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Green DM, Lahiri T, Raraigh KS, Ruiz F, Spano J, Antos N, Bonitz L, Christon L, Gregoire-Bottex M, Hale JE, Langfelder-Schwind E, La Parra Perez Á, Maguiness K, Massie J, McElroy-Barker E, McGarry ME, Mercier A, Munck A, Oliver KE, Self S, Singh K, Smiley M, Snodgrass S, Tluczek A, Tuley P, Lomas P, Wong E, Hempstead SE, Faro A, Ren CL. Cystic Fibrosis Foundation Evidence-Based Guideline for the Management of CRMS/CFSPID. Pediatrics 2024; 153:e2023064657. [PMID: 38577740 DOI: 10.1542/peds.2023-064657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
A multidisciplinary committee developed evidence-based guidelines for the management of cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen-positive, inconclusive diagnosis (CRMS/CFSPID). A total of 24 patient, intervention, comparison, and outcome questions were generated based on surveys sent to people with CRMS/CFSPID and clinicians caring for these individuals, previous recommendations, and expert committee input. Four a priori working groups (genetic testing, monitoring, treatment, and psychosocial/communication issues) were used to provide structure to the committee. A systematic review of the evidence was conducted, and found numerous case series and cohort studies, but no randomized clinical trials. A total of 30 recommendations were graded using the US Preventive Services Task Force methodology. Recommendations that received ≥80% consensus among the entire committee were approved. The resulting recommendations were of moderate to low certainty for the majority of the statements because of the low quality of the evidence. Highlights of the recommendations include thorough evaluation with genetic sequencing, deletion/duplication analysis if <2 disease-causing variants were noted in newborn screening; repeat sweat testing until at least age 8 but limiting further laboratory testing, including microbiology, radiology, and pulmonary function testing; minimal use of medications, which when suggested, should lead to shared decision-making with families; and providing communication with emphasis on social determinants of health and shared decision-making to minimize barriers which may affect processing and understanding of this complex designation. Future research will be needed regarding medication use, antibiotic therapy, and the use of chest imaging for monitoring the development of lung disease.
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Affiliation(s)
- Deanna M Green
- Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Thomas Lahiri
- University of Vermont Children's Hospital, Burlington, Vermont
| | - Karen S Raraigh
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jacquelyn Spano
- Stanford University School of Medicine, Stanford, California
| | - Nicholas Antos
- Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Lynn Bonitz
- Cohen Children's Medical Center of NY/Northwell Health, New Hyde Park, New York
| | - Lillian Christon
- Medical University of South Carolina, Charleston, South Carolina
| | - Myrtha Gregoire-Bottex
- Advanced Pediatric Pulmonology, Pllc, Miramar, Florida
- Memorial Health Network, Hollywood, Florida
| | - Jaime E Hale
- University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | | | - Álvaro La Parra Perez
- John B. Goddard School of Business and Economics, Weber State University, Ogden, Utah
| | - Karen Maguiness
- Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - John Massie
- University of Melbourne Murdoch Childrens Research Institute, Melbourne, Australia
| | | | - Meghan E McGarry
- University of California San Francisco, San Francisco, California
| | - Angelique Mercier
- Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Anne Munck
- Hospital Necker Enfants malades, AP-HP, Paris, France
| | | | - Staci Self
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Kathryn Singh
- University of California, Irvine, Orange, California Miller Children's and Women's Hospital, Long Beach, California
| | | | | | | | | | - Paula Lomas
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Elise Wong
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | | | - Albert Faro
- The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L Ren
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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2
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Kua KL, Rhoads E, Slaven JE, Edwards S, Haas DM, Ren CL, Tiller C, Bjerregaard J, Haneline LS, Tepper RS. Decreased vascular reactivity associated with increased IL-8 in 6-month-old infants of mothers with pre-eclampsia. Pediatr Res 2024:10.1038/s41390-024-03132-4. [PMID: 38509229 DOI: 10.1038/s41390-024-03132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/22/2024] [Accepted: 02/15/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Offspring born to mothers with pre-eclampsia (Pre-E) suffer higher risks of adult cardiovascular diseases, suggesting that exposure to an antiangiogenic environment in-utero has a lasting impact on the development of endothelial function. The goal of this study is to test the hypothesis that in-utero exposure to Pre-E results in alterations of angiogenic factors/cytokines that negatively impact vascular development during infancy. METHODS Infants born from mothers with and without Pre-E were recruited and followed up at 6 months. Plasma cytokines, blood pressure, microvessel density, and vascular reactivity were assessed. RESULTS 6-month-old infants born to mothers with Pre-E had unchanged blood pressure (p = 0.86) and microvessel density (p = 0.57). Vascular reactivity was decreased in infants born to mothers with Pre-E compared to infants born to healthy mothers (p = 0.0345). Interleukin 8 (IL-8) (p = 0.03) and Angiopoeitin-2 (Ang-2) (p = 0.04) were increased in infants born to mothers with Pre-E. We observed that higher IL-8 was associated with lower vascular reactivity (rho = -0.14, p < 0.0001). CONCLUSION At 6 months of age, infants born to mothers with Pre-E had impaired vascular reactivity and higher IL-8 and Ang-2, but similar blood pressure and microvessel density compared to infants born to non-Pre-E mothers. IMPACT STATEMENT Changes in cord blood antiangiogenic factors are documented in infants of mothers with pre-eclampsia and may contribute to offspring risks of adult cardiovascular disease. How these factors evolve during early infancy and their correlation with offspring vascular development have not been studied. This study found that 6-month-old infants born to mothers with pre-eclampsia had decreased vascular reactivity, which was correlated with higher IL-8. These findings underscore the lasting impact of maternal pre-eclampsia on offspring vascular development and highlight the need for long-term follow-up in children born to mothers with pre-eclampsia.
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Affiliation(s)
- Kok Lim Kua
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eli Rhoads
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Nebraska Medical Center, Omaha, NE, USA
| | - James E Slaven
- Department of Biostatistics and Health Data Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shanique Edwards
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Tiller
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep Medicine, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey Bjerregaard
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep Medicine, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laura S Haneline
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert S Tepper
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep Medicine, Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
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Carroll BJ, Ostrenga JS, Fink AK, Antos NJ, Cromwell EA, Ren CL. Clinical outcomes at 9-10 years of age in children born with cystic fibrosis transmembrane conductance regulator related metabolic syndrome. Pediatr Pulmonol 2024. [PMID: 38477633 DOI: 10.1002/ppul.26950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND OBJECTIVES There are limited data on cystic fibrosis (CF) transmembrane conductance regulator-related metabolic syndrome (CRMS) outcomes beyond infancy. The goal of this study was to analyze outcomes of infants with CRMS up to the age of 9-10 years using the CF Foundation Patient Registry (CFFPR). METHODS We analyzed data from the CFFPR for individuals with CF and CRMS born between 2010 and 2020. We classified all patients based on the clinical diagnosis reported by the CF care center and the diagnosis using CFF guideline definitions for CF and CRMS, classifying children into groups based on agreement between clinical report and guideline criteria. Descriptive statistics for the cohort were calculated for demographics, nutritional outcomes, and microbiology for the first year of life and lung function and growth outcomes were summarized for ages 6-10 years. RESULTS From 2010 to 2020, there were 8765 children with diagnosis of CF or CRMS entered into the CFFPR with sufficient diagnostic data for classification, of which 7591 children had a clinical diagnosis of CF and 1174 had a clinical diagnosis of CRMS. CRMS patients exhibited normal nutritional indices and pulmonary function up to age 9-10 years. The presence of respiratory bacteria associated with CF, such as Pseudomonas aeruginosa from CRMS patients ranged from 2.1% to 9.1% after the first year of life. CONCLUSIONS Children with CRMS demonstrate normal pulmonary and nutritional outcomes into school age. However, a small percentage of children continue to culture CF-associated respiratory pathogens after infancy.
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Affiliation(s)
- Brian J Carroll
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joshua S Ostrenga
- Patient Registry Research Division, Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Aliza K Fink
- Patient Registry Research Division, Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Nicholas J Antos
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Elizabeth A Cromwell
- Patient Registry Research Division, Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Zemanick ET, Emerman I, McCreary M, Mayer-Hamblett N, Warden MN, Odem-Davis K, VanDevanter DR, Ren CL, Young J, Konstan MW. Heterogeneity of CFTR modulator-induced sweat chloride concentrations in people with cystic fibrosis. J Cyst Fibros 2024:S1569-1993(24)00015-8. [PMID: 38360461 DOI: 10.1016/j.jcf.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Sweat chloride (SC) concentrations in people with cystic fibrosis (PwCF) reflect relative CF transmembrane conductance regulator (CFTR) protein function, the primary CF defect. Populations with greater SC concentrations tend to have lesser CFTR function and more severe disease courses. CFTR modulator treatment can improve CFTR function within specific CF genotypes and is commonly associated with reduced SC concentration. However, SC concentrations do not necessarily fall to concentrations seen in the unaffected population, suggesting potential for better CFTR treatment outcomes. We characterized post-modulator SC concentration variability among CHEC-SC study participants by genotype and modulator. METHODS PwCF receiving commercially approved modulators for ≥90 days were enrolled for a single SC measurement. Clinical data were obtained from chart review and the CF Foundation Patient Registry (CFFPR). Variability of post-modulator SC concentrations was assessed by cumulative SC concentration frequencies. RESULTS Post-modulator SC concentrations (n = 3787) were collected from 3131 PwCF; most (n = 1769, 47 %) were collected after elexacaftor/tezacaftor/ivacaftor (ETI) treatment. Modulator use was associated with lower SC distributions, with post-ETI concentrations the lowest on average. Most post-ETI SC concentrations were <60 mmol/L (79 %); 26 % were <30 mmol/L. Post-ETI distributions varied by genotype. All genotypes containing at least one F508del allele had individuals with post-ETI SC ≥60 mmol/L, with the largest proportion being F508del/minimal function (31 %). CONCLUSIONS Post-modulator SC concentration heterogeneity was observed among all genotypes and modulators, including ETI. The presence of PwCF with post-modulator SC concentrations within the CF diagnostic range suggests room for additional treatment-associated CFTR restoration in this population.
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Affiliation(s)
- E T Zemanick
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
| | - I Emerman
- Seattle Children's Hospital, Seattle, WA, United States
| | - M McCreary
- Seattle Children's Hospital, Seattle, WA, United States
| | - N Mayer-Hamblett
- Seattle Children's Hospital, Seattle, WA, United States; University of Washington, Seattle, WA, United States
| | - M N Warden
- Seattle Children's Hospital, Seattle, WA, United States
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA, United States
| | - D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - C L Ren
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - J Young
- Seattle Children's Hospital, Seattle, WA, United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Rainbow Babies and Children's Hospital, Cleveland, OH, United States
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Corcoran A, Faig W, Ren CL. Clinical features associated with pulmonary exacerbation diagnosis in infants and young children with cystic fibrosis. Pediatr Pulmonol 2023. [PMID: 38131505 DOI: 10.1002/ppul.26838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
RATIONALE Diagnosing cystic fibrosis (CF) pulmonary exacerbations (PEx) in very young people with CF <3 years (VY-PwCF) is challenging because of the frequency of respiratory viral infections in this age group, and there are limited data on the clinical features associated with the diagnosis of PEx in this age group. The goal of this study was to identify clinical features associated with the diagnosis of PEx in VY-PwCF. METHODS We reviewed the medical records of VY-PwCF followed at the Children's Hospital of Philadelphia born between 2013 and 2019. We collected data from all encounters with respiratory symptoms. PEx was defined by treatment with oral or intravenous antibiotics. Clinical features of PEx and non-PEx encounters were compared using descriptive statistics, and odds ratios of PEx diagnosis were calculated. RESULTS A total of 78 patients were included in the analysis. The mean (SD) number of PEx per patient was 6.17 (5.88). The presence of a wet or nighttime cough and symptoms >3 days in duration were significantly associated with PEx diagnosis (p < .001). In contrast, symptoms such as sore throat or rhinorrhea were not associated with a higher likelihood of PEx. CONCLUSIONS The presence of a wet or night-time cough and longer symptom duration are common features of PEx in VY-PwCF, whereas symptoms suggestive of upper respiratory viral infection are not. Our results will be helpful in counseling families of VY-PwCF in the signs and symptoms of PEx and in planning future research in PEx in this age group.
