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Merlo CA, Thorat T, DerSarkissian M, McGarry LJ, Nguyen C, Gu YM, Healy J, Rubin JL, Brookhart MA. Long-term impact of ivacaftor on mortality rate and health outcomes in people with cystic fibrosis. Thorax 2024:thorax-2023-220558. [PMID: 38937105 DOI: 10.1136/thorax-2023-220558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 04/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Ivacaftor (IVA) has been shown to improve lung function and other clinical outcomes in people with cystic fibrosis (CF). A decade of real-world IVA availability has enabled the examination of long-term outcomes with this treatment. This retrospective, longitudinal cohort study investigated the impact of IVA on mortality rate and health outcomes among people with CF in the US. METHODS Data from the US CF Foundation Patient Registry from January 2010 to December 2019 were analysed. The IVA-treated cohort included people with a CF transmembrane conductance regulator (CFTR) gating mutation (excluding R117H); age-matched comparator cohort included people with a F508del and a minimal function CFTR mutation who had no prior CFTR modulator treatment. Baseline characteristics were balanced between cohorts using standardised mortality ratio weighting generated from propensity scores. Outcomes of interest were overall survival, lung transplant, percent predicted forced expiratory volume in 1 s (ppFEV1), body mass index (BMI), pulmonary exacerbations (PEx), outpatient visits and hospitalisations. FINDINGS Over a maximum follow-up of 7.9 years, the IVA-treated cohort (N=736) had lower rates of mortality (hazard ratio [HR] (95% CI): 0.22 (0.09 to 0.45)), lung transplant (HR: 0.11 (95% CI 0.02 to 0.28)), PEx (rate ratio: 0.49 (95% CI 0.42 to 0.55)) and all-cause hospitalisations (rate ratio: 0.50 (95% CI 0.43 to 0.56)) as well as better lung function (mean difference in ppFEV1: 8.46 (95% CI 7.34 to 9.75)) and higher BMI/BMI z-scores (mean difference 1.20 (95% CI 0.92 to 1.71) kg/m2 and 0.27 (95% CI 0.25 to 0.40), respectively) than the comparator cohort (N=733). INTERPRETATION Our analysis suggests that IVA provides sustained clinical benefits in people with CF over a follow-up period of approximately 8 years. These findings reinforce the existing real-world evidence that IVA can slow disease progression and decrease the healthcare burden of CF over the long term.
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Affiliation(s)
| | - Teja Thorat
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | | | - Lisa J McGarry
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | | | - Yuqian M Gu
- Analysis Group Inc, Los Angeles, California, USA
| | - Joe Healy
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
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2
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Widder S, Carmody LA, Opron K, Kalikin LM, Caverly LJ, LiPuma JJ. Microbial community organization designates distinct pulmonary exacerbation types and predicts treatment outcome in cystic fibrosis. Nat Commun 2024; 15:4889. [PMID: 38849369 PMCID: PMC11161516 DOI: 10.1038/s41467-024-49150-y] [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] [Received: 11/08/2023] [Accepted: 05/23/2024] [Indexed: 06/09/2024] Open
Abstract
Polymicrobial infection of the airways is a hallmark of obstructive lung diseases such as cystic fibrosis (CF), non-CF bronchiectasis, and chronic obstructive pulmonary disease. Pulmonary exacerbations (PEx) in these conditions are associated with accelerated lung function decline and higher mortality rates. Understanding PEx ecology is challenged by high inter-patient variability in airway microbial community profiles. We analyze bacterial communities in 880 CF sputum samples collected during an observational prospective cohort study and develop microbiome descriptors to model community reorganization prior to and during 18 PEx. We identify two microbial dysbiosis regimes with opposing ecology and dynamics. Pathogen-governed PEx show hierarchical community reorganization and reduced diversity, whereas anaerobic bloom PEx display stochasticity and increased diversity. A simulation of antimicrobial treatment predicts better efficacy for hierarchically organized communities. This link between PEx, microbiome organization, and treatment success advances the development of personalized clinical management in CF and, potentially, other obstructive lung diseases.
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Affiliation(s)
- Stefanie Widder
- Department of Medicine 1, Research Division Infection Biology, Medical University of Vienna, 1090, Vienna, Austria.
| | - Lisa A Carmody
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Kristopher Opron
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Linda M Kalikin
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - John J LiPuma
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
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McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Adjunctive Systemic Corticosteroids for Pulmonary Exacerbations of Cystic Fibrosis. Ann Am Thorac Soc 2024; 21:716-726. [PMID: 38096105 PMCID: PMC11109904 DOI: 10.1513/annalsats.202308-673oc] [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] [Received: 08/04/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
Rationale: Pulmonary exacerbations (PEx) remain the most common cause of morbidity, recurrent hospitalization, and diminished survival in people with cystic fibrosis (PWCF) and are characterized by excess inflammation. Corticosteroids are potent, widely available antiinflammatory drugs. However, corticosteroid efficacy data from randomized controlled trials in PWCF are limited. Objectives: To determine whether adjunctive systemic corticosteroid therapy is associated with improved outcomes in acute CF PEx. Methods: We performed a secondary analysis of Standardized Treatment of Pulmonary Exacerbations 2 (STOP2), a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx, that included the use of corticosteroids as a stratification criterion in its randomization protocol. Corticosteroid treatment effects were determined after propensity score matching for covariates including age, sex, baseline forced expiratory volume in 1 second (FEV1), genotype, and randomization arm. The primary outcome measure was the change in percentage predicted FEV1 (ppFEV1). Symptoms, time to next PEx, and the incidence of adverse events (AEs) and serious adverse events (SAEs) were assessed as secondary endpoints. Phenotypic factors associated with the clinical decision to prescribe steroids were also investigated. Results: Corticosteroids were prescribed for 168 of 982 PEx events in STOP2 (17%). Steroid prescription was associated with decreased baseline ppFEV1, increased age, and female sex. Cotreatment with corticosteroids was independent of treatment arm allocation and did not result in greater mean ppFEV1 response, longer median time to next PEx, or more substantial symptomatic improvement compared with propensity-matched PWCF receiving antibiotics alone. AEs were not increased in corticosteroid-treated PWCF. The total number of SAEs-but not the number of corticosteroid-related or PEx-related SAEs-was higher among patients receiving corticosteroids. Conclusions: Empiric, physician-directed treatment with systemic corticosteroids, although common, is not associated with improved clinical outcomes in PWCF receiving antibiotics for PEx. Clinical trial registered with www.clinicaltrials.gov (NCT02781610).
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Affiliation(s)
- Oliver J. McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
- Department of Medicine and
| | - Sonya L. Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - Natalie E. West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Don B. Sanders
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - Donald R. VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Patrick A. Flume
- Department of Pediatrics and
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher H. Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington
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Widder S, Carmody L, Opron K, Kalikin L, Caverly L, LiPuma J. Microbial community organization designates distinct pulmonary exacerbation types and predicts treatment outcome in cystic fibrosis. RESEARCH SQUARE 2024:rs.3.rs-4128740. [PMID: 38562856 PMCID: PMC10984025 DOI: 10.21203/rs.3.rs-4128740/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Polymicrobial infection of the airways is a hallmark of obstructive lung diseases such as cystic fibrosis (CF), non-CF bronchiectasis, and chronic obstructive pulmonary disease. Pulmonary exacerbations (PEx) in these conditions are associated with accelerated lung function decline and higher mortality rates. An understanding of the microbial underpinnings of PEx is challenged by high inter-patient variability in airway microbial community profiles. We analyzed bacterial communities in 880 CF sputum samples and developed microbiome descriptors to model community reorganization prior to and during 18 PEx. We identified two microbial dysbiosis regimes with opposing ecology and dynamics. Pathogen-governed PEx showed hierarchical community reorganization and reduced diversity, whereas anaerobic bloom PEx displayed stochasticity and increased diversity. A simulation of antimicrobial treatment predicted better efficacy for hierarchically organized communities. This link between PEx type, microbiome organization, and treatment success advances the development of personalized clinical management in CF and, potentially, other obstructive lung diseases.
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5
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Cohen R, Shteinberg M. Unravelling the "frequent exacerbator" phenotype in cystic fibrosis. Eur Respir J 2024; 63:2400068. [PMID: 38388000 DOI: 10.1183/13993003.00068-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Raya Cohen
- Pulmonology Institute and CF center, Carmel Medical Center, Haifa, Israel
- The B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology Haifa, Haifa, Israel
| | - Michal Shteinberg
- Pulmonology Institute and CF center, Carmel Medical Center, Haifa, Israel
- The B. Rappaport Faculty of Medicine, Technion - Israel Institute of Technology Haifa, Haifa, Israel
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Meißner M, Steinke E, Wielpütz MO, Joachim C, Sommerburg O, Mall MA, Stahl M. Impact of Reanalysis of Nitrogen Multiple-Breath Washout on its Relationship with Chest Magnetic Resonance Imaging Findings in Clinically Stable and Pulmonary Exacerbated Children with Cystic Fibrosis. KLINISCHE PADIATRIE 2024; 236:106-115. [PMID: 38109903 DOI: 10.1055/a-2214-7217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
RATIONALE Multiple-breath washout (MBW)-derived lung clearance index (LCI) detects lung disease in children with cystic fibrosis (CF). Correction of a cross-talk error in the software of the MBW device Exhalyzer D in a new software version has generated significant interest regarding its impact on previous MBW findings. Since LCI and chest magnetic resonance imaging (MRI) correlated before in CF children, this study aims to reassess previous MBW data after correction. PATIENTS/METHODS Reanalysis of the main findings from a previously published study comparing MBW and MRI in a pediatric CF cohort by reassessment of nitrogen (N2) MBW of 61 stable children with CF, 75 age-matched healthy controls (HC), and 15 CF children with pulmonary exacerbation (PEx) in the corrected software version. RESULTS The corrected LCI (N2LCIcor) decreased in the entire cohort (-17.0 (11.2)%), HC (-8.5 (8.2)%), stable CF children (-22.2 (11.1)%), and within the PEx group at baseline, at PEx and after antibiotic therapy (-21.5 (7.3)%; -22.5 (6.1)%; -21.4 (6.6)%; all P<0.01). N2LCIcor and N2LCIpre correlated with chest MRI scores in stable CF (r=0.70 to 0.84; all P<0.01) without a significant difference between N2LCIcor and N2LCIpre. Change in LCI from baseline to PEx and from PEx to after therapy decreased from N2LCIpre to N2LCIcor, but these changes remained significant (all P=0.001). DISCUSSION/CONCLUSIONS Our results indicate that N2LCIcor is significantly lower than N2LCIpre, but key results published in the original study demonstrating N2MBW and MRI as complementary methods for clinical surveillance in children with CF remain unaffected.
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Affiliation(s)
- Maria Meißner
- Dept. of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Steinke
- Dept. of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- associated partner site, German Center for Lung Research (DZL), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité, Berlin Institute of Health (BIH) at Charité, Berlin, Germany
| | - Mark Oliver Wielpütz
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
| | - Cornelia Joachim
- Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, University of Heidelberg, Heidelberg, Germany
| | - Olaf Sommerburg
- Translational Lung Research Center (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
- Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, University of Heidelberg, Heidelberg, Germany
| | - Marcus Alexander Mall
- Dept. of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- associated partner site, German Center for Lung Research (DZL), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité, Berlin Institute of Health (BIH) at Charité, Berlin, Germany
| | - Mirjam Stahl
- Dept. of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- associated partner site, German Center for Lung Research (DZL), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité, Berlin Institute of Health (BIH) at Charité, Berlin, Germany
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7
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Steuart R, Pan AY, Woolums A, Benscoter D, Russell CJ, Henningfeld J, Thomson J. Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies. Pediatr Pulmonol 2024; 59:300-313. [PMID: 37937895 DOI: 10.1002/ppul.26746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/22/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown. OBJECTIVE To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies. METHODS This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering. RESULTS Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability. CONCLUSION Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.
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Affiliation(s)
- Rebecca Steuart
- Section of Special Needs, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Henningfeld
- Department of Pediatrics, Section of Pulmonary Medicine, Milwaukee, Wisconsin, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Balmuri SR, Noaman S, Usman H, Niepa THR. Altering the interfacial rheology of Pseudomonas aeruginosa and Staphylococcus aureus with N-acetyl cysteine and cysteamine. Front Cell Infect Microbiol 2024; 13:1338477. [PMID: 38304461 PMCID: PMC10834029 DOI: 10.3389/fcimb.2023.1338477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/22/2023] [Indexed: 02/03/2024] Open
Abstract
Introduction Chronic lung infection due to bacterial biofilms is one of the leading causes of mortality in cystic fibrosis (CF) patients. Among many species colonizing the lung airways, Pseudomonas aeruginosa and Staphylococcus aureus are two virulent pathogens involved in mechanically robust biofilms that are difficult to eradicate using airway clearance techniques like lung lavage. To remove such biological materials, glycoside hydrolase-based compounds are commonly employed for targeting and breaking down the biofilm matrix, and subsequently increasing cell susceptibility to antibiotics. Materials and methods In this study, we evaluate the effects of N-acetyl cysteine (NAC) and Cysteamine (CYST) in disrupting interfacial bacterial films, targeting different components of the extracellular polymeric substances (EPS). We characterize the mechanics and structural integrity of the interfacial bacterial films using pendant drop elastometry and scanning electron microscopy. Results and discussion Our results show that the film architectures are compromised by treatment with disrupting agents for 6 h, which reduces film elasticity significantly. These effects are profound in the wild type and mucoid P. aeruginosa, compared to S. aureus. We further assess the effects of competition and cooperation between S. aureus and P. aeruginosa on the mechanics of composite interfacial films. Films of S. aureus and wild-type P. aeruginosa cocultures lose mechanical strength while those of S. aureus and mucoid P. aeruginosa exhibit improved storage modulus. Treatment with NAC and CYST reduces the elastic property of both composite films, owing to the drugs' ability to disintegrate their EPS matrix. Overall, our results provide new insights into methods for assessing the efficacy of mucolytic agents against interfacial biofilms relevant to cystic fibrosis infection.
