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Laflamme OD, Johnson N, Steele K, Chavez L, Cheng SY, Rabin HR, Cheema ZM, Mamic E, Gomez LC, Leong J, Quon BS, Sadatsafavi M, Stephenson AL, Wranik WD, Eckford PDW, Wallenburg J, Bowerman C, Stanojevic S. Socioeconomic burden of cystic fibrosis in Canada. BMJ Open Respir Res 2024; 11:e002309. [PMID: 39122474 PMCID: PMC11331897 DOI: 10.1136/bmjresp-2024-002309] [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: 01/11/2024] [Accepted: 07/11/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Cost of illness studies are important tools to summarise the burden of disease for individuals, the healthcare system and society. The lack of standardised methods for reporting costs for cystic fibrosis (CF) makes it difficult to quantify the total socioeconomic burden. In this study, we aimed to comprehensively report the socioeconomic burden of CF in Canada. METHODS The total cost of CF in Canada was calculated by triangulating information from three sources (Canadian CF Registry, customised Burden of Disease survey and publicly available information). A prevalence-based, bottom-up, human capital approach was applied, and costs were categorised into four perspectives (ie, healthcare system, individual/caregiver, variable (ie, medicines) and society) and three domains (ie, direct, indirect and intangible). All costs were converted into 2021 Canadian dollars (CAD) and adjusted for inflation. The cost of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies was excluded. RESULTS The total socioeconomic burden of CF in Canada in 2021 across the four perspectives was $C414 million. Direct costs accounted for two-thirds of the total costs, with medications comprising half of all direct costs. Out-of-pocket costs to individuals and caregivers represented 18.7% of all direct costs. Indirect costs representing absenteeism accounted for one-third of the total cost. CONCLUSION This comprehensive cost of illness study for CF represents a community-oriented approach describing the socioeconomic burden of living with CF and serves as a benchmark for future studies.
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Affiliation(s)
- Olivier D Laflamme
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Noah Johnson
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kim Steele
- Cystic Fibrosis Canada, Toronto, Ontario, Canada
| | - Luis Chavez
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Harvey R Rabin
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zain M Cheema
- Cystic Fibrosis Canada, Toronto, Ontario, Canada
- Department of Medicine, Hamilton, Hamilton, Ontario, Canada
| | - Eunice Mamic
- Cystic Fibrosis Canada, Toronto, Ontario, Canada
| | - Lilian C Gomez
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeanette Leong
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bradley S Quon
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Anne L Stephenson
- Division of Respirology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - W Dominika Wranik
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Public and International Affairs, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | - Cole Bowerman
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Medicine, Hamilton, Hamilton, Ontario, Canada
| | - Sanja Stanojevic
- Department of Community Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Zampoli M, Sykes J, Verstraete J, Cheng SY, Morrow B, Pepper MS, Stewart C, Zar HJ, Stephenson AL. Global disparities in cystic fibrosis outcomes prior to CFTR modulators: A CF registries cohort study in South Africa and Canada. J Cyst Fibros 2024; 23:334-340. [PMID: 37704465 DOI: 10.1016/j.jcf.2023.09.003] [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: 02/28/2023] [Revised: 08/01/2023] [Accepted: 09/07/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Outcomes of cystic fibrosis (CF) differ between low-middle income and high-income countries, but comparative data are lacking. We compared South African (SA) and Canadian CF outcomes to explore what disparities existed prior to access of CFTR modulators in Canada. METHODS A cross-sectional study of SA and Canadian CF registries data for period 1 January to 31 December 2018. CF registry data were harmonised between countries to compare lung function and nutrition outcomes. Poor nutrition was defined as BMIz-score < -1 in children and < 18.5 kg/m2 in adults. Standardised mean difference (SMD) >10 was considered significant. RESULTS After excluding Canadians on CFTR modulators and lung transplant recipients, data on 4049 Canadian and 446 SA people was analysed. Compared to Canada, people in SA were younger (median age 15.8 years vs. 24.1 years: SMD 52) with fewer males (47.8% vs 54.2%; SMD 12.5) and White (70.9% vs. 93.3%; SMD 61.3). Class I-III CFTR mutation frequency was similar in SA (n = 384, 86.1%) and Canada (n = 3426, 84.9%). After adjusting for age, gender, diagnosis age, genotype, P.aeruginosa infection and pulmonary treatments, FEV1pp was 8.9% lower (95% CI 6.3% to 11.4%) and poor nutrition 1.7-fold more common (OR 1.70; 95% CI 1.19-2.41) in SA compared to Canada. CONCLUSION Lung function and nutrition was significantly lower in SA compared to Canada. Global disparities in CF outcomes between high and low-middle income countries are likely to widen as CFTR modulators are rapidly scaled up in only high-income countries.
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Affiliation(s)
- Marco Zampoli
- Department of Paediatrics and Child Health, University of Cape Town, South Africa; South African MRC Unit for Child and Adolescent Health, University of Cape Town, South Africa.
| | - Jenna Sykes
- Department of Respirology, Adult Cystic Fibrosis Program, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Janine Verstraete
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | | | - Brenda Morrow
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - Michael S Pepper
- Department of Immunology, Institute for Cellular and Molecular Medicine, SAMRC Extramural Unit for Stem Cell Research and Therapy, University of Pretoria, South Africa
| | - Cheryl Stewart
- Department of Basic Medical Sciences, The University of the West Indies, Mona, Jamaica
| | - Heather J Zar
- Department of Paediatrics and Child Health, University of Cape Town, South Africa; South African MRC Unit for Child and Adolescent Health, University of Cape Town, South Africa
| | - Anne L Stephenson
- Department of Respirology, Adult Cystic Fibrosis Program, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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da Silva LVRF, Athanazio RA, Tonon CR, Ferreira JC, Tanni SE. Use of elexacaftor+tezacaftor+ivacaftor in individuals with cystic fibrosis and at least one F508del allele: a systematic review and meta-analysis. J Bras Pneumol 2024; 49:e20230187. [PMID: 38198345 PMCID: PMC10760416 DOI: 10.36416/1806-3756/e20230187] [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: 05/27/2023] [Accepted: 08/11/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE To evaluate the effect of treatment with the combination of three cystic fibrosis transmembrane conductance regulator (CFTR) modulators-elexacaftor+tezacaftor+ivacaftor (ETI)-on important clinical endpoints in individuals with cystic fibrosis. METHODS This was a systematic review and meta-analysis of randomized clinical trials that compared the use of ETI in individuals with CF and at least one F508del allele with that of placebo or with an active comparator such as other combinations of CFTR modulators, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) methodology. We searched the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from their inception to December 26th, 2022. The risk of bias was assessed using the Cochrane risk-of-bias tool, and the quality of evidence was based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We retrieved 54 studies in the primary search. Of these, 6 met the inclusion criteria and were analyzed (1,127 patients; 577 and 550 in the intervention and control groups, respectively). The meta-analysis revealed that the use of ETI increased FEV1% [risk difference (RD), +10.47%; 95% CI, 6.88-14.06], reduced the number of acute pulmonary exacerbations (RD, -0.16; 95% CI, -0.28 to -0.04), and improved quality of life (RD, +14.93; 95% CI, 9.98-19.89) and BMI (RD, +1.07 kg/m2; 95% CI, 0.90-1.25). Adverse events did not differ between groups (RD, -0.03; 95% CI, -0.08 to 0.01), and none of the studies reported deaths. CONCLUSIONS Our findings demonstrate that ETI treatment substantially improves clinically significant, patient-centered outcomes.