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Affiliation(s)
- Aoife Corcoran
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Walter Faig
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Martiniano SL, Wu R, Farrell PM, Ren CL, Sontag MK, Elbert A, McColley SA. Late Diagnosis in the Era of Universal Newborn Screening Negatively Affects Short- and Long-Term Growth and Health Outcomes in Infants with Cystic Fibrosis. J Pediatr 2023; 262:113595. [PMID: 37406853 DOI: 10.1016/j.jpeds.2023.113595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
Newborn screening for cystic fibrosis was fully implemented in the US by 2010, but delays in timeliness of evaluation for infants with positive newborn screening tests persist. Through evaluation of national patient registry data, we determined that late initiation of cystic fibrosis care is associated with poorer long-term nutritional outcomes.
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Affiliation(s)
- Stacey L Martiniano
- University of Colorado School of Medicine, Aurora, CO; Breathing Institute, Children's Hospital Colorado, Aurora, CO.
| | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Philip M Farrell
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Clement L Ren
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Children's Hospital of Philadelphia, Division of Pulmonary and Sleep Medicine, Philadelphia, PA
| | - Marci K Sontag
- Center for Public Health Innovation, CI International, Littleton, CO
| | | | - Susanna A McColley
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
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Cogen JD, Sanders DB, Slaven JE, Faino AV, Somayaji R, Gibson RL, Hoffman LR, Ren CL. Antibiotic Regimen Changes during Cystic Fibrosis Pediatric Pulmonary Exacerbation Treatment. Ann Am Thorac Soc 2023; 20:1293-1298. [PMID: 37327485 PMCID: PMC10502882 DOI: 10.1513/annalsats.202301-078oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/16/2023] [Indexed: 06/18/2023] Open
Abstract
Rationale/Objectives: Antibiotic selection for in-hospital treatment of pulmonary exacerbations (PEx) in people with cystic fibrosis (CF) is typically guided by previous respiratory culture results or past PEx antibiotic treatment. In the absence of clinical improvement during PEx treatment, antibiotics are frequently changed in search of a regimen that better alleviates symptoms and restores lung function. The clinical benefits of changing antibiotics during PEx treatment are largely uncharacterized. Methods: This was a retrospective cohort study using the Cystic Fibrosis Foundation Patient Registry Pediatric Health Information System. PEx were included if they occurred in children with CF from 6 to 21 years old who had been treated with intravenous antibiotics between January 1, 2006, and December 31, 2018. PEx with lengths of stay <5 or >21 days or for which treatment was delivered in an intensive care unit were excluded. An antibiotic change was defined as the addition or subtraction of any intravenous antibiotic between Hospital Day 6 and the day before hospital discharge. Inverse probability of treatment weighting was used to adjust for disease severity and indication bias, which might influence a decision to change antibiotics. Results: In all, 4,099 children with CF contributed 18,745 PEx for analysis, of which 8,169 PEx (43.6%) included a change in intravenous antibiotics on or after Hospital Day 6. The mean change in pre- to post-treatment percent predicted forced expiratory volume in 1 second (ppFEV1) was 11.3 (standard error, 0.21) among events in which an intravenous antibiotic change occurred versus 12.2 (0.18) among PEx without an intravenous antibiotic change (P = 0.001). Similarly, the odds of return to ⩾90% of baseline ppFEV1 were less for PEx with antibiotic changes than for those without changes (odds ratio [OR], 0.89 [95% confidence interval (CI), 0.80-0.98]). The odds of returning to ⩾100% of baseline ppFEV1 did not differ between PEx with versus without antibiotic changes (OR, 0.94 [95% CI, 0.86-1.03]). In addition, PEx treated with intravenous antibiotic changes were associated with higher odds of future PEx (OR, 1.17 [95% CI, 1.12-1.22]). Conclusions: In this retrospective study, changing intravenous antibiotics during PEx treatment in children with CF was common and not associated with improved clinical outcomes.
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Affiliation(s)
- Jonathan D. Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Don B. Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, and
| | - James E. Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anna V. Faino
- Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Ranjani Somayaji
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
| | - Ron L. Gibson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Lucas R. Hoffman
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Clement L. Ren
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Tsukahara K, Scully T, McDonough J, Boas H, DeMauro SB, Ren CL, Allen J. Reactance inversion in a cohort of former preterms: Physiology or artifact? Pediatr Pulmonol 2023; 58:2681-2684. [PMID: 37341587 PMCID: PMC10529034 DOI: 10.1002/ppul.26553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/11/2023] [Accepted: 06/03/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Katharine Tsukahara
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tryce Scully
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph McDonough
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Boas
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Clement L Ren
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julian Allen
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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VanDevanter DR, Zemanick ET, Konstan MW, Ren CL, Odem-Davis K, Emerman I, Young J, Mayer-Hamblett N. Willingness of people with cystic fibrosis receiving elexacaftor/tezacaftor/ivacaftor (ETI) to participate in randomized modulator and inhaled antimicrobial clinical trials. J Cyst Fibros 2023; 22:652-655. [PMID: 37100705 PMCID: PMC10523954 DOI: 10.1016/j.jcf.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To assess the feasibility of enrolling people with CF (pwCF) taking the CFTR modulator elexacaftor/tezacaftor/ivacaftor (ETI) in clinical trials of a new modulator. METHODS PwCF receiving ETI at CHEC-SC study (NCT03350828) enrollment were surveyed for interest in 2-week to 6-month placebo- (PC) and active-comparator (AC) modulator studies. Those taking inhaled antimicrobials (inhABX) were surveyed for interest in PC inhABX studies. RESULTS Of 1791 respondents, 75% [95% CI 73, 77] would enroll in a 2-week PC modulator study versus 51% [49, 54] for a 6-month study; 82% [81, 84] and 63% [61, 65] would enroll in 2-week and 6 month AC studies; 77% [74, 80] of 551 taking inhABX would enroll in a 2-week PC inhABX study versus 59% [55, 63] for a 6-month study. Previous clinical trial experience increased willingness. CONCLUSIONS Study designs will affect feasibility of future clinical trials of new modulators and inhABX in people receiving ETI.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH United States.
| | - E T Zemanick
- University of Colorado, Anschutz Medical Campus, Aurora CO United States
| | - M W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH United States; Rainbow Babies and Children's Hospital, Cleveland, OH United States
| | - C L Ren
- Children's Hospital of Philadelphia, Philadelphia, PA United States
| | - K Odem-Davis
- Seattle Children's Hospital, Seattle, WA United States
| | - I Emerman
- Seattle Children's Hospital, Seattle, WA United States
| | - J Young
- Seattle Children's Hospital, Seattle, WA United States
| | - N Mayer-Hamblett
- Seattle Children's Hospital, Seattle, WA United States; University of Washington, Seattle, WA United States
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Feld L, Dobkin SL, Maniaci J, Ren CL. Pediatric pulmonology year in review 2021 and 2022: Physiology. Pediatr Pulmonol 2023. [PMID: 37171109 DOI: 10.1002/ppul.26462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/13/2023]
Abstract
Pulmonary physiology is a core element of pediatric pulmonology care and research. This article reviews some of the notable publications in physiology that were published in Pediatric Pulmonology in 2021 and 2022.
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Affiliation(s)
- Lance Feld
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shoshana L Dobkin
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jon Maniaci
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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11
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Rehani MR, Marcus MS, Harris AB, Farrell PM, Ren CL. Variation in cystic fibrosis newborn screening algorithms in the United States. Pediatr Pulmonol 2023; 58:927-933. [PMID: 36507555 DOI: 10.1002/ppul.26279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE Cystic fibrosis (CF) newborn screening (NBS) algorithms in the United States vary by state. Differences in CF NBS algorithms could potentially affect the detection rate of CF newborns and lead to disparities in CF diagnosis amongst different racial and ethnic groups. OBJECTIVES Generate a database of CF NBS algorithms in the United States and identify processes that may potentially lead to missed diagnoses or lead to healthcare disparities. METHODS We sent an online survey to state and regional CF and NBS leaders about the type and threshold of immunoreactive trypsinogen (IRT) cutoff used and methods used for CFTR gene variant analysis. Follow-up by email and phone was done to ensure a response from every state, clarify responses, and resolve discordances. RESULTS There is wide variation in the NBS algorithms employed by different states. Approximately half the states use a floating IRT cutoff, and half use a fixed IRT cutoff. CFTR variant analysis also varies widely, with two states analyzing only for the F508del variant and four states incorporating CFTR gene sequencing. The other states use CFTR variant panels ranging from 23 to 365 CFTR variants. CONCLUSIONS CF NBS algorithms vary widely amongst the different states in the United States, which affects the ability of CF NBS to diagnose newborn infants with CF consistently and uniformly across the country and potentially may miss more infants with CF from minority populations. Our results identify an important area for quality improvement in CF NBS.
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Affiliation(s)
- Maryann R Rehani
- Milken Institute of Public Health, George Washington University, Washington, District of Columbia, USA.,Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Mary S Marcus
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Anne B Harris
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Philip M Farrell
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Clement L Ren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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McGarry ME, Ren CL, Wu R, Farrell PM, McColley SA. Detection of disease-causing CFTR variants in state newborn screening programs. Pediatr Pulmonol 2023; 58:465-474. [PMID: 36237137 PMCID: PMC9870974 DOI: 10.1002/ppul.26209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Newborn screening (NBS) algorithms for cystic fibrosis (CF) vary in the United State of America and include different cystic fibrosis transmembrane conductance regulator (CFTR) variants. CFTR variant distribution varies among racial and ethnic groups. OBJECTIVE Our objectives were to identify differences in detection rate by race and ethnicity for CFTR variant panels, identify each US state detection rate for CFTR variant panels, and describe the rate of false-negative NBS and delayed diagnoses by race and ethnicity. METHODS This is a cross-sectional analysis of the detection rate of at least 1 CFTR variant for seven panels by race and ethnicity in genotyped people with CF (PwCF) or CFTR-related metabolic syndrome (CRMS)/CFTR-related disorders in CF Foundation Patient Registry (CFFPR) in 2020. We estimated the case detection rate of CFTR variant panels by applying the detection rate to Census data. Using data from CFFPR, we compared the rate of delayed diagnosis or false-negative NBS by race and ethnicity. RESULTS For all panels, detection of at least 1 CFTR variant was highest in non-Hispanic White PwCF (87.5%-97.0%), and lowest in Black, Asian, and Hispanic PwCF (41.9%-93.1%). Detection of at least 1 CFTR variant was lowest in Black and Asian people with CRMS/CFTR-related disorders (48.4%-64.8%). States with increased racial and ethnic diversity have lower detection rates for all panels. Overall, 3.8% PwCF had a false-negative NBS and 11.8% had a delayed diagnosis; Black, Hispanic, and mixed-race PwCF were overrepresented. CONCLUSION CFTR variant panels have lower detection rates in minoritized racial and ethnic groups leading to false-negative NBS, delayed diagnosis, and likely health disparities.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Clement L Ren
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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13
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McColley SA, Martiniano SL, Ren CL, Sontag MK, Rychlik K, Balmert L, Elbert A, Wu R, Farrell PM. Disparities in first evaluation of infants with cystic fibrosis since implementation of newborn screening. J Cyst Fibros 2023; 22:89-97. [PMID: 35871976 DOI: 10.1016/j.jcf.2022.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/04/2022] [Accepted: 07/13/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We evaluated whether implementation of cystic fibrosis (CF) newborn screening (NBS) leads to equitable timeliness of initial evaluation. We compared age at first event (AFE, age at sweat test, encounter and/or care episode) between infants categorized as Black/African American, American Indian/ Native Alaskan, Asian, and/or Hispanic and/or other (Group 1) to White and not Hispanic infants (Group 2). METHODS This retrospective cohort study from the Cystic Fibrosis Foundation Patient Registry (CFFPR) included infants born 2010-2018. Race and ethnicity categories followed US Census definitions. The primary outcome was AFE; the secondary outcome was weight for age (WFA) z-score averaged 12 to < 24 months. We compared distributions by Wilcoxon rank-sum test and proportions by Chi-square or Fisher's exact tests. A nested cohort study used a linear mixed effects model of variables that affect WFA, chosen a priori, to evaluate associations with 1-year WFA z-score. RESULTS Among 6354 infants, 21% were in Group 1. Group 1 median AFE was 31 days (IQR 19, 49) and Group 2 was 22 days (IQR 14,36) (p< .001). Median WFA z-score at 1-2 years was lower in Group 1. In 3017 infants with complete data on variables of interest, AFE, Black race, CFTR variant class I-III, prematurity and public insurance were associated with lower 1-year WFA z-score. CONCLUSIONS Differences in AFE for infants with CF from historically marginalized groups may exacerbate long standing health disparities. We speculate that inequitable identification of CFTR gene variants and/or bias may influence timeliness of evaluation after an out-of-range NBS.
