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Wagner BD, Zemanick ET, Sagel SD, Robertson CE, Stevens MJ, Mayer-Hamblett N, Retsch-Bogart G, Ramsey BW, Harris JK. Limited effects of azithromycin on the oropharyngeal microbiome in children with CF and early pseudomonas infection. BMC Microbiol 2023; 23:312. [PMID: 37891457 PMCID: PMC10612347 DOI: 10.1186/s12866-023-03073-8] [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: 08/23/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Tobramycin inhalation solution (TIS) and chronic azithromycin (AZ) have known clinical benefits for children with CF, likely due to antimicrobial and anti-inflammatory activity. The effects of chronic AZ in combination with TIS on the airway microbiome have not been extensively investigated. Oropharyngeal swab samples were collected in the OPTIMIZE multicenter, randomized, placebo-controlled trial examining the addition of AZ to TIS in 198 children with CF and early P. aeruginosa infection. Bacterial small subunit rRNA gene community profiles were determined. The effects of TIS and AZ were assessed on oropharyngeal microbial diversity and composition to uncover whether effects on the bacterial community may be a mechanism of action related to the observed changes in clinical outcomes. RESULTS Substantial changes in bacterial communities (total bacterial load, diversity and relative abundance of specific taxa) were observed by week 3 of TIS treatment for both the AZ and placebo groups. On average, these shifts were due to changes in non-traditional CF taxa that were not sustained at the later study visits (weeks 13 and 26). Bacterial community measures did not differ between the AZ and placebo groups. CONCLUSIONS This study provides further evidence that the mechanism for AZ's effect on clinical outcomes is not due solely to action on airway microbial composition.
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Affiliation(s)
- Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA.
- Children's Hospital Colorado, Aurora, CO, USA.
| | - Edith T Zemanick
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Scott D Sagel
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - Mark J Stevens
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | | | - Bonnie W Ramsey
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - J Kirk Harris
- Children's Hospital Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
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2
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Mayer-Hamblett N, Clancy JP, Jain R, Donaldson SH, Fajac I, Goss CH, Polineni D, Ratjen F, Quon BS, Zemanick ET, Bell SC, Davies JC, Jain M, Konstan MW, Kerper NR, LaRosa T, Mall MA, McKone E, Pearson K, Pilewski JM, Quittell L, Rayment JH, Rowe SM, Taylor-Cousar JL, Retsch-Bogart G, Downey DG. Advancing the pipeline of cystic fibrosis clinical trials: a new roadmap with a global trial network perspective. Lancet Respir Med 2023; 11:932-944. [PMID: 37699421 PMCID: PMC10982891 DOI: 10.1016/s2213-2600(23)00297-7] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023]
Abstract
The growing use of modulator therapies aimed at restoring cystic fibrosis transmembrane conductance regulator (CFTR) protein function in people with cystic fibrosis has fundamentally altered clinical trial strategies needed to advance new therapeutics across an orphan disease population that is now divided by CFTR modulator eligibility. The development of a robust pipeline of nucleic acid-based therapies (NABTs)-initially directed towards the estimated 10% of the cystic fibrosis population who are genetically ineligible for, or intolerant of, CFTR modulators-is dependent on the optimisation of restricted trial participant resources across multiple development programmes, a challenge that will preclude the use of gold standard placebo-controlled trials. Advancement of a full pipeline of symptomatic therapies across the entire cystic fibrosis population will be challenged by smaller effect sizes and uncertainty regarding their clinical importance in a growing modulator-treated population with more mild and stable pulmonary disease. In this Series paper, we aim to lay the foundation for clinical trial strategy and community partnership that must deviate from established and familiar precedent to advance the future pipeline of cystic fibrosis therapeutics.
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Affiliation(s)
- Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA.
| | | | - Raksha Jain
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Scott H Donaldson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Isabelle Fajac
- Assistance Publique, Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Christopher H Goss
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University of Washington, Seattle, WA, USA
| | - Deepika Polineni
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | - Felix Ratjen
- Translational Medicine Research Institute, The Hospital for Sick Children, Toronto, ON, Canada; Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia; Children's Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, London, UK; Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Manu Jain
- University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | | | | | - Marcus A Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Centre for Lung Research, Berlin, Germany; Berlin Institute of Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Edward McKone
- St. Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | | | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lynne Quittell
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | | | | | | | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC, USA
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
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3
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Wainwright C, McColley SA, McNally P, Powers M, Ratjen F, Rayment JH, Retsch-Bogart G, Roesch E, Ahluwalia N, Chin A, Chu C, Lu M, Menon P, Waltz D, Weinstock T, Zelazoski L, Davies JC. Long-Term Safety and Efficacy of Elexacaftor/Tezacaftor/Ivacaftor in Children Aged ⩾6 Years with Cystic Fibrosis and at Least One F508del Allele: A Phase 3, Open-Label Clinical Trial. Am J Respir Crit Care Med 2023; 208:68-78. [PMID: 37154609 PMCID: PMC10870850 DOI: 10.1164/rccm.202301-0021oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 01/05/2023] [Accepted: 05/05/2023] [Indexed: 05/10/2023] Open
Abstract
