1
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Crispino AA, Musolino AM, Buonsenso D, Caloiero M, Concolino D. Point of care lung ultrasound in preschool children with cystic fibrosis: a case-controlled, prospective, pilot study. J Ultrasound 2024; 27:303-314. [PMID: 38240960 PMCID: PMC11178747 DOI: 10.1007/s40477-023-00841-0] [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: 09/05/2023] [Accepted: 10/26/2023] [Indexed: 06/15/2024] Open
Abstract
AIMS Respiratory complications in Cystic Fibrosis (CF) are still the leading cause of death nowadays in these patients. High-Resolution Computed Tomography is the gold standard method for staging lung disease in CF. In this study we assessed lung ultrasound findings in asymptomatic preschool patients affected by CF. METHODS This is a case-control study with a total of 70 enrolled patients (20 patients affected by CF, 50 healthy controls) aged from 31 to 6 years. All included patients were without intercurrent lung problems and without antibiotic therapy in the last 30 days. For each patient a lung Point of Care Ultrasound (POCUS) of lung was performed. RESULTS B lines < 3 and sub-pleural consolidations < 1 cm were statistically more frequent in CF patients, both in terms of number of affected patients (p 0.02 and p 0.0001 respectively) and frequency (p 0.0181 and p 0.0001 respectively); the prevalence of B lines < 3 in control group was high (47.73%) however the prevalence of sub-pleural consolidations was very low (2.27%). In both groups coalescent B lines affected a greater number of infants and were in higher number of findings than patients aged between 2 and 6 years. CONCLUSIONS The presence of multiple subpleural pulmonary consolidations < 1 cm in asymptomatic preschool children could be a ultrasound markers of subclinical pulmonary disease such as CF. POCUS of lung is confirmed as a useful tool for the clinician as confirmation of a clinical suspicion, help reduce the use of ionizing radiation.
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Affiliation(s)
- Antonio Alessandro Crispino
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy.
| | - Anna Maria Musolino
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centro Di Salute Globale, Università Cattolica del Sacro Cuore, Rome, Italia
| | - Mimma Caloiero
- Unità Operativa Di Pediatria, Presidio Ospedaliero "Giovanni Paolo II" Lamezia Terme, Azienda Sanitaria Provinciale Di Catanzaro, Lamezia Terme, Italy
| | - Daniela Concolino
- Pediatric Unit, Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
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2
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Masson VK, Nussbaum E, Gelb AF, Tashkin DP, Randhawa I, Nadel JA, Fireizen Y, De Celie-Germana JK, Madera D, Senanayake D. Isolated abnormal FEF75% detects unsuspected bronchiolar obstruction in CF children. Pediatr Res 2023; 94:1051-1056. [PMID: 36914809 DOI: 10.1038/s41390-023-02532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 11/21/2022] [Accepted: 11/29/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND Physiologic detection of bronchiolar obstruction in children with cystic fibrosis (CF) may be clinically unsuspected because of normal routine spirometry despite bronchiectasis on lung CT. METHODS Children from two accredited CF facilities had spirometry obtained every 3 months when clinically stable. Pre-bronchodilator maximum expiratory flow volume curves were retrospectively analyzed over 16 years to detect an isolated abnormal FEF75%, despite normal routine spirometry. RESULTS At Miller Children's and Women's Hospital (MCWH), an abnormal FEF75% was initially detected in 26 CF children at age 7.5 ± 4 (SD) years despite normal routine spirometry initially. FEF75% remained an isolated abnormality for 2.5 ± 1.5 years after it was initially detected in these 26 CF children. At Cohen Children's Medical Center (CCMC), despite normal routine spirometry initially, abnormal FEF75% occurred in 13 children at age 11.7 ± 4.5 years, and abnormal FEF25-75% in 10 children at age 11.8 ± 5.3 years. CONCLUSIONS FEF75% was most sensitive spirometric test for diagnosing both early and isolated progressive bronchiolar obstruction. Data from CCMC in older children demonstrated the simultaneous detection of abnormal FEF75% and FEF25-75% values consistent with greater bronchiolar obstruction when serial spirometry was initiated at an older age. IMPACT There is very little published spirometric data regarding diagnosis of isolated small airways obstruction in CF children. FEF75% can easily detect unsuspected small airways obstruction in CF children with normal routine spirometry and bronchiectasis on lung CT and optimize targeted modulatory therapies.
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Affiliation(s)
- Vicki K Masson
- Pulmonary Division, Miller Children's and Women's Hospital, Long Beach Memorial Hospital, Long Beach, CA, USA
- University of California, Irvine, School of Medicine, Irvine, CA, USA
- Stony Brook University Medical Center, Children's Hospital, Stony Brook, NY, USA
| | - Eliezer Nussbaum
- Pulmonary Division, Miller Children's and Women's Hospital, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Arthur F Gelb
- Pulmonary Division, Miller Children's and Women's Hospital, Long Beach Memorial Hospital, Long Beach, CA, USA.
- Geffen School of Medicine, Pulmonary and Critical Care Division, Department of Medicine, UCLA Medical Center, Los Angeles, CA, USA.
- Lakewood Regional Medical Center, Lakewood, CA, USA.
| | - Donald P Tashkin
- Geffen School of Medicine, Pulmonary and Critical Care Division, Department of Medicine, UCLA Medical Center, Los Angeles, CA, USA
| | - Inderpal Randhawa
- Pulmonary Division, Miller Children's and Women's Hospital, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Jay A Nadel
- Cardiovascular Research Institute, Pulmonary and Critical Care Division, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Yaron Fireizen
- Pulmonary Division, Miller Children's and Women's Hospital, Long Beach Memorial Hospital, Long Beach, CA, USA
| | | | - Danielle Madera
- Cohen Children's Medical Center, Northwell Health, New York City, NY, USA
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3
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Gapp S, Garbade SF, Feyh P, Brockow I, Nennstiel U, Hoffmann GF, Sommerburg O, Gramer G. German newborn screening for Cystic fibrosis: Parental perspectives and suggestions for improvements. Pediatr Pulmonol 2023; 58:844-852. [PMID: 36444714 DOI: 10.1002/ppul.26263] [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: 03/13/2022] [Revised: 11/20/2022] [Accepted: 11/26/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Cystic fibrosis (CF) was added to the German newborn bloodspot screening (NBS) panel in 2016. This study assesses parental perceptions of CF-NBS and confirmatory testing. METHODS Prospective questionnaire-based survey administered to parents of children with positive CF-NBS over 40 months after initiation of CF-NBS in Southwest Germany. Parental perceptions were compared to results from Bavaria and Switzerland. RESULTS Questionnaires with 29 standardized questions were sent to 343 families with children born between October 2016 and January 2020. A total of 178 (51.9%) replied. Although required by law, only a minority were informed about CF-NBS by a physician. The information provided about NBS was sufficient for 78% of parents. Regarding the information about positive CF-NBS, 52.9% were satisfied but the majority expressed negative emotions (89.5%). While most of these were resolved after confirmatory diagnostics, 17% of parents of children with false-positive CF-NBS and 66.7% of children confirmed with CF remained anxious. Waiting time for sweat testing was >3 days in 56.1%, considerably longer than in more centralized screening systems. Parents who waited for a maximum of 3 days were significantly more satisfied. 70.7% of parents were satisfied with the information given during confirmatory diagnostics and 91.4% were satisfied with participating in CF-NBS. CONCLUSIONS CF-NBS stands in high regard with parents. Smooth organization, timely initiation of confirmatory testing, and professional communication are most important to limit parental anxiety. A more centralized system of confirmatory diagnostics appears advantageous in several regards as it reduces time from positive NBS to final diagnosis and increases parental satisfaction.
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Affiliation(s)
- Simon Gapp
- Center for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sven F Garbade
- Center for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrik Feyh
- Center for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Inken Brockow
- Screening Center, Bavarian Health and Food Safety Authority (LGL), Oberschleißheim, Germany
| | - Uta Nennstiel
- Screening Center, Bavarian Health and Food Safety Authority (LGL), Oberschleißheim, Germany
| | - Georg F Hoffmann
- Center for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Olaf Sommerburg
- Translational Lung Research Center (TLRC), German Lung Research Center (DZL), University of Heidelberg, Heidelberg, Germany.,Center for Pediatric and Adolescent Medicine, Division of Pediatric Pulmonology & Allergy and Cystic Fibrosis Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Gwendolyn Gramer
- Center for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Metabolic Medicine, University Hospital Heidelberg, Heidelberg, Germany.,University Medical Center Hamburg-Eppendorf, University Children's Hospital, Hamburg, Germany
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4
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Gifford AH, Taylor-Cousar JL, Davies JC, McNally P. Update on Clinical Outcomes of Highly Effective Modulator Therapy. Clin Chest Med 2022; 43:677-695. [PMID: 36344074 DOI: 10.1016/j.ccm.2022.06.009] [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] [Indexed: 11/06/2022]
Abstract
Based on the cystic fibrosis transmembrane conductance regulator (CFTR) genotype, approximately 90% of people with cystic fibrosis (CF) are candidates for highly effective modulator therapy (HEMT). Clinical trials conducted over the last 11 years have shown that these oral therapies substantially restore CFTR function, leading to improvements in lung function, nutritional status, and health-related quality of life. Here, we review safety and efficacy data from phase 3 clinical trials and observational studies which support the use of HEMT in most adults and children with CF. We also discuss opportunities for additional investigation in groups underrepresented or excluded from phase 3 clinical trials, and challenges in the evaluation of the safety and efficacy of HEMT at increasingly earlier stages of CFTR-mediated pathophysiology.
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Affiliation(s)
- Alex H Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Bolwell Building 6174, Cleveland, OH 44106, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Jennifer L Taylor-Cousar
- Department of Internal Medicine, National Jewish Medical Center, Denver, CO, USA; Department of Pediatrics, National Jewish Medical Center, Denver, CO, USA
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, England, United Kingdom; Royal Brompton & Harefield Hospital, Guys & St Thomas' Trust, London, United Kingdom
| | - Paul McNally
- Department of Paediatrics, RCSI University of Medicine and Health Sciences, Dublin, Ireland; Cystic Fibrosis Center, Children's Health Ireland, Dublin, Ireland
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5
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Perrem L. Routine clinical monitoring fails to identify children at high risk of lung function decline. J Cyst Fibros 2022; 21:904-905. [PMID: 36050145 DOI: 10.1016/j.jcf.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Canada; Translational Medicine Program, SickKids Research Institute, Toronto, Canada.
