The quality of well-being in cystic fibrosis

The estimation of health state utility values in rare diseases: do the approaches in submissions for NICE technology appraisals reflect the existing literature? A scoping review

BACKGROUND

Rare diseases negatively impact patients' quality of life, but the estimation of health state utility values (HSUVs) in research studies and cost-utility models for health technology assessment is challenging.

OBJECTIVES

This study compared the methods for estimating the HSUVs included in manufacturers' submissions of orphan drugs to the National Institute for Health and Care Excellence (NICE) with those of published studies addressing the same rare diseases to understand whether manufacturers fully exploited the existing literature in developing their economic models.

METHODS

All NICE Technology Appraisal (TA) and Highly Specialized Technologies (HST) guidance documents of non-cancer European Medicines Agency (EMA) orphan medicinal products were reviewed and compared with any published primary studies, retrieved via PubMed until November 2020, and estimating HSUVs for the same conditions addressed in manufacturers' submissions.

RESULTS

We identified 22 NICE TA/HST appraisal reports addressing 19 different rare diseases. Sixteen reports presented original HSUVs estimated using EQ-5D or Health Utility Index (n = 12), direct methods (n = 2) or mapping (n = 2), while the other six included values obtained from the literature only. In parallel, we identified 111 published studies: 86.6% used preference-based measures (mainly EQ-5D, 60.7%), 12.5% direct techniques, and 2.7% mapping. The collection of values from non-patient populations (using 'vignettes') was more frequent in manufacturers' submissions than in the literature (22.7% vs. 8.0%).

CONCLUSIONS

The agreement on methodological choices between manufacturers' submissions and published literature was only partial. More efforts should be made by manufacturers to accurately reflect the academic literature and its methodological recommendations in orphan drugs submissions.

Should the physiotherapy outcomes airway clearance, physical activity and fitness be recorded on the Australian Cystic Fibrosis Data Registry? A consensus approach

BACKGROUND

Physiotherapy is a cornerstone of cystic fibrosis (CF) management, yet the Australian CF Data Registry (ACFDR) currently does not record physiotherapy-related data. This study aimed to gather opinions from lead Australian CF physiotherapists regarding the importance and feasibility of collecting physiotherapy-related data on the ACFDR.

METHODS

A three-round online Delphi survey was conducted to gather expert stakeholder opinion and consensus agreement. Lead physiotherapists from all 23 Australian CF centres were invited to participate. Round one explored the potential benefits, barriers and importance of recording three physiotherapy-related domains on the ACFDR: airway clearance, physical activity and fitness. Subsequent rounds were developed based on the findings from the previous round and sought consensus (80% agreement) for the inclusion of physiotherapy-related data on the ACFDR and for the most appropriate methods of collecting such data.

RESULTS

The response rate was > 80% for all rounds. Participants agreed that collection of airway clearance, physical activity and fitness data on the ACFDR was important and feasible. Findings suggested that airway clearance and physical activity should be collected using self-reported questionnaires, while fitness should be measured using a field-based test.

CONCLUSIONS

Australian lead CF physiotherapists believe that collection of airway clearance, physical activity and fitness on the ACFDR is important and feasible. Future work is needed to pilot the data collection procedure to examine its feasibility in real-world clinical settings. This study demonstrates how Delphi methodology can provide a contemporary summary of expert clinicians' opinion that may underpin nation-wide health service improvement.

Endurance cycle ergometry tests performed at a sub-maximal work rate elicit peak physiological and symptom responses in adults with cystic fibrosis

Time to symptom limitation (T_lim ) achieved during constant work rate tests is considerably more responsive to change than measures commonly recorded during ramp-based tests, such as peak rate of oxygen uptake and maximal work rate (W_max ). There is limited literature on the use of, and physiological and symptom responses to, constant work rate cycle ergometry tests in people with cystic fibrosis (CF). The results of this study provide evidence that the constant work rate cycle ergometry test, when conducted at 80% of the W_max , elicits peak physiological and symptom responses and appears to be safe in adults with CF. For clinicians prescribing exercise at an intensity approaching or equivalent to 80% of the W_max in a non-laboratory-based setting, consideration needs to be given to the level of supervision and patient monitoring required.

Physical activity in children and adolescents with cystic fibrosis: A systematic review and meta-analysis

BACKGROUND

Exercise and physical activity (PA) are essential components of the care of cystic fibrosis (CF) patients. Lower PA levels have been associated with worse pulmonary function, aerobic fitness, glycemic control, and bone mineral density. Most people with CF do not engage in the recommended amounts of PA.

OBJECTIVE

To determine the level of PA in children and adolescents with CF.

METHODS

A systematic review with meta-analysis was conducted without language restrictions in five databases. Were included studies that analyzed PA measured by objective and subjective instruments in children and adolescents with CF. Two independent reviewers analyzed the studies, extracted the data, and assessed the quality of evidence. The risk of bias of the included studies was assessed with the National Heart, Lung, and Blood Institute's risk-of-bias tool.

RESULTS

Of the 1535 reports returned by the initial search, 20 articles reporting on 785 patients were included in the data synthesis. The forest plot showed that the CF group had a similar moderate-to-vigorous PA (MVPA) (mean difference, -7.79; 95% CI -15.65 to 0.08 min/d; P = .05) and sedentary time (mean difference, -50.81; 95%CI, -109.96 to 8.35 min/d; P = .09) to the control group.

CONCLUSION

Children and adolescents with CF have a similar MVPA and sedentary time compared to controls. There are many options, subjective and objective, for assessing PA in this population. Optimal tool selection should guarantee more valid results.

High-Intensity Interval Training Is Effective at Increasing Exercise Endurance Capacity and Is Well Tolerated by Adults with Cystic Fibrosis

BACKGROUND

To optimize outcomes in people with cystic fibrosis (CF), guidelines recommend 30 to 60 min of moderate-intensity aerobic exercise on most days. Accumulating this volume of exercise contributes importantly to the substantial treatment burden associated with CF. Therefore, the main aim of this study was to investigate the effects of low-volume high-intensity interval training (HIIT) on exercise capacity in people with CF.

METHODS

This randomized controlled trial included people with CF aged ≥15 years, who were allocated to either eight weeks of thrice-weekly 10-min sessions of HIIT (experimental group) or eight weeks of weekly contact (control group). Before and after the intervention period, participants completed measurements of time to symptom limitation (T_lim) during a constant work rate cycle ergometry test (primary outcome), and maximal work rate (W_max) during a ramp-based cycle ergometry test and health-related quality of life (HRQoL).

RESULTS

Fourteen participants (median (IQR) age 31 (28, 35) years, forced expiratory volume in 1 second (FEV₁) 61 (45, 80) % predicted) were included (seven in each group). Compared to the control group, participants in the experimental group demonstrated a greater magnitude of change in T_lim, W_max (p = 0.017 for both) and in the physical function domain of HRQoL (p = 0.03). No other between-group differences were demonstrated. Mild post-exercise muscle soreness was reported on a single occasion by four participants. Overall, participants attended 93% of all HIIT sessions.

DISCUSSION

Eight weeks of low-volume (i.e., 30-min/week) HIIT produced gains in exercise capacity and self-reported physical function and was well tolerated by people with CF.

Occupational performance status and reliability of the Canadian Occupational Performance Measure in children with cystic fibrosis

Background/Aims

Cystic fibrosis affects the respiratory system and may interfere with an individual's occupational performance. This study intended to evaluate the reliability of the Canadian Occupational Performance Measure in children with cystic fibrosis and to compare the occupational performance of children with cystic fibrosis to that of healthy participants.

Methods

A total of 21 children with cystic fibrosis were included in the reliability and comparison phases of this study and 30 healthy children were recruited for the comparison phase. The Canadian Occupational Performance Measure was used to collect data on occupational performance and satisfaction. Intraclass correlation coefficients and standard error measurements were obtained to evaluate the reliability of the Canadian Occupational Performance Measure. An independent t-test was used to compare the occupational performance of the two groups.