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Affiliation(s)
- Luiz Vicente Ribeiro Ferreira da Silva
- . Unidade de Pneumologia Pediátrica, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Suzana Erico Tanni
- . Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Botucatu, (SP) Brasil
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Gokdemir Y, Eralp EE, Ergenekon AP, Yilmaz Yegit C, Yanaz M, Mursaloğlu H, Uzunoglu B, Kocamaz D, Tastan G, Kenis Coskun O, Filbrun A, Enochs C, Bouma S, Iwanicki C, Karakoc F, Nasr SZ, Karadag B. Implementation of standardized cystic fibrosis care algorithm to improve the center data-quality improvement project international collaboration. J Cyst Fibros 2023; 22:710-714. [PMID: 37037703 DOI: 10.1016/j.jcf.2023.03.016] [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: 07/19/2022] [Revised: 02/26/2023] [Accepted: 03/26/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND A collaboration between the University of Michigan (U of M) Cystic Fibrosis Center (CFC) and Marmara University (MU) CFC was initiated to improve the health status of people with cystic fibrosis (pwCF) at MU through implementing Quality Improvement (QI) initiatives. The main aim was to improve lung function in children with FEV1pp <80. The secondary aim was to assess the changes in health related quality of life. METHODS Included in the project were pwCF who received cystic fibrosis (CF) care at the MU CFC and were 6-18 years of age with an FEV1pp <80. Flow charts were created and a standardized CF care algorithm was implemented. Weekly case review were done to develop individualized treatment plans. Appropriate intervention was applied and patient data were assessed at baseline, 3, 6, 9 and 12 months. The Cystic Fibrosis Revised Questionnaire (CFQ-R) was completed. RESULTS 55 pwCF were included (mean age:11.8 ± 3.3 years). Mean FEV1pp (SD) at baseline, 6 and 12 month was 63.7 (14.6), 66.9 (16.6), 70.4 (19.2), respectively, with a relative increase of 5.0% in 6 months (p:0.002) and 10.5% in 12 months compared to baseline (p<0.001). Physical functioning, eating problems and respiratory symptoms domains of the CFQ-R questionnaire were improved at the end of the one year for 6-13 (p = 0.024, p = 0.009, p = 0.002) and 13-18 year olds (p = 0.013, p = 0.002, p = 0.038). CONCLUSION There was significant improvement in pwCF with FEV1<80%pp after implementing this QI project. The processes and assessments used can be adopted by other low-middle income countries to improve similar measures.
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Affiliation(s)
- Yasemin Gokdemir
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey.
| | - Ela Erdem Eralp
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Almala Pinar Ergenekon
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Cansu Yilmaz Yegit
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Muruvvet Yanaz
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Hakan Mursaloğlu
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey; King's College Hospital, Department of Emergency Medicine, London, England, United Kingdom
| | - Burcu Uzunoglu
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Damla Kocamaz
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Gamze Tastan
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Ozge Kenis Coskun
- Marmara University School of Medicine, Department of Physical Therapy and Rehabilitation, Istanbul, Turkey
| | - Amy Filbrun
- Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan, United States.
| | - Catherine Enochs
- Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan, United States.
| | - Sandra Bouma
- Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan, United States.
| | - Courtney Iwanicki
- Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan, United States.
| | - Fazilet Karakoc
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
| | - Samya Z Nasr
- Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan, United States.
| | - Bulent Karadag
- Marmara University School of Medicine, Division of Pediatric Pulmonology, Mimar Sinan Cad. No:10, Istanbul 34899, Turkey
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Desai S, Zhang W, Sutherland JM, Singer J, Quon BS. Factors associated with frequent high-cost individuals with cystic fibrosis and their healthcare utilization and cost patterns. Sci Rep 2023; 13:8910. [PMID: 37264136 DOI: 10.1038/s41598-023-35942-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
Cystic fibrosis (CF) is a progressive multi-organ disease with significant morbidity placing extensive demands on the healthcare system. Little is known about those individuals with CF who continually incur high costs over multiple years. Understanding their characteristics may help inform opportunities to improve management and care, and potentially reduce costs. The purpose of this study was to identify and understand the clinical and demographic attributes of frequent high-costing CF individuals and characterize their healthcare utilization and costs over time. A longitudinal study of retrospective data was completed in British Columbia, Canada by linking the Canadian CF Registry with provincial healthcare administrative databases for the period between 2009 and 2017. Multivariable Cox regression models were employed to identify baseline factors associated with becoming a frequent high-cost CF user (vs. not a frequent high-cost CF user) in the follow-up period. We found that severe lung impairment (Hazard Ratio [HR]: 3.71, 95% confidence interval [CI], 1.49-9.21), lung transplantation (HR: 4.23, 95% CI, 1.68-10.69), liver cirrhosis with portal hypertension (HR: 10.96, 95% CI: 3.85-31.20) and female sex (HR: 1.97, 95% CI: 1.13-3.44) were associated with becoming a frequent high-cost CF user. Fifty-nine (17% of cohort) frequent high-cost CF users accounted for more than one-third of the overall total healthcare costs, largely due to inpatient hospitalization and outpatient medication costs.
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Affiliation(s)
- Sameer Desai
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Wei Zhang
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Jason M Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Bradley S Quon
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, #166 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Escaldelai FMD, Silva Filho LVRFD, Neri LDCL, Bergamaschi DP. Quality of anthropometric data measured in children and adolescents with cystic fibrosis: a scoping review. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 41:e2021333. [PMID: 36888749 PMCID: PMC9984155 DOI: 10.1590/1984-0462/2023/41/2021333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/06/2022] [Indexed: 03/08/2023]
Abstract
OBJECTIVE This study aimed to identify methodological aspects involved in determining anthropometric measurements among studies assessing the nutritional status of individuals with cystic fibrosis (CF). METHODS A search of the literature was performed on MEDLINE via Pubmed, Embase, and Web of Science databases. The population comprised children and adolescents with CF. Observational studies and clinical trials using anthropometric and body composition measures and indices determined by dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance assessment (BIA) were included. Use of a standardized procedure for data collection was defined when details on the instruments and their calibration were given, the measuring procedures were described, and when it was clear measures had been determined by a trained team, or the use of an anthropometric reference manual was cited. Data extracted were expressed as absolute and relative frequencies. RESULTS A total of 32 articles were included, and a total of 233 measures or indices were observed. The most frequently used measures were body mass index (kg/m2; 35%), weight (kg; 33%), and height (cm; 33%). Among the 28 studies that used anthropometric measures, 21 (75%) provided a complete or partial description of the measurement instruments used, 3 (11%) reported information on equipment calibration, 10 (36%) indicated the measurement procedures employed by assessors, and 2 (7%) stated a trained team had carried out the measurements. CONCLUSIONS The poor description of measuring procedures precluded a meaningful evaluation of data quality. Scientific debate on this theme can help raise awareness of the need to ensure quality in collecting and fully presenting data.
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Khan MS, Douglas P, Hansell AL, Simmonds NJ, Piel FB. Assessing the health risk of living near composting facilities on lung health, fungal and bacterial disease in cystic fibrosis: a UK CF Registry study. Environ Health 2022; 21:130. [PMID: 36517903 PMCID: PMC9753251 DOI: 10.1186/s12940-022-00932-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 06/17/2023]
Abstract
AIM To explore the health risk of living near permitted composting sites (PCSs) on disease severity in children and adults with cystic fibrosis (CF) across the UK. METHODS: A semi-individual cross-sectional study was used to examine the risk of disease severity in people with CF (pwCF) within and beyond 4 km of PCSs in the UK in 2016. All pwCF registered in the UK CF Registry were eligible for this study. Linear and Poisson regressions, adjusted for age, gender, genotype, BMI, Pseudomonas aeruginosa and deprivation, were used to quantify associations between distance to a PCS and percent predicted forced expiratory volume in one second (ppFEV1), pulmonary exacerbations (#IVdays), and fungal and bacterial infections. RESULTS The mean age of the 9,361 pwCF (3,931 children and 5,430 adults) studied was 20.1 (SD = 14.1) years; 53.3% were male; and 49.2% were homozygous F508del. Over 10% of pwCF (n = 1,015) lived within 4 km of a PCS. We found no statistically significant difference in ppFEV1 and #IVdays/year in children. However, in adults, ppFEV1 was -1.07% lower (95% confidence interval (CI): -2.29%, 0.16%) and #IVdays/year were 1.02 day higher (95%CI: 1.01, 1.04) within 4 km of a PCS. Furthermore, there were statistically significant differences in mean ppFEV1 in CF adults with Aspergillus fumigatus (58.2.% vs 62.0%, p = 0.005) and Candida spp. (56.9% vs 59.9%, p = 0.029) residing within 4 km of a PCS. No associations were identified for allergic bronchopulmonary aspergillosis, P. aeruginosa or Staphylococcus aureus. CONCLUSIONS This novel national study provides evidence that adults with CF living near a PCS may experience small reductions in lung function, an increased risk of pulmonary exacerbations, and more frequent fungal infections. If confirmed by studies using refined exposure assessment methods accounting for bioaerosol dispersion, these results could have important implications for the living environment of pwCF.
