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McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Adjunctive Systemic Corticosteroids for Pulmonary Exacerbations of Cystic Fibrosis. Ann Am Thorac Soc 2024; 21:716-726. [PMID: 38096105 DOI: 10.1513/annalsats.202308-673oc] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
Rationale: Pulmonary exacerbations (PEx) remain the most common cause of morbidity, recurrent hospitalization, and diminished survival in people with cystic fibrosis (PWCF) and are characterized by excess inflammation. Corticosteroids are potent, widely available antiinflammatory drugs. However, corticosteroid efficacy data from randomized controlled trials in PWCF are limited. Objectives: To determine whether adjunctive systemic corticosteroid therapy is associated with improved outcomes in acute CF PEx. Methods: We performed a secondary analysis of Standardized Treatment of Pulmonary Exacerbations 2 (STOP2), a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx, that included the use of corticosteroids as a stratification criterion in its randomization protocol. Corticosteroid treatment effects were determined after propensity score matching for covariates including age, sex, baseline forced expiratory volume in 1 second (FEV1), genotype, and randomization arm. The primary outcome measure was the change in percentage predicted FEV1 (ppFEV1). Symptoms, time to next PEx, and the incidence of adverse events (AEs) and serious adverse events (SAEs) were assessed as secondary endpoints. Phenotypic factors associated with the clinical decision to prescribe steroids were also investigated. Results: Corticosteroids were prescribed for 168 of 982 PEx events in STOP2 (17%). Steroid prescription was associated with decreased baseline ppFEV1, increased age, and female sex. Cotreatment with corticosteroids was independent of treatment arm allocation and did not result in greater mean ppFEV1 response, longer median time to next PEx, or more substantial symptomatic improvement compared with propensity-matched PWCF receiving antibiotics alone. AEs were not increased in corticosteroid-treated PWCF. The total number of SAEs-but not the number of corticosteroid-related or PEx-related SAEs-was higher among patients receiving corticosteroids. Conclusions: Empiric, physician-directed treatment with systemic corticosteroids, although common, is not associated with improved clinical outcomes in PWCF receiving antibiotics for PEx. Clinical trial registered with www.clinicaltrials.gov (NCT02781610).
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Affiliation(s)
- Oliver J McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Medicine and
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
| | - Patrick A Flume
- Department of Pediatrics and
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington
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Thornton CS, Caverly LJ, Kalikin LM, Carmody LA, McClellan S, LeBar W, Sanders DB, West NE, Goss CH, Flume PA, Heltshe SL, VanDevanter DR, LiPuma JJ. Prevalence and Clinical Impact of Respiratory Viral Infections from the STOP2 Study of Cystic Fibrosis Pulmonary Exacerbations. Ann Am Thorac Soc 2024; 21:595-603. [PMID: 37963297 PMCID: PMC10995546 DOI: 10.1513/annalsats.202306-576oc] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/14/2023] [Indexed: 11/16/2023] Open
Abstract
Rationale: Rates of viral respiratory infection (VRI) are similar in people with cystic fibrosis (CF) and the general population; however, the associations between VRI and CF pulmonary exacerbations (PEx) require further elucidation.Objectives: To determine VRI prevalence during CF PEx and evaluate associations between VRI, clinical presentation, and treatment response.Methods: The STOP2 (Standardized Treatment of Pulmonary Exacerbations II) study was a multicenter randomized trial to evaluate different durations of intravenous antibiotic therapy for PEx. In this ancillary study, participant sputum samples from up to three study visits were tested for respiratory viruses using multiplex polymerase chain reactions. Baselines and treatment-associated changes in mean lung function (percent predicted forced expiratory volume in 1 s), respiratory symptoms (Chronic Respiratory Infection Symptom Score), weight, and C-reactive protein were compared as a function of virus detection. Odds of PEx retreatment within 30 days and future PEx hazard were modeled by logistic and Cox proportional hazards regression, respectively.Results: A total of 1,254 sputum samples from 621 study participants were analyzed. One or more respiratory viruses were detected in sputum samples from 245 participants (39.5%). Virus-positive participants were more likely to be receiving CF transmembrane conductance regulator modulator therapy (45% vs. 34%) and/or chronic azithromycin therapy (54% vs. 44%) and more likely to have received treatment for nontuberculous Mycobacterium infection in the preceding 2 years (7% vs. 3%). At study visit 1, virus-positive participants were more symptomatic (mean Chronic Respiratory Infection Symptom Score, 53.8 vs. 51.1), had evidence of greater systemic inflammation (log10 C-reactive protein concentration, 1.32 log10 mg/L vs. 1.23 log10 mg/L), and had a greater drop in percent predicted forced expiratory volume in 1 second from the prior 6-month baseline (5.8 vs. 3.6). Virus positivity was associated with reduced risk of future PEx (hazard ratio, 0.82; 95% confidence interval, 0.69-0.99; P = 0.034) and longer median time to next PEx (255 d vs. 172 d; P = 0.021) compared with virus negativity.Conclusions: More than one-third of STOP2 participants treated for a PEx had a positive test result for a respiratory virus with more symptomatic initial presentation compared with virus-negative participants, but favorable long-term outcomes. More refined phenotyping of PEx, taking VRIs into account, may aid in optimizing personalized management of PEx.Clinical trial registered with www.clinicaltrials.gov (NCT02781610).
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Affiliation(s)
| | | | | | | | - Scott McClellan
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - William LeBar
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Don B. Sanders
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Natalie E. West
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher H. Goss
- Department of Medicine and
- Department of Pediatrics, University of Washington, Seattle, Washington
- CF Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - Patrick A. Flume
- Department of Medicine and
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina; and
| | - Sonya L. Heltshe
- Department of Pediatrics, University of Washington, Seattle, Washington
- CF Therapeutics Development Network Coordinating Center, Seattle Children’s Research Institute, Seattle, Washington
| | - Donald R. VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Burgel PR, Southern KW, Addy C, Battezzati A, Berry C, Bouchara JP, Brokaar E, Brown W, Azevedo P, Durieu I, Ekkelenkamp M, Finlayson F, Forton J, Gardecki J, Hodkova P, Hong G, Lowdon J, Madge S, Martin C, McKone E, Munck A, Ooi CY, Perrem L, Piper A, Prayle A, Ratjen F, Rosenfeld M, Sanders DB, Schwarz C, Taccetti G, Wainwright C, West NE, Wilschanski M, Bevan A, Castellani C, Drevinek P, Gartner S, Gramegna A, Lammertyn E, Landau EEC, Plant BJ, Smyth AR, van Koningsbruggen-Rietschel S, Middleton PG. Standards for the care of people with cystic fibrosis (CF); recognising and addressing CF health issues. J Cyst Fibros 2024:S1569-1993(24)00005-5. [PMID: 38233247 DOI: 10.1016/j.jcf.2024.01.005] [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] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
This is the third in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on recognising and addressing CF health issues. The guidance was produced with wide stakeholder engagement, including people from the CF community, using an evidence-based framework. Authors contributed sections, and summary statements which were reviewed by a Delphi consultation. Monitoring and treating airway infection, inflammation and pulmonary exacerbations remains important, despite the widespread availability of CFTR modulators and their accompanying health improvements. Extrapulmonary CF-specific health issues persist, such as diabetes, liver disease, bone disease, stones and other renal issues, and intestinal obstruction. These health issues require multidisciplinary care with input from the relevant specialists. Cancer is more common in people with CF compared to the general population, and requires regular screening. The CF life journey requires mental and emotional adaptation to psychosocial and physical challenges, with support from the CF team and the CF psychologist. This is particularly important when life gets challenging, with disease progression requiring increased treatments, breathing support and potentially transplantation. Planning for end of life remains a necessary aspect of care and should be discussed openly, honestly, with sensitivity and compassion for the person with CF and their family. CF teams should proactively recognise and address CF-specific health issues, and support mental and emotional wellbeing while accompanying people with CF and their families on their life journey.
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Affiliation(s)
- Pierre-Régis Burgel
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Institut Cochin, Inserm U1016, Université Paris-Cité, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, Institute in the Park, Alder Hey Children's Hospital, University of Liverpool, Eaton Road, Liverpool L12 2AP, UK.
| | - Charlotte Addy
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alberto Battezzati
- Clinical Nutrition Unit, Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, and ICANS-DIS, Department of Food Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Claire Berry
- Department of Nutrition and Dietetics, Alder Hey Children's NHS Trust, Liverpool, UK
| | - Jean-Philippe Bouchara
- University of Brest, Fungal Respiratory Infections Research Unit, SFR ICAT, University of Angers, Angers, France
| | - Edwin Brokaar
- Department of Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands
| | - Whitney Brown
- Cystic Fibrosis Foundation, Inova Fairfax Hospital, Bethesda, Maryland, USA, Falls Church, VA, USA
| | - Pilar Azevedo
- Cystic Fibrosis Reference Centre-Centro, Hospitalar Universitário Lisboa Norte, Portugal
| | - Isabelle Durieu
- Cystic Fibrosis Reference Center (Constitutif), Service de médecine interne et de pathologie vasculaire, Hospices Civils de Lyon, Hôpital Lyon Sud, RESearch on HealthcAre PErformance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France; ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Miquel Ekkelenkamp
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Felicity Finlayson
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | | | - Johanna Gardecki
- CF Centre at Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pavla Hodkova
- CF Center at University Hospital Motol, Prague, Czech Republic
| | - Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jacqueline Lowdon
- Clinical Specialist Paediatric Cystic Fibrosis Dietitian, Leeds Children's Hospital, UK
| | - Su Madge
- Royal Brompton Hospital, Part of Guys and StThomas's Hospital, London, UK
| | - Clémence Martin
- Institut Cochin, Inserm U1016, Université Paris-Cité and National Reference Center for Cystic Fibrosis, Hôpital Cochin AP-HP, ERN-Lung CF Network, Paris 75014, France
| | - Edward McKone
- St.Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Anne Munck
- Hospital Necker Enfants-Malades, AP-HP, CF Centre, Université Paris Descartes, Paris, France
| | - Chee Y Ooi
- School of Clinical Medicine, Discipline of Paediatrics and Child Health, Faculty of Medicine & Health, Department of Gastroenterology, Sydney Children's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Perrem
- Department of Respiratory Medicine, Children's Health Ireland, Dublin, Ireland
| | - Amanda Piper
- Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Andrew Prayle
- Child Health, Lifespan and Population Health & Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics and Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carsten Schwarz
- Division Cystic Fibrosis, CF Center, Clinic Westbrandenburg, HMU-Health and Medical University, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Italy
| | | | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, CF Center, Hadassah Medical Center, Jerusalem, Israel
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, Genova 16147, Italy
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Silvia Gartner
- Cystic Fibrosis Unit and Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Respiratory Unit and Adult Cystic Fibrosis Center, Università degli Studi di Milano, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elise Lammertyn
- Cystic Fibrosis Europe, Brussels, Belgium and the Belgian CF Association, Brussels, Belgium
| | - Eddie Edwina C Landau
- The Graub CF Center, Pulmonary Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Barry J Plant
- Cork Centre for Cystic Fibrosis (3CF), Cork University Hospital, University College Cork, Ireland
| | - Alan R Smyth
- School of Medicine, Dentistry and Biomedical Sciences, Belfast and NIHR Nottingham Biomedical Research Centre, Queens University Belfast, Nottingham, UK
| | | | - Peter G Middleton
- Westmead Clinical School, Department Respiratory & Sleep Medicine, Westmead Hospital, University of Sydney and CITRICA, Westmead, Australia
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Sanders DB, Bartz TM, Zemanick ET, Hoppe JE, Hinckley Stukovsky KD, Cogen JD, Bendy L, McNamara S, Enright E, Kime NA, Kronmal RA, Edwards TC, Morgan WJ, Rosenfeld M. A Pilot Randomized Clinical Trial of Pediatric Cystic Fibrosis Pulmonary Exacerbations Treatment Strategies. Ann Am Thorac Soc 2023; 20:1769-1776. [PMID: 37683122 DOI: 10.1513/annalsats.202303-245oc] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 09/08/2023] [Indexed: 09/10/2023] Open
Abstract
Rationale: Despite the high prevalence and clear morbidity of cystic fibrosis (CF) pulmonary exacerbations (PEx), there have been no published clinical trials of outpatient exacerbation management. Objectives: To assess the feasibility of a pediatric clinical trial in which treatment of mild PEx is assigned randomly to immediate oral antibiotics or tailored therapy (increased airway clearance alone with oral antibiotics added only for prespecified criteria). The outcome on which sample size was based was the proportion of tailored therapy participants who avoided oral antibiotics during the 28 days after randomization. Methods: In this randomized, open-label, pilot feasibility study at 10 U.S. sites, children 6-18 years of age with CF were enrolled at their well baseline visits and followed through their first randomized PEx. Results: One hundred twenty-one participants were enrolled, of whom 94 (78%) reported symptoms of PEx at least once; of these, 81 (86%) had at least one exacerbation that met randomization criteria, of whom 63 (78%) were randomized. Feasibility goals were met, including enrollment, early detection of symptoms of PEx, and ability to randomize. Among the 33 participants assigned to tailored therapy, 10 (30%) received oral antibiotics, while 29 of 30 (97%) assigned to immediate antibiotics received oral antibiotics. The avoidance of oral antibiotics in 70% (95% confidence interval, 54-85%) was statistically significantly different from our null hypothesis that <10% of participants assigned to the tailored therapy arm would avoid antibiotics. Conclusions: Our pilot study demonstrates that conducting a randomized trial of oral antibiotic treatment strategies for mild PEx in children with CF is feasible and that assignment to a tailored therapy arm may reduce antibiotic exposure. Clinical trial registered with www.clinicaltrials.gov (NCT04608019).