Rationale: A 24-week, phase 3, open-label study showed elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was safe and efficacious in children aged 6-11 years with cystic fibrosis (CF) and one or more F508del-CFTR alleles. Objectives: To assess long-term safety and efficacy of ELX/TEZ/IVA in children who completed the pivotal 24-week phase 3 trial. Methods: In this phase 3, two-part (part A and part B), open-label extension study, children aged ⩾6 years with CF heterozygous for F508del and a minimal function CFTR mutation (F/MF genotypes) or homozygous for F508del (F/F genotype) who completed the 24-week parent study received ELX/TEZ/IVA based on weight. Children weighing <30 kg received ELX 100 mg once daily/TEZ 50 mg once daily/IVA 75 mg every 12 hours, whereas children weighing ⩾30 kg received ELX 200 mg once daily/TEZ 100 mg once daily/IVA 150 mg every 12 hours (adult dose). The 96-week analysis of part A of this extension study is reported here. Measurements and Main Results: Sixty-four children (F/MF genotypes, n = 36; F/F genotype, n = 28) were enrolled and received one or more doses of ELX/TEZ/IVA. Mean (SD) period of exposure to ELX/TEZ/IVA was 93.9 (11.1) weeks. The primary endpoint was safety and tolerability. Adverse events and serious adverse events were consistent with common manifestations of CF disease. Overall, exposure-adjusted rates of adverse events and serious adverse events (407.74 and 4.72 events per 100 patient-years) were lower than in the parent study (987.04 and 8.68 events per 100 patient-years). One child (1.6%) had an adverse event of aggression that was moderate in severity and resolved after study drug discontinuation. From parent study baseline at Week 96 of this extension study, the mean percent predicted FEV1 increased (11.2 [95% confidence interval (CI), 8.3 to 14.2] percentage points), sweat chloride concentration decreased (-62.3 [95% CI, -65.9 to -58.8] mmol/L), Cystic Fibrosis Questionnaire-Revised respiratory domain score increased (13.3 [95% CI, 11.4 to 15.1] points), and lung clearance index 2.5 decreased (-2.00 [95% CI, -2.45 to -1.55] units). Increases in growth parameters were also observed. The estimated pulmonary exacerbation rate per 48 weeks was 0.04. The annualized rate of change in percent predicted FEV1 was 0.51 (95% CI, -0.73 to 1.75) percentage points per year. Conclusions: ELX/TEZ/IVA continued to be generally safe and well tolerated in children aged ⩾6 years through an additional 96 weeks of treatment. Improvements in lung function, respiratory symptoms, and CFTR function observed in the parent study were maintained. These results demonstrate the favorable long-term safety profile and durable clinical benefits of ELX/TEZ/IVA in this pediatric population. Clinical trial registered with www.clinicaltrials.gov (NCT04183790).
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Affiliation(s)
- Claire Wainwright
- Queensland Children’s Hospital, South Brisbane, Queensland, Australia
- Child Health Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Susanna A. McColley
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul McNally
- Children’s Health Ireland, Dublin, Ireland
- Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | | | | | - Erica Roesch
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Anna Chin
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Chenghao Chu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Mengdi Lu
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - Prema Menon
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | - David Waltz
- Vertex Pharmaceuticals Incorporated, Boston, Massachusetts
| | | | | | - Jane C. Davies
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
- Royal Brompton Hospital, Part of Guy’s and St. Thomas’ NHS Trust, London, United Kingdom
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4
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Mayer-Hamblett N, Ratjen F, Russell R, Donaldson SH, Riekert KA, Sawicki GS, Odem-Davis K, Young JK, Rosenbluth D, Taylor-Cousar JL, Goss CH, Retsch-Bogart G, Clancy JP, Genatossio A, O'Sullivan BP, Berlinski A, Millard SL, Omlor G, Wyatt CA, Moffett K, Nichols DP, Gifford AH. Discontinuation versus continuation of hypertonic saline or dornase alfa in modulator treated people with cystic fibrosis (SIMPLIFY): results from two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials. Lancet Respir Med 2023; 11:329-340. [PMID: 36343646 PMCID: PMC10065895 DOI: 10.1016/s2213-2600(22)00434-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reducing treatment burden is a priority for people with cystic fibrosis, whose health has benefited from using new modulators that substantially increase CFTR protein function. The SIMPLIFY study aimed to assess the effects of discontinuing nebulised hypertonic saline or dornase alfa in individuals using the CFTR modulator elexacaftor plus tezacaftor plus ivacaftor (ETI). METHODS The SIMPLIFY study included two parallel, multicentre, open-label, randomised, controlled, non-inferiority trials at 80 participating clinics across the USA in the Cystic Fibrosis Therapeutics Development Network. We included individuals with cystic fibrosis aged 12-17 years with percent predicted FEV1 (ppFEV1) of 70% or more, or those aged 18 years or older with ppFEV1 of 60% or more, if they had been taking ETI and either (or both) mucoactive therapies (≥3% hypertonic saline or dornase alfa) for at least 90 days before screening. Participants on both hypertonic saline and dornase alfa were randomly assigned to one of the two trials, and those on a single therapy were assigned to the applicable trial. All participants were then randomly assigned 1:1 to continue or discontinue therapy for 6 weeks using permuted blocks of varying size, stratified by baseline ppFEV1 (week 0; ≥90% or <90%), single or concurrent use of hypertonic saline and dornase alfa, previous SIMPLIFY study participation (yes or no), and age (≥18 or <18 years). For participants randomly assigned to continue their therapy during a given trial, this therapy was instructed to be taken at least once daily according to each participant's pre-existing, clinically prescribed regimen. Hypertonic saline concentration was required to be at least 3%. The primary objective for each trial was to determine whether discontinuing was non-inferior to continuing, measured by the 6-week change in ppFEV1 in the per-protocol population. We established a non-inferiority margin of -3% for the difference between groups in the 6-week change in ppFEV1. Safety outcomes were analysed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT04378153. FINDINGS From Aug 25, 2020, to May 25, 2022, a total of 672 unique participants were screened for eligibility for one or both trials, resulting in 847 total random assignments across both trials with 594 unique participants. 370 participants were randomly assigned in the hypertonic saline trial and 477 in the dornase alfa trial. Participants across both trials had an average ppFEV1 of 96·9%. Discontinuing treatment was non-inferior to continuing treatment with respect to the absolute 6-week change in ppFEV1 in both the hypertonic saline trial (-0·19% [95% CI -0·85 to 0·48] in the discontinuation group [n=133] vs 0·14% [-0·51 to 0·78] in the continuation group [n=140]; between-group difference -0·32% [-1·25 to 0·60]) and dornase alfa trial (0·18% [-0·38 to 0·74] in the discontinuation group [n=199] vs -0·16% [-0·73 to 0·41] in the continuation group [n=193]; between-group difference 0·35% [-0·45 to 1·14]), with consistent results in the intention-to-treat populations. In the hypertonic saline trial, 64 (35%) of 184 in the discontinuation group versus 44 (24%) of 186 participants in the continuation group and, in the dornase alfa trial, 89 (37%) of 240 in the discontinuation group versus 55 (23%) of 237 in the continuation group had at least one adverse event. INTERPRETATION In individuals with cystic fibrosis on ETI with relatively well preserved pulmonary function, discontinuing daily hypertonic saline or dornase alfa for 6 weeks did not result in clinically meaningful differences in pulmonary function when compared with continuing treatment.