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Affiliation(s)
- Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States.
| | - Stacey L Martiniano
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Children's Hospital Colorado, Aurora, CO, United States
| | - Clement L Ren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Marci K Sontag
- Center for Public Health Innovation, CI International, Littleton, CO, United States
| | - Karen Rychlik
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, United States
| | - Lauren Balmert
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | | | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, MD, United States
| | - Philip M Farrell
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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14
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Ren CL, Slaven JE, Haas DM, Haneline LS, Tiller C, Hogg G, Bjerregaard J, Tepper RS. Forced expiratory flows and diffusion capacity in infants born from mothers with pre-eclampsia. Pediatr Pulmonol 2022; 57:2481-2490. [PMID: 35796049 PMCID: PMC9489632 DOI: 10.1002/ppul.26064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 01/01/2023]
Abstract
RATIONALE Animal models suggest pre-eclampsia (Pre-E) affects alveolar development, but data from humans are lacking. OBJECTIVE Assess the impact of Pre-E on airway function, diffusion capacity, and respiratory morbidity in preterm and term infants born from mothers with Pre-E. METHODS Infants born from mothers with and without Pre-E were recruited for this study; term and preterm infants were included in both cohorts. Respiratory morbidity in the first 12 months of life was assessed through monthly phone surveys. Raised volume rapid thoracoabdominal compression and measurement of diffusion capacity of the lung to carbon monoxide (DLCO) were performed at 6 months corrected age. MEASUREMENTS AND MAIN RESULTS There were 146 infants in the Pre-E cohort and 143 in the control cohort. The Pre-E cohort was further divided into nonsevere (N = 41) and severe (N = 105) groups. There was no significant difference in DLCO and DLCO/alveolar volume among the three groups. Forced vital capacity was similar among the three groups, but the nonsevere Pre-E group had significantly higher forced expiratory flows than the other two groups. After adjusting for multiple covariates including prematurity, the severe Pre-E group had a lower risk for wheezing in the first year of life compared to the other two groups. CONCLUSIONS Pre-E is not associated with reduced DLCO, lower forced expiratory flows, or increased wheezing in the first year of life. These results differ from animal models and highlight the complex relationships between Pre-E and lung function and respiratory morbidity in human infants.
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Affiliation(s)
- Clement L. Ren
- Division of Pulmonary and Sleep MedicineChildren's Hospital of PhiladephiaPhiladelphiaPennsylvaniaUSA
- Department of Pediatrics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - James E. Slaven
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIndianaUSA
| | - David M. Haas
- Department of Obstetrics and GynecologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Laura S. Haneline
- Department of Pediatrics, Division of Neonatal‐Perinatal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Christina Tiller
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Graham Hogg
- Department of Obstetrics and GynecologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jeffrey Bjerregaard
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Robert S. Tepper
- Department of Pediatrics, Division of Pulmonary, Allergy, and Sleep MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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15
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Rosenfeld M, Ostrenga J, Cromwell EA, Magaret A, Szczesniak R, Fink A, Schechter MS, Faro A, Ren CL, Morgan W, Sanders DB. Real-world Associations of US Cystic Fibrosis Newborn Screening Programs With Nutritional and Pulmonary Outcomes. JAMA Pediatr 2022; 176:990-999. [PMID: 35913705 PMCID: PMC9344390 DOI: 10.1001/jamapediatrics.2022.2674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
IMPORTANCE Newborn screening (NBS) for cystic fibrosis (CF) has been universal in the US since 2010, but its association with clinical outcomes is unclear. OBJECTIVE To describe the real-world effectiveness of NBS programs for CF in the US on outcomes up to age 10 years. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study using CF Foundation Patient Registry data from January 1, 2000, to December 31, 2018. The staggered implementation of NBS programs by state was used to compare longitudinal outcomes among children in the same birth cohort born before vs after the implementation of NBS for CF in their state of birth. Participants included children with an established diagnosis of CF born between January 1, 2000, to December 31, 2018, in any of the 44 states that implemented NBS for CF between 2003 and 2010. Data were analyzed from October 5, 2020, to April 22, 2022. EXPOSURES Birth before vs after the implementation of NBS for CF in the state of birth. MAIN OUTCOMES AND MEASURES Longitudinal trajectory of height and weight percentiles from diagnosis, lung function (forced expiratory volume in 1 second, [FEV1] percent predicted) from age 6 years, and age at initial and chronic infection with Pseudomonas aeruginosa using linear mixed-effects and time-to-event models adjusting for birth cohort and potential confounders. RESULTS A total of 9571 participants (4713 female participants [49.2%]) were eligible for inclusion, with 4510 (47.1%) in the pre-NBS cohort. NBS was associated with higher weight and height percentiles in the first year of life (weight, 6.0; 95% CI, 3.1-8.4; height, 6.6; 95% CI, 3.8-9.3), but these differences decreased with age. There was no association between NBS and FEV1 at age 6 years, but the percent-predicted FEV1 did increase more rapidly with age in the post-NBS cohort. NBS was associated with older age at chronic P aeruginosa infection (hazard ratio, 0.69; 95% CI, 0.54-0.89) but not initial P aeruginosa infection (hazard ratio, 0.88; 95% CI, 0.77-1.01). CONCLUSIONS AND RELEVANCE NBS for CF in the US was associated with improved nutritional status up to age 10 years, a more rapid increase in lung function, and delayed chronic P aeruginosa infection. In the future, as highly effective modulator therapies become available for infants with CF, NBS will allow for presymptomatic initiation of these disease-modifying therapies before irreversible organ damage.
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Affiliation(s)
- Margaret Rosenfeld
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle
| | | | | | - Amalia Magaret
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle
| | - Rhonda Szczesniak
- Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, Ohio
| | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland,National Organization for Rare Disorders, Washington, District of Columbia
| | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L. Ren
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wayne Morgan
- Department of Pediatrics, University of Arizona, Tucson
| | - Don B. Sanders
- Department of Pediatrics, Indiana University, Indianapolis
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16
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Madde A, Okoniewski W, Sanders DB, Ren CL, Weiner DJ, Forno E. Nutritional status and lung function in children with pancreatic-sufficient cystic fibrosis. J Cyst Fibros 2022; 21:769-776. [PMID: 34972650 PMCID: PMC9237179 DOI: 10.1016/j.jcf.2021.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/06/2021] [Accepted: 12/15/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is a strong association between nutrition and long-term FEV1 in cystic fibrosis (CF), but studies have been driven by data from subjects with pancreatic insufficiency (PI-CF). We thus evaluated the association between body mass index (BMI) and FEV1 percent-predicted (FEV1pp) in children with pancreatic sufficiency (PS-CF) and contrasted it with the association in PI-CF. METHODS We utilized data from the CF Foundation Patient Registry. The cohort included children born 1995-2010, diagnosed <2 years of age, and who had annualized data on BMI percentile and FEV1pp at ages 6-16 years. Pancreatic status was defined based on pancreatic enzyme replacement therapy. The association between BMI and FEV1 was evaluated using linear and mixed-effects longitudinal regression. RESULTS There were 424 children with PS-CF and 7,849 with PI-CF. The association between BMI and FEV1 differed significantly by pancreatic status: each 10-pct higher BMI was associated with 2% [95%CI = 1.9-2.1] higher FEV1pp in PI-CF, compared to just 0.9% [0.5-1.3] in PS-CF (PINTERACTION < 0.001). Within the at-risk nutritional category (BMI <25pct), each 10-pct higher BMI was associated with 5% higher FEV1pp in PI-CF, but no significant increase in PS-CF. Moreover, in PS-CF, overweight/obesity (BMI ≥85pct) was associated with decreasing FEV1pp. In addition, FEV1pp decline through age 20 years in youth with PS-CF was modest (-0.6% per year) and independent of BMI (BMI*age PINTERACTION = 0.37). CONCLUSIONS In children with PS-CF, BMI remains an important determinant of lung function. However, it may be less critical to attain a BMI >50th percentile; and BMI ≥85th percentile may be detrimental.
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Affiliation(s)
- Ankitha Madde
- Pediatric Pulmonary Medicine, UPMC, Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - William Okoniewski
- Pediatric Pulmonary Medicine, UPMC, Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, IN, USA; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, IN, USA; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel J Weiner
- Pediatric Pulmonary Medicine, UPMC, Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Erick Forno
- Pediatric Pulmonary Medicine, UPMC, Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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17
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Bouzek DC, Ren CL, Thompson M, Slaven JE, Sanders DB. Evaluating FEV1 decline in diagnosis and management of pulmonary exacerbations in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:1709-1716. [PMID: 35429154 PMCID: PMC9321873 DOI: 10.1002/ppul.25925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/22/2022] [Accepted: 04/10/2022] [Indexed: 11/25/2022]
Abstract
RATIONALE Forced expiratory volume in 1 s (FEV1) decline (ΔFEV1) is associated with pulmonary exacerbation (PEx) diagnosis in cystic fibrosis (CF). Spirometry may not be available during telehealth visits and could impair clinician ability to diagnose PEx. This study aims to (1) identify the associations between degrees of ΔFEV1 (decrease of <5% predicted vs. 5%-9% predicted vs. ≥10% predicted from baseline), clinical symptoms, and clinician-diagnosed PEx and (2) evaluate the correlation between respiratory symptoms, ΔFEV1, and antibiotic treatment. METHODS Retrospective, descriptive study of PEx diagnosis and management in 628 outpatient clinical encounters with spirometry in 178 patients with CF ages 6-17 years at Riley Hospital for Children during 2019. Odds ratios (OR) of symptoms associated with clinician-defined PEx diagnosis and antibiotic management stratified by ΔFEV1 decline were determined. RESULTS Clinician-diagnosed PEx occurred at 199 (31.7%) visits; increased cough (77.4%) and sputum/wet cough (57.8%) were the most frequently reported symptoms. Compared to no ΔFEV1, the odds of a clinician-diagnosed PEx were increased when ΔFEV15%-9% and ΔFEV1≥10% was present with increased cough (OR 1.56, 95% confidence interval [CI] 1.25-1.94 and OR 1.82, 95% CI 1.52-2.19, respectively), increased sputum (OR 1.59, 95% CI 1.20-2.12 and OR 1.78, 95% CI 1.37-2.32, respectively), and increased cough and sputum together (OR 1.51, 95% CI 1.08-2.13 and OR 1.68, 95% CI 1.22-2.31, respectively). CONCLUSIONS ΔFEV1 is associated with increased likelihood that cough and sputum are diagnosed as a PEx. Spirometry is essential for PEx diagnosis and treatment and is a necessary component of all clinical encounters.
