation of serum VIP and aCGRP during pulmonary exacerbation in cystic fibrosis: A longitudinal pilot study of patients undergoing antibiotic therapy. PLoS One 2023; 18:e0284511. [PMID: 37146001 PMCID: PMC10162560 DOI: 10.1371/journal.pone.0284511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 04/02/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Objective monitoring of improvement during treatment of pulmonary exacerbation can be difficulty in children when pulmonary function testing cannot be obtained. Thus, the identification of predictive biomarkers to determine the efficacy of drug treatments is of high priority. The major aim of the current study was to investigate the serum levels of vasoactive intestinal peptide (VIP) and alpha calcitonin gene related peptide (aCGRP) of cystic fibrosis pediatric patients during pulmonary exacerbation and post-antibiotic therapy, and possible associations of their levels with different clinicopathological parameters. METHODS 21 patients with cystic fibrosis were recruited at onset of pulmonary exacerbation. Serum was collected at time of admission, three days post-antibiotic therapy, and two weeks post-antibiotic therapy (end of antibiotic therapy). Serum VIP and aCGRP levels were measured using ELISA. RESULTS Overall least square means of serum aCGRP level but not VIP changed from time of exacerbation to completion of antibiotic therapy (p = 0.005). Serum VIP was significantly associated with the presence of diabetes mellitus (p = 0.026) and other comorbidities (p = 0.013), and with type of antibiotic therapy (p = 0.019). Serum aCGRP level was significantly associated with type of antibiotic therapy (p = 0.012) and positive Staphylococcus aureus microbiology test (p = 0.046). CONCLUSION This study could only show significant changes in serum aCGRP levels following treatment of pulmonary exacerbations. Future studies with larger sample size are required to investigate the clinical importance of VIP and aCGRP in cystic fibrosis patients.
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Affiliation(s)
- Maha S Al-Keilani
- Department of Clinical Pharmacy, College of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Samah Awad
- Department of Pediatrics and Neonatology, College of Medicine, Jordan University of Science and Technology, Irbid, Jordan
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Hanan M Hammouri
- Department of Mathematics and Statistics, College of Science and Arts, Jordan University of Science and Technology, Irbid, Jordan
| | - Tala Al Shalakhti
- Department of Pediatrics and Neonatology, College of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Basima A Almomani
- Department of Clinical Pharmacy, College of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Muna M Dahabreh
- Department of Respiratory Medicine, Royal London Hospital Barts NHS Trust, London, United Kingdom
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5
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Hatziagorou E, Avramidou V, Gioulvanidou M, Talimtzi P, Kouroukli E, Mantsiou C, Lialias I, Nousia L, Tsanakas J. Pulmonary exacerbations, airway pathogens, and long-term course of lung clearance index in children and young adults with cystic fibrosis. Pediatr Pulmonol 2022; 57:3069-3076. [PMID: 36059241 DOI: 10.1002/ppul.26136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 07/29/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx), pathogens colonizing the respiratory tract, and patients' age are associated with progressive worsening of lung function among patients with cystic fibrosis (CF). However, the effect of these factors on longitudinal changes of Lung Clearance Index (LCI) remains unclear. AIM To assess the role of age, different types of bronchial infection, and PEx on LCI deterioration. METHODS We conducted a retrospective study assessing multiple-breath washout (MBW) and spirometry changes among CF patients evaluated at quarterly outpatient clinic visits over 8 years. MBW and spirometry were performed at each visit, sputum samples and/or cough swabs were obtained for culture, whereas respiratory symptoms and clinical examination findings were recorded. Patients who had ≥5 serial MBW measurements, one of which coincided with a pulmonary exacerbation, were reviewed. RESULTS Seventy-six patients were included in the study: mean age of 10.61 years (range 1.75-23.75). A total of 1152 MBW tests and 1047 spirometry tests were performed. LCI was significantly higher among CF patients aged 11-15, 16-20, and over 20 years than those under 5 years of age; ΔLCI: 1.16 (confidence interval [CI] 0.43-1.90) and 3.25 (CI 2.33-4.17), respectively. Furthermore, LCI was significantly elevated in CF patients with positive cultures for Pseudomonas aeruginosa (0.52 LCI [CI -0.12 to 0.71]) and Stenotrophomonas Maltophilia (1.41 LCI [CI 0.61-2.21]). Moreover, increased values of LCI in CF patients were significantly associated with increased risk of PEx (odds ratio [OR] 1.19, CI [1.14-1.25], p < 0.001). CONCLUSION LCI demonstrates a progression of lung disease and corresponds to changes in bacterial infections and PEx among patients with CF. LCI may be a valuable marker for tracking disease deterioration and may have a role in the routine clinical care of patients with CF.
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Affiliation(s)
- Elpis Hatziagorou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Avramidou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Gioulvanidou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Persefoni Talimtzi
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleana Kouroukli
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysanthi Mantsiou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Lialias
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lemonia Nousia
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Tsanakas
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Britto CJ, Ratjen F, Clancy JP. Emerging Approaches to Monitor and Modify Care in the Era of Cystic Fibrosis Transmembrane Conductance Regulators. Clin Chest Med 2022; 43:631-646. [PMID: 36344071 DOI: 10.1016/j.ccm.2022.06.006] [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: 11/06/2022]
Abstract
As we characterize the clinical benefits of highly effective modulator therapy (HEMT) in the cystic fibrosis (CF) population, our paradigm for treating and monitoring disease continues to evolve. More sensitive approaches are necessary to detect early disease and clinical progression. This article reviews evolving strategies to assess disease control and progression in the HEMT era. This article also explores developments in pulmonary function monitoring, advanced respiratory imaging, tools for the collection of patient-reported outcomes, and their application to profile individual responses, guide therapeutic decisions, and improve the quality of life of people with CF.
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Affiliation(s)
- Clemente J Britto
- Yale Adult Cystic Fibrosis Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine.
| | - Felix Ratjen
- Division of Respiratory Medicine, Translational Medicine, University of Toronto Hospital for Sick Children, 555 University Avenue, Toronto Ontario M5G 1X8, Canada
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Caverly LJ, Riquelme SA, Hisert KB. The Impact of Highly Effective Modulator Therapy on Cystic Fibrosis Microbiology and Inflammation. Clin Chest Med 2022; 43:647-665. [PMID: 36344072 PMCID: PMC10224747 DOI: 10.1016/j.ccm.2022.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Highly effective cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator therapy (HEMT) corrects the underlying molecular defect causing CF disease. HEMT decreases symptom burden and improves clinical metrics and quality of life for most people with CF (PwCF) and eligible cftr mutations. Improvements in measures of pulmonary health suggest that restoration of function of defective CFTR anion channels by HEMT not only enhances airway mucociliary clearance, but also reduces chronic pulmonary infection and inflammation. This article reviews the evidence for how HEMT influences the dynamic and interdependent processes of infection and inflammation in the CF airway, and what questions remain unanswered.
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Affiliation(s)
- Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, L2221 UH South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5212, USA
| | - Sebastián A Riquelme
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, Columbia University Medical Center, 650West 168th Street, New York, NY 10032, USA
| | - Katherine B Hisert
- Department of Medicine, National Jewish Health, Smith A550, 1400 Jackson Street, Denver, CO 80205, USA.
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Imanzadeh F, Kerami F, Hassanzad M, Hosseini A, Hajipour M, Khanbabaee G, Dara N, Khatami K, Farahbakhsh N, Sayyari A. The association of fecal calprotectin and respiratory exacerbation in cystic fibrosis patients. BMC Gastroenterol 2022; 22:494. [DOI: 10.1186/s12876-022-02553-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 10/17/2022] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background
CF patients experience several episodes of pulmonary exacerbations and reduction in their lung function progressively. Lung function is not the only diagnostic index by physicians to decide if CF patients require antibiotic therapy following pulmonary exacerbations. Non-invasive fecal indicators are increasingly being used to assess intestinal inflammation. Calprotectin is the most extensively utilized fecal biomarker in recent CF researches.
Methods
In this longitudinal study, 30 CF patients (1–18 years) without current infectious gastroenteritis were recruited from Mofid Children's Hospital and Masih Daneshvari Hospital, Tehran, Iran. Then, fecal calprotectin levels were evaluated before treatment, two weeks after systemic antibiotic administration, as well as recurrence of pulmonary exacerbation after first post-hospital discharge.
Results
The initial fecal calprotectin level in CF patients receiving antibiotics was 651.13 ± 671.04, significantly decreasing two weeks after antibiotic therapy and following recurrence (171.81 ± 224.40, 607.93 ± 549.89, respectively; P < 0.01). Following systemic antibiotic treatment, the patient's respiratory and GI symptoms improved (P < 0.01).
Conclusion
Our findings revealed that fecal calprotectin modifications are associated with CF pulmonary exacerbations and antibiotic treatment could reduce calprotectin levels. Therefore, the fecal calprotectin level could be considered as a diagnostic tool and an index to follow the response to treatment in CF pulmonary exacerbations.
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α-Tocopherol Pharmacokinetics in Adults with Cystic Fibrosis: Benefits of Supplemental Vitamin C Administration. Nutrients 2022; 14:nu14183717. [PMID: 36145092 PMCID: PMC9505313 DOI: 10.3390/nu14183717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Numerous abnormalities in cystic fibrosis (CF) could influence tocopherol absorption, transportation, storage, metabolism and excretion. We hypothesized that the oxidative distress due to inflammation in CF increases vitamin E utilization, which could be positively influenced by supplemental vitamin C administration. METHODS Immediately before and after receiving vitamin C (500 mg) twice daily for 3.5 weeks, adult CF patients (n = 6) with moderately advanced respiratory tract (RT) disease consumed a standardized breakfast with 30% fat and a capsule containing 50 mg each hexadeuterium (d6)-α- and dideuterium (d2)-γ-tocopheryl acetates. Blood samples were taken frequently up to 72 h; plasma tocopherol pharmacokinetics were determined. During both trials, d6-α- and d2-γ-tocopherols were similarly absorbed and reached similar maximal plasma concentrations ~18-20 h. As predicted, during vitamin C supplementation, the rates of plasma d6-α-tocopherol decline were significantly slower. CONCLUSIONS The vitamin C-induced decrease in the plasma disappearance rate of α-tocopherol suggests that vitamin C recycled α-tocopherol, thereby augmenting its concentrations. We conclude that some attention should be paid to plasma ascorbic acid concentrations in CF patients, particularly to those individuals with more advanced RT inflammatory disease and including those with severe exacerbations.