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Affiliation(s)
| | - Sena Noaman
- Department of Chemical and Petroleum Engineering, Pittsburgh, PA, United States
| | - Huda Usman
- Department of Chemical and Petroleum Engineering, Pittsburgh, PA, United States
| | - Tagbo H. R. Niepa
- Department of Chemical and Petroleum Engineering, Pittsburgh, PA, United States
- Center for Medicine and the Microbiome, Pittsburgh, PA, United States
- The McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Chemical Engineering, Pittsburgh, PA, United States
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, United States
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Wang A, Lee M, Keller A, Jian S, Lowe K, Finklea JD, Jain R. Sex differences in outcomes of people with cystic fibrosis treated with elexacaftor/tezacaftor/ivacaftor. J Cyst Fibros 2024; 23:91-98. [PMID: 37244841 DOI: 10.1016/j.jcf.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND There is a well described sex-disparity in outcomes of individuals with cystic fibrosis (CF), with females faring worse than males. Given the dramatic improvement in overall health of people with CF using CF transmembrane conductance regulator (CFTR) modulator therapy, elexacaftor/tezacaftor/ivacaftor (ETI), the sex-disparity in CF warrants re-examination. METHODS We evaluated the effects of ETI use by sex prior to versus after initiation of ETI by pulmonary exacerbations (PEx), percent predicted forced expiratory volume in one second (ppFEV1), presence of Pseudomonas aeruginosa in sputum cultures, and body mass index (BMI). We used univariate and multivariable longitudinal regression adjusting for key confounders, such as age, race, CFTR modulator taken prior to ETI and baseline ppFEV1. RESULTS We included 251 individuals started on ETI between January 2014 to September 2022. We collected data for a mean of 5.45 years pre-ETI and 2.38 years post-ETI. We found the adjusted presence of PEx decreased more in males than females pre- to post-ETI with the odds of having a PEx in males being 0.57 (43% reduction) versus females 0.75 (25% reduction) (p = 0.049). We found no statistical difference by sex for ppFEV1, presence of Pseudomonas aeruginosa or BMI pre- to post-ETI by sex. CONCLUSION After treatment with ETI, there was a greater decline in PEx in males versus females. Long-term impact of ETI by sex is still unknown, but we will need to seek ways to effectively tailor care for individuals with CF and consider pharmacokinetic studies of ETI comparing males to females.
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Affiliation(s)
- Angela Wang
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - MinJae Lee
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ashley Keller
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Southwestern Center, Dallas, TX, USA
| | - Sarah Jian
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Southwestern Center, Dallas, TX, USA
| | - Karen Lowe
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Southwestern Center, Dallas, TX, USA
| | - James D Finklea
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Southwestern Center, Dallas, TX, USA
| | - Raksha Jain
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Southwestern Center, Dallas, TX, USA.
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Savi D, Lucca F, Tridello G, Meneghelli I, Comello I, Tomezzoli S, Signorini M, Proietti E, Cucchetto G, Volpi S, Cipolli M. Long-term clinical outcomes of elexacaftor/tezacaftor/ivacaftor therapy in adults with cystic fibrosis and advanced pulmonary disease. Respir Med 2023; 219:107406. [PMID: 37690570 DOI: 10.1016/j.rmed.2023.107406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The combination of cystic fibrosis transmembrane conductance regulator (CFTR) modulators elexacaftor, tezacaftor and ivacaftor (ELX/TEZ/IVA) has been approved for treatment of cystic fibrosis (CF) patients (pwCF) homozygous and heterozygous for Phe508del. We aim to assess the long-term effects of ELX/TEZ/IVA therapy on clinical outcomes in severe pwCF. METHODS Lung function, pulmonary exacerbation (PEx), sweat chloride concentration, body mass index (BMI) and the respiratory domain of the cystic fibrosis questionnaire-revised (CFQ-R RD) were prospectively evaluated in a cohort of pwCF who were candidates for inclusion in a compassionate program of ELX/TEZ/IVA therapy. All procedures were performed at baseline and then at 12 and 24 months after initiation of modulator therapy. The number of PExs in the year before the study enrollment was collected from our records. RESULTS Thirty-six adult pwCF (median age 36.7 years; BMI 19.8 kg/m2; FEV1 36.5% predicted) were recruited from 2019. At 12 and 24 months after initiation, the absolute change in ppFEV1 (percent predicted forced expiratory volume in 1 s) from baseline was +12.5% (p < 0.0001) and +13% (p < 0.0001), respectively. A median of 4.0 exacerbations per patient was reported in the preceding year, while the median number of PExs was 0.0 and 1.0 after 12 and 24 months, respectively, of modulator therapy (both p < 0.0001). After 12 and 24 months of ELX/TEZ/IVA therapy, the CFQ-R RD score improved by 22.4 points (p < 0.0001) and 16.7 points (p < 0.0001), and sweat chloride levels decreased by 65.5 mmol/L (p < 0.0001) and 60 mmol/L (p < 0.0001), respectively. BMI significantly increased. CONCLUSIONS Long-term ELX/TEZ/IVA combination therapy markedly impacts the clinical status of patients with severe CF, showing a sustained improvement in lung function and PEx rate.
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Affiliation(s)
- Daniela Savi
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Francesca Lucca
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Gloria Tridello
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Ilaria Meneghelli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Isabella Comello
- UOSD Cystic Fibrosis Unit, Department of Medical Direction of the Hospital, Treviso, Italy; Department of Women and Child Health, University of Padova, Padova, Italy.
| | - Sara Tomezzoli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Monica Signorini
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | | | - Giulia Cucchetto
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Sonia Volpi
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
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Gill ER, Goss CH, Sagel SD, Wright ML, Horner SD, Zuñiga JA. Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale. RESEARCH SQUARE 2023:rs.3.rs-3232522. [PMID: 37790510 PMCID: PMC10543508 DOI: 10.21203/rs.3.rs-3232522/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. Methods A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. Results A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. Conclusion Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.
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12
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Byrwa DJ, Perez GF, Roach CM, Prentice S, Goetz DM. Airway clearance therapy in the school environment: Retrospective analysis of a cohort of pediatric patients with cystic fibrosis. J Cyst Fibros 2023; 22:811-815. [PMID: 36702656 DOI: 10.1016/j.jcf.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Adherence to airway clearance therapy (ACT) in pediatric cystic fibrosis (CF) patients is reported to be below 50% and inability to sustain daily care is linked to poor health outcomes7,8,9. Through a collaboration between a CF care center and several schools, we hypothesized that ACT completed at school by pediatric CF patients will improve lung function while decreasing pulmonary exacerbations (PEx), days of antibiotics (abx) and hospitalizations. METHODS This was a retrospective case-control study at a single CF care center consisting of 50 CF patients age < 18 at time when data was recorded (2012-2020). The case group used high-frequency chest wall oscillation or positive expiratory pressure devices at school for at least 1 year after self-reported or physician identified inadequate use at home. Lung function and measures of healthcare utilization were collected. RESULTS In the case group (n = 14), paired t-tests showed that after initiation of ACT at school, there were significant reductions in PEx requiring IV or PO abx (P = 0.010), total days of abx (P = 0.032), and visits to the CF care center (P = 0.037). There was no change in these outcomes in the matched control group (n = 36). CONCLUSIONS This is the first known study to highlight an initiative between a CF care center and schools which utilized airway clearance devices at school to ensure pediatric CF patients completed ACT. Through increased adherence, this relationship was associated with improved health outcomes. Use of alternative strategies may help patients with CF sustain adequate airway clearance.
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Affiliation(s)
- David J Byrwa
- John R. Oishei Children's Hospital, Buffalo, NY, United States; University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States; UBMD Pediatrics, Buffalo, NY, United States.
| | - Geovanny F Perez
- John R. Oishei Children's Hospital, Buffalo, NY, United States; University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States; UBMD Pediatrics, Buffalo, NY, United States
| | | | | | - Danielle M Goetz
- John R. Oishei Children's Hospital, Buffalo, NY, United States; University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States; UBMD Pediatrics, Buffalo, NY, United States
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13
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Sutharsan S, Dillenhoefer S, Welsner M, Stehling F, Brinkmann F, Burkhart M, Ellemunter H, Dittrich AM, Smaczny C, Eickmeier O, Kappler M, Schwarz C, Sieber S, Naehrig S, Naehrlich L. Impact of elexacaftor/tezacaftor/ivacaftor on lung function, nutritional status, pulmonary exacerbation frequency and sweat chloride in people with cystic fibrosis: real-world evidence from the German CF Registry. THE LANCET REGIONAL HEALTH. EUROPE 2023; 32:100690. [PMID: 37554663 PMCID: PMC10405057 DOI: 10.1016/j.lanepe.2023.100690] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Treatment with elexacaftor/tezacaftor/ivacaftor (ETI) improves multiple clinical outcomes in people with cystic fibrosis (pwCF) with at least one F508del allele. This study evaluated the real-world impact of ETI on lung function, nutritional status, pulmonary exacerbation frequency, and sweat chloride concentrations in a large group of pwCF. METHODS This observational cohort study used data from the German CF Registry for pwCF who received ETI therapy and were followed up for a period of 12 months. FINDINGS The study included 2645 pwCF from 67 centres in Germany (mean age 28.0 ± 11.5 years). Over the first year after ETI was initiated, percent predicted forced expiratory volume in 1 s (ppFEV1) increased by 11.3% (95% confidence interval [CI] 10.8-11.8, p < 0.0001), body mass index (BMI) z-score increased by 0.3 (95% CI 0.3-0.4, p < 0.0001) in individuals aged 12 to <18 years and BMI in adults increased by 1.4 kg/m2 (95% CI 1.3-1.4, p < 0.0001), pulmonary exacerbations decreased by 75.9% (p < 0.0001) and mean sweat chloride concentration decreased by 50.9 mmol/L (95% CI -52.6, -49.3, p < 0.0001). Improvements in ppFEV1 over the first year of therapy were greater in pwCF who had not previously received cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy (12.6% [95% CI 11.9-13.4] vs. 9.7% [95% CI 9.0-10.5] in those with prior CFTR modulator treatment. INTERPRETATION These real-world data are consistent with the findings of randomised clinical trials, and support the use of ETI as a highly effective treatment option for pwCF who have at least one F508del allele. FUNDING None.
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Affiliation(s)
- Sivagurunathan Sutharsan
- Department of Pulmonary Medicine, University Hospital Essen-Ruhrlandklinik, Adult Cystic Fibrosis Center, University of Duisburg-Essen, Essen, Germany
| | - Stefanie Dillenhoefer
- Department of Pediatric Pulmonology, Cystic Fibrosis Center, University Children's Hospital of Ruhr University Bochum at St. Josef-Hospital, Bochum, Germany
| | - Matthias Welsner
- Department of Pulmonary Medicine, University Hospital Essen-Ruhrlandklinik, Adult Cystic Fibrosis Center, University of Duisburg-Essen, Essen, Germany
| | - Florian Stehling
- Pediatric Pulmonology and Sleep Medicine, Children's University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Folke Brinkmann
- Department of Pediatric Pneumology & Allergology, The University of Lübeck, University Medical Center Schleswig-Holstein, Campus Centrum Lübeck, Member of Airway Research Center North (ARCN) of the German Center of Lung Research (DZL), Lübeck, Germany
| | | | - Helmut Ellemunter
- Medical University of Innsbruck, Cystic Fibrosis Centre Innsbruck, Innsbruck, Austria
| | - Anna-Maria Dittrich
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Germany
| | - Christina Smaczny
- University Hospital Frankfurt/Main, Goethe University, Pneumology and Allergology, Christiane Herzog CF Center Frankfurt/Main, Frankfurt/Main, Germany
| | - Olaf Eickmeier
- Pediatric Allergology, Pulmonology & Cystic Fibrosis, Christiane Herzog CF Center- Frankfurt a.M., University Hospital Frankfurt a.M., Germany
| | - Matthias Kappler
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Carsten Schwarz
- Division Cystic Fibrosis, HMU-Health and Medical University Potsdam, Clinic Westbrandenburg, Potsdam, Germany
| | - Sarah Sieber
- STAT-UP Statistical Consulting & Data Science GmbH, Munich, Germany
| | - Susanne Naehrig
- Department of Internal Medicine V, Cystic Fibrosis Center for Adults, University Hospital, Ludwig Maximilian University (LMU) Munich, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany
- Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
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14
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Merjaneh L, Sidhaye AR, Vu PT, Heltshe SL, Goss CH, Flume PA, Kelly A, Rosenfeld M. Role of hyperglycemia in cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2023; 22:868-874. [PMID: 37394317 PMCID: PMC10756929 DOI: 10.1016/j.jcf.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 06/09/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Hyperglycemia could affect treatment response during cystic fibrosis (CF) exacerbations. We aimed to evaluate the prevalence and associations of hyperglycemia with exacerbation outcomes. We also evaluated feasibility of continuous glucose monitoring (CGM) during exacerbations. METHODS The STOP2 study assessed efficacy and safety of different durations of intravenous antibiotics for CF exacerbations. We conducted a secondary data analysis of random glucose levels measured as part of clinical care during exacerbations. A small subset of participants also underwent CGM per research protocol. The associations between hyperglycemia, defined as random glucose ≥140 mg/dL, and changes in weight and lung function with exacerbation treatment were evaluated with linear regression after adjustment for confounding variables. RESULTS Glucose levels were available for 182 STOP2 participants of mean (SD) age 31.6 (10.8) years, baseline percent predicted (pp) FEV1 53.6 (22.5); 37% had CF related diabetes and 27% were on insulin. Hyperglycemia was detected in 44% of participants. Adjusted mean difference (95% CI) was 1.34% (-1.39, 4.08) (p = 0.336) for change in ppFEV1 and 0.33 kg (-0.11, 0.78) (p = 0.145) for change in weight between hyperglycemic and non-hyperglycemic groups. Ten participants not on antidiabetic agents in the 4 weeks prior to enrollment underwent CGM; mean (SD) time spent >140 mg/dL was 24.6% (12.5) with 9/10 participants spending >4.5% time >140 mg/dL. CONCLUSIONS Hyperglycemia identified with random glucose is prevalent during CF exacerbations but not associated with changes in lung function or weight with exacerbation treatment. CGM is feasible and may provide a useful tool for hyperglycemia monitoring during exacerbations.