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Affiliation(s)
- Muhammad Saleem Khan
- UK Small Area Health Statistics Unit, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, Imperial College London, London, UK
| | - Philippa Douglas
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, Imperial College London, London, UK
- Centre for Radiation, Chemical and Environmental Hazards, UK Health Security Agency (UKHSA), Harwell Science Campus, Didcot, UK
- Centre for Environmental Health and Sustainability, University of Leicester, Leicester, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, University of Leicester, Leicester, UK
| | - Anna L. Hansell
- Centre for Environmental Health and Sustainability, University of Leicester, Leicester, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, University of Leicester, Leicester, UK
| | - Nicholas J. Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Frédéric B. Piel
- UK Small Area Health Statistics Unit, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Units in Environmental Exposures and Health, Imperial College London, London, UK
- MRC Centre for Environment and Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Protection Research Unit in Chemical and Radiation Threats and Hazards, Imperial College London, London, UK
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Abstract
Survival statistics, estimated using data from national cystic fibrosis (CF) registries, inform the CF community and monitor disease progression. This study aimed to estimate survival among people with CF in Australia and to identify factors associated with survival. This population-based cohort study used prospectively collected data from 23 Australian CF centres participating in the Australian CF Data Registry (ACFDR) from 2005-2020. Period survival analysis was used to calculate median age of survival estimates for each 5-year window from 2005-2009 until 2016-2020. The overall median survival was estimated using the Kaplan-Meier method. Between 2005-2020 the ACFDR followed 4,601 people with CF, noting 516 (11.2%) deaths including 195 following lung transplantation. Out of the total sample, more than half (52.5%) were male and 395 (8.6%) had undergone lung transplantation. Two thirds of people with CF (66.1%) were diagnosed before six weeks of age or by newborn/prenatal screening. The overall median age of survival was estimated as 54.0 years (95% CI: 51.0-57.04). Estimated median survival increased from 48.9 years (95% CI: 44.7-53.5) for people with CF born in 2005-2009, to 56.3 years (95% CI: 51.2-60.4) for those born in 2016-2020. Factors independently associated with reduced survival include receiving a lung transplant, having low FEV1pp and BMI. Median survival estimates are increasing in CF in Australia. This likely reflects multiple factors, including newborn screening, improvement in diagnosis, refinements in CF management and centre-based multidisciplinary care.
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Galiniak S, Podgórski R, Rachel M, Mazur A. Serum leptin and neuropeptide Y in patients with cystic fibrosis—A single center study. Front Med (Lausanne) 2022; 9:959584. [PMID: 36186778 PMCID: PMC9515389 DOI: 10.3389/fmed.2022.959584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Along with the significant elongation in the average life expectancy of patients with cystic fibrosis (CF), there are still significant discrepancies in the height, weight, and body mass index (BMI) of patients compared to controls without CF. The correlation between hormones that regulate appetite and body fat mass may be an additional factor in weight loss or poor weight gain in CF patients. Our objective was to estimate serum concentrations of leptin and neuropeptide Y in patients with CF as well as to assess correlations between studied hormones and the clinical parameters of CF. Leptin and neuropeptide Y serum concentrations after an overnight fast were measured using an enzyme-linked immunosorbent assay. All study participants had anthropometric tests and spirometry. In addition, fasting serum lipid profile was also analyzed. Fasting leptin levels in CF were significantly higher in patients with CF patients (13.9 ± 6.9 vs. 6.5 ± 2.6 ng/mL, p < 0.001) compared to controls. There were no differences in leptin concentration between female and male CF participants (15.7 ± 7.8 vs. 12.2 ± 5.6 ng/mL, p = 0.13). Leptin was correlated with age (R = 0.64, p < 0.001), BMI (R = 0.65, p < 0.001), spirometry results (R = −0.49, p < 0.01), and body fat (R = 0.5, p < 0.05). There were no differences in neuropeptide Y concentration between participants with CF and controls as well as neuropeptide Y was not correlated with any studied parameters. The results of our study suggest that weight loss may be associated with a decreased level of leptin, while reduced pulmonary function in CF may be related to an elevated level of leptin.
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Pryor JB, Bradford MC, Jennerich AL, Wai TYH, Pilewski JM, Kapnadak SG, Aitken ML, Goss CH, Ramos KJ. Body Mass Index Recovery after Lung Transplant for Cystic Fibrosis. Ann Am Thorac Soc 2022; 19:1130-1138. [PMID: 35044894 PMCID: PMC9278631 DOI: 10.1513/annalsats.202108-969oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/14/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Many lung transplant recipients with cystic fibrosis (CF) have low preoperative body mass index (BMI); however, post-transplant BMI recovery is not well understood. Objectives: To evaluate BMI recovery (⩾18.5 kg/m2) among CF lung transplant recipients with low preoperative BMI and to investigate the association of survival with BMI recovery. Methods: The United Network for Organ Sharing and CF Foundation patient registries (June 2005-December 2016) were used to identify CF lung transplant recipients. Among recipients surviving ⩾1 year, Cox modeling compared post-transplant 1-year conditional survival between recipients with low (<17 and 17-18.49 kg/m2) versus normal preoperative BMI, stratified by BMI recovery. Results: Of 1,977 CF lung transplant recipients, 272 (14%) and 449 (23%) had a preoperative BMI of <17 and 17-18.49 kg/m2, respectively. For subgroups with a BMI of <17 and 17-18.49 kg/m2, 29% versus 49%, respectively, of those alive at 1 year recovered their BMI. Among recipients with low preoperative BMI, adjusted post-transplant 1-year conditional survival was worse than that in those with preoperative BMI ⩾ 18.5 kg/m2; however, BMI recovery mitigated this. Preoperative BMI < 17 kg/m2 had an adjusted hazard ratio of 1.29 (95% confidence interval [CI], 0.92-1.81) with BMI recovery versus 1.57 (95% CI, 1.09-2.25) without recovery, and preoperative BMI 17-18.49 kg/m2 had an adjusted hazard ratio of 1.28 (95% CI, 1.02-1.61) with BMI recovery versus 1.72 (95% CI, 1.14-2.59) without recovery. Conclusions: Patients with lower preoperative BMI were less likely to achieve BMI recovery within 1 year. However, for those who did, BMI recovery within 1 year after transplant was associated with longer survival.