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Affiliation(s)
- Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA.
| | - Felix Ratjen
- Translational Medicine Research Institute, The Hospital for Sick Children, Toronto, ON, Canada; Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Renee Russell
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Scott H Donaldson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gregory S Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Julia K Young
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Daniel Rosenbluth
- Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jennifer L Taylor-Cousar
- Department of Internal Medicine, National Jewish Health, Denver, CO, USA; Department of Pediatrics, National Jewish Health, Denver, CO, USA
| | - Christopher H Goss
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Brian P O'Sullivan
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Ariel Berlinski
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Susan L Millard
- Department of Pediatrics, Spectrum Health, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Gregory Omlor
- Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
| | - Colby A Wyatt
- Department of Pediatrics, The Barbara Bush Children's Hospital, Maine Medical Center, Portland, ME, USA
| | - Kathryn Moffett
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| | - David P Nichols
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alex H Gifford
- Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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5
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Wainwright C, McColley S, McNally P, Powers M, Ratjen F, Rayment J, Retsch-Bogart G, Roesch E, Ahluwalia N, Chin A, Chu C, Lu M, Menon P, Moskowitz S, Waltz D, Weinstock T, Xuan F, Zelazoski L, Davies J. 163 Long-term safety and efficacy of elexacaftor/tezacaftor/ivacaftor in children 6 years and older with cystic fibrosis and at least one F508del alleles: 96-week interim results from an open-label extension study. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)00854-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nichols DP, Singh PK, Baines A, Caverly LJ, Chmiel JF, GIbson RL, Lascano J, Morgan SJ, Retsch-Bogart G, Saiman L, Sadeghi H, Billings JL, Heltshe SL, Kirby S, Kong A, Nick JA, Mayer-Hamblett N. Testing the effects of combining azithromycin with inhaled tobramycin for P. aeruginosa in cystic fibrosis: a randomised, controlled clinical trial. Thorax 2022; 77:581-588. [PMID: 34706982 PMCID: PMC9043040 DOI: 10.1136/thoraxjnl-2021-217782] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/30/2021] [Indexed: 11/03/2022]
Abstract
RATIONALE Inhaled tobramycin and oral azithromycin are common chronic therapies in people with cystic fibrosis and Pseudomonas aeruginosa airway infection. Some studies have shown that azithromycin can reduce the ability of tobramycin to kill P. aeruginosa. This trial was done to test the effects of combining azithromycin with inhaled tobramycin on clinical and microbiological outcomes in people already using inhaled tobramycin. We theorised that those randomised to placebo (no azithromycin) would have greater improvement in forced expiratory volume in one second (FEV1) and greater reduction in P. aeruginosa sputum in response to tobramycin. METHODS A 6-week prospective, randomised, placebo-controlled, double-blind trial testing oral azithromycin versus placebo combined with clinically prescribed inhaled tobramycin in individuals with cystic fibrosis and P. aeruginosa airway infection. RESULTS Over a 6-week period, including 4 weeks of inhaled tobramycin, the relative change in FEV1 did not statistically significantly differ between groups (azithromycin (n=56) minus placebo (n=52) difference: 3.44%; 95% CI: -0.48 to 7.35; p=0.085). Differences in secondary clinical outcomes, including patient-reported symptom scores, weight and need for additional antibiotics, did not significantly differ. Among the 29 azithromycin and 35 placebo participants providing paired sputum samples, the 6-week change in P. aeruginosa density differed in favour of the placebo group (difference: 0.75 log10 CFU/mL; 95% CI: 0.03 to 1.47; p=0.043). CONCLUSIONS Despite having greater reduction in P. aeruginosa density in participants able to provide sputum samples, participants randomised to placebo with inhaled tobramycin did not experience significantly greater improvements in lung function or other clinical outcomes compared with those randomised to azithromycin with tobramycin.