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Affiliation(s)
- Lina Merjaneh
- Division of Endocrinology and Diabetes, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98145, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Aniket R Sidhaye
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD 21287, USA
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Andrea Kelly
- Department of Pediatrics, Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98145, USA
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15
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Widder S, Opron K, Carmody LA, Kalikin LM, Caverly LJ, LiPuma JJ. Microbial community organization designates distinct pulmonary exacerbation types and predicts treatment outcome in cystic fibrosis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.21.550012. [PMID: 37546739 PMCID: PMC10401930 DOI: 10.1101/2023.07.21.550012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Polymicrobial infection of the airways is a hallmark of obstructive lung diseases such as cystic fibrosis (CF), non-CF bronchiectasis, and chronic obstructive pulmonary disease (COPD). Intermittent pulmonary exacerbations (PEx) in these conditions are associated with lung function decline and higher mortality rates. An understanding of the microbial underpinnings of PEx is challenged by high inter-patient variability in airway microbial community profiles. We analyzed 880 near-daily CF sputum samples and developed non-standard microbiome descriptors to model community reorganization prior and during 18 PEx. We identified two communal microbial regimes with opposing ecology and dynamics. Whereas pathogen-governed dysbiosis showed hierarchical community organization and reduced diversity, anaerobic bloom dysbiosis displayed stochasticity and increased diversity. Microbiome organization modulated the relevance of pathogens and a simulation of antimicrobial treatment predicted better efficacy for hierarchically organized microbiota. This causal link between PEx, microbiome organization, and treatment success advances the development of personalized dysbiosis management in CF and, potentially, other obstructive lung diseases.
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16
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Walicka-Serzysko K, Postek M, Borawska-Kowalczyk U, Milczewska J, Sands D. Pulmonary Function Tests in the Evaluation of Early Lung Disease in Cystic Fibrosis. J Clin Med 2023; 12:4735. [PMID: 37510850 PMCID: PMC10380830 DOI: 10.3390/jcm12144735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Properly evaluating respiratory system dysfunction is essential in children with cystic fibrosis (CF). This prospective study aimed to assess the course of early lung disease based on multiple breath nitrogen washout (MBNW), impulse oscillometry (IOS), and conventional techniques, such as spirometry and body plethysmography. METHODS Over a 2 year recruitment period, subjects with CF aged 7-18 performed pulmonary function tests (PFTs). Moreover, the nutritional and microbiological status, frequency of pulmonary exacerbations (PExs), and patients' health-related quality of life (HRQoL) were assessed. RESULTS The mean age of the children (n = 69) was 14.09 ± 3.26 years; F/M 37/32. Spirometry-based diagnoses of normal lung function (forced expiratory volume in 1 s, FEV1 ≥ 90%pred), mild (FEV1 70-89%pred) and moderate (FEV1 40-69%pred) lung diseases were established in 34 (49.3%), 25 (36.2%), and 10 (14.5%) patients, respectively. An elevated lung clearance index (LCI > 6.98) was observed in 85% of the subjects with normal FEV1. The presence of Pseudomonas aeruginosa infection (n = 16) and the number of PExs treated with IV antibiotics were associated with significantly worse PFT results. CONCLUSIONS MBNW and IOS are more helpful tools than conventional techniques in assessing early lung disease in CF. LCI is a more useful parameter for detecting functional abnormalities than FEV1 in school-age children.
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Affiliation(s)
- Katarzyna Walicka-Serzysko
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Magdalena Postek
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Urszula Borawska-Kowalczyk
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Justyna Milczewska
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
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17
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O'Dea AL, Feng R, Glaser LJ, Kubrak C, Rubenstein RC, Dorgan DJ, Hadjiliadis D, Kawut SM, Hong G. The Clinical Association between Aspergillus fumigatus and Respiratory Outcomes in Adolescents and Adults with Cystic Fibrosis. Ann Am Thorac Soc 2023; 20:984-992. [PMID: 36800434 DOI: 10.1513/annalsats.202210-852oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/17/2023] [Indexed: 02/19/2023] Open
Abstract
Rationale: The clinical significance of Aspergillus fumigatus (Af) detection in the absence of allergic bronchopulmonary aspergillosis in cystic fibrosis (CF) airways remains unclear. Yet, some clinicians initiate antifungal therapy for Af-positive respiratory cultures out of concern for infection in people with CF. Objectives: To determine the association between the presence of Af and respiratory outcomes in individuals with CF. Methods: We conducted a prospective longitudinal cohort study of 206 adults and adolescents (age 14 yr and older) with CF and collected sputum for selective fungus culture. We assessed clinical outcome measurements, including patient-reported outcomes (measured by the Cystic Fibrosis Questionnaire-Revised), spirometry, and number of pulmonary exacerbations (PEx) for a 1-year period. We used mixed-effects linear models to determine the association between positive Af culture results, defined as Af detection in sputum culture at the study visit, with both respiratory domain score and forced expiratory volume in 1 second (FEV1) percent predicted, adjusted for confounders. Mixed-effects Poisson regression models were employed to examine the association between positive Af culture results and PEx events. We explored the association between Af history, defined as Af detection at baseline or within 2 years of enrollment, and respiratory outcomes. Results: Af prevalence was 10.3% (95% confidence interval [CI], 6.8, 15.7) at baseline. Forty-eight (23.3%; 95% CI, 17.7, 29.7) participants had at least one Af-positive culture result during the study period. Positive Af culture result was not associated with lower respiratory domain score. However, Af history was associated with a 6.48-point lower respiratory domain score, reflective of worse respiratory quality of life (95% CI, -11.96, -0.99; P = 0.02). Positive Af culture result was associated with a 2.54% lower FEV1 percent predicted (95% CI, -4.64, -0.44; P = 0.02) and a 1.71-fold increase in severe PEx incidence (95% CI, 1.05, 2.76; P = 0.03). Conclusions: Positive Af culture result was not associated with lower patient-reported, respiratory-related quality of life. Yet, positive Af culture result was associated with both lower FEV1 percent predicted and increased frequency of severe PEx warranting intravenous antibiotics in adolescents and adults with CF. Future studies are required to better understand the direct role of Af in lung disease progression in CF.
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Affiliation(s)
- Anna L O'Dea
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, and
| | - Laurel J Glaser
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina Kubrak
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri; and
| | - Ronald C Rubenstein
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri; and
| | - Daniel J Dorgan
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
| | - Denis Hadjiliadis
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
- Center for Clinical Epidemiology and Biostatistics, and
| | - Gina Hong
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
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Fainardi V, Capoferri G, Tornesello M, Pisi G, Esposito S. Telemedicine and Its Application in Cystic Fibrosis. J Pers Med 2023; 13:1041. [PMID: 37511654 PMCID: PMC10381340 DOI: 10.3390/jpm13071041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
The care of cystic fibrosis (CF) traditionally consists of regular visits to the clinic where a multidisciplinary team can visit the patient, adjust treatments and monitor the disease. During the COVID-19 pandemic when access to hospitals and medical environments was very limited, the role of telemedicine was crucial to keep in touch with patients with chronic diseases such as CF. Increasing evidence demonstrates that electronic health can successfully support healthcare professionals in the management of people with CF. The use of devices connected to digital platforms or smartphones results in a continuous flow of data that can be shared with the clinician and the team in order to improve the knowledge of patients' diseases and the level of care needed. This narrative review aims to describe the application of telemedicine in CF disease with pros and cons. A literature analysis showed that telemedicine has several advantages in the management of patients with CF. With the evolving support of digital technology, telemedicine can promote clinical visits, adherence to daily treatment, including respiratory physiotherapy and physical exercise, early identification of pulmonary exacerbations and management of psychological issues. The main disadvantages are missed physical exam findings, lack of physical contact that can prevent conversation on sensitive topics, lack of access to technology and lack of technological skills. Furthermore, healthcare operators need appropriate training for telemedicine systems and need time to organise and analyse data generated remotely, which may increase the burden of daily work. Hybrid personalised care models that marge telemedicine and traditional care can be an ideal solution.
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Affiliation(s)
- Valentina Fainardi
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Gaia Capoferri
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Marco Tornesello
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Giovanna Pisi
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
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Wong CH, Smith S, Kansra S. Digital technology for early identification of exacerbations in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 4:CD014606. [PMID: 37057835 PMCID: PMC10103544 DOI: 10.1002/14651858.cd014606.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-limiting genetic condition affecting various organ systems including the gastrointestinal tract, endocrine system and especially the respiratory tract. Pulmonary exacerbations in CF result in increased symptoms, an acceleration in the rate of lung decline and an increased need for treatment. Early detection of infections or clinical worsening provides an opportunity for proactive treatment that may affect clinical outcomes. OBJECTIVES To evaluate whether digital technology can effectively predict pulmonary exacerbations to allow earlier intervention and improved health outcomes without increasing the burden of treatment in people with CF. SEARCH METHODS We used standard, extensive Cochrane search methods. We searched the Cochrane Cystic Fibrosis Trials Register and the reference lists of relevant articles and reviews on 13 October 2022. We searched Embase and the clinical trial registries on 3 January 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs in people with CF looking at whether digital technology can effectively predict pulmonary exacerbations to allow earlier intervention and improved health outcomes without increasing the burden of treatment. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. pulmonary exacerbations and 2. quality of life (QoL). Our secondary outcomes were 3. lung function, 4. hospitalisations, 5. intravenous (IV) antibiotics, 6. microbiology, 7. cost-effectiveness and 8. ADVERSE EVENTS We used GRADE to assess certainty of evidence. MAIN RESULTS We included three studies (415 participants) in people with CF aged 15 to 41 years over a 12-month period. One was a multicentre RCT, whilst two were single-centre RCTs. The three studies were mostly similar in their risk of bias, having low or unclear risk of selection bias but a high risk of detection bias, due to the unblinded design of these studies. The studies used a variety of digital technologies to monitor symptoms such as a digital symptom diary either with or without home spirometry monitoring. As the trials only included adults and older children, we are not certain that the results would apply to younger children. One of our primary outcomes was to assess time to detection of pulmonary exacerbation and number of pulmonary exacerbations identified between the intervention and routine care groups. We were largely unable to pool results in a meta-analysis due to the variety of methodologies and ways of reporting data. Two studies noted a shorter time to detection of exacerbations in the intervention group and one of these also reported that the intervention group had a shorter time to first exacerbation (hazard ratio for time to first exacerbation 1.45, 95% confidence interval (CI) 1.09 to 1.93), whilst a further study reported a shorter time to detection of exacerbations in the intervention group requiring oral or IV antibiotics compared to the control group (median: 70 (interquartile range (IQR) 123) days with intervention versus 141 (IQR 140) days with control; P = 0.02). However, all three studies were concordant in finding no probable effect on spirometry in the intervention groups when compared with their routine care groups over a 12-month period. We found that there is probably no difference between groups with regard to QoL scores across most domains except for Weight and Body Image, which favoured the usual care group. There is also probably no difference in the number of days of additional IV antibiotics needed or newly detected pathogens. No studies reported serious adverse events directly linked to the intervention and one study reported their smartphone application was generally well received. AUTHORS' CONCLUSIONS Pulmonary exacerbations are universally accepted to be detrimental to progression of CF-related lung disease, therefore, it is intuitive that early detection and intervention would help to improve outcomes. Digital technology provides an opportunity to detect physiological and symptomatic changes to identify exacerbations early. Our review found that digital technologies based on recording physiological change (spirometry) and symptoms probably allow earlier identification of exacerbations as a group. However, this may not reduce the number of exacerbations warranting IV antibiotics and there is probably no effect on lung function. This may be partly due to inconsistent definitions of pulmonary exacerbations and discrepancy in the management strategies for pulmonary exacerbations. Overall, the intervention may make little or no difference to QoL scores. The adherence to and uptake of digital technologies, especially those which include physiological measurements, are not well sustained and the costs of these need to be balanced against the clinical efficacy.