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Traci M Bartz
- Collaborative Health Studies Coordinating Center, Department of Biostatistics
| | - Edith T Zemanick
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Jordana E Hoppe
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | | | - Jonathan D Cogen
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Lisa Bendy
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Sharon McNamara
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Erika Enright
- Collaborative Health Studies Coordinating Center, Department of Biostatistics
| | - Noah A Kime
- Collaborative Health Studies Coordinating Center, Department of Biostatistics
| | - Richard A Kronmal
- Collaborative Health Studies Coordinating Center, Department of Biostatistics
| | | | - Wayne J Morgan
- Department of Pediatrics, College of Medicine, University of Arizona, Tucson, Arizona
| | - Margaret Rosenfeld
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
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Kopp BT, Ross SE, Bojja D, Guglani L, Chandler JD, Tirouvanziam R, Thompson M, Slaven JE, Chmiel JF, Siracusa C, Sanders DB. Nasal airway inflammatory responses and pathogen detection in infants with cystic fibrosis. J Cyst Fibros 2023:S1569-1993(23)01670-3. [PMID: 37977937 DOI: 10.1016/j.jcf.2023.10.020] [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] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Detecting airway inflammation non-invasively in infants with cystic fibrosis (CF) is difficult. We hypothesized that markers of inflammation in CF [IL-1β, IL-6, IL-8, IL-10, IL-17A, neutrophil elastase (NE) and tumor necrosis factor (TNF-α)] could be measured in infants with CF from nasal fluid and would be elevated during viral infections or clinician-defined pulmonary exacerbations (PEx). METHODS We collected nasal fluid, nasal swabs, and hair samples from 34 infants with CF during monthly clinic visits, sick visits, and hospitalizations. Nasal fluid was isolated and analyzed for cytokines. Respiratory viral detection on nasal swabs was performed using the Luminex NxTAG® Respiratory Pathogen Panel. Hair samples were analyzed for nicotine concentration by reverse-phase high-performance liquid chromatography. We compared nasal cytokine concentrations between the presence and absence of detected respiratory viruses, PEx, and smoke exposure. RESULTS A total of 246 samples were analyzed. Compared to measurements in the absence of respiratory viruses, mean concentrations of IL-6, IL-8, TNF-α, and NE were significantly increased while IL-17A was significantly decreased in infants positive for respiratory viruses. IL-17A was significantly decreased and NE increased in those with a PEx. IL-8 and NE were significantly increased in infants with enteric pathogen positivity on airway cultures, but not P. aeruginosa or S. aureus. Compared to those with no smoke exposure, there were significantly higher levels of IL-6, IL-10, and NE in infants with detectable levels of nicotine. CONCLUSIONS Noninvasive collection of nasal fluid may identify inflammation in infants with CF during changing clinical or environmental exposures.
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Affiliation(s)
- Benjamin T Kopp
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sydney E Ross
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dinesh Bojja
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Lokesh Guglani
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joshua D Chandler
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Rabindra Tirouvanziam
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Misty Thompson
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James E Slaven
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James F Chmiel
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher Siracusa
- Division of Pulmonary Medicine, Cincinnati Children's Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Don B Sanders
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA.
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Deschamp AR, Chen Y, Wang WF, Rasic M, Hatch J, Sanders DB, Ranganathan SC, Ferkol T, Perkins D, Finn P, Davis SD. The association between gut microbiome and growth in infants with cystic fibrosis. J Cyst Fibros 2023; 22:1010-1016. [PMID: 37598041 PMCID: PMC10840679 DOI: 10.1016/j.jcf.2023.08.001] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/24/2023] [Accepted: 08/02/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND In cystic fibrosis (CF), pathophysiologic changes in the gastrointestinal tract lead to malnutrition and altered gut microbiome. Microbiome alterations have been linked to linear growth, gut inflammation and respiratory manifestations. Elucidating these gut microbiome alterations may provide insight into future nutritional management in CF. METHODS Infants were followed for 12-months at four sites in the United States (US-CF) and Australia (AUS-CF). 16S rRNA gene sequencing was performed on longitudinal stool samples. Associations between microbial abundance and age, antibiotic prophylaxis, malnutrition, and breast feeding were evaluated using generalized linear mixed models. Taxonomic and predictive functional features were compared between groups. RESULTS Infants with CF (N = 78) were enrolled as part of a larger study. AUS-CF infants had higher mean weight-for-age z-scores than US-CF infants (p = 0.02). A subset of participants (CF N = 40, non-CF disease controls N = 10) provided stool samples for microbiome analysis. AUS-CF infants had lower stool alpha diversity compared to US-CF infants (p < 0.001). AUS-CF infants had higher relative abundance of stool Proteobacteria compared to US-CF infants which was associated with antibiotic prophylaxis (p < 0.001). Malnutrition (weight-for-age <10th percentile) was associated with depleted Lactococcus (p < 0.001). Antibiotic prophylaxis (p = 0.002) and malnutrition (p = 0.012) were linked with predicted decreased activity of metabolic pathways responsible for short chain fatty acid processing. CONCLUSIONS In infants with CF, gut microbiome composition and diversity differed between the two continents. Gut microbial diversity was not linked to growth. The relationship between malnutrition and antibiotic prophylaxis with reduced SCFA fermentation could have implications for gut health and function and warrants additional investigation.
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Affiliation(s)
- A R Deschamp
- Indiana University School of Medicine, Riley Children's Hospital, 340 10th Street, Indianapolis, IN 46202, United States of America.
| | - Y Chen
- University of Illinois Chicago, 1200 West Harrison Street, Chicago, Illinois 60607, United States of America
| | - W F Wang
- University of Illinois Chicago, 1200 West Harrison Street, Chicago, Illinois 60607, United States of America
| | - M Rasic
- University of Illinois Chicago, 1200 West Harrison Street, Chicago, Illinois 60607, United States of America
| | - J Hatch
- Indiana University School of Medicine, Riley Children's Hospital, 340 10th Street, Indianapolis, IN 46202, United States of America
| | - D B Sanders
- Indiana University School of Medicine, Riley Children's Hospital, 340 10th Street, Indianapolis, IN 46202, United States of America
| | - S C Ranganathan
- Royal Children's Hospital, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - T Ferkol
- Washington University, 660 S Euclid Ave, St. Louis, MO 63110, United States of America
| | - D Perkins
- University of Illinois Chicago, 1200 West Harrison Street, Chicago, Illinois 60607, United States of America
| | - P Finn
- University of Illinois Chicago, 1200 West Harrison Street, Chicago, Illinois 60607, United States of America
| | - S D Davis
- Indiana University School of Medicine, Riley Children's Hospital, 340 10th Street, Indianapolis, IN 46202, United States of America
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Gold LS, Hansen RN, Heltshe SL, Flume PA, Goss CH, West NE, Sanders DB, Kessler L. Characteristics associated with cystic fibrosis-related pulmonary exacerbation treatment location. J Cyst Fibros 2023:S1569-1993(23)00926-8. [PMID: 37805355 PMCID: PMC10995101 DOI: 10.1016/j.jcf.2023.10.004] [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: 03/01/2023] [Revised: 09/01/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023]
Abstract
Previous studies indicate that hospital rather than home treatment of pulmonary exacerbations (PEx) in people with cystic fibrosis (CF) can improve outcomes. We evaluated characteristics of adult participants from the Standardized Treatment of Pulmonary Exacerbations (STOP2) trial with two separate comparisons: (1) those who were treated initially in hospital (N = 768) to those treated initially at home (N = 214) and (2) those treated only in hospital (N = 328) to those who were treated only at home or both at home and in hospital (N = 654). Participants who had Medicaid insurance, were treated for shorter duration, and traveled longer to reach treatment centers were more likely to have been treated initially in the hospital. Having Medicaid insurance, being treated for a shorter duration, and being male were associated with being treated only in the hospital. This analysis suggests decisions about the location of treatment are based on pragmatic factors rather than on clinical characteristics.
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Affiliation(s)
- Laura S Gold
- Department of Radiology, University of Washington, O1-140-6 UW Tower, 4333 Brooklyn Ave NE, Box 359558, Seattle, WA 98195-9558, United States.
| | - Ryan N Hansen
- School of Pharmacy, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington, Seattle, WA, United States; Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Christopher H Goss
- Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, WA, United States
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8
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Heltshe SL, Russell R, VanDevanter DR, Sanders DB. Re-examining baseline lung function recovery following IV-treated pulmonary exacerbations. J Cyst Fibros 2023; 22:864-867. [PMID: 36803635 PMCID: PMC10427727 DOI: 10.1016/j.jcf.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 12/06/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023]
Abstract
CF registry pulmonary exacerbation (PEx) analyses have employed "before and after" spirometry recovery, where the best percent predicted forced expiratory volume in 1 s (ppFEV1) prior to PEx ("baseline") is compared to the best ppFEV1 <3 months post-PEx. This methodology lacks comparators and ascribes recovery failure to PEx. Herein, we describe 2014 CF Foundation Patient Registry PEx analyses including a comparator: recovery around nonPEx events, birthdays. 49.6% of 7357 individuals with PEx achieved baseline ppFEV1 recovery while 36.6% of 14,141 achieved baseline recovery after birthdays; individuals with both PEx and birthdays were more likely to recover baseline after PEx than after birthdays (47% versus 34%); mean ppFEV1 declines were 0.3 (SD=9.3) and 3.1 (9.3), respectively. Post-event measure number had more effect on baseline recovery than did real ppFEV1 loss in simulations, suggesting that PEx recovery analyses lacking comparators are prone to artifact and poorly describe PEx contributions to disease progression.
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Affiliation(s)
- Sonya L Heltshe
- University of Washington School of Medicine, 1920 Terry Ave, Suite 400, Seattle, WA 98101, United States; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States.
| | - Renee Russell
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Don B Sanders
- Indiana University School of Medicine, Indianapolis, IN, United States
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9
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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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10
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McElvaney OJ, Heltshe SL, Odem-Davis K, West NE, Sanders DB, Fogarty B, VanDevanter DR, Flume PA, Goss CH. Impact of lumacaftor/ivacaftor and tezacaftor/ivacaftor on treatment response in pulmonary exacerbations of F508del/F508del cystic fibrosis. J Cyst Fibros 2023; 22:875-879. [PMID: 37407341 PMCID: PMC10761587 DOI: 10.1016/j.jcf.2023.06.012] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) remain a major cause of morbidity and mortality in people with cystic fibrosis (PWCF). Although the combination cystic fibrosis transmembrane conductance regulator (CFTR) modulators lumacaftor/ivacaftor and tezacaftor/ivacaftor have been shown to reduce PEx frequency, their influence on clinical and biochemical responses to acute PEx treatment is unknown. METHODS We performed a secondary analysis of STOP2, a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx. Propensity score matching was used to compare outcomes in antibiotic-treated F508del/F508del PWCF receiving lumacaftor/ivacaftor or tezacaftor/ivacaftor with those observed in antibiotic-treated F508del/F508del controls not receiving CFTR modulator therapy. The primary outcome measure was the change in percent predicted FEV1 (ppFEV1) following completion of intravenous (IV) antibiotics, with post-antibiotic changes in symptoms, serum C-reactive protein (CRP) concentrations and weight included as secondary endpoints. RESULTS Among 982 PEx events in randomized PWCF, 480 were homozygous for F508del, of whom 289 were receiving lumacaftor/ivacaftor or tezacaftor/ivacaftor at initiation of antibiotic therapy. Modulator-treated F508del/F508del PWCF did not demonstrate greater improvements in ppFEV1, symptoms, serum CRP or weight following antibiotic treatment compared to modulator-naïve controls matched for age, sex, baseline ppFEV1, genotype, body mass index, initial CRP, initial symptoms, exacerbation history, diabetic status, randomization arm and concomitant medical therapy. CONCLUSION In the acute setting, CFTR modulator therapy with lumacaftor/ivacaftor or tezacaftor/ivacaftor does not convey additional clinical or biochemical advantage above standardized PEx treatment in F508del/F508del PWCF.
