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Merlo CA, Thorat T, DerSarkissian M, McGarry LJ, Nguyen C, Gu YM, Healy J, Rubin JL, Brookhart MA. Long-term impact of ivacaftor on mortality rate and health outcomes in people with cystic fibrosis. Thorax 2024; 79:925-933. [PMID: 38937105 DOI: 10.1136/thorax-2023-220558] [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: 06/06/2023] [Accepted: 04/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Ivacaftor (IVA) has been shown to improve lung function and other clinical outcomes in people with cystic fibrosis (CF). A decade of real-world IVA availability has enabled the examination of long-term outcomes with this treatment. This retrospective, longitudinal cohort study investigated the impact of IVA on mortality rate and health outcomes among people with CF in the US. METHODS Data from the US CF Foundation Patient Registry from January 2010 to December 2019 were analysed. The IVA-treated cohort included people with a CF transmembrane conductance regulator (CFTR) gating mutation (excluding R117H); age-matched comparator cohort included people with a F508del and a minimal function CFTR mutation who had no prior CFTR modulator treatment. Baseline characteristics were balanced between cohorts using standardised mortality ratio weighting generated from propensity scores. Outcomes of interest were overall survival, lung transplant, percent predicted forced expiratory volume in 1 s (ppFEV1), body mass index (BMI), pulmonary exacerbations (PEx), outpatient visits and hospitalisations. FINDINGS Over a maximum follow-up of 7.9 years, the IVA-treated cohort (N=736) had lower rates of mortality (hazard ratio [HR] (95% CI): 0.22 (0.09 to 0.45)), lung transplant (HR: 0.11 (95% CI 0.02 to 0.28)), PEx (rate ratio: 0.49 (95% CI 0.42 to 0.55)) and all-cause hospitalisations (rate ratio: 0.50 (95% CI 0.43 to 0.56)) as well as better lung function (mean difference in ppFEV1: 8.46 (95% CI 7.34 to 9.75)) and higher BMI/BMI z-scores (mean difference 1.20 (95% CI 0.92 to 1.71) kg/m2 and 0.27 (95% CI 0.25 to 0.40), respectively) than the comparator cohort (N=733). INTERPRETATION Our analysis suggests that IVA provides sustained clinical benefits in people with CF over a follow-up period of approximately 8 years. These findings reinforce the existing real-world evidence that IVA can slow disease progression and decrease the healthcare burden of CF over the long term.
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Affiliation(s)
| | - Teja Thorat
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | | | - Lisa J McGarry
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | | | - Yuqian M Gu
- Analysis Group Inc, Los Angeles, California, USA
| | - Joe Healy
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
| | - Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts, USA
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Saiman L, Waters V, LiPuma JJ, Hoffman LR, Alby K, Zhang SX, Yau YC, Downey DG, Sermet-Gaudelus I, Bouchara JP, Kidd TJ, Bell SC, Brown AW. Practical Guidance for Clinical Microbiology Laboratories: Updated guidance for processing respiratory tract samples from people with cystic fibrosis. Clin Microbiol Rev 2024; 37:e0021521. [PMID: 39158301 PMCID: PMC11391703 DOI: 10.1128/cmr.00215-21] [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: 08/20/2024] Open
Abstract
SUMMARYThis guidance presents recommendations for clinical microbiology laboratories for processing respiratory samples from people with cystic fibrosis (pwCF). Appropriate processing of respiratory samples is crucial to detect bacterial and fungal pathogens, guide treatment, monitor the epidemiology of cystic fibrosis (CF) pathogens, and assess therapeutic interventions. Thanks to CF transmembrane conductance regulator modulator therapy, the health of pwCF has improved, but as a result, fewer pwCF spontaneously expectorate sputum. Thus, the collection of sputum samples has decreased, while the collection of other types of respiratory samples such as oropharyngeal and bronchoalveolar lavage samples has increased. To optimize the detection of microorganisms, including Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, and Burkholderia cepacia complex; other less common non-lactose fermenting Gram-negative bacilli, e.g., Stenotrophomonas maltophilia, Inquilinus, Achromobacter, Ralstonia, and Pandoraea species; and yeasts and filamentous fungi, non-selective and selective culture media are recommended for all types of respiratory samples, including samples obtained from pwCF after lung transplantation. There are no consensus recommendations for laboratory practices to detect, characterize, and report small colony variants (SCVs) of S. aureus, although studies are ongoing to address the potential clinical impact of SCVs. Accurate identification of less common Gram-negative bacilli, e.g., S. maltophilia, Inquilinus, Achromobacter, Ralstonia, and Pandoraea species, as well as yeasts and filamentous fungi, is recommended to understand their epidemiology and clinical importance in pwCF. However, conventional biochemical tests and automated platforms may not accurately identify CF pathogens. MALDI-TOF MS provides excellent genus-level identification, but databases may lack representation of CF pathogens to the species-level. Thus, DNA sequence analysis should be routinely available to laboratories for selected clinical circumstances. Antimicrobial susceptibility testing (AST) is not recommended for every routine surveillance culture obtained from pwCF, although selective AST may be helpful, e.g., for unusual pathogens or exacerbations unresponsive to initial therapy. While this guidance reflects current care paradigms for pwCF, recommendations will continue to evolve as CF research expands the evidence base for laboratory practices.
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Affiliation(s)
- Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
- Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Valerie Waters
- Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - John J LiPuma
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lucas R Hoffman
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Kevin Alby
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Sean X Zhang
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yvonne C Yau
- Division of Microbiology, Department of Paediatric Laboratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, Ireland
| | | | - Jean-Philippe Bouchara
- University of Angers-University of Brest, Infections Respiratoires Fongiques, Angers, France
| | - Timothy J Kidd
- Microbiology Division, Pathology Queensland Central Laboratory, The University of Queensland, Brisbane, Australia
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia
| | - Scott C Bell
- The Prince Charles Hospital, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- The Translational Research Institute, Brisbane, Australia
| | - A Whitney Brown
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
- Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, Virginia, USA
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Bugenhagen SM, Grant JCE, Rosenbluth DB, Bhalla S. Update on the Role of Chest Imaging in Cystic Fibrosis. Radiographics 2024; 44:e240008. [PMID: 39172707 DOI: 10.1148/rg.240008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Cystic fibrosis is a genetic disease with multisystem involvement and associated morbidity and mortality that are most directly related to progressive lung disease. The hallmark findings of cystic fibrosis in the lungs are chronic inflammation and infection, leading to progressive loss of pulmonary function and often requiring lung transplant. Predominant lung findings include mucous plugging, bronchiectasis, and air trapping, often with associated atelectasis, consolidation, and emphysema; these findings form the basis of several clinical scoring systems that are used for imaging assessment. Recently, there have been major breakthroughs in the pharmacologic management of cystic fibrosis, including highly effective modulator therapies that directly target the underlying cystic fibrosis transmembrane conductance regulator molecular defect, often leading to remarkable improvements in lung function and quality of life with corresponding significant improvements in imaging markers. The authors review current guidelines regarding cystic fibrosis with respect to disease monitoring, identifying complications, and managing advanced lung disease. In addition, they discuss the evolving role of imaging, including current trends, emerging technologies, and proposed updates to imaging guidelines endorsed by international expert committees on cystic fibrosis, which favor increased use of cross-sectional imaging to enable earlier detection of structural changes in early disease and more sensitive detection of acute changes in advanced disease. It is important for radiologists to be familiar with these trends and updates so that they can most effectively assist clinicians in guiding the management of patients with cystic fibrosis in all stages of disease. ©RSNA, 2024.
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Affiliation(s)
- Scott M Bugenhagen
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
| | - Jacob C E Grant
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
| | - Daniel B Rosenbluth
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
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Tung NWH, Edmondson C, Westrupp N, Rosenthal M, Davies JC. Neutrophil-to-lymphocyte ratio as a biomarker of acute pulmonary exacerbations in children with cystic fibrosis: a retrospective cohort study. Arch Dis Child 2024; 109:748-754. [PMID: 38876505 DOI: 10.1136/archdischild-2024-327056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/30/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Neutrophils are key contributors to chronic airway inflammation in cystic fibrosis (CF) lung disease, although airway and blood-based neutrophil markers are seldom used. The neutrophil-to-lymphocyte ratio (NLR) is an accessible biomarker, the clinical utility of which has not been adequately studied. OBJECTIVE This study aimed to investigate the characteristics of the NLR in children with CF and its correlations with acute pulmonary exacerbations and spirometry. DESIGN A previous study had collected clinical data from children with CF for a 3-year period between 2016 and 2021. Retrospectively, NLR values were categorised according to patients' clinical status during blood sample collection as 'stable', 'acute pulmonary exacerbation' or 'elective admission for chronic clinical concern'. MAIN OUTCOME MEASURES Demographic characteristics associated with the NLR; changes in NLR values in relation to clinical status; relationship between NLR and lung function. RESULTS 141 children with CF were included. NLR values during clinical stability were higher in females and increased with age. For children admitted for intravenous antibiotics, NLR values significantly increased from clinical stability (median (IQR)=1.13 (0.75-1.51)) to acute pulmonary exacerbations (median (IQR)=1.50 (0.96-2.65), p=0.001), but similar changes were not observed in elective admissions. The NLR was not associated with lung function. CONCLUSIONS The NLR demonstrated associations with clinical status in children with CF with significant elevations during acute pulmonary exacerbations. While its utility as a single-marker measure is limited, monitoring the NLR over time may help identify periods of increased inflammation.
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Affiliation(s)
| | - Claire Edmondson
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Nicole Westrupp
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark Rosenthal
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jane C Davies
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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Almulhem M, Ward C, Haq I, Gray RD, Brodlie M. Definitions of pulmonary exacerbation in people with cystic fibrosis: a scoping review. BMJ Open Respir Res 2024; 11:e002456. [PMID: 39147400 PMCID: PMC11331921 DOI: 10.1136/bmjresp-2024-002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/17/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Pulmonary exacerbations (PExs) are clinically important in people with cystic fibrosis (CF). Multiple definitions have been used for PEx, and this scoping review aimed to identify the different definitions reported in the literature and to ascertain which signs and symptoms are commonly used to define them. METHODS A search was performed using Embase, MEDLINE, Cochrane Library, Scopus and CINAHL. All publications reporting clinical trials or prospective observational studies involving definitions of PEx in people with CF published in English from January 1990 to December 2022 were included. Data were then extracted for qualitative thematic analysis. RESULTS A total of 14 039 records were identified, with 7647 titles and abstracts screened once duplicates were removed, 898 reviewed as full text and 377 meeting the inclusion criteria. Pre-existing definitions were used in 148 publications. In 75% of papers, an objective definition was used, while 25% used a subjective definition, which subcategorised into treatment-based definitions (76%) and those involving clinician judgement (24%). Objective definitions were subcategorised into three groups: those based on a combination of signs and symptoms (50%), those based on a predefined combination of signs and symptoms plus the initiation of acute treatment (47%) and scores involving different clinical features each with a specific weighting (3%). The most common signs and symptoms reported in the definitions were, in order, sputum production, cough, lung function, weight/appetite, dyspnoea, chest X-ray changes, chest sounds, fever, fatigue or lethargy and haemoptysis. CONCLUSION We have identified substantial variation in the definitions of PEx in people with CF reported in the literature. There is a requirement for the development of internationally agreed-upon, standardised and validated age-specific definitions. Such definitions would allow comparison between studies and effective meta-analysis to be performed and are especially important in the highly effective modulator therapy era in CF care.
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Affiliation(s)
- Maryam Almulhem
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- College of Applied Medical Sciences, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Christopher Ward
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Iram Haq
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Robert D Gray
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Hilliam Y, Armbruster CR, Rapsinski GJ, Marshall CW, Moore J, Koirala J, Krainz L, Gaston JR, Cooper VS, Lee SE, Bomberger JM. Cystic fibrosis pathogens persist in the upper respiratory tract following initiation of elexacaftor/tezacaftor/ivacaftor therapy. Microbiol Spectr 2024; 12:e0078724. [PMID: 38916354 PMCID: PMC11302335 DOI: 10.1128/spectrum.00787-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024] Open
Abstract
Elexacaftor/tezacaftor/ivacaftor (ETI) therapy has revolutionized the treatment of cystic fibrosis (CF) for most affected individuals but the effects of treatment on sinus microbiota are still unknown. Changes to the airway microbiota in CF are associated with disease state and alterations to the bacterial community after ETI initiation may require changes to clinical management regimens. We collected sinus swab samples from the middle meatus in an observational study of 38 adults with CF and chronic rhinosinusitis (CRS) from 2017 to 2021 and captured the initiation of ETI therapy. We performed 16S and custom amplicon sequencing to characterize the sinus microbiota pre- and post-ETI. Real-time quantitative PCR (RT-qPCR) was performed to estimate total bacterial abundance. Sinus samples from people with CF (pwCF) clustered into three community types, dependent on the dominant bacterial organism: a Pseudomonas-dominant, Staphylococcus-dominant, and mixed dominance cluster. Shannon's diversity index was low and not significantly altered post-ETI. Total bacterial load was not significantly lowered post-ETI. Pseudomonas spp. abundance was significantly reduced post-ETI, but eradication was not observed. Staphylococcus spp. became the dominant organism in most individuals post-ETI and we showed the presence of methicillin-resistant Staphylococcus aureus (MRSA) in the sinus both pre- and post-ETI. We also demonstrated that the sinus microbiome is predictive of the presence of Pseudomonas spp., Staphylococcus spp., and Serratia spp. in the sputum. Pseudomonas spp. and Staphylococcus spp., including MRSA, persist in the sinuses of pwCF after ETI therapy, indicating that these pathogens will continue to be important in CF airway disease management in the era of highly effective modulator therapies (HEMT).IMPORTANCEHighly effective modulator therapies (HEMT), such as elexacaftor/tezacaftor/ivacaftor (ETI), for cystic fibrosis (CF) have revolutionized patient care and quality of life for most affected individuals. The effects of these therapies on the microbiota of the airways are still unclear, though work has already been published on changes to microbiota in the sputum. Our study presents evidence for reduced relative abundance of Pseudomonas spp. in the sinuses following ETI therapy. We also show that Staphylococcus spp. becomes the dominant organism in the sinus communities of most individuals in this cohort after ETI therapy. We identified methicillin-resistant Staphylococcus aureus (MRSA) in the sinus microbiota both pre- and post-therapy. These findings demonstrate that pathogen monitoring and treatment will remain a vital part of airway disease management for people with cystic fibrosis (pwCF) in the era of HEMT.