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Affiliation(s)
- Chu-Hai Wong
- Department of Paediatric Respiratory Medicine, Sheffield Children's Hospital NHS Trust, Sheffield, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Sonal Kansra
- Department of Paediatric Respiratory Medicine, Sheffield Children's Hospital NHS Trust, Sheffield, UK
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20
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Schwarz C, Wimmer E, Holz F, Grehn C, Staab D, Eschenhagen PN. Antibiotic Therapy for Pulmonary Exacerbations in Cystic Fibrosis-A Single-Centre Prospective Observational Study. Antibiotics (Basel) 2023; 12:antibiotics12040734. [PMID: 37107096 PMCID: PMC10135273 DOI: 10.3390/antibiotics12040734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/30/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
People with cystic fibrosis experience bronchopulmonary exacerbations, leading to lung damage, lung function decline, increased mortality, and a poor health-related quality of life. To date, there are still open questions regarding the rationale for antibiotic use and the optimal duration of antibiotic therapy. This prospective single-center study (DRKS00012924) analyzes exacerbation treatment over 28 days in 96 pediatric and adult people with cystic fibrosis who started oral and/or intravenous antibiotic therapy in an inpatient or outpatient setting after clinician diagnosis of bronchopulmonary exacerbation. Biomarkers of exacerbation were examined in terms of their ability to predict response to treatment and the need for antibiotic therapy. The mean duration of antibiotic therapy was 14 days. Inpatient treatment was associated with a poorer health status, but no significant difference was found in the modified Fuchs exacerbation score between inpatients and outpatients. A significant increase of in-hospital FEV1, home spirometry FEV1, and body-mass index and a significant decrease of the modified Fuchs symptom score, C-reactive protein, and 8 out of the 12 domain scores of the revised cystic fibrosis questionnaire were demonstrated after 28 days. However, a trend towards a FEV1 decline in the inpatient group on day 28 could be demonstrated, while FEV1 was maintained in the outpatient group. Correlation analyses of changes between baseline and day 28 show a strong positive correlation between home spirometry and in-hospital FEV1, strong negative correlations between FEV1 and the modified Fuchs exacerbation score and between FEV1 and C-reactive protein, and a moderately negative correlation between FEV1 and the three domains of the revised cystic fibrosis questionnaire. Responders and non-responders to antibiotic therapy were defined in terms of FEV1 improvement after therapy. A higher baseline C-reactive protein, a greater decrease in C-reactive protein, a higher baseline modified Fuchs exacerbation score, and a greater decrease in the score after 28 days could be found in the responder group, while other baseline and follow-up parameters like FEV1 showed no significant differences. Our data show that the modified Fuchs exacerbation score is applicable in a clinical setting and can detect acute exacerbations regardless of health status. Home spirometry is a useful tool for outpatient exacerbation management. A change in C-reactive protein and a modified Fuchs score change are suitable follow-up markers of exacerbation due to their strong correlation with FEV1. Further studies are needed to assess which patients would benefit from a longer duration of antibiotic therapy. C-reactive protein at exacerbation onset and C-reactive protein decline during and after therapy better predict antibiotic therapy success than FEV1 at therapy onset, while the modified Fuchs score indicates exacerbation regardless of the need for antibiotic therapy, suggesting that antibiotic therapy is only part of exacerbation management.
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Affiliation(s)
- Carsten Schwarz
- Cystic Fibrosis Center, Clinic Westbrandenburg, 14467 Potsdam, Germany
- Department of Education and Research, HMU Health and Medical University Potsdam, 14471 Potsdam, Germany
| | - Eliana Wimmer
- Paediatric Practice at Traveplatz, Dr. Kilger, Dr. Kabelitz, Dr. Shetty, 10247 Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
| | - Frederik Holz
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
| | - Claudia Grehn
- BIH Berlin Institute of Health, Charité University Medicine Berlin, 13353 Berlin, Germany
| | - Doris Staab
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany
| | - Patience Ndidi Eschenhagen
- Cystic Fibrosis Center, Clinic Westbrandenburg, 14467 Potsdam, Germany
- Department of Education and Research, HMU Health and Medical University Potsdam, 14471 Potsdam, Germany
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21
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Brackenborough K, Ellis H, Flight WG. Respiratory Viruses and Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:196-208. [PMID: 36535663 DOI: 10.1055/s-0042-1758728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The threat of respiratory virus infection to human health and well-being has been clearly highlighted by the coronavirus disease 2019 (COVID-19) pandemic. For people with cystic fibrosis (CF), the clinical significance of viral infections long predated the emergence of severe acute respiratory syndrome coronavirus 2. This article reviews the epidemiology, diagnosis, and treatment of respiratory virus infection in the context of CF as well as the current understanding of interactions between viruses and other microorganisms in the CF lung. The incidence of respiratory virus infection in CF varies by age with young children typically experiencing more frequent episodes than adolescents and adults. At all ages, respiratory viruses are very common in CF and are associated with pulmonary exacerbations. Respiratory viruses are identified at up to 69% of exacerbations, while viruses are also frequently detected during clinical stability. The full impact of COVID-19 in CF is yet to be established. Early studies found that rates of COVID-19 were lower in CF cohorts than in the general population. The reasons for this are unclear but may be related to the effects of shielding, infection control practices, maintenance CF therapies, or the inflammatory milieu in the CF lung. Observational studies have consistently identified that prior solid organ transplantation is a key risk factor for poor outcomes from COVID-19 in CF. Several key priorities for future research are highlighted. First, the impact of highly effective CFTR modulator therapy on the epidemiology and pathophysiology of viral infections in CF requires investigation. Second, the impact of respiratory viruses on the development and dynamics of the CF lung microbiota is poorly understood and viral infection may have important interactions with bacteria and fungi in the airway. Finally, bacteriophages represent a key focus of future investigation both for their role in transmission of antimicrobial resistance and as a promising treatment modality for multiresistant pathogens.
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Affiliation(s)
- Kate Brackenborough
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Huw Ellis
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - William G Flight
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom.,Research and Development, GlaxoSmithKline plc, Brentford, United Kingdom
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22
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Mannem H, Aversa M, Keller T, Kapnadak SG. The Lung Transplant Candidate, Indications, Timing, and Selection Criteria. Clin Chest Med 2023; 44:15-33. [PMID: 36774161 DOI: 10.1016/j.ccm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation can be lifesaving for patients with advanced lung disease. Demographics are evolving with recipients now sicker but determining candidacy remains predicated on one's underlying lung disease prognosis, along with the likelihood of posttransplant success. Determining optimal timing can be challenging, and most programs favor initiating the process early and proactively to allow time for patient education, informed decision-making, and preparation. A comprehensive, multidisciplinary evaluation is used to elucidate disease progrnosis and identify risk factors for poor posttransplant outcomes. Candidacy criteria vary significantly by center, and close communication between referring and transplant providers is necessary to improve access to transplant and outcomes.
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Affiliation(s)
- Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia School of Medicine, PO Box 800546, Clinical Department Wing, 1 Hospital Drive, Charlottesville, VA 22908, USA
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON M5S 3H2, Canada
| | - Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA.
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23
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Simmonds NJ, van der Ent CK, Colombo C, Kinnman N, DeSouza C, Thorat T, Chew ML, Chandarana K, Castellani C. VOCAL: An observational study of ivacaftor for people with cystic fibrosis and selected non-G551D-CFTR gating mutations. J Cyst Fibros 2023; 22:124-131. [PMID: 35613999 DOI: 10.1016/j.jcf.2022.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND VOCAL was an observational study of the effect of long-term ivacaftor on real-world clinical outcomes and healthcare resource utilization (HCRU) in people with cystic fibrosis (pwCF) in Italy, the Netherlands, and the UK. METHODS pwCF aged ≥6 years with non-G551D-CFTR gating mutations were eligible. Prospective data were collected up to 48 months after enrollment; retrospective data were collected to ensure that 12 months of pre-ivacaftor data were available. Endpoints included absolute change from baseline in percent predicted forced expiratory volume in 1 second (ppFEV1) and measures of nutritional status. Pulmonary exacerbation (PEx) rates, HCRU, and respiratory microbiology during ivacaftor treatment were compared with data from the 12-month period before initiation. RESULTS Seventy-three eligible pwCF were enrolled and received ivacaftor; 65 (89.0%) completed the study (48 [65.8%] completed ≥48 months of ivacaftor). During the first 6 months of ivacaftor, ppFEV1, body mass index (BMI), and BMI-for-age z-score showed least-squares mean absolute improvements of 10.8 percentage points, 0.79 kg/m2, and 0.54, respectively; improvements were maintained through 48 months. Rates of PEx, antibiotic use due to PEx, and hospitalization decreased by >50% during ivacaftor treatment compared with before ivacaftor. The number of respiratory cultures and sputum was lower post-ivacaftor, as was the percentage of pwCF with positive respiratory cultures for 3 of 9 pathogens evaluated (Pseudomonas aeruginosa, Aspergillus fumigatus, Stenotrophomonas maltophilia). Reported safety results were consistent with CF and ivacaftor's known safety profile. CONCLUSIONS These results demonstrate the positive long-term effectiveness of ivacaftor on clinical outcomes and HCRU in pwCF with non-G551D-CFTR gating mutations in real-world settings.
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Affiliation(s)
- Nicholas J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK, and National Heart and Lung Institute, Imperial College London, London, UK.
| | - C Kors van der Ent
- Department of Pediatric Respiratory Diseases, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Nils Kinnman
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | | | - Teja Thorat
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Marci L Chew
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | | | - Carlo Castellani
- Cystic Fibrosis Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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24
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Gileles-Hillel A, Soesman LH, Miari S, Breuer O, Tsabari R, Elyashar-Earon H, Armoni S, Sprikkelman AB, Reiter J, Zangen D, Lavi E, Kerem E, Cohen-Cymberknoh M. The utility of glucose area under the curve from the oral glucose tolerance test as a screening tool for cystic fibrosis-related diabetes. Pediatr Pulmonol 2022; 57:2774-2780. [PMID: 35999051 DOI: 10.1002/ppul.26100] [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: 12/22/2021] [Revised: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Consistently abnormal glucose levels on oral glucose tolerance test (OGTT) are the most effective screening tool for cystic fibrosis-related diabetes (CFRD). However, some cystic fibrosis (CF) patients demonstrate abnormal glucose profiles not reaching levels required for CFRD diagnosis and are, therefore, left untreated. Since CFRD is associated with disease deterioration, early diagnosis and treatment are desirable. AIM To explore the association between the area under the curve of glucose (G-AUC) obtained during a five-point 2-h standard OGTT and CF disease severity parameters. METHODS All CF patients referred for an annual routine OGTT at the Hadassah CF Center between 2002 and 2018, were included. Disease severity parameters were correlated with the G-AUC. RESULTS Two hundred forty-two OGTTs were performed in 81 patients (mean age 19.7 ± 9.0 years); 54% were normal, 14% showed impaired glucose tolerance (IGT), 5% had values in the indeterminate range (INDET), 11% had both IGT and INDET and 16% were diagnosed with CFRD. A gradual increase in mean G-AUC was observed among the groups. In multivariate regression models, G-AUC ≥ 295 mg h/dl was independently associated with an increased number of pulmonary exacerbations (PEx). Not all the patients having this value met the CFRD definition. CONCLUSION Patients who do not fulfill the criteria for CFRD may have abnormal glucose metabolism identifiable by abnormally high G-AUC values, which may be associated with more PEx. The potential advantage of treating these patients with insulin and the subsequent reduction in PEx needs further investigation.