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Affiliation(s)
| | - Miranda C. Bradford
- Biostatistics Epidemiology and Analytics in Research, Seattle Children’s Research Institute, Seattle, Washington; and
| | - Ann L. Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Travis Y. Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Joseph M. Pilewski
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Moira L. Aitken
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
| | - Christopher H. Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, and
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12
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Zampoli M, Kassanjee R, Verstraete J, Westwood A, Zar HJ, Morrow BM. Trends in cystic fibrosis survival over 40 years in South Africa: An observational cohort study. Pediatr Pulmonol 2022; 57:908-918. [PMID: 34967140 DOI: 10.1002/ppul.25810] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Temporal trends in cystic fibrosis (CF) survival from low-middle-income settings is poorly reported. We describe changes in CF survival after diagnosis over 40 years from a South African (SA) CF center. METHODS An observational cohort study of people diagnosed with CF from 1974 to 2019. Changes in age-specific mortality rates from 2000 (vs. before 2000) were estimated using multivariable Poisson regression. Data were stratified by current age < or ≥10 years and models controlled for diagnosis age, sex, ethnicity, genotype, and Pseudomonas aeruginosa (PA) infection. A second analysis explored the association of mortality with weight and forced expiratory volume in 1 s reported as z-scores (FEV1z-scores) at age 5-8 years. RESULTS A total of 288 people (52% male; 57% Caucasian; 44% p.Phe508del homozygous) were included (median diagnosis age 0.5 years: Q1, Q3: 0.2, 2.5); 100 (35%) died and 30 (10%) lost to follow-up. Among age >10 years, age-specific mortality from 2000 was significantly lower (adjusted hazard ratio [aHR]: 0.14; 95% confidence interval [CI]: 0.06, 0.29; p < 0.001), but not among age <10 years (aHR: 0.67; 95% CI: 0.28, 1.64; p = 0.383). In children <10 years, Caucasian ethnicity was associated with lower mortality (aHR 0.17; 95% CI: 0.05, 0.63), and longer times since first PA infection with higher mortality (aHR: 1.31; 95% CI: 1.01, 1.68). Mortality was sevenfold higher if FEV1z was <-2.0 at age 5-8 years (aHR: 7.64; 95% CI: 2.58, 22.59). CONCLUSION Overall, CF survival has significantly improved in SA from 2000 in people older than 10 years. However, increased risk of mortality persists in young non-Caucasian children, and with FEV1z <-2.0 at age 5-8 years.
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Affiliation(s)
- Marco Zampoli
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,MRC Unit for Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Janine Verstraete
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Anthony Westwood
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,MRC Unit for Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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13
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Nutrition in Cystic Fibrosis—Some Notes on the Fat Recommendations. Nutrients 2022; 14:nu14040853. [PMID: 35215502 PMCID: PMC8875685 DOI: 10.3390/nu14040853] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 12/15/2022] Open
Abstract
Nutrition is important in cystic fibrosis (CF) because the disease is associated with a higher energy consumption, special nutritional deficiencies, and malabsorption mainly related to pancreatic insufficiency. The clinical course with deterioration of lung function has been shown to relate to nutrition. Despite general recommendation of high energy intake, the clinical deterioration is difficult to restrain suggesting that special needs have not been identified and specified. It is well-known that the CF phenotype is associated with lipid abnormalities, especially in the essential or conditionally essential fatty acids. This review will concentrate on the qualitative aspects of fat metabolism, which has mainly been neglected in dietary fat recommendations focusing on fat quantity. For more than 60 years it has been known and confirmed that the patients have a deficiency of linoleic acid, an n-6 essential fatty acid of importance for membrane structure and function. The ratio between arachidonic acid and docosahexaenoic acid, conditionally essential fatty acids of the n-6 and n-3 series, respectively, is often increased. The recently discovered relations between the CFTR modulators and lipid metabolism raise new interests in this field and together with new technology provide possibilities to specify further specify personalized therapy.
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14
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Bayomy OF, Ramos KJ, Goss CH. Improving lung transplant outcomes in France: the high emergency lung transplantation programme. Eur Respir J 2022; 59:59/1/2102209. [PMID: 35086845 PMCID: PMC8896388 DOI: 10.1183/13993003.02209-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/22/2021] [Indexed: 01/29/2023]
Affiliation(s)
- Omar F. Bayomy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kathleen J. Ramos
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, 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 Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
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15
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Ratti GA, Fernandez GS, Schechter MS, Stalvey MS, Ostrenga J, Fink AK, Jain R. Bone mineral density screening by DXA for people with cystic fibrosis: A registry analysis of patient and program factors influencing rates of screening. J Cyst Fibros 2022; 21:784-791. [DOI: 10.1016/j.jcf.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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Patel M, McCormick A, Tamaroff J, Dunn J, Mitchell JA, Lin KY, Farmer J, Rummey C, Perlman SL, Delatycki MB, Wilmot GR, Mathews KD, Yoon G, Hoyle J, Corti M, Subramony SH, Zesiewicz T, Lynch D, McCormack SE. Body Mass Index and Height in the Friedreich Ataxia Clinical Outcome Measures Study. NEUROLOGY-GENETICS 2021; 7:e638. [PMID: 34786480 PMCID: PMC8589265 DOI: 10.1212/nxg.0000000000000638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/31/2021] [Indexed: 01/11/2023]
Abstract
Background and Objectives Body mass index (BMI) and height are important indices of health. We tested the association between these outcomes and clinical characteristics in Friedreich ataxia (FRDA), a progressive neuromuscular disorder. Methods Participants (N = 961) were enrolled in a prospective natural history study (Friedreich Ataxia Clinical Outcome Measure Study). Age- and sex-specific BMI and height Z-scores were calculated using CDC 2000 references for participants younger than 18 years. For adults aged 18 years or older, height Z-scores were also calculated, and absolute BMI was reported. Univariate and multivariate linear regression analyses tested the associations between exposures, covariates, and BMI or height measured at the baseline visit. In children, the superimposition by translation and rotation analysis method was used to compare linear growth trajectories between FRDA and a healthy reference cohort, the Bone Mineral Density in Childhood Study (n = 1,535 used for analysis). Results Median age at the baseline was 20 years (IQR, 13–33 years); 49% (n = 475) were women. A substantial proportion of children (17%) were underweight (BMI-Z < fifth percentile), and female sex was associated with lower BMI-Z (β = −0.34, p < 0.05). In adults, older age was associated with higher BMI (β = 0.09, p < 0.05). Regarding height, in children, older age (β −0.06, p < 0.05) and worse modified Friedreich Ataxia Rating Scale (mFARS) scores (β = −1.05 for fourth quartile vs first quartile, p < 0.01) were associated with shorter stature. In girls, the magnitude of the pubertal growth spurt was less, and in boys, the pubertal growth spurt occurred later (p < 0.001 for both) than in a healthy reference cohort. In adults, in unadjusted analyses, both earlier age of FRDA symptom onset (=0.09, p < 0.05) and longer guanine-adenine-adenine repeat length (shorter of the 2 GAA repeats, β = −0.12, p < 0.01) were associated with shorter stature. Both adults and children with higher mFARS scores and/or who were nonambulatory were less likely to have height and weight measurements recorded at clinical visits. Discussion FRDA affects both weight gain and linear growth. These insights will inform assessments of affected individuals in both research and clinical settings.
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Affiliation(s)
- Maya Patel
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Ashley McCormick
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Jaclyn Tamaroff
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Julia Dunn
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Jonathan A Mitchell
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Kimberly Y Lin
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Jennifer Farmer
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Christian Rummey
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Susan L Perlman
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Martin B Delatycki
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - George R Wilmot
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Katherine D Mathews
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Grace Yoon
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Joseph Hoyle
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Manuela Corti
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - S H Subramony
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Theresa Zesiewicz
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - David Lynch
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Shana E McCormack
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
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Ratjen F, VanDevanter DR. Retracing changes in cystic fibrosis understanding and management over the past twenty years. J Cyst Fibros 2021; 21:3-9. [PMID: 34602342 DOI: 10.1016/j.jcf.2021.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Canada
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH USA.
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18
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Zampoli M, Verstraete J, Frauendorf M, Kassanjee R, Workman L, Morrow BM, Zar HJ. Cystic fibrosis in South Africa: spectrum of disease and determinants of outcome. ERJ Open Res 2021; 7:00856-2020. [PMID: 34350279 PMCID: PMC8326682 DOI: 10.1183/23120541.00856-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/14/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Little is known about cystic fibrosis (CF) in low- to middle-income settings. This study aimed to describe the spectrum and outcomes of CF in South Africa (SA) from the recently established SA CF registry (SACFR). Methods Demographic, diagnosis and clinical data were extracted from the SACFR. Cross-sectional univariable and multivariable regression analysis of best forced expiratory volume in 1 s (FEV1; age≥6 years) and nutrition (all ages) in 2018 was conducted to investigate factors associated with severe lung disease (SLD; FEV1 ≤3.0 z-score) and undernutrition. Results By December 2018, ancestry of 447 individuals included in the SACFR was Caucasian (315; 70%), mixed (87; 19%) and black African (41; 9%). Median diagnosis age was 7.6 months (IQR 2.7-37.1). Genotype was p.Phe508del homozygous (220; 49%); p.Phe508del heterozygous (144; 32%) and neither p.Phe508del or unknown Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) variant in 83 (19%); the second most frequent CFTR variant was 3120+1G>A, common in black Africans. Median age of patients in 2018 was 14.7 years (IQR 7.4-24.4). SLD was independently associated with chronic methicillin-resistant Staphylococcus aureus (MRSA) (adjusted odds ratio( aOR) 16.75; 95% CI 1.74-161.50), undernutrition (aOR 5.20; 95% CI 2.23-12.13) and age (aOR 2.23 per 10 years; 95% CI 1.50-3.31). Undernutrition was associated in univariable analysis with low weight at diagnosis, non-Caucasian ancestry, chronic P. aeruginosa infection and lower socioeconomic status. Conclusion Interventions targeting MRSA infection and nutrition are needed to improve CF outcomes in SA. Most people with CF in SA are eligible for highly effective CFTR modulator therapy.