Results

The test–retest reliability using a 7-day interval was 0.86–0.87 (standard error: 1.79–1.91). The agreement between therapists' scores for inter-rater reliability ranged from 0.87 to 0.90 (standard error: 1.44–1.68). There was a significant difference in performance subscale scores between children with cystic fibrosis and healthy children (P<0.05). There was no significant between-group difference in satisfaction scores.

Conclusions

The Canadian Occupational Performance Measure is a reliable tool for evaluating the occupational performance of children with cystic fibrosis. Cystic fibrosis directly and indirectly affects occupational performance. Children with cystic fibrosis and their parents may require help and education in the performance and organisation of activities and occupations.

Exercise and Cystic Fibrosis

Cystic fibrosis (CF) is an autosomal recessive, inherited congenital disease caused by the mutation of the family autosomal CF gene, with cumulative exocrine secretion characterized by inflammation, tracheal remodeling, and mucus accumulation. With the development of modern medical technology, CF patients are living longer lives and receiving more and more treatments, including traditional drugs, physical therapy, and gene therapy. Exercise is widely used to prevent and treat metabolic diseases such as cardiovascular diseases, obesity, diabetes, and metabolic syndrome. Regular exercise is beneficial to aerobic capacity and lung health. Exercise therapy has been of great interest since people realized that CF can be affected by exercise. Exercise alone can be used as an ACT (airway clearance technique), which promotes the removal of mucosal cilia. Exercise therapy is more easily accepted by any society, which helps to normalize the lives of CF patients, rather than placing a psychological burden on them. In this chapter, we will review the latest research progress about exercise in CF.

Variable agreement between wearable heart rate monitors during exercise in cystic fibrosis

In people with cystic fibrosis (CF), greater cardiorespiratory fitness is associated with improved survival and quality of life. Wearable activity monitors are a popular method of monitoring exercise, with measures of heart rate used to indicate exercise intensity. We assessed the agreement of heart rate recordings obtained using the Fitbit Charge HR^™, Polar® H7 heart rate sensor and Masimo SET® Rad-5v pulse oximeter with the three-lead ECG during continuous and interval exercise.

Adults with CF completed two exercise sessions, of 15-min duration per session, on a cycle ergometer while wearing the previously mentioned monitors. Firstly, participants cycled at 30% of estimated peak workload (W_peak). Secondly, participants cycled at 1-min intervals at 60% of W_peak interspersed with 2 min of unloaded cycling. Heart rate readings on all devices were recorded at minute intervals and their agreement was analysed using the Bland–Altman method.

The Polar® H7 heart rate sensor had the best agreement with three-lead ECG, with a bias of 0±1 bpm during both continuous and interval exercise. The Masimo SET® Rad-5v pulse oximeter had good agreement, with a bias of 1±7 bpm and 1±5 bpm during continuous and interval exercise, respectively. The Fitbit Charge HR^™ demonstrated less agreement, with a bias of 9±17 bpm and 5±13 bpm during continuous and interval exercise, respectively.

The Fitbit Charge HR^™ is not recommended for assessing heart rate during exercise in adults with CF. Findings support the use of the Polar® H7 for accurate heart rate monitoring.

The Fitbit Charge HR^™ does not provide accurate heart rate measurements during exercise in adults with cystic fibrosis. The Polar® H7 and Masimo SET® Rad-5v pulse oximeter do provide accurate measurements of heart rate.http://bit.ly/2KX0Yvy

Mobility related physical and functional losses due to aging and disease - a motivation for lower limb exoskeletons

BACKGROUND

Physical and functional losses due to aging and diseases decrease human mobility, independence, and quality of life. This study is aimed at summarizing and quantifying these losses in order to motivate solutions to overcome them with a special focus on the possibilities by using lower limb exoskeletons.

METHODS

A narrative literature review was performed to determine a broad range of mobility-related physical and functional measures that are affected by aging and selected cardiovascular, respiratory, musculoskeletal, and neurological diseases.

RESULTS

The study identified that decreases in limb maximum muscle force and power (33% and 49%, respectively, 25-75 yrs) and in maximum oxygen consumption (40%, 20-80 yrs) occur for older adults compared to young adults. Reaction times more than double (18-90 yrs) and losses in the visual, vestibular, and somatosensory systems were reported. Additionally, we found decreases in steps per day (75%, 60-85 yrs), maximum walking speed (24% 25-75 yrs), and maximum six-minute and self-selected walking speed (38% and 21%, respectively, 20-85 yrs), while we found increases in the number of falls relative to the number of steps per day (800%), injuries due to falls (472%, 30-90 yrs) and deaths caused by fall (4000%, 65-90 yrs). Measures were identified to be worse for individuals with impaired mobility. Additional detrimental effects identified for them were the loss of upright standing and locomotion, freezing in movement, joint stress, pain, and changes in gait patterns.

DISCUSSION

This review shows that aging and chronic conditions result in wide-ranging losses in physical and sensory capabilities. While the impact of these losses are relatively modest for level walking, they become limiting during more demanding tasks such as walking on inclined ground, climbing stairs, or walking over longer periods, and especially when coupled with a debilitating disease. As the physical and functional parameters are closely related, we believe that lost functional capabilities can be indirectly improved by training of the physical capabilities. However, assistive devices can supplement the lost functional capabilities directly by compensating for losses with propulsion, weight support, and balance support.

CONCLUSIONS

Exoskeletons are a new generation of assistive devices that have the potential to provide both, training capabilities and functional compensation, to enhance human mobility.

Effects of high intensity interval training on exercise capacity in people with cystic fibrosis: study protocol for a randomised controlled trial

BACKGROUND

In people with cystic fibrosis (CF), higher exercise capacity is associated with better health-related quality of life (HRQoL), reduced risk of hospitalisation for a respiratory infection and survival. Therefore, optimisation of exercise capacity is an important treatment goal. The Australian and New Zealand clinical practice guidelines recommend that people with CF complete 30 to 60 min of moderate intensity aerobic exercise on most days of the week. This recommendation can be difficult to achieve by people with CF because of time constraints, and intolerable breathlessness and muscle fatigue during continuous exercise. In contrast, a low-volume, high intensity interval training (HIIT) program may be a more achievable and efficient training method to improve exercise capacity in people with CF.

METHODS

A randomised controlled trial will be undertaken. Forty people with CF (aged ≥15 years) will be randomly allocated, on a 1:1 ratio, to either the experimental or control group. Regardless of their group allocation, all participants will be asked to continue with their usual daily treatment for the study duration. Those in the experimental group will complete 8 weeks of thrice weekly HIIT on a cycle ergometer. Those in the control group will receive weekly contact with the investigators. The primary outcome of this study is exercise capacity. Secondary outcomes are HRQoL, exercise self-efficacy, feelings of anxiety, depression and enjoyment. These outcomes will be recorded at baseline (i.e. prior to randomisation) and following the 8-week intervention period. The study will also report other outcomes of the HIIT program (cardiovascular responses, symptom response, post-exercise muscle soreness and tolerance) and behaviour change techniques such as reinforcement, feedback and goal setting, used during the HIIT program.

DISCUSSION

This study will determine the effects of 8-weeks of supervised, low-volume HIIT, completed on a cycle ergometer on measures of exercise capacity, HRQoL, exercise self-efficacy, feelings of anxiety, depression and enjoyment. If effective, this type of training could be an attractive alternative to traditional continuous training because it may be more achievable and time efficient.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR):12617001271392 (04/09/2017).