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Affiliation(s)
- Alex Gileles-Hillel
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Liora H Soesman
- Department of Pediatrics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Silwan Miari
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Breuer
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Reuven Tsabari
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hila Elyashar-Earon
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel
| | | | - Aline B Sprikkelman
- Department of Pediatric Pulmonology and Pediatric Allergology, University of Groningen, Groningen, The Netherlands
| | - Joel Reiter
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Zangen
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Pediatric Endocrinology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eran Lavi
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Pediatric Endocrinology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eitan Kerem
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonary Unit and Cystic Fibrosis Center, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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25
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Tanner KT, Daniel RM, Bilton D, Simmonds NJ, Sharples LD, Keogh RH. Mediation of the total effect of cystic fibrosis-related diabetes on mortality: A UK Cystic Fibrosis Registry cohort study. Diabet Med 2022; 39:e14958. [PMID: 36075586 PMCID: PMC9826418 DOI: 10.1111/dme.14958] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/12/2022] [Accepted: 09/07/2022] [Indexed: 01/11/2023]
Abstract
AIM To investigate whether the effect of cystic fibrosis-related diabetes (CFRD) on the composite outcome of mortality or transplant could act through lung function, pulmonary exacerbations and/or nutritional status. METHODS A retrospective cohort of adult cystic fibrosis (CF) patients who had not been diagnosed with CFRD were identified from the UK Cystic Fibrosis Registry (n = 2750). Rate of death or transplant was compared between patients who did and did not develop CFRD (with insulin use) during follow-up using Poisson regression, separately by sex. Causal mediation methods were used to investigate whether lung function, pulmonary exacerbations and nutritional status lie on the causal pathway between insulin-treated CFRD and mortality/transplant. RESULTS At all ages, the mortality/transplant rate was higher in both men and women diagnosed with CFRD. Pulmonary exacerbations were the strongest mediator of the effect of CFRD on mortality/transplant, with an estimated 15% [95% CI: 7%, 28%] of the effect at 2 years post-CFRD diagnosis attributed to exacerbations, growing to 24% [95% CI: 9%, 46%] at 4 years post-diagnosis. Neither lung function nor nutritional status were found to be significant mediators of this effect. Estimates were similar but with wider confidence intervals in a cohort that additionally included people with CFRD but not using insulin. CONCLUSION There is evidence that pulmonary exacerbations mediate the effect of CFRD on mortality but, as they are estimated to mediate less than one-quarter of the total effect, the mechanism through which CFRD influences survival may involve other factors.
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Affiliation(s)
- Kamaryn T. Tanner
- Department of Medical StatisticsThe London School of Hygiene and Tropical MedicineLondonUK
| | | | - Diana Bilton
- Imperial College London, Faculty of MedicineNational Heart and Lung InstituteLondonUK
- Royal Brompton HospitalLondonUK
| | - Nicholas J. Simmonds
- Imperial College London, Faculty of MedicineNational Heart and Lung InstituteLondonUK
- Royal Brompton HospitalLondonUK
| | - Linda D. Sharples
- Department of Medical StatisticsThe London School of Hygiene and Tropical MedicineLondonUK
| | - Ruth H. Keogh
- Department of Medical StatisticsThe London School of Hygiene and Tropical MedicineLondonUK
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26
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Ramos KJ, Hee Wai T, Stephenson AL, Sykes J, Stanojevic S, Rodriguez PJ, Bansal A, Mayer-Hamblett N, Goss CH, Kapnadak SG. Development and Internal Validation of a Prognostic Model of the Probability of Death or Lung Transplantation Within 2 Years for Patients With Cystic Fibrosis and FEV 1 ≤ 50% Predicted. Chest 2022; 162:757-767. [PMID: 35643116 PMCID: PMC9633811 DOI: 10.1016/j.chest.2022.05.021] [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] [Received: 08/18/2021] [Revised: 04/19/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Improved methods are needed to risk-stratify patients with cystic fibrosis (CF) and reduced FEV1. RESEARCH QUESTIONS What are the predictors of death or lung transplantation (LTx) within 2 years among patients with CF whose FEV1 ≤ 50% predicted? Do these markers similarly predict outcomes among G551D patients taking ivacaftor since 2012? STUDY DESIGN AND METHODS Patients with CF, age ≥ 6 years with FEV1 ≤ 50% predicted as of December 31, 2014, were identified in a data set that merged Cystic Fibrosis Foundation and United Network for Organ Sharing (UNOS) registries. The least absolute shrinkage and selection operator (LASSO) method was applied to a randomly selected training set to select important prognostic variables. Accuracy and association of the model with death or LTx with 2 years (2-year death or LTx) were validated via logistic regression on an independent test set. Sensitivity analyses explored predictors for patients with UNOS data. RESULTS FEV1 percent predicted (OR, 1.51 for 5% decrease; 95% CI, 1.27-1.81), number of pulmonary exacerbations treated with IV antibiotics (OR, 1.35; 95% CI, 1.11-1.65), and continuous or nocturnal oxygen (OR, 3.71; 95% CI, 1.81-7.59) were significantly associated with 2-year death or LTx. Our model predicted outcomes with greater sensitivity (ratio of sensitivity, 1.26; 95% CI, 1.02-1.54), ratio of positive predictive value (1.25; 95% CI, 1.05-1.51), and ratio of negative predictive value (1.04; 95% CI, 1.01-1.07) than FEV1 < 30% predicted. Among those taking ivacaftor in 2014, only FEV1 remained associated with 2-year death or LTx. For patients with UNOS data, LASSO identified additional covariates of interest, including noninvasive ventilation use, low hemoglobin, pulmonary arterial systolic pressure, supplemental oxygen, mechanical ventilation, FEV1 percent predicted, and cardiac index. INTERPRETATION Among individuals with CF and FEV1 ≤ 50% predicted, FEV1 percent predicted, oxygen therapy, and number of pulmonary exacerbations predicted 2-year death or LTx. Although limited by small sample size, only FEV1 remained predictive in patients receiving highly effective modulator therapy. Additional physiologic variables could improve prognostication in CF.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Travis Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jenna Sykes
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Patricia J Rodriguez
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Aasthaa Bansal
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Nicole Mayer-Hamblett
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Research Institute, Seattle, WA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Research Institute, Seattle, WA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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27
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Lloyd EC, Cogen JD, Maples H, Bell SC, Saiman L. Antimicrobial Stewardship in Cystic Fibrosis. J Pediatric Infect Dis Soc 2022; 11:S53-S61. [PMID: 36069899 DOI: 10.1093/jpids/piac071] [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: 03/03/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
The chronic airway infection and inflammation characteristic of cystic fibrosis (CF) ultimately leads to progressive lung disease, the primary cause of death in persons with CF (pwCF). Despite many recent advances in CF clinical care, efforts to preserve lung function in many pwCF still necessitate frequent antimicrobial use. Incorporating antimicrobial stewardship (AMS) principles into management of pulmonary exacerbations (PEx) would facilitate development of best practices for antimicrobial utilization at CF care centers. However, AMS can be challenging in CF given the unique aspects of chronic, polymicrobial infection in the CF airways, lack of evidence-based guidelines for managing PEx, limited utility for antimicrobial susceptibility testing, and increased frequency of adverse drug events in pwCF. This article describes current evidence-based antimicrobial treatment strategies for pwCF, highlights the potential for AMS to beneficially impact CF care, and provides practical strategies for integrating AMS programs into the management of PEx in pwCF.
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Affiliation(s)
- Elizabeth C Lloyd
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jonathan D Cogen
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Holly Maples
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas, USA.,Quality and Safety Division, Arkansas Children's, Little Rock, Arkansas, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Children's Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA.,Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, New York, USA
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28
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Abstract
BACKGROUND Cystic fibrosis is a genetic disorder in which abnormal mucus in the lungs is associated with susceptibility to persistent infection. Pulmonary exacerbations are when symptoms of infection become more severe. Antibiotics are an essential part of treatment for exacerbations and inhaled antibiotics may be used alone or in conjunction with oral antibiotics for milder exacerbations or with intravenous antibiotics for more severe infections. Inhaled antibiotics do not cause the same adverse effects as intravenous antibiotics and may prove an alternative in people with poor access to their veins. This is an update of a previously published review. OBJECTIVES To determine if treatment of pulmonary exacerbations with inhaled antibiotics in people with cystic fibrosis improves their quality of life, reduces time off school or work, and improves their long-term lung function. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Group's Cystic Fibrosis Trials Register. Date of the last search: 7 March 2022. We also searched ClinicalTrials.gov, the Australia and New Zealand Clinical Trials Registry and WHO ICTRP for relevant trials. Date of last search: 3 May 2022. SELECTION CRITERIA Randomised controlled trials in people with cystic fibrosis with a pulmonary exacerbation in whom treatment with inhaled antibiotics was compared to placebo, standard treatment or another inhaled antibiotic for between one and four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted data. They assessed the certainty of the evidence using the GRADE criteria. Authors of the included trials were contacted for more information. MAIN RESULTS Five trials with 183 participants are included in the review. Two trials (77 participants) compared inhaled antibiotics alone to intravenous antibiotics alone and three trials (106 participants) compared a combination of inhaled and intravenous antibiotics to intravenous antibiotics alone. Trials were heterogenous in design and two were only available in abstract form. Risk of bias was difficult to assess in most trials but, for four out of five trials, we judged there to be a high risk from lack of blinding and an unclear risk with regards to randomisation. Results were not fully reported and only limited data were available for analysis. One trial was a cross-over design and we only included data from the first intervention arm. Inhaled antibiotics alone versus intravenous antibiotics alone Only one trial (18 participants) reported a perceived improvement in lifestyle (quality of life) in both groups (very low-certainty evidence). Neither trial reported on time off work or school. Both trials measured lung function, but there was no difference reported between treatment groups (very low-certainty evidence). With regards to our secondary outcomes, one trial (18 participants) reported no difference in the need for additional antibiotics and the second trial (59 participants) reported on the time to next exacerbation. In neither case was a difference between treatments identified (both very low-certainty evidence). The single trial (18 participants) measuring adverse events and sputum microbiology did not observe any in either treatment group for either outcome (very low-certainty evidence). Inhaled antibiotics plus intravenous antibiotics versus intravenous antibiotics alone Inhaled antibiotics plus intravenous antibiotics may make little or no difference to quality of life compared to intravenous antibiotics alone. None of the trials reported time off work or school. All three trials measured lung function, but found no difference between groups in forced expiratory volume in one second (two trials; 44 participants; very low-certainty evidence) or vital capacity (one trial; 62 participants). None of the trials reported on the need for additional antibiotics. Inhaled plus intravenous antibiotics may make little difference to the time to next exacerbation; however, one trial (28 participants) reported on hospital admissions and found no difference between groups. There is likely no difference between groups in adverse events (very low-certainty evidence) and one trial (62 participants) reported no difference in the emergence of antibiotic-resistant organisms (very low-certainty evidence). AUTHORS' CONCLUSIONS We identified only low- or very low-certainty evidence to judge the effectiveness of inhaled antibiotics for the treatment of pulmonary exacerbations in people with cystic fibrosis. The included trials were not sufficiently powered to achieve their goals. Hence, we are unable to demonstrate whether one treatment was superior to the other or not. Further research is needed to establish whether inhaled tobramycin may be used as an alternative to intravenous tobramycin for some pulmonary exacerbations.
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Affiliation(s)
- Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola J Rowbotham
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, The University of Nottingham, Nottingham, UK
| | - Edward Charbek
- Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University School of Medicine, St Louis, MO, USA
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29
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Blayac M, Coll P, Urbach V, Fanen P, Epaud R, Lanone S. The Impact of Air Pollution on the Course of Cystic Fibrosis: A Review. Front Physiol 2022; 13:908230. [PMID: 35721541 PMCID: PMC9202997 DOI: 10.3389/fphys.2022.908230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Cystic fibrosis (CF) is a lethal and widespread autosomal recessive disorder affecting over 80,000 people worldwide. It is caused by mutations of the CFTR gene, which encodes an epithelial anion channel. CF is characterized by a great phenotypic variability which is currently not fully understood. Although CF is genetically determined, the course of the disease might also depend on multiple other factors. Air pollution, whose effects on health and contribution to respiratory diseases are well established, is one environmental factor suspected to modulate the disease severity and influence the lung phenotype of CF patients. This is of particular interest as pulmonary failure is the primary cause of death in CF. The present review discusses current knowledge on the impact of air pollution on CF pathogenesis and aims to explore the underlying cellular and biological mechanisms involved in these effects.
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Affiliation(s)
- Marion Blayac
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
| | - Patrice Coll
- Université Paris Cité and Univ Paris Est Créteil, CNRS, LISA, Paris, France
| | | | - Pascale Fanen
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- AP-HP, Hopital Henri-Mondor, Service Génétique, Creteil, France
| | - Ralph Epaud
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- Centre Hospitalier Intercommunal, Centre des Maladies Respiratoires Rares (RespiRare®)-CRCM, Creteil, France
| | - Sophie Lanone
- Univ Paris Est Creteil, INSERM, IMRB, Creteil, France
- *Correspondence: Sophie Lanone,
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Balfour-Lynn IM, King JA. CFTR modulator therapies - Effect on life expectancy in people with cystic fibrosis. Paediatr Respir Rev 2022; 42:3-8. [PMID: 32565113 PMCID: PMC7255286 DOI: 10.1016/j.prrv.2020.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
CFTR modulators have dramatically changed the clinical course of CF in those fortunate enough to receive them. Inevitably, randomised controlled trials during the development of these drugs are too short to use mortality as an outcome. Evidence for their effect on life expectancy are best gained from real world registry studies specifically looking at mortality, but these are only available for ivacaftor to date. Therefore, indirect evidence must be obtained by looking at outcomes known to affect mortality and seeing the effect of these drugs on those outcomes.