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Affiliation(s)
- Marco Zampoli
- Dept of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,South African MRC Unit for Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Janine Verstraete
- Dept of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lesley Workman
- Dept of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Brenda M Morrow
- Dept of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Dept of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,South African MRC Unit for Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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19
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McDonald CM, Alvarez JA, Bailey J, Bowser EK, Farnham K, Mangus M, Padula L, Porco K, Rozga M. Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2021; 121:1591-1636.e3. [PMID: 32565399 PMCID: PMC8542104 DOI: 10.1016/j.jand.2020.03.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 12/13/2022]
Abstract
The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.
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20
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Stanojevic S, Davis SD, Perrem L, Shaw M, Retsch-Bogart G, Davis M, Jensen R, Clem CC, Isaac SM, Guido J, Jara S, France L, McDonald N, Solomon M, Sweezey N, Grasemann H, Waters V, Sanders DB, Ratjen FA. Determinants of lung disease progression measured by lung clearance index in children with cystic fibrosis. Eur Respir J 2021; 58:13993003.03380-2020. [PMID: 33542049 DOI: 10.1183/13993003.03380-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023]
Abstract
The lung clearance index (LCI) measured by the multiple breath washout (MBW) test is sensitive to early lung disease in children with cystic fibrosis. While LCI worsens during the preschool years in cystic fibrosis, there is limited evidence to clarify whether this continues during the early school age years, and whether the trajectory of disease progression as measured by LCI is modifiable.A cohort of children (healthy and cystic fibrosis) previously studied for 12 months as preschoolers were followed during school age (5-10 years). LCI was measured every 3 months for a period of 24 months using the Exhalyzer D MBW nitrogen washout device. Linear mixed effects regression was used to model changes in LCI over time.A total of 582 MBW measurements in 48 healthy subjects and 845 measurements in 64 cystic fibrosis subjects were available. The majority of children with cystic fibrosis had elevated LCI at the first preschool and first school age visits (57.8% (37 out of 64)), whereas all but six had normal forced expiratory volume in 1 s (FEV1) values at the first school age visit. During school age years, the course of disease was stable (-0.02 units·year-1 (95% CI -0.14-0.10). LCI measured during preschool years, as well as the rate of LCI change during this time period, were important determinants of LCI and FEV1, at school age.Preschool LCI was a major determinant of school age LCI; these findings further support that the preschool years are critical for early intervention strategies.
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Affiliation(s)
- Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Stephanie D Davis
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Lucy Perrem
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - George Retsch-Bogart
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Miriam Davis
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Renee Jensen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Charles C Clem
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah M Isaac
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Julia Guido
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Jara
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lisa France
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nancy McDonald
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Valerie Waters
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - D B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Felix A Ratjen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
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21
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Schlüter DK, Ostrenga JS, Carr SB, Fink AK, Faro A, Szczesniak RD, Keogh RH, Charman SC, Marshall BC, Goss CH, Taylor-Robinson D. Lung function in children with cystic fibrosis in the USA and UK: a comparative longitudinal analysis of national registry data. Thorax 2021; 77:136-142. [PMID: 33975926 PMCID: PMC8581063 DOI: 10.1136/thoraxjnl-2021-216849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/30/2021] [Accepted: 04/18/2021] [Indexed: 12/18/2022]
Abstract
Rationale A previous analysis found significantly higher lung function in the US paediatric cystic fibrosis (CF) population compared with the UK with this difference apparently decreasing in adolescence and adulthood. However, the cross-sectional nature of the study makes it hard to interpret these results. Objectives To compare longitudinal trajectories of lung function in children with CF between the USA and UK and to explore reasons for any differences. Methods We used mixed effects regression analysis to model lung function trajectories in the study populations. Using descriptive statistics, we compared early growth and nutrition (height, weight, body mass index), infections (Pseudomonas aeruginosa, Staphylococcus aureus) and treatments (rhDnase, hypertonic saline, inhaled antibiotics). Results We included 9463 children from the USA and 3055 children from the UK with homozygous F508del genotype. Lung function was higher in the USA than in the UK when first measured at age six and remained higher throughout childhood. We did not find important differences in early growth and nutrition, or P.aeruginosa infection. Prescription of rhDNase and hypertonic saline was more common in the USA. Inhaled antibiotics were prescribed at similar levels in both countries, but Tobramycin was prescribed more in the USA and colistin in the UK. S. aureus infection was more common in the USA than the UK. Conclusions Children with CF and homozygous F508del genotype in the USA had better lung function than UK children. These differences do not appear to be explained by early growth or nutrition, but differences in the use of early treatments need further investigation.
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Affiliation(s)
- Daniela K Schlüter
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - Siobhán B Carr
- Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Rhonda D Szczesniak
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Christopher H Goss
- Departments of Medicine and Pediatrics, University of Washington, Seattle, Washington, USA
| | - David Taylor-Robinson
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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22
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Clinical Characteristics Associated With Lung Function Decline in Individuals With Adult-Diagnosed Cystic Fibrosis: Contemporary Analysis of the Canadian CF Registry. Chest 2021; 160:65-73. [PMID: 33617807 DOI: 10.1016/j.chest.2021.02.015] [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: 11/22/2020] [Revised: 02/01/2021] [Accepted: 02/08/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Individuals with cystic fibrosis (CF) diagnosed as adults represent a rare but growing subset of the CF population. Limited studies have described their lung function trajectories. RESEARCH QUESTION What is the overall trajectory of lung function and clinical characteristics associated with lung function decline in people who receive a diagnosis of CF as adults? STUDY DESIGN AND METHODS The Canadian CF Patient Registry (CCFR) was used to identify patients with CF who were ≥ 18 years of age at diagnosis and received a diagnosis between 2000 and 2017. Linear mixed-effects models were used to quantify the change in lung function over age and to examine clinical characteristics associated with lung function decline. RESULTS Lung function was stable in early adulthood, with a decline in middle adulthood (age 30-50 years) and a greater decline after 50 years of age. Individuals who receive a diagnosis at older ages (> 50 years: slope, -0.71%/y; 41-50 years: -0.68%/y; 31-40 years: -0.29%/y; 18-30 years: -0.28%/y) and those demonstrating pulmonary symptoms (slope, -0.41%/y) compared with no pulmonary symptoms at baseline were associated with faster rate of lung function decline. INTERPRETATION The lung function of who receive a diagnosis of CF as adults in the CCFR declines slowly compared with estimates from the overall adult CF population. Individuals with adult-diagnosed CF who are older and demonstrate pulmonary symptoms at diagnosis experience a faster rate of lung function decline and should be monitored more closely.
