1
|
Teng L, Dedousis N, Adeshirlarijaney A, Kanshana JS, Liu M, Hodges CA, Kohan AB. Impaired intestinal free fatty acid transport followed by chylomicron malformation, not pancreatic insufficiency, cause metabolic defects in cystic fibrosis. J Lipid Res 2024; 65:100551. [PMID: 39002195 DOI: 10.1016/j.jlr.2024.100551] [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: 12/06/2023] [Revised: 04/03/2024] [Accepted: 04/29/2024] [Indexed: 07/15/2024] Open
Abstract
Intestinal disease is one of the earliest manifestations of cystic fibrosis (CF) in children and is closely tied to deficits in growth and nutrition, both of which are directly linked to future mortality. Patients are treated aggressively with pancreatic enzyme replacement therapy and a high-fat diet to circumvent fat malabsorption, but this does not reverse growth and nutritional defects. We hypothesized that defects in chylomicron production could explain why CF body weights and nutrition are so resistant to clinical treatments. We used gold standard intestinal lipid absorption and metabolism approaches, including mouse mesenteric lymph cannulation, in vivo chylomicron secretion kinetics, transmission electron microscopy, small intestinal organoids, and chylomicron metabolism assays to test this hypothesis. In mice expressing the G542X mutation in cystic fibrosis transmembrane conductance regulator (CFTR-/- mice), we find that defective FFA trafficking across the epithelium into enterocytes drives a chylomicron formation defect. Furthermore, G542X mice secrete small, triglyceride-poor chylomicrons into the lymph and blood. These defective chylomicrons are cleared into extraintestinal tissues at ∼10-fold faster than WT chylomicrons. This defect in FFA absorption resulting in dysfunctional chylomicrons cannot be explained by steatorrhea or pancreatic insufficiency and is maintained in primary small intestinal organoids treated with micellar lipids. These studies suggest that the ultrahigh-fat diet that most people with CF are counselled to follow may instead make steatorrhea and malabsorption defects worse by overloading the absorptive capacity of the CF small intestine.
Collapse
Affiliation(s)
- Lihong Teng
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nikolaos Dedousis
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aneseh Adeshirlarijaney
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jitendra S Kanshana
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Min Liu
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Craig A Hodges
- Department of Genetics and Genome Sciences and Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Alison B Kohan
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
2
|
Miles C, Ling N, Paul E, Armstrong D. Presentation, characteristics and management of obstructive intestinal conditions in cystic fibrosis. Frontline Gastroenterol 2024; 15:222-227. [PMID: 38665789 PMCID: PMC11042455 DOI: 10.1136/flgastro-2023-102533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/21/2023] [Indexed: 04/28/2024] Open
Abstract
Objective Constipation and distal intestinal obstruction syndrome (DIOS) are common gastrointestinal manifestations of cystic fibrosis (CF). The primary aim was to describe the characteristics of constipation and DIOS hospitalisations in a paediatric and adult CF service over a 12-year period. The secondary aims were to determine the proportion of constipation and DIOS presentations which met the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) CF Working Group definitions and to describe management strategies of both conditions. Method A retrospective study of children and adults with CF who were admitted with a primary diagnosis of constipation or DIOS between 1 January 2011 and 31 December 2022. ESPGHAN definitions for constipation and DIOS were retrospectively applied to all admissions to determine if the primary medical diagnosis met ESPGHAN criteria. Results During the 12-year study period, 42 hospitalisations for constipation were recorded in 19 patients, and 33 hospitalisations for DIOS were recorded in 23 patients. 88.10% of constipation episodes met ESPGHAN definitions, compared with 3.0% of DIOS episodes. Constipation and DIOS were primarily treated with polyethylene glycol (PEG). The use of sodium amidotrizoate meglumine enemas was significantly higher in the DIOS group (p=0.045). Those admitted with DIOS were significantly less likely to be recommended a weaning dose of PEG (p=0.018). Conclusion Children and adults with CF are more commonly admitted for the management of constipation than DIOS. There is considerable variation in diagnostic and therapeutic practice, and this study highlights the need to enhance the translation and adoption of existing best-practice guidelines.
Collapse
Affiliation(s)
- Caitlin Miles
- Nutrition and Dietetics, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Natalie Ling
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Eldho Paul
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Melbourne, Victoria, Australia
| | - David Armstrong
- Department of Respiratory and Sleep Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Mainz JG, Lester K, Elnazir B, Williamson M, McKone E, Cox D, Linnane B, Zagoya C, Duckstein F, Barucha A, Davies JC, McNally P. Reduction in abdominal symptoms (CFAbd-Score), faecal M2-pyruvate-kinase and Calprotectin over one year of treatment with Elexacaftor-Tezacaftor-Ivacaftor in people with CF aged ≥12 years - The RECOVER study. J Cyst Fibros 2024; 23:474-480. [PMID: 37806792 DOI: 10.1016/j.jcf.2023.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/23/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND RECOVER is a multicentre post-approval study of Elexacaftor/Tezacaftor/Ivacaftor (ETI) in pwCF in Ireland and the UK. The CFAbd-Score is the first validated CF-specific patient reported outcome measure (PROM) focusing on gastrointestinal symptoms; it comprises 28 items in 5 domains. In a preliminary study, we previously reported reductions in abdominal symptoms (AS) in pwCF after 26 weeks of ETI-therapy using the CFAbd-Score. AIM to assess changes in AS in a second, large cohort and explore novel GI-biomarkers of gut inflammation and cell-proliferation in pwCF over one year of ETI-therapy. METHODS Participants were recruited as part of the RECOVER study at 8 sites (Ireland&UK). The CFAbd-Score was administered prior to ETI-initiation, and subsequently at 1,2,6 and 12 months on treatment. Faecal M2-pyruvate kinase (M2-PK) and calprotectin (FC) were quantified in samples collected at baseline, 1 and 6 months. RESULTS 108 CFAbd-Scores and 73 stool samples were collected at baseline. After 12 months of ETI-therapy, total CFAbd-Scores had significantly declined (15.0±1.4→9.8±1.2pts/p<0.001), and so had all its five domains of "pain" (16.9±2.0pts→9.9±1.8pts/p<0.01), "GERD" (14.4±1.8→9.9±1.6/p<0.05), "disorders of bowel movements" (19.2±1.4→14.1±1.5/p<0.01), "appetite" (7.0±1.1→4.6±1.2/p<0.01) and "impaired-QoL" (13.3±1.9→7.5±1.5/p<0.001). Levels of M2-PK and FC significantly decreased during ETI-therapy. DISCUSSION In-depth analysis of AS with the CFAbd-Score reveals a statistically significant, clinically relevant and sustained improvement with ETI. We attribute this to high sensitivity of the implemented CF-specific PROM, developed and validated following FDA-guidelines. Furthermore, for the first time during ETI-therapy a significant decline in faecal M2-PK, a marker of inflammation and cell-proliferation, was found, in parallel to FC.
Collapse
Affiliation(s)
- Jochen G Mainz
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.
| | - Karen Lester
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | - Ed McKone
- St Vincent's University Hospital, Dublin, Ireland
| | - Des Cox
- Children's Health Ireland, Dublin, Ireland
| | - Barry Linnane
- University of Limerick School of Medicine, Limerick, Ireland
| | - Carlos Zagoya
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Franziska Duckstein
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Anton Barucha
- Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany; Department of Gastroenterology, Brandenburg Medical School (MHB) University, Brandenburg an der Havel, Germany
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton Hospital, Guy's & St Thomas' NHS Trust, London, UK
| | - Paul McNally
- RCSI University of Medicine and Health Sciences, Dublin, Ireland; Children's Health Ireland, Dublin, Ireland
| |
Collapse
|
4
|
Hoppe JE, Sjoberg J, Hong G, Poch K, Zemanick ET, Thee S, Edmondson C, Patel D, Sathe M, Borowitz D, Putman MS, Lechtzin N, Riekert KA, Basile M, Goss CH, Jarosz ME, Rosenfeld M. Remote endpoints for clinical trials in cystic fibrosis: Report from the U.S. CF foundation remote endpoints task force. J Cyst Fibros 2024:S1569-1993(24)00023-7. [PMID: 38429150 DOI: 10.1016/j.jcf.2024.02.011] [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: 10/11/2023] [Revised: 01/18/2024] [Accepted: 02/19/2024] [Indexed: 03/03/2024]
Abstract
The COVID-19 pandemic necessitated a rapid shift in clinical research to perform virtual visits and remote endpoint assessments, providing a key opportunity to optimize the use of remote endpoints for clinical trials in cystic fibrosis. The use of remote endpoints could allow more diverse participation in clinical trials while minimizing participant burden but must be robustly evaluated to ensure adequate performance and feasibility. In response, the Cystic Fibrosis Foundation convened the Remote Endpoint Task Force (Supplemental Table 1), a multidisciplinary group of CF researchers with remote endpoint expertise and community members tasked to better understand the current and future use of remote endpoints for clinical research. Here, we describe the current use of remote endpoints in CF clinical research, address key unanswered questions regarding their use and feasibility, and discuss the next steps to determine clinical trial readiness.
Collapse
Affiliation(s)
- Jordana E Hoppe
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA.
| | | | - Gina Hong
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Katie Poch
- Department of Medicine, National Jewish Health, Denver CO, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA
| | - Stephanie Thee
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Center, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claire Edmondson
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital, London WC1N3JH, USA
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St. Louis MO, USA
| | - Meghana Sathe
- Pediatric Gastroenterology and Nutrition, University of Texas Southwestern/Children's Health, Dallas Texas, USA
| | - Drucy Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA
| | - Melissa S Putman
- Division of Pediatric Endocrinology, Boston Children's Hospital, Boston MA, USA
| | - Noah Lechtzin
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore Maryland, USA
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore Maryland, USA
| | - Melissa Basile
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset NY, USA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle Washington, USA; Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Research Institute, Seattle Washington, USA
| | | | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Research Institute, Seattle Washington, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Anton-Păduraru DT, Murgu AM, Bozomitu LI, Mîndru DE, Iliescu Halițchi CO, Trofin F, Ciongradi CI, Sârbu I, Eṣanu IM, Azoicăi AN. Diagnosis and Management of Gastrointestinal Manifestations in Children with Cystic Fibrosis. Diagnostics (Basel) 2024; 14:228. [PMID: 38275475 PMCID: PMC10814426 DOI: 10.3390/diagnostics14020228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/16/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
Cystic fibrosis (CF) is primarily known for its pulmonary consequences, which are extensively explored in the existing literature. However, it is noteworthy that individuals with CF commonly display gastrointestinal (G-I) manifestations due to the substantial presence of the cystic fibrosis transmembrane conductance regulator (CFTR) protein in the intestinal tract. Recognized as pivotal nonpulmonary aspects of CF, G-I manifestations exhibit a diverse spectrum. Identifying and effectively managing these manifestations are crucial for sustaining health and influencing the overall quality of life for CF patients. This review aims to synthesize existing knowledge, providing a comprehensive overview of the G-I manifestations associated with CF. Each specific G-I manifestation, along with the diagnostic methodologies and therapeutic approaches, is delineated, encompassing the impact of innovative treatments targeting the fundamental effects of CF on the G-I tract. The findings underscore the imperative for prompt diagnosis and meticulous management of G-I manifestations, necessitating a multidisciplinary team approach for optimal care and enhancement of the quality of life for affected individuals. In conclusion, the authors emphasize the urgency for further clinical studies to establish a more robust evidence base for managing G-I symptoms within the context of this chronic disease. Such endeavors are deemed essential for advancing understanding and refining the clinical care of CF patients with G-I manifestations.
Collapse
Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (L.I.B.); (D.E.M.); (C.O.I.H.); (A.N.A.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (L.I.B.); (D.E.M.); (C.O.I.H.); (A.N.A.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
| | - Laura Iulia Bozomitu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (L.I.B.); (D.E.M.); (C.O.I.H.); (A.N.A.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
| | - Dana Elena Mîndru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (L.I.B.); (D.E.M.); (C.O.I.H.); (A.N.A.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
| | - Codruța Olimpiada Iliescu Halițchi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (L.I.B.); (D.E.M.); (C.O.I.H.); (A.N.A.)