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Affiliation(s)
- I M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.
| | - J A King
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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Real Life With Tezacaftor and Ivacaftor in Adult Patients With Cystic Fibrosis: Spanish Multicenter Study. Arch Bronconeumol 2022; 58:672-674. [DOI: 10.1016/j.arbres.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 11/19/2022]
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Clinical Impact of Aspergillus fumigatus in Children with Cystic Fibrosis. Microorganisms 2022; 10:microorganisms10040739. [PMID: 35456789 PMCID: PMC9032721 DOI: 10.3390/microorganisms10040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background. The clinical relevance of Aspergillus fumigatus (Af) in cystic fibrosis (CF) is controversial. The aims of the study were to assess the prevalence of Af disease in our cohort of CF patients and evaluate whether allergic bronchopulmonary aspergillosis (ABPA) and sensitization to Af affected lung function, body mass index (BMI) and exacerbations. Methods. Clinical data and lung function of CF patients aged 6−18 years followed at the CF Centre of Parma (Italy) were recorded. Patients were classified as: patients with no signs of Af, patients sensitized or colonized by Af, patients with ABPA or patients with Aspergillus bronchitis (Ab). Results. Of 38 CF patients (14.2 years (6.2−18.8) M 23), 8 (21%) showed Af sensitization, 7 (18.4%) showed ABPA, 1 (2.6%) showed Af colonization and 1 (2.6%) showed Ab. Compared to non-ABPA, patients with ABPA had lower BMI (15.9 ± 1.6 vs. 19.7 ± 3.4, p < 0.005), lower lung function (FEV1 61.5 ± 25.9% vs. 92.3 ± 19.3%, p < 0.001) and more exacerbations/year (4.43 ± 2.44 vs. 1.74 ± 2.33, p < 0.005). Patients with Af sensitization showed more exacerbations/year than non-Af patients (3.5 ± 3.2 vs. 0.9 ± 1.2, p < 0.005). ABPA and sensitized patients had more abnormalities on chest CT scans. Conclusion. This study showed the relevant clinical impact of ABPA and Af sensitization in terms of exacerbations and lung structural damage.
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Carson SW, Psoter K, Koehler K, Siklosi KR, Montemayor K, Toporek A, West NE, Lechtzin N, Hansel NN, Collaco JM, Merlo CA. Indoor air pollution exposure is associated with greater morbidity in cystic fibrosis. J Cyst Fibros 2022; 21:e129-e135. [PMID: 34531156 PMCID: PMC8918065 DOI: 10.1016/j.jcf.2021.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/10/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Exposure to higher levels of outdoor air pollution is associated with increased morbidity in individuals with cystic fibrosis. Limited information exist regarding the potential adverse effects of indoor air pollution on those with cystic fibrosis. METHODS Individuals with cystic fibrosis who were enrolled in the Twin and Sibling Study from 2000-2013, self-reported exposure to four known sources of indoor air pollution (secondhand smoke, forced hot air, wood stove and fireplace). Change in lung function, rates of hospitalizations and pulmonary exacerbations were followed over 4 years to compare outcomes in those who were exposed to those who were not exposed. RESULTS Of 1432 participants with data on secondhand smoke exposure, 362 (25.3%) were exposed. Of 765 individuals with data on forced hot air exposure, 491 (64.2%) were exposed. Of 1247 participants with data on wood stove exposure and 830 with data on fireplace exposure, 182 (14.6%) and 373 (44.9%) were exposed, respectively. In longitudinal analysis, pediatric individuals either exposed to secondhand smoke or to forced hot air had a 0.60% predicted/year decrease in FEV1% predicted (P=0.002) or a 0.46% predicted/year decrease in FEV1% predicted (P=0.048), respectively compared to individuals who were not exposed. Adults exposed to secondhand smoke had a 42% increased yearly risk of hospitalization compared to those who were not exposed (P=0.045). CONCLUSIONS Our questionnaire-based data suggest that exposure to sources of indoor air pollution increase morbidity in both the pediatric and adult cystic fibrosis populations. Future studies with quantitative indoor air quality assessments are needed.
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Affiliation(s)
- Sara W. Carson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Kevin Psoter
- Department of Pediatrics, Division of General Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Karen R. Siklosi
- Department of Pediatrics, Division of Pulmonology, Johns Hopkins University, Baltimore, MD
| | - Kristina Montemayor
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Alexandra Toporek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Natalie E. West
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Noah Lechtzin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Nadia N. Hansel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Joseph M. Collaco
- Department of Pediatrics, Division of Pulmonology, Johns Hopkins University, Baltimore, MD
| | - Christian A Merlo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Kazmerski TM, Jain R, Lee M, Taylor-Cousar JL. Parenthood impacts short-term health outcomes in people with cystic fibrosis. J Cyst Fibros 2022; 21:662-668. [PMID: 35181269 DOI: 10.1016/j.jcf.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/19/2022] [Accepted: 02/09/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND People with cystic fibrosis (CF) are living longer, healthier lives. A growing number are considering parenthood. There is a substantial knowledge gap regarding the health impacts of parenthood on people with CF. METHODS Using data from the United Kingdom CF registry from 2015 to 2019, we evaluated the impact of having a child on percent predicted forced expiratory volume in 1 second (ppFEV1), body mass index (BMI), and pulmonary exacerbations via multivariable longitudinal data analysis adjusting for age and sex in the year before a person with CF became a parent to the first year following parenthood. We examined whether changes from pre- to post-parenthood differed by sex or CF transmembrane conductance regulator (CFTR) modulator use. RESULTS Among 296 people with CF who became parents, we found a significant decrease in ppFEV1, (adjusted mean difference -3.19, CI: -4.31, -2.07; p<0.01) and BMI (adjusted mean difference -0.28, CI: -0.51, -0.05; p<0.02) and a significant increase in pulmonary exacerbations (adjusted rate ratio 1.3, CI: 1.13, 1.49; p<0.01) in the year following the birth of a child compared to the year prior. Further analysis showed that CFTR modulator use mitigated parenthood impacts on ppFEV1, but not on BMI and pulmonary exacerbations. Females experienced significantly worse impacts on BMI from pre- to post-parenthood compared to males. CONCLUSIONS Parenthood adversely impacts short-term health outcomes for people with CF and CFTR modulator use mitigates such effects. To better understand the impact of the widespread use of highly effective CFTR modulators, longer-term, prospective parenthood studies are needed.
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Affiliation(s)
- Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raksha Jain
- Internal Medicine, Pulmonary and Critical Care, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - MinJae Lee
- Division of Biostatistics, Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Woollam M, Siegel A, Grocki P, Saunders JL, Sanders DB, Agarwal M, Davis MD. Preliminary method for profiling volatile organic compounds in breath that correlate with pulmonary function and other clinical traits of subjects diagnosed with cystic fibrosis: a pilot study. J Breath Res 2022; 16. [PMID: 35120338 DOI: 10.1088/1752-7163/ac522f] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/04/2022] [Indexed: 11/12/2022]
Abstract
Cystic fibrosis (CF) is characterized by chronic respiratory infections which progressively decrease lung function over time. Affected individuals experience episodes of intensified respiratory symptoms called pulmonary exacerbations (PEx) which accelerate pulmonary function decline and decrease survival. There is no standard classification for PEx, which results in treatments that are heterogeneous. Improving PEx classification and management is a significant priority for people with CF. Previous studies have shown volatile organic compounds (VOCs) in exhaled breath can be used as biomarkers because they are products of metabolic pathways dysregulated by different diseases. To provide insights on PEx classification and other clinical factors, exhaled breath was collected from subjects with CF, with some experiencing PEx and others at baseline. Exhaled breath was collected in Tedlar bags during tidal breathing for VOC analysis by solid phase microextraction coupled to gas chromatography-mass spectrometry. Statistical significance testing between quantitative and categorical clinical variables displayed percent-predicted forced expiratory volume in one second (FEV1pp) was decreased in subjects experiencing PEx. VOCs correlating with other clinical variables (body mass index, age, use of highly effective modulator therapies, and need for antibiotics) were also explored. VOCs correlating to potential confounding variables were removed and analyzed by regression for correlations with FEV1pp measurements. The VOC with the highest correlation with FEV1pp (3,7-dimethyldecane) also gave the lowest p-value when comparing subjects at baseline and during PEx. Receiver operator characteristic curves showed 3,7-dimethyldecane had a higher ability to classify PEx (area under the curve (AUC) = 0.91) relative to FEV1pp values at collection (AUC = 0.83). However, normalized ΔFEV1pp values had the highest capability to distinguish PEx (AUC = 0.93). These results show that exhaled VOCs may be a source of biomarkers for various clinical traits of CF, including PEx, that should be explored in larger sample cohorts and validation studies.
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Affiliation(s)
- Mark Woollam
- Chemistry and Chemical Biology, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Amanda Siegel
- Department of Chemistry and Chemical Biology, Indiana University Purdue University Indianapolis, 402 N Blackford St., LD326, Indianapolis, Indiana, 46202, UNITED STATES
| | - Paul Grocki
- Chemistry and Chemical Biology, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Jessica L Saunders
- Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, 46202, UNITED STATES
| | - Don B Sanders
- Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, 46202, UNITED STATES
| | - Mangilal Agarwal
- Mechanical and Energy Engineering, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Michael D Davis
- Pulmonary Medicine, Herman B Wells Center for Pediatric Research, 1044 W. Walnut St., Indianapolis, Indiana, 46202, UNITED STATES
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Henderson AG, Davis JM, Keith JD, Green ME, Oden AM, Rowe SM, Birket SE. Static mucus impairs bacterial clearance and allows chronic infection with Pseudomonas aeruginosa in the cystic fibrosis rat. Eur Respir J 2022; 60:2101032. [PMID: 35115338 PMCID: PMC9944330 DOI: 10.1183/13993003.01032-2021] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
Cystic fibrosis (CF) airway disease is characterised by chronic Pseudomonas aeruginosa infection. Successful eradication strategies have been hampered by a poor understanding of the mechanisms underlying conversion to chronicity. The CFTR-knockout (KO) rat harbors a progressive defect in mucociliary transport and viscosity. KO rats were infected before and after the appearance of the mucus defect, using a clinical, mucoid-isolate of P. aeruginosa embedded in agarose beads. Young KO rats that were exposed to bacteria before the development of mucociliary transport defects resolved the infection and subsequent tissue damage. However, older KO rats that were infected in the presence of hyperviscous and static mucus were unable to eradicate bacteria, but instead had bacterial persistence through 28 days post-infection that was accompanied by airway mucus occlusion and lingering inflammation. Normal rats responded to infection with increased mucociliary transport to supernormal rates, which reduced the severity of a second bacterial exposure. We therefore conclude that the aberrant mucus present in the CF airway permits persistence of P. aeruginosa in the lung.
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Affiliation(s)
- Alexander G Henderson
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joy M Davis
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Johnathan D Keith
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Morgan E Green
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley M Oden
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Steven M Rowe
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Susan E Birket
- Department of Medicine and Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
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Nash EF, Choyce J, Carrolan V, Justice E, Shaw KL, Sitch A, Mistry H, Whitehouse JL. A prospective randomised controlled mixed-methods pilot study of home monitoring in adults with cystic fibrosis. Ther Adv Respir Dis 2022; 16:17534666211070133. [PMID: 35274585 PMCID: PMC8921750 DOI: 10.1177/17534666211070133] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Home monitoring (HM) is able to detect more pulmonary exacerbations (PEx) than routine care (RC) in individuals with cystic fibrosis (CF), but there is currently no evidence for benefits in health outcomes. Patient experiences of using HM and a health economics assessment have not been rigorously assessed to date. This study aimed to assess the effects of HM on hospital admissions, quality of life, antibiotic requirements, exacerbation frequency, lung function, nutritional outcomes, anxiety, depression, costs and health outcomes, as well as the qualitative effects on the patient experience. METHODS This randomised controlled mixed-methods pilot study recruited CF adults cared for in one large regional CF centre. Participants were randomly allocated 1:1 to the intervention cohort [twice-weekly HM of symptoms measured by the Cystic Fibrosis Respiratory Symptom Diary - Chronic Respiratory Infection Symptom Score (CFRSD-CRISS) and forced expiratory volume in one second (FEV1)] or a control cohort (routine clinical care) for the 12-month study period. Measurements were recorded at study visits at baseline, 3, 6, 9 and 12 months. Spirometry, body weight, comorbidities, medications, hospital inpatient days, courses of antibiotics (oral and intravenous) and PEx (defined by the modified Fuchs criteria) were recorded at each study visit. Health status, capability and cost-effectiveness were measured at each study visit by the Hospital Anxiety and Depression Scale (HADS), the ICEpop CAPability measure for Adults (ICECAP-A), EuroQol 5 dimensions (EQ-5D-5L) questionnaire and an adapted resource use questionnaire. The patient experience of HM was assessed by semi-structured qualitative interviews at baseline and 12 months. RESULTS Eighty-eight participants were recruited, with 44 (50%) randomised to receive HM and 44 (50%) randomised to receive RC. Patient hospital inpatient bed days per annum and overall health-related quality of life were similar between the groups. Protocol-defined PEx requiring intravenous and oral antibiotics were detected more frequently in the HM group, with no other differences between the groups in the secondary outcomes. The total mean National Health Service (NHS) costs were approximately £1500 more per patient for the RC arm than the HM group. The qualitative analysis demonstrated that the patient experience of HM was generally positive and overall the intervention was well accepted. CONCLUSION The findings of this trial confirm that HM is effective in detecting PEx in adults with CF. There were no significant differences in hospital inpatient bed days and overall health-related quality of life between the groups. Despite the cost of the HM equipment and the salary of the research fellow to respond to the results, health economics analysis suggests the intervention was less expensive than RC. HM was generally well accepted, with most participants reporting that it resulted in them feeling more empowered and reassured. TRIAL REGISTRATION The study protocol was registered with Clinicaltrials.gov (NCT02994706) on 16 July 2014 and published in a peer reviewed journal.Data from this trial has been presented in abstract form at the ECFS Conference in Lyon in September 2020.