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Affiliation(s)
- Yasmin Hilliam
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Catherine R. Armbruster
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Glenn J. Rapsinski
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - John Moore
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Junu Koirala
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Leah Krainz
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jordan R. Gaston
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vaughn S. Cooper
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stella E. Lee
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jennifer M. Bomberger
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Winiarska HM, Springer D, Wojtaś F, Wysocka E, Cofta S. CFTR Modulators Therapy Efficacy in Reducing Cystic Fibrosis (CF) Exacerbation and Improving Selected Spirometry Parameters: A Real-Life Study in a Single-Centre Polish Population. J Clin Med 2024; 13:4491. [PMID: 39124756 PMCID: PMC11312460 DOI: 10.3390/jcm13154491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/10/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Cystic fibrosis is a genetically determined disease that significantly influences and shortens life. Treatment with CFTR modulators (CFTR-T) is a new hope for patients. It can change the predictive values of a poor prognosis (e.g., exacerbation rate and FEV1 value). The aim of the study was to analyse exacerbation incidence and spirometry data before and after one year (+/- 2 weeks) of CFTR-T in 85 CF patients at the CF Centre in Poznań. To our knowledge, this is the first analysis of CFTR-T efficiency in the Central-Eastern Europe population. Methods: We retrospectively analysed the spirometry and exacerbation data of 85 CF adult patients (both men and women), who in the middle of 2022 began treatment with CFTR modulators. Results: The one-year ratio of hospitalisation caused by severe exacerbations lowered from 1.25 to 0.21 per patient per year. We also saw a 66% decline in ambulatory exacerbations. The median FEV1% increased by 9.60% in absolute values and by 460 mL. Even in the group with very severe obstruction (FEV1 < 35%), there was an increase in median FEV1% of 5.9 in absolute values. We also proved the increase in FVC% (median 17.10% in absolute value and 600 mL) in the study group. Conclusions: After one year of treatment, an impressive improvement was observed in two important predictive values of poor prognosis: exacerbation rate and FEV1 values. Further observation is needed to determine how long the improvement will be present and its influence on quality of life and life expectancy.
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Affiliation(s)
- Hanna M. Winiarska
- Department of Pulmonology, Allergology and Pulmonary Oncology, Poznan University of Medical Sciences, 84 Szamarzewskiego St, 60-569 Poznań, Poland; (D.S.); (F.W.); (S.C.)
| | - Daria Springer
- Department of Pulmonology, Allergology and Pulmonary Oncology, Poznan University of Medical Sciences, 84 Szamarzewskiego St, 60-569 Poznań, Poland; (D.S.); (F.W.); (S.C.)
| | - Filip Wojtaś
- Department of Pulmonology, Allergology and Pulmonary Oncology, Poznan University of Medical Sciences, 84 Szamarzewskiego St, 60-569 Poznań, Poland; (D.S.); (F.W.); (S.C.)
| | - Ewa Wysocka
- Chair and Department of Laboratory Diagnostics, Poznan University of Medical Sciences, 84 Szamarzewskiego St, 60-569 Poznań, Poland;
| | - Szczepan Cofta
- Department of Pulmonology, Allergology and Pulmonary Oncology, Poznan University of Medical Sciences, 84 Szamarzewskiego St, 60-569 Poznań, Poland; (D.S.); (F.W.); (S.C.)
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8
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Gill ER, Goss CH, Sagel SD, Wright ML, Horner SD, Zuñiga JA. Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale. BMC Pulm Med 2024; 24:360. [PMID: 39049032 PMCID: PMC11271016 DOI: 10.1186/s12890-024-03148-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 07/03/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. METHODS A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. RESULTS A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. CONCLUSION Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.
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Affiliation(s)
- Eliana R Gill
- Division of Biobehavioral Nursing and Health Informatics, Department of Nursing, University of Washington, Seattle, WA, USA.
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michelle L Wright
- The University of Texas at Austin School of Nursing, Austin, TX, USA
| | - Sharon D Horner
- The University of Texas at Austin School of Nursing, Austin, TX, USA
| | - Julie A Zuñiga
- The University of Texas at Austin School of Nursing, Austin, TX, USA
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9
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Schechter MS, Ostrenga JS, Cromwell EA, Ren CL, Fink AK, Sanders DB, Morgan WJ. Treatment of small as well as large declines in lung function enhances recovery to baseline in people with CF. Pediatr Pulmonol 2024. [PMID: 38995116 DOI: 10.1002/ppul.27176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/01/2024] [Accepted: 07/03/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND The benefit of antibiotic treatment of acute drops in FEV1 percent predicted (FEV1pp) has been clearly established, but data from the early 2000s showed inconsistent treatment. Further, there is no empirical evidence for what magnitude of drop is clinically significant. METHODS We used data from the CF Foundation Patient Registry (CFFPR) from 2016 to 2019 to determine the association between treatment (any IV antibiotics, only oral or newly prescribed inhaled antibiotics, or no antibiotic therapy) following a decline of ≥5% from baseline FEV1pp and return to 100% baseline FEV1pp days using multivariable logistic regression including an interaction between the magnitude of decline and treatment category. RESULTS Overall, 16,495 PWCF had a decline: 16.5% were treated with IV antibiotics, 25.0% non-IV antibiotics, and 58.5% received no antibiotics. Antibiotic treatment was more likely for those with lower lung function, history of a positive PA culture, older age and larger FEV1 decline (p < 0.001). Treatment with IV antibiotics or oral/inhaled antibiotics was associated with a higher odds of recovery to baseline compared to no treatment across all levels of decline, including declines of 5%-10%. CONCLUSIONS A large proportion of acute drops in FEV1pp continue to be untreated, especially in younger patients and those with higher baseline lung function. Acute drops as small as 5% predicted are less likely to be recovered if antibiotic treatment is not prescribed. These findings suggest the need for more aggressive antimicrobial treatment of acute drops in FEV1, including those of a magnitude previously believed to be associated with self-recovery.
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Affiliation(s)
- Michael S Schechter
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | - Clement L Ren
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
- National Organization for Rare Disorders, Washington, District of Columbia, USA
| | - D B Sanders
- Indiana University., Indianapolis, Indiana, USA
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10
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Kazmerski TM, Moy C, Aliaj E, Hudson J, Wright B, Poranski M, Sjoberg J, Taylor-Cousar JL, Georgiopoulos AM, Ladores SL, Trimble A, Tangpricha V, Khan FN, Ramasamy R, Leitner DV, West NE, Santos RD, Stransky OM, Wilson A, Keller A, Jain R. Prioritizing sexual and reproductive health research and care for people with cystic fibrosis: A 2023 workshop report from the Cystic Fibrosis Foundation Sexual Health, Reproduction, and Gender (SHARING) Research Working Group. J Cyst Fibros 2024; 23:639-646. [PMID: 38485603 DOI: 10.1016/j.jcf.2024.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 08/31/2024]
Abstract
BACKGROUND To address sexual and reproductive health (SRH) concerns among people with cystic fibrosis(PwCF), the CF Foundation created the Sexual Health, Reproduction, and Gender Research (SHARING) Working Group. This report summarizes CF community SRH research priorities and workshop discussions/future study planning. METHODS Pre-workshop, we distributed a community prioritization survey on CF SRH research/care. During the workshop, we used results and reviewed existing research to establish research priorities and design studies to address identified knowledge gaps. RESULTS A total of 303 respondents (85 % PwCF, 15 % caregivers) completed the survey. Highly-rated SRH topics were: 1) effects of CF modulator therapy on sex hormones; 2) effects of sex hormones on CF; 3) fertility; 4) pregnancy; and 5) SRH/mental health. Twenty-four workshop participants established the need for further research on sex hormones and CF, optimizing SRH care provision, and fertility/ART. CONCLUSION SRH is an important and emerging area in CF and thoughtful consideration of community perspectives can ensure that future research is relevant and responsive.
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Affiliation(s)
- Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, University Center, 120 Lytton Ave, Suite M060, Pittsburgh, PA 15213, United States; Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, PA 15213, United States.
| | - Christie Moy
- Cystic Fibrosis Foundation, Bethesda, MD 15213, United States.
| | - Enid Aliaj
- Cystic Fibrosis Foundation, Bethesda, MD 15213, United States.
| | - Jessica Hudson
- Cystic Fibrosis Foundation, Bethesda, MD 15213, United States.
| | - Brandon Wright
- Patient Partner, SHARING Research Working Group, Bethesda, MD 20814, United States
| | - Maddie Poranski
- Patient Partner, SHARING Research Working Group, Bethesda, MD 20814, United States
| | - Jacqui Sjoberg
- Patient Partner, SHARING Research Working Group, Bethesda, MD 20814, United States
| | | | - Anna M Georgiopoulos
- Massachusetts General Hospital, 55 Fruit St, Yawkey 6900, Boston, MA 02114, United States.
| | - Sigrid L Ladores
- School of Nursing, The University of Alabama at Birmingham, 1720 S. 2nd Ave., NB485-A, Birmingham, AL 35294, United States.
| | - Aaron Trimble
- Oregon Health and Sciences University, 3270 Southwest Pavilion Loop OHSU Physicians Pavilion, Portland, OR 97239, United States.
| | - Vin Tangpricha
- Department of Medicine, Emory University School of Medicine, 100 Woodruff Circle Atlanta, Atlanta, GA, 30322, United States.
| | - Farah Naz Khan
- University of Washington, 1959 NE Pacific St., Seattle, WA 98195, United States.
| | - Ranjith Ramasamy
- University of Miami, 1120 NW 14th Street, Miami, FL 33136, United States.
| | | | - Natalie E West
- The Johns Hopkins University, 1830 Building 5th Floor Pulmonary, Baltimore, MD 21287, United States.
| | - Rochelle Delos Santos
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, United States.
| | - Olivia M Stransky
- Center for Innovative Research on Gender Health Equity (CONVERGE), University of Pittsburgh, Pittsburgh, PA 15213, United States.
| | - Alexandra Wilson
- National Jewish Health, 1400 Jackson St. J318 Denver, CO 80206, United States.
| | - Ashley Keller
- University of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390-8558, United States.
| | - Raksha Jain
- University of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390-8558, United States.
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11
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Cogen JD, Quon BS. Update on the diagnosis and management of cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2024; 23:603-611. [PMID: 38677887 DOI: 10.1016/j.jcf.2024.04.004] [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: 01/09/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024]
Abstract
Pulmonary exacerbations in people with cystic fibrosis are associated with significant morbidity and reduced quality of life. Pulmonary exacerbation treatment guidelines, published by an expert panel assembled by the Cystic Fibrosis Foundation nearly 15 years ago, were primarily consensus-based as there were several gaps in the evidence base. In particular, limited evidence existed regarding optimal pulmonary exacerbation treatment strategies, including duration of antibiotic therapy, treatment location, antibiotic selection, and the role of systemic corticosteroids. Over the last decade, results from observational studies and large multi-center randomized controlled trials have begun to answer important questions related to pulmonary exacerbation treatment. This review focuses on the diagnosis, etiology, and changing epidemiology of pulmonary exacerbations, and also summarizes the most recent and up-to-date studies describing pulmonary exacerbation treatment. Finally, this review provides consideration for future pulmonary exacerbation research priorities, particularly in the current highly effective modulator therapy era.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.
| | - Bradley S Quon
- Division of Respiratory Medicine, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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12
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Gill ER, Dill C, Goss CH, Sagel SD, Wright ML, Horner SD, Zuñiga JA. Symptom phenotyping in people with cystic fibrosis during acute pulmonary exacerbations using machine-learning K-means clustering analysis. J Cyst Fibros 2024:S1569-1993(24)00077-8. [PMID: 38851922 DOI: 10.1016/j.jcf.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/15/2024] [Accepted: 05/23/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION People with cystic fibrosis (PwCF) experience frequent symptoms associated with chronic lung disease. A complication of CF is a pulmonary exacerbation (PEx), which is often preceded by an increase in symptoms and a decline in lung function. A symptom cluster is when two or more symptoms co-occur and are related; symptom clusters have contributed meaningful knowledge in other diseases. The purpose of this study is to discover symptom clustering patterns in PwCF during a PEx to illuminate symptom phenotypes and assess differences in recovery from PExs. METHODS This study was a secondary, longitudinal analysis (N = 72). Participants at least 10 years of age and being treated with intravenous antibiotics for a CF PEx were enrolled in the United States. Symptoms were collected on treatment days 1-21 using the CF Respiratory Symptom Diary (CFRSD)-Chronic Respiratory Symptom Score (CRISS). K-means clustering was computed on day 1 symptom data to detect clustering patterns. Linear regression and multi-level growth models were performed. RESULTS Symptoms significantly clustered based on severity: low symptom (LS)-phenotype (n = 42), high symptom (HS)-phenotype (n = 30). HS-phenotype had worse symptoms and CRISS scores (p< 0.01) than LS-phenotype. HS-phenotype was associated with spending 5 more nights in the hospital annually (p< 0.01) than LS-phenotype. HS-phenotype had worse symptoms over 21 days than LS-phenotype (p< 0.0001). CONCLUSION Symptoms significantly cluster on day 1 of a CF-PEx. PwCF with HS-phenotype spend more nights in the hospital and are less likely to experience the same resolution in symptoms by the end of PEx treatment than LS-phenotype.