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity–Microbiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania;
| | - Carmen Iulia Ciongradi
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
- 2nd Department of Surgery, Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Ioan Sârbu
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
- 2nd Department of Surgery, Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Irina Mihaela Eṣanu
- Medical Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania;
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (L.I.B.); (D.E.M.); (C.O.I.H.); (A.N.A.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania; (C.I.C.); (I.S.)
| |
Collapse
|
7
|
Patel D, Jose F, Baker J, Moshiree B. Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract in Cystic Fibrosis. Curr Gastroenterol Rep 2024; 26:9-19. [PMID: 38057499 DOI: 10.1007/s11894-023-00906-4] [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] [Accepted: 10/26/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW To discuss all the various motility disorders impacting people with Cystic Fibrosis (PwCF) and provide diagnostic and management approaches from a group of pediatric and adult CF and motility experts and physiologists with experience in the management of this disease. RECENT FINDINGS Gastrointestinal (GI) symptoms coexist with pulmonary symptoms in PwCF regardless of age and sex. The GI manifestations include gastroesophageal reflux disease, esophageal dysmotility gastroparesis, small bowel dysmotility, small intestinal bacterial overgrowth syndrome, distal idiopathic obstruction syndrome, constipation, and pelvic floor disorders. They are quite debilitating, limiting the patients' quality of life and affecting their nutrition and ability to socialize. This genetic disorder affects many organ systems and is chronic, potentially impacting fertility and future family planning, requiring a multidisciplinary approach. Our review discusses the treatments of motility disorders in CF, their prevalence and pathophysiology. We have provided a framework for clinicians who care for these patients that can help to guide their clinical management.
Collapse
Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, SSM Cardinal Glennon Children's Medical Center, Saint Louis University, St Louis, MO, USA
| | - Folashade Jose
- Pediatric Gastroenterology, Hepatology, and Nutrition, Clinical Associate Professor, Levine Childrens Hospital, Carolina Pediatric Gastroenterology, Charlotte, NC, USA
| | | | - Baha Moshiree
- Division of Gastroenterology, Atrium Health Wake Forest Medical University, Charlotte, NC, USA.
| |
Collapse
|
8
|
Katz TE, Wakefield CE, Signorelli C, Day AS, Vernon-Roberts A, Ooi CY. Gastroenterology services for patients with Cystic Fibrosis across Australia and New Zealand: a multi-stakeholder assessment of patients' and professionals' perspectives. Front Pediatr 2023; 11:1322941. [PMID: 38161436 PMCID: PMC10755025 DOI: 10.3389/fped.2023.1322941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Gastrointestinal (GI) symptoms are common in individuals with Cystic Fibrosis (CF). International research has highlighted that GI care for this group of patients is lacking. Gastroenterology services to CF clinics across Australasia are yet to be examined. This study aimed to describe the current service delivery model and identify areas for improvement that may lead to positive patient outcomes. Materials and methods CF clinicians (dietitians, clinical nurse consultants, respiratory consultants), gastroenterologists (GE), and patients or their carers from Australia and New Zealand (NZ) were surveyed online to gather their opinions on CF gastroenterology services provided in their region. Data were analysed using descriptive statistics (frequencies and percentages). Likert scale questions were analysed by grouping responses 1-5 and 6-10, presented alongside the median and interquartile range (IQR). Mann-Whitney U and chi-square tests were used to look at differences between stakeholder groups. Results One hundred and fifty-six health professionals and 172 patients or their carers completed the survey. Results showed that the current GI model of care is predominantly a publicly funded service delivered outside of CF clinic time. GE are largely not integrated into the CF team and report a lack of training opportunities. There is a higher level of dissatisfaction with the current service model in NZ than Australia. Discussion No stakeholder group deemed the current CF gastroenterology service model as adequate, leaving opportunity for transformations in this field. Ideally this study will invigorate the need for promotion and integration of GI services that would ultimately benefit the whole CF community.
Collapse
Affiliation(s)
- Tamarah E. Katz
- Department of Nutrition and Dietetics, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| | - Claire E. Wakefield
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| | - Christina Signorelli
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| | - Andrew S. Day
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Department of Gastroenterology, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | | | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, Sydney, NSW, Australia
- Department of Gastroenterology, Sydney Children’s Hospital, Randwick, Sydney, NSW, Australia
| |
Collapse
|
9
|
Davis TA, Miller A, Hachem C, Velez C, Patel D. The current state of gastrointestinal motility evaluation in cystic fibrosis: a comprehensive literature review. Transl Gastroenterol Hepatol 2023; 9:10. [PMID: 38317748 PMCID: PMC10838618 DOI: 10.21037/tgh-23-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/11/2023] [Indexed: 02/07/2024] Open
Abstract
Background and Objective As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential. Methods A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data. Key Content and Findings Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided. Conclusions The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.
Collapse
Affiliation(s)
- Trevor A. Davis
- Division of Gastroenterology, Department of Pediatrics, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - Abra Miller
- Division of Gastroenterology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO, USA
| | - Christine Hachem
- Division of Gastroenterology, Department of Medicine, Saint Louis University School of Medicine, University Hospital, St. Louis, MO, USA
| | - Christopher Velez
- Division of Gastroenterology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Dhiren Patel
- Division of Gastroenterology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO, USA
| |
Collapse
|
10
|
Lusman SS. Update on Cystic Fibrosis in Pediatric Patients. Curr Gastroenterol Rep 2023; 25:308-315. [PMID: 37653358 DOI: 10.1007/s11894-023-00896-3] [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] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is an inherited, multisystem disease that affects the gastrointestinal system in numerous ways. This article reviews the nutritional, gastrointestinal, and hepatobiliary manifestations of cystic fibrosis with an emphasis on the effects of CFTR modulator therapy. RECENT FINDINGS The life expectancy of individuals with cystic fibrosis has increased substantially in recent years. CFTR modulator therapy improves pulmonary function and results in weight gain. An individualized approach to nutrition is encouraged. Pancreatic exocrine function may improve with intervention early in life. The use of non-invasive methods to screen for hepatobiliary involvement is recommended. Highly effective CFTR modulators lead to increased survival and improved quality of life for many individuals. Their effects on gastrointestinal symptoms and hepatobiliary disease are not fully understood. Patient-reported outcome measures and biomarkers are important clinical endpoints for studying the effects of modulators.
Collapse
Affiliation(s)
- Sarah Shrager Lusman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH 17 East - 105L, New York, NY, 10032, USA.
| |
Collapse
|
11
|
Mainz JG, Barucha A, Huang P, Bechinger L, Duckstein F, Polte L, Sadrieh P, Nährlich L, Eickmeier O, Van Dullemen S, Eschenhagen P, Schwarz C, Lüth S, Zagoya C, Graepler-Mainka U. Dynamics of abdominal symptoms during the start of a new therapy with elexacaftor/tezacaftor/ivacaftor using the novel CFAbd-day2day questionnaire. Front Pharmacol 2023; 14:1167407. [PMID: 38026920 PMCID: PMC10658783 DOI: 10.3389/fphar.2023.1167407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023] Open
Abstract
Background: Elexacaftor-tezacaftor-ivacaftor (ETI) is a novel, highly effective CFTR modulator combination proven to enhance lung function and body weight in people with cystic fibrosis (pwCF) carrying a F508del mutation. Recently, we revealed significant reductions in abdominal symptoms (AS) in German, British, and Irish pwCF after 24-26 weeks of ETI using the CFAbd-Score, the first patient-reported outcome measure (PROM) specifically developed and validated for pwCF following FDA guidelines. Notably, many pwCF reported marked changes in their AS during the first days of the new treatment. To capture these immediate effects, we developed the CFAbd-day2day, a CF-specific GI-diary, following FDA and COSMIN guidelines. Aim: To prospectively capture the immediate dynamics of AS using the CFAbd-day2day 14 days before and 14-28 days after ETI initiation. In addition, we aim to provide validation steps of the novel PROM concerning sensitivity to changes. Methods: To develop the CFAbd-day2day, focus groups (community voice = pwCF and their proxies and CF specialists from different fields) were repeatedly consulted. Before and during the new ETI therapy, pwCF prospectively scored AS on a daily basis with the CFAbd-day2day. Results: Altogether, 45 pwCF attended in five CF centers prospectively completed the CFAbd-day2day before (mean ± sd:14 ± 7 days) and after (mean ± sd: 28 ± 23 days) ETI initiation. On the one hand, cumulative scores significantly decreased during the 3-4-week time frame after ETI initiation, compared to 2 weeks prior to therapy. On the other hand, many patients who revealed a relatively stable level of AS before ETI reported changes during the first days of treatment with the highly effective CFTR modulators. Factors like pain and flatulence increased in up to 21% of patients during the first 14 days of therapy, but they improved during days 15-27. Conclusion: The CFAbd-day2day, specifically developed and in the process of validation to prospectively capture GI symptoms in pwCF, provides new substantial insights into the dynamics of AS in pwCF receiving a new treatment with ETI. This novel tool is also helpful in prospectively monitoring patients with specific GI problems. International implementation and further validation steps of the diary are ongoing.
Collapse
Affiliation(s)
- Jochen G. Mainz
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Anton Barucha
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Pu Huang
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Lilith Bechinger
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Franziska Duckstein
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Louise Polte
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Pauline Sadrieh
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | - Lutz Nährlich
- CF Center for Children Justus-Liebig-Universität Gießen, Universitätsklinikum Gießen-Marburg GmbH, Gießen, Germany
| | - Olaf Eickmeier
- Division of Allergy, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, University Hospital, Frankfurt, Germany
| | - Suzanne Van Dullemen
- Division of Allergy, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, University Hospital, Frankfurt, Germany
| | | | | | - Stefan Lüth
- Department of Gastroenterology, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Carlos Zagoya
- CF-Center, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
- Medizinische Hochschule Brandenburg (MHB), Universitätsklinikum, Brandenburg an der Havel, Germany
| | | |
Collapse
|
12
|
Affiliation(s)
- Sabina Sabharwal
- From the Division of Gastroenterology and Nutrition & Harvard Medical School, Boston Children's Hospital, Boston, MA
| | - Sarah Shrager Lusman
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
13
|
Frantzen T, Barsky S, LaVecchia G, Marowitz M, Wang J. Evolving Nutritional Needs in Cystic Fibrosis. Life (Basel) 2023; 13:1431. [PMID: 37511806 PMCID: PMC10381916 DOI: 10.3390/life13071431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/30/2023] Open
Abstract
The course of cystic fibrosis (CF) as a nutritional illness is diverging since the introduction of highly effective modulator therapy, leading to more heterogeneous phenotypes of the disease despite CF genetic mutations that portend worse prognosis. This may become more evident as we follow the pediatric CF population into adulthood as some highly effective modulator therapies (HEMT) are approved for those as young as 1 year old. This review will outline the current research and knowledge available in the evolving nutritional health of people with CF as it relates to the impact of HEMT on anthropometrics, body composition, and energy expenditure, exocrine and endocrine pancreatic insufficiencies (the latter resulting in CF-related diabetes), vitamin and mineral deficiencies, and nutritional health in CF as it relates to pregnancy and lung transplantation.
Collapse
Affiliation(s)
- Theresa Frantzen
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, NY 11042, USA
| | - Sara Barsky
- Division of Pediatric Pulmonology, The Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, NY 11042, USA
| | - Geralyn LaVecchia
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, NY 11042, USA
| | - Michelle Marowitz
- Division of Pediatric Pulmonology, The Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, NY 11042, USA
| | - Janice Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, NY 11042, USA
| |
Collapse
|
14
|
Schwarzenberg SJ, Vu PT, Skalland M, Hoffman LR, Pope C, Gelfond D, Narkewicz MR, Nichols DP, Heltshe SL, Donaldson SH, Frederick CA, Kelly A, Pittman JE, Ratjen F, Rosenfeld M, Sagel SD, Solomon GM, Stalvey MS, Clancy JP, Rowe SM, Freedman SD. Elexacaftor/tezacaftor/ivacaftor and gastrointestinal outcomes in cystic fibrosis: Report of promise-GI. J Cyst Fibros 2023; 22:282-289. [PMID: 36280527 PMCID: PMC10144072 DOI: 10.1016/j.jcf.2022.10.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 09/12/2022] [Accepted: 10/10/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Elexacaftor/tezacaftor/ivacaftor (ETI) improves pulmonary disease in people with cystic fibrosis (PwCF), but its effect on gastrointestinal symptoms, which also affect quality of life, is not clear. METHODS PROMISE is a 56-center prospective, observational study of ETI in PwCF >12 years and at least one F508del allele. Gastrointestinal symptoms, evaluated by validated questionnaires: Patient Assessment of Upper Gastrointestinal Disorders-Symptom (PAGI-SYM), Patient Assessment of Constipation-Symptom (PAC-SYM), Patient Assessment of Constipation-Quality of Life (PAC-QOL)), fecal calprotectin, steatocrit and elastase-1 were measured before and 6 months after ETI initiation. Mean difference and 95% confidence intervals were obtained from linear regression with adjustment for age and sex. RESULTS 438 participants fully completed at least 1 questionnaire. Mean (SD) for baseline PAGI-SYM, PAC-SYM, and PAC-QOL total scores were 0.56 (0.59), 0.47 (0.45), and 0.69 (0.53) out of maximum 5, 4, and 5, respectively (higher score indicates greater severity). Corresponding age- and sex-adjusted 6 months mean changes (95% CI) in total scores were -0.15 (-0.21, -0.09) for PAGI-SYM, -0.14 (-0.19, -0.09) for PAC-SYM, and -0.15 (-0.21, -0.10) for PAC-QOL. While statistically significant, changes were small and unlikely to be of clinical importance. Fecal calprotectin showed a change (95% CI) from baseline of -66.2 µg/g (-86.1, -46.2) at 6 months, while fecal elastase and steatocrit did not meaningfully change. CONCLUSIONS After 6 months of ETI, fecal markers of inflammation decreased. Gastrointestinal symptoms improved, but the effect size was small. Pancreatic insufficiency did not improve.