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Hine C, Desai M, Davies J, Sapey E, Nagakumar P. A systematic review of lung clearance index in non-cystic fibrosis, non-primary ciliary dyskinesia bronchiectasis. Respir Med 2022; 201:106937. [DOI: 10.1016/j.rmed.2022.106937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/11/2022] [Accepted: 07/16/2022] [Indexed: 11/27/2022]
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Wojsyk-Banaszak I, Więckowska B, Stachowiak Z, Kycler M, Szczepankiewicz A. Predictive value of impulse oscillometry and multiple breath washout parameters in pediatric patients with cystic fibrosis pulmonary exacerbation. Pediatr Pulmonol 2022; 57:1466-1474. [PMID: 35293155 DOI: 10.1002/ppul.25891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PE) tend to complicate the course of cystic fibrosis (CF) and worsen the disease prognosis. One of the diagnostic criteria for an exacerbation is the forced expiratory volume in the first second (FEV1 ) decline. Not all children, however, are able to perform spirometry. Therefore, the aim of this study was to evaluate alternative lung function tests in the diagnosis of PE. METHODS We assessed retrospectively the results of impulse oscillometry (IOS) and lung clearance index in multiple breath washout (MBW) during 259 visits in 47 CF paediatric patients. The differences in the results were compared between patients diagnosed with PE (ΔPE) and those in stable condition (ΔS). RESULTS Among the whole group of patients, we found significant differences between the changes during exacerbation (ΔPEs) and stable condition (ΔSs) values for lung clearance index (LCI), Sacin , R5Hz, R5-20Hz, X10Hz, AX, and Fres. The predictive values of Fres and X10Hz in IOS (AUCROC 0.71 both parameters) were higher than those of LCI (AUCROC 0.67). There was no difference in the predictive values (AUCROC ) of Δ LCI and IOS parameters in the subgroups of patients stratified based on FEV1 z-score cut-off value of -1.64. In both groups of patients, predictive values of LCI were slightly lower than of IOS parameters (AUC 0.66 for LCI vs. 0.69 for both ΔX10Hz z-score and Δ Fres z-score in patients with FEV1 z-score ≥-1.64 and AUC 0.67 for LCI vs 0.69 for both ΔX10Hz zscore and Δ Fres zscore in patients with FEV1 <1.64. CONCLUSIONS Both IOS and MBW measurements are useful in the assessment of pediatric CF patients with PE. LCI has a similar predictive value to IOS in children with CF independently of their FEV1 value.
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Affiliation(s)
- Irena Wojsyk-Banaszak
- Department of Paediatric Pulmonology, Allergy, and Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Więckowska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Zuzanna Stachowiak
- Unit of Molecular and Cell Biology, Department of Paediatric Pulmonology, Allergy, and Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Kycler
- Department of Paediatric Pulmonology, Allergy, and Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Szczepankiewicz
- Unit of Molecular and Cell Biology, Department of Paediatric Pulmonology, Allergy, and Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
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12
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The role of procalcitonin as a biomarker for acute pulmonary exacerbation in subjects with cystic fibrosis and non-cystic fibrosis bronchiectasis. MARMARA MEDICAL JOURNAL 2022. [DOI: 10.5472/marumj.1114952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Ciet P, Bertolo S, Ros M, Casciaro R, Cipolli M, Colagrande S, Costa S, Galici V, Gramegna A, Lanza C, Lucca F, Macconi L, Majo F, Paciaroni A, Parisi GF, Rizzo F, Salamone I, Santangelo T, Scudeller L, Saba L, Tomà P, Morana G. State-of-the-art review of lung imaging in cystic fibrosis with recommendations for pulmonologists and radiologists from the "iMAging managEment of cySTic fibROsis" (MAESTRO) consortium. Eur Respir Rev 2022; 31:31/163/210173. [PMID: 35321929 DOI: 10.1183/16000617.0173-2021] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Imaging represents an important noninvasive means to assess cystic fibrosis (CF) lung disease, which remains the main cause of morbidity and mortality in CF patients. While the development of new imaging techniques has revolutionised clinical practice, advances have posed diagnostic and monitoring challenges. The authors aim to summarise these challenges and make evidence-based recommendations regarding imaging assessment for both clinicians and radiologists. STUDY DESIGN A committee of 21 experts in CF from the 10 largest specialist centres in Italy was convened, including a radiologist and a pulmonologist from each centre, with the overall aim of developing clear and actionable recommendations for lung imaging in CF. An a priori threshold of at least 80% of the votes was required for acceptance of each statement of recommendation. RESULTS After a systematic review of the relevant literature, the committee convened to evaluate 167 articles. Following five RAND conferences, consensus statements were developed by an executive subcommittee. The entire consensus committee voted and approved 28 main statements. CONCLUSIONS There is a need for international guidelines regarding the appropriate timing and selection of imaging modality for patients with CF lung disease; timing and selection depends upon the clinical scenario, the patient's age, lung function and type of treatment. Despite its ubiquity, the use of the chest radiograph remains controversial. Both computed tomography and magnetic resonance imaging should be routinely used to monitor CF lung disease. Future studies should focus on imaging protocol harmonisation both for computed tomography and for magnetic resonance imaging. The introduction of artificial intelligence imaging analysis may further revolutionise clinical practice by providing fast and reliable quantitative outcomes to assess disease status. To date, there is no evidence supporting the use of lung ultrasound to monitor CF lung disease.
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Affiliation(s)
- Pierluigi Ciet
- Radiology and Nuclear Medicine Dept, Erasmus MC, Rotterdam, The Netherlands .,Pediatric Pulmonology and Allergology Dept, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands.,Depts of Radiology and Medical Science, University of Cagliari, Cagliari, Italy
| | - Silvia Bertolo
- Radiology Dept, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Mirco Ros
- Dept of Pediatrics, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Rosaria Casciaro
- Dept of Pediatrics, IRCCS Institute "Giannina Gaslini", Cystic Fibrosis Centre, Genoa, Italy
| | - Marco Cipolli
- Regional Reference Cystic Fibrosis center, University hospital of Verona, Verona, Italy
| | - Stefano Colagrande
- Dept of Experimental and Clinical Biomedical Sciences, Radiodiagnostic Unit n. 2, University of Florence- Careggi Hospital, Florence, Italy
| | - Stefano Costa
- Dept of Pediatrics, Gaetano Martino Hospital, Messina, Italy
| | - Valeria Galici
- Cystic Fibrosis Centre, Dept of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Andrea Gramegna
- Respiratory Disease and Adult Cystic Fibrosis Centre, Internal Medicine Dept, IRCCS Ca' Granda, Milan, Italy.,Dept of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Cecilia Lanza
- Radiology Dept, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Francesca Lucca
- Regional Reference Cystic Fibrosis center, University hospital of Verona, Verona, Italy
| | - Letizia Macconi
- Radiology Dept, Tuscany Reference Cystic Fibrosis Centre, Meyer Children's Hospital, Florence, Italy
| | - Fabio Majo
- Dept of Pediatrics, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Giuseppe Fabio Parisi
- Pediatric Pulmonology Unit, Dept of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesca Rizzo
- Radiology Dept, IRCCS Institute "Giannina Gaslini", Cystic Fibrosis Center, Genoa, Italy
| | | | - Teresa Santangelo
- Dept of Radiology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Luigia Scudeller
- Clinical Epidemiology, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy
| | - Luca Saba
- Depts of Radiology and Medical Science, University of Cagliari, Cagliari, Italy
| | - Paolo Tomà
- Dept of Radiology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Giovanni Morana
- Radiology Dept, Ca'Foncello S. Maria Hospital, Treviso, Italy
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14
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Gambazza S, Mariani A, Brivio A, Carta F, Blardone C, Lisiero S, Russo M, Colombo C. Time Free From Hospitalization in Children and Adolescents With Cystic Fibrosis: Findings From FEV 1, Lung Clearance Index and Peak Work Rate. Front Pediatr 2022; 10:926248. [PMID: 35813385 PMCID: PMC9257036 DOI: 10.3389/fped.2022.926248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An exercise test combined with a multiple breath washout nitrogen test (MBWN2) may offer a comprehensive clinical evaluation of cystic fibrosis (CF) disease in children with normal spirometry. The purpose of the present study is to explore whether information derived from spirometry, MBWN2, and exercise tests can help the CF multidisciplinary team to characterize time free from hospitalization due to pulmonary exacerbation (PE) in a cohort of pediatric patients with CF. METHODS This prospective observational study was carried out at the Lombardia Region Reference Center for Cystic Fibrosis in Milano, Italy. In 2015, we consecutively enrolled children and adolescents aged <18 years with spirometry, MBWN2, and Godfrey exercise test performed during an outpatient visit. RESULTS Over a median follow-up time of 2.2 years (interquartile range [IQR], 2.01; 3.18), 28 patients aged between 13.0 and 17.4 years were included. When lung functions were outside the normal range, 50% of patients were hospitalized 4 months after the outpatient visit, and their response to exercise was abnormal (100%). Half of the individuals with normal forced expiratory volume in the first second (FEV1) and abnormal lung clearance index (LCI) experienced the first hospital admission 9 months after the clinic visit, and 84.2% presented an abnormal response to exercise. Conversely, 15.8% had abnormal exercise responses when lung functions were considered normal, with half of the adolescents hospitalized at 11 months. CONCLUSION Maintaining ventilation homogeneity, along with a normal ability to sustain intense work, may have a positive impact on the burden of CF disease, here conceived as time free from hospitalization due to PE.