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Affiliation(s)
- David P Nichols
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Pradeep K Singh
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Arthur Baines
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Chmiel
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ronald L GIbson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jorge Lascano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Sarah J Morgan
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - George Retsch-Bogart
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Hossein Sadeghi
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Joanne L Billings
- Department of Medicine, Pulmonary, Allergy and Critical Care Division, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Shannon Kirby
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Ada Kong
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jerry A Nick
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
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7
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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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8
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Shaw M, Oppelaar MC, Jensen R, Stanojevic S, Davis SD, Retsch-Bogart G, Ratjen FA. The utility of moment ratios and abbreviated endpoints of the multiple breath washout test in preschool children with cystic fibrosis. Pediatr Pulmonol 2020; 55:649-653. [PMID: 31899855 DOI: 10.1002/ppul.24618] [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: 09/06/2019] [Accepted: 12/12/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND The multiple breath washout (MBW) test may be most useful in tracking disease progression over time to inform treatment decisions. In the clinical setting, alternative outcomes, which can be obtained quickly and easily, may facilitate interpretation of clinically relevant changes in lung function. METHODS In this secondary analysis of data from 78 cystic fibrosis (CF) and 72 healthy control (HC) subjects between the ages of 2.6 and 5.9 years, MBW was performed at enrollment, 1, 3, 6, 9, and 12 months, as well as during symptomatic visits using the Exhalyzer D (EcoMedics AG, Duernten, Switzerland). The lung clearance index, LCI2.5, was compared to moment ratios (M1 /M0 and M2 /M0 ) at the standard cutoff (1/40th of starting tracer gas concentration) as well as LCI5 and moment ratios at 1/20th of the starting concentration (M1 /M0 at LCI5 , and M2 /M0 at LCI5 ). RESULTS All outcomes were able to distinguish between health and disease. LCI5 reduced testing time by 40% and increased feasibility by more than 10%. The limits of biological reproducibility in healthy children were similar between LCI2.5 (15%), LCI5 (12%), M1 /M0 at LCI2.5 (14%), and M1 /M0 at LCI5 (12%), but markedly larger for M2 /M0 at LCI2.5 (30%) and M2 /M0 at LCI5 (25%). Each outcome deteriorated significantly with worsening pulmonary symptoms, the magnitude of deterioration was greatest for M2 /M0 . CONCLUSIONS In preschool children with CF, LCI5 was more feasible to obtain and track disease progression. The second moment ratio was most sensitive to pulmonary symptoms, but had the greatest variability both within and between subjects.
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Affiliation(s)
- Michelle Shaw
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martinus C Oppelaar
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatric Pulmonology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Renee Jensen
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanja Stanojevic
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Felix A Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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9
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Ratjen F, Davis SD, Stanojevic S, Kronmal RA, Hinckley Stukovsky KD, Jorgensen N, Rosenfeld M, Kerby G, Kopecky C, Anthony M, Mogayzel P, Walker D, Zeglin B, Hoover W, Hathorne H, Slaten K, Dorkin H(H, Fowler R, Fenton C(N, Ulles M, Goetz D, Caci N, Cahill B, Roach C, Retsch-Bogart G, Johnson R, Cunnion R, McColley S, Ward S, Bell E, McPhail G, Keller K, Thornton K, Parsons A, Chmiel J, Schaefer C, Tribout M, Consiglio B, Tribout H, McCoy K, Johnson T, Olson P, Raterman L, Hiatt P, Walker B, Schaap N, Davis M, Davis S, Clem C, Bendy L, Starner T, Lux C, Carver T, Thompson R, Williams A, Schmoll C, Hastings PM, Noe J, Roth L, Kump T, McNamara J, Franck Thompson E, Yousef S, Wezel G(G, Oquendo O, Darling A, Valencia W, Milla C, Zirbes J, Rubenstein R, Donnelly E, Malpass J, Weiner D, Agostini B, Hartigan E, Cornell A, Klein B, Bucher J, Nusbaum P, Rosenfeld M, McNamara S, Genatossio A, Pittman J, Hicks T, Bauer I, Siegel M, Isaac S, Jensen R, Au J, Stanojevic S, Ratjen F, McDonald N, Prentice C, Chilvers M, Richmond M. Inhaled hypertonic saline in preschool children with cystic fibrosis (SHIP): a multicentre, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine 2019; 7:802-809. [DOI: 10.1016/s2213-2600(19)30187-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023]
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10
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Reix P, Klingel M, Davis S, Retsch-Bogart G, Stanojevic S, Ratjen F. WS07-3 Effect of cumulative bacterial infection on the Lung Clearance Index in preschool children with cystic fibrosis. J Cyst Fibros 2019. [DOI: 10.1016/s1569-1993(19)30156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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11
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Miranda C, Cardenas M, Bedoya M, Retsch-Bogart G, Colin AA. Nonsystemic allergic bronchopulmonary aspergillosis in cystic fibrosis: A suggested paradigm for the evolution from topical to systemic disease. Pediatr Pulmonol 2019; 54:684-687. [PMID: 30938080 DOI: 10.1002/ppul.24325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/26/2019] [Accepted: 03/10/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Carolina Miranda
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Monica Cardenas
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Mariana Bedoya
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida
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12
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Retsch-Bogart G, Mayer-Hamblett N, Ramsey BW. Reply to Shanthikumar et al.: Azithromycin for Early Pseudomonas Infection in Cystic Fibrosis: Do the Benefits Outweigh the Harms? Am J Respir Crit Care Med 2018; 198:1349-1350. [PMID: 30138567 DOI: 10.1164/rccm.201808-1462le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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13