Collapse
Affiliation(s)
- Sarah Jane Schwarzenberg
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Academic Office Building, 2450 Riverside Ave S AO-201, Minneapolis, MN 55454, USA.
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Michelle Skalland
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Lucas R Hoffman
- Department of Pediatrics and Department of Microbiology, University of Washington School of Medicine, Seattle, WA, USA
| | - Christopher Pope
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Michael R Narkewicz
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - David P Nichols
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Scott H Donaldson
- Department of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Carla A Frederick
- Jacobs School of Medicine and Biomedical Sciences of the University of Buffalo, NY, USA
| | - Andrea Kelly
- Division of Endocrinology & Diabetes, Children's Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica E Pittman
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO, USA
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine, Hospital for Sick Children, University of Toronto, Canada
| | - Margaret Rosenfeld
- Department of Epidemiology and Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Scott D Sagel
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - George M Solomon
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael S Stalvey
- Department of Pediatrics and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Steven M Rowe
- Department of Medicine and the Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Steven D Freedman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
15
|
Sathe M, Moshiree B, Aliaj E, Lee M, Hudson J, Gifford A, Attel S, Gamel B, Freedman SD, Schwarzenberg SJ, Freeman AJ. Need to study simplification of gastrointestinal medication regimen in cystic fibrosis in the era of highly effective modulators. Pediatr Pulmonol 2023; 58:811-818. [PMID: 36448312 DOI: 10.1002/ppul.26257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/13/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The success of highly effective modulator therapy (HEMT) has led to consideration of simpler regimens for people with CF (PwCF) with opportunities to modify burdensome regimens. Despite the intuitive appeal of discontinuing chronic therapies no longer necessary, this process should be pursued systematically to ensure safety, adherence, and validate patient-centered preferences. We designed a questionnaire to determine the state of use of acid-suppressive medications (ASM) and pancreatic enzyme therapy (PERT), current self-withdrawal and provider-directed withdrawal practices, and interest in a standardized withdrawal study. METHODS In collaboration with CF Foundation (CFF), a questionnaire was developed and distributed to members of Community Voice (CV, comprised of PwCF and their loved ones), and CF providers regarding the need to study simplifying the gastrointestinal (GI) regimen for PwCF on HEMT. RESULTS Approximately 20-40% of CV or CF providers have decreased or stopped ASM for those on HEMT. For PERT, CV and CF providers have decreased dose (34%-48% and approximately 25%, respectively) more often than having stopped it altogether (13%-24% and 3%-12%, respectively). Cumulatively, there is interest in pursuing research in this area (86% CV and 89% CF providers) and willingness to enroll in such a study (80% CV and 89% CF providers). CONCLUSION Systematically studying the withdrawal of common GI medications, ASM and PERT, is important to CV and CF providers. Decreases in dosing and withdrawal are already taking place without evidence to support this practice. This questionnaire is the first step in designing a GI medication simplification study in PwCF on HEMT.
Collapse
Affiliation(s)
- Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, Texas, USA
| | - Baha Moshiree
- Division of Gastroenterology, Wake Forest/Atrium Health, Charlotte, North Carolina, USA
| | - Enid Aliaj
- Cystic Fibrosis Foundation: Community Partnerships, Bethesda, Maryland, USA
| | - MinJae Lee
- Division of Biostatistics, Department of Population & Data Sciences, University of Texas Southwestern, Dallas, Texas, USA
| | - Jessica Hudson
- Cystic Fibrosis Foundation: Community Partnerships, Bethesda, Maryland, USA
| | - Alex Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, Ohio, Cleveland, USA.,Division of Pediatric Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Susan Attel
- Patient Representative, Children's Health, Dallas, Texas, USA
| | - Breck Gamel
- Patient Representative, Children's Health, Dallas, Texas, USA
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah Jane Schwarzenberg
- University of Minnesota/MHealth Fairview Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - A Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital/Ohio State School of Medicine, Columbus, Ohio, USA
| |
Collapse
|
16
|
A FOETUS WITH CYSTIC FIBROSIS – TO TREAT OR NOT TO TREAT? Respir Med Res 2023; 83:101006. [PMID: 37037055 DOI: 10.1016/j.resmer.2023.101006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/25/2023] [Accepted: 02/11/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is an autosomal recessive health condition caused by gene mutations causing quantitative and or qualitative defect in the cystic-fibrosis transmembrane conductance regulator (CFTR) protein. CFTR defects lead to abnormal ion transport affecting multiple body systems. In CF thick secretions accumulate causing impairment in the pancreas, whole airways, gut and reproductive organs. CFTR MODULATORS AND PREGNANCY CFTR modulators have improved the quantity and quality of life of CF patients. There is limited literature on CFTR modulator use in pregnancy and its impact on foetal health. A recent case report described a child with CF being born with pancreatic sufficiency following in-utero CFTR modulator exposure. We review the potential impact of in-utero exposure to CFTR modulators, focusing on pancreatic function and future fertility of unborn individuals with CF. CONCLUSION CFTR modulator exposure in-utero is a new concept, therefore the consequences on foetal health remain uncertain. Foetal exposure to modulators could prevent pancreatic damage and infertility.
Collapse
|
17
|
Moshiree B, Freeman AJ, Vu PT, Khan U, Ufret-Vincenty C, Heltshe SL, Goss CH, Schwarzenberg SJ, Freedman SD, Borowitz D, Sathe M. Multicenter prospective study showing a high gastrointestinal symptom burden in cystic fibrosis. J Cyst Fibros 2023; 22:266-274. [PMID: 36319569 PMCID: PMC10147845 DOI: 10.1016/j.jcf.2022.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 10/15/2022] [Accepted: 10/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND AIMS People with cystic fibrosis (PwCF) suffer from gastrointestinal (GI) symptoms affecting their quality of life (QOL). Despite the relevance of GI symptoms to the overall health of PwCF, a paucity of studies only have comprehensively assessed the prevalence, severity and QOL of GI symptoms in both children and adults with Cystic Fibrosis (CF). METHODS Eligible participants ≥2 years of age across 26 US CF centers were followed for 4 weeks. Three validated GI electronic patient-reported outcome measures (ePROMs) with a recall period of 2 weeks and a stool-specific questionnaire were administered weekly over four weeks. Total and domain scores of ePROMs were evaluated overall and in subgroups using linear mixed-effect models. RESULTS Of 402 enrolled, 58% were ≥ 18 years of age (52% male). The mean (SD) of the total score for PAC-SYM was 0.52 (0.55), for PAGI-SYM was 0.63 (0.67), and for PAC-QOL was 0.67 (0.55). For specific ePROM questions, prevalence of moderate to very severe symptoms were as follows: straining (20.3%), fullness (18.3%), incomplete bowel movements (17.1%), bloating (16.4%), distension (16.4%), abdominal pain (upper-5.1%, lower-7.5%). Comparing participants ≥18 versus <18, a higher prevalence of bloating (63.7% versus 27.3%), lower abdominal pain (39.8% vs 26.2%), stomach fullness (75.6% versus 56.2%), and abdominal distension (60.2% versus 34.9%) was found. Both age groups reported high treatment dissatisfaction as measured with PAC-QOL, mean 1.39 (95% CI: 1.30, 1.47). CONCLUSION GI symptoms were reported in all age ranges irrespective of gender, with higher prevalence observed amongst older and female subgroups. Dissatisfaction with GI targeted treatments were reported in a large proportion of participants despite therapy, highlighting an unmet need for clinical interventions. CLINICALTRIALS GOV: NCT03801993.
Collapse
Affiliation(s)
- Baha Moshiree
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Atrium Health, Charlotte, NC, United States.
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, United States
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Carmen Ufret-Vincenty
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States; Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Drucy Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States
| | - Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, TX, United States
| |
Collapse
|
18
|
Caley LR, Zagoya C, Duckstein F, White H, Shimmin D, Jones AM, Barrett J, Whitehouse JL, Floto RA, Mainz JG, Peckham DG. Diabetes is associated with increased burden of gastrointestinal symptoms in adults with cystic fibrosis. J Cyst Fibros 2023; 22:275-281. [PMID: 36710099 DOI: 10.1016/j.jcf.2023.01.010] [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: 07/13/2022] [Revised: 12/09/2022] [Accepted: 01/17/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Individuals with diabetes mellitus (DM) are known to frequently experience gastrointestinal (GI) symptoms. In contrast, the impact of cystic fibrosis-related diabetes (CFRD) on accentuating GI symptoms in people with cystic fibrosis (pwCF) is unknown. We sought to examine this. METHODS Abdominal symptoms were measured using the validated CF-specific GI symptom questionnaire - CFAbd-Score© - as part of a multicentre cohort study in pancreatic insufficient adults with CF, not on cystic fibrosis transmembrane conductance regulator (CFTR) modulators. The CFAbd-Score total score (0-100pts), its 5 domains, alongside nine specific GI symptoms associated with DM, were compared between the CFRD and non-CFRD groups. RESULTS 27 (31%) and 61 (69%) participants with CF were recruited in the CFRD and non-CFRD groups respectively. Total CFAbd-Score and the two domains: gastroesophageal reflux disease and disorders of appetite were significantly higher in the CFRD group compared to the non-CFRD group (p<0.05), with the mean total CFAbd-Score being 25.4 ± 2.5 and 18.4 ± 1.5 in the CFRD and non-CFRD groups respectively. Among the nine GI symptoms commonly reported as elevated in DM, bloating and nausea were significantly more common in individuals with CFRD compared to those without (p<0.05). CONCLUSIONS Individuals with CFRD overall, have a higher GI symptom burden, according to CFAbd-Scores. Specifically, they experience significantly more bloating and nausea. Close monitoring and further research is needed to better understand and manage GI symptoms in this group.