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Affiliation(s)
- Simone Gambazza
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy
| | - Alessandra Mariani
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy.,Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Cystic Fibrosis Centre of Milan, Milan, Italy
| | - Anna Brivio
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy.,Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Cystic Fibrosis Centre of Milan, Milan, Italy
| | - Federica Carta
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy.,Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Cystic Fibrosis Centre of Milan, Milan, Italy
| | - Chiara Blardone
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy.,Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Cystic Fibrosis Centre of Milan, Milan, Italy
| | - Saba Lisiero
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy.,Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Cystic Fibrosis Centre of Milan, Milan, Italy
| | - Maria Russo
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Cystic Fibrosis Centre of Milan, Milan, Italy
| | - Carla Colombo
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Healthcare Professions Department, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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15
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VanDevanter DR, Heltshe SL, Skalland M, West NE, Sanders DB, Goss CH, Flume PA. C-reactive protein (CRP) as a biomarker of pulmonary exacerbation presentation and treatment response. J Cyst Fibros 2021; 21:588-593. [PMID: 34933824 DOI: 10.1016/j.jcf.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND C-reactive protein (CRP) has been proposed as a biomarker for pulmonary exacerbation (PEx) diagnosis and treatment response. CRP >75mg/L has been associated with increased risk of PEx treatment failure. We have analyzed CRP measures as biomarkers for clinical response during the STOP2 PEx study (NCT02781610). METHODS CRP measures were collected at antimicrobial treatment start (V1), seven to 10 days later (V2), and two weeks after treatment end (V3). V1 log10CRP concentrations and log10CRP change from V1 to V3 correlations with clinical responses (changes in lung function and symptom score) were assessed by least squares regression. Odds of intravenous (IV) antimicrobial retreatment within 30 days and future PEx hazard associated with V1 and V3 CRP concentrations and V1 CRP >75 mg/L were studied by adjusted logistic regression and proportional hazards modeling, respectively. RESULTS In all, 951 of 982 STOP2 subjects (92.7%) had CRP measures at V1. V1 log10CRP varied significantly by V1 lung function subgroup, symptom score quartile, and sex, but not by age subgroup. V1 log10CRP correlated moderately with log10CRP change at V3 (r2=0.255) but less so with lung function (r2=0.016) or symptom (r2=0.031) changes at V3. Higher V1 CRP was associated with greater response. CRP changes from V1 to V3 only weakly correlated with lung function (r2=0.061) and symptom (r2=0.066) changes. However, V3 log10CRP was associated with increased odds of retreatment (P = .0081) and future PEx hazard (P = .0114). DISCUSSION Despite consistent trends, log10CRP change was highly variable with only limited utility as a biomarker of PEx treatment response.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve Univ. School of Medicine, Cleveland OH, USA.
| | - S L Heltshe
- Univ. of Washington, Seattle WA, USA; CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - M Skalland
- CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - N E West
- Johns Hopkins University, Baltimore MD, USA
| | - D B Sanders
- Indiana Univ. School of Medicine, Indianapolis IN, USA
| | - C H Goss
- Univ. of Washington, Seattle WA, USA
| | - P A Flume
- Medical Univ. of South Carolina, Charleston SC, USA
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16
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Lepissier A, Addy C, Hayes K, Noel S, Bui S, Burgel PR, Dupont L, Eickmeier O, Fayon M, Leal T, Lopes C, Downey DG, Sermet-Gaudelus I. Inflammation biomarkers in sputum for clinical trials in cystic fibrosis: current understanding and gaps in knowledge. J Cyst Fibros 2021; 21:691-706. [PMID: 34772643 DOI: 10.1016/j.jcf.2021.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022]
Abstract
RATIONALE Sputum biomarkers hold promise as a direct measure of inflammation within the cystic fibrosis (CF) lung, but variability in study design and sampling methodology have limited their use. A full evaluation of the reliability, validity and clinical relevance of individual biomarkers is required to optimise their use within CF clinical research. OBJECTIVES A biomarker Special Interest Working Group was established within the European Cystic Fibrosis Society-Clinical Trials Network Standardisation Committee, to perform a review of the evidence regarding sputum biomarkers in CF. METHODS From the 139 included articles, we identified 71 sputum biomarkers to undergo evaluation of their clinimetric properties, responsiveness, discriminant, concurrent and convergent validity. RESULTS Current evidence confirms the potential of sputum biomarkers as outcome measures in clinical trials. Inconsistency in responsiveness, concurrent and convergent validity require further research into these markers and processing standardisation before translation into wider use. Of the 71 biomarkers identified, Neutrophil Elastase (NE), IL-8, TNF-α and IL-1β, demonstrated validity and responsiveness to be currently considered for use in clinical trials. Other biomarkers show future promise, including IL-6, calprotectin, HMGB-1 and YKL-40. CONCLUSION A concerted international effort across the cystic fibrosis community is needed to promote high quality biomarker trial design, establish large population-based biomarker studies, and work together to create standards for collection, storage and analysis of sputum biomarkers.
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Affiliation(s)
- Agathe Lepissier
- Paediatric Center for Cystic Fibrosis, Centre de Référence Maladies Rares, Mucoviscidose et Maladies Apparentées, Hôpital Necker Enfants Malades 149 rue de Sévres, Paris 75743, France; INSERM U1151, Institut Necker Enfants Malades, 160 rue de Vaugirard, Paris 75743, France; European Reference Network (ERN Lung)
| | - Charlotte Addy
- Northern Ireland Clinical Research Facility, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL; All Wales Adult Cystic Fibrosis Centre, University Hopsital Llandough, Penlan Road, CF64 2XX
| | - Kate Hayes
- Northern Ireland Clinical Research Facility, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL
| | - Sabrina Noel
- INSERM U1151, Institut Necker Enfants Malades, 160 rue de Vaugirard, Paris 75743, France
| | - Stéphanie Bui
- Université de Bordeaux (INSERM U1045), CHU de Bordeaux, (CIC1401), F-33000 Bordeaux, France
| | - Pierre-Régis Burgel
- European Reference Network (ERN Lung); National Reference Cystic Fibrosis Center and Department of Respiratory Medicine, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, 75014, France; Institut Cochin, INSERM U1016 and Université de Paris; Paris 75014, France
| | - Lieven Dupont
- University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
| | - Olaf Eickmeier
- Facharzt für Kinder- und Jugendmedizin, Universitätsklinikum Frankfurt a.M., Johann Wolfgang-Goethe-Universität, Allergologie, Pneumologie & Mukoviszidose, Theodor-Stern-Kai 7, 60590 Frankfurt/Main
| | - Michael Fayon
- Université de Bordeaux (INSERM U1045), CHU de Bordeaux, (CIC1401), F-33000 Bordeaux, France
| | - Teresinha Leal
- Louvain Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Carlos Lopes
- Departamento do Tórax, Hospital de Santa Maria, Lisbon
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL
| | - Isabelle Sermet-Gaudelus
- Paediatric Center for Cystic Fibrosis, Centre de Référence Maladies Rares, Mucoviscidose et Maladies Apparentées, Hôpital Necker Enfants Malades 149 rue de Sévres, Paris 75743, France; INSERM U1151, Institut Necker Enfants Malades, 160 rue de Vaugirard, Paris 75743, France; European Reference Network (ERN Lung); Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Hôpital Necker Enfants Malades 149 rue de Sévres, INSERM U1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris 75743, France.
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17
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Lung Clearance Index in Children with Cystic Fibrosis during Pulmonary Exacerbation. J Clin Med 2021; 10:jcm10214884. [PMID: 34768401 PMCID: PMC8584600 DOI: 10.3390/jcm10214884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Pulmonary exacerbation (PEx) is one of the main factors affecting the quality of life and life expectancy in patients with cystic fibrosis (CF). Our study aimed to evaluate the change in selected pulmonary function parameters, including lung clearance index (LCI), in patients with CF diagnosed with PEx. (2) Methods: We enrolled 40 children with CF aged 6–17. They performed spirometry and multiple breath nitrogen washout (MBNW) tests during a stable condition period at the beginning and the end of intravenous antibiotic treatment. (3) Results: LCI increased by 65% and FEV1 decreased by ≥10% in 40% of patients with CF during PEx. An absolute change in LCI between a stable condition period and PEx was 1.05 (±1.92) units, which corresponds to a relative change of 11.48% (±18.61) of the baseline. The relative decrease in FEV1 was −9.22% (±12.00) and the z-score was −0.67 (±1.13). After the PEx treatment, FEV1 increased by 11.05% (±9.04) on average, whereas LCI decreased by 1.21 ± 1.59 units on average, which represented 9.42% ± 11.40 compared to the value at the beginning of PEx. (4) Conclusions: The change in LCI captures a higher proportion of events with functional impairment than FEV1 in school-age children with CF.
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18
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Valk A, Willers C, Shahim K, Pusterla O, Bauman G, Sandkühler R, Bieri O, Wyler F, Latzin P. Defect distribution index: A novel metric for functional lung MRI in cystic fibrosis. Magn Reson Med 2021; 86:3224-3235. [PMID: 34337778 PMCID: PMC9292253 DOI: 10.1002/mrm.28947] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/26/2021] [Accepted: 07/15/2021] [Indexed: 11/22/2022]
Abstract
Purpose Lung impairment from functional MRI is frequently assessed as defect percentage. The defect distribution, however, is currently not quantified. The purpose of this work was to develop a novel measure that quantifies how clustered or scattered defects in functional lung MRI appear, and to evaluate it in pediatric cystic fibrosis. Theory The defect distribution index (DDI) calculates a score for each lung voxel categorized as defected. The index increases according to how densely and how far an expanding circle around a defect voxel contains more than 50% defect voxels. Methods Fractional ventilation and perfusion maps of 53 children with cystic fibrosis were previously acquired with matrix pencil decomposition MRI. In this work, the DDI is compared to a visual score of 3 raters who evaluated how clustered the lung defects appear. Further, spearman correlations between DDI and lung function parameters were determined. Results The DDI strongly correlates with the visual scoring (r = 0.90 for ventilation; r = 0.88 for perfusion; P < .0001). Although correlations between DDI and defect percentage are moderate to strong (r = 0.61 for ventilation; r = 0.75 for perfusion; P < .0001), the DDI distinguishes between patients with comparable defect percentage. Conclusion The DDI is a novel measure for functional lung MRI. It provides complementary information to the defect percentage because the DDI assesses defect distribution rather than defect size. The DDI is applicable to matrix pencil MRI data of cystic fibrosis patients and shows very good agreement with human perception of defect distributions. Click here for author‐reader discussions
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Affiliation(s)
- Anne Valk
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Division of Paediatric Pulmonology and Allergology, Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Corin Willers
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kamal Shahim
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Orso Pusterla
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland.,Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Grzegorz Bauman
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Robin Sandkühler
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Florian Wyler
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Latzin
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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19
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Khanal S, Webster M, Niu N, Zielonka J, Nunez M, Chupp G, Slade MD, Cohn L, Sauler M, Gomez JL, Tarran R, Sharma L, Dela Cruz CS, Egan M, Laguna T, Britto CJ. SPLUNC1: a novel marker of cystic fibrosis exacerbations. Eur Respir J 2021; 58:13993003.00507-2020. [PMID: 33958427 DOI: 10.1183/13993003.00507-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/29/2021] [Indexed: 11/05/2022]
Abstract
Acute pulmonary Exacerbations (AE) are episodes of clinical worsening in cystic fibrosis (CF), often precipitated by infection. Timely detection is critical to minimise morbidity and lung function declines associated with acute inflammation during AE. Based on our previous observations that airway protein Short Palate Lung Nasal epithelium Clone 1 (SPLUNC1) is regulated by inflammatory signals, we investigated the use of SPLUNC1 fluctuations to diagnose and predict AE in CF.We enrolled CF participants from two independent cohorts to measure AE markers of inflammation in sputum and recorded clinical outcomes for a 1-year follow-up period.SPLUNC1 levels were high in healthy controls (n=9, 10.7 μg mL-1), and significantly decreased in CF participants without AE (n=30, 5.7 μg mL-1, p=0.016). SPLUNC1 levels were 71.9% lower during AE (n=14, 1.6 μg mL-1, p=0.0034) regardless of age, sex, CF-causing mutation, or microbiology findings. Cytokines Il-1β and TNFα were also increased in AE, whereas lung function did not consistently decrease. Stable CF participants with lower SPLUNC1 levels were much more likely to have an AE at 60 days (HR: 11.49, Standard Error: 0.83, p=0.0033). Low-SPLUNC1 stable participants remained at higher AE risk even one year after sputum collection (HR: 3.21, Standard Error: 0.47, p=0.0125). SPLUNC1 was downregulated by inflammatory cytokines and proteases increased in sputum during AE.In acute CF care, low SPLUNC1 levels could support a decision to increase airway clearance or to initiate pharmacological interventions. In asymptomatic, stable patients, low SPLUNC1 levels could inform changes in clinical management to improve long-term disease control and clinical outcomes in CF.