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Affiliation(s)
- Drake C Bouzek
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Misty Thompson
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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18
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Sontag MK, Miller JI, McKasson S, Gaviglio A, Martiniano SL, West R, Vazquez M, Ren CL, Farrell PM, McColley SA, Kellar-Guenther Y. Newborn Screening for Cystic Fibrosis: A Qualitative Study of Successes and Challenges from Universal Screening in the United States. Int J Neonatal Screen 2022; 8:ijns8030038. [PMID: 35892468 PMCID: PMC9326751 DOI: 10.3390/ijns8030038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Cystic fibrosis (CF) newborn screening (NBS) was universally adopted in 2009 in the United States. Variations in NBS practices between states may impact the timing of diagnosis and intervention. Quantitative metrics can provide insight into NBS programs (NBSP), but the nuances cannot be elucidated without additional feedback from programs. This study was designed to determine facilitators and barriers to timely diagnosis and intervention following NBS for CF. The median age at the first CF event for infants with CF within each state was used to define early and late states (n = 15 per group); multiple CF centers were invited in states with more than two CF centers. Thirty states were eligible, and 61 NBSP and CF centers were invited to participate in structured interviews to determine facilitators and barriers. Once saturation of themes was reached, no other interviews were conducted. Forty-five interviews were conducted (n = 16 early CF center, n = 12 late CF center, n = 11 early NBSP, and n = 6 late NBSP). Most interviewees reported good communication between CF centers and NBSP. Communication between primary care providers (PCPs) and families was identified as a challenge, leading to delays in referral and subsequent diagnosis. The misperception of low clinical risk in infants from racial and ethnic minority groups was a barrier to early diagnostic evaluation for all groups. NBSP and CF centers have strong relationships. Early diagnosis may be facilitated through more engagement with PCPs. Quality improvement initiatives should focus on continuing strong partnerships between CF centers and NBS programs, improving education, communication strategies, and partnerships with PCPs, and improving CF NBS timeliness and accuracy.
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Affiliation(s)
- Marci K. Sontag
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
- Colorado School of Public Health, University of Colorado Anschutz Medical Center, Aurora, CO 80045, USA
- Correspondence: ; Tel.: +1-303-867-1315
| | - Joshua I. Miller
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Sarah McKasson
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Amy Gaviglio
- Connetics Consulting, Minneapolis, MN 55417, USA;
| | - Stacey L. Martiniano
- Children’s Hospital Colorado, Aurora, CO 80045, USA;
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Rhonda West
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Marisol Vazquez
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL 60611, USA; (M.V.); (S.A.M.)
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Clement L. Ren
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
- Division of Pulmonary and Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Philip M. Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI 53705, USA;
| | - Susanna A. McColley
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL 60611, USA; (M.V.); (S.A.M.)
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Yvonne Kellar-Guenther
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
- Colorado School of Public Health, University of Colorado Anschutz Medical Center, Aurora, CO 80045, USA
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19
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Voynow JA, Feng R, Ren CL, Dylag AM, Kemp JS, McDowell K, Sharp J, Moore PE, Eichenwald E, Panitch H, Clem C, Johnson R, Davis SD. Pulmonary function tests in extremely low gestational age infants at one year of age. Pediatr Pulmonol 2022; 57:435-447. [PMID: 34779149 DOI: 10.1002/ppul.25757] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 11/08/2022]
Abstract
RATIONALE Identifying neonatal and post-discharge exposures among extremely low gestational age newborns (ELGANs) that drive increased pulmonary morbidity and abnormal lung function at 1 year of age proves challenging. OBJECTIVE The NIH-sponsored Prematurity and Respiratory Outcomes Program (PROP), evaluated infant pulmonary function tests (iPFTs) at 1 year corrected age to determine which demographic and clinical factors are associated with abnormal lung function. METHODS iPFTs were performed on a PROP subcohort of 135 participants following Institutional Review Board (IRB)-approved written consent. Demographic data, Neonatal Intensive Care Unit (NICU) clinical care, and post-NICU exposures were analyzed for association with iPFTs. MAIN RESULTS A significant decrease in forced expiratory volume at 0.5 s (FEV0.5 ) and/or forced expiratory flows at 75% of forced vital capacity (FEF75 ), were associated with male sex and African American race. Clinical factors including longer duration of ventilatory support, exposure to systemic steroids, and weight less than the 10th percentile at 36 weeks postmenstrual age were also associated with airflow obstruction, whereas supplemental oxygen requirement and bronchopulmonary dysplasia were not. Additionally, the need for respiratory medications, technology, or hospitalizations during the first year, ascertained by a quarterly survey, were the only post-NICU factors associated with decreased FEV0.5 and FEF75 . Only 7% of infants had reversible airflow obstruction. CONCLUSIONS Neonatal demographic factors, respiratory support in the NICU, and a history of greater post-NICU medical utilization for respiratory disease had the strongest association with lower lung function at 1 year in ELGANs.
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Affiliation(s)
- Judith A Voynow
- Division of Pediatric Pulmonology, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Rui Feng
- Department of Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Pediatric Pulmonology, University of Rochester, Rochester, New York, USA.,Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Andrew M Dylag
- Division of Neonatology, University of Rochester, Rochester, New York, USA
| | - James S Kemp
- Division of Pediatric Pulmonology, Washington University Medical Center, St. Louis, Missouri, USA
| | - Karen McDowell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jack Sharp
- Division of Pediatric Pulmonology, Duke University Medical Center, Durham, North Carolina, USA.,Division of Pediatric Pulmonology, Texas Children's Hospital, Woodlands, Texas, USA
| | - Paul E Moore
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, University of Texas Health Science Center- Houston, Houston, Texas, USA
| | - Howard Panitch
- Division of Pediatric Pulmonology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Charles Clem
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Robin Johnson
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA.,Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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20
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Chudleigh J, Barben J, Ren CL, Southern KW. International Approaches to Management of CFTR-Related Metabolic Syndrome/Cystic Fibrosis Screen Positive, Inconclusive Diagnosis. Int J Neonatal Screen 2022; 8:ijns8010005. [PMID: 35076474 PMCID: PMC8788507 DOI: 10.3390/ijns8010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
The main aim of the present study was to explore health professionals' reported experiences and approaches to managing children who receive a designation of cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen positive inconclusive diagnosis following a positive NBS result for cystic fibrosis. An online questionnaire was distributed via Qualtrics Survey Software and circulated to a purposive, international sample of health professionals involved in managing children with this designation. In total, 101 clinicians completed the online survey: 39 from the US, six from Canada, and 56 from Europe (including the UK). Results indicated that while respondents reported minor deviations in practice, they were cognizant of recommendations in the updated guidance and for the most part, attempted to implement these into practice consistently internationally. Where variation was reported, the purpose of this appeared to be to enable clinicians to respond to either clinical assessments or parental anxiety in order to improve outcomes for the child and family. Further research is needed to determine if these findings are reflective of both a wider audience of clinicians and actual (rather than reported) practice.
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Affiliation(s)
- Jane Chudleigh
- School of Health Sciences, City, University of London, London EC1V 0HB, UK
- Correspondence: ; Tel.: +44-(0)-7977-933204
| | - Jürg Barben
- Children’s Hospital of Eastern Switzerland, 9000 St. Gallen, Switzerland;
| | - Clement L. Ren
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Kevin W. Southern
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool L69 3BX, UK;
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21
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Ong T, Van Citters AD, Dowd C, Fullmer J, List R, Pai SA, Ren CL, Scalia P, Solomon GM, Sawicki GS. Remote monitoring in telehealth care delivery across the U.S. cystic fibrosis care network. J Cyst Fibros 2021; 20 Suppl 3:57-63. [PMID: 34930544 DOI: 10.1016/j.jcf.2021.08.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) programs and people with CF (PwCF) employed various monitoring methods for virtual care during the COVID-19 pandemic. This paper characterizes experiences with remote monitoring across the U.S. CF community. METHODS The CF Foundation (CFF) sponsored distribution of home spirometers (April 2020 to May 2021), surveys to PwCF and CF programs (July to September 2020), and a second program survey (April to May 2021). We used mixed methods to explore access, use, and perspectives regarding the use of remote monitoring in future care. RESULTS By October 2020, 13,345 spirometers had been distributed, and 19,271 spirometers by May 2021. Programs (n=286) estimated proportions of PwCF with home devices increased over seven months: spirometers (30% to 70%), scales (50% to 70%), oximeters (5% to 10%) with higher estimates in adult programs for spirometers and oximeters. PwCF (n=378) had access to scales (89%), followed by oximeters (48%) and spirometers (47%), often using scales and oximeters weekly, and spirometers monthly. Over both surveys, some programs had no method to collect respiratory specimens for cultures associated with telehealth visits (47%, n=132; 41%, n=118). Most programs (81%) had a process for phlebotomy associated with a telehealth visit, primarily through off-site labs. Both PwCF and programs felt future care should advance remote monitoring and recommended improvements for access, training, and data collection systems. CONCLUSIONS PwCF and programs experienced unprecedented access to remote monitoring and raised its importance for future care. Improvements to current systems may leverage these shared experiences to augment future care models.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, United States.
| | - Aricca D Van Citters
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | | | - Jason Fullmer
- DCMG Pediatric Pulmonology & Sleep Medicine, Dell Children's Medical Group, Austin, TX, United States
| | - Rhonda List
- Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, United States
| | - Shine-Ann Pai
- Marnie Paul Specialty Care Center, Dell Children's Medical Center of Central Texas, Austin, TX, United States
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter Scalia
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - George M Solomon
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Gregory S Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, United States
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22
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Van Citters AD, Dieni O, Scalia P, Dowd C, Sabadosa KA, Fliege JD, Jain M, Miller RW, Ren CL. Barriers and facilitators to implementing telehealth services during the COVID-19 pandemic: A qualitative analysis of interviews with cystic fibrosis care team members. J Cyst Fibros 2021; 20 Suppl 3:23-28. [PMID: 34930537 PMCID: PMC8683122 DOI: 10.1016/j.jcf.2021.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/30/2021] [Accepted: 09/04/2021] [Indexed: 11/19/2022]
Abstract
Background The COVID-19 pandemic forced cystic fibrosis (CF) care programs to rapidly shift from in-person care delivery to telehealth. Our objective was to provide a qualitative exploration of facilitators and barriers to: 1) implementing high-quality telehealth and 2) navigating reimbursement for telehealth services. Methods We used data from the 2020 State of Care CF Program Survey (n=286 U.S. care programs) administered in August-September to identify two cohorts of programs, with variation in telehealth quality (n=12 programs) and reimbursement (n=8 programs). We conducted focus groups and semi-structured interviews with CF program directors and coordinators in December 2020, approximately 9 months from onset of the pandemic. We used the Consolidated Framework for Implementation Research to identify facilitators and barriers of implementation, and inductive thematic analysis to identify facilitators and barriers of reimbursement. Results Factors differentiating programs with greater and lower perceived telehealth quality included telehealth characteristics (perceived advantage over in-person care, cost, platform quality); external influences (needs and resources of those served by the CF program), characteristics of the CF program (compatibility with workflows, relative priority, available resources); characteristics of team members (individual stage of change), and processes for implementation (engaging patients and teams). Reimbursement barriers included documentation to optimize billing; reimbursement of multi-disciplinary team members, remote monitoring, and telephone-only telehealth; and lower volume of patients. Conclusions A number of factors are associated with successful implementation and reimbursement of telehealth. Future efforts should provide guidance and incentives that support telehealth delivery and infrastructure, share best practices across CF programs, and remove barriers.