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Affiliation(s)
- Eliana R Gill
- Division of Biobehavioral Nursing and Health Informatics, Department of Nursing, University of Washington, Seattle, WA, United States.
| | | | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States; Seattle Children's Research Institute, Seattle, WA, United States
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | | | - Sharon D Horner
- The University of Texas at Austin School of Nursing, Austin, Texas, United States
| | - Julie A Zuñiga
- The University of Texas at Austin School of Nursing, Austin, Texas, United States
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13
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Schwarz C, Bend J, Hebestreit H, Hogardt M, Hügel C, Illing S, Mainz JG, Rietschel E, Schmidt S, Schulte-Hubbert B, Sitter H, Wielpütz MO, Hammermann J, Baumann I, Brunsmann F, Dieninghoff D, Eber E, Ellemunter H, Eschenhagen P, Evers C, Gruber S, Koitschev A, Ley-Zaporozhan J, Düesberg U, Mentzel HJ, Nüßlein T, Ringshausen FC, Sedlacek L, Smaczny C, Sommerburg O, Sutharsan S, Vonberg RP, Weber AK, Zerlik J. [CF Lung Disease - a German S3 Guideline: Pseudomonas aeruginosa]. Pneumologie 2024; 78:367-399. [PMID: 38350639 DOI: 10.1055/a-2182-1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Cystic Fibrosis (CF) is the most common autosomal recessive genetic multisystemic disease. In Germany, it affects at least 8000 people. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the airway epithelial lining fluid which leads to reduction of the mucociliary clearance.Even if highly effective, CFTR modulator therapy has been available for some years and people with CF are getting much older than before, recurrent and chronic infections of the airways as well as pulmonary exacerbations still occur. In adult CF life, Pseudomonas aeruginosa (PA) is the most relevant pathogen in colonisation and chronic infection of the lung, leading to further loss of lung function. There are many possibilities to treat PA-infection.This is a S3-clinical guideline which implements a definition for chronic PA-infection and demonstrates evidence-based diagnostic methods and medical treatment in order to give guidance for individual treatment options.
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Affiliation(s)
- Carsten Schwarz
- Klinikum Westbrandenburg GmbH, Standort Potsdam, Deutschland
| | - Jutta Bend
- Mukoviszidose Institut gGmbH, Bonn, Deutschland
| | | | - Michael Hogardt
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Frankfurt, Deutschland
| | - Christian Hügel
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | | | - Jochen G Mainz
- Klinikum Westbrandenburg, Standort Brandenburg an der Havel, Universitätsklinikum der Medizinischen Hochschule Brandenburg (MHB), Brandenburg an der Havel, Deutschland
| | - Ernst Rietschel
- Medizinische Fakultät der Universität zu Köln, Mukoviszidose-Zentrum, Klinik und Poliklinik für Kinder- und Jugendmedizin, Köln, Deutschland
| | - Sebastian Schmidt
- Ernst-Moritz-Arndt Universität Greifswald, Kinderpoliklinik, Allgemeine Pädiatrie, Greifswald, Deutschland
| | | | - Helmut Sitter
- Philipps-Universität Marburg, Institut für theoretische Medizin, Marburg, Deutschland
| | - Marc Oliver Wielpütz
- Universitätsklinikum Heidelberg, Klinik für Diagnostische und Interventionelle Radiologie, Heidelberg, Deutschland
| | - Jutta Hammermann
- Universitäts-Mukoviszidose-Zentrum "Christiane Herzog", Dresden, Deutschland
| | - Ingo Baumann
- Universität Heidelberg, Hals-Nasen-Ohrenklinik, Heidelberg, Deutschland
| | - Frank Brunsmann
- Allianz Chronischer Seltener Erkrankungen (ACHSE) e. V., Deutschland (Patient*innenvertreter)
| | | | - Ernst Eber
- Medizinische Universität Graz, Univ. Klinik für Kinder- und Jugendheilkunde, Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Graz, Österreich
| | - Helmut Ellemunter
- Tirolkliniken GmbH, Department für Kinderheilkunde, Pädiatrie III, Innsbruck, Österreich
| | | | | | - Saskia Gruber
- Medizinische Universität Wien, Universitätsklinik für Kinder- und Jugendheilkunde, Wien, Österreich
| | - Assen Koitschev
- Klinikum Stuttgart - Standort Olgahospital, Klinik für Hals-Nasen-Ohrenkrankheiten, Stuttgart, Deutschland
| | - Julia Ley-Zaporozhan
- Klinik und Poliklinik für Radiologie, Kinderradiologie, LMU München, Deutschland
| | | | - Hans-Joachim Mentzel
- Universitätsklinikum Jena, Sektion Kinderradiologie, Institut für Diagnostische und Interventionelle Radiologie, Jena, Deutschland
| | - Thomas Nüßlein
- Gemeinschaftsklinikum Mittelrhein, Klinik für Kinder- und Jugendmedizin Koblenz und Mayen, Koblenz, Deutschland
| | - Felix C Ringshausen
- Medizinische Hochschule Hannover, Klinik für Pneumologie und Infektiologie und Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland
| | - Ludwig Sedlacek
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | - Christina Smaczny
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Deutschland
| | - Olaf Sommerburg
- Universitätsklinikum Heidelberg, Sektion Pädiatrische Pneumologie, Allergologie und Mukoviszidose-Zentrum, Heidelberg, Deutschland
| | | | - Ralf-Peter Vonberg
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Hannover, Deutschland
| | | | - Jovita Zerlik
- Altonaer Kinderkrankenhaus gGmbH, Abteilung Physiotherapie, Hamburg, Deutschland
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14
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Waters V, Shaw M, Perrem L, Quon BS, Tullis E, Solomon M, Rayment JH, Lavoie A, Tse SM, Daigneault P, Bilodeau L, Price A, Nicholson M, Chin M, Parkins M, McKinney ML, Tam JS, Stanojevic S, Grasemann H, Ratjen F. A randomised trial of oral prednisone for cystic fibrosis pulmonary exacerbation treatment. Eur Respir J 2024; 63:2302278. [PMID: 38697648 DOI: 10.1183/13993003.02278-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/05/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Elevated markers of systemic and pulmonary inflammation are associated with failure to recover lung function following pulmonary exacerbations in people with cystic fibrosis (pwCF). Our aim was to determine whether adjuvant oral prednisone treatment would improve recovery of forced expiratory volume in 1 s (FEV1) % pred in CF pulmonary exacerbations not responding to antibiotic therapy. METHODS This was a randomised, double-blind, placebo-controlled trial in pwCF treated with intravenous antibiotics for a pulmonary exacerbation. At day 7, those who had not returned to >90% baseline FEV1 % pred were randomised to adjuvant prednisone 1 mg·kg-1 twice daily (maximum 60 mg·day-1) or placebo for 7 days. The primary outcome was the difference in proportion of subjects who recovered >90% baseline FEV1 % pred at day 14 of i.v. antibiotic therapy. RESULTS 173 subjects were enrolled, with 76 randomised. 50% of subjects in the prednisone group recovered baseline FEV1 on day 14 compared with 39% of subjects in the placebo group (difference of 11%, 95% CI -11-34%; p=0.34). The mean±sd change in FEV1 % pred from day 7 to day 14 was 6.8±8.8% predicted in the prednisone group and 4.6±6.9% predicted in the placebo group (mean difference 2.2% predicted, 95% CI -1.5-5.9%; p=0.24). Time to subsequent exacerbation was not prolonged in prednisone-treated subjects (hazard ratio 0.83, 95% CI 0.45-1.53; p=0.54). CONCLUSIONS This study failed to detect a difference in FEV1 % pred recovery between adjuvant oral prednisone and placebo treatment in pwCF not responding at day 7 of i.v. antibiotic therapy for pulmonary exacerbations.
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Affiliation(s)
- Valerie Waters
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michelle Shaw
- Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Lucy Perrem
- Department of Respiratory Medicine, Children's Health Ireland, Dublin, Ireland
| | - Bradley S Quon
- Division of Respiratory Medicine, Department of Medicine, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Elizabeth Tullis
- Division of Respirology and Keenan Research Centre of Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jonathan H Rayment
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Annick Lavoie
- Division of Respiratory Medicine and Critical Care, Department of Medicine, Hotel Dieu Hospital, Montreal, QC, Canada
| | - Sze Man Tse
- Division of Respiratory Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Patrick Daigneault
- Division of Respiratory Medicine, Department of Pediatrics, Centre Hospitalier de l'Université de Quebec, Quebec, QC, Canada
| | - Lara Bilodeau
- Division of Respiratory Medicine, Department of Medicine, Institut de l'Université de Cardiologie et Pneumologie de Quebec, Quebec, QC, Canada
| | - April Price
- Division of Respiratory Medicine, Department of Pediatrics, London Health Sciences Centre, London, ON, Canada
| | - Michael Nicholson
- Division of Respiratory Medicine, Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Melanie Chin
- Division of Respiratory Medicine, Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Michael Parkins
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Martha L McKinney
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Julian S Tam
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Hartmut Grasemann
- Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Felix Ratjen
- Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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15
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Khosravi A, Chen Q, Echterhof A, Koff JL, Bollyky PL. Phage Therapy for Respiratory Infections: Opportunities and Challenges. Lung 2024; 202:223-232. [PMID: 38772946 DOI: 10.1007/s00408-024-00700-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/13/2024] [Indexed: 05/23/2024]
Abstract
We are entering the post-antibiotic era. Antimicrobial resistance (AMR) is a critical problem in chronic lung infections resulting in progressive respiratory failure and increased mortality. In the absence of emerging novel antibiotics to counter AMR infections, bacteriophages (phages), viruses that infect bacteria, have become a promising option for chronic respiratory infections. However, while personalized phage therapy is associated with improved outcomes in individual cases, clinical trials demonstrating treatment efficacy are lacking, limiting the therapeutic potential of this approach for respiratory infections. In this review, we address the current state of phage therapy for managing chronic respiratory diseases. We then discuss how phage therapy may address major microbiologic obstacles which hinder disease resolution of chronic lung infections with current antibiotic-based treatment practices. Finally, we highlight the challenges that must be addressed for successful phage therapy clinical trials. Through this discussion, we hope to expand on the potential of phages as an adjuvant therapy in chronic lung infections, as well as the microbiologic challenges that need to be addressed for phage therapy to expand beyond personalized salvage therapy.
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Affiliation(s)
- Arya Khosravi
- Division of Infectious Diseases, School of Medicine, Stanford University, Stanford, CA, USA.
- Division of Infectious Diseases, Department of Medicine, Stanford University, 279 Campus Drive, Beckman Center, Room B237, Stanford, CA, 94305, USA.
| | - Qingquan Chen
- Division of Infectious Diseases, School of Medicine, Stanford University, Stanford, CA, USA
| | - Arne Echterhof
- Division of Infectious Diseases, School of Medicine, Stanford University, Stanford, CA, USA
| | - Jonathan L Koff
- Section of Pulmonary, Critical Care & Sleep Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Paul L Bollyky
- Division of Infectious Diseases, School of Medicine, Stanford University, Stanford, CA, USA
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16
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Colegate SP, Palipana A, Gecili E, Szczesniak RD, Brokamp C. Evaluating precision medicine tools in cystic fibrosis for racial and ethnic fairness. J Clin Transl Sci 2024; 8:e94. [PMID: 39220818 PMCID: PMC11362628 DOI: 10.1017/cts.2024.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/28/2024] [Accepted: 04/23/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction Patients with cystic fibrosis (CF) experience frequent episodes of acute decline in lung function called pulmonary exacerbations (PEx). An existing clinical and place-based precision medicine algorithm that accurately predicts PEx could include racial and ethnic biases in clinical and geospatial training data, leading to unintentional exacerbation of health inequities. Methods We estimated receiver operating characteristic curves based on predictions from a nonstationary Gaussian stochastic process model for PEx within 3, 6, and 12 months among 26,392 individuals aged 6 years and above (2003-2017) from the US CF Foundation Patient Registry. We screened predictors to identify reasons for discriminatory model performance. Results The precision medicine algorithm performed worse predicting a PEx among Black patients when compared with White patients or to patients of another race for all three prediction horizons. There was little to no difference in prediction accuracies among Hispanic and non-Hispanic patients for the same prediction horizons. Differences in F508del, smoking households, secondhand smoke exposure, primary and secondary road densities, distance and drive time to the CF center, and average number of clinical evaluations were key factors associated with race. Conclusions Racial differences in prediction accuracies from our PEx precision medicine algorithm exist. Misclassification of future PEx was attributable to several underlying factors that correspond to race: CF mutation, location where the patient lives, and clinical awareness. Associations of our proxies with race for CF-related health outcomes can lead to systemic racism in data collection and in prediction accuracies from precision medicine algorithms constructed from it.