Physiotherapy management of cystic fibrosis

For many years physiotherapy for cystic fibrosis (CF) was synonymous with a daily routine of postural drainage and percussion. Improved longevity and a desire for independence, together with a clearer understanding of the pathophysiology of the disease, has led to the development of many airway clearance techniques. The contribution of ‘chest’ physiotherapy remained unchallenged until recent times when lack of robust evidence and the presentation of asymptomic infants and adults led some physiotherapists to question this traditional approach. As survival increases into the fourth and fifth decade unique complications have evolved and physiotherapy management is challenged with nonrespiratory aspects of treatment. This review will consider the evidence for, and current practice of airway clearance, the value of exercise and the emerging problems of musculoskeletal complications and incontinence.

Showing Value in Newborn Screening: Challenges in Quantifying the Effectiveness and Cost-Effectiveness of Early Detection of Phenylketonuria and Cystic Fibrosis

Decision makers sometimes request information on the cost savings, cost-effectiveness, or cost-benefit of public health programs. In practice, quantifying the health and economic benefits of population-level screening programs such as newborn screening (NBS) is challenging. It requires that one specify the frequencies of health outcomes and events, such as hospitalizations, for a cohort of children with a given condition under two different scenarios-with or without NBS. Such analyses also assume that everything else, including treatments, is the same between groups. Lack of comparable data for representative screened and unscreened cohorts that are exposed to the same treatments following diagnosis can result in either under- or over-statement of differences. Accordingly, the benefits of early detection may be understated or overstated. This paper illustrates these common problems through a review of past economic evaluations of screening for two historically significant conditions, phenylketonuria and cystic fibrosis. In both examples qualitative judgments about the value of prompt identification and early treatment to an affected child were more influential than specific numerical estimates of lives or costs saved.

Statement on Exercise Testing in Cystic Fibrosis

This statement summarizes the information available on specific exercise test protocols and outcome parameters used in patients with cystic fibrosis (CF) and provides expert consensus recommendations for protocol and performance of exercise tests and basic interpretation of results for clinicians. The conclusions were reached employing consensus meetings and a wide-band Delphi process. Although data on utility are currently limited, standardized exercise testing provides detailed information on physiological health, allows screening for exercise-related adverse reactions and enables exercise counselling. The Godfrey Cycle Ergometer Protocol with monitoring of oxygen saturation and ventilatory gas exchange is recommended for exercise testing in people 10 years and older. Cycle ergometry only with pulse oximetry using the Godfrey protocol or treadmill exercise with pulse oximetry - preferably with measurement of gas exchange - are second best options. Peak oxygen uptake, if assessed, and maximal work rate should be reported as the primary measure of exercise capacity. The final statement was reviewed by the European Cystic Fibrosis society and revised based on the comments received. The document was endorsed by the European Respiratory Society.

Patient-Reported Outcome Instruments for Physical Symptoms Among Patients Receiving Maintenance Dialysis: A Systematic Review

BACKGROUND

Patients with end-stage renal disease (ESRD) receiving dialysis have poor health-related quality of life. Physical symptoms are highly prevalent among dialysis-dependent patients and play important roles in health-related quality of life. A range of symptom assessment tools have been used in dialysis-dependent patients, but there has been no previous systematic assessment of the existing symptom measures' content, validity, and reliability.

STUDY DESIGN

Systematic review of the literature.

SETTINGS & POPULATION

Patients with ESRD on maintenance dialysis therapy.

SELECTION CRITERIA FOR STUDIES

Instruments with 3 or more physical symptoms previously used in dialysis-dependent patients and evidence of validity or reliability testing.

INTERVENTION

Patient-reported physical symptom assessment instrument.

OUTCOMES

Instrument symptom-related content, validity, and reliability.

RESULTS

From 3,148 screened abstracts, 89 full-text articles were eligible for review. After article exclusion and further article identification by reference reviews, 58 articles on 23 symptom assessment instruments with documented reliability or validity testing were identified. Of the assessment instruments, 43.5% were generic and 56.5% were ESRD specific. Symptoms most frequently assessed were fatigue, shortness of breath, insomnia, nausea and vomiting, and appetite. Instruments varied widely in respondent time burden, recall period, and symptom attributes. Few instruments considered recall periods less than 2 weeks and few assessed a range of symptom attributes. Psychometric testing was completed for congruent validity (70%), known-group validity (25%), responsiveness (30%), internal consistency (78%), and test-retest reliability (65%). Content validity was assessed in dialysis populations in 57% of the 23 instruments.

LIMITATIONS

Consideration of physical symptoms only and exclusion of single symptom-focused instruments.

CONCLUSIONS

The number of available instruments focused exclusively on physical symptoms in dialysis patients is limited. Few symptom-containing instruments have short recall periods, assess diverse symptom attributes, and have undergone comprehensive psychometric testing. Improved symptom-focused assessment tools are needed to improve symptom evaluation and symptom responsiveness to intervention among dialysis-dependent patients.

Higher mobility scores in patients with cystic fibrosis are associated with better lung function

OBJECTIVE

The purpose of this study was to determine whether mobility and physical activity were associated with lung function in adults with cystic fibrosis (CF).

DESIGN

This was a prospective cohort observational study in an urban, academic, specialized care center. Participants were ambulatory, nonhospitalized adults with CF.

MAIN OUTCOME MEASURES

Mobility was assessed monthly by the Life-Space Assessment (LSA) questionnaire and quarterly by pedometer. Lung function was assessed by spirometry.

RESULTS

Twenty-seven subjects participated. Subjects recorded mean pedometer steps of 20,213 ± 11,331 over three days and FEV1% predicted of 77.48% ± 22.60% over one year. The LSA score at enrollment was correlated with initial pedometer steps (r = 0.42 and P = 0.03), and mean LSA score over one year was correlated with mean number of steps (r = 0.51 and P = 0.007). LSA mobility and pedometer scores were correlated with FEV1% predicted at enrollment and throughout the study.

CONCLUSIONS

Mobility and physical activity measured by LSA questionnaire and pedometer are positively associated with lung function in adults with CF. This study confirms the importance of mobility and physical activity and supports the utility of a simple office-based questionnaire as a measure of mobility in adults with CF.

Quality of life is associated with physical activity and fitness in cystic fibrosis

Background

Health-related and disease-specific quality of life (HRQoL) has been increasingly valued as relevant clinical parameter in cystic fibrosis (CF) clinical care and clinical trials. HRQoL measures should assess – among other domains – daily functioning from a patient’s perspective. However, validation studies for the most frequently used HRQoL questionnaire in CF, the Cystic Fibrosis Questionnaire (CFQ), have not included measures of physical activity or fitness. The objective of this study was, therefore, to determine the cross-sectional and longitudinal relationships between HRQoL, physical activity and fitness in patients with CF.

Methods

Baseline (n = 76) and 6-month follow-up data (n = 70) from patients with CF (age ≥12 years, FEV1 ≥35%) were analysed. Patients participated in two multi-centre exercise intervention studies with identical assessment methodology. Outcome variables included HRQoL (German revised multi-dimensional disease-specific CFQ (CFQ-R)), body composition, pulmonary function, physical activity, short-term muscle power, and aerobic fitness by peak oxygen uptake and aerobic power.

Results

Peak oxygen uptake was positively related to 7 of 13 HRQoL scales cross-sectionally (r = 0.30-0.46). Muscle power (r = 0.25-0.32) and peak aerobic power (r = 0.24-0.35) were positively related to 4 scales each, and reported physical activity to 1 scale (r = 0.29). Changes in HRQoL-scores were directly and significantly related to changes in reported activity (r = 0.35-0.39), peak aerobic power (r = 0.31-0.34), and peak oxygen uptake (r = 0.26-0.37) in 3 scales each. Established associates of HRQoL such as FEV1 or body mass index correlated positively with fewer scales (all 0.24 < r < 0.55).

Conclusions

HRQoL was associated with physical fitness, especially aerobic fitness, and to a lesser extent with reported physical activity. These findings underline the importance of physical fitness for HRQoL in CF and provide an additional rationale for exercise testing in this population.