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Affiliation(s)
- Aricca D Van Citters
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5, One Medical Center Drive, Lebanon, NH, 03766, USA.
| | - Olivia Dieni
- Cystic Fibrosis Foundation, 4550 Montgomery Avenue, Suite 1100N, Bethesda, MD 20814 USA
| | - Peter Scalia
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5, One Medical Center Drive, Lebanon, NH, 03766, USA
| | - Christopher Dowd
- Cystic Fibrosis Foundation, 4550 Montgomery Avenue, Suite 1100N, Bethesda, MD 20814 USA
| | - Kathryn A Sabadosa
- Cystic Fibrosis Foundation, 4550 Montgomery Avenue, Suite 1100N, Bethesda, MD 20814 USA
| | - Jill D Fliege
- Adult Cystic Fibrosis Nurse Practitioner / Program Coordinator; Pulmonary, Critical Care, Sleep and Allergy Medicine, 985990 Nebraska Medicine, Omaha, NE, 69198-5990, USA
| | - Manu Jain
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Robert W Miller
- Lehigh Valley Reilly Children's Hospital Cystic Fibrosis Center, 1210 Cedar Crest Blvd, Suite 2700, Allentown, PA, 18103, USA
| | - Clement L Ren
- Children's Hospital of Philadelphia, Division of Pulmonary and Sleep Medicine, Colket Translational Research Building, 3501 Civic Center Blvd, Philadelphia, PA, 19104, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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23
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Cristea AI, Ren CL, Amin R, Eldredge LC, Levin JC, Majmudar PP, May AE, Rose RS, Tracy MC, Watters KF, Allen J, Austin ED, Cataletto ME, Collaco JM, Fleck RJ, Gelfand A, Hayes D, Jones MH, Kun SS, Mandell EW, McGrath-Morrow SA, Panitch HB, Popatia R, Rhein LM, Teper A, Woods JC, Iyer N, Baker CD. Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2021; 204:e115-e133. [PMID: 34908518 PMCID: PMC8865713 DOI: 10.1164/rccm.202110-2269st] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods: A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions: The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.
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24
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Bauer SE, Lai HJ, McDonald CM, Asfour F, Slaven JE, Ren CL. Zinc status and growth in infants and young children with cystic fibrosis. Pediatr Pulmonol 2021; 56:3768-3776. [PMID: 34499426 PMCID: PMC8629965 DOI: 10.1002/ppul.25666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/20/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Zinc deficiency is associated with poor growth in children without cystic fibrosis (CF), but its impact on growth in children with CF is unknown. OBJECTIVE To determine the prevalence of low serum Zn (sZn) and its relationship with growth in the first 3 years of life in children with CF. METHODS We utilized data from infants with CF who were enrolled in a longitudinal study of nutrition and lung health and had sZn measured as part of clinical care. Cross-sectional correlations between sZn levels and growth z scores were assessed by Pearson's correlation coefficient. To identify factors associated with sZn status and its association to longitudinal growth patterns, multiple regression analysis with repeated measures were performed using generalized estimating equations. RESULTS A total of 106 sZn measurements from 53 infants were identified. Seventeen infants (32%) had intermittent Zn insufficiency, defined as at least one sZn <70 mcg/dl in their first 3 years of life. There were no significant cross-sectional associations between sZn and growth z scores. However, analysis of longitudinal growth patterns revealed that weight- and length-for-age z scores in children with intermittent Zn insufficiency were lower during early infancy and their weight-for-length z scores at age 3 years were also lower compared to those who were always Zn sufficient. CONCLUSION Low sZn occurs in one-third of children with CF in the first 3 years of life. Cross-sectional and longitudinal analyses revealed discrepant associations between sZn and growth. Therefore, prospective studies are needed to understand the role of Zn in growth in CF.
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Affiliation(s)
- Sarah E Bauer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - HuiChuan J Lai
- Department of Nutritional Sciences, University of Wisconsin, Madison, Wisconsin, USA.,Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, USA
| | - Catherine M McDonald
- Department of Clinical Nutrition, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Fadi Asfour
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - James E Slaven
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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25
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Martiniano SL, Elbert AA, Farrell PM, Ren CL, Sontag MK, Wu R, McColley SA. Outcomes of infants born during the first 9 years of CF newborn screening in the United States: A retrospective Cystic Fibrosis Foundation Patient Registry cohort study. Pediatr Pulmonol 2021; 56:3758-3767. [PMID: 34469079 DOI: 10.1002/ppul.25658] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/05/2021] [Accepted: 08/08/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Newborn screening (NBS) for cystic fibrosis (CF) was implemented in all US states and DC by 2010. This hypothesis-generating study was designed to form the basis of additional analyses and to plan quality improvement initiatives. The aims were to describe the outcomes of infants with CF born during the first 9 years of universal NBS. METHODS We included participants in the CF Foundation Patient Registry born 2010-2018 with age of recorded CF diagnosis 0-365 days old. We compared the age of center-reported diagnosis, age at first CF event (defined as earliest sweat test, clinic visit, or hospitalization), demographics, and outcomes between three cohorts born between 2010-2012, 2013-2015, and 2016-2018. RESULTS In 6354 infants, the median age at first CF event decreased from the first to the third cohort. Weight-for-age (WFA) was < 10th percentile in about 40% of infants at the first CF Center visit. Median WFA z-score at 1-2 years was more than 0 but height-for-age (HFA) z-score was less than 0 through age 5-6 years. The second cohort had a higher HFA z-score than the first cohort at age 5-6 years. Pseudomonas aeruginosa infection was less common in later cohorts. About 1/3 of infants were hospitalized in the first year of life with no changes over time. CONCLUSION Over 9 years of CF NBS, median age at first CF event decreased. CF NBS had positive health impacts, but early life nutritional deficits and a high rate of infant hospitalizations persist.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Clement L Ren
- Division of Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Marci K Sontag
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.,Center for Public Health Innovation at CI International, USA
| | | | - Susanna A McColley
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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26
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Abstract
Wheezing is a common outcome of preterm birth. This article will review the mechanisms, epidemiology, and treatment of wheezing in preterm children with and without a history of bronchopulmonary dysplasia.
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Affiliation(s)
- Eli Rhoads
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory S Montgomery
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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27
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Muston HN, Slaven JE, Tiller C, Clem C, Ferkol TW, Ranganathan S, Davis SD, Ren CL. Hyperinflation is associated with increased respiratory rate and is a more sensitive measure of cystic fibrosis lung disease during infancy compared to forced expiratory measures. Pediatr Pulmonol 2021; 56:2854-2860. [PMID: 34143539 PMCID: PMC8373786 DOI: 10.1002/ppul.25538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The goal of this study was to identify clinical features associated with abnormal infant pulmonary function tests (iPFTs), specifically functional residual capacity (FRC), in infants with cystic fibrosis (CF) diagnosed via newborn screen (NBS). We hypothesized that poor nutritional status in the first 6-12 months would be associated with increased FRC at 12-24 months. METHODS This study utilized a combination of retrospectively and prospectively collected data from ongoing research studies and iPFTs performed for clinical indications. Demographic and clinical features were obtained from the electronic medical record. Forced expiratory flows and volumes were obtained using the raised volume rapid thoracoabdominal technique (RVRTC) and FRC was measured via plethysmography. RESULTS A total of 45 CF NBS infants had iPFTs performed between 12 and 24 months. Mean forced vital capacity, forced expiratory volume in 0.5 s, and forced expiratory flows were all within normal limits. In contrast, the mean FRC z-score was 2.18 (95% confidence interval [CI] = 1.48, 2.88) and the mean respiratory rate (RR) z-score was 1.42 (95% CI = 0.95, 1.89). There was no significant association between poor nutritional status and abnormal lung function. However, there was a significant association between higher RR and increased FRC, and a RR cutoff of 36 breaths/min resulted in 92% sensitivity to detect hyperinflation with 32% specificity. CONCLUSION These results suggest that FRC is a more sensitive measure of early CF lung disease than RVRTC measurements and that RR may be a simple, noninvasive clinical marker to identify CF NBS infants with hyperinflation.
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Affiliation(s)
- Heather N Muston
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christina Tiller
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Charles Clem
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas W Ferkol
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Sarath Ranganathan
- Department of Paediatrics, Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
| | - Stephanie D Davis
- Department of Pediatrics, The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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28
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Delecaris AO, Averill SH, Krasinkiewicz J, Saunders JL, Ren CL. Pediatric pulmonology year in review 2020: Physiology. Pediatr Pulmonol 2021; 56:2444-2448. [PMID: 34043883 DOI: 10.1002/ppul.25504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 11/06/2022]
Abstract
Pulmonary physiology is a core element of pediatric pulmonology care and research. This article reviews some of the notable publications in physiology that were published in Pediatric Pulmonology in 2020.
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Affiliation(s)
- Angela O Delecaris
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samantha H Averill
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan Krasinkiewicz
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jessica L Saunders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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29
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Bauer SE, Wesson M, Oles SK, Ren CL. Outcomes of repeat sweat testing in cystic fibrosis newborn screen positive infants. Pediatr Pulmonol 2021; 56:1521-1526. [PMID: 33512069 DOI: 10.1002/ppul.25296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Infants with a positive cystic fibrosis (CF) newborn screen, only one identified CFTR mutation (NBS+/1 mut), and an initial intermediate sweat chloride (30-59 mmol/L) should have repeat sweat chloride testing (SCT). However, the outcome of repeat SCT and the relationship between initial sweat Cl and subsequent CF diagnosis have not been reported. OBJECTIVE The objective of this study was to analyze the outcomes of repeat SCT and subsequent CF diagnosis in NBS+/1 mut infants based on their initial sweat chloride concentration. METHODS We retrospectively identified all infants born in Indiana from 2007 to 2017 with NBS+/1 mut and initial SCT in the intermediate range. For each infant, we recorded the initial and repeat SCT results and/or a final CF diagnosis. RESULTS From 2007 through 2017 there were 2822 NBS+/1 mut infants of which 2613 (82%) had at least one SCT result. No infants with an initial SCT of 30-39 mmol/L were subsequently diagnosed with CF. Of the 31 infants with an initial SCT of 40-49 mmol/L, only 1 was subsequently diagnosed with CF. In contrast, 61% of those with SCTs of 50-59 mmol/L were later diagnosed with CF. CONCLUSION These results suggest that infants with a positive NBS for CF and one CFTR mutationwhose initial sweat chloride concentration is 50-59 mmol/L need to be monitored more closely forCF with strong consideration for earlier repeat SCTs and immediate genotyping.