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Mayer-Hamblett N, Retsch-Bogart G, Kloster M, Accurso F, Rosenfeld M, Albers G, Black P, Brown P, Cairns A, Davis SD, Graff GR, Kerby GS, Orenstein D, Buckingham R. Azithromycin for Early Pseudomonas Infection in Cystic Fibrosis. The OPTIMIZE Randomized Trial. Am J Respir Crit Care Med 2018; 198:1177-1187. [PMID: 29890086 PMCID: PMC6221579 DOI: 10.1164/rccm.201802-0215oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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: 02/02/2018] [Accepted: 06/06/2018] [Indexed: 12/23/2022] Open
Abstract
RATIONALE New isolation of Pseudomonas aeruginosa (Pa) is generally treated with inhaled antipseudomonal antibiotics such as tobramycin inhalation solution (TIS). A therapeutic approach that complements traditional antimicrobial therapy by reducing the risk of pulmonary exacerbation and inflammation may ultimately prolong the time to Pa recurrence. OBJECTIVES To test the hypothesis that the addition of azithromycin to TIS in children with cystic fibrosis and early Pa decreases the risk of pulmonary exacerbation and prolongs the time to Pa recurrence. METHODS The OPTIMIZE (Optimizing Treatment for Early Pseudomonas aeruginosa Infection in Cystic Fibrosis) trial was a multicenter, double-blind, randomized, placebo-controlled, 18-month trial in children with CF, 6 months to 18 years of age, with early Pa. Azithromycin or placebo was given 3× weekly with standardized TIS. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the time to pulmonary exacerbation requiring antibiotics and the secondary endpoint was the time to Pa recurrence, in addition to other clinical and safety outcomes. A total of 221 participants (111 placebo, 110 azithromycin) out of a planned 274 were enrolled. Enrollment was stopped early by the NHLBI because the trial had reached the prespecified interim boundary for efficacy. The risk of pulmonary exacerbation was reduced by 44% in the azithromycin group as compared with the placebo group (hazard ratio, 0.56; 95% confidence interval, 0.37-0.83; P = 0.004). Weight increased by 1.27 kg in the azithromycin group compared with the placebo group (95% confidence interval, 0.01-2.52; P = 0.046). No significant differences were seen in microbiological or other clinical or safety endpoints. CONCLUSIONS Azithromycin was associated with a significant reduction in the risk of pulmonary exacerbation and a sustained improvement in weight, but had no impact on microbiological outcomes in children with early Pa. Clinical trial registered with clinicaltrials.gov (NCT02054156).
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Affiliation(s)
- Nicole Mayer-Hamblett
- Department of Pediatrics and
- Department of Biostatistics, University of Washington, Seattle, Washington
- Seattle Children’s Hospital, Seattle, Washington
| | - George Retsch-Bogart
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | | | - Frank Accurso
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children’s Hospital Colorado, Aurora, Colorado
| | - Margaret Rosenfeld
- Department of Pediatrics and
- Seattle Children’s Hospital, Seattle, Washington
| | - Gary Albers
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Philip Black
- Children’s Mercy Hospital, Kansas City, Missouri
| | - Perry Brown
- St. Luke’s Regional Medical Center, Boise, Idaho
| | | | - Stephanie D. Davis
- Indiana University Hospital, Indianapolis, Indiana
- James Whitcomb Riley Hospital for Children, Indianapolis, Indiana
| | - Gavin R. Graff
- Hershey Medical Center, Hershey, Pennsylvania
- Penn State Children’s Hospital, Hershey, Pennsylvania; and
| | - Gwendolyn S. Kerby
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children’s Hospital Colorado, Aurora, Colorado
| | - David Orenstein
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - for the OPTIMIZE Study Group
- Department of Pediatrics and
- Department of Biostatistics, University of Washington, Seattle, Washington
- Seattle Children’s Hospital, Seattle, Washington
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children’s Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri
- Children’s Mercy Hospital, Kansas City, Missouri
- St. Luke’s Regional Medical Center, Boise, Idaho
- Maine Medical Center, Portland, Maine
- Indiana University Hospital, Indianapolis, Indiana
- James Whitcomb Riley Hospital for Children, Indianapolis, Indiana
- Hershey Medical Center, Hershey, Pennsylvania
- Penn State Children’s Hospital, Hershey, Pennsylvania; and
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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14
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Rayment JH, Stanojevic S, Davis SD, Retsch-Bogart G, Ratjen F. Lung clearance index to monitor treatment response in pulmonary exacerbations in preschool children with cystic fibrosis. Thorax 2018; 73:451-458. [DOI: 10.1136/thoraxjnl-2017-210979] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/04/2017] [Accepted: 01/22/2018] [Indexed: 11/03/2022]
Abstract
BackgroundAntibiotic treatment for pulmonary symptoms in preschool children with cystic fibrosis (CF) varies among clinicians. The lung clearance index (LCI) is sensitive to early CF lung disease, but its utility to monitor pulmonary exacerbations in young children has not been assessed.ObjectiveWe aim to (1) understand how LCI changes during lower respiratory tract symptoms relative to a recent clinically stable measurement, (2) determine whether LCI can identify antibiotic treatment response and (3) compare LCI changes to changes in spirometric indices.MethodsLCI and spirometry were measured at quarterly clinic visits over a 12-month period in preschool children with CF. Symptomatic visits were identified and classified as treated or untreated. Treatment response was estimated using propensity score matching methods.Results104 symptomatic visits were identified in 78 participants. LCI increased from baseline in both treated (mean relative change +23.8% (95% CI 16.2 to 31.4)) and untreated symptomatic visits (mean relative change +11.2% (95% CI 2.4 to 19.9)). A significant antibiotic treatment effect was observed when LCI was used as the outcome measure (average treatment effect −15.5% (95% CI −25.4 to −5.6)) but not for z-score FEV1.ConclusionLCI significantly deteriorated with pulmonary symptoms relative to baseline and improved with antibiotic treatment. These data suggest that LCI may have a role in the routine clinical care of preschool children with CF.