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Affiliation(s)
- Edward F Nash
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - Jocelyn Choyce
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Victoria Carrolan
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Edwin Justice
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karen L Shaw
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alice Sitch
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Hema Mistry
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Joanna L Whitehouse
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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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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Daly C, Ruane P, O’Reilly K, Longworth L, Vega-Hernandez G. Caregiver burden in cystic fibrosis: a systematic literature review. Ther Adv Respir Dis 2022; 16:17534666221086416. [PMID: 35323061 PMCID: PMC8958690 DOI: 10.1177/17534666221086416] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/23/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cystic fibrosis (CF) affects more than 80,000 people worldwide, having a considerable impact on the quality of life of patients and their caregivers, who assist patients with time-consuming treatment regimens. Despite this, a review of the available evidence has not been previously undertaken. This systematic literature review aimed to identify the humanistic and economic burdens of CF on caregivers. METHODS A systematic literature review was conducted, in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Publications reporting outcomes for the caregivers of people with CF, including utility data, health status, and occupational impact, were reviewed. Sources searched were Embase (OvidSP), Medline (PubMed), the Cochrane Database of Systematic Reviews, and the Epistemonikos database, from 2010 to March 2020. A subsequent search with updated terms identified articles up to April 2020. Electronic searches were supplemented by hand searches to capture all relevant literature. RESULTS A total of 889 articles reporting humanistic burden and 310 reporting economic burden were identified. Following full-text screening by two independent reviewers, 72 articles were included in the review, of which 65 and 17 reported data on humanistic and economic burdens, respectively, with 10 reporting on both. The reviewed literature covered several outcomes and identified multiple key findings: greater disease severity is associated with the reporting of greater caregiver burden and lower utility scores of quality of life; reduced patient lung function is associated with increased caregiver depression and anxiety; and caregiving causes significant occupational impact, with pulmonary exacerbations decreasing caregiver productivity by up to a third compared with the patient being in a 'well' state. CONCLUSION Findings from this systematic literature review highlight the substantial humanistic and economic burdens borne by the caregivers of people with CF. Future research would help to further inform on the link between disease severity and caregiver burden.
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Affiliation(s)
- Conor Daly
- Affiliation during the time of the study
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40
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Bresnick K, Arteaga-Solis E, Millar SJ, Laird G, LeCamus C. Burden of cystic fibrosis in children <12 years of age prior to the introduction of CFTR modulator therapies. BMJ Open Respir Res 2021; 8:8/1/e000998. [PMID: 34857524 PMCID: PMC8640656 DOI: 10.1136/bmjresp-2021-000998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Cystic fibrosis (CF) is a genetic, multisystemic, progressive and life-shortening disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. Different genotypes have been linked to variations in disease progression among people with CF. The burden of illness (BOI) in children with CF is incompletely characterised, particularly as it relates to CFTR genotypes prior to the availability of the first CFTR modulators. This retrospective, cross-sectional, descriptive study evaluated the BOI in US children with CF <12 years of age prior to the first approval of CFTR modulators. Methods Data from the US Cystic Fibrosis Foundation Patient Registry from 2011 were used to summarise key patient and disease characteristics using descriptive statistics, overall and grouped by age (0 to <2 years, 2 to <6 years and 6 to <12 years) and genotype (F508del/F508del, F508del/minimal function (MF), MF/MF, gating mutation on ≥1 allele, residual function mutation on ≥1 allele and R117H on ≥1 allele) group. Results The analysis included 9185 children. Among 6-year-olds to <12-year-olds, mean (SD) per cent predicted FEV1 in 1 s was 92.6% (17.5%). Among all children <12 years of age, the mean (SD) all-cause hospitalisation and pulmonary exacerbation rates in 2011 were 0.4 (1.0) and 0.3 (0.8), respectively. Most (93.6%) had ≥1 positive lung microbiology culture. CF-related medication and nutritional supplementation use was common across all ages and genotypes. More than half (54.7%) had ≥1 CF-related complication. Evidence of disease burden was observed across the age and genotype groups studied. Conclusions Prior to the approval of the first CFTR modulator therapies in children <12 years of age, CF was associated with substantial BOI from an early age—including respiratory infections, hospitalisations/pulmonary exacerbations, need for supplemental nutrition and pharmacological treatments—irrespective of genotype.
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Affiliation(s)
- Kathryn Bresnick
- Real World Evidence, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Emilio Arteaga-Solis
- Global Medical Affairs, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Stefanie J Millar
- Biostatistics & Medical Writing, ICON PLC, North Wales, Pennsylvania, USA
| | - Glen Laird
- Biostatistics, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Cecile LeCamus
- Global Medical Affairs, Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
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Association of site of treatment with clinical outcomes following intravenous antimicrobial treatment of a pulmonary exacerbation. J Cyst Fibros 2021; 21:574-580. [PMID: 34857494 DOI: 10.1016/j.jcf.2021.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the STOP2 (Standardized Treatment of Pulmonary Exacerbations-2) study, intravenous (IV) antimicrobial treatment duration for adults with cystic fibrosis (CF) experiencing pulmonary exacerbations (PEx) was determined based on initial treatment response. The impact of home vs hospital care remains an important clinical question in CF. Our hypothesis was that STOP2 participants treated at home would have less improvement in lung function compared to those treated in the hospital. METHODS Treating clinicians determined PEx treatment location, which was a stratification factor for STOP2 randomization. Lung function, weight, and symptom recovery were evaluated by treatment location. Propensity scores and inverse probability treatment weighting were used to test for differences in clinical response by treatment location. RESULTS In all, 33% of STOP2 participants received IV antimicrobials in the hospital only, 46% both in the hospital and at home, and 21% at home only. Mean (95% CI) ppFEV1 improvement was significantly (p < 0.05) lower for those treated at home only, 5.0 (3.5, 6.5), compared with at home and in the hospital, 7.0 (5.9, 8.1), and in the hospital only, 8.0 (6.7, 9.4). Mean weight (p < 0.001) and symptom (p < 0.05) changes were significantly smaller for those treated at home only compared to those treated in the hospital only. CONCLUSIONS Compared to PEx treatment at home only, treatment in the hospital was associated with greater mean lung function, respiratory symptom, and weight improvements. The limitations of home IV therapy should be addressed in order to optimize outcomes for adults with CF treated at home.
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Sass G, Nazik H, Chatterjee P, Shrestha P, Groleau MC, Déziel E, Stevens DA. Altered Pseudomonas Strategies to Inhibit Surface Aspergillus Colonies. Front Cell Infect Microbiol 2021; 11:734296. [PMID: 34746024 PMCID: PMC8570168 DOI: 10.3389/fcimb.2021.734296] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/17/2021] [Indexed: 01/23/2023] Open
Abstract
Pseudomonas aeruginosa and Aspergillus fumigatus infections frequently co-localize in lungs of immunocompromised patients and individuals with cystic fibrosis (CF). The antifungal activity of P. aeruginosa has been described for its filtrates. Pyoverdine and pyocyanin are the principal antifungal P. aeruginosa molecules active against A. fumigatus biofilm metabolism present in iron-limited or iron-replete planktonic P. aeruginosa culture filtrates, respectively. Using various P. aeruginosa laboratory wild-type strains (PA14, PAO1, PAK), we found antifungal activity against Aspergillus colonies on agar. Comparing 36 PA14 and 7 PAO1 mutants, we found that mutants lacking both major siderophores, pyoverdine and pyochelin, display higher antifungal activity on agar than their wild types, while quorum sensing mutants lost antifungal activity. Addition of ferric iron, but not calcium or magnesium, reduced the antifungal effects of P. aeruginosa on agar, whereas iron-poor agar enhanced antifungal effects. Antifungal activity on agar was mediated by PQS and HHQ, via MvfR. Among the MvfR downstream factors, rhamnolipids and elastase were produced in larger quantities by pyoverdine–pyochelin double mutants and showed antifungal activity on agar. In summary, antifungal factors produced by P. aeruginosa on agar differ from those produced by bacteria grown in liquid cultures, are dependent on quorum sensing, and are downregulated by the availability of ferric iron. Rhamnolipids and elastase seem to be major mediators of Pseudomonas’ antifungal activity on a solid surface.
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Affiliation(s)
- Gabriele Sass
- Infectious Disease Research Laboratory, San Jose, CA, United States
| | - Hasan Nazik
- Infectious Disease Research Laboratory, San Jose, CA, United States
| | | | - Pallabi Shrestha
- Infectious Disease Research Laboratory, San Jose, CA, United States
| | - Marie-Christine Groleau
- Centre Armand-Frappier Santé Biotechnologie, Institute National de la Recherche Scientifique (INRS), Laval, QC, Canada
| | - Eric Déziel
- Centre Armand-Frappier Santé Biotechnologie, Institute National de la Recherche Scientifique (INRS), Laval, QC, Canada
| | - David A Stevens
- Infectious Disease Research Laboratory, San Jose, CA, United States.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
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Al Shakirchi M, Sorjonen K, Klingspor L, Bergman P, Hjelte L, de Monestrol I. The Effects of Aspergillus fumigatus Colonization on Lung Function in Patients with Cystic Fibrosis. J Fungi (Basel) 2021; 7:jof7110944. [PMID: 34829231 PMCID: PMC8618016 DOI: 10.3390/jof7110944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022] Open
Abstract
Aspergillus fumigatus is commonly isolated from CF airways. However, the impact on CF lung progression is not completely understood. In this study, using a 16-year retrospective observational cohort study (2000–2015) that included 132 patients, we determined the annual lung function, measured as percent predicted forced expiratory volume in the first second (ppFEV1), decline before and after the first colonization with A. fumigatus. Further, in the same individual, the ratios of lung function when patients were colonized with A. fumigatus and when they were not were calculated. The impact of eradication, with antifungal treatment or spontaneously, was assessed. The annual ppFEV1 was significantly lower after the first colonization with A. fumigatus. Furthermore, within the same individual, colonization with A. fumigatus for two and three years in a row was associated with 4.3% and 7.9% lower ppFEV1, respectively, compared to when not colonized. Finally, patients who eradicated A. fumigatus the following two years after colonization exhibited 9.9% and 14.5% higher ppFEV1 compared to patients who continued to produce cultures with A. fumigatus for two and three years. Our study demonstrated that A. fumigatus colonization was associated with a negative impact on lung function in the long term and eradication, spontaneously or with treatment, was associated with a better pulmonary outcome.
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Affiliation(s)
- Mahasin Al Shakirchi
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence:
| | - Kimmo Sorjonen
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Lena Klingspor
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, 171 77 Stockholm, Sweden; (L.K.); (P.B.)
| | - Peter Bergman
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, 171 77 Stockholm, Sweden; (L.K.); (P.B.)
- Department of Infectious Diseases, The Immunodeficiency Unit, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Lena Hjelte
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Isabelle de Monestrol
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
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Kauser S, Keyte R, Regan A, Nash EF, Fitch G, Mantzios M, Egan H. Exploring Associations Between Self-Compassion, Self-Criticism, Mental Health, and Quality of Life in Adults with Cystic Fibrosis: Informing Future Interventions. J Clin Psychol Med Settings 2021; 29:332-343. [PMID: 34750694 PMCID: PMC9184429 DOI: 10.1007/s10880-021-09831-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 01/16/2023]
Abstract
Self-compassion is increasingly recognised as an important and beneficial factor in quality of life and mental health-related research, but research within the adult cystic fibrosis (CF) population is scarce. In a cross-sectional study, 114 (56 female, 58 male) adults with CF completed and returned a series of validated questionnaires that assessed CF-related quality of life, negative emotional states (depression, anxiety and stress), self-compassion, and self-criticism. Quality of life and self-compassion were positively correlated, and each in turn were inversely correlated with negative emotional states and self-criticism. Negative emotional states correlated positively to self-criticism. Self-compassion and/or self-criticism moderated ten relationships between various sub-domains of quality of life and negative emotions. Psychological interventions that increase self-compassion may be beneficial for enhancing mental health and quality of life for adults with CF.