Collapse
Affiliation(s)
- L R Caley
- Leeds Institute of Medical Research at St James's University Hospital, University of Leeds, Leeds, United Kingdom.
| | - C Zagoya
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - F Duckstein
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - H White
- Nutrition, Health & Environment, Leeds Beckett University, Leeds, United Kingdom
| | - D Shimmin
- Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - A M Jones
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, United Kingdom
| | - J Barrett
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS, Foundation Trust, Birmingham, United Kingdom
| | - J L Whitehouse
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS, Foundation Trust, Birmingham, United Kingdom
| | - R A Floto
- MRC-Laboratory of Molecular Biology, Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, United Kingdom; Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, United Kingdom
| | - J G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany; Faculty of Health Sciences Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, the Brandenburg Medical School Theodor Fontane and the University of Potsdam, Germany
| | - D G Peckham
- Leeds Institute of Medical Research at St James's University Hospital, University of Leeds, Leeds, United Kingdom; Department of Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| |
Collapse
|
19
|
Anderson JL, Tierney AC, Miles C, Kotsimbos T, King SJ. Probiotic knowledge of adults with cystic fibrosis is limited but is associated with probiotic use: A cross-sectional survey study. Nutr Health 2022:2601060221136653. [PMID: 36366805 DOI: 10.1177/02601060221136653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background: Probiotics are used by people with cystic fibrosis (CF) and other chronic diseases to manage gastrointestinal symptoms. Aim: To describe probiotic knowledge; its relationship with probiotic use, probiotic information sources and factors influencing choice in adults with CF and a general population control group. Methods: A cross-sectional questionnaire study was conducted in adults with CF (n = 205) and Controls (n = 158). Probiotic knowledge was compared between CF and Controls using a knowledge score (maximum 5) based on predefined criteria: (1a) bacteria/microorganism; (1b) live; (2a) administered; (2b) adequate dose and (3) health benefit, using independent samples t-test. Two-way analysis of variance explored knowledge scores between CF and Control and between Ever User and Never User groups. Chi-square and Fisher's exact tests compared knowledge criterion, probiotic sources and influences on probiotic choice between groups. Thematic analysis of open-text responses explored probiotic-related knowledge and influences on probiotic decision making. Results: Knowledge scores (mean ± SD) did not differ between CF (1.70 ± 1.12) and Controls (1.89 ± 0.99), p = 0.13. Probiotic use was associated with knowledge score (p < 0.001). More CF Ever Users than Never Users correctly identified criteria 1a (65% vs. 38%), 1b (16% vs. 0%), 2a (45% vs. 22%) and 3 (73% vs. 42%) (all p < 0.005). CF participants considered 'dairy yoghurt' (69%), 'live cultures' (64%) and 'fermented foods' (37%) as 'all/mostly' probiotic sources. The internet was the commonest source of probiotic-related information. Conclusion: Probiotic knowledge and use were associated in adults with CF. Understanding of probiotic characteristics and sources were limited. Education is needed to help guide patient probiotic decision making.
Collapse
Affiliation(s)
- Jacqueline L Anderson
- Discipline of Food, Nutrition and Dietetics, School of Allied Health, 2080La Trobe University, Bundoora, Australia
| | - Audrey C Tierney
- Discipline of Food, Nutrition and Dietetics, School of Allied Health, 2080La Trobe University, Bundoora, Australia
- School of Allied Health, Health Implementation Science and Technology Centre, Health Research Institute, 8808University of Limerick, Limerick, Ireland
| | - Caitlin Miles
- Nutrition and Dietetics Department, 2538Monash Health, Clayton, Australia
| | - Tom Kotsimbos
- Cystic Fibrosis Service, Department of Allergy, Immunology and Respiratory Medicine, 5392Alfred Health, Melbourne, Australia
- Department of Medicine, 2541Monash University, Melbourne, Australia
| | - Susannah J King
- Discipline of Food, Nutrition and Dietetics, School of Allied Health, 2080La Trobe University, Bundoora, Australia
- Nutrition Department, 5392Alfred Health, Melbourne, Australia
| |
Collapse
|
20
|
Wrigley-Carr HE, van Dorst JM, Ooi CY. Intestinal dysbiosis and inflammation in cystic fibrosis impacts gut and multi-organ axes. MEDICINE IN MICROECOLOGY 2022. [DOI: 10.1016/j.medmic.2022.100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
21
|
Freeman AJ, Huang R, Heltshe SL, Gelfond D, Leung DH, Ramsey BR, Borowitz D, Sathe M. Association between stool consistency and clinical variables among infants with cystic fibrosis: Findings from the BONUS study. J Cyst Fibros 2022; 21:830-836. [PMID: 35585010 PMCID: PMC10056424 DOI: 10.1016/j.jcf.2022.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/04/2022] [Accepted: 05/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Concerns related to stool consistency are common in the first year of life among children with cystic fibrosis (CF). However, normal stool patterns for infants with CF have not been described. METHODS Secondary analysis was completed from the previously described BONUS cohort which followed 231 infants with CF through the first 12 months of life. Pain, stool category, stool frequency, feeding type, PERT dose, acid suppression medication, antibiotics usage, stool softener usage and fecal calprotectin were described at 3, 6, and 12 months. Repeated measure ANOVA was used to test the difference in mean stool number. Generalized linear mixed models were used to investigate the relationship between stool characteristics and various factors. RESULTS The frequency of constipation was stable throughout the first year of life (10-13%) while watery stool significantly decreased from 21.3% at 3 months to 5.8% at 12 months (p=<0.001). The number of stools at months 6 (mean=2.40) and 12 (mean=2.50) are significantly lower than in month 3 (mean=2.83), p<0.025. Exclusive breast feeding was associated with an increased risk for constipation (OR=2.64 [1.60-4.37], p = 0.002) while exclusive formula feeding and acid suppression was associated with decreased risk for constipation (OR=0.40 [0.26-0.61], p=<0.0001 and OR=0.59 [0.39-0.89], p = 0.01 respectively). Pain was not significantly associated with stool consistency. CONCLUSION Stool frequency and consistency evolves in infant with CF in a fashion similar to that reported in non-CF infants over the first year. Constipation was not associated with pain and was less common among infants receiving acid suppression or exclusively formula feeding.
Collapse
Affiliation(s)
- A Jay Freeman
- Associate Professor, Division Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA.
| | - Rong Huang
- Lead Biostatistician, Research Administration, Children's Medical Center Dallas, Dallas, TX, USA
| | - Sonya L Heltshe
- Associate Professor, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA and Division of Pulmonary Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Daniel Gelfond
- WNY Pediatric Gastroenterology and Volunteer Faculty, University of Buffalo School of Medicine, Buffalo, NY, USA
| | - Daniel H Leung
- Associate Professor, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Bonnie R Ramsey
- Vice Chair and Endowed Professor, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Drucy Borowitz
- Emeritus Clinical Professor of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Meghana Sathe
- Associate Professor, Division Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern and Children's Health, Dallas, TX, USA
| | | |
Collapse
|
22
|
Mainz JG, Zagoya C, Polte L, Naehrlich L, Sasse L, Eickmeier O, Smaczny C, Barucha A, Bechinger L, Duckstein F, Kurzidim L, Eschenhagen P, Caley L, Peckham D, Schwarz C. Elexacaftor-Tezacaftor-Ivacaftor Treatment Reduces Abdominal Symptoms in Cystic Fibrosis-Early results Obtained With the CF-Specific CFAbd-Score. Front Pharmacol 2022; 13:877118. [PMID: 35721187 PMCID: PMC9203829 DOI: 10.3389/fphar.2022.877118] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background: The novel and highly effective CFTR modulator combination of elexacaftor-tezacaftor-ivacaftor (ETI) has been shown to improve lung function and body weight in people with Cystic Fibrosis (pwCF) carrying a F508del mutation. However, the impact of these modulators on gastrointestinal (GI) symptoms is relatively unknown. Therefore, the CFAbd-Score was developed and validated following FDA recommendations for development of a PROM including focus groups, multidisciplinary CF specialists, people with CF and their families. The aim of this study was to assess effects of ETI on GI symptoms using the CFAbd-Score. Methods: Gastrointestinal symptoms were prospectively assessed in pwCF using the CFAbd-Score before and up to 26 weeks during therapy. The CFAbd-Score was also administered to a healthy control (HC) group. The one-sided questionnaire includes 28 items grouped in five domains. Data analysis included calculation of scores with a weighting tool, developed according to FDA recommendations. Results: A total of 107 pwCF attended in four CF centres in Germany and four centres in the UK completed the CFAbd-Score on at least two occasions. Results were compared to those obtained from the questionnaire of 45 HCs. Despite differences in demographics, age and proportion of pancreatic insufficiency between German and UK patients, analyses based on linear mixed-effects models at week 24 of ETI therapy revealed that estimated marginal means (EMMs) of total CFAbd-Scores significantly reduced (mean ± SE: 14.9 ± 1.2→10.6 ± 1.4; p < 0.01). Also EMMs of all five domains significantly declined ("pain" 16.3 ± 1.6→10.2 ± 2.3, "GERD" 15.8 ± 1.8→8.2 ± 1.9, "disorders of bowel movement" 20.9 ± 1.5→16.0 ± 1.7, "disorders of appetite" 7.9 ± 1.1→2.6 ± 1.1 and "quality of life impairment" 10.1 ± 1.92→3.9 ± 1.9). However, during 24 weeks, CF participants' symptoms mostly still did not reach the reference levels of HCs. Discussion: Using the CFAbd-Score, the first PROM specifically developed for assessment of CF-related abdominal symptoms, we demonstrate comprehensive improvements in GI symptoms after initiation of the highly effective modulator therapy ETI.
Collapse
Affiliation(s)
- Jochen G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.,Faculty of Health Sciences Joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, The Brandenburg Medical School Theodor Fontane and the University of Potsdam, Potsdam, Germany
| | - Carlos Zagoya
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Louise Polte
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Lenny Sasse
- Department of Pediatrics, Justus-Liebig-University Giessen, Giessen, Germany
| | - Olaf Eickmeier
- Christiane Herzog CF-Zentrum Frankfurt am Main, Universitätsklinikum Frankfurt am Main CF-Zentrum, Frankfurt am Main, Germany
| | - Christina Smaczny
- Christiane Herzog CF-Zentrum Frankfurt am Main, Universitätsklinikum Frankfurt am Main CF-Zentrum, Frankfurt am Main, Germany
| | - Anton Barucha
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Lilith Bechinger
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Franziska Duckstein
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Ludwik Kurzidim
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.,CF-Zentrum Westbrandenburg, Campus Potsdam, Klinikum Westbrandenburg, Potsdam, Germany
| | - Patience Eschenhagen
- CF-Zentrum Westbrandenburg, Campus Potsdam, Klinikum Westbrandenburg, Potsdam, Germany
| | - Laura Caley
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Daniel Peckham
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom.,Adult Cystic Fibrosis Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Carsten Schwarz
- CF-Zentrum Westbrandenburg, Campus Potsdam, Klinikum Westbrandenburg, Potsdam, Germany
| |
Collapse
|
23
|
Correlates of Pancreatic Enzyme Replacement Therapy Intake in Adults with Cystic Fibrosis: Results of a Cross-Sectional Study. Nutrients 2022; 14:nu14071330. [PMID: 35405943 PMCID: PMC9003007 DOI: 10.3390/nu14071330] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/04/2023] Open
Abstract
Most people with cystic fibrosis (pwCF) develop pancreatic insufficiency and are treated with pancreatic enzyme replacement therapy (PERT). We aimed to describe the use of PERT and assess the correlates of PERT dose in adult pwCF. In a cross-sectional study at the Copenhagen CF Centre, the participants reported PERT intake, gastrointestinal (GI) symptoms and the use of concomitant treatments. Demographic and clinical characteristics were extracted from the Danish CF Registry. We used linear regression to assess the correlates of PERT dose per kg bodyweight (U-lipase/kg). We included 120 pwCF with a median age of 32.9 years, 46% women and 72% F508delta homozygote. The PERT dose ranged from 0 to 6160 U-lipase/kg per main meal (mean 1828; SD 1115). The PERT dose was associated with participants' sex (men vs. women: 661; 95% CI: 302; 1020 U-lipase/kg), age (-16; 95% CI: -31; -1 U-lipase/kg per year) and weight (-45; 95% CI: -58; -31 U-lipase/kg per kg). Having less frequent constipation and being lung transplanted were also associated with a higher PERT dose. A third of participants did not take PERT for snacks, and this was associated with the frequency of diarrhoea. These findings indicate that PERT intake may be improved to reduce GI symptoms.
Collapse
|
24
|
Jaudszus A, Pfeifer E, Lorenz M, Beiersdorf N, Hipler UC, Zagoya C, Mainz JG. Abdominal Symptoms Assessed With the CFAbd-Score are Associated With Intestinal Inflammation in Patients With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2022; 74:355-360. [PMID: 34789668 DOI: 10.1097/mpg.0000000000003357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES This prospective study evaluated the relationship between fecal markers of intestinal inflammation and cystic fibrosis (CF)-associated abdominal symptoms. These were assessed using the CFAbd-Score, a CF-specific patient-related outcome measure developed and validated, following FDA guidelines. METHODS In feces from patients with CF (n = 41) and healthy volunteers (n = 27), concentrations of fecal calprotectin (FC), M2-pyruvate kinase (M2-PK), interleukins IL-1β, IL-6, IL-8, and neutrophilic elastase (NE) were measured. Abdominal symptoms during the 2 preceding weeks were recorded using the CFAbd-Score. This patient-reported outcome measure (PROM) for assessment of the multi-organic abdominal involvement in CF includes 28 items in five domains. RESULTS Inflammatory parameters FC, IL-1β, M2-PK, and NE in feces, as well as CFAbd-Scores resulted significantly higher in CF patients than in healthy controls (all P < 0.01). Furthermore, significant differences between both groups were found for pain-symptoms, disorders of bowel movement, impaired quality of life, as well as disorders of eating and appetite. With 83% sensitivity and 74% specificity, FC was the most reliable measure for CF-related intestinal inflammation, which, in the CFAbd-Score, was associated to significantly higher rates of abdominal pain, as well as to general quality of life items such as gastrointestinal-related impaired sleep and frustration. CONCLUSION Using the CFAbd-Score as a CF-specific PROM for identification and quantification of abdominal symptoms revealed that abdominal pain and impaired quality of life are associated with intestinal inflammation in CF.