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Affiliation(s)
- Stephen P. Colegate
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | - Emrah Gecili
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Rhonda D. Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Cole Brokamp
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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17
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Singh J, Robinson P, Pandit C, Kennedy B, Weldon B, Bailey B, John M, Fitzgerald D, Selvadurai H. Factors influencing treatment response of pulmonary exacerbation in children with cystic fibrosis. Minerva Pediatr (Torino) 2024; 76:245-252. [PMID: 38015431 DOI: 10.23736/s2724-5276.23.07221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pulmonary exacerbations in cystic fibrosis (CF) significantly impact morbidity and mortality. This study aimed to assess treatment response rates and identify contributing factors towards treatment response. METHODS In this single-center, retrospective, longitudinal study spanning four years, we analyzed all pulmonary exacerbation admissions. We compared lung function at baseline, admission, end of treatment, and 6-week follow-up. Treatment response was defined as ≥95% recovery of baseline FEV1%. RESULTS There were 78 children who required a total of 184 admissions. The mean duration of treatment was 14.9±2.9 days. FEV1% returned to 95% of baseline in 59% following treatment. The magnitude of the decline in lung function on admission in children who did not respond to treatment was 21.7±15.2% while the decline in children who responded to treatment was 8.3±9.4%, P<0.001. Children who experienced a decline in FEV1% greater than 40% exhibited an 80% reduced likelihood of returning to their baseline values (OR -0.8, 95% CI -0.988; -0.612). Similarly, those with FEV1% reductions in the ranges of 30-39% (OR -0.63, 95% CI -0.821; -0.439), 20-29% (OR -0.52, 95% CI -0.657; -0.383), and 10-19% (OR -0.239, 95% CI -0.33; -0.148) showed progressively lower odds of returning to baseline. Fourty-eight children required readmission within 7.7±5.4 months, children who responded to treatment had a longer time taken to readmission (8.9±6.4 months) versus children who did not respond to treatment (6.4±3.5 months), (OR: -0.20, 95% CI -0.355; -0.048). CONCLUSIONS A greater decline in lung function on admission and readmission within 6 months of the initial admission predicts non-response to treatment. This highlights the importance of re-evaluating follow-up strategies following discharge.
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Affiliation(s)
- Jagdev Singh
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia -
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia -
| | - Paul Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chetan Pandit
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Brendan Kennedy
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Beth Weldon
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Brooke Bailey
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Merilyn John
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Dominic Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Hiran Selvadurai
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Yanaz M, Yilmaz Yegit C, Gulieva A, Kalyoncu M, Selcuk M, Uzunoglu B, Tastan G, Ergenekon AP, Gokdemir Y, Erdem Eralp E, Karakoc F, Karadag B. Electronic home monitoring of children with cystic fibrosis to detect and treat acute pulmonary exacerbations and its effect on 1-year FEV 1. J Cyst Fibros 2024; 23:329-333. [PMID: 37748990 DOI: 10.1016/j.jcf.2023.09.007] [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: 05/13/2023] [Revised: 08/29/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND We aimed to investigate the effect of the use of electronic home spirometry in children with cystic fibrosis (CF) on 1-year FEV1 (% predicted, pp) change. METHODS This is a randomised, one-year prospective study including children with CF between 6 and 18 years of age. Subjects were randomised into home spirometry group (HSG) and usual care group (UCG). Children in HSG performed two pulmonary function tests (PFT) per week. Data regarding acute pulmonary exacerbations (PEx) was obtained from patients' records. At baseline and 12th month, health related quality of life questionnaire for CF patients (CFQ-R) and lung clearance index (LCI) were performed. RESULTS Sixty children were recruited with a median (IQR) age of 13.3 (11.4-15.4) years. Absolute change in FEV1pp from baseline to 12th month as median (IQR) was +1% (-6.75-9.75) in HSG and -2.50% (-7.50-3.25) in UCG (p = 0.10). Sensitivity analysis including only adherent children in HSG (n = 22), yielded an increase of 5% (-3.50-12) in HSG and a decrease of 2.50% (-7.50-3.25) in UCG (p = 0.009). A total of 29 (96.7%) subjects in HSG and 23 (76.7%) in UCG had PEx (p = 0.05). Absolute change in median (IQR) LCI2.5 from baseline to the 12th month was -1.6 [-2.9-0] (p<0.001) in HSG and -1.5 [-2.8-(-0.6)] (p<0.001) in UCG (p = 0.94). There was a significant increase in the social domain of the CFQ-R in HSG (from 59.1 to 76.2, p = 0.01). CONCLUSIONS Electronic home monitoring of children with CF by spirometry may result in improvement in lung function.
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Affiliation(s)
- Muruvvet Yanaz
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey.
| | - Cansu Yilmaz Yegit
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Aynur Gulieva
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Mine Kalyoncu
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Merve Selcuk
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Burcu Uzunoglu
- Selim Coremen Cystic Fibrosis Center, Marmara University School of Medicine, Istanbul, Turkey
| | - Gamze Tastan
- Selim Coremen Cystic Fibrosis Center, Marmara University School of Medicine, Istanbul, Turkey
| | - Almala Pinar Ergenekon
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Yasemin Gokdemir
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Ela Erdem Eralp
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Fazilet Karakoc
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
| | - Bulent Karadag
- Division of Pediatric Pulmonology, Marmara University School of Medicine, Fevzi Çakmak mahallesi, Muhsin Yazıcıoğlu caddesi, No:10, Pendik, Istanbul 34899, Turkey
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Burgel PR, Southern KW, Addy C, Battezzati A, Berry C, Bouchara JP, Brokaar E, Brown W, Azevedo P, Durieu I, Ekkelenkamp M, Finlayson F, Forton J, Gardecki J, Hodkova P, Hong G, Lowdon J, Madge S, Martin C, McKone E, Munck A, Ooi CY, Perrem L, Piper A, Prayle A, Ratjen F, Rosenfeld M, Sanders DB, Schwarz C, Taccetti G, Wainwright C, West NE, Wilschanski M, Bevan A, Castellani C, Drevinek P, Gartner S, Gramegna A, Lammertyn E, Landau EEC, Plant BJ, Smyth AR, van Koningsbruggen-Rietschel S, Middleton PG. Standards for the care of people with cystic fibrosis (CF); recognising and addressing CF health issues. J Cyst Fibros 2024; 23:187-202. [PMID: 38233247 DOI: 10.1016/j.jcf.2024.01.005] [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: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
This is the third in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on recognising and addressing CF health issues. The guidance was produced with wide stakeholder engagement, including people from the CF community, using an evidence-based framework. Authors contributed sections, and summary statements which were reviewed by a Delphi consultation. Monitoring and treating airway infection, inflammation and pulmonary exacerbations remains important, despite the widespread availability of CFTR modulators and their accompanying health improvements. Extrapulmonary CF-specific health issues persist, such as diabetes, liver disease, bone disease, stones and other renal issues, and intestinal obstruction. These health issues require multidisciplinary care with input from the relevant specialists. Cancer is more common in people with CF compared to the general population, and requires regular screening. The CF life journey requires mental and emotional adaptation to psychosocial and physical challenges, with support from the CF team and the CF psychologist. This is particularly important when life gets challenging, with disease progression requiring increased treatments, breathing support and potentially transplantation. Planning for end of life remains a necessary aspect of care and should be discussed openly, honestly, with sensitivity and compassion for the person with CF and their family. CF teams should proactively recognise and address CF-specific health issues, and support mental and emotional wellbeing while accompanying people with CF and their families on their life journey.
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Affiliation(s)
- Pierre-Régis Burgel
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Institut Cochin, Inserm U1016, Université Paris-Cité, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, Institute in the Park, Alder Hey Children's Hospital, University of Liverpool, Eaton Road, Liverpool L12 2AP, UK.
| | - Charlotte Addy
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alberto Battezzati
- Clinical Nutrition Unit, Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, and ICANS-DIS, Department of Food Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Claire Berry
- Department of Nutrition and Dietetics, Alder Hey Children's NHS Trust, Liverpool, UK
| | - Jean-Philippe Bouchara
- University of Brest, Fungal Respiratory Infections Research Unit, SFR ICAT, University of Angers, Angers, France
| | - Edwin Brokaar
- Department of Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands
| | - Whitney Brown
- Cystic Fibrosis Foundation, Inova Fairfax Hospital, Bethesda, Maryland, USA, Falls Church, VA, USA
| | - Pilar Azevedo
- Cystic Fibrosis Reference Centre-Centro, Hospitalar Universitário Lisboa Norte, Portugal
| | - Isabelle Durieu
- Cystic Fibrosis Reference Center (Constitutif), Service de médecine interne et de pathologie vasculaire, Hospices Civils de Lyon, Hôpital Lyon Sud, RESearch on HealthcAre PErformance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France; ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Miquel Ekkelenkamp
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Felicity Finlayson
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | | | - Johanna Gardecki
- CF Centre at Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pavla Hodkova
- CF Center at University Hospital Motol, Prague, Czech Republic
| | - Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jacqueline Lowdon
- Clinical Specialist Paediatric Cystic Fibrosis Dietitian, Leeds Children's Hospital, UK
| | - Su Madge
- Royal Brompton Hospital, Part of Guys and StThomas's Hospital, London, UK
| | - Clémence Martin
- Institut Cochin, Inserm U1016, Université Paris-Cité and National Reference Center for Cystic Fibrosis, Hôpital Cochin AP-HP, ERN-Lung CF Network, Paris 75014, France
| | - Edward McKone
- St.Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Anne Munck
- Hospital Necker Enfants-Malades, AP-HP, CF Centre, Université Paris Descartes, Paris, France
| | - Chee Y Ooi
- School of Clinical Medicine, Discipline of Paediatrics and Child Health, Faculty of Medicine & Health, Department of Gastroenterology, Sydney Children's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Perrem
- Department of Respiratory Medicine, Children's Health Ireland, Dublin, Ireland
| | - Amanda Piper
- Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Andrew Prayle
- Child Health, Lifespan and Population Health & Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics and Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carsten Schwarz
- Division Cystic Fibrosis, CF Center, Clinic Westbrandenburg, HMU-Health and Medical University, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Italy
| | | | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, CF Center, Hadassah Medical Center, Jerusalem, Israel
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, Genova 16147, Italy
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Silvia Gartner
- Cystic Fibrosis Unit and Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Respiratory Unit and Adult Cystic Fibrosis Center, Università degli Studi di Milano, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elise Lammertyn
- Cystic Fibrosis Europe, Brussels, Belgium and the Belgian CF Association, Brussels, Belgium
| | - Eddie Edwina C Landau
- The Graub CF Center, Pulmonary Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Barry J Plant
- Cork Centre for Cystic Fibrosis (3CF), Cork University Hospital, University College Cork, Ireland
| | - Alan R Smyth
- School of Medicine, Dentistry and Biomedical Sciences, Belfast and NIHR Nottingham Biomedical Research Centre, Queens University Belfast, Nottingham, UK
| | | | - Peter G Middleton
- Westmead Clinical School, Department Respiratory & Sleep Medicine, Westmead Hospital, University of Sydney and CITRICA, Westmead, Australia
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Bouteleux B, Beaufils F, Fayon M, Bui S. Home-spirometry exacerbation profiles in children with cystic fibrosis. Pediatr Pulmonol 2024; 59:552-561. [PMID: 38014613 DOI: 10.1002/ppul.26781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 11/01/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) are strong predictors of respiratory disease progression in children with cystic fibrosis (CwCF) and may be associated with persistent decreased lung function after acute management. Telemonitoring devices can be used for early detection and monitoring of PEx, but its utility is debated. RESEARCH QUESTION Which symptoms and telemonitoring spirometry characterics are related to outcome dynamics following initial PEx management? METHODS This retrospective study included CwCF followed at Bordeaux University Hospital, France. All severe PEx episodes treated with intravenous (IV) antibiotics (ATB) between 1 January 2017 and 31 December 2021 in CwCF using home telemonitoring were analyzed. Symptoms and home spirometry data were collected 45 days before and up to 60 days after each IV ATB course. We defined three response profiles based on terciles of baseline forced expiratory volume in 1 s (FEV1 ) recovery. RESULTS A total of 346 IV ATB courses for PEx were administered to 65 CwCF during the study period. The drop in FEV1 became significant 8 days before IV ATB initiation. Forty-one percent of IV ATB courses failed to restore baseline FEV1 . The magnitude of FEV1 drop and a greater delay in the initiation of treatment correlated with a low response level. On the 14th day of the IV treatment, a FEV1 recovery less than 94% of baseline was associated with a nonresponder profile. INTERPRETATION Home spirometry may facilitate the early recognition of PEx to implement earlier interventions. This study also provides an outcome lung function threshold which identifies low responders to IV ATB.