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Ringshausen FC, Hellmuth T, Dittrich AM. [Evidence-based treatment of cystic fibrosis]. Internist (Berl) 2020; 61:1212-1229. [PMID: 33201261 DOI: 10.1007/s00108-020-00896-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mucoviscidosis (cystic fibrosis [CF]) is the most common autosomal recessive inherited multisystem disease with fatal outcome. It is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, which lead to a dysfunctional chloride channel and a defective CFTR protein. As a consequence, retention of insufficiently hydrated mucus affects multiple essential organs, mainly the lungs and airways, pancreas, liver, biliary tract and intestines. This leads to inflammation and infection, fibrosis and progressive tissue destruction. Respiratory failure is the major cause of mortality; however, in the no more than 30 years since the molecular characterization of the basic CFTR defect causing CF, tremendous success has been made with respect to the long-term prognosis of people with CF. This improvement in the prognosis was achieved by the cooperative spirit and networking of the very active and international CF research community and by establishing a multidisciplinary clinical CF team that implements the existing evidence in various aspects of standardized care together with the CF patient. This narrative review article presents the evidence in selected aspects of CF treatment, with special consideration of the most recent development of highly effective CFTR modulator treatment. This treatment will soon become available for more than 90% of the global CF patients and transform the pathophysiology as well as the course of disease towards a treatable chronic condition in internal medicine.
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Affiliation(s)
- F C Ringshausen
- Klinik für Pneumologie, OE 6870, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - T Hellmuth
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - A-M Dittrich
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
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Bradbury NA. Cystic Fibrosis and Genotype-Dependent Therapy: Is There a Need for a Sex-Specific Therapy? GENDER AND THE GENOME 2020. [DOI: 10.1177/2470289720937025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulation (CFTR) anion channel. Loss of CFTR protein and/or function disrupts chloride, bicarbonate, and fluid transport and also impacts epithelial sodium transport. Such altered ion and fluid transport produces mucus obstruction, inflammation, pulmonary infection, and damage to multiple organs. Although an autosomal disease, it is apparent that gender differences in life expectancy and quality of life do exist. Conventionally established therapies have treated the downstream sequelae of CFTR dysfunction and have led to a steady increase in life expectancy. Physicians now have access to medications that treat the basic defect in CF, in the form of CFTR modulators. These drugs target the trafficking and/or function of CFTR to improve clinical outcomes for patients. This review summarizes the science behind CFTR modulators and shows how these drugs have dramatically changed how patients with CF are treated. Surprisingly, although the drug target(s) are identical in males and females, CF females seem to display a greater improvement than their male counterparts.
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Affiliation(s)
- Neil A. Bradbury
- Department of Physiology and Biophysics and Center for Genetic Diseases, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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Saunders C, Jensen R, Robinson PD, Stanojevic S, Klingel M, Short C, Davies JC, Ratjen F. Integrating the multiple breath washout test into international multicentre trials. J Cyst Fibros 2020; 19:602-607. [DOI: 10.1016/j.jcf.2019.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 01/22/2023]
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Lascano-Vaca Y, Ortiz-Prado E, Gomez-Barreno L, Simbaña-Rivera K, Vasconez E, Lister A, Arteaga-Espinosa ME, Perez GF. Clinical, genetic and microbiological characterization of pediatric patients with cystic fibrosis in a public Hospital in Ecuador. BMC Pediatr 2020; 20:111. [PMID: 32143663 PMCID: PMC7060626 DOI: 10.1186/s12887-020-2013-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 02/27/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND To carry out a complete clinical, pathological, genetic and microbiological characterization of pediatric patients with molecular confirmed cystic fibrosis (CF) attending the Carlos Andrade Marín Hospital (HCAM) within the study period. METHODS A cross-sectional analysis of the pediatric population with a confirmed diagnosis of CF disease who attended HCAM, one of the largest tertiary-level hospitals in Ecuador, between 2017 and 2018 was performed. All demographic, clinical and genetic variables were obtained from the electronic medical records (EMR) stored by the hospital. RESULTS Forty seven patients with CF were included in the study. Gender distribution was similar between male (48.9%, n = 23) and female patients (51.1%, n = 24). The Tiffeneau-Pinelli index (FEV1/FVC) changed significantly after nine months post-diagnosis (85.55 ± 13.26; p < 0.05). The most common pathogenic genetic variants were F508del, found in 52.78% of the cohort (n = 19); H609R, found in 36.11% (n = 13); g.204099A > C, found in 14.1% (n = 7), followed by G85E and the N1303K with 11.11% (n = 3) each. CONCLUSIONS To our best knowledge, this is the first study exploring the clinical, genetic and bacteriological profile of CF's patients in Ecuador. Within the cohort of patients, an important and unique genetic feature was characterized by the presence of the g.204099A > C and the c.206359C > A homozygous polymorphism as well as the presence of the H609R variant, a mutation only reported among Ecuadorians.
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Affiliation(s)
- Yazmina Lascano-Vaca
- Pediatric Pneumology Service, Pediatric Unit of the Carlos Andrade Marin Specialties Hospital, Quito, Ecuador
| | - Esteban Ortiz-Prado
- One Health Research Group, Universidad de Las Americas, José Queri and Av. de los Granados, Quito, Ecuador.
| | - Lenin Gomez-Barreno
- One Health Research Group, Universidad de Las Americas, José Queri and Av. de los Granados, Quito, Ecuador
| | - Katherine Simbaña-Rivera
- One Health Research Group, Universidad de Las Americas, José Queri and Av. de los Granados, Quito, Ecuador
| | - Eduardo Vasconez
- One Health Research Group, Universidad de Las Americas, José Queri and Av. de los Granados, Quito, Ecuador
| | - Alexander Lister
- Faculty of Medicine, University of Southampton, Southampton, England
| | | | - Geovanny F Perez
- Division of Pulmonary and Sleep Medicine, Children's National Health System, Washington, DC, USA
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Wijker NE, Vidmar S, Grimwood K, Sly PD, Byrnes CA, Carlin JB, Cooper PJ, Robertson CF, Massie RJ, Kemner van de Corput MP, Cheney J, Tiddens HA, Wainwright CE. Early markers of cystic fibrosis structural lung disease: follow-up of the ACFBAL cohort. Eur Respir J 2020; 55:13993003.01694-2019. [DOI: 10.1183/13993003.01694-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/30/2019] [Indexed: 12/31/2022]
Abstract
Little is known about early predictors of later cystic fibrosis (CF) structural lung disease. This study examined early predictors of progressive structural lung abnormalities in children who completed the Australasian CF Bronchoalveolar Lavage (ACFBAL) clinical trial at age 5-years and participated in an observational follow-up study (CF-FAB).Eight Australian and New Zealand CF centres participated in CF-FAB and provided follow-up chest computed-tomography (CT) scans for children who had completed the ACFBAL study with baseline scans at age 5-years. CT scans were annotated using PRAGMA-CF scoring. Ordinal regression analysis and linear regression were used to investigate associations between PRAGMA-CF (Perth–Rotterdam Annotated Grid Morphometric Analysis for CF) outcomes at follow-up and variables measured during the ACFBAL study.99 out of 157 ACFBAL children (mean±sd age 13±1.5 years) participated in the CF-FAB study. The probability of bronchiectasis at follow-up increased with airway disease severity on the baseline CT scan. In multiple regression (retaining factors at p<0.05) the extent of bronchiectasis at follow-up was associated with baseline atelectasis (OR 7.2, 95% CI 2.4–22; p≤ 0.001), bronchoalveolar lavage (BAL) log2 interleukin (IL)-8 (OR 1.2, 95% CI 1.05–1.5; p=0.010) and body mass index z-score (OR 0.49, 95% CI 0.24–1.00; p=0.05) at age 5 years. Percentage trapped air at follow-up was associated with BAL log2 IL-8 (coefficient 1.3, 95% CI 0.57–2.1; p<0.001) at age 5 years.The extent of airway disease, atelectasis, airway inflammation and poor nutritional status in early childhood are risk factors for progressive structural lung disease in adolescence.