Collapse
Affiliation(s)
- Anke Jaudszus
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Elena Pfeifer
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Michael Lorenz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Nathalie Beiersdorf
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | | | - Carlos Zagoya
- Brandenburg Medical School/Medizinische Hochschule Brandenburg (MHB), University, Pediatric Pulmonology/Cystic Fibrosis, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Jochen G Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany.,Brandenburg Medical School/Medizinische Hochschule Brandenburg (MHB), University, Pediatric Pulmonology/Cystic Fibrosis, Klinikum Westbrandenburg, Brandenburg an der Havel, Germany.,Faculty of Health Sciences, joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, the Brandenburg Medical School Theodor Fontane and the University of Potsdam, Germany
| |
Collapse
|
25
|
Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
Collapse
Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| |
Collapse
|
26
|
Raun AMT, Brekke G, Mølgaard C, Jaudszus A, Mainz JG, Pressler T, Skov M. Impact of timing of PERT on gastrointestinal symptoms in Danish children and adolescents with CF. Acta Paediatr 2022; 111:432-439. [PMID: 34626004 DOI: 10.1111/apa.16143] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/24/2021] [Accepted: 10/07/2021] [Indexed: 12/16/2022]
Abstract
AIM Gastrointestinal (GI) symptoms are often reported by CF patients. Despite a proven relation to exocrine pancreatic insufficiency (PI), it remains unclear whether GI symptoms are related to the timing of pancreatic enzyme replacement therapy (PERT). Whereas most international recommendations suggest administration of PERT at the beginning of meals, it has not been studied whether such a proceeding is associated with lower burden of symptoms. METHODS Thirty CF patients aged 0-17 years of age with PI were randomised to four weeks of PERT prior to meals followed by four weeks of PERT after meals or vice versa. Using the CF-specific validated CFAbd-Score, abdominal pain, dysfunctional bowel habits and Quality of Life (QoL) related to GI symptoms were assessed in relation to the timing of PERT. Data were analysed using a linear mixed model. RESULTS There was no significant difference regarding abdominal pain, bowel habits or QoL related to GI symptoms when timing of PERT was changed from prior to after meals. CONCLUSION No significant difference was found when administration mode of PERT changed from prior to after meals or vice versa. However, after an individual assessment, some patients may profit from changing administration mode of PERT from prior to after meals.
Collapse
Affiliation(s)
- Anne Mette Terp Raun
- Rigshospitalet, Pediatric Nutrition Unit Copenhagen University HospitalRigshospitalet Copenhagen Denmark
- Rigshospitalet, CF Center CopenhagenDepartment of Pediatrics and Adolescent Medicine Copenhagen Denmark
| | - Ghita Brekke
- Rigshospitalet, Pediatric Nutrition Unit Copenhagen University HospitalRigshospitalet Copenhagen Denmark
- Rigshospitalet, CF Center CopenhagenDepartment of Pediatrics and Adolescent Medicine Copenhagen Denmark
| | - Christian Mølgaard
- Rigshospitalet, Pediatric Nutrition Unit Copenhagen University HospitalRigshospitalet Copenhagen Denmark
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | | | - Jochen G. Mainz
- Cystic Fibrosis Center Brandenburg Medical School (MHB) University Brandenburg an der Havel Germany
- Faculty of Health Sciences Joint Faculty of the Brandenburg University of Technology Cottbus –Senftenberg The Brandenburg Medical School Theodor FontaneUniversity of Potsdam, Cottbus Brandenburg an der Havel and Potsdam Germany
| | - Tacjana Pressler
- Rigshospitalet, CF Center CopenhagenDepartment of Pediatrics and Adolescent Medicine Copenhagen Denmark
| | - Marianne Skov
- Rigshospitalet, CF Center CopenhagenDepartment of Pediatrics and Adolescent Medicine Copenhagen Denmark
| |
Collapse
|
27
|
Anderson JL, Tierney AC, Miles C, Kotsimbos T, King SJ. PROBIOTIC USE IN ADULTS WITH CYSTIC FIBROSIS IS COMMON AND INFLUENCED BY GASTROINTESTINAL HEALTH NEEDS: A CROSS SECTIONAL SURVEY STUDY. J Hum Nutr Diet 2022; 35:444-454. [DOI: 10.1111/jhn.12991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/10/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Jacqueline L Anderson
- Department of Dietetics, Nutrition and Sport, School of Allied Health La Trobe University Victoria Australia
| | - Audrey C Tierney
- Department of Dietetics, Nutrition and Sport, School of Allied Health La Trobe University Victoria Australia
- School of Allied Health, Health Implementation Science and Technology Centre, Health Research Institute University of Limerick Limerick Ireland
| | - Caitlin Miles
- Nutrition and Dietetics Department, Monash Health Clayton Victoria Australia
| | - Tom Kotsimbos
- Cystic Fibrosis Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Health Melbourne Victoria Australia
- Department of Medicine Monash University Melbourne Australia
| | - Susannah J King
- Department of Dietetics, Nutrition and Sport, School of Allied Health La Trobe University Victoria Australia
- Cystic Fibrosis Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Health Melbourne Victoria Australia
- Nutrition Department Alfred Health Melbourne Victoria Australia
| |
Collapse
|
28
|
Tam RY, van Dorst JM, McKay I, Coffey M, Ooi CY. Intestinal Inflammation and Alterations in the Gut Microbiota in Cystic Fibrosis: A Review of the Current Evidence, Pathophysiology and Future Directions. J Clin Med 2022; 11:jcm11030649. [PMID: 35160099 PMCID: PMC8836727 DOI: 10.3390/jcm11030649] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting autosomal recessive multisystem disease. While its burden of morbidity and mortality is classically associated with pulmonary disease, CF also profoundly affects the gastrointestinal (GI) tract. Chronic low-grade inflammation and alterations to the gut microbiota are hallmarks of the CF intestine. The etiology of these manifestations is likely multifactorial, resulting from cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, a high-fat CF diet, and the use of antibiotics. There may also be a bidirectional pathophysiological link between intestinal inflammation and changes to the gut microbiome. Additionally, a growing body of evidence suggests that these GI manifestations may have significant clinical associations with growth and nutrition, quality of life, and respiratory function in CF. As such, the potential utility of GI therapies and long-term GI outcomes are areas of interest in CF. Further research involving microbial modulation and multi-omics techniques may reveal novel insights. This article provides an overview of the current evidence, pathophysiology, and future research and therapeutic considerations pertaining to intestinal inflammation and alterations in the gut microbiota in CF.
Collapse
Affiliation(s)
- Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
| | - Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
| | - Isabelle McKay
- Wagga Wagga Base Hospital, Wagga Wagga, NSW 2650, Australia;
| | - Michael Coffey
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, NSW 2031, Australia
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW 2031, Australia; (R.Y.T.); (J.M.v.D.); (M.C.)
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney, NSW 2031, Australia
- Correspondence:
| |
Collapse
|
29
|
Abstract
Objective: To systematically review the problem of appetite loss after major abdominal surgery. Summary of Background Data: Appetite loss is a common problem after major abdominal surgery. Understanding of etiology and treatment options is limited. Methods: We searched Medline, Cochrane Central Register of Controlled Trials, and Web of Science for studies describing postoperative appetite loss. Data were extracted to clarify definition, etiology, measurement, surgical influence, pharmacological, and nonpharmacological treatment. PROSPERO registration ID: CRD42021224489. Results: Out of 6144 articles, we included 165 studies, 121 of which were also analyzed quantitatively. A total of 19.8% were randomized, controlled trials (n = 24) and 80.2% were nonrandomized studies (n = 97). The studies included 20,506 patients undergoing the following surgeries: esophageal (n = 33 studies), gastric (n = 48), small bowel (n = 6), colon (n = 27), rectal (n = 20), hepatobiliary (n = 6), and pancreatic (n = 13). Appetite was mostly measured with the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ C30, n = 54). In a meta-analysis of 4 randomized controlled trials gum chewing reduced time to first hunger by 21.2 hours among patients who had bowel surgery. Other reported treatment options with positive effects on appetite but lower levels of evidence include, among others, intravenous ghrelin administration, the oral Japanese herbal medicine Rikkunshito, oral mosapride citrate, multidisciplin-ary-counseling, and watching cooking shows. No studies investigated the effect of well-known appetite stimulants such as cannabinoids, steroids, or megestrol acetate on surgical patients. Conclusions: Appetite loss after major abdominal surgery is common and associated with increased morbidity and reduced quality of life. Recent studies demonstrate the influence of reduced gastric volume and ghrelin secretion, and increased satiety hormone secretion. There are various treatment options available including level IA evidence for postoperative gum chewing. In the future, surgical trials should include the assessment of appetite loss as a relevant outcome measure.
Collapse
|
30
|
van Dorst JM, Tam RY, Ooi CY. What Do We Know about the Microbiome in Cystic Fibrosis? Is There a Role for Probiotics and Prebiotics? Nutrients 2022; 14:nu14030480. [PMID: 35276841 PMCID: PMC8840103 DOI: 10.3390/nu14030480] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-shortening genetic disorder that affects the cystic fibrosis transmembrane conductance regulator (CFTR) protein. In the gastrointestinal (GI) tract, CFTR dysfunction results in low intestinal pH, thick and inspissated mucus, a lack of endogenous pancreatic enzymes, and reduced motility. These mechanisms, combined with antibiotic therapies, drive GI inflammation and significant alteration of the GI microbiota (dysbiosis). Dysbiosis and inflammation are key factors in systemic inflammation and GI complications including malignancy. The following review examines the potential for probiotic and prebiotic therapies to provide clinical benefits through modulation of the microbiome. Evidence from randomised control trials suggest probiotics are likely to improve GI inflammation and reduce the incidence of CF pulmonary exacerbations. However, the highly variable, low-quality data is a barrier to the implementation of probiotics into routine CF care. Epidemiological studies and clinical trials support the potential of dietary fibre and prebiotic supplements to beneficially modulate the microbiome in gastrointestinal conditions. To date, limited evidence is available on their safety and efficacy in CF. Variable responses to probiotics and prebiotics highlight the need for personalised approaches that consider an individual’s underlying microbiota, diet, and existing medications against the backdrop of the complex nutritional needs in CF.
Collapse
Affiliation(s)
- Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
- Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney 2031, Australia
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney 2031, Australia
- Correspondence:
| |
Collapse
|
31
|
Intestinal function and transit associate with gut microbiota dysbiosis in cystic fibrosis. J Cyst Fibros 2021; 21:506-513. [PMID: 34895838 DOI: 10.1016/j.jcf.2021.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/04/2021] [Accepted: 11/23/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Most people with cystic fibrosis (pwCF) suffer from gastrointestinal symptoms and are at risk of gut complications. Gut microbiota dysbiosis is apparent within the CF population across all age groups, with evidence linking dysbiosis to intestinal inflammation and other markers of health. This pilot study aimed to investigate the potential relationships between the gut microbiota and gastrointestinal physiology, transit, and health. STUDY DESIGN Faecal samples from 10 pwCF and matched controls were subject to 16S rRNA sequencing. Results were combined with clinical metadata and MRI metrics of gut function to investigate relationships. RESULTS pwCF had significantly reduced microbiota diversity compared to controls. Microbiota compositions were significantly different, suggesting remodelling of core and rarer satellite taxa in CF. Dissimilarity between groups was driven by a variety of taxa, including Escherichia coli, Bacteroides spp., Clostridium spp., and Faecalibacterium prausnitzii. The core taxa were explained primarily by CF disease, whilst the satellite taxa were associated with pulmonary antibiotic usage, CF disease, and gut function metrics. Species-specific ordination biplots revealed relationships between taxa and the clinical or MRI-based variables observed. CONCLUSIONS Alterations in gut function and transit resultant of CF disease are associated with the gut microbiota composition, notably the satellite taxa. Delayed transit in the small intestine might allow for the expansion of satellite taxa resulting in potential downstream consequences for core community function in the colon.