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Affiliation(s)
| | - Fabien Beaufils
- CHU Bordeaux, Département de Physiologie, Département de Pédiatrie, Service de Pneumologie Pédiatrique, Centre de Ressources et de Compétences pour la Mucoviscidose, Centre d'Investigation Clinique, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Université de Bordeaux, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Bordeaux, France
| | - Michael Fayon
- CHU Bordeaux, Département de Physiologie, Département de Pédiatrie, Service de Pneumologie Pédiatrique, Centre de Ressources et de Compétences pour la Mucoviscidose, Centre d'Investigation Clinique, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Université de Bordeaux, Pessac, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Bordeaux, France
| | - Stéphanie Bui
- CHU Bordeaux, Département de Physiologie, Département de Pédiatrie, Service de Pneumologie Pédiatrique, Centre de Ressources et de Compétences pour la Mucoviscidose, Centre d'Investigation Clinique, Bordeaux, France
- INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, Bordeaux, France
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21
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Houston CJ, Alkhatib A, Einarsson GG, Tunney MM, Taggart CC, Downey DG. Diminished airway host innate response in people with cystic fibrosis who experience frequent pulmonary exacerbations. Eur Respir J 2024; 63:2301228. [PMID: 38135443 PMCID: PMC10882324 DOI: 10.1183/13993003.01228-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023]
Abstract
RATIONALE Pulmonary exacerbations are clinically impactful events that accelerate cystic fibrosis (CF) lung disease progression. The pathophysiological mechanisms underlying an increased frequency of pulmonary exacerbations have not been explored. OBJECTIVES To compare host immune response during intravenous antibiotic treatment of pulmonary exacerbations in people with CF who have a history of frequent versus infrequent exacerbations. METHODS Adults with CF were recruited at onset of antibiotic treatment of a pulmonary exacerbation and were categorised as infrequent or frequent exacerbators based on their pulmonary exacerbation frequency in the previous 12 months. Clinical parameters, sputum bacterial load and sputum inflammatory markers were measured on day 0, day 5 and at the end of treatment. Shotgun proteomic analysis was performed on sputum using liquid chromatography-mass spectrometry. MEASUREMENTS AND MAIN RESULTS Many sputum proteins were differentially enriched between infrequent and frequent exacerbators (day 0 n=23 and day 5 n=31). The majority of these proteins had a higher abundance in infrequent exacerbators and were secreted innate host defence proteins with antimicrobial, antiprotease and immunomodulatory functions. Several differentially enriched proteins were validated using ELISA and Western blot including secretory leukocyte protease inhibitor (SLPI), lipocalin-1 and cystatin SA. Sputum from frequent exacerbators demonstrated potent ability to cleave exogenous recombinant SLPI in a neutrophil elastase dependent manner. Frequent exacerbators had increased sputum inflammatory markers (interleukin (IL)-1β and IL-8) and total bacterial load compared to infrequent exacerbators. CONCLUSIONS A diminished innate host protein defence may play a role in the pathophysiological mechanisms of frequent CF pulmonary exacerbations. Frequent exacerbators may benefit from therapies targeting this dysregulated host immune response.
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Affiliation(s)
- Claire J Houston
- Airway Innate Immunity Research Group, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Aya Alkhatib
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | | | - Clifford C Taggart
- Airway Innate Immunity Research Group, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Joint senior authors
| | - Damian G Downey
- Belfast Health and Social Care Trust, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Joint senior authors
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Steuart R, Pan AY, Woolums A, Benscoter D, Russell CJ, Henningfeld J, Thomson J. Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies. Pediatr Pulmonol 2024; 59:300-313. [PMID: 37937895 DOI: 10.1002/ppul.26746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/22/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown. OBJECTIVE To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies. METHODS This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering. RESULTS Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability. CONCLUSION Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.
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Affiliation(s)
- Rebecca Steuart
- Section of Special Needs, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Henningfeld
- Department of Pediatrics, Section of Pulmonary Medicine, Milwaukee, Wisconsin, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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De Marchis M, Montemitro E, Boni A, Federici A, Di Giovanni D, Cristiani L, Cutrera R, Fiocchi AG. Lung clearance index short-term variability in cystic fibrosis: a pre-post pulmonary exacerbation study. Ital J Pediatr 2024; 50:6. [PMID: 38233941 PMCID: PMC10795345 DOI: 10.1186/s13052-023-01574-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 12/26/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Multiple Breath washout (MBW) represents an important tool to detect early a possible pulmonary exacerbation especially in Cystic Fibrosis (CF) disease. Lung clearance index (LCI) is the most commonly reported multiple breath washout (MBW) index and in the last years was used as management measure for evaluation. Our aim was to analyze clinical utility of LCI index variability in pulmonary exacerbation in CF after intravenous (IV) antibiotic therapy. METHODS A single-center study was conducted at CF Unit of Bambino Gesù Children's Hospital among hospitalized > 3 years patients for pulmonary exacerbations and treated with antibiotic IV treatment for 14 days. MBW and spirometry were evaluated within 72 h of admission to hospital and at the end of hospitalization. Descriptive analysis was conducted and correlations between quantitative variables were investigated. RESULTS Fifty-seven patients (M22/F35) with an average age 18.56 (± 8.54) years were enrolled. LCI2.5 was significantly reduced at the end of antibiotic treatment in both pediatric and adult populations with an average reduction of -6,99%; 37/57 patients denoted an improvement, 20/57 are stable or worsened in LCI2.5 values and 4/57 (7.02%) had a significant deterioration (> 15%) at end of treatment. On the contrary a significative elevation of FEV1 and FVC were found, respectively of + 7,30% and of + 5,46%. A positive good correlection among LCI 2.5 and Scond (rho = + 0,615, p = 0.000) and LCI 2.5 and Sacin (rho = + 0,649, p = 0.000) and a negative strong correlation between FEV1 and LCI 2.5 were found in post treatment period. A similar modification of LCI 2.5 and FEV1 was noticed in both adult and pediatric population. CONCLUSIONS LCI may have a role in the routine clinical care of both adult and pediatric CF patients as a good tool to assess response to IV antibiotic end-therapy in the same way as FEV1.
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Affiliation(s)
- Matteo De Marchis
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
- University of Magna Graecia of Catanzaro, Calabria, Italy.
| | - Enza Montemitro
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alessandra Boni
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alessandra Federici
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Daniele Di Giovanni
- Industrial Engineering Department, University of Rome Tor Vergata, Rome, Italy
- Unicamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - Luca Cristiani
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Renato Cutrera
- Pneumology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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Farahbakhsh N, Fatahi S, Shirvani A, Motaharifard MS, Mohkam M, Tabatabaii SA, Khanbabaee G, Yaghoobpoor S, Davoodi SZ, Hosseini AH. Vitamin D deficiency in patients with cystic fibrosis: a systematic review and meta-analysis. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2024; 43:11. [PMID: 38233891 PMCID: PMC10795301 DOI: 10.1186/s41043-024-00499-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/05/2024] [Indexed: 01/19/2024]
Abstract
AIM Vitamin D is a prominent modulator of immunity and respiratory function. It plays a vital role in respiratory diseases such as cystic fibrosis (CF). S. However, there is a dearth of information on patients with CF. The purpose of the meta-analysis is to highlight the importance of following the existing guidelines regarding maintenance of Vitamin D serum levels in patients with CF. METHODS The systematic search was conducted without utilizing any time or language limitations in original database from the beginning until March 2022. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by I2 statistics and Cochrane Q test. RESULTS Pooled analysis using the random-effects model of the 8 case-control studies with 13 effect sizes revealed that the serum 25-OH-vitamin D in participants with cystic fibrosis was significantly lower than controls in pediatrics and adolescences (WMD: - 3.41 ng/ml, 95% CI - 5.02, - 1.80, p = < 0.001) and adults (WMD: - 2.60 ng/ml, 95% CI - 4.32, - 0.89, p = 0.003). Based on data from 12 studies (21 effect sizes) with a total of 1622 participants, the prevalence of vitamin D levels of 20-30 ng/ml in CF patients was 36% among pediatrics/adolescents and 63% among adults. In addition, 27% of pediatric/adolescent CF patients and 35% of adult CF patients had vitamin D levels of below 20 ng/ml. CONCLUSIONS As a result, according to the existing guidelines, our results proved the need to pay attention to the level of vitamin D in these patients.
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Affiliation(s)
- Nazanin Farahbakhsh
- Department of Pediatric Pulmonology, Mofid Pediatrics Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somaye Fatahi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Faculty of Medical Education, Shahid Beheshty University of Medical Sciences, Tehran, Iran
| | - Monireh Sadat Motaharifard
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoumeh Mohkam
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Tabatabaii
- Department of Pediatric Pulmonology, Mofid Pediatrics Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghamartaj Khanbabaee
- Department of Pediatric Pulmonology, Mofid Pediatrics Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shirin Yaghoobpoor
- Student Research Committee, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedeh Zahra Davoodi
- Student Research Committee, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Hosseini
- Pediatric Gastroenterology, Hepatology, and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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List R, Solomon G, Bichl S, Horton BJ, Shen S, Corcoran B, Sadeghi H, Britto MT, Ren C, Albon D. Improved recognition of lung function decline as signal of cystic fibrosis pulmonary exacerbation: a Cystic Fibrosis Learning Network Innovation Laboratory quality improvement initiative. BMJ Open Qual 2023; 12:e002466. [PMID: 38154821 PMCID: PMC10759080 DOI: 10.1136/bmjoq-2023-002466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Cystic fibrosis (CF) is a systemic autosomal recessive condition characterised by progressive lung disease. CF pulmonary exacerbations (PEx) are episodes of worsening respiratory status, and frequent PEx are a risk factor for accelerated lung function decline, yet many people with CF (PwCF) go untreated at the time of decline. The goal of this quality improvement (QI) initiative was to improve recognition, treatment and follow-up of PEx in PwCF. METHODS Using the Model for Improvement, the Cystic Fibrosis Learning Network (CFLN) initiated a QI innovation laboratory (iLab) with a global aim to decrease the rate of lung function decline in PwCF. The iLab standardised definitions for signals of PEx using a threshold for decline in forced expiratory volume in one second (FEV1) and/or changes in symptoms. The FEV1 decline signal was termed FIES (FEV1-indicated exacerbation signal). Processes for screening and recognition of FIES and/or symptom changes, a treatment algorithm and follow-up in the presence of a signal were tested concurrently in multiple settings. SPECIFIC AIMS The specific aim is to increase the per cent of PwCF assessed for a PEx signal at ambulatory encounters and to increase the per cent of recommendations to follow-up within 6 weeks for PwCF experiencing a PEx signal. RESULTS FIES recognition increased from 18.6% to 73.4% across all teams during the iLab, and every team showed an improvement. Of PwCF assessed, 15.8% experienced an FIES event (>10% decline in FEV1 per cent predicted (FEV1pp)). Follow-up within 6 weeks was recommended for an average of 70.5% of those assessed for FIES and had an FEV1pp decline greater than 5%. CONCLUSION The CFLN iLab successfully defined and implemented a process to recognise and follow-up PEx signals. This process has the potential to be spread to the larger CF community. Further studies are needed to assess the impact of these processes on PwCF outcomes.
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Affiliation(s)
- Rhonda List
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - George Solomon
- Pulmonary, Allergy, & Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stacy Bichl
- Division of Pulmonary Medicine, Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - Shiyi Shen
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Bean Corcoran
- Connecticut Chapter, Cystic Fibrosis Foundation, Weston, Connecticut, USA
| | - Hossein Sadeghi
- Pediatric Pulmonology and Sleep Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center James M Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Clement Ren
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dana Albon
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Graham BI, Harris JK, Zemanick ET, Wagner BD. Integrating airway microbiome and blood proteomics data to identify multi-omic networks associated with response to pulmonary infection. THE MICROBE 2023; 1:100023. [PMID: 38264413 PMCID: PMC10805068 DOI: 10.1016/j.microb.2023.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Host response to airway infections can vary widely. Cystic fibrosis (CF) pulmonary exacerbations provide an opportunity to better understand the interplay between respiratory microbes and the host. This study aimed to investigate the observed heterogeneity in airway infection recovery by analyzing microbiome and host response (i.e., blood proteome) data collected during the onset of 33 pulmonary infection events. We used sparse multiple canonical correlation network (SmCCNet) analysis to integrate these two types of -omics data along with a clinical measure of recovery. Four microbe-protein SmCCNet subnetworks at infection onset were identified that strongly correlate with recovery. Our findings support existing knowledge regarding CF airway infections. Additionally, we discovered novel microbe-protein subnetworks that are associated with recovery and merit further investigation.
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Affiliation(s)
- Brenton I.M. Graham
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - J. Kirk Harris
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Edith T. Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brandie D. Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Somayaji R, Quon BS. Breath of fresh insight: unraveling the evolution of our understanding of cystic fibrosis pulmonary exacerbations. Curr Opin Pulm Med 2023; 29:587-594. [PMID: 37642491 DOI: 10.1097/mcp.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Pulmonary exacerbations are critical events with significant negative impacts in persons with cystic fibrosis, but their diagnosis and management are highly variable. Highly effective modulator therapies have greatly improved health and reduced exacerbation events, but have also reshaped how they present. This review discusses the complexities of the diagnosis and management of pulmonary exacerbations as well as the emerging work and evidence in this area. RECENT FINDINGS The shifting epidemiology and our understanding of risk factors for pulmonary exacerbations are discussed. As symptoms may be more subtle in the modulator context, novel technologies including studies of remote monitoring are presented. The continued relevance of pulmonary exacerbations, the heterogeneity in their management, as well as current and forthcoming clinical trials to optimize treatment approaches are detailed. SUMMARY In spite of the dramatic reductions in pulmonary exacerbations, airway infections persist, a proportion of persons with cystic fibrosis either on or off modulator therapies continue to experience exacerbation events, and long-term data is lacking. Innovative approaches and studies will be crucial to enable standardized and generalizable strategies to improve outcomes in persons with cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- Department of Medicine, Cumming School of Medicine
- Department of Microbiology, Immunology and Infectious Disease
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada
| | - Bradley S Quon
- Department of Medicine, Faculty of Medicine, University of British Columbia
- Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, Canada
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Savi D, Lucca F, Tridello G, Meneghelli I, Comello I, Tomezzoli S, Signorini M, Proietti E, Cucchetto G, Volpi S, Cipolli M. Long-term clinical outcomes of elexacaftor/tezacaftor/ivacaftor therapy in adults with cystic fibrosis and advanced pulmonary disease. Respir Med 2023; 219:107406. [PMID: 37690570 DOI: 10.1016/j.rmed.2023.107406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The combination of cystic fibrosis transmembrane conductance regulator (CFTR) modulators elexacaftor, tezacaftor and ivacaftor (ELX/TEZ/IVA) has been approved for treatment of cystic fibrosis (CF) patients (pwCF) homozygous and heterozygous for Phe508del. We aim to assess the long-term effects of ELX/TEZ/IVA therapy on clinical outcomes in severe pwCF. METHODS Lung function, pulmonary exacerbation (PEx), sweat chloride concentration, body mass index (BMI) and the respiratory domain of the cystic fibrosis questionnaire-revised (CFQ-R RD) were prospectively evaluated in a cohort of pwCF who were candidates for inclusion in a compassionate program of ELX/TEZ/IVA therapy. All procedures were performed at baseline and then at 12 and 24 months after initiation of modulator therapy. The number of PExs in the year before the study enrollment was collected from our records. RESULTS Thirty-six adult pwCF (median age 36.7 years; BMI 19.8 kg/m2; FEV1 36.5% predicted) were recruited from 2019. At 12 and 24 months after initiation, the absolute change in ppFEV1 (percent predicted forced expiratory volume in 1 s) from baseline was +12.5% (p < 0.0001) and +13% (p < 0.0001), respectively. A median of 4.0 exacerbations per patient was reported in the preceding year, while the median number of PExs was 0.0 and 1.0 after 12 and 24 months, respectively, of modulator therapy (both p < 0.0001). After 12 and 24 months of ELX/TEZ/IVA therapy, the CFQ-R RD score improved by 22.4 points (p < 0.0001) and 16.7 points (p < 0.0001), and sweat chloride levels decreased by 65.5 mmol/L (p < 0.0001) and 60 mmol/L (p < 0.0001), respectively. BMI significantly increased. CONCLUSIONS Long-term ELX/TEZ/IVA combination therapy markedly impacts the clinical status of patients with severe CF, showing a sustained improvement in lung function and PEx rate.