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6
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Going the Extra Mile: Why Clinical Research in Cystic Fibrosis Must Include Children. CHILDREN 2022; 9:children9071080. [PMID: 35884064 PMCID: PMC9323167 DOI: 10.3390/children9071080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/14/2022] [Indexed: 11/16/2022]
Abstract
This is an exciting time for research and novel drug development in cystic fibrosis. However, rarely has the adage, “Children are not just little adults” been more relevant. This article is divided into two main sections. In the first, we explore why it is important to involve children in research. We discuss the potential benefits of understanding a disease and its treatment in children, and we highlight that children have the same legal and ethical right to evidence-based therapy as adults. Additionally, we discuss why extrapolation from adults may be inappropriate, for example, medication pharmacokinetics may be different in children, and there may be unpredictable adverse effects. In the second part, we discuss how to involve children and their families in research. We outline the importance and the complexities of selecting appropriate outcome measures, and we discuss the role co-design may have in improving the involvement of children. We highlight the importance of appropriate staffing and resourcing, and we outline some of the common challenges and possible solutions, including practical tips on obtaining consent/assent in children and adolescents. We conclude that it is unethical to simply rely on extrapolation from adult studies because research in young children is challenging and that research should be seen as a normal part of the paediatric therapeutic journey.
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7
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He N, Liu X, Vegter AR, Evans TIA, Gray JS, Guo J, Moll SR, Guo LJ, Luo M, Ma N, Sun X, Liang B, Yan Z, Feng Z, Qi L, Joshi AS, Shahin W, Yi Y, Gibson-Corley KN, Hoffman EA, Wang K, Mueller C, Engelhardt JF, Rosen BH. Ferret models of alpha-1 antitrypsin deficiency develop lung and liver disease. JCI Insight 2022; 7:e143004. [PMID: 35104244 PMCID: PMC8983124 DOI: 10.1172/jci.insight.143004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is the most common genetic cause and risk factor for chronic obstructive pulmonary disease, but the field lacks a large-animal model that allows for longitudinal assessment of pulmonary function. We hypothesized that ferrets would model human AATD-related lung and hepatic disease. AAT-knockout (AAT-KO) and PiZZ (E342K, the most common mutation in humans) ferrets were generated and compared with matched controls using custom-designed flexiVent modules to perform pulmonary function tests, quantitative computed tomography (QCT), bronchoalveolar lavage (BAL) proteomics, and alveolar morphometry. Complete loss of AAT (AAT-KO) led to increased pulmonary compliance and expiratory airflow limitation, consistent with obstructive lung disease. QCT and morphometry confirmed emphysema and airspace enlargement, respectively. Pathway analysis of BAL proteomics data revealed inflammatory lung disease and impaired cellular migration. The PiZ mutation resulted in altered AAT protein folding in the liver, hepatic injury, and reduced plasma concentrations of AAT, and PiZZ ferrets developed obstructive lung disease. In summary, AAT-KO and PiZZ ferrets model the progressive obstructive pulmonary disease seen in AAT-deficient patients and may serve as a platform for preclinical testing of therapeutics including gene therapy.
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Affiliation(s)
- Nan He
- Department of Anatomy and Cell Biology
| | | | | | | | | | | | | | | | | | | | | | - Bo Liang
- Department of Anatomy and Cell Biology
| | | | | | - Lisi Qi
- Department of Anatomy and Cell Biology
| | | | | | - Yaling Yi
- Department of Anatomy and Cell Biology
| | | | | | - Kai Wang
- Department of Biostatistics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Christian Mueller
- Department of Pediatrics, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - John F. Engelhardt
- Department of Anatomy and Cell Biology
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Bradley H. Rosen
- Department of Anatomy and Cell Biology
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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8
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Muston HN, Slaven JE, Tiller C, Clem C, Ferkol TW, Ranganathan S, Davis SD, Ren CL. Hyperinflation is associated with increased respiratory rate and is a more sensitive measure of cystic fibrosis lung disease during infancy compared to forced expiratory measures. Pediatr Pulmonol 2021; 56:2854-2860. [PMID: 34143539 PMCID: PMC8373786 DOI: 10.1002/ppul.25538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The goal of this study was to identify clinical features associated with abnormal infant pulmonary function tests (iPFTs), specifically functional residual capacity (FRC), in infants with cystic fibrosis (CF) diagnosed via newborn screen (NBS). We hypothesized that poor nutritional status in the first 6-12 months would be associated with increased FRC at 12-24 months. METHODS This study utilized a combination of retrospectively and prospectively collected data from ongoing research studies and iPFTs performed for clinical indications. Demographic and clinical features were obtained from the electronic medical record. Forced expiratory flows and volumes were obtained using the raised volume rapid thoracoabdominal technique (RVRTC) and FRC was measured via plethysmography. RESULTS A total of 45 CF NBS infants had iPFTs performed between 12 and 24 months. Mean forced vital capacity, forced expiratory volume in 0.5 s, and forced expiratory flows were all within normal limits. In contrast, the mean FRC z-score was 2.18 (95% confidence interval [CI] = 1.48, 2.88) and the mean respiratory rate (RR) z-score was 1.42 (95% CI = 0.95, 1.89). There was no significant association between poor nutritional status and abnormal lung function. However, there was a significant association between higher RR and increased FRC, and a RR cutoff of 36 breaths/min resulted in 92% sensitivity to detect hyperinflation with 32% specificity. CONCLUSION These results suggest that FRC is a more sensitive measure of early CF lung disease than RVRTC measurements and that RR may be a simple, noninvasive clinical marker to identify CF NBS infants with hyperinflation.
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Affiliation(s)
- Heather N Muston
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christina Tiller
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Charles Clem
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas W Ferkol
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sarath Ranganathan
- Department of Paediatrics, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
| | - Stephanie D Davis
- Department of Pediatrics, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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9
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Mondéjar-López P, Horsley A, Ratjen F, Bertolo S, de Vicente H, Asensio de la Cruz Ò. A multimodal approach to detect and monitor early lung disease in cystic fibrosis. Expert Rev Respir Med 2021; 15:761-772. [PMID: 33843417 DOI: 10.1080/17476348.2021.1908131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: In the early stages, lung involvement in cystic fibrosis (CF) can be silent, with disease progression occurring in the absence of clinical symptoms. Irreversible airway damage is present in the early stages of disease; however, reliable biomarkers of early damage due to inflammation and infection that are universally applicable in day-to-day patient management have yet to be identified.Areas covered: At present, the main methods of detecting and monitoring early lung disease in CF are the lung clearance index (LCI), computed tomography (CT), and magnetic resonance imaging (MRI). LCI can be used to detect patients who may require more intense monitoring, identify exacerbations, and monitor responses to new interventions. High-resolution CT detects structural alterations in the lungs of CF patients with the best resolution of current imaging techniques. MRI is a radiation-free imaging alternative that provides both morphological and functional information. The role of MRI for short-term follow-up and pulmonary exacerbations is currently being investigated.Expert opinion: The roles of LCI and MRI are expected to expand considerably over the next few years. Meanwhile, closer collaboration between pulmonology and radiology specialties is an important goal toward improving care and optimizing outcomes in young patients with CF.
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Affiliation(s)
- Pedro Mondéjar-López
- Pediatric Pulmonologist, Pediatric Pulmonology and Cystic Fibrosis Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Alexander Horsley
- Honorary Consultant, Respiratory Research Group, Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
| | - Felix Ratjen
- Head, Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Silvia Bertolo
- Radiologist, Department of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
| | | | - Òscar Asensio de la Cruz
- Pediatric Pulmonologist, Pediatric Unit, University Hospital Parc Taulí de Sabadell, Sabadell, Spain
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10
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Liu H, Sarkar S, Azzopardi K, Day S, Yeow S, Ranganathan S, Sutton P. A bacterial stimulation assay for bronchoalveolar lavage immune cells from young children with cystic fibrosis. Scand J Immunol 2021; 94:e13040. [PMID: 33759233 DOI: 10.1111/sji.13040] [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: 02/21/2021] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Abstract
Cystic Fibrosis (CF) is primarily a progressive lung disease, characterized by chronic pulmonary infections with opportunistic pathogens. Such infections typically commence early in life, producing an inflammatory response marked by IL-8 chemokine production and neutrophilic infiltration, major contributory factors in CF progression. Studying this inflammation, especially early in life, is critical for developing new strategies for preventing or slowing disruption to the structural integrity of the CF airways. However, evaluating the immune responses of bronchoalveolar lavage (BAL) cells from children with CF faces technical challenges, including contamination carried from the lung due to pre-existing infections and low cell number availability. Here, we describe a technique for preparing BAL cells from young children with CF and using those cells in a bacterial stimulation assay. Initial antibiotic treatment proved essential for preventing resident bacteria from overgrowing BAL cell cultures, or non-specifically activating the cells. ACTB, identified as an optimal reference gene, was validated for accurate analysis of gene expression in these cells. Pseudomonas aeruginosa and Staphylococcus aureus were used as bacterial stimulants to evaluate the immune response of BAL cells from young children with CF. Addition of gentamicin prevented bacterial overgrowth, although if added after 3 hours of culture an extremely variable response resulted, with the bacteria causing a suppressive effect in some cultures. Addition of gentamicin after 1 hour of culture completely prevented this suppressive effect. This technique was then able to reproducibly measure the IL-8 response to stimulation with S. aureus and P. aeruginosa, including co-stimulation with both bacteria.
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Affiliation(s)
- Haipei Liu
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Pediatric Respiratory Medicine, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sohinee Sarkar
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia
| | - Kristy Azzopardi
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia
| | - Sophie Day
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia
| | - Serene Yeow
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia
| | - Sarath Ranganathan
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Vic., Australia
| | - Philip Sutton
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia
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11
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Muston HN, Perrem L, Davis MD, Ratjen F, Ren CL. The remaining barriers to normalcy in CF: Advances in assessment of CF lung disease. Pediatr Pulmonol 2021; 56 Suppl 1:S90-S96. [PMID: 32589821 DOI: 10.1002/ppul.24929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/20/2020] [Accepted: 06/23/2020] [Indexed: 11/12/2022]
Abstract
Despite early diagnosis of cystic fibrosis (CF) through newborn screening, a substantial proportion of infants and young children with CF still demonstrate physiologic and structural evidence of lung disease progression, such as obstructive airway disease and bronchiectasis. The growing availability of highly effective CF transmembrane conductance regulatory modulator therapy to the vast majority of people with CF has led to the potential to alter the natural history of CF lung disease, but to assess the full impact of these therapies on CF lung disease and to help guide treatment, sensitive measures of early and mild disease are needed. Chest imaging using computed tomography or magnetic resonance imaging is one approach, but technologic barriers and/or concern about exposure to ionizing radiation may limit its use. However, advances in physiologic measurement techniques and exhaled breath analysis offer another option for assessment of CF lung disease.