Collapse
|
32
|
Stefano MA, Sandy NS, Zagoya C, Duckstein F, Ribeiro AF, Mainz JG, Lomazi EA. Diagnosing constipation in patients with cystic fibrosis applying ESPGHAN criteria. J Cyst Fibros 2021; 21:497-501. [PMID: 34511390 DOI: 10.1016/j.jcf.2021.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Marina Abib Stefano
- Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Natascha Silva Sandy
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Zagoya
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Franziska Duckstein
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Antonio Fernando Ribeiro
- Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Jochen G Mainz
- Cystic Fibrosis Center, Brandenburg Medical School (MHB) University. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany; Faculty of Health Sciences, joint Faculty of the Brandenburg University of Technology Cottbus-Senftenberg, the Brandenburg Medical School Theodor Fontane and the University of Potsdam, Germany
| | - Elizete Aparecida Lomazi
- Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
| |
Collapse
|
33
|
Colonic Transit Time and Fecal Impaction in Children and Adolescents With Cystic Fibrosis-associated Constipation. J Pediatr Gastroenterol Nutr 2021; 73:319-324. [PMID: 34128499 DOI: 10.1097/mpg.0000000000003202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Constipation is prevalent in pediatric cystic fibrosis (CF) patients and colonic motility has not been studied in this population. In this study, we aimed to evaluate the total and segmental colonic transit time in children and adolescents with CF based on the presence of constipation and radiological fecal impaction. METHODS In this case series, all patients aged 3 to 20 years of a CF reference center were invited to participate. CF-associated constipation was diagnosed based on the European Society for Paediatric Gastroenterology Hepatology and Nutrition criteria. Total and segmental colonic transit time was determined using radiopaque markers. Fecal impaction on plain abdominal radiography was assessed based on the Barr score. RESULTS Of the 43 eligible patients, 34 (79%) agreed to participate. Constipation was found in 44.1% of children and adolescents, predominantly in girls. The total colonic transit time (medians of 42 and 24 hours, respectively, P = 0.028) and the segmental right colon transit time (medians of 8 and 2 hours, respectively, P = 0.012) were significantly longer in CF-associated constipation group than in the group of patients without constipation. The frequency of radiological fecal impaction was similar in patients with (50.0%) and without (64.2%) CF-associated constipation (P = 0.70). There was no relationship between radiological fecal impaction and the total and segmental colonic transit time. CONCLUSIONS Children and adolescents with CF-associated constipation had a longer total and segmental right colon transit time. Colonic transit time was similar in patients with and without radiological fecal impaction.
Collapse
|
34
|
Birimberg-Schwartz L, Wilschanski M. Cystic Fibrosis Related Gastrointestinal Manifestations - Moving Forward. J Cyst Fibros 2021; 20:562-563. [PMID: 34452731 DOI: 10.1016/j.jcf.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Liron Birimberg-Schwartz
- Department of Pediatric Gastroenterology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Michael Wilschanski
- Department of Pediatric Gastroenterology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Israel.
| |
Collapse
|
35
|
The Intestinal Microbiome and Cystic Fibrosis Transmembrane Conductance Regulator Modulators: Emerging Themes in the Management of Gastrointestinal Manifestations of Cystic Fibrosis. Curr Gastroenterol Rep 2021; 23:17. [PMID: 34448955 DOI: 10.1007/s11894-021-00817-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW While commonly associated with pulmonary manifestations, cystic fibrosis (CF) is a systemic disease with wide-ranging effects on the gastrointestinal (GI) tract. This article reviews major recent updates in gastroenterological CF care and research. RECENT FINDINGS The high burden of GI symptoms in CF has led to recent studies assessing GI-specific symptom questionnaires and scoring systems. Intestinal dysbiosis potentially contributes to gastrointestinal symptoms in patients with CF and an increased risk of gastrointestinal cancers in CF. An increased incidence of colorectal cancer (CRC) has led to CF-specific CRC screening and surveillance recommendations. Pharmacologic therapies targeting specific cystic fibrosis transmembrane conductance regulator (CFTR) mutations have shown promise in treating GI manifestations of CF. New research has highlighted the importance of intestinal dysbiosis in CF. Future studies should assess whether CFTR modulators affect the gut microbiome and whether altering the gut microbiome will impact GI symptoms and GI cancer risk.
Collapse
|
36
|
Smith S, Rowbotham N, Davies G, Gathercole K, Collins SJ, Elliott Z, Herbert S, Allen L, Ng C, Smyth A. How can we relieve gastrointestinal symptoms in people with cystic fibrosis? An international qualitative survey. BMJ Open Respir Res 2021; 7:7/1/e000614. [PMID: 32900780 PMCID: PMC7478045 DOI: 10.1136/bmjresp-2020-000614] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/22/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Relieving gastrointestinal (GI) symptoms was identified as a 'top ten' priority by our James Lind Alliance Priority Setting Partnership in cystic fibrosis (CF). We conducted an online survey to find out more about the effect of GI symptoms in CF. METHODS We co-produced an online survey distributed to the CF community via web-based platforms. The survey consisted of open and closed questions designed to help us learn more about the effects of GI symptoms for people with CF (pwCF). We analysed the data using descriptive statistics and thematic analysis. We promoted the survey via social media and web-based platforms which allowed respondents from any country to take part. Our participants came from the CF community, including: adults and children with CF, parents and close family of pwCF and healthcare professionals (HCPs) working with pwCF. RESULTS There were 276 respondents: 90 (33%) pwCF, 79 (29%) family, 107 (39%) HCPs. The most commonly reported symptoms by lay respondents were stomach cramps/pain, bloating and a 'combination of symptoms'. The top three symptoms that HCPs said were reported to them were reduced appetite, bloating and constipation. Almost all (94% (85/90)) HCPs thought medications helped to relieve GI symptoms but only 58% (82/141) of lay respondents agreed. CONCLUSIONS Our survey has shown that GI symptoms among our participants are prevalent and intrude on daily lives of pwCF. There is a need for well-designed clinical studies to provide better evidence for management of GI symptoms and complications.
Collapse
Affiliation(s)
- Sherie Smith
- Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Nicola Rowbotham
- Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | | | | | - Sarah J Collins
- CF Department, Royal Brompton and Harefield NHS Trust, London, UK
| | | | - Sophie Herbert
- Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | | | - Christabella Ng
- Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Alan Smyth
- Child Health Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| |
Collapse
|
37
|
Sathe M, Moshiree B, Vu PT, Khan U, Heltshe SL, Romasco M, Freedman SD, Schwarzenberg SJ, Goss CH, Freeman AJ. Utilization of electronic patient-reported outcome measures in cystic fibrosis research: Application to the GALAXY study. J Cyst Fibros 2021; 20:605-611. [PMID: 34305007 DOI: 10.1016/j.jcf.2021.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Food and Drug Administration considers patient-reported outcome measures (PROMs) an essential part of clinical research studies for approval of new drugs and new indications for existing drugs. GALAXY evaluated the feasibility of electronic PROMs (ePROMS) to conduct a comprehensive evaluation of gastrointestinal (GI) symptoms in persons with cystic fibrosis (pwCF). METHODS Three validated GI ePROMs (PAC-SYM, PAGI-SYM and PAC-QOL) were combined with a Stool-Specific questionnaire to make up the GALAXY ePROMs and administered prospectively across 26 CF centers in the United States. The ePROMs were completed at enrollment visit and then electronically at weeks 1, 2 and 4. PwCF at least 2 years and older were eligible for the study. Reminders were only provided by the mobile application during the study window. RESULTS There were 402 participants enrolled in GALAXY. Of those, 169 (42%) were under 18 years old and 193 (48%) were female. The proportion of all follow-up weeks with at least 1 ePROM fully completed was 80%, slightly higher in those ≥18 years of age (82.5%) compared to those <18 years of age (76.5%). When assessing the completion for all 4 ePROMs, the percentage was 77.6%, also higher among those ≥18 year of age (81.5% versus 72.2% for < 18 years of age). CONCLUSION Using ePROMs, our study demonstrated that GI symptoms can be feasibly collected with good reproducibility and with minimal involvement of research coordinator time. This mechanism of symptom collection may provide an efficient tool for future CF trials.
Collapse
Affiliation(s)
- Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, TX.
| | - Baha Moshiree
- Division of Gastroenterology, Atrium Health, Charlotte, NC
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Melita Romasco
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - A Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| |
Collapse
|
38
|
Ng C, Dellschaft NS, Hoad CL, Marciani L, Ban L, Prayle AP, Barr HL, Jaudszus A, Mainz JG, Spiller RC, Gowland P, Major G, Smyth AR. Postprandial changes in gastrointestinal function and transit in cystic fibrosis assessed by Magnetic Resonance Imaging. J Cyst Fibros 2021; 20:591-597. [PMID: 32561324 DOI: 10.1016/j.jcf.2020.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/24/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is a multi-system genetic disorder affecting >72,000 people worldwide. Most CF patients experience gastrointestinal symptoms and can develop complications. However, the mechanisms of CF gut disease are not well understood. We evaluated gut function and transit in CF using magnetic resonance imaging (MRI). We hypothesised oro-caecal transit time (OCTT) is longer in CF; with lower small bowel water content (SBWC). METHODS Twelve CF patients aged 12-40 years and 12 age and sex-matched controls underwent serial MRIs over 1 day with standardised meals. The primary endpoint was OCTT, assessed by the appearance of a food bolus in the caecum. Other measures included corrected SBWC and corrected colonic volume (both area under the curve, AUC), gastric half-emptying time and gastrointestinal symptoms. RESULTS OCTT was longer in CF (CF 330 mins [270, >360] vs. controls 210 mins [173, 315], p = 0.04), with no difference in gastric half-emptying times. Corrected SBWC was higher in CF (CF 62 L.min/m2 [36, 80] vs. controls 34 L.min/m2 [28, 41], p = 0.021); minimal postprandial decrease between T240 and T300 (CF 13 mL/m2 [-13, 57] vs. controls 102 mL/m2 [67, 108], p = 0.002) suggests impaired ileal emptying. Corrected colonic volumes were higher in CF (CF 186 L.min/m2 [167, 206] vs. controls 123 L.min/m2 [89, 146], p = 0.012). There were no differences in gastrointestinal symptoms. CONCLUSIONS MRI provides novel insights into CF pathophysiology. Sub-clinical ileal obstruction may be more prevalent than previously thought. Gastrointestinal MRI shows promise as an investigational tool in CF.
Collapse
Affiliation(s)
- Christabella Ng
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Neele S Dellschaft
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Luca Marciani
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Lu Ban
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Andrew P Prayle
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Helen L Barr
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Wolfson Cystic Fibrosis Unit, Nottingham University Hospitals NHS Trust, UK
| | - Anke Jaudszus
- Jena University Hospital, Cystic Fibrosis Centre, Jena, Germany
| | - Jochen G Mainz
- Jena University Hospital, Cystic Fibrosis Centre, Jena, Germany; Brandenburg Medical School (MHB), University, Kinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Robin C Spiller
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, University of Nottingham, UK
| | - Penny Gowland
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Giles Major
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Nottingham Digestive Diseases Centre, University of Nottingham, UK
| | - Alan R Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, UK; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
| |
Collapse
|
39
|
J Burton S, Hachem C, Abraham JM. Luminal Gastrointestinal Manifestations of Cystic Fibrosis. Curr Gastroenterol Rep 2021; 23:4. [PMID: 33758994 DOI: 10.1007/s11894-021-00806-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW People with cystic fibrosis (CF) are living longer. General age-related and CF-specific gastrointestinal symptoms are increasingly recognized. In this article, we review the latest data on luminal gastrointestinal manifestations in CF. RECENT FINDINGS People with CF have increased incidence of gastroesophageal reflux disease symptoms and often prescribed proton-pump inhibitors (PPI). PPI use may increase risk of pulmonary exacerbations. Evidence to support gastric fundoplication to improve pulmonary outcomes is limited. Features of intestinal dysmotility are common. There are distinct differences in the gut microbiome in the CF population which may have clinical implications. CF is a possible hereditary digestive cancer syndrome, particularly in regard to colorectal cancer (CRC) with earlier incidence of CRC and advanced colonic neoplasia. Early screening colonoscopy is warranted in the CF population. Gastrointestinal manifestations in CF are prevalent across all digestive organs. More study on the effect of interventions for symptomatic treatment and cancer screening is needed.