Trial registration

ClinicalTrials.gov, NCT00231686

Utilization of patient-reported outcomes as a step towards collaborative medicine

Patient-reported outcomes (PROs) have been successfully developed for a variety of chronic respiratory diseases, such as asthma and cystic fibrosis (CF). They have recently been used to evaluate the efficacy of new medications and assess current patient functioning. Although regulatory bodies have favored PROs that measures symptoms, other domains of functioning, such as treatment burden, should be considered. This review examines current guidelines for the development and application of PROs in clinical trials, describes methods for selecting appropriate measures for paediatric populations, and presents a model incorporating PROs into clinical practice. Guidance on interpretation of these measures and graphic presentation of results are illustrated. PROs can serve as the link between the health care provider and patient to foster collaborative and personalized medicine. This model promotes greater patient responsibility, facilitates communication with providers, encourages shared decision-making, and enhances adherence.

Cycle ergometer tests in children with cystic fibrosis: reliability and feasibility

The aim of this study was to assess the reliability and feasibility of cycle ergometer tests in young children with cystic fibrosis (CF). Children with CF aged 6-11 years and with stable lung disease performed two cycle ergometry tests (intermittent sprint and continuous incremental) on two occasions 1 week apart. Reliability was assessed using repeated-measures ANOVA. Bias was considered to be significant at P < 0.05 level and a coefficient of variation (CV) below 10% was considered acceptable. Feasibility and acceptability data were also collected. Sixteen children with CF completed the study: (9M:7F), 8.7(1.8) years, FEV(1) %predicted: 88.1(17.4). Power measurements recorded during the intermittent sprint test demonstrated significant bias over days (P < 0.05) and CVs were between 10% and 15%. Peak work capacity recorded during the continuous incremental test was reliable (bias P < 0.05, CV < 10%), as was heart rate and SpO(2) recorded during both tests (bias P < 0.05, CV < 10%). No problems were experienced in administering the tests and all children completed both tests on two separate occasions. There was a mixed response to questions on acceptability of tests. This is the first study to provide information on the reliability of performance measures recorded during an intermittent sprint protocol (peak power) and a continuous incremental cycle ergometry (peak work capacity) in children with CF.

Exercise as part of a cystic fibrosis therapeutic routine

The role of exercise in cystic fibrosis (CF) is well established, and over the last three decades it has become an important component in the management of all individuals with CF. The role of exercise as a prognostic indicator or therapeutic tool is an important area of research interest in CF care internationally. This article summarizes the currently available evidence regarding exercise capacity in CF, the potential effects of exercise on health outcomes in CF and the challenges faced when trying to incorporate exercise into a CF therapeutic routine, and highlights some methods to facilitate the incorporation of exercise into CF therapeutic routines.

Evaluation of the relationship between individual well-being and future health care utilization and cost

Escalating health care expenditures highlight the need to identify modifiable predictors of short-term utilization and cost. Thus, the predictive value of individual well-being scores was explored with respect to 1-year health care expenditures and hospital utilization among 2245 employees and members of a health plan who completed the Well-Being Assessment (WBA). The relationship between well-being scores and hospital admissions, emergency room (ER) visits, and medical and prescription expenditures 12-months post WBA was evaluated using multivariate statistical models controlling for participant characteristics and prior cost and utilization. An inverse relationship existed between well-being scores and all measured outcomes (P≤0.01). For every point increase in well-being on a 100-point scale, respondents were 2.2% less likely to have an admission, 1.7% less likely to have an ER visit, and 1.0% less likely to incur any health care costs. Among those who did incur cost, each point increase in well-being was associated with 1% less cost, and individuals with low well-being scores (≤50) had 2.7 times the median annual expenditure of individuals with high well-being (>75) ($5172 and $1885, respectively). Also, well-being proved lowest among respondents who incurred more than $20,000, and was highest among those who incurred ≤$5000, with median scores of 71.1 and 80.3, respectively. These results indicate that individual well-being is a strong predictor of important near-term health care outcomes. Thus, well-being improvement efforts represent a promising approach to decrease future health care utilization and expenditures.

The role of exercise in maintaining health in cystic fibrosis

PURPOSE OF REVIEW

Consensus statements about the care of people with cystic fibrosis (CF) recommend exercise as part of a wider management strategy. Many of these recommendations are based on high-quality evidence that regular exercise improves some important clinical outcomes, such as lung function and quality of life. However, the evidence about the effect of exercise on other clinical outcomes is less extensive or lower in quality. This article will review the physiological effects of exercise on a range of outcomes in people with CF, the mechanisms by which exercise may improve these outcomes and the quality and findings of clinical research into the effects of exercise in the management of CF.

RECENT FINDINGS

Substantial evidence confirms that exercise significantly reduces the rate of decline in lung function in people with CF, at least in part by increasing mucus clearance. Regular exercise training over 6 months improves aerobic exercise capacity. Bone health is often poor in people with CF, but only indirect evidence supports that increasing the amount of exercise will have a beneficial effect on bone density. CF-related diabetes is also a common sequela of the disease, but again only evidence from type-2 diabetes exists to support exercise as a way of managing it.

SUMMARY

Although its effects on some outcomes are unclear, the overall effect of exercise on quality of life is substantially beneficial and the evidence available for other specific outcomes is directly or indirectly supportive, so it appears appropriate to recommend it in clinical practice.

Exercise metabolism during moderate-intensity exercise in children with cystic fibrosis following heavy-intensity exercise

Muscle metabolism is increased following exercise in healthy individuals, affecting exercise metabolism during subsequent physical work. We hypothesized that following heavy-intensity exercise (HIE), disease factors in children with cystic fibrosis (CF) would further exacerbate exercise metabolism and perceived exertion during subsequent exercise. Nineteen children with CF (age, 13.4 ± 3.1 years; 10 female) and 19 healthy controls (age, 13.8 ± 3.5 years; 10 female) performed 10 bouts of HIE interspersed with 1 min of recovery between each bout. Three minutes later participants completed a 10-min moderate-intensity exercise (MIE) test (test 1). The MIE test was subsequently repeated 1 h (test 2) and 24 h (test 3) later. Each MIE test was identical and participants exercised at individualized work rates, calibrated by an initial graded maximal cardiopulmonary exercise test, while metabolic and perceived exertion measurements were taken. Following HIE, mixed-model ANOVAs showed a significant difference in oxygen uptake (VO2) and rating of perceived exertion (RPE) between the 2 groups across the MIE tests (p < 0.01). In controls, VO2 (L·min–1) and RPE decreased significantly from test 1 to test 2 (p < 0.01) and test 2 to test 3 (p < 0.05). However, in children with CF, VO2 (L·min–1) increased significantly from test 1 to test 2 (p < 0.01), while RPE did not differ, both VO2 and RPE decreased significantly from test 2 to test 3 (p < 0.01). In conclusion, following HIE the metabolic and perceptual responses to MIE in both groups decreased 24 h later during test 3. These data show that children with mild-to-moderate CF have the capability to perform HIE and 24 h allows sufficient time for recovery.

Exercise and quality of life in patients with cystic fibrosis: A 12-week intervention study

It was hypothesised that increased exercise capacity is related to improved quality of life (QoL) in patients with cystic fibrosis (CF). A 12-week individually tailored unsupervised aerobic exercise programme was offered to 42 patients with CF. At the start and at the end of the exercise programme, data on QoL, current exercise habits and preferences, anthropometric data, exercise test, and lung function test were collected. Adherence was observed by a heart rate (HR) monitor. A total of 24 patients accepted to be enrolled in the exercise programme and 14 completed the programme. Another 14 patients declined to be enrolled in the exercise programme but completed the Cystic Fibrosis Questionnaire for Adolescents and Adults (CFQ-R 14+). Four patients did not want to participate at all. The 14 patients completing the exercise programme had a significantly increased VO_2max, but they showed no significant change in total QoL score. However, the scores in the domain of treatment burden and emotional functioning increased significantly. There was no significant difference in QoL and lung function between patients participating in the exercise programme (n = 24) and non-participants (n = 14). A 12-week individually tailored unsupervised aerobic exercise programme where HR monitors were used significantly affected VO_2max. Improvement in QoL could not be demonstrated in this study.