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15
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Zemanick ET, Wagner BD, Robertson CE, Ahrens RC, Chmiel JF, Clancy JP, Gibson RL, Harris WT, Kurland G, Laguna TA, McColley SA, McCoy K, Retsch-Bogart G, Sobush KT, Zeitlin PL, Stevens MJ, Accurso FJ, Sagel SD, Harris JK. Airway microbiota across age and disease spectrum in cystic fibrosis. Eur Respir J 2017; 50:50/5/1700832. [PMID: 29146601 DOI: 10.1183/13993003.00832-2017] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/10/2017] [Indexed: 01/20/2023]
Abstract
Our objectives were to characterise the microbiota in cystic fibrosis (CF) bronchoalveolar lavage fluid (BALF), and determine its relationship to inflammation and disease status.BALF from paediatric and adult CF patients and paediatric disease controls undergoing clinically indicated bronchoscopy was analysed for total bacterial load and for microbiota by 16S rDNA sequencing.We examined 191 BALF samples (146 CF and 45 disease controls) from 13 CF centres. In CF patients aged <2 years, nontraditional taxa (e.gStreptococcus, Prevotella and Veillonella) constituted ∼50% of the microbiota, whereas in CF patients aged ≥6 years, traditional CF taxa (e.gPseudomonas, Staphylococcus and Stenotrophomonas) predominated. Sequencing detected a dominant taxon not traditionally associated with CF (e.gStreptococcus or Prevotella) in 20% of CF BALF and identified bacteria in 24% of culture-negative BALF. Microbial diversity and relative abundance of Streptococcus, Prevotella and Veillonella were inversely associated with airway inflammation. Microbiota communities were distinct in CF compared with disease controls, but did not differ based on pulmonary exacerbation status in CF.The CF microbiota detected in BALF differs with age. In CF patients aged <2 years, Streptococcus predominates, whereas classic CF pathogens predominate in most older children and adults.
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Affiliation(s)
| | - Brandie D Wagner
- University of Colorado School of Medicine, Aurora, CO, USA.,Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | | | | | - James F Chmiel
- Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - John P Clancy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ronald L Gibson
- University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | | | | | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, IL, USA
| | - Karen McCoy
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Mark J Stevens
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Scott D Sagel
- University of Colorado School of Medicine, Aurora, CO, USA
| | - J Kirk Harris
- University of Colorado School of Medicine, Aurora, CO, USA
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16
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Oude Engberink E, Ratjen F, Davis SD, Retsch-Bogart G, Amin R, Stanojevic S. Inter-test reproducibility of the lung clearance index measured by multiple breath washout. Eur Respir J 2017; 50:50/4/1700433. [PMID: 28982773 PMCID: PMC5898949 DOI: 10.1183/13993003.00433-2017] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/06/2017] [Indexed: 01/15/2023]
Abstract
The lung clearance index (LCI) has strong intra-test repeatability; however, the inter-test reproducibility of the LCI is poorly defined. The aim of the present study was to define a physiologically meaningful change in LCI in preschool children, which discriminates changes associated with disease progression from biological variability. Repeated LCI measurements from a longitudinal cohort study of children with cystic fibrosis and age-matched controls were collected to define the inter-visit reproducibility of the LCI. Absolute change, the coefficient of variation, Bland–Altman limits of agreement, the coefficient of repeatability, intra-class correlation coefficient, and percentage changes were calculated. LCI measurements (n=505) from 71 healthy and 77 cystic fibrosis participants (aged 2.6–6 years) were analysed. LCI variability was proportional to its magnitude, such that reproducibility defined by absolute changes is biased. A physiologically relevant change for quarterly LCI measurements in health was defined as exceeding ±15%. In clinically stable cystic fibrosis participants, the threshold was higher (±25%); however, for measurements made 24 h apart, the threshold was similar to that observed in health (±17%). A percentage change in LCI greater than ±15% in preschool children can be considered physiologically relevant and greater than the biological variability of the test. Biological variability of lung clearance index is dependent on magnitude; % change is better for tracking patientshttp://ow.ly/tgbX30dBbCX
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Affiliation(s)
- Esther Oude Engberink
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Division of Respiratory Medicine and Allergy, Dept of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Felix Ratjen
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie D Davis
- Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Reshma Amin
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sanja Stanojevic
- Division of Respiratory Medicine, Dept of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada .,Dept of Medicine, University of Toronto, Toronto, ON, Canada
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17
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Carpenter D, Gonzalez D, Retsch-Bogart G, Sleath B, Wilfond B. Methodological and Ethical Issues in Pediatric Medication Safety Research. Pediatrics 2017; 140:e20170195. [PMID: 28778857 PMCID: PMC5574727 DOI: 10.1542/peds.2017-0195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 12/26/2022] Open
Abstract
In May 2016, the Eshelman School of Pharmacy at The University of North Carolina at Chapel Hill convened the PharmSci conference to address the topic of "methodological and ethical issues in pediatric medication safety research." A multidisciplinary group of experts representing a diverse array of perspectives, including those of the US Food and Drug Administration, children's hospitals, and academia, identified important considerations for pediatric medication safety research and opportunities to advance the field. This executive summary describes current challenges that clinicians and researchers encounter related to pediatric medication safety research and identifies innovative and ethically sound methodologies to address these challenges to improve children's health. This article addresses 5 areas: (1) pediatric drug development and drug trials; (2) conducting comparative effectiveness research in pediatric populations; (3) child and parent engagement on study teams; (4) improving communication with children and parents; and (5) assessing child-reported outcomes and adverse drug events.