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Affiliation(s)
- Heather N Muston
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Michael D Davis
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
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12
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Hatziagorou E, Kampouras A, Avramidou V, Toulia I, Chrysochoou EA, Galogavrou M, Kirvassilis F, Tsanakas J. Toward the Establishment of New Clinical Endpoints for Cystic Fibrosis: The Role of Lung Clearance Index and Cardiopulmonary Exercise Testing. Front Pediatr 2021; 9:635719. [PMID: 33718306 PMCID: PMC7946844 DOI: 10.3389/fped.2021.635719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/03/2021] [Indexed: 01/25/2023] Open
Abstract
As Cystic Fibrosis (CF) treatment advances, research evidence has highlighted the value and applicability of Lung Clearance Index and Cardiopulmonary Exercise Testing as endpoints for clinical trials. In the context of these new endpoints for CF trials, we have explored the use of these two test outcomes for routine CF care. In this review we have presented the use of these methods in assessing disease severity, disease progression, and the efficacy of new interventions with considerations for future research.
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Affiliation(s)
- Elpis Hatziagorou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Asterios Kampouras
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Avramidou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ilektra Toulia
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elisavet-Anna Chrysochoou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Galogavrou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Kirvassilis
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Tsanakas
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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13
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Teper A, Smithuis F, Rodríguez V, Salvaggio O, Maccallini G, Aranda C, Lubovich S, Zaragoza S, García-Bournissen F. Comparison between two newborn screening strategies for cystic fibrosis in Argentina: IRT/IRT versus IRT/PAP. Pediatr Pulmonol 2021; 56:113-119. [PMID: 33095477 DOI: 10.1002/ppul.25130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/10/2020] [Accepted: 10/14/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The benefits of early cystic fibrosis (CF) detection using newborn screening (NBS) has led to widespread use in NBS programs. Since 2002, a two-stage immunoreactive trypsinogen (IRT/IRT) screening strategy has been used as a CFNBS method in all public maternity units in the City of Buenos Aires, Argentina. However, novel screening strategies may be more efficient. The aim of this study is to prospectively compare two CFNBS strategies: IRT/IRT and IRT/PAP (pancreatitis-associated protein). METHODS A two-year prospective study was performed. IRT was measured in dried blood samples collected 48-72 h after birth. When an IRT value was abnormal, PAP was determined, and a second visit was scheduled to obtain another sample for IRT before 25 days of life. Newborns with a positive CFNBS were referred for a confirmatory sweat test. RESULTS There were 69,827 births in the City of Buenos Aires during the period studied; 918 (1.31%) had an abnormal IRT. A total of 207 children (22.5%) failed to return for the second IRT, but only two PAP (0.2%) were not performed. IRT/IRT was more likely to lead to a referral for sweat testing than IRT/PAP (odds ratio 2.3 [95% confidence interval 1.8-2.9], p < .001). Sensitivity and specificity were: 80% and 100% and 86.5% and 82.6% for IRT/IRT and IRT/PAP strategies, respectively. CONCLUSION The IRT/PAP strategy is more sensitive than IRT/IRT and has similar specificity; it avoids a second visit and unnecessary sweat testing, and it reduces loss to follow-up in our population.
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Affiliation(s)
- Alejandro Teper
- Respiratory Center, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Fernando Smithuis
- Newborn Screening Laboratory, Hospital General de Agudos Dr. Carlos Durand, City of Buenos Aires, Argentina
| | - Viviana Rodríguez
- Respiratory Center, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Orlando Salvaggio
- Respiratory Center, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Gustavo Maccallini
- Newborn Screening Laboratory, Hospital General de Agudos Dr. Carlos Durand, City of Buenos Aires, Argentina
| | - Claudio Aranda
- Newborn Screening Laboratory, Hospital General de Agudos Dr. Carlos Durand, City of Buenos Aires, Argentina
| | - Silvina Lubovich
- Respiratory Center, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Silvina Zaragoza
- Respiratory Center, Hospital de Niños Dr. Ricardo Gutiérrez, City of Buenos Aires, Argentina
| | - Facundo García-Bournissen
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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14
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Akkerman-Nijland AM, Akkerman OW, Grasmeijer F, Hagedoorn P, Frijlink HW, Rottier BL, Koppelman GH, Touw DJ. The pharmacokinetics of antibiotics in cystic fibrosis. Expert Opin Drug Metab Toxicol 2020; 17:53-68. [PMID: 33213220 DOI: 10.1080/17425255.2021.1836157] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Dosing of antibiotics in people with cystic fibrosis (CF) is challenging, due to altered pharmacokinetics, difficulty of lung tissue penetration, and increasing presence of antimicrobial resistance. AREAS COVERED The purpose of this work is to critically review original data as well as previous reviews and guidelines on pharmacokinetics of systemic and inhaled antibiotics in CF, with the aim to propose strategies for optimization of antibacterial therapy in both children and adults with CF. EXPERT OPINION For systemic antibiotics, absorption is comparable in CF patients and non-CF controls. The volume of distribution (Vd) of most antibiotics is similar between people with CF with normal body composition and healthy individuals. However, there are a few exceptions, like cefotiam and tobramycin. Many antibiotic class-dependent changes in drug metabolism and excretion are reported, with an increased total body clearance for ß-lactam antibiotics, aminoglycosides, fluoroquinolones, and trimethoprim. We, therefore, recommend following class-specific guidelines for CF, mostly resulting in higher dosages per kg bodyweight in CF compared to non-CF controls. Higher local antibiotic concentrations in the airways can be obtained by inhalation therapy, with which eradication of bacteria may be achieved while minimizing systemic exposure and risk of toxicity.
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Affiliation(s)
- Anne M Akkerman-Nijland
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Floris Grasmeijer
- Department of Pharmacy, PureIMS B.V , Roden, The Netherlands.,Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , Groningen, The Netherlands
| | - Paul Hagedoorn
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , Groningen, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , Groningen, The Netherlands
| | - Bart L Rottier
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Gerard H Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Daniel J Touw
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
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15
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Walicka-Serzysko K, Postek M, Milczewska J, Sands D. Lung function deterioration in school children with cystic fibrosis. Pediatr Pulmonol 2020; 55:3030-3038. [PMID: 32761970 DOI: 10.1002/ppul.25013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/16/2020] [Accepted: 08/05/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Lung disease in cystic fibrosis (CF) begins early in life but the capabilities for detecting abnormalities of pulmonary dysfunction in children remain limited. OBJECTIVE The study aimed to evaluate the early progression of lung function by the analysis of pulmonary hyperinflation, ventilation inhomogeneity (VI), trapped gas and airway obstruction with age. METHODS One hundred CF children aged 7 to 18, divided into two groups aged 7 to 12 (n = 40) and 13 to 18 (n = 60), were enrolled. Patients performed multiple-breath nitrogen washout (MBNW) tests and plethysmography for measurements of lung clearance index (LCI), functional residual capacity (FRCpleth , FRCMBNW ), volume of trapped gas (VT ), total resistance, and effective and specific effective airway resistance (Reff , sReff ). RESULTS We obtained a positive correlation of FRCpleth , FRCMBNW , and LCI with age. A linear correlation between FRCMBNW and FRCpleth (P < .0001) was observed. VI was higher in the group of older patients (9.79 in the group aged 7-12 and 11.67 in the group aged 13-18). An increased effective specific airway resistance >2 (z-score) was present in 58% of all subjects (50% and 63.3%, respectively). Pulmonary hyperinflation (FRCpleth >2 z-score) was observed in 33% of all patients: 25% and 36.6%, respectively. Trapped gas (VT > 2 z-score) was present in 18% of all children: 30% and 10%, respectively. CONCLUSION A gradual decline in lung function is associated with an increase in VI, airway obstruction, pulmonary hyperinflation and development of trapped gas. In children who cannot perform either spirometry or plethysmography, MBNW can deliver a measurement of LCI connecting with VI as well as FRCMBNW to indicate indirectly the increase of hyperinflation.
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Affiliation(s)
- Katarzyna Walicka-Serzysko
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland.,Cystic Fibrosis Centre, Clinical Department of Lung Diseases, Pediatric Hospital, Dziekanow Lesny, Poland
| | - Magdalena Postek
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland.,Cystic Fibrosis Centre, Clinical Department of Lung Diseases, Pediatric Hospital, Dziekanow Lesny, Poland
| | - Justyna Milczewska
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland.,Cystic Fibrosis Centre, Clinical Department of Lung Diseases, Pediatric Hospital, Dziekanow Lesny, Poland
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland.,Cystic Fibrosis Centre, Clinical Department of Lung Diseases, Pediatric Hospital, Dziekanow Lesny, Poland
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16
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Shanthikumar S, Burton M, Saffery R, Ranganathan SC, Neeland MR. Single-Cell Flow Cytometry Profiling of BAL in Children. Am J Respir Cell Mol Biol 2020; 63:152-159. [PMID: 32207982 DOI: 10.1165/rcmb.2019-0453ma] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Childhood pulmonary diseases not only cause childhood morbidity and mortality but also can cause long-term pulmonary impairment. The clinical management of many childhood pulmonary diseases is hampered by a limited understanding of the underlying pathophysiological mechanisms. Flow cytometry, which can be used to phenotype individual cell populations or isolate cells for downstream analysis, represents a crucial technology that can help to elucidate the pathophysiology of these conditions. Here, we describe a flow cytometry-based method for purification and characterization of cell populations in BAL from children. This includes assessment of the effect of cryopreservation on cell phenotype and frequency, a knowledge gap recently identified by an American Thoracic Society report on flow cytometry in lung samples. To our knowledge, this is the first study to simultaneously quantify alveolar macrophages, T cells (CD4 and CD8), B cells, natural killer cells, dendritic cells, granulocytes, and monocytes (CD16+/CD16-) in the BAL of children. The protocols described can be used to advance investigation of the pathophysiology of childhood pulmonary diseases.
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Affiliation(s)
- Shivanthan Shanthikumar
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Respiratory Diseases.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Richard Saffery
- Epigenetics, and.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sarath C Ranganathan
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Respiratory Diseases.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melanie R Neeland
- Population Allergy, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; and.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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17
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Infant spirometry as a predictor of lung function at early childhood in cystic fibrosis patients. J Cyst Fibros 2020; 20:937-940. [PMID: 32952083 DOI: 10.1016/j.jcf.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Infant pulmonary function testing using the raised volume rapid thoracoabdominal compression (RVRTC) technique requires sedation and is time consuming. Many cystic fibrosis (CF) centers do not have access to equipment and the utility of routine testing remains to be determined. We aimed to assess whether RVRTC tests performed during infancy predict spirometry at early school age. METHODS The RVRTC-based forced expiratory flow measures in infants were compared to the first adequately performed spirometry at school age. All tests were carried out during routine clinic visits and expressed as age related z-scores; only test occasions where patients were considered stable were included in the analysis. RESULTS 47 patients had useable infant RVRTC as well as matching school age spirometry data. There was weak correlation between infant FEV0.5 and early school age FEV1 (R = 0.29, p = 0.05). Four infants had significantly low zFEV0.5 (zFEV0.5 < -1.96), of which one of those remained under that limit at childhood. Changes in spirometry between infancy and early childhood were negatively correlated to baseline FEV0.5 (R = 0.61 p<0.001) reflecting that the change was driven by where individuals started off with. There was no difference in clinical characteristics between those improving, those with stable or deteriorating in lung function. CONCLUSION Infant RVRTC measures were not predictive of pulmonary function in early school age, likely due to the high proportion of measures of forced expiratory flows within the normal range at both time points.