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Affiliation(s)
- Oliver J McElvaney
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States
| | - Sonya L Heltshe
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore MD, United States
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis IN, United States
| | - Barbra Fogarty
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH, United States
| | - Patrick A Flume
- Department of Pediatrics, Medical University of South Carolina, Charleston SC, United States; Department of Medicine, Medical University of South Carolina, Charleston SC, United States
| | - Christopher H Goss
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Medicine, University of Washington, Seattle WA, United States; Department of Pediatrics, University of Washington, Seattle WA, United States.
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11
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Sanders DB. Growth trajectories in young children with cystic fibrosis: Where are we going? J Cyst Fibros 2023; 22:370-371. [PMID: 37142524 DOI: 10.1016/j.jcf.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Don B Sanders
- Indiana University School of Medicine Indianapolis, United States.
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12
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Perrem L, Stanojevic S, Solomon M, Grasemann H, Sweezey N, Waters V, Sanders DB, Davis SD, Ratjen F. Evaluation of clinically relevant changes in the lung clearance index in children with cystic fibrosis and healthy controls. Thorax 2023; 78:362-367. [PMID: 35428702 DOI: 10.1136/thoraxjnl-2021-218347] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The limits of reproducibility of the lung clearance index (LCI) are higher in children with cystic fibrosis (CF) compared with healthy children, and it is currently unclear what defines a clinically meaningful change. METHODS In a prospective multisite observational study of children with CF and healthy controls (HCs), we measured LCI, FEV1% predicted and symptom scores at quarterly visits over 2 years. Two reviewers performed a detailed review of visits to evaluate the frequency that between visit LCI changes outside ±10%, ±15%, ±20% represented a clinically relevant signal. In the setting of acute respiratory symptoms, we used a generalised estimating equation model, with a logit link function to determine the ability of LCI worsening at different thresholds to predict failure of lung function recovery at follow-up. RESULTS Clinically relevant LCI changes outside ±10%, ±15% and ±20% were observed at 25.7%, 15.0% and 8.3% of CF visits (n=744), respectively. The proportions of LCI changes categorised as noise, reflecting biological variability, were comparable between CF and HC at the 10% (CF 9.9% vs HC 13.0%), 15% (CF 4.3% vs HC 3.1%) and 20% (CF 2.4% vs HC 1.0%) thresholds. Compared with symptomatic CF visits without a worsening in LCI, events with ≥10% LCI increase were more likely to fail to recover baseline LCI at follow-up. CONCLUSION The limits of reproducibility of the LCI in healthy children can be used to detect clinically relevant changes and thus inform clinical care in children with CF.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada .,Postgraduate Medical Education, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Valerie Waters
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Stephanie D Davis
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
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13
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Patel P, Yeley J, Brown C, Wesson M, Lesko BG, Slaven JE, Chmiel JF, Jain R, Sanders DB. Immunoreactive Trypsinogen in Infants Born to Women with Cystic Fibrosis Taking Elexacaftor–Tezacaftor–Ivacaftor. Int J Neonatal Screen 2023; 9:ijns9010010. [PMID: 36975847 PMCID: PMC10056483 DOI: 10.3390/ijns9010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023] Open
Abstract
Most people with cystic fibrosis (CF) are diagnosed following abnormal newborn screening (NBS), which begins with measurement of immunoreactive trypsinogen (IRT) values. A case report found low concentrations of IRT in an infant with CF exposed to the CF transmembrane conductance regulator (CFTR) modulator, elexacaftor–tezacaftor–ivacaftor (ETI), in utero. However, IRT values in infants born to mothers taking ETI have not been systematically assessed. We hypothesized that ETI-exposed infants have lower IRT values than newborns with CF, CFTR-related metabolic syndrome/CF screen positive, inconclusive diagnosis (CRMS/CFSPID), or CF carriers. IRT values were collected from infants born in Indiana between 1 January 2020, and 2 June 2022, with ≥1 CFTR mutation. IRT values were compared to infants born to mothers with CF taking ETI followed at our institution. Compared to infants identified with CF (n = 51), CRMS/CFSPID (n = 21), and CF carriers (n = 489), ETI-exposed infants (n = 19) had lower IRT values (p < 0.001). Infants with normal NBS results for CF had similar median (interquartile range) IRT values, 22.5 (16.8, 30.6) ng/mL, as ETI-exposed infants, 18.9 (15.2, 26.5). IRT values from ETI-exposed infants were lower than for infants with abnormal NBS for CF. We recommend that NBS programs consider performing CFTR variant analysis for all ETI-exposed infants.
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Affiliation(s)
- Payal Patel
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jana Yeley
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Cynthia Brown
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Melissa Wesson
- Department of Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Barbara G. Lesko
- Department of Pathology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James E. Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James F. Chmiel
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Raksha Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Don B. Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Correspondence:
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14
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Bauer SE, Rhoads E, Wall BL, Sanders DB. The Effects of Air Pollution in Pediatric Respiratory Disease. Am J Respir Crit Care Med 2023; 207:346-348. [PMID: 36154892 DOI: 10.1164/rccm.202107-1583rr] [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] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Sarah E Bauer
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana; and.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Eli Rhoads
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana; and.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Brittany L Wall
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana; and.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana; and.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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15
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Sanders DB, Deschamp AR, Hatch JE, Slaven JE, Gebregziabher N, Corput MKVD, Tiddens HAWM, Rosenow T, Storch GA, Hall GL, Stick SM, Ranganathan S, Ferkol TW, Davis SD. Association between early respiratory viral infections and structural lung disease in infants with cystic fibrosis. J Cyst Fibros 2022; 21:1020-1026. [PMID: 35523715 PMCID: PMC10564322 DOI: 10.1016/j.jcf.2022.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 01/18/2021] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Infants with cystic fibrosis (CF) develop structural lung disease early in life, and viral infections are associated with progressive lung disease. We hypothesized that the presence of respiratory viruses would be associated with structural lung disease on computed tomography (CT) of the chest in infants with CF. METHODS Infants with CF were enrolled before 4 months of age. Multiplex PCR assays were performed on nasal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent CT imaging at approximately 12 months of age. Associations between Perth-Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) CT scores and respiratory viruses and symptoms were assessed with Spearman correlation coefficients. RESULTS Sixty infants were included for analysis. Human rhinovirus was the most common virus detected, on 28% of tested nasal swabs and in 85% of participants. The median (IQR) extent of lung fields that was healthy based on PRAGMA-CF was 98.7 (0.8)%. There were no associations between PRAGMA-CF and age at first virus, or detection of any virus, including rhinovirus, respiratory syncytial virus, or parainfluenza. The extent of airway wall thickening was associated with ever having wheezed (ρ = 0.31, p = 0.02) and number of encounters with cough (ρ = 0.25, p = 0.0495). CONCLUSIONS Infants with CF had minimal structural lung disease. We did not find an association between respiratory viruses and CT abnormalities. Wheezing and frequency of cough were associated with early structural changes.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Ashley R Deschamp
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, USA
| | - Joseph E Hatch
- Department of Pediatrics, UNC Children's, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Netsanet Gebregziabher
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mariette Kemner-van de Corput
- Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medial Center Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia Children's Hospital, University Medial Center Rotterdam, Netherlands
| | - Harm A W M Tiddens
- Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medial Center Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia Children's Hospital, University Medial Center Rotterdam, Netherlands
| | - Tim Rosenow
- The Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Nedlands, Western Australia; Children's Lung Health, Wal-yan Respiratory Research Centre, Telethon Kids Institute and School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Gregory A Storch
- Department of Pediatrics, Washington University, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Graham L Hall
- Children's Lung Health, Wal-yan Respiratory Research Centre, Telethon Kids Institute and School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Stephen M Stick
- Department of Pediatrics, University of Western Australia, Telethon Kids Institute, Perth, Australia
| | - Sarath Ranganathan
- Department of Respiratory and Sleep Medicine, Royal Children's Hospital, Parkville, Australia; Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Thomas W Ferkol
- Department of Pediatrics, Washington University, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Stephanie D Davis
- Department of Pediatrics, UNC Children's, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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16
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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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17
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VanDevanter DR, West NE, Sanders DB, Skalland M, Goss CH, Flume PA, Heltshe SL. Antipseudomonal treatment decisions during CF exacerbation management. J Cyst Fibros 2022; 21:753-758. [PMID: 35466039 PMCID: PMC9509480 DOI: 10.1016/j.jcf.2022.04.006] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/01/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) pulmonary exacerbation (PEx) treatment guidelines suggest that Pseudomonas aeruginosa (Pa) airway infection be treated with two antipseudomonal agents. METHODS We retrospectively studied treatment responses for STOP2 PEx treatment trial (NCT02781610) participants with a history of Pa infection. Mean lung function and symptom changes from intravenous (IV) antimicrobial treatment start to Visit 2 (7 to 10 days later) were compared between those receiving one, two, and three+ antipseudomonal classes before Visit 2 by ANCOVA. Odds of PEx retreatment with IV antimicrobials within 30 days and future IV-treated PEx hazard were modeled by logistic and Cox proportional hazards regression, respectively. Sensitivity analyses limited to the most common one-, two-, and three-class regimens, to only IV/oral antipseudomonal treatments, and with more stringent Pa infection definitions were conducted. RESULTS Among 751 participants, 50 (6.7%) were treated with one antipseudomonal class before Visit 2, while 552 (73.5%) and 149 (19.8%) were treated with two and with three+ classes, respectively. Females and participants with a negative Pa culture in the prior month were more likely to be treated with a single class. The most common single, double, and triple class regimens were beta-lactam (BL; n = 42), BL/aminoglycoside (AG; n = 459), and BL/AG/fluoroquinolone (FQ; n = 73). No lung function or symptom response, odds of retreatment, or future PEx hazard differences were observed by number of antipseudomonal classes administered in primary or sensitivity analyses. CONCLUSIONS We were unable to identify additional benefit when multiple antipseudomonal classes are used to treat PEx in people with CF and Pa.