Avaliação da qualidade de vida de pacientes com fibrose cística por meio do Cystic Fibrosis Questionnaire

OBJETIVO: Avaliar a qualidade de vida (QV) de pacientes com fibrose cística (FC) acompanhados em um centro universitário de referência em atendimento a FC. MÉTODOS: Estudo transversal com a aplicação do Cystic Fibrosis Questionnaire (CFQ) e escore de Shwachman em pacientes com FC entre abril de 2008 e junho de 2009. RESULTADOS: Participaram 75 pacientes, com média de idade de 12,5 ± 5,1 anos (variação: 6,1-26,4 anos). Os pacientes foram divididos em três grupos de acordo com a idade: grupo I (< 12 anos), II (12-14 anos) e III (> 14 anos). As pontuações mais altas e mais baixas no CFQ foram para o domínio alimentação do grupo III (89,3 ± 16,2) e para o domínio social no grupo II (59,5 ± 22,3), respectivamente. Houve uma diferença significativa no domínio tratamento entre os grupos III e I (p = 0,001). Pacientes com escore de Shwachman < 70 apresentaram diferenças significativas em relação aos domínios social (grupo I; p = 0,045), respiratório (grupo II; p = 0,053) e digestivo (p = 0,042) quando comparados aqueles com escores > 70. No grupo III, não se observou associação entre gravidade e QV. Nos grupos I e II, não se observou diferenças entre os pacientes com VEF1 < 80% do previsto e os demais pacientes em todos os domínios do CFQ. Entretanto, no grupo III, as médias dos pacientes com VEF1 < 80% do previsto foram significativamente menores nos domínios físico (p = 0,012), imagem corporal (p = 0,031), respiratório (p = 0,023), emocional (p = 0,041) e papel social (p = 0,024). CONCLUSÕES: A avaliação da QV em pacientes com FC é importante, pois contribui para uma melhor aderência ao tratamento.

Life-space mobility is associated with frequency of hospitalization in adults with cystic fibrosis

INTRODUCTION AND OBJECTIVES

  The Life-Space Assessment can be used to measure a patient's level of mobility. This study evaluated the relationship between life-space mobility and frequency of hospitalization in the previous year and other clinical markers of health among adults with cystic fibrosis (CF).

METHODS

  The Life-Space Assessment was administered to ambulatory adults with CF in clinic or by telephone. Life-space mobility was correlated with the most recent forced expiratory volume in one second as a percent of the predicted value (FEV(1) % predicted), body mass index (BMI) and number of hospitalizations in the previous year.

RESULTS

  Forty-eight subjects completed the Life-Space Assessment. Subjects had a life-space score of 88 ± 26, FEV(1) % predicted of 66% ± 26% and BMI of 22.5 ± 3.3. There was a statistically significant negative linear correlation between the number of times a subject was hospitalized in the previous year and life-space mobility (P = 0.001, R(2) = 0.20). This association was independent of FEV(1) % predicted and BMI.

CONCLUSION

  The life-space mobility score is associated with frequency of hospitalization in adults with CF. A prospective study should be undertaken to assess the ability of the Life-Space Assessment to predict hospitalization and other outcomes in adults with CF.

Muscle length and joint range of motion in children with cystic fibrosis compared to children developing typically

PURPOSE

To explore range of motion in children with cystic fibrosis (CF) compared to children developing typically. With the increasing longevity of people with CF, musculoskeletal concerns are becoming more prevalent and should be identified and considered in management plans. Reduced range of motion (ROM) in older people with CF has been demonstrated, and the age at which these changes begin to occur must be explored.

METHODS

Participants were 38 children with CF (aged 7-14 years) and 38 children developing typically, matched for age and gender. Muscle length and joint ROM measurements were compared, using analysis of variance, in the thoracolumbar region (extension, flexion, lateral flexion), upper limb (pectoralis minor, pectoralis major, shoulder horizontal abduction), and lower limb (hip internal and external rotation, hamstrings, gastrocnemius-soleus).

RESULTS

Children with CF had significantly shorter pectoralis minor, pectoralis major, and gastrocnemius-soleus muscles and significantly greater range of shoulder horizontal abduction than matched controls.

CONCLUSION

Altered ROM was identified in children with CF, strengthening the rationale to support proactive physiotherapy management of the musculoskeletal system, aiming to optimize function across the increasing lifespan. Evaluation and management of ROM and its impact on activity and participation are important areas for future research and clinical practice.

Is postoperative function after hip or knee arthroplasty influenced by preoperative functional levels?

Our objective was to evaluate functional outcomes after surgery in a subgroup of patients presenting for hip and knee surgery who had low functional scores before surgery. One hundred twenty-seven unilateral total hip and knee arthroplasty patients were assessed preoperatively and 3 consecutive years after arthroplasty using: Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form 36 (SF-36), and the Quality of Well-Being index scales. Patients were placed into 2 groups based on preoperative WOMAC function scores; 51 points or more, worse functioning group, and less than 51 points, higher functioning group. Regardless of time, the worse functioning group in both procedures performed worse on the Quality of Well-Being index, SF-36 (function score), SF-36 (social score), and WOMAC total and pain scores (P < or = .0001). The greatest change (range, 2%-638%) for all variables in both groups for both procedures occurred during the first year. Patients that had severe/extreme functional impairment had worse 3-year outcomes compared with patients getting surgery when their functional levels were better.

Evaluation of the SenseWear activity monitor during exercise in cystic fibrosis and in health

OBJECTIVE

Determine the SenseWear Pro3 Armband (SWA) accuracy for estimating energy expenditure (EE) and step count during treadmill walking in cystic fibrosis (CF) compared to healthy adults.

HYPOTHESIS

SWA estimation of EE would be less accurate for CF, than for healthy subjects, due to interference with the SWA skin sensors caused by the high salt concentration in the sweat of CF subjects.

METHODS

17 CF (mean age 26 yr; FEV1 54% predicted) and 17 age-matched control subjects walked slightly faster than their comfortable pace on a treadmill for 20 min, whilst simultaneously wearing the SWA and breathing through an open-circuit indirect calorimetry (IC) system. Subjects' steps were manually counted.

RESULTS

Combined EE data from all subjects showed no significant difference in EE measured by IC (6.0+/-3.4 kcal min(-1)) compared to the SWA estimate (6.3+/-2.5 kcal min(-1)), however the SWA significantly overestimated EE at low exercise intensities and underestimated EE at high exercise intensities. Correlations between EE values, estimated by the SWA and measured by IC, were greater than 0.85 (p<0.001) for both the CF and control group. Standard multiple regression showed that diagnosis of CF independently predicted less than 0.1% of the difference between the IC measure of EE and the SWA estimate. The SWA recorded slightly but significantly fewer steps (113+/-12 steps min(-1)) than the manual count (119+/-9 steps min(-1)).

CONCLUSION

Diagnosis of CF had no significant negative impact on the accuracy of the SWA estimate of EE. The SWA provided a reasonably accurate estimate of EE and step count during treadmill walking.