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18
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19
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Abstract
BACKGROUND People with cystic fibrosis are at an increased risk of fat-soluble vitamin deficiency, including vitamin E. Vitamin E deficiency can cause a host of conditions such as haemolytic anaemia, cerebellar ataxia and cognitive difficulties. Vitamin E supplementation is widely recommended for people with cystic fibrosis and aims to ameliorate this deficiency. This is an updated version of the review. OBJECTIVES To determine the effects of any level of vitamin E supplementation on the frequency of vitamin E deficiency disorders in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Group's Cystic Fibrosis Trials Register and also searched international online trial registries for any ongoing clinical trials that were not identified during our register search. Date of last search of the Register: 11 August 2020. Date of last search of international online trial registries: 20 July 2020. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled trials comparing any preparation of vitamin E supplementation to placebo or no supplement, regardless of dosage or duration. DATA COLLECTION AND ANALYSIS Two authors extracted outcome data from each study (published information) and assessed the risk of bias of each included study. They assessed the quality of the evidence using GRADE. MAIN RESULTS Four studies with a total of 141 participants were included in the review, two of these were in children (aged six months to 14.5 years), and two did not specify participants' age. All studies used different formulations and doses of vitamin E for various durations of treatment (10 days to six months). Two studies compared the supplementation of fat-soluble as well as water-soluble formulations to no supplementation in different arms of the same study. A third study compared a water-soluble formulation to a placebo; and in the fourth study a fat-soluble formulation of vitamin E was assessed against placebo. There was limited detail about randomisation and blinding in the included studies which compromises the quality of the evidence base for the review. The heterogeneous mix of the formulations with differing biovailabilities among these studies also limits the generalisability of the data to the wider cystic fibrosis population. None of the studies in either comparison report the review's primary outcomes of vitamin E total lipid ratio or the incidence of vitamin E-specific deficiency disorders, or the secondary outcomes lung function or quality of life. Water-soluble vitamin E Water-soluble vitamin E may improve serum vitamin E levels compared with control at six months, one study (45 participants), mean difference (MD) 19.74 umol/L (95% confidence interval (CI) 13.48 to 26.00) (low-quality evidence). Similar results were also seen at one month, two studies (32 participants), MD 17.66 umol/L (95% CI 10.59 to 24.74) and at three months, one study (45 participants), MD 11.61 umol/L (95% CI 4.77 to 18.45). Only one study (45 participants) reported weight (secondary outcome of growth and nutritional status) at one and six months, but showed no difference between treatment and control at either time point. Fat-soluble vitamin E Two studies (36 participants) reported higher levels of serum vitamin E at one month with fat-soluble vitamin E compared with control, MD 13.59 umol/L (95% CI 9.52 to 17.66); however, at three months one study (36 participants) showed no difference between treatment and control. No studies in this comparison reported on growth or nutritional status. AUTHORS' CONCLUSIONS Vitamin E supplementation may lead to an improvement in vitamin E levels in people with cystic fibrosis, although evidence we assessed was low quality. No data on other outcomes of interest were available to allow conclusions about any other benefits of this therapy. In future, larger studies are needed, especially in people already being treated with enteric-coated pancreatic enzymes and supplemented with vitamin E, to look at more specific outcome measures such as vitamin E status, lung function and nutritional status. Future studies could also look at the optimal dose of vitamin E required to achieve maximal clinical effectiveness.
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Affiliation(s)
- Peter O Okebukola
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sonal Kansra
- Department of Paediatric Respiratory Medicine, Sheffield Children's Hospital NHS Trust, Sheffield, UK
| | - Joanne Barrett
- West Midlands Adult Cystic Fibrosis Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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20
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Fitzgerald C, Linnane B, George S, Ni Chroinin M, Mullane D, Herzig M, Greally P, Elnazir B, Healy F, Mc Nally P, Javadpour S, Cox D, Fitzpatrick P. Neonatal screening programme for CF: Results from the Irish Comparative Outcomes Study (ICOS). Pediatr Pulmonol 2020; 55:2323-2329. [PMID: 32470170 DOI: 10.1002/ppul.24876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/23/2020] [Accepted: 05/09/2020] [Indexed: 11/07/2022]
Abstract
The introduction of NBS in Ireland in July 2011, provided a unique opportunity to investigate clinical outcomes using a comparative historical cohort study. Clinical cohort: children clinically diagnosed with CF born 1 July 2008 to 30 June 2011, and NBS cohort: children diagnosed with CF through NBS born 1 July 2011 to 30 June 2016. Clinical data were collected from the CF Registry of Ireland, medical charts, and data on weight/height before diagnosis from public health nurses and family doctors. SPSS was used for analysis. A total of 232 patients were recruited (response 93%) (93 clinically diagnosed, 139 NBS-detected). Following exclusions of meconium ileus (MI) (40), diagnosis outside Ireland (4), and being designated as CFSPID (2), a total of 77 clinically diagnosed patients and 109 NBS detected children were included in analysis. Over half were homozygous for F508del mutation. Being clinically diagnosed was independently associated with hospitalization for infective exacerbation of CF < 36 months (OR, 2.80; 95%CI 1.24-6.29). Diagnosis to first acquisition of Pseudomonas aeruginosa was significantly longer in NBS than clinically detected; from birth there was no significant difference. Weight and length/height were significantly greater in NBS cohort at 6 and 12 months. We provide evidence of improved growth, reduced hospitalization for acute exacerbations, and delayed P. aeruginosa acquisition (from diagnosis) to age 3 for the NBS cohort. Screening practices likely account for the non-significant difference in P. aeruginosa acquisition from birth.
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Affiliation(s)
- Catherine Fitzgerald
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Barry Linnane
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Sherly George
- Department of Nursing, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - David Mullane
- Department of Paediatrics, Galway University Hospital, Galway, Ireland
| | - Mary Herzig
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Peter Greally
- Respiratory Department, The Children's University Hospital, Temple St, Dublin, Ireland
| | - Basil Elnazir
- Department of Respirology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Fiona Healy
- Respiratory Department, The Children's University Hospital, Temple St, Dublin, Ireland
| | - Paul Mc Nally
- Department of Respirology, Our Lady's Children's Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sheila Javadpour
- Department of Respirology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Des Cox
- Department of Respirology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Patricia Fitzpatrick
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
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21
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Ring AM, Carlens J, Bush A, Castillo-Corullón S, Fasola S, Gaboli MP, Griese M, Koucky V, La Grutta S, Lombardi E, Proesmans M, Schwerk N, Snijders D, Nielsen KG, Buchvald F. Pulmonary function testing in children's interstitial lung disease. Eur Respir Rev 2020; 29:29/157/200019. [PMID: 32699025 DOI: 10.1183/16000617.0019-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/11/2020] [Indexed: 12/17/2022] Open
Abstract
The use of pulmonary function tests (PFTs) has been widely described in airway diseases like asthma and cystic fibrosis, but for children's interstitial lung disease (chILD), which encompasses a broad spectrum of pathologies, the usefulness of PFTs is still undetermined, despite widespread use in adult interstitial lung disease. A literature review was initiated by the COST/Enter chILD working group aiming to describe published studies, to identify gaps in knowledge and to propose future research goals in regard to spirometry, whole-body plethysmography, infant and pre-school PFTs, measurement of diffusing capacity, multiple breath washout and cardiopulmonary exercise tests in chILD. The search revealed a limited number of papers published in the past three decades, of which the majority were descriptive and did not report pulmonary function as the main outcome.PFTs may be useful in different stages of management of children with suspected or confirmed chILD, but the chILD spectrum is diverse and includes a heterogeneous patient group in all ages. Research studies in well-defined patient cohorts are needed to establish which PFT and outcomes are most relevant for diagnosis, evaluation of disease severity and course, and monitoring individual conditions both for improvement in clinical care and as end-points in future randomised controlled trials.
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Affiliation(s)
- Astrid Madsen Ring
- Paediatric Pulmonary Service, Dept of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Danish PCD & chILD Centre, CF Centre Copenhagen, Copenhagen, Denmark.,Joint first authors
| | - Julia Carlens
- Clinic for Paediatric Pneumology, Allergology and Neonatology, Medizinische Hochschule Hannover Zentrum fur Kinderheilkunde und Jugendmedizin, Hannover, Germany.,Joint first authors
| | - Andy Bush
- Paediatrics and Paediatric Respiratory Medicine, Imperial College London, London, UK.,Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Silvia Castillo-Corullón
- Unidad de Neumología infantil y Fibrosis quística, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Salvatore Fasola
- Institute of Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
| | - Mirella Piera Gaboli
- Neumologia Infantil y Unidad de Cuidados Intensivos Pediatricos, Hospital Universitario Salamanca, Salamanca, Spain
| | - Matthias Griese
- University Hospital of Munich, Dr. von Hauner Children's Hospital, German Center for Lung Research (DZL), Munich, Germany
| | - Vaclav Koucky
- Dept of Paediatrics, Univerzita Karlova v Praze 2 lekarska fakulta, Prague, Czech Republic
| | - Stefania La Grutta
- Institute of Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
| | - Enrico Lombardi
- Pediatric Pulmonary Unit, Anna Meyer Pediatric University-Hospital, Florence, Italy
| | | | - Nicolaus Schwerk
- Clinic for Paediatric Pneumology, Allergology and Neonatology, Medizinische Hochschule Hannover Zentrum fur Kinderheilkunde und Jugendmedizin, Hannover, Germany
| | | | - Kim Gjerum Nielsen
- Paediatric Pulmonary Service, Dept of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Danish PCD & chILD Centre, CF Centre Copenhagen, Copenhagen, Denmark.,Joint last authors
| | - Frederik Buchvald
- Paediatric Pulmonary Service, Dept of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Danish PCD & chILD Centre, CF Centre Copenhagen, Copenhagen, Denmark .,Joint last authors
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22
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Davies G, Thia LP, Stocks J, Bush A, Hoo AF, Wade A, Nguyen TTD, Brody AS, Calder A, Klein NJ, Carr SB, Wallis C, Suri R, Pao CS, Ruiz G, Balfour-Lynn IM. Minimal change in structural, functional and inflammatory markers of lung disease in newborn screened infants with cystic fibrosis at one year. J Cyst Fibros 2020; 19:896-901. [PMID: 32044244 DOI: 10.1016/j.jcf.2020.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND With the widespread introduction of newborn screening for cystic fibrosis (CF), there has been considerable emphasis on the need to develop objective markers of lung health that can be used during infancy. We hypothesised that in a newborn screened (NBS) UK cohort, evidence of airway inflammation and infection at one year would be associated with adverse structural and functional outcomes at the same age. METHODS Infants underwent lung function testing, chest CT scan and bronchoscopy with bronchoalveolar lavage (BAL) at 1 year of age when clinically well. Microbiology cultures were also available from routine cough swabs. RESULTS 65 infants had lung function, CT and BAL. Mean (SD) lung clearance index and forced expiratory volume in 0.5 s z-scores were 0.9(1.2) and -0.6(1.1) respectively; median Brody II CF-CT air trapping score on chest CT =0 (interquartile range 0-1, maximum possible score 27). Infants isolating any significant pathogen by 1 yr of age had higher LCI z-score (mean difference 0.9; 95%CI:0.4-1.4; p = 0.001) and a trend towards higher air trapping scores on CT (p = 0.06). BAL neutrophil elastase was detectable in 23% (10/43) infants in whom BAL supernatant was available. This did not relate to air trapping score on CT. CONCLUSIONS In this UK NBS cohort at one year of age, lung and airway damage is much milder and associations between inflammation, abnormal physiology and structural changes were at best weak, contrary to our hypothesis and previously published reports. Continued follow-up will clarify longer term implications of these very mild structural, functional and inflammatory changes.