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Affiliation(s)
- Sara Khanal
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan Webster
- Department of Cell Biology & Physiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Naiqian Niu
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jana Zielonka
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Myra Nunez
- Division of Pediatric Respiratory Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Geoffrey Chupp
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Martin D Slade
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lauren Cohn
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maor Sauler
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jose L Gomez
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Robert Tarran
- Department of Cell Biology & Physiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lokesh Sharma
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles S Dela Cruz
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marie Egan
- Division of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Theresa Laguna
- Division of Pediatric Respiratory Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Clemente J Britto
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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20
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Gifford AH, Polineni D, He J, D'Amico JL, Dorman DB, Williams MA, Nymon AB, Balwan A, Budden T, Zuckerman JB. A pilot study of cystic fibrosis exacerbation response phenotypes reveals contrasting serum and sputum iron trends. Sci Rep 2021; 11:4897. [PMID: 33649353 PMCID: PMC7921142 DOI: 10.1038/s41598-021-84041-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/11/2021] [Indexed: 11/09/2022] Open
Abstract
The cystic fibrosis (CF) community seeks to explain heterogeneous outcomes of pulmonary exacerbation (PEX) treatment. Serum and sputum inflammatory mediators may identify people with CF (PwCF) at risk for suboptimal responses. However, lack of an established association between response phenotypes and these mediators limits clinical application. In this pilot study, we prospectively characterized treatment response phenotypes by assessing health-related quality-of-life (HRQoL) during PEX. We also measured lung function and iron-related biochemical parameters in serum and sputum. We classified subjects as sustained symptom-responders (SRs) or non-sustained symptom-responders (NSRs) based on the absence or presence, respectively, of worsened symptom scores after initial improvement. We used linear mixed models (LMMs) to determine whether trends in lung function, hematologic, serum, and sputum indices of inflammation differed between response cohorts. In 20 PwCF, we identified 10 SRs and 10 NSRs with no significant differences in lung function at PEX onset and treatment durations. SRs had better model-predicted trends in lung function than NSRs during PEX. Non-linear trends in serum and sputum iron levels significantly differed between SRs and NSRs. In adults with cystic fibrosis, PEX treatment response phenotypes may be correlated with distinctive trends in serum and sputum iron concentrations.
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Affiliation(s)
- Alex H Gifford
- Section of Pulmonary Medicine, 5C, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Deepika Polineni
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 3007, Kansas City, KS, 66160, USA.
| | - Jianghua He
- Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jessica L D'Amico
- Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Dana B Dorman
- Section of Pulmonary Medicine, 5C, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Molly A Williams
- Section of Pulmonary Medicine, 5C, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Amanda B Nymon
- Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Akshu Balwan
- Pulmonary and Critical Care Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Theodore Budden
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 3007, Kansas City, KS, 66160, USA
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21
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Walicka-Serzysko K, Postek M, Jeneralska N, Cichocka A, Milczewska J, Sands D. The effects of the addition of a new airway clearance device to chest physiotherapy in children with cystic fibrosis pulmonary exacerbations. JOURNAL OF MOTHER AND CHILD 2021; 24:16-24. [PMID: 33544556 PMCID: PMC8258837 DOI: 10.34763/jmotherandchild.20202403.2013.d-20-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chest physiotherapy plays a crucial role in managing cystic fibrosis, especially during pulmonary exacerbations. This study evaluated the effects of adding a new airway clearance device to chest physiotherapy in subjects with cystic fibrosis hospitalised due to pulmonary exacerbations. METHODS This prospective open-label study was carried out at the Pediatric Cystic Fibrosis Centre in Poland between October 2017 and August 2018. Cystic fibrosis patients aged 10 to 18 years who were admitted to the hospital and required intravenous antibiotic therapy due to pulmonary exacerbations were consecutively allocated (1:1) to either chest physiotherapy alone or chest physiotherapy with a new airway clearance device (Simeox; PhysioAssist). Patients performed spirometry and multiple-breath nitrogen washout for lung clearance index assessment upon admission and prior to discharge. RESULTS Forty-eight cystic fibrosis patients were included (24 in each group). Spirometry parameters in both groups improved significantly after intravenous antibiotic therapy. A significant improvement in the maximum expiratory flow at 25% of forced vital capacity was observed only in the group with a new airway clearance device (p < 0.01 vs. baseline). Trends towards a lower lung clearance index ratio were similar in both groups. No adverse events were observed in either group. CONCLUSIONS Spirometry parameters increased significantly in cystic fibrosis patients treated for pulmonary exacerbations with intravenous antibiotic therapy and intensive chest physiotherapy. The new airway clearance device was safe and well tolerated when added to chest physiotherapy and may be another option for the treatment of pulmonary exacerbation in cystic fibrosis.
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Affiliation(s)
- Katarzyna Walicka-Serzysko
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland, E-mail:
| | - Magdalena Postek
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland
| | | | | | - Justyna Milczewska
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland,Cystic Fibrosis Centre, Pediatric Hospital, Dziekanow Lesny, Poland
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22
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McLeod C, Wood J, Schultz A, Norman R, Smith S, Blyth CC, Webb S, Smyth AR, Snelling TL. Outcomes and endpoints reported in studies of pulmonary exacerbations in people with cystic fibrosis: A systematic review. J Cyst Fibros 2020; 19:858-867. [PMID: 33191129 DOI: 10.1016/j.jcf.2020.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is no consensus about which outcomes should be evaluated in studies of pulmonary exacerbations in people with cystic fibrosis (CF). Outcomes used for evaluation should be meaningful; that is, they should capture how people feel, function or survive and be acknowledged as important to people with CF, or should be reliable surrogates of those outcomes. We aimed to summarise the outcomes and corresponding endpoints which have been reported in studies of pulmonary exacerbations, and to identify those which are most likely to be meaningful. METHODS A PROSPERO registered systematic review (CRD42020151785) was conducted in Medline, Embase and Cochrane from inception until July 2020. Registered trials were also included. RESULTS 144 studies met the inclusion criteria. A wide range of outcomes and corresponding endpoints were reported. Death, QoL and many patient-reported outcomes are likely to be meaningful as they directly capture how people feel, function or survive. Forced expiratory volume in 1-second [FEV1] is a validated surrogate of risk of death and reduced QoL. The extent of structural lung disease has also been correlated with lung function, pulmonary exacerbations and risk of death. Since no evidence of a correlation between airway microbiology or biomarkers with clinically meaningful outcomes was found, the value of these as surrogates was unclear. CONCLUSIONS Death, QoL, patient-reported outcomes, FEV1, and structural lung changes were identified as outcomes that are most likely to be meaningful. Development of a core outcome set in collaboration with stakeholders including people with CF is recommended.
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Affiliation(s)
- Charlie McLeod
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, 15 Hospital Ave, Nedlands WA 6009, Australia; Infectious Diseases Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia; Division of Paediatrics, Faculty of Medicine, University of Western Australia, 35 Stirling Hwy, Nedlands 6009, Australia.
| | - Jamie Wood
- Physiotherapy Department, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands 6009, Australia; Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, United States of America.
| | - André Schultz
- Centre for Respiratory Health, Telethon Kids Institute, University of Western Australia, 35 Stirling Hwy, Nedlands 6009, Australia; Respiratory Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia.
| | - Richard Norman
- School of Public health, 400 Curtin University, Kent St, Bentley 6102, Australia.
| | - Sherie Smith
- Evidence Based Child Health Group, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Christopher C Blyth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, 15 Hospital Ave, Nedlands WA 6009, Australia; Infectious Diseases Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands 6009, Australia; Pathwest Laboratory Medicine WA, QEII Medical Centre, Nedlands 6009, Australia.
| | - Steve Webb
- St John of God Hospital, 12 Salvado Road, Subiaco 6008, Australia; School of Population Health and Preventive Medicine, 553 St Kilda Rd, Monash University, Melbourne 3004, Australia.
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Thomas L Snelling
- Menzies School of Health Research, PO Box 41096 Casuarina NT 0811, Australia; Sydney School of Public Health, Faculty of Medicine and Health, Edward Ford Building, University of Sydney NSW 2006, Australia.