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Bell SC, Mall MA, Gutierrez H, Macek M, Madge S, Davies JC, Burgel PR, Tullis E, Castaños C, Castellani C, Byrnes CA, Cathcart F, Chotirmall SH, Cosgriff R, Eichler I, Fajac I, Goss CH, Drevinek P, Farrell PM, Gravelle AM, Havermans T, Mayer-Hamblett N, Kashirskaya N, Kerem E, Mathew JL, McKone EF, Naehrlich L, Nasr SZ, Oates GR, O'Neill C, Pypops U, Raraigh KS, Rowe SM, Southern KW, Sivam S, Stephenson AL, Zampoli M, Ratjen F. The future of cystic fibrosis care: a global perspective. THE LANCET. RESPIRATORY MEDICINE 2020; 8:65-124. [PMID: 31570318 PMCID: PMC8862661 DOI: 10.1016/s2213-2600(19)30337-6] [Citation(s) in RCA: 569] [Impact Index Per Article: 142.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/19/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
Abstract
The past six decades have seen remarkable improvements in health outcomes for people with cystic fibrosis, which was once a fatal disease of infants and young children. However, although life expectancy for people with cystic fibrosis has increased substantially, the disease continues to limit survival and quality of life, and results in a large burden of care for people with cystic fibrosis and their families. Furthermore, epidemiological studies in the past two decades have shown that cystic fibrosis occurs and is more frequent than was previously thought in populations of non-European descent, and the disease is now recognised in many regions of the world. The Lancet Respiratory Medicine Commission on the future of cystic fibrosis care was established at a time of great change in the clinical care of people with the disease, with a growing population of adult patients, widespread genetic testing supporting the diagnosis of cystic fibrosis, and the development of therapies targeting defects in the cystic fibrosis transmembrane conductance regulator (CFTR), which are likely to affect the natural trajectory of the disease. The aim of the Commission was to bring to the attention of patients, health-care professionals, researchers, funders, service providers, and policy makers the various challenges associated with the changing landscape of cystic fibrosis care and the opportunities available for progress, providing a blueprint for the future of cystic fibrosis care. The discovery of the CFTR gene in the late 1980s triggered a surge of basic research that enhanced understanding of the pathophysiology and the genotype-phenotype relationships of this clinically variable disease. Until recently, available treatments could only control symptoms and restrict the complications of cystic fibrosis, but advances in CFTR modulator therapies to address the basic defect of cystic fibrosis have been remarkable and the field is evolving rapidly. However, CFTR modulators approved for use to date are highly expensive, which has prompted questions about the affordability of new treatments and served to emphasise the considerable gap in health outcomes for patients with cystic fibrosis between high-income countries, and low-income and middle-income countries (LMICs). Advances in clinical care have been multifaceted and include earlier diagnosis through the implementation of newborn screening programmes, formalised airway clearance therapy, and reduced malnutrition through the use of effective pancreatic enzyme replacement and a high-energy, high-protein diet. Centre-based care has become the norm in high-income countries, allowing patients to benefit from the skills of expert members of multidisciplinary teams. Pharmacological interventions to address respiratory manifestations now include drugs that target airway mucus and airway surface liquid hydration, and antimicrobial therapies such as antibiotic eradication treatment in early-stage infections and protocols for maintenance therapy of chronic infections. Despite the recent breakthrough with CFTR modulators for cystic fibrosis, the development of novel mucolytic, anti-inflammatory, and anti-infective therapies is likely to remain important, especially for patients with more advanced stages of lung disease. As the median age of patients with cystic fibrosis increases, with a rapid increase in the population of adults living with the disease, complications of cystic fibrosis are becoming increasingly common. Steps need to be taken to ensure that enough highly qualified professionals are present in cystic fibrosis centres to meet the needs of ageing patients, and new technologies need to be adopted to support communication between patients and health-care providers. In considering the future of cystic fibrosis care, the Commission focused on five key areas, which are discussed in this report: the changing epidemiology of cystic fibrosis (section 1); future challenges of clinical care and its delivery (section 2); the building of cystic fibrosis care globally (section 3); novel therapeutics (section 4); and patient engagement (section 5). In panel 1, we summarise key messages of the Commission. The challenges faced by all stakeholders in building and developing cystic fibrosis care globally are substantial, but many opportunities exist for improved care and health outcomes for patients in countries with established cystic fibrosis care programmes, and in LMICs where integrated multidisciplinary care is not available and resources are lacking at present. A concerted effort is needed to ensure that all patients with cystic fibrosis have access to high-quality health care in the future.
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Affiliation(s)
- Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia; QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
| | - Marcus A Mall
- Charité - Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany; German Center for Lung Research, Berlin, Germany
| | | | - Milan Macek
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Susan Madge
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Jane C Davies
- Royal Brompton and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Pierre-Régis Burgel
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Descartes, Institut Cochin, Paris, France
| | - Elizabeth Tullis
- St Michael's Hospital, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Claudio Castaños
- Hospital de Pediatria "Juan P Garrahan", Buenos Aires, Argentina
| | - Carlo Castellani
- Cystic Fibrosis Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Catherine A Byrnes
- Starship Children's Hospital, Auckland, New Zealand; University of Auckland, Auckland, New Zealand
| | - Fiona Cathcart
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | | | - Isabelle Fajac
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris Descartes, Institut Cochin, Paris, France
| | | | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | | | - Anna M Gravelle
- Cystic Fibrosis Clinic, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Trudy Havermans
- Cystic Fibrosis Centre, University Hospital Leuven, Leuven, Belgium
| | - Nicole Mayer-Hamblett
- University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | - Joseph L Mathew
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Edward F McKone
- School of Medicine, St Vincent's University Hospital, Dublin, Ireland; University College Dublin School of Medicine, Dublin, Ireland
| | - Lutz Naehrlich
- Universities of Giessen and Marburg Lung Center, German Center of Lung Research, Justus-Liebig-University Giessen, Giessen, Germany
| | - Samya Z Nasr
- CS Mott Children's Hospital, Ann Arbor, MI, USA; University of Michigan, Ann Arbor, MI, USA
| | | | | | | | | | - Steven M Rowe
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin W Southern
- Alder Hey Children's Hospital, Liverpool, UK; University of Liverpool, Liverpool, UK
| | - Sheila Sivam
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Anne L Stephenson
- St Michael's Hospital, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Marco Zampoli
- Division of Paediatric Pulmonology and MRC Unit for Child and Adolescent Health, University of Cape Town, Cape Town, South Africa; Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Felix Ratjen
- University of Toronto, Toronto, ON, Canada; Division of Respiratory Medicine, Department of Paediatrics, Translational Medicine Research Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Dhochak N, Jat KR, Sankar J, Lodha R, Kabra SK. Predictors of Malnutrition in Children with Cystic Fibrosis. Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1607-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Savant AP, McColley SA. Cystic fibrosis year in review 2018, part 1. Pediatr Pulmonol 2019; 54:1117-1128. [PMID: 31106528 DOI: 10.1002/ppul.24361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 12/14/2022]
Abstract
Cystic fibrosis research and case reports were robust in the year 2018. This report summarizes research and cases related to Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) modulator therapies, inflammation and infection, epidemiology and the physiologic, and imaging assessment of disease.