Early oxygen uptake recovery following exercise testing in children with chronic chest diseases

The value of exercise testing as an objective measure of disease severity in patients with chronic chest diseases (CCD) is becoming increasingly recognized. The aim of this study was to investigate changes in oxygen uptake (VO2) during early recovery following maximal cardiopulmonary exercise testing (CPXT) in relation to functional capacity and markers of disease severity. Twenty-seven children with CCD (age 12.7 +/- 3.1 years; 17 female) [19 children with Cystic fibrosis (CF) (age 13.4 +/- 3.1 years; 10 female) and 8 with other stable non-CF chest diseases (NON-CF) (age 11.1 +/- 2.2 years; 7 female)] and 27 healthy controls (age 13.2 +/- 3.3 years; 17 female) underwent CPXT on a cycle ergometer. On-line respiratory gas analysis measured VO2 before and during CPXT to peak VO2) (VO2(peak)), and during the first 10 min of recovery. Early VO2 recovery was quantified by the time (sec) to reach 50% of the VO2 (peak) value. Early VO2 recovery was correlated against spirometry [forced expiratory volume in 1 sec (FEV(1)) and forced expiratory flow between 25% and 75% of the forced vital capacity (FEF(25-75))] and aerobic fitness (VO2)(peak)) as a measure of functional capacity. Disease severity was graded in the CF patients by the Shwachman score (SS). Compared to controls, children with CCD demonstrated a significantly reduced VO2(peak) (P = 0.011), FEV(1) (P < 0.001), FEF(25-75) (P < 0.001), and a significantly prolonged early (VO2) recovery (P = 0.024). In the CF patients the SS was significantly correlated with early VO2 recovery (r = -0.63, P = 0.004), FEV(1) (r = 0.72, P = 0.001), and FEF(25-75) (r = 0.57, P = 0.011). In the children with CCD, FEV(1), FEF(25-75), and BMI were not significantly correlated with VO2(peak) or early VO2 recovery. Lung function does not necessarily reflect aerobic fitness and the ability to recover from exercise in these patients. A significant relationship was found between VO2(peak) and early VO2 recovery (r = -0.39, P = 0.044) in the children with CCD, showing that a greater aerobic fitness corresponded with a faster recovery.

Clinical exercise testing in children and adolescents with cystic fibrosis

PURPOSE

To review the most common field and laboratory exercise tests available for children and adolescents with cystic fibrosis (CF).

METHODS

Relevant studies for this review were identified by electronic search of Medline and PubMed databases between the years 1958 and 2008. The bibliographies of all accessed publications were also searched. Key descriptors were cystic fibrosis, exercise testing, aerobic fitness, children, and adolescents.

RESULTS

Five field tests were selected for presentation, including discussion of their strengths and weaknesses. Laboratory tests measuring aerobic and anaerobic responses to exercise in children with CF were also selected for presentation and discussed along with a summary of safety considerations for exercise testing of children with CF.

CONCLUSION

Exercise testing is regarded an important prognostic tool in CF care. However, despite its beneficial effects, clinical exercise testing seems underused. Clinicians and their staff should encourage patients with CF to be physically active and recommend exercise testing annually.

Health-related fitness and trainability in children with cystic fibrosis

The objective of this study was to examine the effects of a supervised exercise training program performed during an in patient rehabilitation course on various attributes of health-related fitness, e.g., flexibility, balance and coordination. 286 patients with CF, age range 6-18 years (11.8 +/- 3.4 years), mean forced expiratory volume in 1 sec (FEV1 82.7 +/- 22.3% predicted) were included. Patients performed the modified Munich fitness test (mMFT) to assess flexibility, balance, strength and coordination. To assess aerobic capacity a 6-min walk-test (6MWT) was performed. In addition, some of the patients performed an incremental exercise test on a bicycle ergometer using the Godfrey protocol before and after the exercise training program. The supervised training program consisted of 4-6 weeks of different sports activities 5 times per week. After training, pulmonary function showed a significant (P < 0.05) increase. All test items of the mMFT improved significantly (P < 0.05). Compared to healthy children test scores achieved from children with CF in the mMFT were lower but within a normal range. Our children with CF had a lower walk distance in 6MWT (P < 0.05) compared to healthy. Our findings clearly demonstrated benefits of a systematic exercise training program on components of physical fitness in patients with CF, with improvements of test-tasks to predicted normal in some cases. The results from our study suggested that an exercise training program in CF should be focused on several aspects of physical fitness including all components of physical fitness, e.g. aerobic endurance, flexibility, balance and motor skills.

Predictive value of chest CT in patients with cystic fibrosis: a single-center 10-year experience

OBJECTIVE

The objective of our study was to assess the accuracy of one of the most used scoring systems, the Bhalla scoring system, in the detection of lung impairment in patients with cystic fibrosis and in the prediction of cystic fibrosis progression.

MATERIALS AND METHODS

From the database of our center, 300 CT examinations performed between 1991 and 2001 were reviewed. Pulmonary function tests performed the same day as radiologic assessment were available. Of this group, 145 examinations were retrospectively included, referring to 87 patients with confirmed cystic fibrosis and a mean age (+/- SD) of 15.6 +/- 8.4 years (range, 9 months-38 years). Thirty patients underwent one CT examination, 56 underwent two examinations, and one patient underwent three examinations. The mean interval between two examinations was 36.5 months. The 145 examinations were independently reviewed by three radiologists who were blinded to the clinical and pulmonary function test results. The CT examinations were assessed using the scoring system proposed by Bhalla and colleagues.

RESULTS

CT assessed using the Bhalla scoring system is mildly correlated with functional pulmonary test results and has high interobserver reproducibility. The CT score significantly changed between scans obtained in a mean interval of 36.5 months, whereas functional pulmonary test results did not, suggesting that CT is more sensitive than function tests for detecting small changes. However, the variation in CT scores did not predict progression of functional pulmonary test results or progression of CT findings between scans.

CONCLUSION

CT assessment based on the Bhalla scoring system is more sensitive than pulmonary function tests in detecting initial morphologic changes. However, we found no evidence of the predictive value of CT.

Reliability and validity of the habitual activity estimation scale (HAES) in patients with cystic fibrosis

PURPOSE

To understand potential benefits of exercise in the cystic fibrosis (CF) population, there needs to be accurate methods to quantify it. The Habitual Activity Estimation Scale (HAES) questionnaire has been shown to be a feasible tool to measure physical activity however the reliability and validity have yet to be determined in the CF population.

METHODS

Fourteen (seven male, seven female) patients aged 16.2 +/- 4.2 years with CF participated in this study. Participants were clinically stable at the time of the study and participating in their habitual physical activity. To assess reliability, patients completed the HAES and a validated 3-day activity diary, and wore an ActiGraph Accelerometer for two consecutive weeks. Validity was assessed by comparing the activity results of each of the three instruments over a single week time period.

RESULTS

ICC estimates of reliability for the HAES, diary, and accelerometer were 0.72 (P < 0.0001), 0.76 (P < 0.0001), 0.63 (P < 0.0001), respectively. Validity analysis indicated that there were significant relationships between the participants' activity results as estimated by the HAES, diary and accelerometer. Further, significant relationships were detected between activity measures when broken into morning, afternoon, or evening periods, and between measures from weekday or weekend days. There were also significant relationships among the three instruments when recording different activity levels (somewhat inactive, somewhat active, and very active).

CONCLUSION

The findings of this study suggest that the HAES questionnaire is a reliable and valid instrument that can be used to assess activities of varying intensity in patients with CF.

The Association Between Depression, Lung Function, and Health-Related Quality of Life Among Adults With Cystic Fibrosis

BACKGROUND

More than 40% of people born with cystic fibrosis (CF) now reach adulthood. Greater attention is being focused on improving their health-related quality of life (HRQoL). While markers of disease severity such as lung function are only modestly associated with HRQoL, in other chronic illnesses depression is an important correlate. The objective of this study was to evaluate the relationships among lung function (ie, FEV(1) percent predicted), depressive symptoms, and HRQoL among adults with CF.

METHODS

Seventy-six adults with CF completed a mail-based survey. The Beck Depression Inventory and the Cystic Fibrosis Questionnaire were used to assess depressive symptoms and HRQoL, respectively. Values for FEV(1) percent predicted were abstracted from the medical record.