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Perrem L, Ratjen F. Designing Clinical Trials for Anti-Inflammatory Therapies in Cystic Fibrosis. Front Pharmacol 2020; 11:576293. [PMID: 33013419 PMCID: PMC7516261 DOI: 10.3389/fphar.2020.576293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/24/2020] [Indexed: 01/15/2023] Open
Abstract
The inflammatory response in the CF airway begins early in the disease process and becomes persistent through life in most patients. Inflammation, which is predominantly neutrophilic, worsens airway obstruction and plays a critical role in the development of structural lung damage. While cystic fibrosis transmembrane regulator modulators will likely have a dramatic impact on the trajectory of CF lung disease over the coming years, addressing other important aspects of lung disease such as inflammation will nevertheless remain a priority. Considering the central role of neutrophils and their products in the inflammatory response, potential therapies should ultimately affect neutrophils and their products. The ideal anti-inflammatory therapy would exert a dual effect on the pro-inflammatory and pro-resolution arms of the inflammatory cascade, both of which contribute to dysregulated inflammation in CF. This review outlines the key factors to be considered in the design of clinical trials evaluating anti-inflammatory therapies in CF. Important lessons have been learned from previous clinical trials in this area and choosing the right efficacy endpoints is key to the success of any anti-inflammatory drug development program. Identifying and validating non-invasive biomarkers, novel imaging techniques and sensitive lung function tests capable of monitoring disease activity and therapeutic response are important areas of research and will be useful for the design of future anti-inflammatory drug trials.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, ON, Canada
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25
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Hisert KB, Birkland TP, Schoenfelt KQ, Long ME, Grogan B, Carter S, Liles WC, McKone EF, Becker L, Manicone AM, Gharib SA. CFTR Modulator Therapy Enhances Peripheral Blood Monocyte Contributions to Immune Responses in People With Cystic Fibrosis. Front Pharmacol 2020; 11:1219. [PMID: 33013356 PMCID: PMC7461946 DOI: 10.3389/fphar.2020.01219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background CFTR modulators decrease some etiologies of CF airway inflammation; however, data indicate that non-resolving airway infection and inflammation persist in individuals with CF and chronic bacterial infections. Thus, identification of therapies that diminish airway inflammation without allowing unrestrained bacterial growth remains a critical research goal. Novel strategies for combatting deleterious airway inflammation in the CFTR modulator era require better understanding of cellular contributions to chronic CF airway disease, and how inflammatory cells change after initiation of CFTR modulator therapy. Peripheral blood monocytes, which traffic to the CF airway, can develop both pro-inflammatory and inflammation-resolving phenotypes, represent intriguing cellular targets for focused therapies. This therapeutic approach, however, requires a more detailed knowledge of CF monocyte cellular programming and phenotypes. Material and Methods In order to characterize the inflammatory phenotype of CF monocytes, and how these cells change after initiation of CFTR modulator therapy, we studied adults (n=10) with CF, chronic airway infections, and the CFTR-R117H mutations before and 7 days after initiation of ivacaftor. Transcriptomes of freshly isolated blood monocytes were interrogated by RNA-sequencing (RNA-seq) followed by pathway-based analyses. Plasma concentrations of cytokines and chemokines were evaluated by multiplex ELISA. Results RNAseq identified approximately 50 monocyte genes for which basal expression was significantly changed in all 10 subjects after 7 days of ivacaftor. Of these, the majority were increased in expression post ivacaftor, including many genes traditionally associated with enhanced inflammation and immune responses. Pathway analyses confirmed that transcriptional programs were overwhelmingly up-regulated in monocytes after 7 days of ivacaftor, including biological modules associated with immunity, cell cycle, oxidative phosphorylation, and the unfolded protein response. Ivacaftor increased plasma concentrations of CXCL2, a neutrophil chemokine secreted by monocytes and macrophages, and CCL2, a monocyte chemokine. Conclusions Our results demonstrate that ivacaftor causes acute changes in blood monocyte transcriptional profiles and plasma chemokines, and suggest that increased monocyte inflammatory signals and changes in myeloid cell trafficking may contribute to changes in airway inflammation in people taking CFTR modulators. To our knowledge, this is the first report investigating the transcriptomic response of circulating blood monocytes in CF subjects treated with a CFTR modulator.
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Affiliation(s)
- Katherine B Hisert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, United States.,Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Timothy P Birkland
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Kelly Q Schoenfelt
- Ben May Department for Cancer Research, University of Chicago, Chicago, IL, United States
| | - Matthew E Long
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Brenda Grogan
- Department of Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Suzanne Carter
- Department of Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - W Conrad Liles
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Edward F McKone
- Department of Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Lev Becker
- Ben May Department for Cancer Research, University of Chicago, Chicago, IL, United States
| | - Anne M Manicone
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Sina A Gharib
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States
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Jain R, Baines A, Khan U, Wagner BD, Sagel SD. Evaluation of airway and circulating inflammatory biomarkers for cystic fibrosis drug development. J Cyst Fibros 2020; 20:50-56. [PMID: 32622665 DOI: 10.1016/j.jcf.2020.06.017] [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] [Received: 04/21/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Biomarkers of inflammation in blood and sputum can play a critical role in anti-inflammatory drug development in cystic fibrosis (CF). The objectives of this analysis were to examine relationships between airway and systemic measurements of inflammation, associations between inflammatory biomarkers and FEV1, differences in airway and systemic inflammation by baseline covariates, reproducibility of serum biomarkers, and to assess the effects of freezing and delayed processing on sputum analyte measurements. METHODS We analyzed baseline and serial concentrations of inflammatory markers in blood and induced sputum collected from individuals with CF ages 10 years and older who participated in a multicenter clinical trial. RESULTS Among circulating biomarkers, serum high sensitivity C-reactive protein (hsCRP) and serum amyloid A (SAA) correlated most strongly with each other (rs = 0.85). Comparing sputum-based inflammation measurements, sputum neutrophil elastase and myeloperoxidase (MPO) were the most highly correlated (rs = 0.88). Markers most strongly correlated with ppFEV1 were serum hsCRP (rs = -0.55), SAA (rs =-0.58), and sputum neutrophil elastase (rs = -0.53). Within-subject standard deviation was consistently lower than between-subject standard deviation for all serum biomarkers. Serum calprotectin and MPO had the highest ratio of between-to-within subject variability. Freezing and delayed sputum processing were not associated with significant differences in measurements of sputum neutrophil elastase, IL-1β, or MPO. CONCLUSIONS Among the biomarkers analyzed, serum hsCRP and sputum neutrophil elastase are promising candidates to include in CF anti-inflammatory clinical trials to avoid redundancy, minimize variation, and serve as correlates of lung disease severity and change.
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Affiliation(s)
- Raksha Jain
- Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas 75390-8558, TX, USA.
| | - Arthur Baines
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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Smith LJ, Horsley A, Bray J, Hughes PJC, Biancardi A, Norquay G, Wildman M, West N, Marshall H, Wild JM. The assessment of short and long term changes in lung function in CF using 129Xe MRI. Eur Respir J 2020; 56:2000441. [PMID: 32631840 DOI: 10.1183/13993003.00441-2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION 129Xe ventilation MRI is sensitive to detect early CF lung disease and response to treatment. 129Xe-MRI could play a significant role in clinical trials and patient management. Here we present data on the repeatability of imaging measurements and their sensitivity to longitudinal change. METHODS 29 children and adults with CF and a range of disease severity were assessed twice, a median [IQR] of 16.0 [14.4,19.5] months apart. Patients performed 129Xe-MRI, lung clearance index (LCI), body plethysmography and spirometry at both visits. Eleven patients repeated 129Xe-MRI in the same session to assess the within-visit repeatability. The ventilation defect percentage (VDP) was the primary metric calculated from 129Xe-MRI. RESULTS At baseline, mean (sd) age=23.0 (11.1) years and FEV1 z-score=-2.2 (2.0). Median [IQR] VDP=9.5 [3.4,31.6]%, LCI=9.0 [7.7,13.7]. Within-visit and inter-visit repeatability of VDP was high. At 16 months there was no single trend of 129Xe-MRI disease progression. Visible 129Xe-MRI ventilation changes were common, which reflected changes in VDP. Based on the within-visit repeatability, a significant short-term change in VDP is >±1.6%. For longer-term follow up, changes in VDP of up to ±7.7% can be expected, or ±4.1% for patients with normal FEV1. No patient had a significant change in FEV1, however 59% had change in VDP >±1.6%. In patients with normal FEV1, there were significant changes in ventilation and in VDP. CONCLUSIONS 129Xe-MRI is a highly effective method for assessing longitudinal lung disease in patients with CF. VDP has great potential as a sensitive clinical outcome measure of lung function and endpoint for clinical trials.
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Affiliation(s)
- Laurie J Smith
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Alex Horsley
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Respiratory Research Group, Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
| | - Jody Bray
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Paul J C Hughes
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Alberto Biancardi
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Graham Norquay
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Martin Wildman
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Noreen West
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Helen Marshall
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jim M Wild
- POLARIS, Imaging Sciences, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Houston CJ, Taggart CC, Downey DG. The role of inflammation in cystic fibrosis pulmonary exacerbations. Expert Rev Respir Med 2020; 14:889-903. [PMID: 32544353 DOI: 10.1080/17476348.2020.1778469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cystic Fibrosis pulmonary exacerbations are critical events in the lives of people with CF that have deleterious effects on lung function, quality of life, and life expectancy. There are significant unmet needs in the management of exacerbations. We review here the associated inflammatory changes that underlie these events and are of interest for the development of biomarkers of exacerbation. AREAS COVERED Inflammatory responses in CF are abnormal and contribute to a sustained proinflammatory lung microenvironment, abundant in proinflammatory mediators and deficient in counter-regulatory mediators that terminate and resolve inflammation. There is increasing interest in these inflammatory pathways to discover novel biomarkers for pulmonary exacerbation management. In this review, we explore the inflammatory changes occurring during intravenous antibiotic therapy for exacerbation and how they may be applied as biomarkers to guide exacerbation therapy. A literature search was conducted using the PubMed database in February 2020. EXPERT OPINION Heterogeneity in inflammatory responses to treatment of a pulmonary exacerbation, a disease process with complex pathophysiology, limits the clinical utility of individual biomarkers. Biomarker panels may be a more successful strategy to capture informative changes within the CF population to improve pulmonary exacerbation management and outcomes.