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Affiliation(s)
| | | | - George Retsch-Bogart
- Department of Pediatrics, School of Medicine
- Clinical and Translational Research Center of the North Carolina Translational and Clinical Sciences Institute, and
- Cystic Fibrosis Therapeutics Development Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, University of Washington, Seattle, Washington
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18
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Stanojevic S, Davis SD, Retsch-Bogart G, Webster H, Davis M, Johnson RC, Jensen R, Pizarro ME, Kane M, Clem CC, Schornick L, Subbarao P, Ratjen FA. Progression of Lung Disease in Preschool Patients with Cystic Fibrosis. Am J Respir Crit Care Med 2017; 195:1216-1225. [PMID: 27943680 DOI: 10.1164/rccm.201610-2158oc] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Implementation of intervention strategies to prevent lung damage in early cystic fibrosis (CF) requires objective outcome measures that capture and track lung disease. OBJECTIVES To define the utility of the Lung Clearance Index (LCI), measured by multiple breath washout, as a means to track disease progression in preschool children with CF. METHODS Children with CF between the ages of 2.5 and 6 years with a confirmed diagnosis of CF and age-matched healthy control subjects were enrolled at three North American CF centers. Multiple breath washout tests were performed at baseline, 1, 3, 6, and 12 months to mimic time points chosen in clinical care and interventional trials; spirometry was also conducted. A generalized linear mixed-effects model was used to distinguish LCI changes associated with normal growth and development (i.e., healthy children) from the progression of CF lung disease. MEASUREMENTS AND MAIN RESULTS Data were collected on 156 participants with 800 LCI measurements. Although both LCI and spirometry discriminated health from disease, only the LCI identified significant deterioration of lung function in CF over time. The LCI worsened during cough episodes and pulmonary exacerbations, whereas similar symptoms in healthy children were not associated with increased LCI values. CONCLUSIONS LCI is a useful marker to track early disease progression and may serve as a tool to guide therapies in young patients with CF.
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Affiliation(s)
- Sanja Stanojevic
- 1 Division of Respiratory Medicine, and.,2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Stephanie D Davis
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - George Retsch-Bogart
- 4 Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Hailey Webster
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Miriam Davis
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Robin C Johnson
- 4 Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Renee Jensen
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Maria Ester Pizarro
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada.,5 Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mica Kane
- 2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Charles C Clem
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Leah Schornick
- 3 Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Padmaja Subbarao
- 1 Division of Respiratory Medicine, and.,2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Felix A Ratjen
- 1 Division of Respiratory Medicine, and.,2 Physiology and Experimental Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
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Faro A, Wood RE, Schechter MS, Leong AB, Wittkugel E, Abode K, Chmiel JF, Daines C, Davis S, Eber E, Huddleston C, Kilbaugh T, Kurland G, Midulla F, Molter D, Montgomery GS, Retsch-Bogart G, Rutter MJ, Visner G, Walczak SA, Ferkol TW, Michelson PH. Official American Thoracic Society Technical Standards: Flexible Airway Endoscopy in Children. Am J Respir Crit Care Med 2015; 191:1066-80. [DOI: 10.1164/rccm.201503-0474st] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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20
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Mayer-Hamblett N, Ramsey BW, Kulasekara HD, Wolter DJ, Houston LS, Pope CE, Kulasekara BR, Armbruster CR, Burns JL, Retsch-Bogart G, Rosenfeld M, Gibson RL, Miller SI, Khan U, Hoffman LR. Pseudomonas aeruginosa phenotypes associated with eradication failure in children with cystic fibrosis. Clin Infect Dis 2014; 59:624-31. [PMID: 24863401 DOI: 10.1093/cid/ciu385] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pseudomonas aeruginosa is a key respiratory pathogen in people with cystic fibrosis (CF). Due to its association with lung disease progression, initial detection of P. aeruginosa in CF respiratory cultures usually results in antibiotic treatment with the goal of eradication. Pseudomonas aeruginosa exhibits many different phenotypes in vitro that could serve as useful prognostic markers, but the relative relationships between these phenotypes and failure to eradicate P. aeruginosa have not been well characterized. METHODS We measured 22 easily assayed in vitro phenotypes among the baseline P. aeruginosa isolates collected from 194 participants in the 18-month EPIC clinical trial, which assessed outcomes after antibiotic eradication therapy for newly identified P. aeruginosa. We then evaluated the associations between these baseline isolate phenotypes and subsequent outcomes during the trial, including failure to eradicate after antipseudomonal therapy, emergence of mucoidy, and occurrence of an exacerbation. RESULTS Baseline P. aeruginosa isolates frequently exhibited phenotypes thought to represent chronic adaptation, including mucoidy. Wrinkly colony surface and irregular colony edges were both associated with increased risk of eradication failure (hazard ratios [95% confidence intervals], 1.99 [1.03-3.83] and 2.14 [1.32-3.47], respectively). Phenotypes reflecting defective quorum sensing were significantly associated with subsequent mucoidy, but no phenotype was significantly associated with subsequent exacerbations during the trial. CONCLUSIONS Pseudomonas aeruginosa phenotypes commonly considered to reflect chronic adaptation were observed frequently among isolates at early detection. We found that 2 easily assayed colony phenotypes were associated with failure to eradicate after antipseudomonal therapy, both of which have been previously associated with altered biofilm formation and defective quorum sensing.