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Affiliation(s)
- Gwyneth Davies
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Lena P Thia
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Paediatric Respiratory Medicine, Cardiff University and Children's Hospital for Wales, Cardiff, United Kingdom
| | - Janet Stocks
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Imperial College & Royal Brompton & Harefield Hospital NHS Foundation Trust, London, United Kingdom
| | - Ah-Fong Hoo
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Angie Wade
- Clinical Epidemiology, Nutrition and Biostatistics Section, UCL GOS ICH, London, United Kingdom
| | - The Thanh Diem Nguyen
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Alan S Brody
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Alistair Calder
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Nigel J Klein
- Infection, Inflammation and Rheumatology Section, UCL GOS ICH, London, United Kingdom
| | - Siobhán B Carr
- Department of Paediatric Respiratory Medicine, Imperial College & Royal Brompton & Harefield Hospital NHS Foundation Trust, London, United Kingdom
| | - Colin Wallis
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Ranjan Suri
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Caroline S Pao
- Department of Paediatric Respiratory Medicine, Royal London Hospital, London, United Kingdom
| | - Gary Ruiz
- Department of Paediatric Respiratory Medicine, Kings College Hospital, London, United Kingdom
| | - Ian M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Imperial College & Royal Brompton & Harefield Hospital NHS Foundation Trust, London, United Kingdom
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Early Cystic Fibrosis Lung Disease. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Matusovsky OS, Kachmar L, Ijpma G, Panariti A, Benedetti A, Martin JG, Lauzon AM. Contractile Properties of Intrapulmonary Airway Smooth Muscle in Cystic Fibrosis. Am J Respir Cell Mol Biol 2019; 60:434-444. [PMID: 30359078 DOI: 10.1165/rcmb.2018-0005oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal-recessive disease caused by mutations in the CF transmembrane conductance regulator gene. Many patients with CF have asthma-like symptoms and airway hyperresponsiveness, which are potentially associated with altered airway smooth muscle (ASM) contractility. Our goal in this study was to assess the contractility of the CF intrapulmonary ASM. ASM strips were dissected from human control and CF intrapulmonary airways, and assessed for methacholine-induced shortening velocity, maximal force, and stress. We also assessed isoproterenol responses in maximally methacholine-contracted ASM. ASM strips were then incubated for 16 hours with IL-13 and measurements were repeated. Myosin light chain kinase (MLCK) expression was assessed by Western blotting. Airways were immunostained for morphometry. ASM mass was increased in CF airways, which likely contributes to airway hyperresponsiveness. Although ASM contractile properties were not intrinsically different between patients with CF and control subjects, CF ASM responded differently in the presence of the inflammatory mediator IL-13, showing impairment in β-adrenergic-induced relaxation. Indeed, the percentage of relaxation measured at maximal isoproterenol concentrations in the CF ASM was significantly lower after incubation with IL-13 (46.0% ± 6.7% relaxation) than without IL-13 (74.0% ± 7.7% relaxation, P = 0.018). It was also significantly lower than that observed in control ASM incubated with IL-13 (68.8% ± 4.9% relaxation, P = 0.048) and without IL-13 (82.4% ± 9.9%, P = 0.0035). CF ASM incubated with IL-13 also expressed greater levels of MLCK. Thus, our data suggest that the combination of an increase in ASM mass, increased MLCK expression, and inflammation-induced β-adrenergic hyporesponsiveness may contribute to airway dysfunction in CF.
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Affiliation(s)
- Oleg S Matusovsky
- 1 Meakins-Christie Laboratories, Research Institute of the McGill University Health Center
| | - Linda Kachmar
- 1 Meakins-Christie Laboratories, Research Institute of the McGill University Health Center
| | - Gijs Ijpma
- 1 Meakins-Christie Laboratories, Research Institute of the McGill University Health Center
| | - Alice Panariti
- 1 Meakins-Christie Laboratories, Research Institute of the McGill University Health Center
| | - Andrea Benedetti
- 2 Department of Medicine, and.,3 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; and.,4 Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montréal, Québec, Canada
| | - James G Martin
- 1 Meakins-Christie Laboratories, Research Institute of the McGill University Health Center.,2 Department of Medicine, and
| | - Anne-Marie Lauzon
- 1 Meakins-Christie Laboratories, Research Institute of the McGill University Health Center.,2 Department of Medicine, and
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25
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Ratjen F, Davis SD, Stanojevic S, Kronmal RA, Hinckley Stukovsky KD, Jorgensen N, Rosenfeld M, Kerby G, Kopecky C, Anthony M, Mogayzel P, Walker D, Zeglin B, Hoover W, Hathorne H, Slaten K, Dorkin H(H, Fowler R, Fenton C(N, Ulles M, Goetz D, Caci N, Cahill B, Roach C, Retsch-Bogart G, Johnson R, Cunnion R, McColley S, Ward S, Bell E, McPhail G, Keller K, Thornton K, Parsons A, Chmiel J, Schaefer C, Tribout M, Consiglio B, Tribout H, McCoy K, Johnson T, Olson P, Raterman L, Hiatt P, Walker B, Schaap N, Davis M, Davis S, Clem C, Bendy L, Starner T, Lux C, Carver T, Thompson R, Williams A, Schmoll C, Hastings PM, Noe J, Roth L, Kump T, McNamara J, Franck Thompson E, Yousef S, Wezel G(G, Oquendo O, Darling A, Valencia W, Milla C, Zirbes J, Rubenstein R, Donnelly E, Malpass J, Weiner D, Agostini B, Hartigan E, Cornell A, Klein B, Bucher J, Nusbaum P, Rosenfeld M, McNamara S, Genatossio A, Pittman J, Hicks T, Bauer I, Siegel M, Isaac S, Jensen R, Au J, Stanojevic S, Ratjen F, McDonald N, Prentice C, Chilvers M, Richmond M. Inhaled hypertonic saline in preschool children with cystic fibrosis (SHIP): a multicentre, randomised, double-blind, placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:802-809. [DOI: 10.1016/s2213-2600(19)30187-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023]
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Abstract
Cystic fibrosis (CF) is an autosomal recessive disease characterized by pancreatic insufficiency and chronic endobronchial airway infection. This latter feature results in progressive bronchiectasis and ultimately respiratory failure, which is the leading cause of death in patients with CF. Other complications include sinusitis, diabetes mellitus, bowel obstruction, hepatobiliary disease, hyponatremic dehydration, and infertility. Diagnosis of CF is confirmed by demonstration of elevated sweat chloride. Most cases of CF are identified through newborn screening (NBS). There are also infants with positive NBS but inconclusive diagnostic testing; a small proportion of these infants may go on to develop CF. CF is a lifelong, life-limiting disease, but an organized care center network with multidisciplinary approach, quality improvement initiatives, and research has led to markedly increased survival and development of adult CF care programs. In the past few years, medications that directly target the underlying CF defect have been developed, which should result in even greater survival benefits. [Pediatr Ann. 2019;48(4):e154-e161.].
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Newbegin K, Pilkington K, Shanthikumar S, Ranganathan S. Clinical utility of surveillance computed tomography scans in infants with cystic fibrosis. Pediatr Pulmonol 2018; 53:1387-1390. [PMID: 29984485 DOI: 10.1002/ppul.24132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/21/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND In cystic fibrosis (CF), irreversible lung disease arises in early life, and is often asymptomatic and unrecognised. Chest computed tomography (CT) scans have been used to detect asymptomatic lung disease in research; however, the clinical utility of chest CT is unknown. This study aimed to determine the effect of surveillance CT in early life on the clinical management of patients with CF. WORKING HYPOTHESIS Surveillance CT in early life changes the management of patients with CF. METHODS A medical record review of patients in the AREST-CF cohort who had chest CT at 1 and 3 years of age was performed. Information extracted included CT scan findings and the effect of CT results on clinical management. RESULTS The chest CT scans and records of 50 subjects with CF were reviewed. The majority of CT scans (n = 75; 75%) were abnormal. N = 31 (31%) of scans overall led to a direct change in management. The number of CT scans needed to be performed to lead to a treatment change was 3.2. The majority (n = 18, 58%) of changes in management were prompted by the finding of bronchiectasis. CONCLUSION To the authors knowledge, this is the first study to highlight that early life surveillance CT frequently results in changes in clinical management, and hence may have a role beyond research and in routine care. If this can be shown to contribute to improved outcomes (such as reduced rates of bronchiectasis), then, as radiation doses diminish, chest CT could have an important clinical role.
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Affiliation(s)
- Katy Newbegin
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Katie Pilkington
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Shivanthan Shanthikumar
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Sarath Ranganathan
- Respiratory and Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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30
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Lu Z, Foong RE, Kowalik K, Moraes TJ, Dubeau A, Lefebvre D, Davis SD, Balkovec S, Becker A, Mandhane P, Turvey SE, Lou W, Sears MR, Ratjen F, Subbarao P. Reference equations for the interpretation of forced expiratory and plethysmographic measurements in infants. Pediatr Pulmonol 2018; 53:907-916. [PMID: 29790670 DOI: 10.1002/ppul.24063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/08/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pulmonary function testing is commonly performed for diagnosis and clinical management of respiratory diseases. It is important to use appropriate reference equations from healthy subjects for interpretation of data from infants with lung disease. This study aimed to determine if published reference equations were similar to forced flow measures and plethysmographic infant pulmonary function testing data collected in the Canadian Healthy Infant Longitudinal Development (CHILD) Study. METHODS Reference equations for five pulmonary function variables (FEV0.5 , FVC, FEF25-75 , FEV0.5 /FVC ratio and plethysmography (FRCpleth )) were developed using data from the nSpire system. New reference equations developed using healthy data from the CHILD Study were compared to previously published reference equations for forced flow and plethysmographic measures. RESULTS The current analysis included 131 infants (on 181 test occasions) with forced flow measures and 161 infants (on 246 test occasions) with plethysmography measures, aged 3-24 months. Age and length were major determinants of both forced flow and plethysmography measures. In addition, ethnicity (Caucasian vs non-Caucasian) was significantly associated with FEV0.5 /FVC and FEF25-75 measures. We found that the published reference equations based on custom-built equipment or commercially available systems provided poor fit to our current pulmonary function testing data, resulting in placing a large proportion of our healthy population outside the normal ranges. CONCLUSIONS Our current data support the need for population and device specific reference data for infant pulmonary function studies. By deriving new equipment-specific reference equations for our healthy population, we provide normative data to other centers utilizing this equipment.