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Affiliation(s)
- Sarah E Bauer
- Division of Pediatrics, Indiana University, Indianapolis, Indiana, USA
| | - Melissa Wesson
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, Indiana, USA
| | - Sylwia K Oles
- Division of Pediatrics, Indiana University, Indianapolis, Indiana, USA
| | - Clement L Ren
- Division of Pediatrics, Indiana University, Indianapolis, Indiana, USA
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30
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Sontag MK, Farrell PM, Kellar-Guenther Y, Martiniano SL, Miller JI, Ren CL, McColley SA. Comment on Munck et al., Feb, 2021. J Cyst Fibros 2021; 20:717-718. [PMID: 34020895 DOI: 10.1016/j.jcf.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Marci K Sontag
- Center for Public Health Innovation at CI International, Littleton, CO, United States; University of Colorado Anschutz Medical Center, Aurora, Colorado United States.
| | - Phillip M Farrell
- Departments of Pediatrics and Population Health Sciences. UW School of Medicine and Public Health, Madison, WI, United States
| | - Yvonne Kellar-Guenther
- Center for Public Health Innovation at CI International, Littleton, CO, United States; University of Colorado Anschutz Medical Center, Aurora, Colorado United States
| | - Stacey L Martiniano
- Children's Hospital Colorado, Aurora, Colorado, United States; University of Colorado Anschutz Medical Center, Aurora, Colorado United States
| | - Joshua I Miller
- Center for Public Health Innovation at CI International, Littleton, CO, United States; University of Colorado Anschutz Medical Center, Aurora, Colorado United States
| | - Clement L Ren
- Indiana University School of Medicine, United States; Riley Hospital for Children, United States
| | - Susanna A McColley
- Ann & Robert H. Lurie Children's Hospital, United States; Northwestern University Feinberg School of Medicine, United States
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Patel S, Thompson MD, Slaven JE, Sanders DB, Ren CL. Reduction of pulmonary exacerbations in young children with cystic fibrosis during the COVID-19 pandemic. Pediatr Pulmonol 2021; 56:1271-1273. [PMID: 33434352 PMCID: PMC8014497 DOI: 10.1002/ppul.25250] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/20/2020] [Accepted: 12/25/2020] [Indexed: 11/05/2022]
Abstract
To assess the impact of COVID-19 restrictions on cystic fibrosis (CF) pulmonary exacerbations (PEx) we performed a retrospective review of PEx events at our CF Center and compared the rate of PEx in 2019 versus 2020. Restrictions on social interaction due to the COVID-19 pandemic were associated with a lower number of PEx events at our pediatric CF Center, suggesting that these restrictions also reduced exposure to other respiratory viral infection in children with CF.
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Affiliation(s)
- Shreya Patel
- Indiana University School of MedicineIndianapolisIndianaUSA
| | - Misty D. Thompson
- Division of Pediatric Pulmonology, Allergy, and Sleep MedicineRiley Hospital for ChildrenIndianapolisIndianaUSA
- Department of PediatricsIndiana University School of MedicineIndianapolisIndianaUSA
| | - James E. Slaven
- Department of BiostatisticsIndiana University/Purdue University at IndianapolisIndianaUSA
| | - Don B. Sanders
- Division of Pediatric Pulmonology, Allergy, and Sleep MedicineRiley Hospital for ChildrenIndianapolisIndianaUSA
- Department of PediatricsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Clement L. Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep MedicineRiley Hospital for ChildrenIndianapolisIndianaUSA
- Department of PediatricsIndiana University School of MedicineIndianapolisIndianaUSA
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Muston HN, Perrem L, Davis MD, Ratjen F, Ren CL. The remaining barriers to normalcy in CF: Advances in assessment of CF lung disease. Pediatr Pulmonol 2021; 56 Suppl 1:S90-S96. [PMID: 32589821 DOI: 10.1002/ppul.24929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/20/2020] [Accepted: 06/23/2020] [Indexed: 11/12/2022]
Abstract
Despite early diagnosis of cystic fibrosis (CF) through newborn screening, a substantial proportion of infants and young children with CF still demonstrate physiologic and structural evidence of lung disease progression, such as obstructive airway disease and bronchiectasis. The growing availability of highly effective CF transmembrane conductance regulatory modulator therapy to the vast majority of people with CF has led to the potential to alter the natural history of CF lung disease, but to assess the full impact of these therapies on CF lung disease and to help guide treatment, sensitive measures of early and mild disease are needed. Chest imaging using computed tomography or magnetic resonance imaging is one approach, but technologic barriers and/or concern about exposure to ionizing radiation may limit its use. However, advances in physiologic measurement techniques and exhaled breath analysis offer another option for assessment of CF lung disease.
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Affiliation(s)
- Heather N Muston
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Michael D Davis
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
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Barben J, Castellani C, Munck A, Davies JC, de Winter-de Groot KM, Gartner S, Kashirskaya N, Linnane B, Mayell SJ, McColley S, Ooi CY, Proesmans M, Ren CL, Salinas D, Sands D, Sermet-Gaudelus I, Sommerburg O, Southern KW. Updated guidance on the management of children with cystic fibrosis transmembrane conductance regulator-related metabolic syndrome/cystic fibrosis screen positive, inconclusive diagnosis (CRMS/CFSPID). J Cyst Fibros 2020; 20:810-819. [PMID: 33257262 DOI: 10.1016/j.jcf.2020.11.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/30/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
Over the past two decades there has been considerable progress with the evaluation and management of infants with an inconclusive diagnosis following Newborn Screening (NBS) for cystic Fibrosis (CF). In addition, we have an increasing amount of evidence on which to base guidance on the management of these infants and, importantly, we have a consistent designation being used across the globe of CRMS/CFSPID. There is still work to be undertaken and research questions to answer, but these infants now receive more consistent and appropriate care pathways than previously. It is clear that the majority of these infants remain healthy, do not convert to a diagnosis of CF in childhood, and advice on management should reflect this. However, it is also clear that some will convert to a CF diagnosis and monitoring of these infants should facilitate their early recognition. Those infants that do not convert to a CF diagnosis have some potential of developing a CFTR-RD later in life. At present, it is not possible to quantify this risk, but families need to be provided with clear information of what to look out for. This paper contains a number of changes from previous guidance in light of developing evidence, but the major change is the recommendation of a detailed assessment of the child with CRMS/CFSPID in the sixth year of age, including respiratory function assessment and imaging. With these data, the CF team can discuss future care arrangements with the family and come to a shared decision on the best way forward, which may include discharge to primary care with appropriate information. Information is key for these families, and we recommend consideration of a further appointment when the individual is a young adult to directly communicate the implications of the CRMS/CFSPID designation.
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Affiliation(s)
- Jürg Barben
- Paediatric Pulmonology & CF Centre, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland.
| | - Carlo Castellani
- Istituto Giannina Gaslini, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Anne Munck
- CF referent physician for the French Society of Newborn Screening, Hopital Necker Enfants-Malades, AP-HP, CF centre, Université Paris Descartes, France
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, UK; Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Karin M de Winter-de Groot
- Department of Paediatric Pulmonology & Allergology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Silvia Gartner
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Nataliya Kashirskaya
- Laboratory of genetic epidemiology, Research Centre for Medical Genetics, Moscow, Russian Federation
| | - Barry Linnane
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Sarah J Mayell
- Regional Paediatric CF Centre, Alder Hey Children's Hospital, Liverpool, UK
| | - Susanna McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Stanley Manne Children's Research Institute, Ann and Robert H Lurie Children's Hospital of Chicago, USA
| | - Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Australia; Department of Gastroenterology and Molecular and Integrative Cystic Fibrosis Research Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Marijke Proesmans
- Division of Woman and Child, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Clement L Ren
- Department of Pediatrics, Indiana University School of Medicine, Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indianapolis, USA
| | - Danieli Salinas
- Department of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, USA
| | - Dorota Sands
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades/INSERM U1151, Service de Pneumologie et Allergologie Pédiatriques Centre de Référence Maladies Rares, Mucoviscidose et maladies de CFTR, Hôpital Necker Enfants Malades Paris. Université de Paris. ERN Lung, France
| | - Olaf Sommerburg
- Paediatric Pulmonology, Allergology & CF Centre, Department of Paediatrics III, and Translational Lung Research Center, German Lung Research Center, University Hospital Heidelberg, Germany
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, UK
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Ren CL. [Pay attention to the diagnosis and treatment of tricuspid valve dysfunction related to pacemaker lead]. Zhonghua Yi Xue Za Zhi 2020; 100:3121-3125. [PMID: 33142394 DOI: 10.3760/cma.j.cn112137-20200717-02148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- C L Ren
- Department of Cardiovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
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Ren CL, Yao MH, Zhang L, Wang R, Jiang SL. [Surgical treatment of tricuspid valve disease due to permanent pacemaker lead]. Zhonghua Yi Xue Za Zhi 2020; 100:3147-3151. [PMID: 33142396 DOI: 10.3760/cma.j.cn112137-20200427-01345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To summarize the etiology and surgical treatment experience of tricuspid valve disease due to permanent pacemaker lead. Methods: The medical records of 22 patients who underwent tricuspid valve operation for tricuspid valve disease due to permanent cardiac pacemaker lead from January 2008 to December 2017 were retrospectively reviewed. There were 12 males and 10 females, with a mean age of (62.6±12.1) years old (45-82 years old). All patients underwent tricuspid valve surgery via open thoracotomy under general anesthesia, including 8 patients through median thoracotomy approach, 4 patients through right mini-thoracotomy approach, and 10 patients with endoscopy-assisted and totally endoscopic technique. Moreover, 8 patients underwent tricuspid valve replacement, and 14 patients received tricuspid valve repair. Results: During the operation, 10 cases of severe tricuspid regurgitation were detected due to valve and subvalvular structures dysfunction involved in the pacing electrode, 7 cases showed tricuspid annulus dilation, and pacing electrode-related infective endocarditis were involved in the tricuspid valve of 5 cases. Compared with conventional median thoracotomy surgery, the amount of postoperative drainage fluid and hospitalization time after minimally invasive surgery (including right mini-thoracotomy and endoscopic surgery) were significantly reduced [281(120, 489) ml vs 368(180, 560) ml, P=0.02; 9.2(4.8, 14.5) d vs 11.2(6.3, 16.9) d, P=0.03]. Postoperative echocardiographic data showed that the size of the right atrium and ventricle in these patients was significantly reduced compared with preoperative data, and their cardiac function were normal. There was no difference of pacing electrode parameters between pre-and postoperative period. All 22 patients were cured and discharged, with no valve-and pacemaker-related complications. Conclusions: Patients with tricuspid valve disease due to permanent cardiac pacemaker lead should actively undergo surgery including tricuspid replacement or repair according to different etiologies, which exhibit satisfactory outcomes. Minimally invasive endoscopic tricuspid surgery is a new technique for the treatment of isolated tricuspid valve disease, with less surgical trauma and faster recovery.