RESULTS

Thirty percent of participants screened positive for depressive symptoms. Depressive symptoms and lung function were inversely correlated (rho = -0.25; p < .05). Correlations between depressive symptoms and HRQoL were maintained after stratifying by lung function. In the absence of depressive symptoms, those patients with good lung function (ie, FEV(1), > 70% predicted) reported better physical HRQoL than those with poor lung function. Participants with both depressive symptoms and poor lung function reported significantly worse HRQoL on all domains than participants without depressive symptoms regardless of lung function status.

CONCLUSIONS

Depressive symptoms are prevalent among adults with CF and are associated with poorer HRQoL even after controlling for lung function. These results suggest that screening for and treating depression is important and may potentially improve HRQoL among patients with CF.

Assessing the usefulness of outcomes measured in a cystic fibrosis treatment trial

Forced expiratory volume in 1s (FEV(1)) is the usual primary outcome variable in clinical trials in cystic fibrosis (CF). Usually, several secondary outcomes are also measured. We assessed which secondary outcomes are likely to give additional clinically useful information about treatment effects, in order to inform the design of future studies. The study was performed as part of a trial comparing daily rhDNase with alternate day rhDNase and hypertonic saline in CF. The primary outcome was FEV(1). Secondary outcomes were forced vital capacity (FVC), forced expiratory flow at 25-75% of forced vital capacity (FEF(25-75)), number of pulmonary exacerbations, weight gain, quality of life (QOL), and exercise tolerance. The usefulness of each secondary outcome was investigated by assessing if the change in that outcome over the treatment period could be predicted from the primary outcome. Change in FEV(1) correlated with changes in FVC (r(2)=0.76, P=0.001), FEF(25-75) (r(2)=0.64, P=0.001), weight (r(2)=0.08, P=0.001), and change in oxygen saturation with exercise (r(2)=0.08, P=0.001). However, it did not correlate with changes in visual analogue score (VAS) with exercise, QOL, nor with the occurrence of pulmonary exacerbations. Only the outcomes QOL and VAS with exercise actually provided additional information to FEV(1) in this study.

Modified shuttle test performance in hospitalized children and adolescents with cystic fibrosis

BACKGROUND

The Modified Shuttle Test (MST) is a valid and sensitive measure of exercise capacity in adult CF patients. Recently, its validity in children has been demonstrated. The aim of this study was to demonstrate the utility of the MST as a measure of responsiveness to hospitalisation for i.v. antibiotic and supportive therapy in children and adolescents with CF.

METHODS

28 children and adolescents (40 admissions) performed a MST and lung function within 48 h of admission and discharge to hospital for administration of intravenous antibiotics. Mean age was 12.7 years and antibiotic therapy length was 14.7 days.

RESULTS

Upon admission, the mean (S.D.) FEV(1) was 63 (19)% predicted, FVC was 80 (18)% predicted, FEF(25-75) 43 (29)% predicted and MST distance 718 (232) m. FEV(1) increased by 15% (p<or=0.001), FVC by 13% (p<or=0.001), FEF(25-75) by 39% (p<or=0.001) and MST distance by 102 m (p<or=0.001). The percentage improvement in MST distance at 18% (p<or=0.001) was similar to that for FEV(1), but could not be predicted by the change in FEV(1).

CONCLUSION

This study demonstrated the utility of the MST to assess the effect of hospitalisation for i.v. antibiotic and supportive therapy in children and adolescents with CF.

Gender differences in health-related quality of life of adolescents with cystic fibrosis

Background

Female patients with cystic fibrosis (CF) have consistently poorer survival rates than males across all ages. To determine if gender differences exist in health-related quality of life (HRQOL) of adolescent patients with CF, we performed a cross-section analysis of CF patients recruited from 2 medical centers in 2 cities during 1997–2001.

Methods

We used the 87-item child self-report form of the Child Health Questionnaire to measure 12 health domains. Data was also collected on age and forced expiratory volume in 1 second (FEV₁). We analyzed data from 98 subjects and performed univariate analyses and linear regression or ordinal logistic regression for multivariable analyses.

Results

The mean (SD) age was 14.6 (2.5) years; 50 (51.0%) were female; and mean FEV₁ was 71.6% (25.6%) of predicted. There were no statistically significant gender differences in age or FEV₁. In univariate analyses, females reported significantly poorer HRQOL in 5 of the 12 domains. In multivariable analyses controlling for FEV₁ and age, we found that female gender was associated with significantly lower global health (p < 0.05), mental health (p < 0.01), and general health perceptions (p < 0.05) scores.

Conclusion

Further research will need to focus on the causes of these differences in HRQOL and on potential interventions to improve HRQOL of adolescent patients with CF.

A crossover, randomized, controlled trial of dornase alfa before versus after physiotherapy in cystic fibrosis

OBJECTIVE

Although dornase alfa is a widely used, aerosolized, mucolytic agent in patients with cystic fibrosis (CF), its efficacy in relation to the timing of physiotherapy has not been tested. We sought to determine whether dornase alfa is more efficacious when it is administered 30 minutes before versus 30 minutes after physiotherapy/positive expiratory pressure (PEP) therapy in clinically stable children.

METHODS

Using a crossover, randomized, double-blind, and placebo-controlled trial, we undertook a 6-week study of the efficacy of dornase alfa in relation to the timing of physiotherapy at home. There were 2 treatment orders. Dornase alfa before + placebo after physiotherapy/PEP for 2 weeks was followed by a 2-week washout and then the reverse order placebo before and dornase alfa after physiotherapy/PEP for the final 2 weeks. The second treatment order reversed the placebo and dornase alfa therapy for the first and last 2-week blocks. The main outcome measures used included the change in predicted percentage of forced expiratory volume in 1 second (FEV1), a composite quality of well-being score (QWB), and a measure of aerobic fitness (maximal oxygen consumption, [VO2max]), determined using shuttle testing.

RESULTS

Fifty-two patients who had CF (27 female) with mild to moderate suppurative lung disease, were a mean +/- SD age of 10.7 +/- 3.2 years, had Shwachman scores of 86 +/- 11.8, had predicted FEV1 of 83% +/- 18%, had quality of well-being score of 0.76 +/- 0.08, and had VO2max of 42.6 +/- 6.3 ml/kg per min were enrolled. Fifty patients completed the study. Intention-to-treat analysis was used. Nonsignificant mean (95% confidence interval) differences in FEV1 (0.02 L [-0.05 to 0.10]), VO2max (-0.75 ml/kg per min [-1.85 to 0.35]), and QWB (0.005 [-0.94 to 0.0028]) for dornase alfa after physiotherapy/PEP were detected. A post hoc analysis showed that patients who were colonized persistently with Pseudomonas aeruginosa had a significantly greater improvement in FEV1 (0.12 L [0.23 to 0.01] vs -0.04 L [0.05 to -0.13]) when dornase alfa was administered after physiotherapy/PEP.

CONCLUSIONS

Dornase alfa is equally efficacious when delivered before or after physiotherapy/PEP in patients with CF. Patients who are colonized persistently with P aeruginosa may derive more improvement in FEV1 when dornase alfa is delivered after physiotherapy/PEP.