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Affiliation(s)
- Zihang Lu
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Rachel E Foong
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Curtin University of Technology, Perth, Western Australia
| | - Krzysztof Kowalik
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Aimee Dubeau
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Diana Lefebvre
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine; Department of Pediatrics; Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Susan Balkovec
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Allan Becker
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Piush Mandhane
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart E Turvey
- Department of Pediatrics, Child & Family Research Institute, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Malcolm R Sears
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Padmaja Subbarao
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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31
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Ponzano S, Nigrelli G, Fregonese L, Eichler I, Bertozzi F, Bandiera T, Galietta LJV, Papaluca M. A European regulatory perspective on cystic fibrosis: current treatments, trends in drug development and translational challenges for CFTR modulators. Eur Respir Rev 2018; 27:27/148/170124. [PMID: 29653946 DOI: 10.1183/16000617.0124-2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/14/2018] [Indexed: 12/18/2022] Open
Abstract
In this article we analyse the current authorised treatments and trends in early drug development for cystic fibrosis (CF) in the European Union for the time period 2000-2016. The analysis indicates a significant improvement in the innovation and development of new potential medicines for CF, shifting from products that act on the symptoms of the disease towards new therapies targeting the cause of CF. However, within these new innovative medicines, results for CF transmembrane conductance regulator (CFTR) modulators indicate that one major challenge for turning a CF concept product into an actual medicine for the benefit of patients resides in the fact that, although pre-clinical models have shown good predictability for certain mutations, a good correlation to clinical end-points or biomarkers (e.g. forced expiratory volume in 1 s and sweat chloride) for all mutations has not yet been achieved. In this respect, the use of alternative end-points and innovative nonclinical models could be helpful for the understanding of those translational discrepancies. Collaborative endeavours to promote further research and development in these areas as well as early dialogue with the regulatory bodies available at the European competent authorities are recommended.
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Affiliation(s)
- Stefano Ponzano
- European Medicines Agency, London, UK.,D3 PharmaChemistry, Istituto Italiano di Tecnologia, Genova, Italy
| | | | | | | | - Fabio Bertozzi
- D3 PharmaChemistry, Istituto Italiano di Tecnologia, Genova, Italy
| | - Tiziano Bandiera
- D3 PharmaChemistry, Istituto Italiano di Tecnologia, Genova, Italy
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32
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Heltshe SL, Cogen J, Ramos KJ, Goss CH. Cystic Fibrosis: The Dawn of a New Therapeutic Era. Am J Respir Crit Care Med 2017; 195:979-984. [PMID: 27710011 DOI: 10.1164/rccm.201606-1250pp] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sonya L Heltshe
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and.,2 Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Jonathan Cogen
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and
| | - Kathleen J Ramos
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; and
| | - Christopher H Goss
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and.,3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; and.,2 Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
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33
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Caudri D, Turkovic L, Ng J, de Klerk NH, Rosenow T, Hall GL, Ranganathan SC, Sly PD, Stick SM. The association between Staphylococcus aureus and subsequent bronchiectasis in children with cystic fibrosis. J Cyst Fibros 2017; 17:462-469. [PMID: 29274943 DOI: 10.1016/j.jcf.2017.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Staphylococcus aureus (S. aureus) may be related to more rapid progression of cystic fibrosis (CF) lung disease. METHODS In the AREST CF cohort study, children diagnosed with CF undergo annual bronchoscopies with bronchoalveolar lavage and ultra-low-dose, chest computed tomography (CT) up to 6-years-old. Spirometry was assessed 3-monthly from the age of 4years. Associations between de novo S. aureus acquisition before school age and CT and lung function at ages 5-7years were investigated. Models were adjusted for multiple markers of disease severity at baseline. RESULTS De novo S. aureus acquisition at 3-years-old (n/N=12/122) was associated with increased bronchiectasis score at age 5-6years. This association decreased but remained significant after adjustment for confounders. S. aureus at 3 was associated with significantly reduced FEF25-75 at age 5-7years, but not with FEV1-%-predicted. CONCLUSION De novo S. aureus acquisition at age 3 is associated with later bronchiectasis and FEF25-75 in children with CF.
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Affiliation(s)
- Daan Caudri
- Telethon Kids Institute, Perth, Australia; Dept. of Respiratory Medicine, Princess Margaret Hospital, Perth, Australia; Dept. of Pediatrics/Respiratory Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | | | - Jolyn Ng
- Telethon Kids Institute, Perth, Australia
| | | | | | - Graham L Hall
- Telethon Kids Institute, Perth, Australia; Centre of Child Health Research, The University of Western Australia, Perth, Australia; School of Physiotherapy and Exercise Science, Curtin University, Australia
| | - Sarath C Ranganathan
- Murdoch Childrens Research Institute, Parkville, Australia; Department of Respiratory and Sleep Medicine, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Peter D Sly
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Stephen M Stick
- Telethon Kids Institute, Perth, Australia; Dept. of Respiratory Medicine, Princess Margaret Hospital, Perth, Australia
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Davies G, Stocks J, Thia LP, Hoo AF, Bush A, Aurora P, Brennan L, Lee S, Lum S, Cottam P, Miles J, Chudleigh J, Kirkby J, Balfour-Lynn IM, Carr SB, Wallis C, Wyatt H, Wade A. Pulmonary function deficits in newborn screened infants with cystic fibrosis managed with standard UK care are mild and transient. Eur Respir J 2017; 50:50/5/1700326. [PMID: 29122914 DOI: 10.1183/13993003.00326-2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 08/03/2017] [Indexed: 12/17/2022]
Abstract
With the advent of novel designer molecules for cystic fibrosis (CF) treatment, there is huge need for early-life clinical trial outcomes, such as infant lung function (ILF). We investigated the degree and tracking of ILF abnormality during the first 2 years of life in CF newborn screened infants.Forced expiratory volume in 0.5 s (FEV0.5), lung clearance index (LCI) and plethysmographic functional residual capacity were measured at ∼3 months, 1 year and 2 years in 62 infants with CF and 34 controls.By 2 years there was no significant difference in FEV0.5 z-score between CF and controls, whereas mean LCI z-score was 0.81 (95% CI 0.45-1.17) higher in CF. However, there was no significant association between LCI z-score at 2 years with either 3-month or 1-year results. Despite minimal average group changes in any ILF outcome during the second year of life, marked within-subject changes occurred. No child had abnormal LCI or FEV0.5 on all test occasions, precluding the ability to identify "high-risk" infants in early life.In conclusion, changes in lung function are mild and transient during the first 2 years of life in newborn screened infants with CF when managed according to a standardised UK treatment protocol. Their potential role in tracking disease to later childhood will be ascertained by ongoing follow-up.
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Affiliation(s)
- Gwyneth Davies
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK .,Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Janet Stocks
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lena P Thia
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ah-Fong Hoo
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Andrew Bush
- Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Paul Aurora
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lucy Brennan
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Simon Lee
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sooky Lum
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Philippa Cottam
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Joanne Miles
- Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jane Chudleigh
- Dept of Child Health, King's College London, London, UK.,Dept of Child Health, City, University of London, London, UK
| | - Jane Kirkby
- Respiratory, Anaesthesia and Critical Care Section, Infection, Immunity, Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ian M Balfour-Lynn
- Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Siobhán B Carr
- Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.,Dept of Paediatric Respiratory Medicine, Royal London Hospital, London, UK
| | - Colin Wallis
- Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Hilary Wyatt
- Dept of Child Health, King's College London, London, UK
| | - Angie Wade
- Clinical Epidemiology, Nutrition and Biostatistics, Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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35
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Gauthier R, Cabon Y, Giroux-Metges MA, Du Boisbaudry C, Reix P, Le Bourgeois M, Chiron R, Molinari N, Saguintaah M, Amsallem F, Matecki S. Early follow-up of lung disease in infants with cystic fibrosis using the raised volume rapid thoracic compression technique and computed tomography during quiet breathing. Pediatr Pulmonol 2017; 52:1283-1290. [PMID: 28861941 DOI: 10.1002/ppul.23786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Among the different techniques used to monitor lung disease progression in infants with CF diagnosed by Newborn screening (NBS), raised volume-rapid thoracic compression (RVRTC) remains a promising tool. However, the need of sedation and positive pressure ventilation considerably limits its clinical use. We recently described a semi-quantitative method to evaluate air trapping by chest tomography during quite breathing without sedation (CTqb score). This parameter is the radiological sign of airway obstruction and could be also used for lung disease follow-up in infants with CF. However, its discriminative power compared with RVRTC and correlation with lung function parameters are not known. OBJECTIVES To compare the discriminative powers of the CTqb score and RVRTC parameters and to determine their correlation during the first year of life of infants with CF. METHODS In this multicenter longitudinal study, infants with CF diagnosed by NBS underwent RVRTC and CT during quite breathing at 10 ± 4 weeks (n = 30) and then at 13 ± 1 months of age (n = 28). RESULTS All RVRTC parameters and the CTqb score remained stable between evaluations. The CTqb score showed a higher discriminative power than forced expiratory volume in 0.5 s (FEV0.5 ; the main RVRTC parameter) at both visits (66% and 50% of abnormal values vs 30% and 28%, respectively). No correlation was found between CTqb score and, the different RVRTC parameters or the plethysmographic functional residual capacity, indicating that they evaluate different aspect of CF lung disease.