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Affiliation(s)
- D R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - N E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - D B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - M Skalland
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - C H Goss
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - P A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - S L Heltshe
- CF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States; Department of Pediatrics, University of Washington, Seattle, WA, United States
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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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19
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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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20
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Perrem L, Stanojevic S, Shaw M, Pornillos M, Guido J, Sanders DB, Solomon M, Grasemann H, Sweezey N, Waters V, Davis SD, Ratjen F. Comparative analysis of respiratory symptom scores to detect acute respiratory events in children with cystic fibrosis. J Cyst Fibros 2022; 22:296-305. [PMID: 35753986 DOI: 10.1016/j.jcf.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patient-reported outcomes (PROs) are important outcome measures in research and clinical practice. This study describes the longitudinal variability the Cystic Fibrosis Questionnaire-Revised (CFQ-R) Respiratory score and the Chronic Respiratory Infection Symptom Score (CRISS), as well as their ability to identify acute respiratory events in children with CF. METHODS In this prospective observational study, the parent-proxy (6 -13 years) and self-reported (6-18 years) CFQ-R Respiratory score and CRISS (6-18 years) were measured every 3 months over 2 years. The lung clearance index (LCI) and FEV1 were also measured. We compared the diagnostic accuracy of the PROs in distinguishing acute respiratory events and clinically stable visits, using the minimal important difference of each PRO as the threshold. RESULTS A total of 98 children with CF were included. On average, the symptom scores did not change between clinically stable visits. The positive predictive value (PPV) and negative predictive value (NPV) of a ≥8.5-point worsening in the parent-proxy CFQ-R score to identify acute respiratory events (n=119) (PPV 70.2% and NPV 87.0%) were higher than for the self-reported CFQ-R score (PPV 58.9% and NPV 72.2%). The PPV and NPV of an ≥11-point change in the CRISS for acute respiratory events (n=137) was 56.5% and 79.6%, respectively. The PPV and NPV of all PROs were increased when combined with the LCI and/or FEV1pp. CONCLUSION Symptoms scores differ in their ability to identify acute respiratory events in children with CF; PPV and NPV of all PROs were improved when combined with lung function outcomes.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Canada; Translational Medicine Program, SickKids Research Institute, Toronto, Canada; Royal College of Surgeons in Ireland, Dublin, Ireland; National Children's Research Centre, Children's Health Ireland, Dublin 5, Ireland.
| | - Sanja Stanojevic
- Institute of Health Policy Management and Evaluation, University of Toronto, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Michelle Shaw
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Maryjess Pornillos
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Julia Guido
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Canada; Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Canada; Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Valerie Waters
- Department of Paediatrics, University of Toronto, Canada; Translational Medicine Program, SickKids Research Institute, Toronto, Canada; Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Canada
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Canada; Translational Medicine Program, SickKids Research Institute, Toronto, Canada
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21
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Gold LS, Hansen RN, Patrick DL, Tabah A, Heltshe SL, Flume PA, Goss CH, West NE, Sanders DB, VanDevanter DR, Kessler L. Health care costs in a randomized trial of antimicrobial duration among cystic fibrosis patients with pulmonary exacerbations. J Cyst Fibros 2022; 21:594-599. [PMID: 35300932 DOI: 10.1016/j.jcf.2022.03.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of these analyses was to determine whether overall costs were reduced in cystic fibrosis (CF) patients experiencing pulmonary exacerbation (PEx) who received shorter versus longer durations of treatment. METHODS Among people with CF experiencing PEx, we calculated 30-day inpatient, outpatient, emergency room, and medication costs and summed these to derive total costs in 2020 USD. Using the Kaplan-Meier sample average (KMSA) method, we calculated adjusted costs and differences in costs within two pairs of randomized groups: early robust responders (ERR) randomized to receive treatment for 10 days (ERR-10 days) or 14 days (ERR-14 days), and non-early robust responders (NERR) randomized to receive treatment for 14 days (NERR-14 days) or 21 days (NERR-21 days). RESULTS Patients in the shorter treatment duration groups had shorter lengths of stay per hospitalization (mean ± standard deviation (SD) for ERR-10 days: 7.9 ± 3.0 days per hospitalization compared to 10.1 ± 4.2 days in ERR-14 days; for NERR-14 days: 8.7 ± 4.9 days per hospitalization compared to 9.6 ± 6.5 days in NERR-21 days). We found statistically significantly lower adjusted mean costs (95% confidence interval) among those who were randomized to receive shorter treatment durations (ERR-10 days: $60,800 ($59,150 - $62,430) vs $74,420 ($72,610 - $76,450) in ERR-14 days; NERR-14 days: $66,690 ($65,960-$67,400) versus $74,830 ($73,980-$75,650) in NERR-21 days). CONCLUSIONS Tied with earlier evidence that shorter treatment duration was not associated with worse clinical outcomes, our analyses indicate that treating with shorter antimicrobial durations can reduce costs without diminishing clinical outcomes.
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Affiliation(s)
- Laura S Gold
- Department of Radiology, University of Washington, O1-140-6 UW Tower, 4333 Brooklyn Ave NE, Box 359558, Seattle, WA 98195-9558, United States.
| | - Ryan N Hansen
- School of Pharmacy, University of Washington, Seattle, WA, United States; Department of Health Services, University of Washington, Seattle, WA, United States
| | - Donald L Patrick
- Department of Health Services, University of Washington, Seattle, WA, United States
| | - Ashley Tabah
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington, Seattle, WA, United States; Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, United States
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Christopher H Goss
- Department of Pediatrics, University of Washington, Seattle, WA, United States; Department of Medicine, University of Washington, Seattle, WA, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Don B Sanders
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Larry Kessler
- Department of Health Services, University of Washington, Seattle, WA, United States
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22
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Woollam M, Siegel A, Grocki P, Saunders JL, Sanders DB, Agarwal M, Davis MD. Preliminary method for profiling volatile organic compounds in breath that correlate with pulmonary function and other clinical traits of subjects diagnosed with cystic fibrosis: a pilot study. J Breath Res 2022; 16. [PMID: 35120338 DOI: 10.1088/1752-7163/ac522f] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/04/2022] [Indexed: 11/12/2022]
Abstract
Cystic fibrosis (CF) is characterized by chronic respiratory infections which progressively decrease lung function over time. Affected individuals experience episodes of intensified respiratory symptoms called pulmonary exacerbations (PEx) which accelerate pulmonary function decline and decrease survival. There is no standard classification for PEx, which results in treatments that are heterogeneous. Improving PEx classification and management is a significant priority for people with CF. Previous studies have shown volatile organic compounds (VOCs) in exhaled breath can be used as biomarkers because they are products of metabolic pathways dysregulated by different diseases. To provide insights on PEx classification and other clinical factors, exhaled breath was collected from subjects with CF, with some experiencing PEx and others at baseline. Exhaled breath was collected in Tedlar bags during tidal breathing for VOC analysis by solid phase microextraction coupled to gas chromatography-mass spectrometry. Statistical significance testing between quantitative and categorical clinical variables displayed percent-predicted forced expiratory volume in one second (FEV1pp) was decreased in subjects experiencing PEx. VOCs correlating with other clinical variables (body mass index, age, use of highly effective modulator therapies, and need for antibiotics) were also explored. VOCs correlating to potential confounding variables were removed and analyzed by regression for correlations with FEV1pp measurements. The VOC with the highest correlation with FEV1pp (3,7-dimethyldecane) also gave the lowest p-value when comparing subjects at baseline and during PEx. Receiver operator characteristic curves showed 3,7-dimethyldecane had a higher ability to classify PEx (area under the curve (AUC) = 0.91) relative to FEV1pp values at collection (AUC = 0.83). However, normalized ΔFEV1pp values had the highest capability to distinguish PEx (AUC = 0.93). These results show that exhaled VOCs may be a source of biomarkers for various clinical traits of CF, including PEx, that should be explored in larger sample cohorts and validation studies.
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Affiliation(s)
- Mark Woollam
- Chemistry and Chemical Biology, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Amanda Siegel
- Department of Chemistry and Chemical Biology, Indiana University Purdue University Indianapolis, 402 N Blackford St., LD326, Indianapolis, Indiana, 46202, UNITED STATES
| | - Paul Grocki
- Chemistry and Chemical Biology, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Jessica L Saunders
- Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, 46202, UNITED STATES
| | - Don B Sanders
- Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, 46202, UNITED STATES
| | - Mangilal Agarwal
- Mechanical and Energy Engineering, Indiana University - Purdue University at Indianapolis, 755 West Michigan Street 1140, Indianapolis, Indiana, 46202, UNITED STATES
| | - Michael D Davis
- Pulmonary Medicine, Herman B Wells Center for Pediatric Research, 1044 W. Walnut St., Indianapolis, Indiana, 46202, UNITED STATES
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23
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VanDevanter DR, Heltshe SL, Skalland M, West NE, Sanders DB, Goss CH, Flume PA. C-reactive protein (CRP) as a biomarker of pulmonary exacerbation presentation and treatment response. J Cyst Fibros 2021; 21:588-593. [PMID: 34933824 DOI: 10.1016/j.jcf.2021.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/19/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND C-reactive protein (CRP) has been proposed as a biomarker for pulmonary exacerbation (PEx) diagnosis and treatment response. CRP >75mg/L has been associated with increased risk of PEx treatment failure. We have analyzed CRP measures as biomarkers for clinical response during the STOP2 PEx study (NCT02781610). METHODS CRP measures were collected at antimicrobial treatment start (V1), seven to 10 days later (V2), and two weeks after treatment end (V3). V1 log10CRP concentrations and log10CRP change from V1 to V3 correlations with clinical responses (changes in lung function and symptom score) were assessed by least squares regression. Odds of intravenous (IV) antimicrobial retreatment within 30 days and future PEx hazard associated with V1 and V3 CRP concentrations and V1 CRP >75 mg/L were studied by adjusted logistic regression and proportional hazards modeling, respectively. RESULTS In all, 951 of 982 STOP2 subjects (92.7%) had CRP measures at V1. V1 log10CRP varied significantly by V1 lung function subgroup, symptom score quartile, and sex, but not by age subgroup. V1 log10CRP correlated moderately with log10CRP change at V3 (r2=0.255) but less so with lung function (r2=0.016) or symptom (r2=0.031) changes at V3. Higher V1 CRP was associated with greater response. CRP changes from V1 to V3 only weakly correlated with lung function (r2=0.061) and symptom (r2=0.066) changes. However, V3 log10CRP was associated with increased odds of retreatment (P = .0081) and future PEx hazard (P = .0114). DISCUSSION Despite consistent trends, log10CRP change was highly variable with only limited utility as a biomarker of PEx treatment response.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve Univ. School of Medicine, Cleveland OH, USA.
| | - S L Heltshe
- Univ. of Washington, Seattle WA, USA; CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - M Skalland
- CFF TDNCC, Seattle Children's Hospital, Seattle WA, USA
| | - N E West
- Johns Hopkins University, Baltimore MD, USA
| | - D B Sanders
- Indiana Univ. School of Medicine, Indianapolis IN, USA
| | - C H Goss
- Univ. of Washington, Seattle WA, USA
| | - P A Flume
- Medical Univ. of South Carolina, Charleston SC, USA
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24
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Virgin FW, Thurm C, Sanders DB, Freeman AJ, Cogen J, Gamel B, Sawicki G, Fink AK. Prevalence, variability, and predictors of sinus surgery in pediatric patients with cystic fibrosis. Pediatr Pulmonol 2021; 56:4029-4038. [PMID: 34648689 DOI: 10.1002/ppul.25669] [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: 04/26/2021] [Revised: 08/21/2021] [Accepted: 09/04/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Chronic rhinosinusitis is common among individuals with cystic fibrosis (CF) and has an impact on quality of life. Sinus surgery is a treatment option, but minimal literature exists regarding prevalence and indications. METHODS Using the linked CF Foundation Patient Registry (CFFPR) - Pediatric Health Information Systems (PHIS) database, we investigated variability in receipt of surgery, predictors of surgery, and time to first surgery. We included individuals less than 18 receiving care between 2006 and 2015 at a CF Foundation care program that is also a PHIS-participating-hospital. We used logistic regression to examine predictors of receipt of surgery and a Kaplan-Meier curve to examine time to first surgery among those born 2005-2007. RESULTS There were 11,545 children and adolescents and 2156 (18.7%) received at least one surgery. Variation in number of surgeries was observed across hospitals (median: 63 [IQR, 33-110]). There was an inconsistent pattern between receipt of surgery and markers of disease severity; those receiving surgery having increased odds of treatment use and pulmonary exacerbations and decreased odds of lower lung function and body mass index. Among the cohort of young children, 159 (14%) had at least one surgery with a median age at first surgery of 5.6 (IQR, 3.9-7.0). CONCLUSIONS The use of sinus surgery is frequent, but variable, among children and adolescents. Clinical factors are associated with receipt of surgery, but further understanding is needed on other factors that impact variability in use. Our study indicates the need for additional evaluation of the management of CF-related CRS and indications for surgery.