Relationship between FEV1 and peak oxygen uptake in children with cystic fibrosis

Cross-sectional data do not truly convey the manner in which declining lung function affects peak oxygen uptake (peak VO2) within a given patient with cystic fibrosis. We hypothesized that there would be a concomitant decline in peak VO2 with FEV1 over time. Twenty-eight children aged 8-17 years with cystic fibrosis performed annual ergometer tests over a 5-year period to determine peak VO2 and within-patient predictors of change in peak VO2. Analysis was done using a mixed-effects model. During the study period, the annual decline in FEV1 averaged 2.7% of the predicted value per year. Peak VO2 fell during the observation period in 70% of patients, with an average annualized decline of 1.9 ml x min(-1) x kg(-1). This rate of decline was greater in older children in contrast to younger children, some of whom had an improvement in peak VO2 over the first few years, consistent with growth and maturation. There was no difference in this rate of decline between sexes, but girls started with a slightly lower peak VO2 (37.9 vs. 45.1 ml x min(-1) x kg(-1)). In patients with FEV1 <80% predicted, declining FEV1 was highly correlated with falling peak VO2, whereas it remained stable over 4-5 years in patients whose FEV1 was >80% predicted and remained in that range. We conclude that peak VO2 remains stable or rises slightly over time in younger patients, while it shows a downward trend in older children with CF, particularly once FEV1 falls below 80% predicted. Peak VO2 is correlated with FEV1 during childhood in patients with cystic fibrosis, and both FEV1 and age influence peak VO2.

The cost-effectiveness of neonatal screening for cystic fibrosis: an analysis of alternative scenarios using a decision model

Background

The use of neonatal screening for cystic fibrosis is widely debated in the United Kingdom and elsewhere, but the evidence available to inform policy is limited. This paper explores the cost-effectiveness of adding screening for cystic fibrosis to an existing routine neonatal screening programme for congenital hypothyroidism and phenylketonuria, under alternative scenarios and assumptions.

Methods

The study is based on a decision model comparing screening to no screening in terms of a number of outcome measures, including diagnosis of cystic fibrosis, life-time treatment costs, life years and QALYs gained. The setting is a hypothetical UK health region without an existing neonatal screening programme for cystic fibrosis.

Results

Under initial assumptions, neonatal screening (using an immunoreactive trypsin/DNA two stage screening protocol) costs £5,387 per infant diagnosed, or £1.83 per infant screened (1998 costs). Neonatal screening for cystic fibrosis produces an incremental cost-effectiveness of £6,864 per QALY gained, in our base case scenario (an assumed benefit of a 6 month delay in the emergence of symptoms). A difference of 11 months or more in the emergence of symptoms (and mean survival) means neonatal screening is both less costly and produces better outcomes than no screening.

Conclusion

Neonatal screening is expensive as a method of diagnosis. Neonatal screening may be a cost-effective intervention if the hypothesised delays in the onset of symptoms are confirmed. Implementing both antenatal and neonatal screening would undermine potential economic benefits, since a reduction in the birth incidence of cystic fibrosis would reduce the cost-effectiveness of neonatal screening.

Psychological and family functioning and quality of life in adolescents with cystic fibrosis

BACKGROUND

The life expectancy of individuals with CF has increased to 33 years. Thus, issues such as quality of life and psychological well-being, previously thought to be of lesser importance than physical well-being, are now recognised as significant factors. This study examined the interrelationships between quality of life, family functioning, individual psychopathology and optimism of adolescents with CF.

METHODS

Adolescents attending the CF clinic completed a number of questionnaires. Quality of Life was measured using the Cystic Fibrosis Questionnaire, family functioning by the Family Environment Scale (3rd edition), general psychopathology with the Symptom Checklist-90-Revised and optimism for the future by the Hunter Opinions and Personal Expectations Scale. Disease severity was assessed using the Shwachman score and spirometry at the time of questionnaire completion.

RESULTS

The level of psychopathology (12.5% of those 13 years and over) in the group was lower than that reported for young people in Australia (15-20%). The results indicated that young people with a delayed diagnosis and those who are alienated from their families may be in need of additional psychosocial support. The group was hopeful and positive about their future and these attributes were independent of clinical measures of disease severity. In general, these young people scored relatively highly on the quality of life scale. For example the mean standardised score for physical functioning was 70 points, for respiratory symptoms was 63 points and for emotional state was 78 points. Increased levels of psychopathology and lack of hope for the future were however associated with lower ratings on a number of quality of life measures. Family cohesiveness, expressiveness and organization were associated with better psychological functioning in the young people.

CONCLUSIONS

Adolescents with CF appear to be a psychologically well functioning and well-adjusted group. These findings support the importance of a more sophisticated model of well-being for adolescents with CF, which explores the young person's views on their quality of life and wider support frameworks rather than relying solely on measures of physical health to gauge well-being.

Validation of the SF-36 for the assessment of quality of life in adolescents and adults with cystic fibrosis

BACKGROUND

Generic health-related quality of life measures are often applied to disease groups without assessment of their psychometric properties. The current work assesses the properties of the Short Form 36-item (SF-36) questionnaire in a British sample of adolescents and adults with cystic fibrosis (CF).

METHODS

Two hundred and twenty-three adolescents and adults with CF completed the SF-36 with a further 185 approached and not responding by non-completion of the questionnaire. The structure and internal reliability of the instrument was assessed by principal components analysis, Cronbach alpha coefficients and item to domain correlations. Differences between disease severity groups were assessed by analysis of variance.

RESULTS

Factor analysis of the SF-36 scores broadly confirmed domain structures for the SF-36. Cronbach alpha coefficients were high (range 0.82-0.91) and item-to-same domain correlations were stronger than item-to-unrelated domain correlations. Examination of differences between mild, moderate and severe disease states revealed four significant main effects for: physical functioning, role limitation due to physical functioning, general health perceptions and energy and vitality. The analysis also revealed the presence of numerous ceiling effects across domains.

CONCLUSIONS

The domain structure of the SF-36 was demonstrated to be robust. However, the discriminatory ability of the measure was disappointing. The presence of ceiling effects and the low frequency of differences between intermediate disease severity groups indicated that the SF-36 was not discriminatory with respect to mild disease states or progression of illness.

The psychosocial and psychiatric side of cystic fibrosis in adolescents and adults

Increasing numbers of cystic fibrosis (CF) patients are surviving into adulthood. An understanding of the psychiatric and psychosocial aspects of CF in adults and adolescents is therefore more important than ever. There is a large body of evidence indicating that the psychological and psychosocial functioning of people with CF is similar to that of well people, until the disease becomes severe. However, there is also evidence that patients do suffer an increased likelihood of psychiatric problems, such as depression, and of scoring poorly on physical functioning measures of quality of life. Studies have found conflicting evidence as to any association between degree of respiratory impairment and psychological functioning. Coping styles seem to have a large effect upon the quality of life of CF patients. People with cystic fibrosis can have problems with sexuality, platonic relationships and independence. Families of patients also suffer problems, which can affect the patients themselves. Non-compliance is a complicated problem with many patients. New treatments for people with CF are emerging, such as lobe transplants from live donors and gene therapy, with possible new psychosocial problems resulting. Furthermore, older studies are becoming increasingly inapplicable as treatment and prognosis changes. Therefore, more research is needed in this field.

Gender differences in habitual activity in children with cystic fibrosis

AIMS

(1) To compare habitual activity levels in prepubescent and pubescent boys and girls with different degrees of CF lung disease severity and healthy controls. (2) To assess the relation between habitual activity levels and measures of fitness, lung function, nutrition, pancreatic status, and quality of life.

METHODS AND RESULTS

A total of 148 children (75 girls and 73 boys) with CF and matched controls were studied. Regardless of disease severity, there were no differences in habitual activity between prepubescent boys and girls with CF. Pubescent boys with CF were significantly more active than girls with the same degree of disease severity. There were no significant differences in habitual activity between prepubescent children with CF and controls. Pubescent children with mild CF were significantly more active than controls, but those with moderate to severe disease were less active than controls. The best correlates with habitual activity levels were anaerobic power, aerobic capacity, and quality of life. In children with moderate to severe disease, nutrition status correlated significantly with activity levels. The impact of pancreatic status on activity levels and other measures of fitness was most apparent in pubescent girls.

CONCLUSION

Gender differences in habitual activity were evident only after the onset of puberty. The impact of pancreatic insufficiency on measures of fitness and habitual activity was greatest in pubescent females. The reason for this gender difference may be an interplay of genetic, hormonal, and societal factors and is the focus of a longitudinal study.