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Affiliation(s)
- Rémi Gauthier
- Pediatric Functional Exploration Unit, Hôpital Nord, Amiens University Hospital, Amiens, France
| | - Yann Cabon
- Medical Informatics Department, Montpellier University Hospital, Montpellier, France
| | | | | | - Phillipe Reix
- Pediatric Functional Exploration Unit, CF Center Lyon University Hospital, Paris, France
| | - Muriel Le Bourgeois
- Pediatric Functional Exploration Unit and CF Center, Necker University Hospital, Paris, France
| | - Raphael Chiron
- Cystic Fibrosis Center, Montpellier University Hospital, France
| | - Nicolas Molinari
- Medical Informatics Department, Montpellier University Hospital, Montpellier, France
| | - Magali Saguintaah
- Pediatric Imaging Department, Montpellier University Hospital, France
| | - Francis Amsallem
- Pediatric Functional Exploration Unit, UMR CNRS 9214-Inserm, U1046, Montpellier University Hospital, Montpellier, France
| | - Stefan Matecki
- Pediatric Functional Exploration Unit, UMR CNRS 9214-Inserm, U1046, Montpellier University Hospital, Montpellier, France
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Gunasekara L, Al-Saiedy M, Green F, Pratt R, Bjornson C, Yang A, Michael Schoel W, Mitchell I, Brindle M, Montgomery M, Keys E, Dennis J, Shrestha G, Amrein M. Pulmonary surfactant dysfunction in pediatric cystic fibrosis: Mechanisms and reversal with a lipid-sequestering drug. J Cyst Fibros 2017; 16:565-572. [DOI: 10.1016/j.jcf.2017.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/31/2017] [Accepted: 04/25/2017] [Indexed: 01/21/2023]
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Stanojevic S, Davis SD, Retsch-Bogart G, Webster H, Davis M, Johnson RC, Jensen R, Pizarro ME, Kane M, Clem CC, Schornick L, Subbarao P, Ratjen FA. Progression of Lung Disease in Preschool Patients with Cystic Fibrosis. Am J Respir Crit Care Med 2017; 195:1216-1225. [PMID: 27943680 DOI: 10.1164/rccm.201610-2158oc] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Implementation of intervention strategies to prevent lung damage in early cystic fibrosis (CF) requires objective outcome measures that capture and track lung disease. OBJECTIVES To define the utility of the Lung Clearance Index (LCI), measured by multiple breath washout, as a means to track disease progression in preschool children with CF. METHODS Children with CF between the ages of 2.5 and 6 years with a confirmed diagnosis of CF and age-matched healthy control subjects were enrolled at three North American CF centers. Multiple breath washout tests were performed at baseline, 1, 3, 6, and 12 months to mimic time points chosen in clinical care and interventional trials; spirometry was also conducted. A generalized linear mixed-effects model was used to distinguish LCI changes associated with normal growth and development (i.e., healthy children) from the progression of CF lung disease. MEASUREMENTS AND MAIN RESULTS Data were collected on 156 participants with 800 LCI measurements. Although both LCI and spirometry discriminated health from disease, only the LCI identified significant deterioration of lung function in CF over time. The LCI worsened during cough episodes and pulmonary exacerbations, whereas similar symptoms in healthy children were not associated with increased LCI values. CONCLUSIONS LCI is a useful marker to track early disease progression and may serve as a tool to guide therapies in young patients with CF.
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Affiliation(s)
- Sanja Stanojevic
- 1 Division of Respiratory Medicine, and.,2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Stephanie D Davis
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - George Retsch-Bogart
- 4 Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Hailey Webster
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Miriam Davis
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robin C Johnson
- 4 Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Renee Jensen
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Maria Ester Pizarro
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada.,5 Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mica Kane
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Charles C Clem
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Leah Schornick
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Padmaja Subbarao
- 1 Division of Respiratory Medicine, and.,2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Felix A Ratjen
- 1 Division of Respiratory Medicine, and.,2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
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Ranganathan SC, Hall GL, Sly PD, Stick SM. Early Lung Disease in Infants and Preschool Children with Cystic Fibrosis. What Have We Learned and What Should We Do about It? Am J Respir Crit Care Med 2017; 195:1567-1575. [PMID: 27911585 PMCID: PMC6850725 DOI: 10.1164/rccm.201606-1107ci] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 12/01/2016] [Indexed: 12/27/2022] Open
Abstract
The past decade has seen significant advances in understanding of the pathogenesis and progression of lung disease in cystic fibrosis (CF). Pulmonary inflammation, infection, and structural lung damage manifest very early in life and are prevalent among preschool children and infants, often in the absence of symptoms or signs. Early childhood represents a pivotal period amenable to intervention strategies that could delay or prevent the onset of lung damage and alter the longer-term clinical trajectory for individuals with CF. This review summarizes what we have learned about early lung disease in children with CF and discusses the implications for future clinical practice and research.
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Affiliation(s)
- Sarath C. Ranganathan
- Department of Respiratory Medicine, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infection and Immunity, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Graham L. Hall
- Telethon Kids Institute, Perth, Western Australia, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Peter D. Sly
- Department of Respiratory and Sleep Medicine, Children’s Health Queensland, South Brisbane, Queensland, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia; and
| | - Stephen M. Stick
- Telethon Kids Institute, Perth, Western Australia, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - on behalf of the Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST-CF)
- Department of Respiratory Medicine, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infection and Immunity, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Telethon Kids Institute, Perth, Western Australia, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Children’s Health Queensland, South Brisbane, Queensland, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia; and
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
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Pittman JE, Noah H, Calloway HE, Davis SD, Leigh MW, Drumm M, Sagel SD, Accurso FJ, Knowles MR, Sontag MK. Early childhood lung function is a stronger predictor of adolescent lung function in cystic fibrosis than early Pseudomonas aeruginosa infection. PLoS One 2017; 12:e0177215. [PMID: 28505188 PMCID: PMC5432103 DOI: 10.1371/journal.pone.0177215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/24/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Pseudomonas aeruginosa has been suggested as a major determinant of poor pulmonary outcomes in cystic fibrosis (CF), although other factors play a role. Our objective was to investigate the association of early childhood Pseudomonas infection on differences in lung function in adolescence with CF. METHODS Two populations of subjects with CF were studied: from the Gene Modifier Study (GMS), 346 F508del homozygotes with severe vs. mild adolescent lung disease, and from the Colorado Newborn Screen Study (NBS) 172 subjects diagnosed with CF by newborn screening. Associations of Pseudomonas infection and lung function in early childhood with lung function in adolescence were investigated using multivariate linear regression analyses. RESULTS Among GMS subjects, those with severe adolescent lung disease had worse lung function in childhood (FEV1 25 percentage points lower) compared to subjects with mild adolescent lung disease, regardless of early childhood Pseudomonas status. Among NBS subjects, those with lowest adolescent lung function had significantly lower early childhood lung function and faster rate of decline in FEV1 than subjects with highest adolescent lung function; early Pseudomonas infection was not associated with rate of FEV1 decline. The strongest predictor of adolescent lung function was early childhood lung function. Subjects with a higher percentage of cultures positive for Pseudomonas before age 6 or a lower BMI at 2-4 years old also had lower adolescent lung function, though these associations were not as strong as with early childhood lung function. CONCLUSIONS In separate analyses of two distinct populations of subjects with CF, we found a strong correlation between lower lung function in early childhood and adolescence, regardless of early childhood Pseudomonas status. Factors in addition to early Pseudomonas infection have a strong impact on lung function in early childhood in CF. Further exploration may identify novel underlying genetic or environmental factors that predispose children with CF to early loss of lung function.
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Affiliation(s)
- Jessica E. Pittman
- Washington University School of Medicine, Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, St. Louis, MO, United States of America
| | - Hannah Noah
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Hollin E. Calloway
- Stanford University School of Medicine, Department of Otolaryngology Head & Neck Surgery, Palo Alto, CA, United States of America
| | - Stephanie D. Davis
- Indiana University School of Medicine/Riley Hospital for Children, Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indianapolis, IN, United States of America
| | - Margaret W. Leigh
- University of North Carolina at Chapel Hill, Department of Pediatrics, Chapel Hill, NC, United States of America
- University of North Carolina at Chapel Hill, Marisco Lung Institute, Chapel Hill, NC, United States of America
| | - Mitchell Drumm
- Departments of Pediatrics and Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, United States of America
| | - Scott D. Sagel
- Department of Pediatrics, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Frank J. Accurso
- Department of Pediatrics, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Michael R. Knowles
- University of North Carolina at Chapel Hill, Marisco Lung Institute, Chapel Hill, NC, United States of America
| | - Marci K. Sontag
- Department of Pediatrics, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, United States of America
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De Boeck K, Haarman E, Hull J, Lands LC, Moeller A, Munck A, Riethmüller J, Tiddens H, Volpi S, Leadbetter J, Charlton B, Malfroot A. Inhaled dry powder mannitol in children with cystic fibrosis: A randomised efficacy and safety trial. J Cyst Fibros 2017; 16:380-387. [DOI: 10.1016/j.jcf.2017.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/21/2016] [Accepted: 02/03/2017] [Indexed: 11/30/2022]
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Abstract
BACKGROUND People with cystic fibrosis are at an increased risk of fat-soluble vitamin deficiency including vitamin E. Vitamin E deficiency can cause a host of conditions such as haemolytic anaemia, cerebellar ataxia and cognitive difficulties. Vitamin E supplementation is widely recommended in cystic fibrosis and aims to ameliorate this deficiency. This is an updated version of the review. OBJECTIVES To determine the effects of any level of vitamin E supplementation on the frequency of vitamin E deficiency disorders in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Group's Cystic Fibrosis Trials Register and also searched international trial registers for any ongoing clinical trials that were not identified during our register search.Date of last search of the Register: 10 October 2016. Date of last search of international trial registers: 15 February 2017. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled trials comparing any preparation of vitamin E supplementation to placebo or no supplement, regardless of dosage or duration. DATA COLLECTION AND ANALYSIS Two authors extracted outcome data from each study (published information) and assessed the risk of bias of each included study. MAIN RESULTS Four studies with a total of 141 participants were included in the review, two of these were in children (aged six months to 14.5 years), and the other two did not specify participants' age. All studies used different formulations and doses of vitamin E for various durations of treatment (10 days to six months). Two studies compared the supplementation of fat-soluble as well as water-soluble formulations to no supplementation in different arms of the same study. A third study compared a water-soluble formulation to a placebo; and in the fourth study a fat-soluble formulation of vitamin E was assessed against placebo.At one month, three months and six months, water-soluble vitamin E significantly improved serum vitamin E levels compared with control: at one month, two studies, mean difference 17.66 (95% confidence interval 10.59 to 24.74); at three months, one study, mean difference 11.61 (95% confidence interval 4.77 to 18.45); and at six months, one study, mean difference 19.74 (95% confidence interval 13.48 to 26.00). At one month fat-soluble vitamin E significantly improved serum vitamin E levels compared with control: one month, two studies, mean difference 13.59 (95% CI 9.52 to 17.66). The findings at three months were imprecise; one study; mean difference 6.40 (95% confidence interval -1.45 to 14.25).None of the studies report the review's primary outcomes of vitamin E total lipid ratio or the incidence of vitamin E-specific deficiency disorders, or the secondary outcomes lung function or quality of life. Only one study, comparing water-soluble vitamin E with placebo, reported the secondary outcome of growth and nutritional status (weight), but the results are uncertain due to imprecision around the effect estimate.There was limited detail about randomisation and blinding in the included studies which compromises the quality of the evidence base for the review. The heterogeneous mix of the formulations with differing biovailabilities among these studies also limits the generalisability of the data to the wider cystic fibrosis population. AUTHORS' CONCLUSIONS Vitamin E supplementation led to an improvement in vitamin E levels in people with cystic fibrosis, although the studies may have been at risk of bias. No data on other outcomes of interest were available to allow conclusions about any other benefits of this therapy.In future, larger studies are needed, especially in people already being treated with enteric-coated pancreatic enzymes and supplemented with vitamin E, to look at more specific outcome measures such as vitamin E status, lung function and nutritional status. Future studies could also look at the optimal dose of vitamin E required to achieve maximal clinical effectiveness.