Collapse
Affiliation(s)
- Samuel J Burton
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MI, USA
| | - Christine Hachem
- Division of Gastroenterology and Hepatology, Saint Louis University, St. Louis, MI, USA
| | - James M Abraham
- Department of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
40
|
PROMISE: Working with the CF community to understand emerging clinical and research needs for those treated with highly effective CFTR modulator therapy. J Cyst Fibros 2021; 20:205-212. [PMID: 33619012 DOI: 10.1016/j.jcf.2021.02.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/25/2021] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
Highly effective CFTR modulator drug therapy is increasingly available to those with cystic fibrosis. Multiple observational research studies are now being conducted to better understand the impacts of this important therapeutic milestone on long-term outcomes, patient care needs, and future research priorities. PROMISE is a large, multi-disciplinary academic study focused on the broad impacts of starting elexacaftor/tezacaftor/ivacaftor in the US population age 6 years and older. The many areas of investigation and rationale for each are discussed by organ systems, along with recognition of remaining important questions that will not be addressed by this study alone. Knowledge gained through this and multiple complementary studies around the world will help to understand important health outcomes, clinical care priorities, and research needs for a large majority of people treated with these or similarly effective medications targeting the primary cellular impairment in cystic fibrosis.
Collapse
|
41
|
Freeman AJ, Sathe M, Aliaj E, Borowitz D, Fogarty B, Goss CH, Freedman S, Heltshe SL, Khan U, Riva D, Roman C, Romasco M, Schwarzenberg SJ, Ufret-Vincenty CA, Moshiree B. Designing the GALAXY study: Partnering with the cystic fibrosis community to optimize assessment of gastrointestinal symptoms. J Cyst Fibros 2021; 20:598-604. [PMID: 33451899 DOI: 10.1016/j.jcf.2020.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal (GI) involvement among persons with cystic fibrosis (CF) is highly prevalent, representing a significant source of morbidity. Persons with CF have identified GI concerns as a top research priority, yet universal clinical outcome measures capturing many of the GI symptoms experienced in CF are lacking. The GALAXY study was envisioned to address this unmet need. METHODS The GALAXY study team partnered with Community Voice, a community of patients with CF and their caregivers, to identify the patient reported outcome measures that most accurately reflected their experience with GI symptoms in CF. We also surveyed CF care teams to identify the comfort level of various team members (providers, nurses and dieticians) in managing a variety of GI conditions. RESULTS Members of Community Voice identified the combination of PAC-SYM, PAGI-SYM, PAC-QOL and the Bristol Stool scale with three additional symptom-specific questions as patient-reported outcome measures that comprehensively captured the CF experience with GI disease. CF care team providers reported a high level of comfort in treating GI conditions including constipation (92%), GERD (93%), and gassiness (77%), however comfort level was limited to only first-line interventions. CONCLUSION By partnering with persons with CF as well as their caregivers and medical providers, the GALAXY study is designed to uniquely capture the prevalence and severity of GI involvement among persons with CF in a manner that reflects the CF patient experience. The results of GALAXY will inform the development of future interventional trials and serve as a reproducible and objective study endpoint.
Collapse
Affiliation(s)
- A Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA.
| | - Meghana Sathe
- Division of Gastroenterology, Hepatology and Nutrition, Children's Health University of Texas Southwestern, Dallas, TX, USA
| | - Enid Aliaj
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Drucy Borowitz
- Cystic Fibrosis Foundation, Bethesda, MD, USA; Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Barbra Fogarty
- Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Christopher H Goss
- Seattle Children's Hospital Research Institute, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Steven Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sonya L Heltshe
- Seattle Children's Hospital Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Umer Khan
- Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Dara Riva
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | - Melita Romasco
- Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | | | | | - Baha Moshiree
- University of North Carolina, Atrium Health, Charlotte, NC, USA
| |
Collapse
|
42
|
Beaufils F, Mas E, Mittaine M, Addra M, Fayon M, Delhaes L, Clouzeau H, Galode F, Lamireau T, Bui S, Enaud R. Increased Fecal Calprotectin Is Associated with Worse Gastrointestinal Symptoms and Quality of Life Scores in Children with Cystic Fibrosis. J Clin Med 2020; 9:jcm9124080. [PMID: 33348735 PMCID: PMC7766355 DOI: 10.3390/jcm9124080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 02/06/2023] Open
Abstract
In cystic fibrosis (CF), cystic fibrosis transmembrane regulator (CFTR) dysfunction leads to digestive disorders that promote intestinal inflammation and dysbiosis enhancing gastrointestinal symptoms. In pancreatic insufficiency CF patients, both intestinal inflammation and dysbiosis, are associated with an increase in the fecal calprotectin (FC) level. However, associations between the FC level, gastrointestinal symptoms, and quality of life (QoL) remain poorly studied. We aimed to assess such associations in pancreatic insufficiency CF children. The FC level was measured in pancreatic insufficiency CF children’s stool samples. Children and their parents completed two questionnaires: The Gastrointestinal Symptoms Scales 3.0-PedsQLTM and the Quality of Life Pediatric Inventory 4.0-PedsQLTM. Lower scores indicated worse symptomatology or QoL. Thirty-seven CF children were included. A FC level above 250 µg/g was associated with worse gastrointestinal symptoms and QoL scores. The FC level was inversely correlated with several gastrointestinal scores assessed by children (i.e., Total, “Heart Burn Reflux”, “Nausea and Vomiting”, and “Gas and Bloating”). Several QoL scores were correlated with gastrointestinal scores. The FC level was weakly associated with clinical parameters. Some gastrointestinal and QoL scores were related to disease severity associated parameters. In CF, the FC level, biomarker previously related to intestinal inflammation and dysbiosis, was associated with worse digestive symptoms and QoL scores.
Collapse
Affiliation(s)
- Fabien Beaufils
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-5-56-79-98-24
| | - Emmanuel Mas
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
- INSERM, INRA, ENVT, Université de Toulouse, UPS, F-31000 Toulouse, France
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, F-31300 Toulouse, France
| | - Marie Mittaine
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
| | - Martin Addra
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
| | - Michael Fayon
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Laurence Delhaes
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
- CHU Bordeaux, Service de Parasitologie-Mycologie, F-33000 Bordeaux, France
| | - Haude Clouzeau
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - François Galode
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Thierry Lamireau
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Stéphanie Bui
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Raphaël Enaud
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| |
Collapse
|
43
|
Stefano MA, Poderoso RE, Mainz JG, Ribeiro JD, Ribeiro AF, Lomazi EA. Prevalence of constipation in cystic fibrosis patients: a systematic review of observational studies. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
44
|
Stefano MA, Poderoso RE, Mainz JG, Ribeiro JD, Ribeiro AF, Lomazi EA. Prevalence of constipation in cystic fibrosis patients: a systematic review of observational studies. J Pediatr (Rio J) 2020; 96:686-692. [PMID: 32389617 PMCID: PMC9432222 DOI: 10.1016/j.jped.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To systematically revise the literature in search of data about the prevalence of constipation in patients with cystic fibrosis according to the publications in this field, which partly refer to guidelines defined in 2010 by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. SOURCES Systematic review selecting articles based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, including Cystic Fibrosis patients of all ages. Sources of information were selected to identify the articles without period limitation: CADTH - Canadian Agency for Drugs and Technologies in Health, CINAHL Complete, Clinical Trials US NIH, Cochrane Library, Embase, MEDLINE via Ovid, Scopus, Web Of Science, PubMed, SciELO, MEDLINE and LILACS , Health Systems Evidence, PDQ Evidence, CRD Canadian Agency for Drugs and Technologies in Health, INAHTA - International Network of Agencies for Health Technology Assessment, and PEDro. FINDINGS The prevalence of constipation was reported in eight observational studies. Only two studies assessed the frequency of constipation as a primary objective; in the others, constipation was quoted along with the prevalence of the spectrum of gastrointestinal manifestations. Altogether, the publications included 2,018 patients, the reported prevalence varied from 10% to 57%. Only two of the six articles published after 2010 followed the definition recommended by the European Society. CONCLUSIONS Constipation is a frequent but still insufficiently assessed complaint of Cystic Fibrosis patients. The use of diverse diagnostic criteria restricts comparison and epidemiological conclusions, future studies should compulsorily apply the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition definition.
Collapse
Affiliation(s)
- Marina A Stefano
- Universidade Estadual de Campinas, Centro de Referência em Fibrose Cística, Campinas, SP, Brazil
| | - Rosana E Poderoso
- Universidade Estadual de Campinas, Biblioteca da Faculdade de Ciências Médicas, Campinas, SP, Brazil
| | - Jochen G Mainz
- University Klinikum Westbrandenburg Klinik für Kinder- und Jugendmedizin, Brandenburg Medical School (MHB), Head of Pediatric Pulmonology and Cystic Fibrosis, Hochstraße, Germany
| | - Jose D Ribeiro
- Universidade Estadual de Campinas, Departamento de Pediatria, Campinas, SP, Brazil; Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Centro de Referência em Fibrose Cística, Campinas, SP, Brazil
| | - Antonio F Ribeiro
- Universidade Estadual de Campinas, Departamento de Pediatria, Campinas, SP, Brazil; Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Centro de Referência em Fibrose Cística, Campinas, SP, Brazil
| | - Elizete Aparecida Lomazi
- Universidade Estadual de Campinas, Departamento de Pediatria, Campinas, SP, Brazil; Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Centro de Referência em Fibrose Cística, Campinas, SP, Brazil.
| |
Collapse
|
45
|
Abstract
CLINICAL ISSUE Abdominal complications are often the first indications for cystic fibrosis (CF), a multiorgan disease. A broad range of abdominal manifestations are associated with the disease, including gastrointestinal abnormalities (such as meconium ileus in newborns and distal intestinal obstruction syndrome in older children) and hepatobiliary alterations (e.g., cholelithiasis, microgallbladder, hepatosteatosis, biliary cirrhosis). A characteristic finding is pancreatic involvement, which leads to exocrine and over the course of time to endocrine insufficiency. STANDARD RADIOLOGICAL METHODS Ultrasonography is the preferred and often sole modality for a precise diagnosis of abdominal CF manifestations. However, all imaging modalities can be used, depending on the pathology: X‑ray, fluoroscopic examinations, computed tomography, magnetic resonance imaging (also with application of magnetic resonance cholangiopancreatography). METHODICAL INNOVATIONS/PERFORMANCE Scoring systems are useful for standardized diagnostics. Sonographic findings, described using a scoring system, correlate with clinical symptoms, such as pancreatic lipomatosis with abdominal pain (p = 0.018), flatulence (p = 0.006), and gastroesophageal reflux (p = 0.006). EVALUATION/PRACTICAL RECOMMENDATIONS A standardized approach with structured reporting is important due to the numerous abdominal CF manifestations. To enable precise follow-up analyses, scoring systems based on sonographic findings are excellent.
Collapse
|
46
|
Lusman SS, Borowitz D, Marshall BC, Narkewicz MR, Gonska T, Grand RJ, Simon RH, Mascarenhas MR, Schwarzenberg SJ, Freedman SD. DIGEST: Developing innovative gastroenterology specialty training. J Cyst Fibros 2020; 20:586-590. [PMID: 32736950 PMCID: PMC7387932 DOI: 10.1016/j.jcf.2020.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022]
Abstract
There is a need for adult and pediatric gastroenterologists with expertise in CF. The DIGEST program was created to meet this need. This article reports on the development, implementation and results of DIGEST.
Individuals with cystic fibrosis (CF) now have an increased life expectancy, due to advances in care provided by a multidisciplinary team. The care model has expanded over time to include multiple subspecialties. The Cystic Fibrosis Foundation conducted a survey of Care Center Directors and identified a need for pediatric and adult gastroenterologists with expertise in the diagnosis and treatment of intestinal, pancreatic and hepatic complications of CF. To address this need, the Developing Innovative GastroEnterology Specialty Training (DIGEST) program was created. The development, implementation, and early results of this training program are reported herein.