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Affiliation(s)
- Claire J Houston
- Airway Innate Immunity Group (Aiir), Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Northern Ireland
| | - Clifford C Taggart
- Airway Innate Immunity Group (Aiir), Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Northern Ireland
| | - Damian G Downey
- Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Northern Ireland.,Northern Ireland Regional Adult CF Centre, Belfast Health and Social Care Trust , Belfast, UK
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Lung T1 mapping magnetic resonance imaging in the assessment of pulmonary disease in children with cystic fibrosis: a pilot study. Pediatr Radiol 2020; 50:923-934. [PMID: 32162080 DOI: 10.1007/s00247-020-04638-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/18/2019] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Assessment tools for early cystic fibrosis (CF) lung disease are limited. Detecting early pulmonary disease is crucial to increasing life expectancy by starting interventions to slow the progression of the pulmonary disease with the many treatment options available. OBJECTIVE To compare the utility of lung T1-mapping MRI with ultrashort echo time (UTE) MRI in children with cystic fibrosis in detecting early stage lung disease and monitoring pulmonary exacerbations. MATERIALS AND METHODS We performed a prospective study in 16 children between September 2017 and January 2018. In Phase 1, we compared five CF patients with normal spirometry (mean 11.2 years) to five age- and gender-matched healthy volunteers. In Phase 2, we longitudinally evaluated six CF patients (median 11 years) in acute pulmonary exacerbation. All children had non-contrast lung T1-mapping and UTE MRI and spirometry testing. We compared the mean normalized T1 value and percentage lung volume without T1 value in CF patients and healthy subjects in Phase 1 and during treatment in Phase 2. We also performed cystic fibrosis MRI scoring. We evaluated differences in continuous variables using standard statistical tests. RESULTS In Phase 1, mean normalized T1 values of the lung were significantly lower in CF patients in comparison to healthy controls (P=0.02) except in the right lower lobe (P=0.29). The percentage lung volume without T1 value was also significantly higher in CF patients (P=0.006). UTE MRI showed no significant differences between CF patients and healthy volunteers (P=0.11). In Phase 2, excluding one outlier case who developed systemic disease in the course of treatment, the whole-lung T1 value increased (P=0.001) and perfusion scoring improved (P=0.02) following therapy. We observed no other significant changes in the MRI scoring. CONCLUSION Lung T1-mapping MRI can detect early regional pulmonary CF disease in children and might be helpful in the assessment of acute pulmonary exacerbations.
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Bailey KL, Murphy PJ, Lineberry OK, Haack MR, Dickinson JD, Kalil AC. Procalcitonin predicts the severity of cystic fibrosis pulmonary exacerbations and readmissions in adult patients: a prospective cohort study. J Investig Med 2020; 68:856-863. [PMID: 31969379 DOI: 10.1136/jim-2019-001183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2019] [Indexed: 11/04/2022]
Abstract
Patients with cystic fibrosis (CF) experience multiple pulmonary exacerbations throughout their lifetime, resulting in repeated antibiotic exposure and hospital admissions. Reliable diagnostic markers to guide antibiotic treatment in patients with CF, however, are lacking. Given that the CF airway is characterized by persistent and frequent bacterial infection, our goal was to determine if procalcitonin (PCT) could be used as a severity and prognostic marker of CF exacerbation. We enrolled 40 participants at the time of diagnosis of CF pulmonary exacerbation. Inclusion criteria: age ≥19 years with exacerbation requiring antibiotics as determined by the treating physician. Exclusion criteria: antibiotics initiated more than 48 hours prior to enrollment, and pregnancy. Blood samples were collected on enrollment day and after 7-10 days of treatment. Of the 40 patients enrolled, 23 (57.5%) had detectable levels of PCT (≥0.05 ng/mL). PCT levels were significantly associated with pulmonary exacerbation scores (p=0.01) and per cent decrease in forced expiratory volume in 1 second (FEV1) (p=0.01) compared with the best in the last 12 months. Those who had worsening PCT during treatment had less improvement in FEV1 (p=0.001) and were more likely to be readmitted to the hospital sooner (p<0.0001). Likewise, those who had a detectable PCT at the time of admission were more likely to be readmitted sooner (p=0.03). PCT elevation during antibiotic treatment is associated with less improvement in FEV1 and earlier readmission. A detectable PCT level occurs only in more severe CF exacerbations. Multicenter trials are needed to confirm whether PCT may play a role in the clinical care of patients with CF.
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Affiliation(s)
- Kristina L Bailey
- Research Service, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA .,Int Med-Pulmonary, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Peter J Murphy
- Int Med-Pulmonary, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Olena K Lineberry
- Int Med-Pulmonary, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew R Haack
- Int Med-Pulmonary, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John D Dickinson
- Int Med-Pulmonary, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andre C Kalil
- Int Med-Infectious Disease, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Inflammation in CF: Key Characteristics and Therapeutic Discovery. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_8] [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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Blood biomarkers to predict short-term pulmonary exacerbation risk in children and adolescents with CF: A pilot study. J Cyst Fibros 2020; 19:49-51. [DOI: 10.1016/j.jcf.2019.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/22/2019] [Accepted: 05/26/2019] [Indexed: 11/21/2022]
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Identification of novel blood biomarkers of treatment response in cystic fibrosis pulmonary exacerbations by label-free quantitative proteomics. Sci Rep 2019; 9:17126. [PMID: 31748618 PMCID: PMC6868239 DOI: 10.1038/s41598-019-53759-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/04/2019] [Indexed: 01/06/2023] Open
Abstract
Pulmonary exacerbations (PEx) are clinically impactful events for individuals with CF. Unfortunately, many CF individuals with PEx fail to regain their baseline lung function despite treatment. The objective of this study was to use unbiased proteomic technology to identify novel blood protein biomarkers that change following intravenous (IV) antibiotic treatment and to explore if changes correlate with clinical response by the end of treatment. Blood samples from 25 PEx events derived from 22 unique CF adults were collected within 24 hours of hospital admission, day 5, day 10, and IV antibiotic completion. Three-hundred and forty-six blood proteins were evaluated with label-free liquid chromatography-tandem mass spectrometry (LC-MS/MS) quantitative proteomics and immunoassays. Forty-seven plasma proteins changed significantly following 5 days of IV antibiotic treatment (q-value ≤ 0.10). Early change in IGF2R from hospital admission to day 5 correlated with overall change in symptom score (CFRSD-CRISS) by the end of treatment (r = −0.48, p-value = 0.04). Several plasma proteins identified and quantified by label-free LC-MS/MS changed early following treatment with IV antibiotics and many of these proteins are involved in complement activation and inflammatory/immune-related pathways. Early change in IGF2R correlated with symptom response following IV antibiotic treatment and requires further validation as a predictive biomarker of symptom response.
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Evaluation of Copeptin during Pulmonary Exacerbation in Cystic Fibrosis. Mediators Inflamm 2019; 2019:1939740. [PMID: 31736654 PMCID: PMC6816008 DOI: 10.1155/2019/1939740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/09/2019] [Accepted: 09/17/2019] [Indexed: 01/16/2023] Open
Abstract
Copeptin was found to be a stable biomarker of inflammation and stress response in cardiac, renal, metabolic, and respiratory conditions such as pneumonia. The aim of this study was to investigate the copeptin levels in biological fluids (serum and sputum supernatant) of cystic fibrosis pediatric patients during pulmonary exacerbation and remission and to investigate the possible influence of copeptin levels on disease severity and quality of life. Copeptin serum concentrations were measured in 28 pediatric cystic fibrosis (CF) patients: 13 in stable condition and 15 during pulmonary exacerbation. In 10 CF patients, copeptin was also measured in the sputum. In all the patients, we assessed complete blood count, BMI, sputum culture, lung function, and chest imaging (with Brasfield score). The severity of symptoms was assessed using the Shwachman-Kulczycki (SK) score, and the quality of life was assessed with the Cystic Fibrosis Quality of Life Questionnaire-Revised (CFQ-R). Copeptin concentrations in serum and sputum supernatant was measured using an ELISA kit. Statistical analysis was done in Statistica v.12. Serum and sputum copeptin levels were higher in CF patients during pulmonary exacerbation than in a stable period, but the differences were not significant (p = 0.58 and p = 0.13, respectively). Copeptin did not correlate significantly with any clinical, laboratory, or spirometry markers of exacerbation. There was, however, a significant inverse correlation between the serum copeptin level and symptoms severity (r = ‐0.77, p = 0.008) and radiological changes (r = ‐0.5626, p = 0.036) during pulmonary exacerbation in pediatric CF patients. Copeptin also inversely correlated with the quality of life domains in CF patients: vitality and eating habits, mostly loss of appetite (p = 0.031 and p = 0.016, respectively). Copeptin may be useful to identify patients with a higher risk of deterioration to improve their outcomes.
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Proteomic Profiling to Identify Blood Biomarkers Predictive of Response to Azithromycin in Children and Adolescents With Cystic Fibrosis. Chest 2019; 156:667-673. [PMID: 31201785 DOI: 10.1016/j.chest.2019.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/18/2019] [Accepted: 05/09/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Azithromycin reduces pulmonary exacerbation (PEx) risk in cystic fibrosis (CF), but not all individuals benefit. The goal of this study was to discover blood protein biomarkers predictive of clinical response to azithromycin treatment in children and adolescents with CF. METHODS Novel proteomic technologies were applied to examine 188 serum and plasma protein samples from 40 patients with CF who were randomized to receive azithromycin in the AZ0004 trial. Early changes in blood protein levels from day 0 to day 28 of treatment were examined in relation to changes in FEV1 percent predicted and weight by days 28 and 168, and to predict PEx risk by day 168. RESULTS Early changes in the levels of 15 plasma proteins following 28 days of azithromycin significantly correlated with changes in FEV1 percent predicted from day 0 to day 28 (Q value < 0.10), but this finding was not sustained to day 168. Early changes in serum calprotectin levels following 28 days of azithromycin were predictive of PEx risk by day 168 of treatment (area under the curve = 0.76; 95% CI, 0.57-0.95). Based on a calprotectin cutoff to maximize test sensitivity (88%) and specificity (68%), 40% of subjects who had a calprotectin reduction less than the cutoff experienced at least one PEx compared with only 8% of subjects with calprotectin reduction greater than the cutoff. CONCLUSIONS Early changes in blood protein biomarkers following azithromycin treatment were associated with short-term changes, but not longer term changes, in lung function. Early change in serum calprotectin level was predictive of response to azithromycin in terms of modifying PEx risk.