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Affiliation(s)
- Peter O Okebukola
- Johns Hopkins Bloomberg School of Public HealthDepartment of Health Policy and Management615 North Wolfe StreetBaltimoreMarylandUSA21205
| | - Sonal Kansra
- Sheffield Children's Hospital NHS TrustDepartment of Paediatric Respiratory MedicineWestern BankSheffieldUKS10 2TH
| | - Joanne Barrett
- Heart of England NHS Foundation TrustWest Midlands Adult Cystic Fibrosis CentreBordesley Green EastBirminghamUKB9 5SS
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Microbiome in the pathogenesis of cystic fibrosis and lung transplant-related disease. Transl Res 2017; 179:84-96. [PMID: 27559681 DOI: 10.1016/j.trsl.2016.07.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/26/2016] [Accepted: 07/27/2016] [Indexed: 01/01/2023]
Abstract
Significant advances in culture-independent methods have expanded our knowledge about the diversity of the lung microbial environment. Complex microorganisms and microbial communities can now be identified in the distal airways in a variety of respiratory diseases, including cystic fibrosis (CF) and the posttransplantation lung. Although there are significant methodologic concerns about sampling the lung microbiome, several studies have now shown that the microbiome of the lower respiratory tract is distinct from the upper airway. CF is a disease characterized by chronic airway infections that lead to significant morbidity and mortality. Traditional culture-dependent methods have identified a select group of pathogens that cause exacerbations in CF, but studies using bacterial 16S rRNA gene-based microarrays have shown that the CF microbiome is an intricate and dynamic bacterial ecosystem, which influences both host immune health and disease pathogenesis. These microbial communities can shift with external influences, including antibiotic exposure. In addition, there have been a number of studies suggesting a link between the gut microbiome and respiratory health in CF. Compared with CF, there is significantly less knowledge about the microbiome of the transplanted lung. Risk factors for bronchiolitis obliterans syndrome, one of the leading causes of death, include microbial infections. Lung transplant patients have a unique lung microbiome that is different than the pretransplanted microbiome and changes with time. Understanding the host-pathogen interactions in these diseases may suggest targeted therapies and improve long-term survival in these patients.
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Fayon M, Ladipo Y, Galodé F, Debelleix S, Reix P. Atteinte respiratoire précoce dans la mucoviscidose. Arch Pediatr 2016; 23:12S9-12S14. [DOI: 10.1016/s0929-693x(17)30057-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Britton LJ, Oates GR, Oster RA, Self ST, Troxler RB, Hoover WC, Gutierrez HH, Harris WT. Risk stratification model to detect early pulmonary disease in infants with cystic fibrosis diagnosed by newborn screening. Pediatr Pulmonol 2016; 51:1168-1176. [PMID: 27556254 PMCID: PMC5319853 DOI: 10.1002/ppul.23536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 06/17/2016] [Accepted: 07/08/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The clinical benefit of newborn screening (NBS) for cystic fibrosis (CF) has been primarily nutritional, with less overt respiratory impact. Identification of risk factors for infant CF lung disease could facilitate targeted interventions to improve pulmonary outcomes. METHODS This retrospective study evaluated socioeconomic information, clinical data, and results from routine infant pulmonary function testing (iPFT) of infants diagnosed with CF through NBS (N = 43) at a single CF center over a 4-year period (2008-2012). A five-item composite clinical score was developed and combined with socioeconomic indicators to facilitate identification of CF infants at increased risk of early-onset respiratory impairment. RESULTS Paternal education was positively associated with lung function (P = 0.02). Clinical score <7 (on a scale of 0-10) predicted diminished pulmonary measure (P < 0.005). Retrospective risk stratification by clinical score and paternal education identified CF infants at low, intermediate, or high risk of pulmonary disease. Forced expiratory volume (FEV0.5 %, mean ± SD) averaged 115 ± 19% in the low-risk group, 97 ± 17% in the intermediate-risk group, and 90 ± 8% in the high-risk group (P < 0.005). Results were similar for mid-expiratory flows (FEF25-75 %). Multiple regression analysis confirmed the predictive value of this risk stratification model of CF infant pulmonary health. CONCLUSION We combined socioeconomic and clinical data to risk-stratify CF infants for early-onset lung disease as quantified by iPFT. Our model showed significant differences in infant pulmonary function across risk groups. The developed tool offers an easily available, inexpensive, and non-invasive way to assess risk of respiratory decline in CF infants and identify those meriting targeted therapeutic attention. Pediatr Pulmonol. 2016;51:1168-1176. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Gabriela R Oates
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert A Oster
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Staci T Self
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert B Troxler
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Wynton C Hoover
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hector H Gutierrez
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
| | - William T Harris
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama.
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Darrah RJ, Mitchell AL, Campanaro CK, Barbato ES, Litman P, Sattar A, Hodges CA, Drumm ML, Jacono FJ. Early pulmonary disease manifestations in cystic fibrosis mice. J Cyst Fibros 2016; 15:736-744. [PMID: 27231029 DOI: 10.1016/j.jcf.2016.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 04/30/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Altered pulmonary function is present early in the course of cystic fibrosis (CF), independent of documented infections or onset of pulmonary symptoms. New initiatives in clinical care are focusing on detection and characterization of preclinical disease. Thus, animal models are needed which recapitulate the pulmonary phenotype characteristic of early stage CF. METHODS We investigated young CF mice to determine if they exhibit pulmonary pathophysiology consistent with the early CF lung phenotype. Lung histology and pulmonary mechanics were examined in 12- to 16-week-old congenic C57bl/6 F508del and R117H CF mice using a forced oscillation technique (flexiVent). RESULTS There were no significant differences in the resistance of the large airways. However, in both CF mouse models, prominent differences in the mechanical properties of the peripheral lung compartment were identified including decreased static lung compliance, increased elastance and increased tissue damping. CF mice also had distal airspace enlargement with significantly increased mean linear intercept distances. CONCLUSIONS An impaired ability to stretch and expand the peripheral lung compartment, as well as increased distances between gas exchange surfaces, were present in young CF mice carrying two independent Cftr mutations. This altered pulmonary histopathophysiology in the peripheral lung compartment, which develops in the absence of infection, is similar to the early lung phenotype of CF patients.
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Affiliation(s)
- Rebecca J Darrah
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States.
| | - Anna L Mitchell
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Cara K Campanaro
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Eric S Barbato
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Paul Litman
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Abdus Sattar
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Craig A Hodges
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Mitchell L Drumm
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Frank J Jacono
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, OH 44106, United States
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VanDevanter DR, Kahle JS, O’Sullivan AK, Sikirica S, Hodgkins PS. Cystic fibrosis in young children: A review of disease manifestation, progression, and response to early treatment. J Cyst Fibros 2016; 15:147-57. [DOI: 10.1016/j.jcf.2015.09.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 12/31/2022]
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Durupt S, Mazur S, Reix P. [Therapeutic advances in cystic fibrosis in 2014]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:77-86. [PMID: 25727661 DOI: 10.1016/j.pneumo.2014.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 11/03/2014] [Accepted: 11/08/2014] [Indexed: 06/04/2023]
Abstract
Twenty-five years after the cystic fibrosis (CF) gene identification, this discovery actually begins to benefit to patients. Increasing our knowledge on CFTR biology, as well as technical progress made in order to screen for new drugs have made therapeutic strategies move an important step forward. It is likely that in the forthcoming years, the panel of molecules available for CF patients will be larger, with new activators and potentiators. The disease by itself may consequently change in its natural history. CF is an example of the so-called personalized medicine, aiming to fit treatment according to patient's genetic background. Ongoing clinical trials may enlarge the actually limited eligible number of CF patients for new drugs such as ivacaftor. Beyond this exciting and promising new therapeutic approach, one may not push symptomatic treatments on the side. Improvements have been made for inhaled antibiotics administration, aiming to simplify patient's life; clinical trials using new molecules able to liquefy mucus or with anti-inflammatory properties are actually underway. One important next step in the care for CF will be to design and conduct early intervention trials in CF infants. Newborn screening program have been widely implanted around the word, and cohorts studies have shown that both functional and structural abnormalities occurred very early, making the therapeutic window of opportunity tight.
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Affiliation(s)
- S Durupt
- Service de médecine interne, centre de référence de la mucoviscidose, centre adulte de ressource et de compétences de la mucoviscidose, centre hospitalier Lyon-Sud, 69495 Pierre-Bénite cedex, France
| | - S Mazur
- Équipe EMET, UMR 5558, service de pédiatrie, d'allergologie et de pneumologie, centre de référence de la mucoviscidose, centre pédiatrique de ressources et de compétences de la mucoviscidose, hôpital femme-mère-enfant, 59, boulevard Pinel, 69677 Bron cedex, France
| | - P Reix
- Équipe EMET, UMR 5558, service de pédiatrie, d'allergologie et de pneumologie, centre de référence de la mucoviscidose, centre pédiatrique de ressources et de compétences de la mucoviscidose, hôpital femme-mère-enfant, 59, boulevard Pinel, 69677 Bron cedex, France.
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Reix P, Matecki S, Fayon M. Atteinte respiratoire précoce chez les nourrissons atteints de mucoviscidose. Outils de diagnostic et pistes pour la prise en charge. Rev Mal Respir 2016; 33:102-16. [DOI: 10.1016/j.rmr.2015.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/17/2015] [Indexed: 11/28/2022]
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Matecki S, Kent L, de Boeck K, Le Bourgeois M, Zielen S, Braggion C, Arets H, Bradley J, Davis S, Sermet I, Reix P. Is the raised volume rapid thoracic compression technique ready for use in clinical trials in infants with cystic fibrosis? J Cyst Fibros 2016; 15:10-20. [DOI: 10.1016/j.jcf.2015.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/12/2015] [Accepted: 03/27/2015] [Indexed: 11/29/2022]
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Affiliation(s)
- Thida Ong
- 1 Department of Pediatrics, University of Washington, Seattle, Washington.,2 Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington; and
| | - Bonnie W Ramsey
- 1 Department of Pediatrics, University of Washington, Seattle, Washington.,3 Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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