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Affiliation(s)
- Daniela Savi
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Francesca Lucca
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Gloria Tridello
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Ilaria Meneghelli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Isabella Comello
- UOSD Cystic Fibrosis Unit, Department of Medical Direction of the Hospital, Treviso, Italy; Department of Women and Child Health, University of Padova, Padova, Italy.
| | - Sara Tomezzoli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Monica Signorini
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | | | - Giulia Cucchetto
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Sonia Volpi
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliero Universitaria Integrata di Verona, Pl. Aristide Stefani 1, 37126, Verona, Italy.
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Gatt D, Shaw M, Waters V, Kritzinger F, Solomon M, Dell S, Ratjen F. Treatment response to pulmonary exacerbation in primary ciliary dyskinesia. Pediatr Pulmonol 2023; 58:2857-2864. [PMID: 37449771 DOI: 10.1002/ppul.26599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/19/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Pulmonary exacerbation (Pex) are common in pediatric primary ciliary dyskinesia (PCD), however changes in forced expiratory volume in 1 s precent predicted (FEV1pp) during Pex are not well described. AIM To assess the evolution of FEV1pp during Pex and to define factors associated with failure to return to baseline lung function. METHOD This was a retrospective study of patients with PCD between 2010 and 2022. Pex were defined as the presence of increased respiratory symptoms treated with intravenous (IV) antibiotics. The main outcomes were the changes in FEV1 during therapy and the proportion of patients (responders) achieving ≥90% of baseline FEV1pp values at the end of admission. RESULTS The study included 52 Pex events in 28 children with PCD. The rate of responders was 32/41 (78%) at the end of admission. Nonresponse was associated with lower median body mass index (BMI) Z-score (-2.4 vs. -0.4, p < .01) and with a history of IV treated Pex in the previous year (p = .06). For the 22 Pex with available FEV1pp measurements at mid admission, the median relative and absolute improvement from admission to Day 7 was 9.1% and 6.2%, respectively (p- .001), and from Days 7 to 14 was 4.4% and 2.8%, respectively (p = .08). CONCLUSION In children with PCD treated with IV antibiotics, the majority of lung function recovery happens during the first week of IV therapy. Lower BMI was associated with nonresponse to therapy.
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Affiliation(s)
- Dvir Gatt
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie Waters
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Fiona Kritzinger
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Dell
- Department of Pediatrics, Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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30
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Gill ER, Goss CH, Sagel SD, Wright ML, Horner SD, Zuñiga JA. Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale. RESEARCH SQUARE 2023:rs.3.rs-3232522. [PMID: 37790510 PMCID: PMC10543508 DOI: 10.21203/rs.3.rs-3232522/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. Methods A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. Results A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. Conclusion Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.
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Heltshe SL, Russell R, VanDevanter DR, Sanders DB. Re-examining baseline lung function recovery following IV-treated pulmonary exacerbations. J Cyst Fibros 2023; 22:864-867. [PMID: 36803635 PMCID: PMC10427727 DOI: 10.1016/j.jcf.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023]
Abstract
CF registry pulmonary exacerbation (PEx) analyses have employed "before and after" spirometry recovery, where the best percent predicted forced expiratory volume in 1 s (ppFEV1) prior to PEx ("baseline") is compared to the best ppFEV1 <3 months post-PEx. This methodology lacks comparators and ascribes recovery failure to PEx. Herein, we describe 2014 CF Foundation Patient Registry PEx analyses including a comparator: recovery around nonPEx events, birthdays. 49.6% of 7357 individuals with PEx achieved baseline ppFEV1 recovery while 36.6% of 14,141 achieved baseline recovery after birthdays; individuals with both PEx and birthdays were more likely to recover baseline after PEx than after birthdays (47% versus 34%); mean ppFEV1 declines were 0.3 (SD=9.3) and 3.1 (9.3), respectively. Post-event measure number had more effect on baseline recovery than did real ppFEV1 loss in simulations, suggesting that PEx recovery analyses lacking comparators are prone to artifact and poorly describe PEx contributions to disease progression.
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Affiliation(s)
- Sonya L Heltshe
- University of Washington School of Medicine, 1920 Terry Ave, Suite 400, Seattle, WA 98101, United States; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States.
| | - Renee Russell
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Don B Sanders
- Indiana University School of Medicine, Indianapolis, IN, United States
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Merjaneh L, Sidhaye AR, Vu PT, Heltshe SL, Goss CH, Flume PA, Kelly A, Rosenfeld M. Role of hyperglycemia in cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2023; 22:868-874. [PMID: 37394317 PMCID: PMC10756929 DOI: 10.1016/j.jcf.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 06/09/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Hyperglycemia could affect treatment response during cystic fibrosis (CF) exacerbations. We aimed to evaluate the prevalence and associations of hyperglycemia with exacerbation outcomes. We also evaluated feasibility of continuous glucose monitoring (CGM) during exacerbations. METHODS The STOP2 study assessed efficacy and safety of different durations of intravenous antibiotics for CF exacerbations. We conducted a secondary data analysis of random glucose levels measured as part of clinical care during exacerbations. A small subset of participants also underwent CGM per research protocol. The associations between hyperglycemia, defined as random glucose ≥140 mg/dL, and changes in weight and lung function with exacerbation treatment were evaluated with linear regression after adjustment for confounding variables. RESULTS Glucose levels were available for 182 STOP2 participants of mean (SD) age 31.6 (10.8) years, baseline percent predicted (pp) FEV1 53.6 (22.5); 37% had CF related diabetes and 27% were on insulin. Hyperglycemia was detected in 44% of participants. Adjusted mean difference (95% CI) was 1.34% (-1.39, 4.08) (p = 0.336) for change in ppFEV1 and 0.33 kg (-0.11, 0.78) (p = 0.145) for change in weight between hyperglycemic and non-hyperglycemic groups. Ten participants not on antidiabetic agents in the 4 weeks prior to enrollment underwent CGM; mean (SD) time spent >140 mg/dL was 24.6% (12.5) with 9/10 participants spending >4.5% time >140 mg/dL. CONCLUSIONS Hyperglycemia identified with random glucose is prevalent during CF exacerbations but not associated with changes in lung function or weight with exacerbation treatment. CGM is feasible and may provide a useful tool for hyperglycemia monitoring during exacerbations.
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Affiliation(s)
- Lina Merjaneh
- Division of Endocrinology and Diabetes, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98145, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Aniket R Sidhaye
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD 21287, USA
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Andrea Kelly
- Department of Pediatrics, Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98145, USA
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Blanchard AC, Shaw M, Ratjen F, Tullis E, Daneman N, Waters V. Factors associated with lung function response with oral antibiotic treatment of pulmonary exacerbations in cystic fibrosis. J Cyst Fibros 2023; 22:880-883. [PMID: 37474423 DOI: 10.1016/j.jcf.2023.06.015] [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: 02/11/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/22/2023]
Abstract
Pulmonary exacerbations treated with oral antibiotics (oPEx) have a significant effect on lung function decline in people with cystic fibrosis (CF). However, factors associated with lung function response with oPExs are not well defined. We performed a retrospective cohort study of pediatric and adult patients with CF followed in the Toronto CF Database. Lung function response was measured both as the change in forced expiratory volume in 1 second (FEV1) from Day 0 of antibiotic therapy to end of treatment as well as from baseline to end of treatment. Drop from baseline to Day 0 FEV1 was strongly associated with lung function response (p<0.001). Greater FEV1 improvements were associated with longer antibiotic treatment durations. Older, female patients had less improvements in FEV1 at end of treatment compared to younger, male patients.
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Affiliation(s)
- Ana C Blanchard
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, 3175 Chemin de la Côte Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada
| | - Michelle Shaw
- Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada
| | - Felix Ratjen
- Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada; Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada
| | - Elizabeth Tullis
- Division of Respiratory Medicine, Department of Medicine, St Michael's Hospital, University of Toronto, 30 Bond St, Toronto, M5B 1W8, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto M4N 3M5, Canada
| | - Valerie Waters
- Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada; Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1 × 8, Canada.
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Bagatini MA, Heinzmann-Filho JP, Vendrusculo FM, Pinto LA, Donadio MVF. Impact of COVID-19 social distancing recommendations on pulmonary function, nutritional status, and morbidity in patients with cystic fibrosis. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 42:e2022198. [PMID: 37646749 PMCID: PMC10503424 DOI: 10.1590/1984-0462/2024/42/2022198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/21/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To evaluate the impact of COVID-19 social distancing recommendations on nutritional status, pulmonary function, and morbidity in patients with cystic fibrosis (CF). METHODS A retrospective cohort study including patients older than six years with a diagnosis of CF was performed. Demographic and clinical data, anthropometric measurements, pulmonary function, days of antibiotic use, and length of hospital stay were recorded. Variables were recorded at three time points relative to the baseline for implementation of social distancing measures: T-1 (14 months before implementation), T0 (baseline), and T1 (14 months after implementation). Delta (Δ) was calculated for each period: Δ1 (pre-pandemic T0-T-1) and Δ2 (pandemic T1-T0). RESULTS The study included 25 patients, with a mean age of 11.7±4.3 years. The mean forced expiratory volume in the first second (FEV1) was 85.6±23.6%, and body mass index (BMI) was 17.5±3.0 kg/m2. When comparing the two periods (Δ1 and Δ2), there was a significant increase in the FEV1/forced vital capacity (FVC) ratio (p=0.013) and in the forced expiratory flow between 25 and 75% of vital capacity (FEF25-75%) (p=0.037) in the pandemic period. There was also a significant reduction (p=0.005) in the use of antibiotics in the pandemic period compared with the pre-pandemic period. The Δ1 and Δ2 values did not differ significantly for BMI, FEV1, or length of hospital stay. CONCLUSIONS COVID-19 social distancing recommendations had a positive impact (decrease) on morbidity (use of antibiotics) and small airway obstruction (FEF25-75%) in patients with CF.
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Affiliation(s)
| | | | | | | | - Márcio Vinícius Fagundes Donadio
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Universitat Internacional de Catalunya, Barcelona, España
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Benz C, Middleton A, Elliott A, Harvey A. Physiotherapy via telehealth for acute respiratory exacerbations in paediatric cystic fibrosis. J Telemed Telecare 2023; 29:552-560. [PMID: 33726605 DOI: 10.1177/1357633x21998205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The demand for Hospital in the Home has increased, especially as an avenue for treatment of respiratory exacerbations. However, a limiting factor of Hospital in the Home efficiency is excess travel. Telehealth can potentially increase in-home access to specialist care such as physiotherapy. This study examined clinical outcomes achieved with a hybrid telehealth model and assessed safety and efficiency. METHOD This study was an observational benchmarking study of Hospital in the Home physiotherapy episodes of care during respiratory exacerbations between January 2017-June 2019. The participants were young people aged 8-18 years, with cystic fibrosis receiving intravenous antibiotics and bi-daily physiotherapy. The intervention was physiotherapy via either a hybrid model (1× telehealth, 1× face-to-face session) or standard care (2× face-to-face sessions). The outcomes were frequency of return to at least 95% of baseline percentage predicted forced expiratory volume in the first second (ppFEV1), ppFEV1 change, adverse events, travel time and distance saved. RESULTS There were 82 episodes of Hospital in the Home; 41 hybrid and 41 standard care. Return to at least 95% of baseline was achieved in 49% of the hybrid group and 32% of standard care. Median ppFEV1 change was +6% for the hybrid group and +2% standard care. There were no adverse events. Estimated travel time and distance saved was 16,520 min and 12,301.2 km. CONCLUSION Preliminary information supports a hybrid telehealth physiotherapy model as an alternative to standard care for young people with cystic fibrosis during an exacerbation. Safety of telehealth in conjunction with home visits favoured its use to improve efficiency and capacity without added risk.