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Affiliation(s)
- Frank W Virgin
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Don B Sanders
- Pediatric Pulmonology, Indiana University, Indianapolis, Indiana, USA
| | - Alvin J Freeman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan Cogen
- Department of Pulmonary Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Breck Gamel
- Children's Medical Center, Dallas, Texas, USA
| | - Greg Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
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25
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Pittman JE, Khan U, Laguna TA, Heltshe S, Goss CH, Sanders DB. Rates of adverse and serious adverse events in children with cystic fibrosis. J Cyst Fibros 2021; 20:972-977. [PMID: 33745860 PMCID: PMC8448791 DOI: 10.1016/j.jcf.2021.02.013] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/29/2021] [Accepted: 02/26/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is an autosomal recessive disease characterized by chronic sinopulmonary symptoms and chronic gastrointestinal symptoms that begins in infancy. Children with CF are increasingly being included in clinical trials. In order to fully evaluate the impact of new therapies in future clinical trials, an understanding of baseline adverse event (AE) rates in children with CF is needed. To address this, we determined the rates of common AEs in pediatric patients with CF who participated in two clinical trials. METHODS We reviewed AEs for placebo recipients in the AZ0004 study and inhaled tobramycin recipients in the Early Pseudomonas Infection Control (EPIC) clinical trial. AEs were categorized based on Medical Dictionary for Regulatory Activities (MedDRA) coding classifications and pooled into common, batched AE descriptors. AE rates were estimated from negative binomial models according to age groups, severity of lung disease, and season. RESULTS A total of 433 children had 8,266 total AEs reported, or 18.1 (95% CI 17.0, 19.2) AEs per person per year. Respiratory AEs were the most commonly reported AEs, with a rate of 7.6 events per person-year. The total SAE rate was 0.33 per person per-year. Cough was the most commonly reported respiratory AE, with 61% of subjects reporting at least one episode of cough within 4 months. The rate ratio of any AE was higher in Spring, Fall, and Winter, compared with Summer. CONCLUSIONS AEs occur commonly in pediatric CF clinical trial participants. Season of enrollment could affect AE rates.
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Affiliation(s)
- Jessica E Pittman
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Theresa A Laguna
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sonya Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Don B Sanders
- Division of Pediatric Pulmonary, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States.
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Goss CH, Heltshe SL, West NE, Skalland M, Sanders DB, Jain R, Barto TL, Fogarty B, Marshall BC, VanDevanter DR, Flume PA. A Randomized Trial of Antimicrobial Duration for Cystic Fibrosis Pulmonary Exacerbation Treatment. Am J Respir Crit Care Med 2021; 204:1295-1305. [PMID: 34469706 DOI: 10.1164/rccm.202102-0461oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE People with cystic fibrosis (CF) experience acute worsening of respiratory symptoms and lung function known as pulmonary exacerbations. Treatment with intravenous antimicrobials is common; however, there is scant evidence to support a standard treatment duration. OBJECTIVE Test differing durations of intravenous antimicrobials for CF exacerbations. METHODS STOP2 was a multi-center, randomized, controlled, clinical trial in exacerbation among adults with CF. After 7-10-days of treatment, participants exhibiting pre-defined lung function and symptom improvements were randomized to 10- or 14-days total antimicrobial duration; all others were randomized to 14- or 21-days. MEASUREMENTS The primary outcome was percent predicted forced expiratory volume in 1 second (ppFEV1) change from treatment initiation to two weeks after cessation. Among early responders non-inferiority of 10-days to 14-days was tested; superiority of 21-days compared to 14-days was compared for the others. Symptoms, weight, and adverse events were secondary. RESULTS Among 982 randomized, 277 met improvement criteria and were randomized to 10- or 14-days treatment; the remaining 705 received 21- or 14-days. Mean ppFEV1 change was 12.8 and 13.4 for 10- and 14-days, respectively, a ‒0.65 difference [95%CI ‒3.3, 2.0], excluding the pre-defined noninferiority margin. The 21- and 14-day arms experienced 3.3 and 3.4 mean ppFEV1 changes, a difference of ‒0.10 [‒1.3, 1.1]. Secondary endpoints and sensitivity analyses were supportive. CONCLUSIONS Among CF adults with early treatment improvement during exacerbation, ppFEV1 after 10-days of intravenous antimicrobials is not inferior to 14-days. For those with less improvement after one week, 21-days is not superior to 14-days. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT02781610.
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Affiliation(s)
- Christopher H Goss
- University of Washington, 7284, Medicine, Seattle, Washington, United States.,University of Washington, 7284, Pediatrics, Seattle, Washington, United States.,Seattle Children's Research Institute, 145793, CF Therapeutics Development Network Coordinating Center, Seattle, Washington, United States;
| | - Sonya L Heltshe
- University of Washington, 7284, Pediatrics, Seattle, Washington, United States.,Seattle Children's Research Institute, 145793, CF Therapeutics Development Network Coordinating Center, Seattle, Washington, United States
| | - Natalie E West
- Johns Hopkins Medicine School of Medicine, 1500, Medicine, Baltimore, Maryland, United States
| | - Michelle Skalland
- Seattle Children's Research Institute, 145793, Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle, Washington, United States
| | - Don B Sanders
- Indiana University School of Medicine, 12250, Pediatrics, Indianapolis, Indiana, United States
| | - Raksha Jain
- UT Southwestern, 12334, Medicine, Dallas, Texas, United States
| | - Tara L Barto
- Baylor College of Medicine, 3989, Medicine, Houston, Texas, United States
| | - Barbra Fogarty
- Seattle Children's Research Institute, 145793, Seattle, Washington, United States
| | - Bruce C Marshall
- Cystic Fibrosis Foundation, Medical, Bethesda, Maryland, United States
| | - Donald R VanDevanter
- Case Western Reserve University School of Medicine, 12304, Pediatrics, Cleveland, Ohio, United States
| | - Patrick A Flume
- Medical University of South Carolina, 2345, Medicine, Charleston, South Carolina, United States.,Medical University of South Carolina, 2345, Pediatrics, Charleston, South Carolina, United States
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27
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Stanojevic S, Davis SD, Perrem L, Shaw M, Retsch-Bogart G, Davis M, Jensen R, Clem CC, Isaac SM, Guido J, Jara S, France L, McDonald N, Solomon M, Sweezey N, Grasemann H, Waters V, Sanders DB, Ratjen FA. Determinants of lung disease progression measured by lung clearance index in children with cystic fibrosis. Eur Respir J 2021; 58:13993003.03380-2020. [PMID: 33542049 DOI: 10.1183/13993003.03380-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023]
Abstract
The lung clearance index (LCI) measured by the multiple breath washout (MBW) test is sensitive to early lung disease in children with cystic fibrosis. While LCI worsens during the preschool years in cystic fibrosis, there is limited evidence to clarify whether this continues during the early school age years, and whether the trajectory of disease progression as measured by LCI is modifiable.A cohort of children (healthy and cystic fibrosis) previously studied for 12 months as preschoolers were followed during school age (5-10 years). LCI was measured every 3 months for a period of 24 months using the Exhalyzer D MBW nitrogen washout device. Linear mixed effects regression was used to model changes in LCI over time.A total of 582 MBW measurements in 48 healthy subjects and 845 measurements in 64 cystic fibrosis subjects were available. The majority of children with cystic fibrosis had elevated LCI at the first preschool and first school age visits (57.8% (37 out of 64)), whereas all but six had normal forced expiratory volume in 1 s (FEV1) values at the first school age visit. During school age years, the course of disease was stable (-0.02 units·year-1 (95% CI -0.14-0.10). LCI measured during preschool years, as well as the rate of LCI change during this time period, were important determinants of LCI and FEV1, at school age.Preschool LCI was a major determinant of school age LCI; these findings further support that the preschool years are critical for early intervention strategies.
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Affiliation(s)
- Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Stephanie D Davis
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Lucy Perrem
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - George Retsch-Bogart
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Miriam Davis
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Renee Jensen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Charles C Clem
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah M Isaac
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Julia Guido
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Jara
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lisa France
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nancy McDonald
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Valerie Waters
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - D B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Felix A Ratjen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
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28
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Perrem L, Stanojevic S, Shaw M, Jensen R, McDonald N, Isaac SM, Davis M, Clem C, Guido J, Jara S, France L, Solomon M, Grasemann H, Waters V, Sweezey N, Sanders DB, Davis SD, Ratjen F. Lung Clearance Index to Track Acute Respiratory Events in School-Age Children with Cystic Fibrosis. Am J Respir Crit Care Med 2021; 203:977-986. [PMID: 33030967 DOI: 10.1164/rccm.202006-2433oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: The lung clearance index (LCI) is responsive to acute respiratory events in preschool children with cystic fibrosis (CF), but its utility to identify and manage these events in school-age children with CF is not well defined.Objectives: To describe changes in LCI with acute respiratory events in school-age children with CF.Methods: In a multisite prospective observational study, the LCI and FEV1 were measured quarterly and during acute respiratory events. Linear regression was used to compare relative changes in LCI and FEV1% predicted at acute respiratory events. Logistic regression was used to compare the odds of a significant worsening in LCI and FEV1% predicted at acute respiratory events. Generalized estimating equation models were used to account for repeated events in the same subject.Measurements and Main Results: A total of 98 children with CF were followed for 2 years. There were 265 acute respiratory events. Relative to a stable baseline measure, LCI (+8.9%; 95% confidence interval, 6.5 to 11.3) and FEV1% predicted (-6.6%; 95% confidence interval, -8.3 to -5.0) worsened with acute respiratory events. A greater proportion of events had a worsening in LCI compared with a decline in FEV1% predicted (41.7% vs. 30.0%; P = 0.012); 53.9% of events were associated with worsening in LCI or FEV1. Neither LCI nor FEV1 recovered to baseline values at the next follow-up visit.Conclusions: In school-age children with CF, the LCI is a sensitive measure to assess lung function worsening with acute respiratory events and incomplete recovery at follow-up. In combination, the LCI and FEV1 capture a higher proportion of events with functional impairment.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada.,Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Sanja Stanojevic
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Renee Jensen
- Division of Respiratory Medicine and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Nancy McDonald
- Division of Respiratory Medicine and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sarah M Isaac
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Miriam Davis
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Charles Clem
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Julia Guido
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sylvia Jara
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Lisa France
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Melinda Solomon
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Valerie Waters
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Felix Ratjen
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
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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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Abstract
The first regulatory approval for a drug developed specifically for cystic fibrosis (CF) occurred in 1993, and since then, several other drugs have been approved. Median predicted survival in people with CF in the United States has increased from approximately 30 years to 44.4 years over that same period. Highly effective modulators of the cystic fibrosis transmembrane conductance regulator became available to approximately 90% of people with CF ages 12 years and older in the United States in 2019 and in Europe in 2020. These transformative therapies will surely reduce morbidity and further extend longevity. The drug development pipeline is filled with therapies that address most aspects of CF disease. As survival and CF therapies advance, and the complexity of CF care increases, the process of drug development has become more sophisticated. In addition, detecting meaningful changes in outcome measures has become more difficult as the health status of people with CF improves. Innovative approaches are required to continue to advance drug development in CF. This review provides a general overview of drug development from the preclinical phase through Phase IV. Special considerations with respect to CF are integrated into the discussion of each phase of drug development. As CF care evolves, drug development must continue to evolve as well, until a one-time cure is available to all people with CF.
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Affiliation(s)
- Don B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
| | - James F Chmiel
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at IU Health, Indianapolis, Indiana, USA
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31
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Hoppe JE, Hinds DM, Colborg A, Wagner BD, Morgan WJ, Rosenfeld M, Zemanick ET, Sanders DB. Oral antibiotic prescribing patterns for treatment of pulmonary exacerbations in two large pediatric CF centers. Pediatr Pulmonol 2020; 55:3400-3406. [PMID: 32970375 DOI: 10.1002/ppul.25092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 05/29/2020] [Revised: 08/22/2020] [Accepted: 09/07/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Oral antibiotics are frequently prescribed for outpatient pulmonary exacerbations (PEx) in children with cystic fibrosis (CF). This study aimed to characterize oral antibiotic use for PEx and treatment outcomes at two large US CF centers. METHODS Retrospective, descriptive study of oral antibiotic prescribing practices among children with CF ages 6-17 years over 1 year. The care setting for antibiotic initiation (clinic or phone encounter) was determined and outcomes were compared. RESULTS A total of 763 oral antibiotic courses were prescribed to 312 patients aged 6-17 years (77% of 403 eligible patients) with a median of two courses per year (range: 1-10). Fifty-eight percent of prescriptions were provided over the phone. Penicillin was the most commonly prescribed antibiotic class (36% of prescriptions) but differences in antibiotic class prescriptions were noted between the two centers. Hospitalizations occurred within 3 months following 19% of oral antibiotic courses. Forced expiratory volume in 1 s (FEV1 ) recovered to within 90% of prior baseline within 6 months in 87% of encounters; the mean (SD) % recovery was 99.6% (12.1%) of baseline. Outcomes did not differ between phone and clinic prescriptions. CONCLUSIONS Phone prescriptions, commonly excluded in studies of PEx, made up more than half of all oral antibiotic courses. Heterogeneity in prescribing patterns was observed between the two centers. Most patients had improvement in FEV1 returning to near their prior baseline, but hospitalizations occurred in one-fifth following oral antibiotic treatment. Efforts to optimize PEx treatment must consider care that occurs over the phone; this is particularly important as the use of telemedicine increases.