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Affiliation(s)
- Adrienne P Savant
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Ramsey BW, Downey GP, Goss CH. Update in Cystic Fibrosis 2018. Am J Respir Crit Care Med 2019; 199:1188-1194. [PMID: 30917288 PMCID: PMC6519861 DOI: 10.1164/rccm.201902-0310up] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/25/2019] [Indexed: 01/03/2023] Open
Affiliation(s)
- Bonnie W. Ramsey
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Center for Clinical and Translational Research and
- Division of Pediatric Pulmonology, Department of Pediatrics, and
| | - Gregory P. Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine
- Department of Pediatrics, and
- Department of Biomedical Research, National Jewish Health, Denver, Colorado; and
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, and
- Department of Microbiology and Immunology, University of Colorado, Aurora, Colorado
| | - Christopher H. Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
- Division of Pediatric Pulmonology, Department of Pediatrics, and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Perrem L, Stanojevic S, Solomon M, Carpenter S, Ratjen F. Incidence and risk factors of paediatric cystic fibrosis-related diabetes. J Cyst Fibros 2019; 18:874-878. [PMID: 31072797 DOI: 10.1016/j.jcf.2019.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis (CF) directly linked to increased morbidity and mortality. Both the incidence of type I and type II diabetes has been shown to increase in the general population. In this study, we investigated the incidence and risk factors of CFRD in a paediatric CF population. METHODS Prospectively collected data from the Canadian CF Registry (CCFR) from 2000 to 2016 for patients ages 10 to 18 years was used to determine the incidence of CFRD. Risk factors for CFRD in the Canadian population were investigated using a nested case-control design. Conditional logistic regression analysis with a 4:1 control: case matching was used. RESULTS From 2000 to 2016, 2326 patients with CF aged between 10 through 18 years were included in the CCFR, during this time the overall incidence rate of CFRD was 2.1 cases per 100 patient-years (95% confidence interval 1.8 to 2.3). Incidence rates were stable in the Canadian cohort over three consecutive time periods 2000-2005, 2006-2010; 2011-2016. Worse lung function, female gender, history of allergic bronchopulmonary aspergillosis, Gastrostomy tube insertion and liver disease were statistically significant risk factors for CFRD. CONCLUSION The incidence of CFRD in the Canadian paediatric population has been stable over time, in contrast to the rising rates of Type 1 and Type 2 diabetes in the general paediatric population. The risk factor for CFRD in this contemporary population were consistent with previous studies.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Susan Carpenter
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Ashkenazi M, Nathan N, Sarouk I, Aluma BEB, Dagan A, Bezalel Y, Keler S, Vilozni D, Efrati O. Nutritional Status in Childhood as a Prognostic Factor in Patients with Cystic Fibrosis. Lung 2019; 197:371-376. [DOI: 10.1007/s00408-019-00218-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 03/12/2019] [Indexed: 01/01/2023]
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Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disease caused by variants in the gene encoding the cystic fibrosis transmembrane conduction regulator (CFTR) protein. Loss of CFTR function disrupts chloride, bicarbonate and regulation of sodium transport, producing a cascade of mucus obstruction, inflammation, pulmonary infection, and ultimately damage in numerous organs. Established CF therapies treat the downstream consequences of CFTR dysfunction and have led to steady improvements in patient survival. A class of drugs termed CFTR modulators has recently entered the CF therapeutic landscape. These drugs differ fundamentally from prior therapies in that they aim to improve the function of disease-causing CFTR variants. This review summarizes the science behind CFTR modulators, including their targets, mechanism of action, clinical benefit, and future directions in the field. CFTR modulators have dramatically changed how CF is treated, validated CFTR as a therapeutic target, and opened the door to truly personalized therapies and treatment regimens.
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Affiliation(s)
- John P. Clancy
- Department of PediatricsCincinnati Childrens Hospital Medical CenterCincinnatiOhio
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Evaluating the impact of 2006 Australasian Clinical Practice Guidelines for nutrition in children with cystic fibrosis in Australia. Respir Med 2018; 142:7-14. [PMID: 30170805 DOI: 10.1016/j.rmed.2018.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine the association between the implementation of the 2006 Australasian Clinical Practice Guidelines for Nutrition in Cystic Fibrosis (CF) and the nutritional status of children participating in the Australian Cystic Fibrosis Data Registry (ACFDR). METHODS This research consisted of a quantitative study using ACFDR data and a survey of clinicians and dietitians treating children with CF. Two independent cohorts of children (2-5 years and 6-11 years) were selected from ACFDR between 1998 and 2014 (N = 2304). Generalised estimating equation model was used to assess weight, height and body mass index (BMI) z-scores for each patient before and after the implementation of the nutrition guidelines. A nationwide online survey was sent to 48 clinicians to explore the enablers and barriers to implementation of the guidelines. RESULTS Data analysis showed significant increase (p < 0.05) in mean weight, height and BMI z-scores ranging from 0.06 to 0.18 after implementation of the guidelines in both cohorts of children. Nineteen (39%) clinicians participated in the survey. The majority of the respondents adopted the recommendations into their practice and used the guidelines as part of their professional development. Structural barriers included a lack of adequate staff resources and clinic space for consultations, inappropriate staff classification, high staff turnover and lack of mentoring support. CONCLUSION In children participating in the ACFDR, nutritional status improved after the implementation of the 2006 guidelines. Survey results revealed enablers and barriers to guideline implementation and will inform implementation strategies for the revised Australasian nutrition guidelines for CF, released in 2017.
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McIntyre K, Bertrand DP, Rault G. Using registry data to improve quality of care. J Cyst Fibros 2018; 17:566-572. [DOI: 10.1016/j.jcf.2018.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/09/2018] [Accepted: 06/09/2018] [Indexed: 11/17/2022]
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Clancy JP, Cotton CU, Donaldson SH, Solomon GM, VanDevanter DR, Boyle MP, Gentzsch M, Nick JA, Illek B, Wallenburg JC, Sorscher EJ, Amaral MD, Beekman JM, Naren AP, Bridges RJ, Thomas PJ, Cutting G, Rowe S, Durmowicz AG, Mense M, Boeck KD, Skach W, Penland C, Joseloff E, Bihler H, Mahoney J, Borowitz D, Tuggle KL. CFTR modulator theratyping: Current status, gaps and future directions. J Cyst Fibros 2018; 18:22-34. [PMID: 29934203 DOI: 10.1016/j.jcf.2018.05.004] [Citation(s) in RCA: 179] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND New drugs that improve the function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein with discreet disease-causing variants have been successfully developed for cystic fibrosis (CF) patients. Preclinical model systems have played a critical role in this process, and have the potential to inform researchers and CF healthcare providers regarding the nature of defects in rare CFTR variants, and to potentially support use of modulator therapies in new populations. METHODS The Cystic Fibrosis Foundation (CFF) assembled a workshop of international experts to discuss the use of preclinical model systems to examine the nature of CF-causing variants in CFTR and the role of in vitro CFTR modulator testing to inform in vivo modulator use. The theme of the workshop was centered on CFTR theratyping, a term that encompasses the use of CFTR modulators to define defects in CFTR in vitro, with application to both common and rare CFTR variants. RESULTS Several preclinical model systems were identified in various stages of maturity, ranging from the expression of CFTR variant cDNA in stable cell lines to examination of cells derived from CF patients, including the gastrointestinal tract, the respiratory tree, and the blood. Common themes included the ongoing need for standardization, validation, and defining the predictive capacity of data derived from model systems to estimate clinical outcomes from modulator-treated CF patients. CONCLUSIONS CFTR modulator theratyping is a novel and rapidly evolving field that has the potential to identify rare CFTR variants that are responsive to approved drugs or drugs in development.
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Affiliation(s)
- John Paul Clancy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | | | - Scott H Donaldson
- University of North Carolina at Chapel Hill - Marsico Lung Institute, United States
| | - George M Solomon
- University of Alabama at Birmingham, University of Alabama at Birmingham
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Michael P Boyle
- Cystic Fibrosis Foundation, Johns Hopkins University, United States
| | - Martina Gentzsch
- Marsico Lung Institute/Cystic Fibrosis Research Center, University of North Carolina, Chapel Hill, United States; Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, United States
| | - Jerry A Nick
- National Jewish Health, Denver, CO, United States
| | - Beate Illek
- UCSF Benioff Children's Hospital Oakland, United States
| | - John C Wallenburg
- Cystic Firbosis Canada, Directeur en chef des activites scientifiques, fibrose kystique, Canada
| | | | | | | | | | | | | | - Garry Cutting
- Johns Hopkins University School of Medicine, United States
| | - Steven Rowe
- University of Alabama at Birmingham, University of Alabama at Birmingham
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Schultz A, Sly PD. Cystic Fibrosis Survival Gap Closing between the United States and Canada. Don't Leave Anyone Behind! Am J Respir Crit Care Med 2018; 197:701-703. [PMID: 29182890 DOI: 10.1164/rccm.201711-2201ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- André Schultz
- 1 Telethon Kids Institute University of Western Australia Perth, Western Australia, Australia.,2 Department of Respiratory Medicine Princess Margaret Hospital for Children Perth, Western Australia, Australia.,3 School of Medicine University of Western Australia Perth, Western Australia, Australia and
| | - Peter D Sly
- 4 Child Health Research Centre The University of Queensland Brisbane, Queensland, Australia
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