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Affiliation(s)
- S Kauser
- Department of Psychology, Faculty of Business, Law and Social Sciences, Birmingham City University, Room C332, The Curzon Building, 4 Cardigan Street, Birmingham, B4 7BD, UK.
| | - R Keyte
- Department of Psychology, Faculty of Business, Law and Social Sciences, Birmingham City University, Room C332, The Curzon Building, 4 Cardigan Street, Birmingham, B4 7BD, UK
| | - A Regan
- West Midlands Cystic Fibrosis Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - E F Nash
- West Midlands Cystic Fibrosis Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - G Fitch
- North West Midlands Cystic Fibrosis Centre, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - M Mantzios
- Department of Psychology, Faculty of Business, Law and Social Sciences, Birmingham City University, Room C332, The Curzon Building, 4 Cardigan Street, Birmingham, B4 7BD, UK
| | - H Egan
- Department of Psychology, Faculty of Business, Law and Social Sciences, Birmingham City University, Room C332, The Curzon Building, 4 Cardigan Street, Birmingham, B4 7BD, UK
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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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The feasibility of home monitoring of young people with cystic fibrosis: Results from CLIMB-CF. J Cyst Fibros 2021; 21:70-77. [PMID: 34635459 DOI: 10.1016/j.jcf.2021.09.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND CF is traditionally assessed in clinic. It is unclear if home monitoring of young people with CF is feasible or acceptable. The COVID-19 pandemic has made home monitoring more of a necessity. We report the results of CLIMB-CF, exploring home monitoring's feasibility and potential obstacles. METHODS We designed a mobile app and enrolled participants with CF aged 2-17 years and their parents for six months. They were asked to complete a variety of measures either daily or twice a week. During the study, participants and their parents completed questionnaires exploring depression, anxiety and quality of life. At the end of the study parents and participants completed acceptability questionnaires. RESULTS 148 participants were recruited, 4 withdrew prior to starting the study. 82 participants were female with median (IQR) age 7.9 (5.2-12 years). Median data completeness was 40.1% (13.6-69.9%) for the whole cohort; when assessed by age participants aged ≥ 12 years contributed significantly less (15.6% [9.8-30%]). Data completeness decreased over time. There was no significant difference between parental depression and anxiety scores at the start and the end of the study nor in CFQ-R respiratory domain scores for participants ≥ 14 years. The majority of participants did not feel the introduction of home monitoring impacted their daily lives. CONCLUSIONS Most participants felt home monitoring did not negatively impact their lives and it did not increase depression, anxiety or decrease quality of life. However, uptake was variable, and not well sustained. The teenage years pose a particular challenge and further work is required.
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Wildman MJ, O’Cathain A, Hind D, Maguire C, Arden MA, Hutchings M, Bradley J, Walters SJ, Whelan P, Ainsworth J, Tappenden P, Buchan I, Elliott R, Nicholl J, Elborn S, Michie S, Mandefield L, Sutton L, Hoo ZH, Drabble SJ, Lumley E, Beever D, Navega Biz A, Scott A, Waterhouse S, Robinson L, Hernández Alava M, Sasso A. An intervention to support adherence to inhaled medication in adults with cystic fibrosis: the ACtiF research programme including RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background
People with cystic fibrosis frequently have low levels of adherence to inhaled medications.
Objectives
The objectives were to develop and evaluate an intervention for adults with cystic fibrosis to improve adherence to their inhaled medication.
Design
We used agile software methods to develop an online platform. We used mixed methods to develop a behaviour change intervention for delivery by an interventionist. These were integrated to become the CFHealthHub intervention. We undertook a feasibility study consisting of a pilot randomised controlled trial and process evaluation in two cystic fibrosis centres. We evaluated the intervention using an open-label, parallel-group randomised controlled trial with usual care as the control. Participants were randomised in a 1 : 1 ratio to intervention or usual care. Usual care consisted of clinic visits every 3 months. We undertook a process evaluation alongside the randomised controlled trial, including a fidelity study, a qualitative interview study and a mediation analysis. We undertook a health economic analysis using both a within-trial and model-based analysis.
Setting
The randomised controlled trial took place in 19 UK cystic fibrosis centres.
Participants
Participants were people aged ≥ 16 years with cystic fibrosis, on the cystic fibrosis registry, not post lung transplant or on the active transplant list, who were able to consent and not using dry-powder inhalers.
Intervention
People with cystic fibrosis used a nebuliser with electronic monitoring capabilities. This transferred data automatically to a digital platform. People with cystic fibrosis and clinicians could monitor adherence using these data, including through a mobile application (app). CFHealthHub displayed graphs of adherence data as well as educational and problem-solving information. A trained interventionist helped people with cystic fibrosis to address their adherence.
Main outcome measures
Randomised controlled trial – adjusted incidence rate ratio of pulmonary exacerbations meeting the modified Fuchs criteria over a 12-month follow-up period (primary outcome); change in percentage adherence; and per cent predicted forced expiratory volume in 1 second (key secondary outcomes). Process evaluation – percentage fidelity to intervention delivery, and participant and interventionist perceptions of the intervention. Economic modelling – incremental cost per quality-adjusted life-year gained.
Results
Randomised controlled trial – 608 participants were randomised to the intervention (n = 305) or usual care (n = 303). To our knowledge, this was the largest randomised controlled trial in cystic fibrosis undertaken in the UK. The adjusted rate of exacerbations per year (primary outcome) was 1.63 in the intervention and 1.77 in the usual-care arm (incidence rate ratio 0.96, 95% confidence interval 0.83 to 1.12; p = 0.638) after adjustment for covariates. The adjusted difference in mean weekly normative adherence was 9.5% (95% confidence interval 8.6% to 10.4%) across 1 year, favouring the intervention. Adjusted mean difference in forced expiratory volume in 1 second (per cent) predicted at 12 months was 1.4% (95% confidence interval –0.2% to 3.0%). No adverse events were related to the intervention. Process evaluation – fidelity of intervention delivery was high, the intervention was acceptable to people with cystic fibrosis, participants engaged with the intervention [287/305 (94%) attended the first intervention visit], expected mechanisms of action were identified and contextual factors varied between randomised controlled trial sites. Qualitative interviews with 22 people with cystic fibrosis and 26 interventionists identified that people with cystic fibrosis welcomed the objective adherence data as proof of actions to self and others, and valued the relationship that they built with the interventionists. Economic modelling – the within-trial analysis suggests that the intervention generated 0.01 additional quality-adjusted life-years at an additional cost of £865.91 per patient, leading to an incremental cost-effectiveness ratio of £71,136 per quality-adjusted life-year gained. This should be interpreted with caution owing to the short time horizon. The health economic model suggests that the intervention is expected to generate 0.17 additional quality-adjusted life-years and cost savings of £1790 over a lifetime (70-year) horizon; hence, the intervention is expected to dominate usual care. Assuming a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained, the probability that the intervention generates more net benefit than usual care is 0.89. The model results are dependent on assumptions regarding the duration over which costs and effects of the intervention apply, the impact of the intervention on forced expiratory volume in 1 second (per cent) predicted and the relationship between increased adherence and drug-prescribing levels.
Limitations
Number of exacerbations is a sensitive and valid measure of clinical change used in many trials. However, data collection of this outcome in this context was challenging and could have been subject to bias. It was not possible to measure baseline adherence accurately. It was not possible to quantify the impact of the intervention on the number of packs of medicines prescribed.
Conclusions
We developed a feasible and acceptable intervention that was delivered to fidelity in the randomised controlled trial. We observed no statistically significant difference in the primary outcome of exacerbation rates over 12 months. We observed an increase in normative adherence levels in a disease where adherence levels are low. The magnitude of the increase in adherence may not have been large enough to affect exacerbations.
Future work
Given the non-significant difference in the primary outcome, further research is required to explore why an increase in objective normative adherence did not reduce exacerbations and to develop interventions that reduce exacerbations.
Trial registration
Work package 3.1: Current Controlled Trials ISRCTN13076797. Work packages 3.2 and 3.3: Current Controlled Trials ISRCTN55504164.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin J Wildman
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Pauline Whelan
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Tappenden
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Iain Buchan
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Public Health and Policy, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Rachel Elliott
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jon Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Stuart Elborn
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Laura Mandefield
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Zhe Hui Hoo
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Lumley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Aline Navega Biz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anne Scott
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Louisa Robinson
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Alessandro Sasso
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Duration of intravenous antibiotic treatment for acute exacerbations of cystic fibrosis: A systematic review: Duration of treatment for acute exacerbations of cystic fibrosis. J Cyst Fibros 2021; 21:562-573. [PMID: 34588142 DOI: 10.1016/j.jcf.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/07/2021] [Accepted: 08/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute exacerbations of Cystic Fibrosis (AECF) are associated with significant morbidity. Recommendations are to treat for 2-3 weeks despite limited data. Spirometry is a measure of clinical response yet appears to plateau at 7-10 days. While durations <9 days have been associated with poorer outcomes, a duration of 10 days may be as effective as 14 days, potentially conferring advantages in terms of cost and adverse events. A 2019 Cochrane review by Abbott et al. did not identify any randomised controlled trials (RCT) comparing durations of treatment. Utilising data from non-randomised studies (NRS), we report a systematic review of intravenous antibiotic treatment, exploring changes in FEV1 (Forced Expiratory Volume in 1 second), CRP (C-reactive protein) and peripheral WBC (white blood cell) count in studies with different treatment durations. STUDY DESIGN AND METHODS Systematic review of published literature following a search of MEDLINE, Embase, CINAHL and the Cochrane Clinical Trials register. Guidelines from the Preferred Reporting items for Systematic reviews and Meta-Analysis (PRISMA) and reporting Meta-analysis of Observational studies (MOOSE) statement were followed. RESULTS No randomised controlled trials were identified that specifically examined duration of treatment during AECF. This study included all relevant RCTs and also NRS, grouping according to study characteristics, such as length of treatment, location, year, and also characteristics of the patient population. 52 studies, comprising 79 subgroups, and 1,597 patients, were identified. Mean change (95%CI) in ppFEV1 was 10.13 (9.21-11.05). There was no significant difference in change in ppFEV1 for studies treating for 10-12 days; 8.85 (7.47-10.23), vs 13-15 days; 10.68 (9.53-11.82). Similar changes in CRP and WBC were seen irrespective of treatment duration. CONCLUSION This systematic review provides evidence that shorter durations of treatment may be associated with similar changes in FEV1, CRP and WBC compared with longer durations.
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Wong CH, Smith S, Kansra S. Digital technology for early identification of exacerbations in people with cystic fibrosis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Chu-Hai Wong
- Department of Respiratory Medicine; Sheffield Children's Hospital; Sheffield UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine; University of Nottingham; Nottingham UK
| | - Sonal Kansra
- Department of Paediatric Respiratory Medicine; Sheffield Children's Hospital NHS Trust; Sheffield UK
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Elborn JS, Konstan MW, Taylor-Cousar JL, Fajac I, Horsley A, Sutharsan S, Aaron SD, Daines CL, Uluer A, Downey DG, Lucidi VV, Ahuja S, Springman E, Mershon J, Grosswald R, Rowe SM. Empire-CF study: A phase 2 clinical trial of leukotriene A4 hydrolase inhibitor acebilustat in adult subjects with cystic fibrosis. J Cyst Fibros 2021; 20:1026-1034. [PMID: 34538755 DOI: 10.1016/j.jcf.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is characterized by neutrophilic inflammation in the airways. Leukotriene B4 (LTB4) is a neutrophil chemoattractant and has been implicated in CF pathogenesis. Acebilustat, a novel, synthetic, small-molecule leukotriene A4 hydrolase inhibitor, reduces LTB4 production. We report findings from a randomized placebo-controlled trial of acebilustat in adult subjects with mild-to-moderate lung disease. METHODS Subjects were randomized (1:1:1) to once-daily acebilustat 50 mg, 100 mg or placebo for 48 weeks, concomitantly with their current therapeutic regimen. Subjects were stratified by use of concomitant CF transmembrane conductance regulator (CFTR) modulators, baseline percent predicted forced expiratory volume in 1 second (ppFEV1) 50-75 and >75, and number of pulmonary exacerbations in the past year (1 or >1). Primary endpoints were the change from baseline in ppFEV1 and safety. Secondary endpoints included the rate of pulmonary exacerbations. RESULTS Overall, 199 subjects were randomized and dosed (acebilustat 50 mg, n=67; acebilustat 100 mg, n=66; placebo, n=66). Baseline demographics and disease profile were well balanced among treatment groups. Acebilustat had no statistically significant effect on the primary endpoint of change in ppFEV1 at week 48 or the secondary endpoint pulmonary exacerbations. There was a trend towards reduced pulmonary exacerbations in subjects receiving acebilustat in pre-specified populations with ppFEV1>75 (35% rate reduction) and those on concomitant CFTR modulator therapy (20% rate reduction). Acebilustat was well tolerated. CONCLUSIONS Acebilustat did not improve lung function. A trend towards reduced pulmonary exacerbations in subjects with an earlier stage of lung disease suggests a potential effect in this population.
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Affiliation(s)
- J Stuart Elborn
- Faculty of Medicine Health and Life sciences Queens University School of Medicine, Belfast, UK
| | - Michael W Konstan
- Department of Pediatrics, Case Western Reserve University School of Medicine and Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | | | - Isabelle Fajac
- Physiology Department, Cochin Hospital, APHP Centre, Paris, France; Université de Paris, Paris, France
| | - Alexander Horsley
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Sivagurunathan Sutharsan
- Division of Cystic Fibrosis, Department of Pulmonary Medicine, University Medicine EssenRuhrlandklinik, University of DuisburgEssen, Essen, Germany
| | - Shawn D Aaron
- Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Cori L Daines
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Ahmet Uluer
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Vincenzina V Lucidi
- Cystic Fibrosis Center, Children's Hospital and Research Institute, Bambino Gesu, Rome, Italy
| | | | | | | | | | - Steven M Rowe
- Gregory Fleming James Cystic Fibrosis Research Center and Department of Medicine, University of Alabama at Birmingham, 1918 University Blvd, MCLM 804, Birmingham 35294, AL, USA.
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