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Affiliation(s)
- Jordana E Hoppe
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Daniel M Hinds
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Adrianne Colborg
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine and Lurie Children's Hospital, Chicago, IL, USA
| | - Brandie D Wagner
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Wayne J Morgan
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pulmonary Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
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Dasenbrook EC, Fink AK, Schechter MS, Sanders DB, Millar SJ, Pasta DJ, Mayer-Hamblett N. Rapid lung function decline in adults with early-stage cystic fibrosis lung disease. J Cyst Fibros 2019; 19:527-533. [PMID: 31870629 DOI: 10.1016/j.jcf.2019.12.005] [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] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 12/02/2019] [Accepted: 12/07/2019] [Indexed: 11/26/2022]
Abstract
RATIONALE The prevalence of adults living with cystic fibrosis (CF) who have early-stage lung disease is increasing. OBJECTIVES Describe the prevalence and evaluate spirometric risk factors associated with the subgroup of patients with early-stage lung disease and FEV1 decline of ≥5% predicted/year. METHODS Retrospective cohort study of patients ≥18 years with FEV1% predicted ≥80% included in the US CF Foundation Patient Registry from 2010-2013. Regression models were developed to estimate FEV1 rate of decline. Multivariable logistic analysis was used to assess if spirometric risk factors were associated with FEV1 decline. MEASUREMENTS AND MAIN RESULTS 3,029 subjects were in the study cohort. Approximately 15% of the cohort had a substantial decline in lung function ≥5% predicted/year. In multivariable models adjusted for confounders, FEV1/FVC ratio <0.8 (Odds Ratio (OR) 1.63, 95% confidence interval (CI) 1.31 to 2.02) and history of FEV1% predicted variability (OR 2.35,95%CI 1.74 to 3.18) were associated with rapid lung function decline. CONCLUSIONS Even among adults with early-stage lung disease, approximately 15% are shown to progress and experience a large decline in lung function. This reinforces the concept that lung function in early-stage CF is not normal or mild. Rather, lung function decline may be delayed, but not avoided, in these individuals. Variability in FEV1% predicted and airway obstruction as measured by FEV1/FVC ratio may identify individuals at increased risk of decline. Adults with early-stage lung disease should be followed in clinic to monitor for onset of decline.
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Affiliation(s)
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, MD, United States
| | - Michael S Schechter
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
| | - Don B Sanders
- Indiana University School of Medicine, Indianapolis, IN, United States
| | | | - David J Pasta
- ICON Clinical Research, San Francisco, CA, United States
| | - Nicole Mayer-Hamblett
- University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States
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Sanders DB, Ostrenga JS, Rosenfeld M, Fink AK, Schechter MS, Sawicki GS, Flume PA, Morgan WJ. Predictors of pulmonary exacerbation treatment in cystic fibrosis. J Cyst Fibros 2019; 19:407-414. [PMID: 31257102 DOI: 10.1016/j.jcf.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 08/28/2018] [Revised: 03/19/2019] [Accepted: 06/14/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Most studies of pulmonary exacerbations (PEx) in cystic fibrosis (CF) focus on intravenous (IV)-treated PEx, though most PEx are treated with oral antibiotics. Our objectives were to describe predictors of antibiotic choice and outcomes for PEx initially identified in clinic. METHODS For each patient in the U.S. CF Foundation Patient Registry, we selected the first PEx recorded at a clinic visit in 2013-14 following a clinic visit without a PEx. We used multivariable logistic regression to determine associations between clinical characteristics and antibiotic treatment choice. We determined outcomes in the 90 days after the first PEx. RESULTS Among 14,265 patients with a PEx initially identified in clinic, 21.4% received no antibiotics, 61.5% received new oral and/or inhaled antibiotics, and 17.0% had IV antibiotics within 14 days. Compared to IV antibiotics, patients more likely to receive new oral and/or inhaled antibiotics: were male, <13 years old, had BMI >10th percentile or 18.5 kg/m2, >90 days between clinic visits, FEV1 > 70% predicted at the PEx, no prior-year IV-treated PEx, FEV1 decline <10% predicted, and private insurance. Following the PEx, 30.3% of patients had no clinical encounters within 90 days. Treatment with IV antibiotics within 90 days occurred for 23.7% treated without antibiotics, 22.8% of new oral and/or inhaled antibiotics, and 27.1% of IV antibiotics. CONCLUSION Most PEx identified in clinic are treated with new oral and/or inhaled antibiotics. Markers of disease severity are associated with antibiotic treatment choice. Many patients had no follow-up evaluation within 90 days of treatment.
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Affiliation(s)
- Don B Sanders
- Riley Hospital for Children, Indiana University, Indianapolis, IN, USA.
| | | | | | | | - Michael S Schechter
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
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34
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Sanders DB, Nichols DP. Developmental Milestones in Pediatric Research: A Case for Including Efficacy as Part of Interventional Trials in Infants with Cystic Fibrosis. Am J Respir Crit Care Med 2019; 199:1181-1182. [PMID: 30422678 PMCID: PMC6519866 DOI: 10.1164/rccm.201811-2103ed] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Don B Sanders
- 1 Section of Pediatric Pulmonology, Allergy, and Sleep Medicine Indiana University Indianapolis, Indiana and
| | - Dave P Nichols
- 2 Seattle Children's Hospital University of Washington Seattle, Washington
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35
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Hinds DM, Sanders DB, Slaven JE, Romero M, Davis SD, Stevens JC. Cystic fibrosis in El Salvador. Pediatr Pulmonol 2019; 54:369-371. [PMID: 30694614 DOI: 10.1002/ppul.24232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 07/31/2018] [Accepted: 12/07/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Daniel M Hinds
- Indiana University School of Medicine, Pediatrics, Indianapolis, Indiana
| | - Don B Sanders
- Riley Hospital for Children, Indiana University School of Medicine, Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mauricio Romero
- Benjamin Bloom National Children's Hospital, Pediatrics, San Salvador, El Salvador
| | - Stephanie D Davis
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Indianapolis, Indiana
| | - John C Stevens
- Riley Hospital for Children, Indiana University School of Medicine, Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indianapolis, Indiana
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36
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Kopp BT, Thompson R, Kim J, Konstan R, Diaz A, Smith B, Shrestha C, Rogers LK, Hayes D, Tumin D, Woodley FW, Ramilo O, Sanders DB, Groner JA, Mejias A. Secondhand smoke alters arachidonic acid metabolism and inflammation in infants and children with cystic fibrosis. Thorax 2019; 74:237-246. [PMID: 30661024 DOI: 10.1136/thoraxjnl-2018-211845] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 03/22/2018] [Revised: 11/09/2018] [Accepted: 12/24/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Mechanisms that facilitate early infection and inflammation in cystic fibrosis (CF) are unclear. We previously demonstrated that children with CF and parental-reported secondhand smoke exposure (SHSe) have increased susceptibility to bacterial infections. SHSe hinders arachidonic acid (AA) metabolites that mediate immune function in patients without CF, and may influence CF immune dysfunction. We aimed to define SHSe's impact on inflammation mediators and infection in children with CF. METHODS Seventy-seven children with CF <10 years of age (35 infants <1 year; 42 children 1-10 years) were enrolled and hair nicotine concentrations measured as an objective surrogate of SHSe. AA signalling by serum and macrophage lipidomics, inflammation using blood transcriptional profiles and in vitro macrophage responses to bacterial infection after SHSe were assessed. RESULTS Hair nicotine concentrations were elevated in 63% of patients. Of the AA metabolites measured by plasma lipidomics, prostaglandin D2 (PGD2) concentrations were decreased in children with CF exposed to SHSe, and associated with more frequent hospitalisations (p=0.007) and worsened weight z scores (p=0.008). Children with CF exposed to SHSe demonstrated decreased expression of the prostaglandin genes PTGES3 and PTGR2 and overexpression of inflammatory pathways. These findings were confirmed using an in vitro model, where SHSe was associated with a dose-dependent decrease in PGD2 and increased methicillin-resistant Staphylococcus aureus survival in human CF macrophages. CONCLUSIONS Infants and young children with CF and SHSe have altered AA metabolism and dysregulated inflammatory gene expression resulting in impaired bacterial clearance. Our findings identified potential therapeutic targets to halt early disease progression associated with SHSe in the young population with CF.
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Affiliation(s)
- Benjamin T Kopp
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rohan Thompson
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jeeho Kim
- Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Robert Konstan
- Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alejandro Diaz
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Bennett Smith
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Chandra Shrestha
- Center for Microbial Pathogenesis, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lynette K Rogers
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Don Hayes
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Frederick W Woodley
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Octavio Ramilo
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Don B Sanders
- Riley Children's Hospital, Indianapolis, Indiana, USA
| | - Judith A Groner
- Section of Ambulatory Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Asuncion Mejias
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
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Sanders DB, Li Z, Parker-McGill K, Farrell P, Brody AS. Quantitative chest computerized tomography and FEV 1 equally identify pulmonary exacerbation risk in children with cystic fibrosis. Pediatr Pulmonol 2018; 53:1369-1377. [PMID: 30160050 PMCID: PMC7059197 DOI: 10.1002/ppul.24144] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 08/14/2017] [Accepted: 07/16/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chest computerized tomography (CT) scores are associated with the frequency of future pulmonary exacerbations in people with cystic fibrosis (CF). However, cut-off values to identify children with mild lung disease with different risks for frequent future pulmonary exacerbations have not been identified. METHODS Chest CT scans were assessed using the Brody score for participants of the Pulmozyme Early Intervention Trial (PEIT) and Wisconsin Randomized Clinical Trial of CF Newborn Screening (WI RCT). We determined the area under the receiver operating characteristic (ROC) curve for Brody scores and forced expiratory volume in 1 s (FEV1 ) to compare with the frequency of pulmonary exacerbations up to 10 years later. RESULTS There were 60 participants in the PEIT with mean (SD) age 10.6 (1.7) years at the time of the CT and 81 participants in the WI RCT with mean age 11.5 (3.0) years. The Brody score cut-off that best identified children at-risk for ≥0.3 annual pulmonary exacerbations was 3.6 in the PEIT and 2.1 in the WI RCT. There were no statistical differences between ROC curves for the Brody CT score and FEV1 % predicted in either study (P ≥ 0.4). CONCLUSIONS CT score cut-off values that identify children with CF with mild lung disease at different risks for frequent pulmonary exacerbations over an extended follow up period are similar in separate cohorts. Brody scores and FEV1 % predicted have similar abilities to identify these children, suggesting that FEV1 % predicted alone may be adequate for predicting future frequency of pulmonary exacerbations.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin
| | | | - Philip Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alan S Brody
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Sanders DB, Zhang Z, Farrell PM, Lai HJ. Early life growth patterns persist for 12 years and impact pulmonary outcomes in cystic fibrosis. J Cyst Fibros 2018; 17:528-535. [PMID: 29396025 DOI: 10.1016/j.jcf.2018.01.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [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: 11/20/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND In children with cystic fibrosis (CF), recovery from growth faltering within 2 years of diagnosis (Responders) is associated with better growth and less lung disease at age 6 years. This study examined whether these benefits are sustained through 12 years of age. METHODS Longitudinal growth from 76 children with CF enrolled in the Wisconsin CF Neonatal Screening Project was examined and categorized into 5 groups: R12, R6, and R2, representing Responders who maintained growth improvement to age 12, 6, and 2 years, respectively, and I6 and N6, representing Non-responders whose growth did and did not improve during ages 2-6 years, respectively. Lung disease was evaluated by % predicted forced expiratory volume in one second (FEV1) and chest radiograph (CXR) scores. RESULTS Sixty-two percent were Responders. Within this group, 47% were R12, 28% were R6, and 25% were R2. Among Non-responders, 76% were N6. CF children with meconium ileus (MI) had worse lung function and CXR scores compared to other CF children. Among 53 children with pancreatic insufficiency without MI, R12 had significantly better FEV1 (97-99% predicted) and CXR scores during ages 6-12 years than N6 (89-93% predicted). Both R6 and R2 experienced a decline in FEV1 by ages 10-12 years. CONCLUSIONS Early growth recovery in CF is critical, as malnutrition during infancy tends to persist and catch-up growth after age 2 years is difficult. The longer adequate growth was maintained after early growth recovery, the better the pulmonary outcomes at age 12 years.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, 705 Riley Hospital Dr, Suite 4270, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - Zhumin Zhang
- Department of Nutritional Sciences, 1415 Linden Dr, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53706, USA
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - HuiChuan J Lai
- Department of Nutritional Sciences, 1415 Linden Dr, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53706, USA; Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
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Heltshe SL, West NE, VanDevanter DR, Sanders DB, Beckett VV, Flume PA, Goss CH. Study design considerations for the Standardized Treatment of Pulmonary Exacerbations 2 (STOP2): A trial to compare intravenous antibiotic treatment durations in CF. Contemp Clin Trials 2017; 64:35-40. [PMID: 29170074 DOI: 10.1016/j.cct.2017.11.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 09/19/2017] [Revised: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are common and contribute to morbidity and mortality. Duration of IV antibiotic therapy to treat PEx varies widely in the US, and there are few data to guide treatment decisions. METHODS We combined a survey of CF stakeholders with retrospective analyses of a recent observational study of CF PEx to design a multicenter, randomized, prospective study comparing the efficacy and safety of different durations of IV antibiotics for PEx to meet the needs of people with CF and their caregivers. RESULTS IV antibiotic duration was cited as the most important PEx research question by responding CF physicians and top concern among surveyed CF patients/caregivers. During PEx, forced expiratory volume in 1s (FEV1% predicted) and symptom responses at 7-10days of IV antibiotics identified two distinct groups: early robust responders (ERR) who subsequently experienced greater FEV1 improvements compared to non-ERR (NERR). In addition to greater FEV1 and symptom responses, only 14% of ERR patients were treated with IV antibiotics for >15days, compared with 45% of NERR patients. CONCLUSIONS A divergent trial design that evaluates subjects' interim improvement in FEV1 and symptoms to tailor randomization to IV treatment duration (10 vs. 14days for ERR, 14 vs. 21days for NERR) may alleviate physician and patient concerns about excess or inadequate treatment. Such a study has the potential to provide evidence necessary to standardize IV antibiotic duration in CF PEx care -a first step to conducting PEx research of other treatment features.