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Smith L, Marshall H, Aldag I, Horn F, Collier G, Hughes D, West N, Horsley A, Taylor CJ, Wild J. Longitudinal Assessment of Children with Mild Cystic Fibrosis Using Hyperpolarized Gas Lung Magnetic Resonance Imaging and Lung Clearance Index. Am J Respir Crit Care Med 2019; 197:397-400. [PMID: 28661699 DOI: 10.1164/rccm.201705-0894le] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Laurie Smith
- 1 University of Sheffield Sheffield, United Kingdom.,2 Sheffield Children's Hospital NHS Foundation Trust Sheffield, United Kingdom and
| | | | - Ina Aldag
- 2 Sheffield Children's Hospital NHS Foundation Trust Sheffield, United Kingdom and
| | - Felix Horn
- 1 University of Sheffield Sheffield, United Kingdom
| | | | - David Hughes
- 2 Sheffield Children's Hospital NHS Foundation Trust Sheffield, United Kingdom and
| | - Noreen West
- 2 Sheffield Children's Hospital NHS Foundation Trust Sheffield, United Kingdom and
| | - Alex Horsley
- 3 University of Manchester Manchester, United Kingdom
| | - Chris J Taylor
- 2 Sheffield Children's Hospital NHS Foundation Trust Sheffield, United Kingdom and
| | - Jim Wild
- 1 University of Sheffield Sheffield, United Kingdom
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Fretzayas A, Douros K, Moustaki M, Loukou I. Applications of lung clearance index in monitoring children with cystic fibrosis. World J Clin Pediatr 2019; 8:15-22. [PMID: 31041164 PMCID: PMC6477151 DOI: 10.5409/wjcp.v8.i2.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/03/2019] [Accepted: 02/19/2019] [Indexed: 02/06/2023] Open
Abstract
A sensitive, reproducible and feasible measure of lung function for monitoring the respiratory health is a prerequisite for the optimization of management of the patients with cystic fibrosis (CF). Spirometry has been considered the method of choice, although it is applicable only in children older than 6 years of age, as good cooperation is necessary for its proper performance. However, over the last 15 years, scientific interest in gas dilution techniques and particularly in multiple breath wash out (MBW) method has been revived. The most commonly reported index of MBW is lung clearance index (LCI). The aim of this review is to present the most recent developments in the application of LCI as a monitoring index of respiratory status of CF patients. LCI is a sensitive and reproducible marker of ventilation inhomogeneity. It is more sensitive than spirometry and, unlike spirometry; it can be performed across the whole pediatric age range. Since it is dependent on body size, until at least the age of 6 years, the relative and not the absolute changes are more appropriate for providing clinically meaningful conclusion on ventilation inhomogeneity. Until now, MBW has been mainly used as a research tool. Based on the currently available data LCI cannot safely predict high-resolution computed tomography findings in children with CF, especially in infants. It can be used as an end-point measure for the assessment of beneficial effect of interventions. However, its utility as an outcome measure for the efficacy of therapeutic interventions seems to be dependent on the pathophysiologic mechanisms that underlie each intervention. It seems that more studies, especially longitudinal ones, are required in order to fully clarify the clinical usefulness of LCI, not only in the research setting, but also in every day practice of CF clinic.
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Affiliation(s)
- Andrew Fretzayas
- School of Medicine, University of Athens, Athens 11527, Greece
- Department of Pediatrics, Athens Medical Center, Athens University Medical School, Maroussi 15125, Greece
| | - Konstantinos Douros
- Respiratory Unit, Third Department of Pediatrics, Athens University Medical School, “Attikon” University Hospital, Haidari 12464, Greece
| | - Maria Moustaki
- Department of Cystic Fibrosis, “Agia Sofia”, Children’s Hospital, Athens 11527, Greece
| | - Ioanna Loukou
- Department of Cystic Fibrosis, “Agia Sofia”, Children’s Hospital, Athens 11527, Greece
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Rayment JH, Couch MJ, McDonald N, Kanhere N, Manson D, Santyr G, Ratjen F. Hyperpolarised 129Xe magnetic resonance imaging to monitor treatment response in children with cystic fibrosis. Eur Respir J 2019; 53:13993003.02188-2018. [DOI: 10.1183/13993003.02188-2018] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/02/2019] [Indexed: 01/01/2023]
Abstract
Pulmonary magnetic resonance imaging using hyperpolarised 129Xe gas (XeMRI) can quantify ventilation inhomogeneity by measuring the percentage of unventilated lung volume (ventilation defect per cent (VDP)). While previous studies have demonstrated its sensitivity for detecting early cystic fibrosis (CF) lung disease, the utility of XeMRI to monitor response to therapy in CF is unknown. The aim of this study was to assess the ability of XeMRI to capture treatment response in paediatric CF patients undergoing inpatient antibiotic treatment for a pulmonary exacerbation.15 CF patients aged 8–18 years underwent XeMRI, spirometry, plethysmography and multiple-breath nitrogen washout at the beginning and end of inpatient treatment of a pulmonary exacerbation. VDP was calculated from XeMRI images obtained during a static breath hold using semi-automated k-means clustering and linear binning approaches.XeMRI was well tolerated. VDP, lung clearance index and the forced expiratory volume in 1 s all improved with treatment; however, response was not uniform in individual patients. Of all outcome measures, VDP showed the largest relative improvement (−42.1%, 95% CI −52.1–−31.9%, p<0.0001).These data support further investigation of XeMRI as a tool to capture treatment response in CF lung disease.
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Poncin W, Lebecque P. [Lung clearance index in cystic fibrosis]. Rev Mal Respir 2019; 36:377-395. [PMID: 30686561 DOI: 10.1016/j.rmr.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 03/28/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Small airways' involvement in cystic fibrosis (CF) pulmonary disease is a very early event, which can progress sub-clinically and insidiously since it is poorly reflected by commonly used lung function tests. STATE OF ART Sensitive and discriminative tools are available to investigate small airways function. However their complexity and/or invasiveness has confined their use to research purposes and to some specialized research teams. By contrast, the multiple breath washout (MBW) test is more affordable and non-invasive. Lung clearance index (LCI), which is the most used derived parameter, is reproducible and much more sensitive than spirometry in detecting small airways disease. However, MBW is operator dependent. PERSPECTIVES The recent commercialization of devices assessing LCI launches MBW as a potential tool in routine clinical care, although its use currently remains mostly dedicated to research purposes. However, important differences in LCI between various equipment settings raise a number of theoretical questions. Specific algorithms should be refined and more transparent. Standardization of MBW is still an ongoing process. Whether other MBW derived indices can prove superior over LCI deserves further study. CONCLUSIONS In CF, LCI is now a well-established outcome in research settings to detect early lung function abnormalities and new treatment effects, especially in patients with mild lung disease. In these patients, LCI seems an attractive tool for clinicians too. Yet, further investigation is needed to define clinically significant changes in LCI and to which extent this index can be useful in guiding clinical decisions remains to be studied.
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Affiliation(s)
- W Poncin
- Pôle de pneumologie, ORL et dermatologie, université Catholique de Louvain, institut de recherche expérimentale et clinique (IREC), 1200 Bruxelles, Belgique; Service de médecine physique et réadaptation, cliniques universitaires Saint-Luc, 1200 Bruxelles, Belgique.
| | - P Lebecque
- Pneumologie pédiatrique & centre de référence pour la mucoviscidose, cliniques universitaires Saint-Luc, 1200 Bruxelles, Belgique
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Schechter MS. Reevaluating approaches to cystic fibrosis pulmonary exacerbations. Pediatr Pulmonol 2018; 53:S51-S63. [PMID: 29979495 DOI: 10.1002/ppul.24125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/20/2018] [Indexed: 11/10/2022]
Abstract
Cystic Fibrosis (CF) lung disease is characterized by intermittent acute episodes of worsening signs, symptoms, and pulmonary function; these so-called pulmonary exacerbations (PEx) appear to be important drivers of long-term declines in lung function, quality of life, and life expectancy. Surveillance for development of PEx and their treatment is a fundamental component of chronic CF management, and the merits of novel CF therapies are often judged based on their ability to reduce the frequency of PEx. Given the central role that they play, it is surprising how poorly PEx are understood, how thin is the evidence base for their treatment and how often they are left unrecognized and untreated in clinical practice. This paper reviews what is known and what is unknown regarding the nature of PEx, and discusses the impact of missed recognition and treatment of these episodes as well as the apparent variation in practice across CF care centers. The arguments supporting a liberal, highly sensitive approach to the diagnosis of PEx are presented, as well as recommendation for how care programs can achieve consistency in their early recognition and treatment. A stepwise approach to personalized treatment supported by close follow-up to ensure the successful resolution of all signs and symptoms will lead to the stabilization of patients' lung function and quality of life. Recommendations are made regarding important priorities for research into evidence-based approaches to improving the care of PEx.
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Affiliation(s)
- Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University, Children's Hospital of Richmond at VCU, Richmond, Virginia
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Smith LJ, Collier GJ, Marshall H, Hughes PJ, Biancardi AM, Wildman M, Aldag I, West N, Horsley A, Wild JM. Patterns of regional lung physiology in cystic fibrosis using ventilation magnetic resonance imaging and multiple-breath washout. Eur Respir J 2018; 52:13993003.00821-2018. [DOI: 10.1183/13993003.00821-2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/10/2018] [Indexed: 11/05/2022]
Abstract
Hyperpolarised helium-3 (3He) ventilation magnetic resonance imaging (MRI) and multiple-breath washout (MBW) are sensitive methods for detecting lung disease in cystic fibrosis (CF). We aimed to explore their relationship across a broad range of CF disease severity and patient age, as well as assess the effect of inhaled lung volume on ventilation distribution.32 children and adults with CF underwent MBW and 3He-MRI at a lung volume of end-inspiratory tidal volume (EIVT). In addition, 28 patients performed 3He-MRI at total lung capacity. 3He-MRI scans were quantitatively analysed for ventilation defect percentage (VDP), ventilation heterogeneity index (VHI) and the number and size of individual contiguous ventilation defects. From MBW, the lung clearance index, convection-dependent ventilation heterogeneity (Scond) and convection–diffusion-dependent ventilation heterogeneity (Sacin) were calculated.VDP and VHI at EIVT strongly correlated with lung clearance index (r=0.89 and r=0.88, respectively), Sacin (r=0.84 and r=0.82, respectively) and forced expiratory volume in 1 s (FEV1) (r=−0.79 and r=−0.78, respectively). Two distinct 3He-MRI patterns were highlighted: patients with abnormal FEV1 had significantly (p<0.001) larger, but fewer, contiguous defects than those with normal FEV1, who tended to have numerous small volume defects. These two MRI patterns were delineated by a VDP of ∼10%. At total lung capacity, when compared to EIVT, VDP and VHI reduced in all subjects (p<0.001), demonstrating improved ventilation distribution and regions of volume-reversible and nonreversible ventilation abnormalities.