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Affiliation(s)
- C L Ren
- Department of Cardiovascular Surgery, First Medical Center of PLA General Hospital, Beijing 100853, China
| | - M H Yao
- Department of Cardiovascular Surgery, First Medical Center of PLA General Hospital, Beijing 100853, China
| | - L Zhang
- Department of Cardiovascular Surgery, First Medical Center of PLA General Hospital, Beijing 100853, China
| | - R Wang
- Department of Cardiovascular Surgery, First Medical Center of PLA General Hospital, Beijing 100853, China
| | - S L Jiang
- Department of Cardiovascular Surgery, First Medical Center of PLA General Hospital, Beijing 100853, China
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McColley SA, Elbert A, Wu R, Ren CL, Sontag MK, LeGrys VA. Quantity not sufficient rates and delays in sweat testing in US infants with cystic fibrosis. Pediatr Pulmonol 2020; 55:3053-3056. [PMID: 32797669 DOI: 10.1002/ppul.25027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Diagnostic sweat testing is required for infants with positive newborn-screening (NBS) tests for cystic fibrosis (CF). Infants have "quantity not sufficient" (QNS) sweat volumes more often than older children. A comprehensive study of QNS sweat volumes in infants has not previously been reported. METHODS We surveyed US CF Centers to obtain QNS rates in all infants who had sweat testing at under 14 days and under 3 months of age. We then calculated QNS rates reported to the Cystic Fibrosis Foundation Patient Registry (CFFPR) 2010-2018 in 10-day increments from 1 to 60 days of life. We compared QNS sweat test rates in preterm (<37-weeks gestational age) vs term infants. We assessed age at sweat test and proportion of infants who did not have a sweat test reported by 60 days of age. RESULTS Thirty-nine of 144 (27%) of CF Centers reported a mean QNS rate of 10.5% (range, 0-100) in infants 14-days-old or younger. CFFPR data showed the highest QNS rates in the youngest infants and in those born before 37 weeks of gestation. The median age at sweat testing decreased over time, but more than 22% of infants did not have a sweat test reported by 60 days. CONCLUSION Higher QNS rates are seen in the youngest infants with CF, but more than 80% of infants younger than 2 weeks of age have adequate sweat volumes. Sweat testing should not be delayed in infants with a positive CF NBS test.
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Affiliation(s)
- Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University, Indianapolis, Indiana
| | - Marci K Sontag
- Center for Public Health Innovation, Littleton, Colorado.,Department of Epidemiology, University of Colorado, Denver
| | - Vicky A LeGrys
- Department of Allied Health Science, University of North Carolina, Chapel Hill, North Carolina
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Rhoads E, Wall BL, Ren CL. Pediatric pulmonology year in review 2019: Physiology. Pediatr Pulmonol 2020; 55:2848-2852. [PMID: 32729952 DOI: 10.1002/ppul.24995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 11/07/2022]
Abstract
Pulmonary physiologic assessments are critical for the care and study of pediatric respiratory disease. In 2019, there were numerous contributions to this topic in Pediatric Pulmonology.
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Affiliation(s)
- Eli Rhoads
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Brittany L Wall
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
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Ren CL, Gaston B. Building on the essential foundation of physiology. Pediatr Pulmonol 2020; 55:2492. [PMID: 32662943 DOI: 10.1002/ppul.24950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Benjamin Gaston
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Affiliation(s)
- Clement L Ren
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis
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Dylag AM, Kopin HG, O’Reilly MA, Wang H, Davis SD, Ren CL, Pryhuber GS. Early Neonatal Oxygen Exposure Predicts Pulmonary Morbidity and Functional Deficits at 1 Year. J Pediatr 2020; 223:20-28.e2. [PMID: 32711747 PMCID: PMC9337224 DOI: 10.1016/j.jpeds.2020.04.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/09/2020] [Accepted: 04/14/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the predictive value of cumulative oxygen exposure thresholds over the first 2 postnatal weeks, linking them to bronchopulmonary dysplasia (BPD) and 1-year pulmonary morbidity and lung function in extremely low gestational age newborns. STUDY DESIGN Infants (N = 704) enrolled in the Prematurity and Respiratory Outcomes Program, a multicenter prospective cohort study, that survived to discharge were followed through their neonatal intensive care unit hospitalization to 1-year corrected age. Cumulative oxygen exposure (OxygenAUC14) thresholds were derived from univariate models of BPD, stratifying infants into high-, intermediate-, and low-oxygen exposure groups. These groups were then used in multivariate logistic regressions to prospectively predict post-prematurity respiratory disease (PRD), respiratory morbidity score (RMS) in the entire cohort, and pulmonary function z scores (N = 108 subset of infants) at 1-year corrected age. RESULTS Over the first 14 postnatal days, infants exposed to high oxygen averaged ≥33.1% oxygen, infants exposed to intermediate oxygen averaged 29.1%-33.1%, and infants exposed to low oxygen were below both cutoffs. In multivariate models, infants exposed to high oxygen showed increased PRD and RMS, whereas infants exposed to intermediate oxygen demonstrated increased moderate/severe RMS. Infants in the high/intermediate groups had decreased forced expiratory volume at 0.5 seconds/forced vital capacity ratio. CONCLUSIONS OxygenAUC14 establishes 3 thresholds of oxygen exposure that risk stratify infants early in their neonatal course, thereby predicting short-term (BPD) and 1-year (PRD, RMS) respiratory morbidity. Infants with greater OxygenAUC14 have altered pulmonary function tests at 1 year of age, indicating early evidence of obstructive lung disease and flow limitation, which may predispose extremely low gestational age newborns to increased long-term pulmonary morbidity. TRIAL REGISTRATION ClinicalTrials.gov: NCT01435187.
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Affiliation(s)
- Andrew M. Dylag
- Division of Neonatology, Department of Pediatrics, University of Rochester, Rochester, NY
| | - Hannah G. Kopin
- School of Medicine, School of Public Health Sciences, University of Rochester, Rochester, NY
| | - Michael A. O’Reilly
- Division of Neonatology, Department of Pediatrics, University of Rochester, Rochester, NY
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY
| | - Stephanie D. Davis
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Clement L. Ren
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Gloria S. Pryhuber
- Division of Neonatology, Department of Pediatrics, University of Rochester, Rochester, NY
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Nichols DP, Odem-Davis K, Cogen JD, Goss CH, Ren CL, Skalland M, Somayaji R, Heltshe SL. Pulmonary Outcomes Associated with Long-Term Azithromycin Therapy in Cystic Fibrosis. Am J Respir Crit Care Med 2020; 201:430-437. [PMID: 31661302 PMCID: PMC7049934 DOI: 10.1164/rccm.201906-1206oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: Chronic azithromycin is commonly used in cystic fibrosis based on short controlled clinical trials showing reductions in pulmonary exacerbations and improved FEV1. Long-term effects are unknown. Objectives: Examine pulmonary outcomes among chronic azithromycin users compared with matched controls over years of use and consider combined azithromycin use in cohorts using chronic inhaled tobramycin or aztreonam. Methods: This retrospective cohort study used the U.S. cystic fibrosis Foundation Patient Registry. Incident chronic azithromycin users were compared with matched controls by FEV1% predicted rate of decline and rates of intravenous antibiotic use to treat pulmonary exacerbations. Propensity score methods were utilized to address confounding by indication. Predefined sensitivity analyses based on lung function, Pseudomonas aeruginosa (PA) status, and follow-up time intervals were conducted. Measurements and Main Results: Across 3 years, FEV1% predicted per-year decline was nearly 40% less in those with PA using azithromycin compared with matched controls (slopes, −1.53 versus −2.41% predicted per yr; difference: 0.88; 95% confidence interval [CI], 0.30–1.47). This rate of decline did not differ based on azithromycin use in those without PA. Among all cohorts, use of intravenous antibiotics was no different between azithromycin users and controls. Users of inhaled tobramycin and azithromycin had FEV1% predicted per-year decline of −0.16 versus nonusers (95% CI, −0.44 to 0.13), whereas users of inhaled aztreonam lysine and azithromycin experienced a mean 0.49% predicted per year slower decline than matched controls (95% CI, −0.11 to 1.10). Conclusions: Results from this study provide additional rationale for chronic azithromycin use in PA-positive patients to reduce lung function decline.
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Affiliation(s)
- Dave P Nichols
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, and
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, and
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Department of Pediatrics, University of Washington, Seattle, Washington
| | - Clement L Ren
- Division of Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, Indiana; and
| | - Michelle Skalland
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
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Voynow JA, Fisher K, Sunday ME, Cotten CM, Hamvas A, Hendricks-Muñoz KD, Poindexter BB, Pryhuber GS, Ren CL, Ryan RM, Sharp JK, Young SP, Zhang H, Greenberg RG, Herring AH, Davis SD. Urine gastrin-releasing peptide in the first week correlates with bronchopulmonary dysplasia and post-prematurity respiratory disease. Pediatr Pulmonol 2020; 55:899-908. [PMID: 31995668 PMCID: PMC7071969 DOI: 10.1002/ppul.24665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 01/04/2020] [Indexed: 11/07/2022]
Abstract
RATIONALE Bronchopulmonary dysplasia (BPD) is associated with post-prematurity respiratory disease (PRD) in survivors of extreme preterm birth. Identifying early biomarkers that correlate with later development of BPD and PRD may provide insights for intervention. In a preterm baboon model, elevated gastrin-releasing peptide (GRP) is associated with BPD, and GRP inhibition mitigates BPD occurrence. OBJECTIVE We performed a prospective cohort study to investigate whether urine GRP levels obtained in the first postnatal week were associated with BPD, PRD, and other urinary biomarkers of oxidative stress. METHODS Extremely low gestational age infants (23-28 completed weeks) were enrolled in a US multicenter observational study, The Prematurity and Respiratory Outcomes Program (http://clinicaltrials.gov/ct2/show/NCT01435187). We used multivariable logistic regression to examine the association between urine GRP in the first postnatal week and multiple respiratory outcomes: BPD, defined as supplemental oxygen use at 36 + 0 weeks postmenstrual age, and post-PRD, defined by positive quarterly surveys for increased medical utilization over the first year (PRD score). RESULTS A total of 109 of 257 (42%) infants had BPD, and 120 of 217 (55%) had PRD. On adjusted analysis, GRP level more than 80 was associated with BPD (adjusted odds ratio [aOR], 1.83; 95% confidence interval [CI], 1.03-3.25) and positive PRD score (aOR, 2.46; 95% CI, 1.35-4.48). Urine GRP levels correlated with duration of NICU ventilatory and oxygen support and with biomarkers of oxidative stress: allantoin and 8-hydroxydeoxyguanosine. CONCLUSIONS Urine GRP in the first postnatal week was associated with concurrent urine biomarkers of oxidative stress and with later diagnoses of BPD and PRD.
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Affiliation(s)
- Judith A Voynow
- Division of Pediatric Pulmonology, Duke University, Durham, North Carolina.,Division of Pediatric Pulmonology, Children's Hospital of Richmond, Richmond, Virginia
| | - Kimberley Fisher
- Division of Neonatology, Duke University, Durham, North Carolina
| | - Mary E Sunday
- Department of Pathology, Duke University, Durham, North Carolina
| | - Charles M Cotten
- Division of Neonatology, Duke University, Durham, North Carolina
| | - Aaron Hamvas
- Division of Neonatology, Washington University, St Louis, Missouri.,Division of Neonatology, Northwestern University, Chicago, Illinois
| | | | - Brenda B Poindexter
- Division of Neonatology, Indiana University, Indianapolis, Indiana.,Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Clement L Ren
- Division of Pediatric Pulmonology, University of Rochester, Rochester, New York.,Division of Pediatric Pulmonology, Indiana University, Indianapolis, Indiana
| | - Rita M Ryan
- Division of Neonatology, State University of New York at Buffalo, Buffalo, New York.,Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jack K Sharp
- Division of Pediatric Pulmonology, Duke University, Durham, North Carolina.,Division of Pediatric Pulmonology, State University of New York at Buffalo, Buffalo, New York.,Division of Pediatric Pulmonology, Baylor College of Medicine, Houston, Texas
| | - Sarah P Young
- Division of Medical Genetics, Duke University, Durham, North Carolina
| | - Haoyue Zhang
- Division of Medical Genetics, Duke University, Durham, North Carolina
| | - Rachel G Greenberg
- Division of Neonatology and The Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Amy H Herring
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Indiana University, Indianapolis, Indiana.,Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
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Allen JL, Ren CL, McDonough J, Clem CC. "Reactance inversion" at low frequencies in a child undergoing treatment of a cystic fibrosis exacerbation. Pediatr Investig 2019; 3:257-260. [PMID: 32851332 PMCID: PMC7331296 DOI: 10.1002/ped4.12169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/18/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Impulse oscillometry (IOS) employs high frequency sinusoidal or impulse pressure and flow waveforms to interrogate the mechanical properties of the respiratory system. It has special applications to preschool and younger children who may have difficulty performing the repetitive forced expiratory maneuvers required for spirometry. CASE PRESENTATION We present a case illustrating improvements of respiratory system mechanics measured by IOS in a 6-year-old child with cystic fibrosis (CF) who demonstrated clinical and radiological improvement after a course of therapy with hospitalization and intravenous antibiotics, and initiation of a cystic fibrosis transmembrane regulator (CFTR) protein corrector/potentiator agent. We also report a new finding: observed lower than expected reactance at low compared to high frequencies ("reactance inversion"). CONCLUSION Reactance inversion may reflect parallel pathway inhomogeneities in resistance and elastance or intrabreath airway inertance changes in young children with CF. Further study is needed in children with airway obstruction due to asthma, cystic fibrosis, and chronic lung disease of infancy to demonstrate the prevalence of this finding and whether it is specific to a measurement device.