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Affiliation(s)
- Sonya L Heltshe
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Natalie E West
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - D B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - Valeria V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98121, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA; Division of Pulmonary Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98121, USA
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Heltshe SL, Khan U, Beckett V, Baines A, Emerson J, Sanders DB, Gibson RL, Morgan W, Rosenfeld M. Longitudinal development of initial, chronic and mucoid Pseudomonas aeruginosa infection in young children with cystic fibrosis. J Cyst Fibros 2017; 17:341-347. [PMID: 29110966 DOI: 10.1016/j.jcf.2017.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 05/18/2017] [Revised: 10/02/2017] [Accepted: 10/11/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND While the emergence of chronic and mucoid Pseudomonas aeruginosa (Pa) infection are both associated with poorer outcomes among CF patients, their relationship is poorly understood. We examined the longitudinal relationship of incident, chronic and mucoid Pa in a contemporary, young CF cohort in the current era of Pa eradication therapy. METHODS This retrospective cohort was comprised of patients in the U.S. CF Foundation Patient Registry born 2006-2015, diagnosed before age 2, and with at least 3 respiratory cultures annually. Incidence and age-specific prevalence of Pa infection stages (initial and chronic [≥ 3Pa+cultures in prior year]) and of mucoid Pa were summarized. Transition times and the interaction between Pa stage and acquisition of mucoid Pa were examined via Cox models. RESULTS Among the 5592 CF patients in the cohort followed to a mean age of 5.5years, 64% (n=3580) acquired Pa. Of those, 13% (n=455) developed chronic Pa and 17% (n=594) cultured mucoid Pa. Among those with mucoid Pa, 36% (211/594) had it on their first recorded Pa+culture, while mucoid Pa emerged at or after entering the chronic stage in 12% (73/594). Mucoidy was associated with significantly increased risk of transition to chronic Pa infection (HR=2.59, 95% CI 2.11, 3.19). CONCLUSIONS Two-thirds of early-diagnosed young children with CF acquired Pa during a median 5.6years of follow up, among whom 13% developed chronic Pa and 17% acquired mucoid Pa. Contrary to our hypothesis, 87% of young children who developed mucoid Pa did so before becoming chronically infected.
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Affiliation(s)
- S L Heltshe
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA.
| | - U Khan
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - A Baines
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - J Emerson
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA
| | - D B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN 46202, USA
| | - R L Gibson
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA
| | - W Morgan
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - M Rosenfeld
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98121, USA
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Sanders DB, Zhao Q, Li Z, Farrell PM. Poor recovery from cystic fibrosis pulmonary exacerbations is associated with poor long-term outcomes. Pediatr Pulmonol 2017; 52:1268-1275. [PMID: 28881091 PMCID: PMC5639928 DOI: 10.1002/ppul.23765] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 10/11/2016] [Accepted: 06/20/2017] [Indexed: 02/02/2023]
Abstract
RATIONALE People with CF treated with IV antibiotics for a pulmonary exacerbation (PEx) frequently fail to recover to baseline FEV1 . The long-term impact of these events has not been studied. OBJECTIVES To determine if a patient's spirometric recovery after a PEx is associated with time to next PEx within 1 year, the spirometric recovery after the next PEx, and/or the number of PEx episodes in the next 3 years. METHODS We used data from the CF Foundation Patient Registry from 2004 to 2011. We randomly selected one PEx per patient that met inclusion/exclusion criteria. Patients were defined as Non-Responders if their best FEV1 (in liters) recorded in the 3 months after the PEx was <90% of the best FEV1 (in liters) in the 6 months before the PEx. We compared Responders and Non-Responders using multivariable regression models. RESULTS We randomly chose 13 954 PEx episodes that met inclusion/exclusion criteria. A total of 2 762 (19.8%) patients were classified as Non-Responders. Non-Responders had a shorter median time to the next PEx, 235 (95%CI 218, 252) days, versus >365 days for Responders. Thirty-four percent of Non-Responders at the initial PEx were also Non-Reponders at the next PEx, versus 20% of Responders at the initial PEx. Non-Responders had more PEx episodes over the next 3 years, 4.99 (95%CI 4.84, 5.13), than Responders, 3.46 (95%CI 3.41, 3.51). CONCLUSIONS Poor recovery after a PEx is associated with a shorter time to the next PEx, increased risk of poor recovery at a second PEx, and more frequent subsequent PEx treatments.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.,Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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Sanders DB, Li Z, Zhao Q, Farrell PM. Poor recovery from a pulmonary exacerbation does not lead to accelerated FEV 1 decline. J Cyst Fibros 2017; 17:S1569-1993(17)30818-4. [PMID: 28765072 PMCID: PMC5788732 DOI: 10.1016/j.jcf.2017.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/23/2016] [Revised: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with CF treated for pulmonary exacerbations (PEx) may experience faster subsequent declines in FEV1. Additionally, incomplete recovery to baseline FEV1 occurs frequently following PEx treatment. Whether accelerated declines in FEV1 are preceded by poor PEx recovery has not been studied. METHODS Using 2004 to 2011 CF Foundation Patient Registry data, we randomly selected one PEx among patients ≥6years of age with no organ transplantations, ≥12months of data before and after the PEx, and ≥1 FEV1 recorded within the 6months before and 3months after the PEx. We defined poor PEx recovery as the best FEV1 in the 3months after the PEx <90% of the best FEV1 in the 6months before the PEx. We calculated mean (95% CI) hazard ratios (HR) of having >5% predicted/year FEV1 decline and poor PEx recovery using multi-state Markov models. RESULTS From 13,954 PEx, FEV1 declines of >5% predicted/year were more likely to precede poor spirometric recovery, HR 1.17 (1.08, 1.26), in Markov models adjusted for age and sex. Non-Responders were less likely to have a subsequent fast FEV1 decline, HR 0.41 (0.37, 0.46), than patients who recovered to >90% of baseline FEV1 following PEx treatment. CONCLUSIONS Accelerated declines in FEV1 are more likely to precede a PEx with poor recovery than to occur in the following year. Preventing or halting declines in FEV1 may also have the benefit of preventing PEx episodes.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indiana, IN, USA.
| | - Zhanhai Li
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Qianqian Zhao
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Philip M Farrell
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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Sanders DB, Solomon GM, Beckett VV, West NE, Daines CL, Heltshe SL, VanDevanter DR, Spahr JE, Gibson RL, Nick JA, Marshall BC, Flume PA, Goss CH. Standardized Treatment of Pulmonary Exacerbations (STOP) study: Observations at the initiation of intravenous antibiotics for cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2017; 16:592-599. [PMID: 28460885 DOI: 10.1016/j.jcf.2017.04.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [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: 09/30/2016] [Revised: 03/07/2017] [Accepted: 04/04/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Standardized Treatment of Pulmonary Exacerbations (STOP) program has the intent of defining best practices in the treatment of pulmonary exacerbations (PEx) in patients with cystic fibrosis (CF). The objective of this analysis was to describe the clinical presentations of patients admitted for intravenous (IV) antibiotics and enrolled in a prospective observational PEx study as well as to understand physician treatment goals at the start of the intervention. METHODS We enrolled adolescents and adults admitted to the hospital for a PEx treated with IV antibiotics. We recorded patient and PEx characteristics at the time of enrollment. We surveyed treating physicians on treatment goals as well as their willingness to enroll patients in various study designs. Additional demographic and clinical data were obtained from the CF Foundation Patient Registry. RESULTS Of 220 patients enrolled, 56% were female, 19% were adolescents, and 71% were infected with P. aeruginosa. The mean (SD) FEV1 at enrollment was 51.1 (21.6)% predicted. Most patients (85%) experienced symptoms for ≥7days before admission, 43% had received IV antibiotics within the previous 6months, and 48% received oral and/or inhaled antibiotics prior to IV antibiotic initiation. Forty percent had ≥10% FEV1 decrease from their best value recorded in the previous 6months, but for 20% of patients, their enrollment FEV1 was their best FEV1 recorded within the previous 6months. Physicians reported that their primary treatment objectives were lung function recovery (53%) and improvement of symptoms (47%) of PEx. Most physicians stated they would enroll patients in studies involving 10-day (72%) or 14-day (87%), but not 7-day (29%), treatment regimens. CONCLUSIONS Based on the results of this study, prospective studies are feasible and physician willingness for interventional studies of PEx exists. Results of this observational study will help design future PEx trials.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA.
| | - George M Solomon
- Department of Medicine, Gregory Fleming James Cystic Fibrosis Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Valeria V Beckett
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cori L Daines
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jonathan E Spahr
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ronald L Gibson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
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VanDevanter DR, Heltshe SL, Spahr J, Beckett VV, Daines CL, Dasenbrook EC, Gibson RL, Raksha J, Sanders DB, Goss CH, Flume PA. Rationalizing endpoints for prospective studies of pulmonary exacerbation treatment response in cystic fibrosis. J Cyst Fibros 2017; 16:607-615. [PMID: 28438499 DOI: 10.1016/j.jcf.2017.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [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: 09/30/2016] [Revised: 03/08/2017] [Accepted: 04/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the variability in pulmonary exacerbation (PEx) management within and between Cystic Fibrosis (CF) Care Centers, it is possible that some approaches may be superior to others. A challenge with comparing different PEx management approaches is lack of a community consensus with respect to treatment-response metrics. In this analysis, we assess the feasibility of using different response metrics in prospective randomized studies comparing PEx treatment protocols. METHODS Response parameters were compiled from the recent STOP (Standardized Treatment of PEx) feasibility study. Pulmonary function responses (recovery of best prior 6-month and 12-month FEV1% predicted and absolute and relative FEV1% predicted improvement from treatment initiation) and sign and symptom recovery from treatment initiation (measured by the Chronic Respiratory Infection Symptom Score [CRISS]) were studied as categorical and continuous variables. The proportion of patients retreated within 30days after the end of initial treatment was studied as a categorical variable. Sample sizes required to adequately power prospective 1:1 randomized superiority and non-inferiority studies employing candidate endpoints were explored. RESULTS The most sensitive endpoint was mean change in CRISS from treatment initiation, followed by mean absolute FEV1% predicted change from initiation, with the two responses only modestly correlated (R2=.157; P<0.0001). Recovery of previous best FEV1 was a problematic endpoint due to missing data and a substantial proportion of patients beginning PEx treatment with FEV1 exceeding their previous best measures (12.1% >12-month best, 19.6% >6-month best). Although mean outcome measures deteriorated approximately 2-weeks post-treatment follow-up, the effect was non-uniform: 62.7% of patients experienced an FEV1 worsening versus 49.0% who experienced a CRISS worsening. CONCLUSIONS Results from randomized prospective superiority and non-inferiority studies employing mean CRISS and FEV1 change from treatment initiation should prove compelling to the community. They will need to be large, but appear feasible.