Collapse
Affiliation(s)
- Sarah Shrager Lusman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States.
| | - Drucy Borowitz
- Cystic Fibrosis Foundation, Bethesda, Maryland and State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, United States
| | | | - Michael R Narkewicz
- Digestive Health Institute, Children's Hospital Colorado and Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Tanja Gonska
- The Hospital for Sick Children, University of Toronto, Ontario, Toronto, Canada
| | - Richard J Grand
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Richard H Simon
- University of Michigan Medical School, Ann Arbor, MI, United States
| | - Maria R Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Steven D Freedman
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
47
|
Boon M, Calvo-Lerma J, Claes I, Havermans T, Asseiceira I, Bulfamante A, Garriga M, Masip E, van Schijndel BAM, Fornes V, Barreto C, Colombo C, Crespo P, Vicente S, Janssens H, Hulst J, Witters P, Nobili R, Pereira L, Ruperto M, Van der Wiel E, Mainz JG, De Boeck K, Ribes-Koninckx C. Use of a mobile application for self-management of pancreatic enzyme replacement therapy is associated with improved gastro-intestinal related quality of life in children with Cystic Fibrosis. J Cyst Fibros 2020; 19:562-568. [PMID: 32335023 DOI: 10.1016/j.jcf.2020.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most patients with cystic fibrosis (CF) suffer from pancreatic insufficiency (PI), leading to fat malabsorption, malnutrition, abdominal discomfort and impaired growth. Pancreatic enzyme replacement therapy (PERT) is effective, but evidence based guidelines for dose adjustment are lacking. A mobile app for self-management of PERT was developed in the context of the HORIZON 2020 project MyCyFAPP. It contains an algorithm to calculate individual PERT-doses for optimal fat digestion, based on in vitro and in vivo studies carried out in the same project. In addition, the app includes a symptoms diary, educational material, and it is linked to a web tool allowing health care professionals to evaluate patient's data and provide feedback. METHODS A 6-month open label prospective multicenter interventional clinical trial was performed to assess effects of using the app on gastro-intestinal related quality of life (GI QOL), measured by the CF-PedsQL-GI (shortened, CF specific version of the Pediatric Quality of Life Inventory, Gastrointestinal Symptoms Module). RESULTS One hundred and seventy-one patients with CF and PI between 2 and 18 years were recruited at 6 European CF centers. Self-reported CF-PedsQL-GI improved significantly from month 0 (M0) (84.3, 76.4-90.3) to month 6 (M6) (89.4, 80.35-93.5) (p< 0.0001). Similar improvements were reported by parents. Lower baseline CF-PedsQL-GI was associated with a greater improvement at M6 (p < 0.001). CONCLUSIONS The results suggest that the MyCyFAPP may improve GI QOL for children with CF. This tool may help patients to improve self-management of PERT, especially those with considerable GI symptoms.
Collapse
Affiliation(s)
- M Boon
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium.
| | - J Calvo-Lerma
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - I Claes
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - T Havermans
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - I Asseiceira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - A Bulfamante
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - M Garriga
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Masip
- Gastroenterology and Pediatric cystic Fibrosis Unit, La Fe Hospital, Valencia, Spain
| | - B A M van Schijndel
- Department of Pediatrics, div of Gastro-Enterology, Erasmus MC- Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - V Fornes
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - C Barreto
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - C Colombo
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - P Crespo
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - S Vicente
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - H Janssens
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - J Hulst
- Department of Pediatrics, div of Gastro-Enterology, Erasmus MC- Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - P Witters
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | - R Nobili
- Università degli Studi di Milano, Fondazione IRCCS Ca" Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - L Pereira
- Associação para a Investigação e Desenvolvimento da Faculdade de Medicina, Lisbon, Portugal
| | - M Ruperto
- Unidad de Fibrosis Quística, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Van der Wiel
- Department of Pediatrics, div Respiratory Medicine and Allergology, Erasmus MC-Sophia Children's Hospital, University Hospital Rotterdam, the Netherlands
| | - J G Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Germany; Cystic Fibrosis Center Brandenburg Medical School (MHB), University, Brandenburg an der Havel, Germany
| | - K De Boeck
- Department of Pediatrics, Center for Cystic Fibrosis, University Hospital Leuven, Leuven, Belgium
| | | |
Collapse
|
48
|
Jaudszus A, Zeman E, Jans T, Pfeifer E, Tabori H, Arnold C, Michl RK, Lorenz M, Beiersdorf N, Mainz JG. Validity and Reliability of a Novel Multimodal Questionnaire for the Assessment of Abdominal Symptoms in People with Cystic Fibrosis (CFAbd-Score). PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 12:419-428. [PMID: 30887269 DOI: 10.1007/s40271-019-00361-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE For people with cystic fibrosis, validated patient-reported outcome measures for the assessment of the complex abdominal involvement are lacking. The objective of this study was to examine whether the CFAbd-Score, a novel questionnaire consisting of 28 items, meets the essential requirements (validity and reliability) for a patient-reported outcome measure according to US Food and Drug Administration recommendations. METHODS Content validity was assessed by recording the frequencies and severity of symptoms that occurred during the prior 2 weeks in patients with cystic fibrosis (n = 116; aged ≥ 6 years). Comparing the CFAbd-Score results obtained from patients with cystic fibrosis and healthy controls (n = 88), we determined known-groups validity. To explore the structure of the patient-reported outcome measure, a factor analysis was conducted. Internal consistency of the five extracted score domains was assessed using Cronbach's alpha. For test-retest reliability, a subgroup of patients (n = 43) was reevaluated and intra-class correlation coefficients were determined. RESULTS The CFAbd-Score differentiated patients with cystic fibrosis from healthy controls with a large effect size (17.3 ± 1.1 vs. 8.0 ± 0.7 points; p < 0.001; Cohen's d = 0.85). Items, domains, and scores reflected the relevance to patients with cystic fibrosis and allowed a differentiation between subgroups of patients with cystic fibrosis (e.g., patients with and without abdominal pain, pancreatic sufficiency, and age groups). High item-domain loadings as well as good to excellent internal consistency and reproducibility (Cronbach's α = 0.70-0.92; intra-class correlation coefficient = 0.932, 95% confidence interval 0.874-0.963) indicated construct validity and reliability. CONCLUSIONS The CFAbd-Score has successfully passed through key steps of the iterative process of patient-reported outcome measure development. Prospectively, the CFAbd-Score is proposed as a patient-centered instrument for monitoring abdominal symptoms and, most interestingly, for evaluating changes in symptoms with novel treatments such as cystic fibrosis transmembrane regulator modulators. TRAIL REGISTRATION ClinicalTrials.gov: NCT03052283.
Collapse
Affiliation(s)
- Anke Jaudszus
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - Elisa Zeman
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Tatjana Jans
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Elena Pfeifer
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Harold Tabori
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Christin Arnold
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Ruth K Michl
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Michael Lorenz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Natalie Beiersdorf
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Jochen G Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Pediatric Pulmonology/Cystic Fibrosis, Brandenburg Medical School/Medizinische Hochschule Brandenburg (MHB), Brandenburg an der Havel, Germany
| |
Collapse
|
49
|
Abstract
BACKGROUND Cystic fibrosis (CF) is a multisystem disease and the importance of growth and nutrition has been well established, given its implications for lung function and overall survival. It has been established that intestinal dysbiosis (i.e. microbial imbalance) and inflammation is present in people with CF. Probiotics are commercially available (over-the-counter) and may improve both intestinal and overall health. OBJECTIVES To assess the efficacy and safety of probiotics for improving health outcomes in children and adults with CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last register search: 20 January 2020. We also searched ongoing trials registries and the reference lists of relevant articles and reviews. Date of last search: 29 January 2019. SELECTION CRITERIA Randomised or quasi-randomised controlled trials (RCTs) assessing efficacies and safety of probiotics in children and adults with CF. Cross-over RCTs with a washout phase were included and for those without a washout period, only the first phase of each trial was analysed. DATA COLLECTION AND ANALYSIS We independently extracted data and assessed the risk of bias of the included trials; we used GRADE to assess the certainty of the evidence. We contacted trial authors for additional data. Meta-analyses were undertaken on outcomes at several time points. MAIN RESULTS We identified 17 trials and included 12 RCTs (11 completed and one trial protocol - this trial was terminated early) (464 participants). Eight trials included only children, whilst four trials included both children and adults. Trial duration ranged from one to 12 months. Nine trials compared a probiotic (seven single strain and three multistrain preparations) with a placebo preparation, two trials compared a synbiotic (multistrain) with a placebo preparation and one trial compared two probiotic preparations. Overall we judged the risk of bias in the 12 trials to be low. Three trials had a high risk of performance bias, two trials a high risk of attrition bias and six trials a high risk of reporting bias. Only two trials were judged to have low or unclear risk of bias for all domains. Four trials were sponsored by grants only, two trials by industry only, two trials by both grants and industry and three trials had an unknown funding source. Combined data from four trials (225 participants) suggested probiotics may reduce the number of pulmonary exacerbations during a four to 12 month time-frame, mean difference (MD) -0.32 episodes per participant (95% confidence interval (CI) -0.68 to 0.03; P = 0.07) (low-certainty evidence); however, the 95% CI includes the possibility of both an increased and a reduced number of exacerbations. Additionally, two trials (127 participants) found no evidence of an effect on the duration of antibiotic therapy during the same time period. Combined data from four trials (177 participants) demonstrated probiotics may reduce faecal calprotectin, MD -47.4 µg/g (95% CI -93.28 to -1.54; P = 0.04) (low-certainty evidence), but the results for other biomarkers mainly did not show any difference between probiotics and placebo. Two trials (91 participants) found no evidence of effect on height, weight or body mass index (low-certainty evidence). Combined data from five trials (284 participants) suggested there was no difference in lung function (forced expiratory volume at one second (FEV1) % predicted) during a three- to 12-month time frame, MD 1.36% (95% CI -1.20 to 3.91; P = 0.30) (low-certainty evidence). Combined data from two trials (115 participants) suggested there was no difference in hospitalisation rates during a three- to 12-month time frame, MD -0.44 admissions per participant (95% CI -1.41 to 0.54; P = 0.38) (low-certainty evidence). One trial (37 participants) reported health-related quality of life and while the parent report favoured probiotics, SMD 0.87 (95% CI 0.19 to 1.55) the child self-report did not identify any effect, SMD 0.59 (95% CI -0.07 to 1.26) (low-certainty evidence). There were limited results for gastrointestinal symptoms and intestinal microbial profile which were not analysable. Only four trials and one trial protocol (298 participants) reported adverse events as a priori hypotheses. No trials reported any deaths. One terminated trial (12 participants and available as a protocol only) reported a severe allergic reaction (severe urticaria) for one participant in the probiotic group. Two trials reported a single adverse event each (vomiting in one child and diarrhoea in one child). The estimated number needed to harm for any adverse reaction (serious or not) is 52 people (low-certainty evidence). AUTHORS' CONCLUSIONS Probiotics significantly reduce faecal calprotectin (a marker of intestinal inflammation) in children and adults with CF, however the clinical implications of this require further investigation. Probiotics may make little or no difference to pulmonary exacerbation rates, however, further evidence is required before firm conclusions can be made. Probiotics are associated with a small number of adverse events including vomiting, diarrhoea and allergic reactions. In children and adults with CF, probiotics may be considered by patients and their healthcare providers. Given the variability of probiotic composition and dosage, further adequately-powered multicentre RCTs of at least 12 months duration are required to best assess the efficacy and safety of probiotics for children and adults with CF.
Collapse
Affiliation(s)
- Michael J Coffey
- University of New South WalesSchool of Women's and Children's HealthLevel 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High StreetsRandwickSydneyNSWAustralia2031
- Sydney Children's HospitalJunior Medical Officers DepartmentHigh StreetRandwickSydneyNSWAustralia2031
| | - Millie Garg
- University of New South WalesSchool of Women's and Children's HealthLevel 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High StreetsRandwickSydneyNSWAustralia2031
| | - Nusrat Homaira
- University of New South WalesSchool of Women's and Children's HealthLevel 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High StreetsRandwickSydneyNSWAustralia2031
- Sydney Children's HospitalRespiratory DepartmentHigh StreetRandwickSydneyNew South WalesAustraliaNSW 2031
| | - Adam Jaffe
- University of New South WalesSchool of Women's and Children's HealthLevel 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High StreetsRandwickSydneyNSWAustralia2031
- Sydney Children's HospitalRespiratory DepartmentHigh StreetRandwickSydneyNew South WalesAustraliaNSW 2031
| | - Chee Y Ooi
- University of New South WalesSchool of Women's and Children's HealthLevel 8, Centre for Child Health Research & Innovation Bright Alliance Building Cnr Avoca & High StreetsRandwickSydneyNSWAustralia2031
- Sydney Children's HospitalGastroenterology DepartmentHigh StreetRandwickSydneyNSWAustralia2031
| | | |
Collapse
|
50
|
Gastrointestinal Complications. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|