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Affiliation(s)
- Julian Lewis Allen
- Division of Pulmonary MedicineThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Clement L. Ren
- Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisINUSA
| | - Joseph McDonough
- Division of Pulmonary MedicineThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Charles C. Clem
- Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisINUSA
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Loughlin CE, Muston HN, Pena MA, Ren CL, Yilmaz O, Noah TL. Pediatric Pulmonology year in review 2018: Asthma, physiology/pulmonary function testing, and respiratory infections. Pediatr Pulmonol 2019; 54:1508-1515. [PMID: 31237426 DOI: 10.1002/ppul.24420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. In our "Year in Review" series, we summarize publications in our major topic areas from 2018, in the context of selected literature in these areas from other journals relevant to our discipline. This review covers selected articles on asthma, physiology/lung function testing, and respiratory infections.
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Affiliation(s)
- Ceila E Loughlin
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Heather N Muston
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael A Pena
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Clement L Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ozge Yilmaz
- Department of Pediatrics, Pediatric Allergy and Pulmonology, Celal Bayar University, Manisa, Turkey
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Ryan RM, Feng R, Bazacliu C, Ferkol TW, Ren CL, Mariani TJ, Poindexter BB, Wang F, Moore PE. Black Race Is Associated with a Lower Risk of Bronchopulmonary Dysplasia. J Pediatr 2019; 207:130-135.e2. [PMID: 30612812 PMCID: PMC6458591 DOI: 10.1016/j.jpeds.2018.11.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 10/22/2018] [Accepted: 11/09/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To use a large current prospective cohort of infants <29 weeks to compare bronchopulmonary dysplasia (BPD) rates in black and white infants. STUDY DESIGN The Prematurity and Respiratory Outcome Program (PROP) enrolled 835 infants born in 2011-2013 at <29 weeks of gestation; 728 black or white infants survived to 36 weeks postmenstrual age (PMA). Logistic regression was used to compare BPD outcomes (defined as supplemental oxygen requirement at 36 weeks PMA) between the races, adjusted for gestational age (GA), antenatal steroid use, intubation at birth, and surfactant use at birth. RESULTS Of 707 black or white infants with available BPD outcomes, BPD was lower in black infants (38% vs 45%), even though they were of significantly lower GA. At every GA, BPD was more common in white infants. The aOR for BPD was 0.60 (95% CI, 0.42-0.85; P = .004) for black infants compared with white infants after adjusting for GA. Despite the lower rate of BPD, black infants had a higher rate of first-year post-prematurity respiratory disease (black, 79%; white, 63%). CONCLUSIONS In this large cohort of recently born preterm infants at <29 weeks GA, compared with white infants, black infants had a lower risk of BPD but an increased risk of persistent respiratory morbidity.
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Affiliation(s)
- Rita M Ryan
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | | | - Thomas W Ferkol
- Department of Pediatrics, Washington University, St. Louis, MO
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Thomas J Mariani
- Department of Pediatrics, University of Rochester, Rochester, NY
| | - Brenda B Poindexter
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Fan Wang
- Department of Molecular Cardiology, Lerner Research Institute, The Cleveland Clinic, Cleveland, OH
| | - Paul E Moore
- Department of Pediatrics, Vanderbilt University, Nashville, TN
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Abstract
Cystic fibrosis (CF) is an autosomal recessive disease characterized by pancreatic insufficiency and chronic endobronchial airway infection. This latter feature results in progressive bronchiectasis and ultimately respiratory failure, which is the leading cause of death in patients with CF. Other complications include sinusitis, diabetes mellitus, bowel obstruction, hepatobiliary disease, hyponatremic dehydration, and infertility. Diagnosis of CF is confirmed by demonstration of elevated sweat chloride. Most cases of CF are identified through newborn screening (NBS). There are also infants with positive NBS but inconclusive diagnostic testing; a small proportion of these infants may go on to develop CF. CF is a lifelong, life-limiting disease, but an organized care center network with multidisciplinary approach, quality improvement initiatives, and research has led to markedly increased survival and development of adult CF care programs. In the past few years, medications that directly target the underlying CF defect have been developed, which should result in even greater survival benefits. [Pediatr Ann. 2019;48(4):e154-e161.].
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Yu Y, Esther CR, Ren CL, Loughlin C. Persistent Wheeze in Infants: A Guide for General Pediatricians. Pediatr Ann 2019; 48:e110-e114. [PMID: 30874818 DOI: 10.3928/19382359-20190222-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Infants with persistent wheeze is a common diagnostic challenge for the general pediatrician because of the broad differential diagnoses. The initial diagnostic approach should include a comprehensive history, physical examination, and chest radiography. Additional testing may be warranted. Involvement of a pediatric pulmonary subspecialist may also be indicated. [Pediatr Ann. 2019;48(3):e110-e114.].
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Ren CL, Feng R, Davis SD, Eichenwald E, Jobe A, Moore PE, Panitch HB, Sharp JK, Kisling J, Clem C. Tidal Breathing Measurements at Discharge and Clinical Outcomes in Extremely Low Gestational Age Neonates. Ann Am Thorac Soc 2018; 15:1311-1319. [PMID: 30088802 PMCID: PMC6322016 DOI: 10.1513/annalsats.201802-112oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/07/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The relationship between respiratory function at hospital discharge and the severity of later respiratory disease in extremely low gestational age neonates is not well defined. OBJECTIVES To test the hypothesis that tidal breathing measurements near the time of hospital discharge differ between extremely premature infants with bronchopulmonary dysplasia (BPD) or respiratory disease in the first year of life and those without these conditions. METHODS Study subjects were part of the PROP (Prematurity and Respiratory Outcomes Program) study, a longitudinal cohort study of infants born at less than 29 gestational weeks followed from birth to 1 year of age. Respiratory inductance plethysmography was used for tidal breathing measurements before and after inhaled albuterol 1 week before anticipated hospital discharge. Infants were breathing spontaneously and were receiving less than or equal to 1 L/min nasal cannula flow at 21% to 100% fraction of inspired oxygen. A survey of respiratory morbidity was administered to caregivers at 3, 6, 9, and 12 months corrected age to assess for respiratory disease. We compared tidal breathing measurements in infants with and without BPD (oxygen requirement at 36 wk) and with and without respiratory disease in the first year of life. Measurements were also performed in a comparison cohort of term infants. RESULTS A total of 765 infants survived to 36 weeks postmenstrual age, with research-quality tidal breathing data in 452 out of 564 tested (80.1%). Among these 452 infants, the rate of postdischarge respiratory disease was 65.7%. Compared with a group of 18 term infants, PROP infants had abnormal tidal breathing patterns. However, there were no clinically significant differences in tidal breathing measurements in PROP infants who had BPD or who had respiratory disease in the first year of life compared with those without these diagnoses. Bronchodilator response was not significantly associated with respiratory disease in the first year of life. CONCLUSIONS Extremely premature infants receiving less than 1 L/min nasal cannula support at 21% to 100% fraction of inspired oxygen have tidal breathing measurements that differ from term infants, but these measurements do not differentiate those preterm infants who have BPD or will have respiratory disease in the first year of life from those who do not. Clinical trial registered with www.clinicaltrials.gov (NCT01435187).
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Affiliation(s)
- Clement L. Ren
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - Rui Feng
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stephanie D. Davis
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - Eric Eichenwald
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Jobe
- Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul E. Moore
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Jeff Kisling
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - Charles Clem
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
| | - on behalf of the Prematurity and Respiratory Outcomes Program*
- Riley Hospital for Children and Indiana University, Indianapolis, Indiana
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Children’s Hospital Medical Center, Cincinnati, Ohio
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Texas Children’s Hospital, Houston, Texas; and
- Washington University, St. Louis, Missouri
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Ren CL, Muston HN, Yilmaz O, Noah TL. Pediatric Pulmonology year in review 2017: Part 3. Pediatr Pulmonol 2018; 53:1152-1158. [PMID: 29806188 DOI: 10.1002/ppul.24052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/24/2018] [Indexed: 11/10/2022]
Abstract
Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. We here summarize the past year's publications in our major topic areas, in the context of selected literature in these areas from other journals relevant to our discipline. This review (Part 3 of a 5-part series) covers selected articles on asthma, physiology/lung function testing, and respiratory infections.
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Affiliation(s)
- Clement L Ren
- Riley Children's Hospital, Indiana University School of Medicine, Department of Pediatrics, Indianapolis, Indiana
| | - Heather N Muston
- Riley Children's Hospital, Indiana University School of Medicine, Department of Pediatrics, Indianapolis, Indiana
| | - Ozge Yilmaz
- Pediatric Allergy and Pulmonology, Celal Bayar University Department of Pediatrics, Manisa, Turkey
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Chen YX, Sun X, Shi LY, Wang NT, Peng X, Wang N, Ren CL, Shan XZ. [Isolated vertigo as the first symptom of posterior circulation infarction:reporot of 11 cases]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2018; 32:547-550. [PMID: 29798090 DOI: 10.13201/j.issn.1001-1781.2018.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Indexed: 06/08/2023]
Abstract
Objective:To analyze the clinical characteristics of patients with cerebellar and brainstem infarction who initially presented with isolated vertigo to avoid misdiagnosing of this disease.Method:Eleven patients with cerebellar and brainstem infarction who initially presented with isolated vertigo treated in our clinic between January 2014 and September 2017 were reviewed and the clinical characteristics and imaging presentation of the patients were evaluated.Result:Vertigo as the first attack was in 5 cases, recurrent attacks was in 6 cases,10 cases were with vascular risk factors except for 1 case, initially diagnosed as vestibular neuritis was 4 cases, Meniere's disease was 1 case, posterior circulartion ischemia was 1 case,and unknown causes was 5 cases; delayed neurological symptoms and signs occurring was 4 cases, but not in other cases; finally determined by brain MRI as acute cerebellar infarction was 5 cases, brainstem infarction was 5 cases, and concurrent cerebellar and brainstem infarction was 1 case. All patients had good prognosis.Conclusion:Isolated vertigo due to posterior circulation infarction is easy to be misdiagnosed as peripheral vertigo.Patients presenting with isolated vertigo, when with vascular risk factors, should receive MRI and DWI examinations. Properly diagnosis and treatment may lead a good prognosis.
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Affiliation(s)
- Y X Chen
- Department of Otorhinolaryngology, General Hospital of Chinese People's Armed Police Forces,Beijing,100039,China
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