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Affiliation(s)
- D R VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
| | - S L Heltshe
- University of Washington, Seattle, WA 98121, USA; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - J Spahr
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA
| | - V V Beckett
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - C L Daines
- University of Arizona, Tucson, AZ 85724, USA
| | - E C Dasenbrook
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - R L Gibson
- CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - Jain Raksha
- University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - D B Sanders
- University of Wisconsin, Madison, WI 53792, USA
| | - C H Goss
- University of Washington, Seattle, WA 98121, USA; CFF Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA 98105, USA
| | - P A Flume
- Medical University of South Carolina, Charleston, SC 29425, USA
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Farrell PM, White TB, Howenstine MS, Munck A, Parad RB, Rosenfeld M, Sommerburg O, Accurso FJ, Davies JC, Rock MJ, Sanders DB, Wilschanski M, Sermet-Gaudelus I, Blau H, Gartner S, McColley SA. Diagnosis of Cystic Fibrosis in Screened Populations. J Pediatr 2017; 181S:S33-S44.e2. [PMID: 28129810 DOI: 10.1016/j.jpeds.2016.09.065] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [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] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Cystic fibrosis (CF) can be difficult to diagnose, even when newborn screening (NBS) tests yield positive results. This challenge is exacerbated by the multitude of NBS protocols, misunderstandings about screening vs diagnostic tests, and the lack of guidelines for presumptive diagnoses. There is also confusion regarding the designation of age at diagnosis. STUDY DESIGN To improve diagnosis and achieve standardization in definitions worldwide, the CF Foundation convened a committee of 32 experts with a mission to develop clear and actionable consensus guidelines on diagnosis of CF with an emphasis on screened populations, especially the newborn population. A comprehensive literature review was performed with emphasis on relevant articles published during the past decade. RESULTS After reviewing the common screening protocols and outcome scenarios, 14 of 27 consensus statements were drafted that apply to screened populations. These were approved by 80% or more of the participants. CONCLUSIONS It is recommended that all diagnoses be established by demonstrating dysfunction of the CF transmembrane conductance regulator (CFTR) channel, initially with a sweat chloride test and, when needed, potentially with newer methods assessing membrane transport directly, such as intestinal current measurements. Even in babies with 2 CF-causing mutations detected via NBS, diagnosis must be confirmed by demonstrating CFTR dysfunction. The committee also recommends that the latest classifications identified in the Clinical and Functional Translation of CFTR project [http://www.cftr2.org/index.php] should be used to aid with CF diagnosis. Finally, to avoid delays in treatment, we provide guidelines for presumptive diagnoses and recommend how to determine the age of diagnosis.
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Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Michelle S Howenstine
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Anne Munck
- Centres de Ressources et de Compétences pour la Mucoviscidose, Hôpital Robert Debre, Paris, France
| | - Richard B Parad
- Department of Pediatric and Newborn Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | | | - Frank J Accurso
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jane C Davies
- Pediatric Respirology and Experimental Medicine, Imperial College London and Pediatric Respiratory Medicine, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Michael J Rock
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Don B Sanders
- Department of Pediatrics, Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades/INSERM U1151, Hôpital Necker Enfants Malades, Centres de Ressources et de Compétences pour la Mucoviscidose, Paris, France
| | - Hannah Blau
- Sackler Faculty of Medicine, Graub Cystic Fibrosis Center, Pulmonary Institute Schneider Children's Medical Center of Israel, Petah Tikva, Tel Aviv University, Tel Aviv, Israel
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Abstract
Cystic fibrosis (CF) is the most common autosomal-recessive disease in white persons. Significant advances in therapies and outcomes have occurred for people with CF over the past 30 years. Many of these improvements have come about through the concerted efforts of the CF Foundation and international CF societies; networks of CF care centers; and the worldwide community of care providers, researchers, and patients and families. There are still hurdles to overcome to continue to improve the quality of life, reduce CF complications, prolong survival, and ultimately cure CF. This article reviews the epidemiology of CF, including trends in incidence and prevalence, clinical characteristics, common complications, and survival.
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Affiliation(s)
- Don B. Sanders
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Aliza Fink
- Epidemiology, Cystic Fibrosis Foundation, Bethesda, Maryland
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Sanders DB, Fink A, Mayer- Hamblett N, Schechter MS, Sawicki GS, Rosenfeld M, Flume PA, Morgan WJ. Early Life Growth Trajectories in Cystic Fibrosis are Associated with Pulmonary Function at Age 6 Years. J Pediatr 2015; 167:1081-8.e1. [PMID: 26340874 PMCID: PMC5017309 DOI: 10.1016/j.jpeds.2015.07.044] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [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: 02/10/2015] [Revised: 06/19/2015] [Accepted: 07/24/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine whether severity of lung disease at age 6 years is associated with changes in nutritional status before age 6 within individual children with cystic fibrosis (CF). STUDY DESIGN Children with CF born between 1994 and 2005 and followed in the CF Foundation Patient Registry from age ≤2 through 7 years were assessed according to changes in annualized weight-for-length (WFL) percentiles between ages 0 and 2 years and body mass index (BMI) percentiles between ages 2 and 6 years. The association between growth trajectories before age 6 and forced expiratory volume in 1 second (FEV1)% predicted at age 6-7 years was evaluated using multivariable linear regression. RESULTS A total of 6805 subjects met inclusion criteria. Children with annualized WFL-BMI always >50th percentile (N = 1323 [19%]) had the highest adjusted mean (95% CI) FEV1 at 6-7 years (101.8 [100.1, 103.5]). FEV1 at 6-7 years for children whose WFL-BMI increased >10 percentile points by age 6 years was 98.3 (96.6, 100.0). This was statistically significantly higher than FEV1 for children whose WFL-BMI was stable (94.4 [92.6, 96.2]) or decreased >10 percentile points (92.9 [91.1, 94.8]). Among children whose WFL-BMI increased >10 percentile points, achieving and maintaining WFL-BMI >50th percentile at younger ages was associated with significantly higher FEV1 at 6-7 years. CONCLUSIONS Within-patient changes in nutritional status in the first 6 years of life are significantly associated with FEV1 at age 6-7 years. The establishment of a clear relationship between early childhood growth measurements and later lung function suggests that early nutritional interventions may impact on eventual lung health.
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Affiliation(s)
- Don B. Sanders
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Nicole Mayer- Hamblett
- Department of Biostatistics, University of Washington, Seattle, WA
,Department of Pediatrics, University of Washington, Seattle, WA
| | | | | | | | - Patrick A. Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC
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Affiliation(s)
- Don B Sanders
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, University of Wisconsin, 600 Highland Avenue, K4/920, Madison, WI 53792-9988, United States.
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Cogen J, Emerson J, Sanders DB, Ren C, Schechter MS, Gibson RL, Morgan W, Rosenfeld M. Risk factors for lung function decline in a large cohort of young cystic fibrosis patients. Pediatr Pulmonol 2015; 50:763-70. [PMID: 26061914 PMCID: PMC5462119 DOI: 10.1002/ppul.23217] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [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: 02/26/2015] [Revised: 04/23/2015] [Accepted: 04/28/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify novel risk factors and corroborate previously identified risk factors for mean annual decline in FEV1% predicted in a large, contemporary, United States cohort of young cystic fibrosis (CF) patients. METHODS Retrospective observational study of participants in the EPIC Observational Study, who were Pseudomonas-negative and ≤12 years of age at enrollment in 2004-2006. The associations between potential demographic, clinical, and environmental risk factors evaluated during the baseline year and subsequent mean annual decline in FEV1 percent predicted were evaluated using generalized estimating equations. RESULTS The 946 participants in the current analysis were followed for a mean of 6.2 (SD 1.3) years. Mean annual decline in FEV1% predicted was 1.01% (95%CI 0.85-1.17%). Children with one or no F508del mutations had a significantly smaller annual decline in FEV1 compared to F508del homozygotes. In a multivariable model, risk factors during the baseline year associated with a larger subsequent mean annual lung function decline included female gender, frequent or productive cough, low BMI (<66th percentile, median in the cohort), ≥1 pulmonary exacerbation, high FEV1 (≥115% predicted, in the top quartile), and respiratory culture positive for methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, or Stenotrophomonas maltophilia. CONCLUSIONS We have identified a range of risk factors for FEV1 decline in a large cohort of young, CF patients who were Pa negative at enrollment, including novel as well as previously identified characteristics. These results could inform the design of a clinical trial in which rate of FEV1 decline is the primary endpoint and identify high-risk groups that may benefit from closer monitoring.
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Affiliation(s)
- Jonathan Cogen
- Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Julia Emerson
- Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Don B Sanders
- Department of Pediatrics, American Family Children's Hospital, Madison, Wisconsin
| | - Clement Ren
- Division of Pediatric Pulmonology, University of Rochester, Rochester, New York
| | - Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Virginia Commonwealth University, Children's Hospital of Richmond at VCU, Richmond, Virginia
| | - Ronald L Gibson
- Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Wayne Morgan
- Departments of Pediatrics and Physiology, Pediatric Pulmonary Center, University of Arizona, Tucson, Arizona
| | - Margaret Rosenfeld
- Division of Pulmonary Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
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Ren CL, Fink AK, Petren K, Borowitz DS, McColley SA, Sanders DB, Rosenfeld M, Marshall BC. Outcomes of infants with indeterminate diagnosis detected by cystic fibrosis newborn screening. Pediatrics 2015; 135:e1386-92. [PMID: 25963008 DOI: 10.1542/peds.2014-3698] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [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] [Accepted: 03/09/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cystic fibrosis transmembrane conductance regulator-related metabolic syndrome (CRMS) describes asymptomatic infants with a positive cystic fibrosis (CF) newborn screen (NBS) but inconclusive diagnostic testing for CF. Little is known about the epidemiology and outcomes of CRMS. The goal of this study was to determine the prevalence, clinical features, and short-term outcomes of infants with CRMS. METHODS We analyzed data from the US CF Foundation Patient Registry (CFFPR) from 2010 to 2012. We compared demographic, diagnostic, anthropometric, health care utilization, microbiology, and treatment characteristics between infants with CF and infants with CRMS. RESULTS There were 1983 infants diagnosed via NBS between 2010 and 2012 reported to the CFFPR. By using the CF Foundation guideline definitions, 1540 and 309 infants met the criteria for CF and CRMS, respectively (CF:CRMS ratio = 5.0:1.0). Of note, 40.8% of infants with CRMS were entered into the registry with a clinical diagnosis of CF. Infants with CRMS tended to have normal nutritional indices. However, 11% of infants with CRMS had a positive Pseudomonas aeruginosa respiratory tract culture in the first year of life. CONCLUSIONS CRMS is a common outcome of CF NBS, and some infants with CRMS may develop features concerning for CF disease. A substantial proportion of infants with CRMS were assigned a clinical diagnosis of CF, which may reflect misclassification or clinical features not collected in the CFFPR.
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Affiliation(s)
- Clement L Ren
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Rochester, Rochester, New York;
| | | | | | - Drucy S Borowitz
- Division of Pediatric Pulmonology, Department of Pediatrics, Women and Children's Hospital of Buffalo, Buffalo, New York
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Don B Sanders
- Division of Pediatric Pulmonology, Cystic Fibrosis, and Sleep Medicine/Department of Pediatrics, University of Wisconsin, Madison, Wisconsin; and
| | - Margaret Rosenfeld
- Division of Pulmonary Medicine, Seattle Children's Hospital and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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