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The CF Canada-Sick Kids Program in individual CF therapy: A resource for the advancement of personalized medicine in CF. J Cyst Fibros 2018; 18:35-43. [PMID: 29685812 DOI: 10.1016/j.jcf.2018.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/13/2018] [Accepted: 03/31/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Therapies targeting certain CFTR mutants have been approved, yet variations in clinical response highlight the need for in-vitro and genetic tools that predict patient-specific clinical outcomes. Toward this goal, the CF Canada-Sick Kids Program in Individual CF Therapy (CFIT) is generating a "first of its kind", comprehensive resource containing patient-specific cell cultures and data from 100 CF individuals that will enable modeling of therapeutic responses. METHODS The CFIT program is generating: 1) nasal cells from drug naïve patients suitable for culture and the study of drug responses in vitro, 2) matched gene expression data obtained by sequencing the RNA from the primary nasal tissue, 3) whole genome sequencing of blood derived DNA from each of the 100 participants, 4) induced pluripotent stem cells (iPSCs) generated from each participant's blood sample, 5) CRISPR-edited isogenic control iPSC lines and 6) prospective clinical data from patients treated with CF modulators. RESULTS To date, we have recruited 57 of 100 individuals to CFIT, most of whom are homozygous for F508del (to assess in-vitro: in-vivo correlations with respect to ORKAMBI response) or heterozygous for F508del and a minimal function mutation. In addition, several donors are homozygous for rare nonsense and missense mutations. Nasal epithelial cell cultures and matched iPSC lines are available for many of these donors. CONCLUSIONS This accessible resource will enable development of tools that predict individual outcomes to current and emerging modulators targeting F508del-CFTR and facilitate therapy discovery for rare CF causing mutations.
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Medkova A, Srovnal J, Potomkova J, Volejnikova J, Mihal V. Multifarious diagnostic possibilities of the S100 protein family: predominantly in pediatrics and neonatology. World J Pediatr 2018; 14:315-321. [PMID: 29858979 DOI: 10.1007/s12519-018-0163-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 05/11/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Numerous articles related to S100 proteins have been recently published. This review aims to introduce this large protein family and its importance in the diagnostics of many pathological conditions in children and adults. DATA SOURCES Based on original publications found in database systems, we summarize the current knowledge about the S100 protein group and highlight the most important proteins with focus on pediatric use. RESULTS The S100 family is composed of Ca2+ and Zn2+ binding proteins, which are present only in vertebrates. Some of these proteins can be used as diagnostic markers in cardiology (S100A1, S100A12), oncology (S100A2, S100A5, S100A6, S100A14, S100A16, S100P, S100B), neurology (S100B), rheumatology (S100A8/A9, S100A4, S100A6, and S100A12), nephrology and infections (S100A8, S100A9, S100A8/A9, S100A12). The most useful S100 proteins in pediatrics are S100A8, S100A9, heterodimers S100A8/A9, S100B and S100A12. CONCLUSIONS The S100 family members are promising biomarkers and provide numerous possibilities for implementation into clinical practice to optimize the differential diagnostic process.
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Affiliation(s)
- Anna Medkova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic.
| | - Josef Srovnal
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
- Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacky University Olomouc, Hněvotínská, 1333/5, 779 00, Olomouc, Czech Republic
| | - Jarmila Potomkova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
- Department of Science and Research, University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
| | - Jana Volejnikova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
- Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacky University Olomouc, Hněvotínská, 1333/5, 779 00, Olomouc, Czech Republic
| | - Vladimir Mihal
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, I. P. Pavlova 6, 779 00, Olomouc, Czech Republic
- Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacky University Olomouc, Hněvotínská, 1333/5, 779 00, Olomouc, Czech Republic
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Skolnik K, Quon BS. Recent advances in the understanding and management of cystic fibrosis pulmonary exacerbations. F1000Res 2018; 7. [PMID: 29862015 PMCID: PMC5954331 DOI: 10.12688/f1000research.13926.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
Pulmonary exacerbations are common events in cystic fibrosis and have a profound impact on quality of life, morbidity, and mortality. Pulmonary exacerbation outcomes remain poor and a significant proportion of patients fail to recover their baseline lung function despite receiving aggressive treatment with intravenous antibiotics. This focused review provides an update on some of the recent advances that have taken place in our understanding of the epidemiology, pathophysiology, diagnosis, and management of pulmonary exacerbations in cystic fibrosis as well as direction for future study.
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Affiliation(s)
- Kate Skolnik
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, St Paul's Hospital, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Rayment JH, Stanojevic S, Davis SD, Retsch-Bogart G, Ratjen F. Lung clearance index to monitor treatment response in pulmonary exacerbations in preschool children with cystic fibrosis. Thorax 2018; 73:451-458. [DOI: 10.1136/thoraxjnl-2017-210979] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/04/2017] [Accepted: 01/22/2018] [Indexed: 11/03/2022]
Abstract
BackgroundAntibiotic treatment for pulmonary symptoms in preschool children with cystic fibrosis (CF) varies among clinicians. The lung clearance index (LCI) is sensitive to early CF lung disease, but its utility to monitor pulmonary exacerbations in young children has not been assessed.ObjectiveWe aim to (1) understand how LCI changes during lower respiratory tract symptoms relative to a recent clinically stable measurement, (2) determine whether LCI can identify antibiotic treatment response and (3) compare LCI changes to changes in spirometric indices.MethodsLCI and spirometry were measured at quarterly clinic visits over a 12-month period in preschool children with CF. Symptomatic visits were identified and classified as treated or untreated. Treatment response was estimated using propensity score matching methods.Results104 symptomatic visits were identified in 78 participants. LCI increased from baseline in both treated (mean relative change +23.8% (95% CI 16.2 to 31.4)) and untreated symptomatic visits (mean relative change +11.2% (95% CI 2.4 to 19.9)). A significant antibiotic treatment effect was observed when LCI was used as the outcome measure (average treatment effect −15.5% (95% CI −25.4 to −5.6)) but not for z-score FEV1.ConclusionLCI significantly deteriorated with pulmonary symptoms relative to baseline and improved with antibiotic treatment. These data suggest that LCI may have a role in the routine clinical care of preschool children with CF.
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O'Neill K, Bradley JM, Reid A, Downey DG, Rendall J, McCaughan J, Moore JE, Tunney MM, Elborn JS. Airway infection, systemic inflammation and lung clearance index in children and adults with cystic fibrosis. Eur Respir J 2018; 51:51/2/1701704. [DOI: 10.1183/13993003.01704-2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/17/2017] [Indexed: 11/05/2022]
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Avramidou V, Hatziagorou E, Kampouras A, Hebestreit H, Kourouki E, Kirvassilis F, Tsanakas J. Lung clearance index (LCI) as a predictor of exercise limitation among CF patients. Pediatr Pulmonol 2018; 53:81-87. [PMID: 28950435 DOI: 10.1002/ppul.23833] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 09/01/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION FEV1 is often considered the gold standard to monitor lung disease in cystic fibrosis (CF). Recently, there has been increasing interest in multiple breath washout (MBW) and cardiopulmonary exercise testing (CPET) as alternative or even more sensitive techniques. However, limited data exist on associations among the above methods. AIM To evaluate the correlations between outcome measures of MBW and CPET and to examine if ventilation inhomogeneity can predict exercise intolerance. SUBJECTS AND METHODS Ninety-seven children and adults with CF (47 males, mean [range] age 14.9 (6.6; 26.7) years, mean FEV1 : 90.8% predicted, mean lung clearance index [LCI]: 11.4, and mean peak oxygen uptake [VO2 peak]: 82.4% predicted) performed spirometry, MBW, and CPET on the same day during their admission or outpatient visit. RESULTS LCI, m1 /m0 , and m2 /m0 (P < 0.001) as well as VO2 peak%, breathing reserve (BR), minute ventilation (VE)/VO2 (P < 0.001), and VE/carbon dioxide release (VCO2 ) (P = 0.006) correlated significantly with FEV1 %. LCI, m1 /m0 , and m2 /m0 correlated with VO2 peak (P ≤ 0.001), VE (L/min) (P < 0.05), BR (P < 0.01), VE/VO2 (P < 0.001), and VE/VCO2 (P < 0.01). Multiple regression analysis showed that LCI could predict BR% (P < 0.001, r2 :0.272) and VE/VO2 (P < 0.001, r2 : 0.207) while LCI and FRC could predict VO2 peak% P < 0.001, r2 : 0.216) and VE/VCO2 (P < 0.001, r2 : 0.226). CONCLUSION Ventilation inhomogeneity as indicated by increased LCI is associated with less efficient ventilation during strenuous exercise and negatively impacts exercise capacity in CF.
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Affiliation(s)
- Vasiliki Avramidou
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elpis Hatziagorou
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Asterios Kampouras
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Eleana Kourouki
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotis Kirvassilis
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Tsanakas
- Paediatric Pulmonology and Cystic Fibrosis Unit, 3rd Paediatric Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Roberts JM, Dai DLY, Hollander Z, Ng RT, Tebbutt SJ, Wilcox PG, Sin DD, Quon BS. Multiple reaction monitoring mass spectrometry to identify novel plasma protein biomarkers of treatment response in cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2017; 17:333-340. [PMID: 29174082 DOI: 10.1016/j.jcf.2017.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systemic inflammation decreases with IV antibiotics during the treatment of CF pulmonary exacerbations (PEx). We used multiple reaction monitoring mass spectrometry and immunoassays to monitor blood proteins during PEx treatment to determine if early changes could be used to predict PEx outcomes following treatment. METHODS Blood samples from 25 PEx (22 unique adults) were collected within 24h of admission, day 5, day 10, and at IV antibiotic completion. Ninety-two blood proteins involved in host immunity and inflammation were measured. RESULTS Levels of several blood proteins changed from admission to end of IV antibiotics, most increasing with treatment. Early changes (admission to day 5) in fibrinogen levels had the strongest correlation with overall improvement in CFRSD-CRISS and FEV1% predicted by the end of treatment. CONCLUSIONS Several plasma proteins changed significantly with IV antibiotics. Future studies will evaluate fibrinogen as an early biomarker of PEx treatment response in CF.
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Affiliation(s)
- James M Roberts
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada
| | - Darlene L Y Dai
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada
| | - Zsuzsanna Hollander
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada
| | - Raymond T Ng
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada
| | - Scott J Tebbutt
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, BC, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pearce G Wilcox
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Canada; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Rosenow T. Quantification of CT bronchiectasis and its relationship to ventilation in cystic fibrosis. Thorax 2017; 73:4. [DOI: 10.1136/thoraxjnl-2017-210917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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50
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Peripheral muscle abnormalities in cystic fibrosis: Etiology, clinical implications and response to therapeutic interventions. J Cyst Fibros 2017; 16:538-552. [DOI: 10.1016/j.jcf.2017.02.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 02/10/2017] [Accepted: 02/12/2017] [Indexed: 12/14/2022]
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