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Affiliation(s)
- Cloe Benz
- Physiotherapy, Children's Hospital Westmead, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | | | | | - Adrienne Harvey
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Australia
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36
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Walicka-Serzysko K, Postek M, Borawska-Kowalczyk U, Milczewska J, Sands D. Pulmonary Function Tests in the Evaluation of Early Lung Disease in Cystic Fibrosis. J Clin Med 2023; 12:4735. [PMID: 37510850 PMCID: PMC10380830 DOI: 10.3390/jcm12144735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Properly evaluating respiratory system dysfunction is essential in children with cystic fibrosis (CF). This prospective study aimed to assess the course of early lung disease based on multiple breath nitrogen washout (MBNW), impulse oscillometry (IOS), and conventional techniques, such as spirometry and body plethysmography. METHODS Over a 2 year recruitment period, subjects with CF aged 7-18 performed pulmonary function tests (PFTs). Moreover, the nutritional and microbiological status, frequency of pulmonary exacerbations (PExs), and patients' health-related quality of life (HRQoL) were assessed. RESULTS The mean age of the children (n = 69) was 14.09 ± 3.26 years; F/M 37/32. Spirometry-based diagnoses of normal lung function (forced expiratory volume in 1 s, FEV1 ≥ 90%pred), mild (FEV1 70-89%pred) and moderate (FEV1 40-69%pred) lung diseases were established in 34 (49.3%), 25 (36.2%), and 10 (14.5%) patients, respectively. An elevated lung clearance index (LCI > 6.98) was observed in 85% of the subjects with normal FEV1. The presence of Pseudomonas aeruginosa infection (n = 16) and the number of PExs treated with IV antibiotics were associated with significantly worse PFT results. CONCLUSIONS MBNW and IOS are more helpful tools than conventional techniques in assessing early lung disease in CF. LCI is a more useful parameter for detecting functional abnormalities than FEV1 in school-age children.
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Affiliation(s)
- Katarzyna Walicka-Serzysko
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Magdalena Postek
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Urszula Borawska-Kowalczyk
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Justyna Milczewska
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, 01-211 Warsaw, Poland
- Cystic Fibrosis Centre, Paediatric Hospital, Dziekanow Lesny, 05-092 Łomianki, Poland
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Fainardi V, Capoferri G, Tornesello M, Pisi G, Esposito S. Telemedicine and Its Application in Cystic Fibrosis. J Pers Med 2023; 13:1041. [PMID: 37511654 PMCID: PMC10381340 DOI: 10.3390/jpm13071041] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
The care of cystic fibrosis (CF) traditionally consists of regular visits to the clinic where a multidisciplinary team can visit the patient, adjust treatments and monitor the disease. During the COVID-19 pandemic when access to hospitals and medical environments was very limited, the role of telemedicine was crucial to keep in touch with patients with chronic diseases such as CF. Increasing evidence demonstrates that electronic health can successfully support healthcare professionals in the management of people with CF. The use of devices connected to digital platforms or smartphones results in a continuous flow of data that can be shared with the clinician and the team in order to improve the knowledge of patients' diseases and the level of care needed. This narrative review aims to describe the application of telemedicine in CF disease with pros and cons. A literature analysis showed that telemedicine has several advantages in the management of patients with CF. With the evolving support of digital technology, telemedicine can promote clinical visits, adherence to daily treatment, including respiratory physiotherapy and physical exercise, early identification of pulmonary exacerbations and management of psychological issues. The main disadvantages are missed physical exam findings, lack of physical contact that can prevent conversation on sensitive topics, lack of access to technology and lack of technological skills. Furthermore, healthcare operators need appropriate training for telemedicine systems and need time to organise and analyse data generated remotely, which may increase the burden of daily work. Hybrid personalised care models that marge telemedicine and traditional care can be an ideal solution.
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Affiliation(s)
- Valentina Fainardi
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Gaia Capoferri
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Marco Tornesello
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Giovanna Pisi
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Cystic Fibrosis Unit, Pediatric Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
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Katz JB, Shah P, Trillo CA, Alshaer MH, Peloquin C, Lascano J. Therapeutic drug monitoring in cystic fibrosis and associations with pulmonary exacerbations and lung function. Respir Med 2023; 212:107237. [PMID: 37030586 DOI: 10.1016/j.rmed.2023.107237] [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: 11/03/2022] [Revised: 02/20/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy have resulted in longer life expectancies, yet pulmonary exacerbations remain a leading cause of morbidity. Intravenous antibiotics is the mainstay treatment, however achieving adequate concentrations remains challenging. The effect of therapeutic drug monitoring (TDM) of beta-lactams on exacerbations and lung function has not been studied. METHODS Patient demographics, antibiotic regimens, forced expiratory volume 1 second (FEV1), and exacerbation history was obtained from 32 patients with cystic fibrosis admitted for exacerbations. All patients were colonized with Pseudomonas aeruginosa, received CFTR therapy for at least one year, and had 3-month interval follow ups. Plasma concentrations, FEV1, and exacerbation history was obtained before and after therapeutic drug monitoring. This included peak and trough plasma concentrations of piperacillin-tazobactam and cefepime using liquid chromatography with mass spectrometry. T-test and Mann-Whitney U test were used to compare medians/means of FEV1 and pulmonary exacerbations pre and post-TDM as well as free trough-to-minimum inhibitory concentration ratio (fCmin/MIC) ≥1 and ≥ 4. RESULTS TDM was associated with decreased exacerbations/year from 1.91 to 1.31 (p = 0.04) and among the cohort with >/ = 2 exacerbations per year, there was a longer exacerbation free interval after TDM (196.2 vs 103.7 days, p = 0.02). The decline in FEV1% predicted after therapeutic drug monitoring to the first exacerbation was -4.9 compared to -9.7 prior (p = 0.03). CONCLUSIONS TDM for cystic fibrosis pulmonary exacerbations results in decreased pulmonary exacerbations, longer intervals to pulmonary exacerbation, and lower decline in FEV1% predicted.
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Affiliation(s)
- Jason Brandon Katz
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Purav Shah
- Department of Internal Medicine, Pulmonary and Critical Care Division, Emory, Atlanta, GA, 30322, USA.
| | - Cesar A Trillo
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Jorge Lascano
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
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Iovănescu G, Pop LL, Vintilă DR, Marin KC, Mogoantă CA, Lăzureanu DC, Borugă VM, Ciucă IM. Nasal polyposis from cystic fibrosis in children - the experience of a single center. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2023; 64:235-240. [PMID: 37518881 PMCID: PMC10520370 DOI: 10.47162/rjme.64.2.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is the most common monogenic disease, characterized by clinically notable polymorphism. Respiratory disease is the main factor that influences the disease outcome and prognosis of the patient with CF, bacterial infections being responsible for severe exacerbations and rhinosinusitis a difficult complication, besides lung disease. AIM The aim of the paper was to present a case series of CF-associated nasal polyposis and our management experience, providing new data for nasal and sinus complications. PATIENTS, MATERIALS AND METHODS Patients attending the National Cystic Fibrosis Center, Timişoara, Romania, were evaluated for nasal polyposis. Besides clinical examination, endoscopy, and computed tomography (CT) was performed for comprehensive evaluation. Patients with persistent symptoms or with complicated sinusitis underwent surgical approach. RESULTS Fourteen (18.18%) children were diagnosed with nasal polyposis and had surgery, with positive outcomes. One patient received Omalizumab for an associated, uncontrolled asthma with a subsequent substantial effect with the significant polyp reduction and lack of recurrence. CONCLUSIONS Even if extremely difficult to manage, complicated nasal polyposis CF related might have an improved outcome and better life quality.
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Affiliation(s)
- Gheorghe Iovănescu
- Department of ENT, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Romania;
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Perrem L, Stanojevic S, Solomon M, Grasemann H, Sweezey N, Waters V, Sanders DB, Davis SD, Ratjen F. Evaluation of clinically relevant changes in the lung clearance index in children with cystic fibrosis and healthy controls. Thorax 2023; 78:362-367. [PMID: 35428702 DOI: 10.1136/thoraxjnl-2021-218347] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The limits of reproducibility of the lung clearance index (LCI) are higher in children with cystic fibrosis (CF) compared with healthy children, and it is currently unclear what defines a clinically meaningful change. METHODS In a prospective multisite observational study of children with CF and healthy controls (HCs), we measured LCI, FEV1% predicted and symptom scores at quarterly visits over 2 years. Two reviewers performed a detailed review of visits to evaluate the frequency that between visit LCI changes outside ±10%, ±15%, ±20% represented a clinically relevant signal. In the setting of acute respiratory symptoms, we used a generalised estimating equation model, with a logit link function to determine the ability of LCI worsening at different thresholds to predict failure of lung function recovery at follow-up. RESULTS Clinically relevant LCI changes outside ±10%, ±15% and ±20% were observed at 25.7%, 15.0% and 8.3% of CF visits (n=744), respectively. The proportions of LCI changes categorised as noise, reflecting biological variability, were comparable between CF and HC at the 10% (CF 9.9% vs HC 13.0%), 15% (CF 4.3% vs HC 3.1%) and 20% (CF 2.4% vs HC 1.0%) thresholds. Compared with symptomatic CF visits without a worsening in LCI, events with ≥10% LCI increase were more likely to fail to recover baseline LCI at follow-up. CONCLUSION The limits of reproducibility of the LCI in healthy children can be used to detect clinically relevant changes and thus inform clinical care in children with CF.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada .,Postgraduate Medical Education, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Valerie Waters
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Stephanie D Davis
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
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Milinic T, McElvaney OJ, Goss CH. Diagnosis and Management of Cystic Fibrosis Exacerbations. Semin Respir Crit Care Med 2023; 44:225-241. [PMID: 36746183 PMCID: PMC10131792 DOI: 10.1055/s-0042-1760250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is acute pulmonary exacerbation (PEx). Clinical and microbial epidemiology studies of CF PEx continue to provide important insight into the disease course, prognosis, and complications. This work has now led to several large-scale clinical trials designed to clarify the treatment paradigm for CF PEx. The primary goal of this review is to provide a summary and update of the pathophysiology, clinical and microbial epidemiology, outcome and treatment of CF PEx, biomarkers for exacerbation, and the impact of highly effective modulator therapy on these events moving forward.
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Affiliation(s)
- Tijana Milinic
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Oliver J McElvaney
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher H Goss
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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42
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Thornton CS, Parkins MD. Microbial Epidemiology of the Cystic Fibrosis Airways: Past, Present, and Future. Semin Respir Crit Care Med 2023; 44:269-286. [PMID: 36623820 DOI: 10.1055/s-0042-1758732] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Progressive obstructive lung disease secondary to chronic airway infection, coupled with impaired host immunity, is the leading cause of morbidity and mortality in cystic fibrosis (CF). Classical pathogens found in the airways of persons with CF (pwCF) include Pseudomonas aeruginosa, Staphylococcus aureus, the Burkholderia cepacia complex, Achromobacter species, and Haemophilus influenzae. While traditional respiratory-tract surveillance culturing has focused on this limited range of pathogens, the use of both comprehensive culture and culture-independent molecular approaches have demonstrated complex highly personalized microbial communities. Loss of bacterial community diversity and richness, counteracted with relative increases in dominant taxa by traditional CF pathogens such as Burkholderia or Pseudomonas, have long been considered the hallmark of disease progression. Acquisition of these classic pathogens is viewed as a harbinger of advanced disease and postulated to be driven in part by recurrent and frequent antibiotic exposure driven by frequent acute pulmonary exacerbations. Recently, CF transmembrane conductance regulator (CFTR) modulators, small molecules designed to potentiate or restore diminished protein levels/function, have been successfully developed and have profoundly influenced disease course. Despite the multitude of clinical benefits, structural lung damage and consequent chronic airway infection persist in pwCF. In this article, we review the microbial epidemiology of pwCF, focus on our evolving understanding of these infections in the era of modulators, and identify future challenges in infection surveillance and clinical management.
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Affiliation(s)
- Christina S Thornton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael D Parkins
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
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El Hassani M, Thirion DJG, Koloskoff K, Matouk E, Simard C, Cloutier I, Pilote S, Marsot A. Development and Evaluation of a Height-Based Tobramycin Initial Dosing Nomogram for the Treatment of Adult Cystic Fibrosis Pulmonary Exacerbations. Ther Drug Monit 2023; 45:259-264. [PMID: 36730982 DOI: 10.1097/ftd.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/03/2022] [Indexed: 02/04/2023]
Abstract
ABSTRACT Tobramycin is widely used to treat pulmonary exacerbations of cystic fibrosis. Height has been previously found to be significantly more predictive of tobramycin pharmacokinetics than body weight. This study aimed to develop a height-based initial dosing nomogram and evaluate its performance in peak concentration (Cmax) precision relative to standard and fixed dosing. Monte Carlo simulations were performed to develop a nomogram representing the doses required to reach Cmax targets at different heights. Cmax data observed at 2 clinical centers [McGill University Health Centre (MUHC) and Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ-UL)] were compared with population-predicted Cmax using the doses derived from the nomogram alongside a fixed dose. Height-based dosing resulted in significantly less variable-predicted Cmax values [coefficient of variation (CV) MUHC = 15.7% and IUCPQ-UL = 10.8%] than the Cmax values observed in clinical practice (CV MUHC = 30.0% and CV IUCPQ-UL = 26.9%) and predicted Cmax values obtained from a fixed dose (CV MUHC = 21.2% and CV IUCPQ-UL = 16.3%). An initial dosing nomogram was developed to help reduce pharmacokinetic variability in the observed Cmax. More precise dosing would allow for better clinical outcomes in adult patients with cystic fibrosis.
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Affiliation(s)
- Mehdi El Hassani
- Faculté de pharmacie, Université de Montréal, Montreal, Canada
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de pharmacie, Université de Montréal, Montreal, Canada
| | - Daniel J G Thirion
- Faculté de pharmacie, Université de Montréal, Montreal, Canada
- Department of Pharmacy, McGill University Health Centre, Montreal, Canada
| | - Kevin Koloskoff
- Faculté de pharmacie, Université de Montréal, Montreal, Canada
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de pharmacie, Université de Montréal, Montreal, Canada
| | - Elias Matouk
- Adult Cystic Fibrosis Clinic, Montreal Chest Institute, McGill University, Montreal, Canada
- Department of Medicine, McGill University, Montreal, Canada
- McGill University Health Center Research Institute, Montreal, Canada
| | - Chantale Simard
- Faculté de pharmacie, Université Laval, Quebec, Canada
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec, Canada; and
| | - Isabelle Cloutier
- Faculté de pharmacie, Université Laval, Quebec, Canada
- Département de pharmacie, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec, Canada
| | - Sylvie Pilote
- Faculté de pharmacie, Université Laval, Quebec, Canada
| | - Amélie Marsot
- Faculté de pharmacie, Université de Montréal, Montreal, Canada
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de pharmacie, Université de Montréal, Montreal, Canada
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Riggsbee D, Engdahl S, Pettit RS. Evaluation of the safety of piperacillin-tazobactam extended infusion in pediatric cystic fibrosis patients. Pediatr Pulmonol 2023; 58:1092-1099. [PMID: 36593628 DOI: 10.1002/ppul.26299] [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: 07/27/2022] [Revised: 11/30/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) may be treated with piperacillin-tazobactam (PZT) for acute pulmonary exacerbations. Extending the infusion of PZT is one strategy to increase efficacy. Direct comparison, with respect to the incidence of acute kidney injury (AKI), between these two strategies has not been evaluated in pediatric patients with CF. The primary objective of this study was to compare the incidence of AKI in pediatric CF patients receiving extended infusion (EI) PZT versus traditional infusion (TI). METHODS This IRB-approved, retrospective analysis included patients ages 30 days to 18 years that received PZT for at least 48 h between January 1, 2008, and January 1, 2020. PZT was infused over 30 min (TI group) or 4 h (EI group). RESULTS Two hundred and four patients were included (TI: 109, EI: 95). Median age was 8 years (4-13) and 7 years (3-12) in the TI and EI groups (p = 0.15). The groups did not differ significantly in their baseline characteristics. There were 12 (11%) AKIs in the TI group and 8 (8.4%) in the EI group (p = 0.53). There was one occurrence of serum sickness in the TI group and none in the EI group. The incidence of thrombocytopenia was similar between the two groups. Median treatment duration was 8 days (5-11) and 9 days (5-13) for the TI and EI groups, respectively (p = 0.24). CONCLUSIONS There was no significant increase in AKI in pediatric patients with CF receiving PZT by EI compared with TI. EI may be utilized to optimize the pharmacokinetics of PZT in pediatric CF patients.
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Affiliation(s)
- Daniel Riggsbee
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | - Samantha Engdahl
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | - Rebecca S Pettit
- Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
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Brackenborough K, Ellis H, Flight WG. Respiratory Viruses and Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:196-208. [PMID: 36535663 DOI: 10.1055/s-0042-1758728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The threat of respiratory virus infection to human health and well-being has been clearly highlighted by the coronavirus disease 2019 (COVID-19) pandemic. For people with cystic fibrosis (CF), the clinical significance of viral infections long predated the emergence of severe acute respiratory syndrome coronavirus 2. This article reviews the epidemiology, diagnosis, and treatment of respiratory virus infection in the context of CF as well as the current understanding of interactions between viruses and other microorganisms in the CF lung. The incidence of respiratory virus infection in CF varies by age with young children typically experiencing more frequent episodes than adolescents and adults. At all ages, respiratory viruses are very common in CF and are associated with pulmonary exacerbations. Respiratory viruses are identified at up to 69% of exacerbations, while viruses are also frequently detected during clinical stability. The full impact of COVID-19 in CF is yet to be established. Early studies found that rates of COVID-19 were lower in CF cohorts than in the general population. The reasons for this are unclear but may be related to the effects of shielding, infection control practices, maintenance CF therapies, or the inflammatory milieu in the CF lung. Observational studies have consistently identified that prior solid organ transplantation is a key risk factor for poor outcomes from COVID-19 in CF. Several key priorities for future research are highlighted. First, the impact of highly effective CFTR modulator therapy on the epidemiology and pathophysiology of viral infections in CF requires investigation. Second, the impact of respiratory viruses on the development and dynamics of the CF lung microbiota is poorly understood and viral infection may have important interactions with bacteria and fungi in the airway. Finally, bacteriophages represent a key focus of future investigation both for their role in transmission of antimicrobial resistance and as a promising treatment modality for multiresistant pathogens.
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Affiliation(s)
- Kate Brackenborough
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Huw Ellis
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - William G Flight
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom.,Research and Development, GlaxoSmithKline plc, Brentford, United Kingdom
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46
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Gonzalez-Rosales N, Kasi AS, McCracken CE, Silva GL, Starks M, Stecenko A, Guglani L. Impact of viral respiratory infections on pulmonary exacerbations in children with cystic fibrosis. Pediatr Pulmonol 2023; 58:871-877. [PMID: 36479634 DOI: 10.1002/ppul.26267] [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: 08/21/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Viral respiratory infections trigger pulmonary exacerbations (PEs) in children with cystic fibrosis (CF), but their clinical impact is not well understood. METHODS A retrospective review of pediatric patients with CF who underwent nasopharyngeal respiratory viral panel testing during hospitalization for a PE between 2011 and 2018 was conducted. Patients were dichotomized into viral-positive and viral-negative groups. The results of spirometry, respiratory cultures, duration of hospitalization, and risk for subsequent PEs were analyzed. RESULTS Ninety-five patients had 210 hospitalizations for PE (viral-positive = 71/210, 34%) during the study period. Rhinovirus/enterovirus was the most common virus (52/71, 73%) identified. Viral-positive patients were younger (p < 0.001), had higher baseline forced expiratory volume in 1 s (FEV1) (p = 0.037), continued to maintain higher FEV1 at 3 and 6 months following PE (p = 0.003 and 0.002, respectively), and had a shorter duration of hospitalization (p = 0.006) compared to the viral-negative group. There was no difference between the two groups in the rate of recovery of FEV1 at 3 and 6 months following PE (p = 0.71 and 0.405, respectively), time to the next PE (hazard ratio = 1.34, p = 0.157), number of subsequent PEs in 6 months (p = 0.99), or Pseudomonas aeruginosa (PA) acquisition (p = 0.707). CONCLUSIONS In this single pediatric CF center cohort, one-third of PEs requiring hospitalization were associated with a viral infection, with rhinovirus/enterovirus being the most common. Viral-positive PEs were not associated with a greater decline or delayed recovery of lung function, increased risk for PA acquisition, shortened duration to next PE, longer hospital stay, or an increase in the frequency of subsequent PEs in 6 months compared to viral-negative PEs.
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Affiliation(s)
- Noel Gonzalez-Rosales
- Department of Pediatrics and Children's Healthcare of Atlanta, Center for Cystic Fibrosis and Airways Disease Research, Emory University, Atlanta, Georgia, USA
| | - Ajay S Kasi
- Department of Pediatrics and Children's Healthcare of Atlanta, Center for Cystic Fibrosis and Airways Disease Research, Emory University, Atlanta, Georgia, USA
| | - Courtney E McCracken
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George L Silva
- Department of Pediatrics and Children's Healthcare of Atlanta, Center for Cystic Fibrosis and Airways Disease Research, Emory University, Atlanta, Georgia, USA
| | - Miah Starks
- Children's Healthcare of Atlanta and Emory University Cystic Fibrosis Care Center, Atlanta, Georgia, USA
| | - Arlene Stecenko
- Department of Pediatrics and Children's Healthcare of Atlanta, Center for Cystic Fibrosis and Airways Disease Research, Emory University, Atlanta, Georgia, USA
| | - Lokesh Guglani
- Department of Pediatrics and Children's Healthcare of Atlanta, Center for Cystic Fibrosis and Airways Disease Research, Emory University, Atlanta, Georgia, USA
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47
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Cogen JD, Hall M, Faino AV, Ambroggio L, Blaschke AJ, Brogan TV, Cotter JM, Gibson RL, Grijalva CG, Hersh AL, Lipsett SC, Shah SS, Shapiro DJ, Neuman MI, Gerber JS. Antibiotics and outcomes of CF pulmonary exacerbations in children infected with MRSA and Pseudomonas aeruginosa. J Cyst Fibros 2023; 22:313-319. [PMID: 35945130 PMCID: PMC11315227 DOI: 10.1016/j.jcf.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone. METHODS Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting. RESULTS 943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics. CONCLUSIONS Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States.
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, United States
| | - Anna V Faino
- Core for Biostatistics, Epidemiology, and Analytics in Research, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, Colorado, United States
| | - Anne J Blaschke
- Division of Pediatric Infectious Disease, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Thomas V Brogan
- Division of Critical Care, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States
| | - Jillian M Cotter
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, Colorado, United States
| | - Ronald L Gibson
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Adam L Hersh
- Division of Pediatric Infectious Disease, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, Canada
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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48
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Home Spirometry in Children with Cystic Fibrosis. Bioengineering (Basel) 2023; 10:bioengineering10020242. [PMID: 36829736 PMCID: PMC9952128 DOI: 10.3390/bioengineering10020242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/04/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
We report the implementation of a pediatric home spirometry program at our institution. A respiratory therapist provided either a virtual or an in-person initiation visit that included a coached spirometry session. Families were instructed to perform daily uncoached spirometry sessions for 5 days. The program's quality assurance component was deemed not to be human research by the local IRB. In total, 52 subjects completed an initiation visit (34 with at least 3 additional uncoached spirometry sessions). The clinic spirometry and coached (same-day) sessions and uncoached (same-week) sessions were completed by 12 and 17 subjects, respectively. The median (99% CI) coefficients of variation for FEV1% of the uncoached maneuvers were 3.5% (2.9-5.9%). The median (IQR) FEV1% and FEV1 (mL) absolute differences between coached and uncoached home spirometry were -2% (-4 and +3%) and -25 mL (-93 and +93 mL), respectively. The median (IQR) absolute differences in FEV1% and FEV1 (mL) between coached or uncoached home spirometry and clinic spirometry were -6% (-10 and -2%) and -155 mL (-275 and -88 mL), and -4% (-10 and +5%), and -110 mL (-280 and +9 mL), respectively. Differences in absolute FEV1 (L) and FEV1% were found among different modalities of spirometry performed by people with cystic fibrosis. Understanding the variability of uncoached home spirometry and the differences among coached and uncoached home spirometry, hospital and coached home spirometry, and hospital and uncoached home spirometry for any given individual is crucial to effectively utilize this tool in clinical care.
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49
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Radtke T. Role of physical activity and airway clearance therapy in cystic fibrosis: moving forward in a rapidly changing landscape. Thorax 2023; 78:3-4. [PMID: 36180065 DOI: 10.1136/thorax-2022-219429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas Radtke
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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50
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Beaufils F, Enaud R, Gallode F, Boucher G, Macey J, Berger P, Fayon M, Bui S. Adherence, reliability, and variability of home spirometry telemonitoring in cystic fibrosis. Front Pediatr 2023; 11:1111088. [PMID: 36911035 PMCID: PMC9998040 DOI: 10.3389/fped.2023.1111088] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Forced spirometry is the gold standard to assess lung function, but its accessibility may be limited. By contrast, home spirometry telemonitoring allows a multi-weekly lung function follow-up but its real-life adherence, reliability, and variability according to age have been poorly studied in patients with CF (PwCF). We aimed to compare real-life adherence, reliability and variability of home spirometry between children, teenagers and adults with CF. Methods This real-life observational study included PwCF followed for six months in whom lung function (i.e, forced expiratory volume maximum in 1 s (FEV1), forced vital capacity (FVC), forced mid-expiratory flow (FEF) and FEV1/FVC ratio) was monitored by both conventional and home spirometry between July 2015 and December 2021. The adherence, reliability and variability of home spirometry was assessed in all PwCF and compared between children (<12years old), teenagers (12-18 years old) and adults. Results 174 PwCF were included (74 children, 43 teenagers and 57 adults). Home spirometry was used at least one time per week by 64.1 ± 4.9% PwCF, more frequently in children and teenagers than in adults (79.4 ± 2.9%, 69.2 ± 5.5% and 40.4 ± 11.5% respectively). The reliability to conventional lung function testing was good for all assessed parameters (e.g., FEV1: r = 0.91, p < 0.01) and the variability over the 6 months of observation was low (FEV1 coefficient of variation = 11.5%). For each parameter, reliability was better, and the variability was lower in adults than in teenagers than in children. Conclusion Home spirometry telemonitoring appears to be a reliable tool for multi-weekly lung function follow-up of PwCF.
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Affiliation(s)
- Fabien Beaufils
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique (CIC-P 1401), Bordeaux, France
| | - Raphaël Enaud
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique (CIC-P 1401), Bordeaux, France
| | - François Gallode
- CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Grégory Boucher
- CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Julie Macey
- CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Patrick Berger
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique (CIC-P 1401), Bordeaux, France
| | - Michael Fayon
- Univ. Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique (CIC-P 1401), Bordeaux, France
| | - Stéphanie Bui
- CHU Bordeaux, Département de Pédiatrie, CIC-P 1401, Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique (CIC-P 1401), Bordeaux, France
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