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Affiliation(s)
- Nicole Mayer-Hamblett
- Department of Pediatrics Department of Biostatistics Department of Seattle Children's Hospital, Washington
| | - Bonnie W Ramsey
- Department of Pediatrics Department of Seattle Children's Hospital, Washington
| | | | | | | | | | | | | | - Jane L Burns
- Department of Pediatrics Department of Seattle Children's Hospital, Washington
| | | | - Margaret Rosenfeld
- Department of Pediatrics Department of Seattle Children's Hospital, Washington
| | - Ronald L Gibson
- Department of Pediatrics Department of Seattle Children's Hospital, Washington
| | - Samuel I Miller
- Department of Microbiology Department of Genome Sciences Department of Medicine, University of Washington, Seattle
| | - Umer Khan
- Department of Seattle Children's Hospital, Washington
| | - Lucas R Hoffman
- Department of Pediatrics Department of Microbiology Department of Seattle Children's Hospital, Washington
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Lange L, Hu Y, Zhang H, Xue C, Schmidt E, Tang ZZ, Bizon C, Lange E, Smith J, Turner E, Jun G, Kang H, Peloso G, Auer P, Li KP, Flannick J, Zhang J, Fuchsberger C, Gaulton K, Lindgren C, Locke A, Manning A, Sim X, Rivas M, Holmen O, Gottesman O, Lu Y, Ruderfer D, Stahl E, Duan Q, Li Y, Durda P, Jiao S, Isaacs A, Hofman A, Bis J, Correa A, Griswold M, Jakobsdottir J, Smith A, Schreiner P, Feitosa M, Zhang Q, Huffman J, Crosby J, Wassel C, Do R, Franceschini N, Martin L, Robinson J, Assimes T, Crosslin D, Rosenthal E, Tsai M, Rieder M, Farlow D, Folsom A, Lumley T, Fox E, Carlson C, Peters U, Jackson R, van Duijn C, Uitterlinden A, Levy D, Rotter J, Taylor H, Gudnason V, Siscovick D, Fornage M, Borecki I, Hayward C, Rudan I, Chen Y, Bottinger E, Loos R, Sætrom P, Hveem K, Boehnke M, Groop L, McCarthy M, Meitinger T, Ballantyne C, Gabriel S, O’Donnell C, Post W, North K, Reiner A, Boerwinkle E, Psaty B, Altshuler D, Kathiresan S, Lin DY, Jarvik G, Cupples L, Kooperberg C, Wilson J, Nickerson D, Abecasis G, Rich S, Tracy R, Willer C, Gabriel S, Altshuler D, Abecasis G, Allayee H, Cresci S, Daly M, de Bakker P, DePristo M, Do R, Donnelly P, Farlow D, Fennell T, Garimella K, Hazen S, Hu Y, Jordan D, Jun G, Kathiresan S, Kang H, Kiezun A, Lettre G, Li B, Li M, Newton-Cheh C, Padmanabhan S, Peloso G, Pulit S, Rader D, Reich D, Reilly M, Rivas M, Schwartz S, Scott L, Siscovick D, Spertus J, Stitziel N, Stoletzki N, Sunyaev S, Voight B, Willer C, Rich S, Akylbekova E, Atwood L, Ballantyne C, Barbalic M, Barr R, Benjamin E, Bis J, Boerwinkle E, Bowden D, Brody J, Budoff M, Burke G, Buxbaum S, Carr J, Chen D, Chen I, Chen WM, Concannon P, Crosby J, Cupples L, D’Agostino R, DeStefano A, Dreisbach A, Dupuis J, Durda J, Ellis J, Folsom A, Fornage M, Fox C, Fox E, Funari V, Ganesh S, Gardin J, Goff D, Gordon O, Grody W, Gross M, Guo X, Hall I, Heard-Costa N, Heckbert S, Heintz N, Herrington D, Hickson D, Huang J, Hwang SJ, Jacobs D, Jenny N, Johnson A, Johnson C, Kawut S, Kronmal R, Kurz R, Lange E, Lange L, Larson M, Lawson M, Lewis C, Levy D, Li D, Lin H, Liu C, Liu J, Liu K, Liu X, Liu Y, Longstreth W, Loria C, Lumley T, Lunetta K, Mackey A, Mackey R, Manichaikul A, Maxwell T, McKnight B, Meigs J, Morrison A, Musani S, Mychaleckyj J, Nettleton J, North K, O’Donnell C, O’Leary D, Ong F, Palmas W, Pankow J, Pankratz N, Paul S, Perez M, Person S, Polak J, Post W, Psaty B, Quinlan A, Raffel L, Ramachandran V, Reiner A, Rice K, Rotter J, Sanders J, Schreiner P, Seshadri S, Shea S, Sidney S, Silverstein K, Smith N, Sotoodehnia N, Srinivasan A, Taylor H, Taylor K, Thomas F, Tracy R, Tsai M, Volcik K, Wassel C, Watson K, Wei G, White W, Wiggins K, Wilk J, Williams O, Wilson G, Wilson J, Wolf P, Zakai N, Hardy J, Meschia J, Nalls M, Singleton A, Worrall B, Bamshad M, Barnes K, Abdulhamid I, Accurso F, Anbar R, Beaty T, Bigham A, Black P, Bleecker E, Buckingham K, Cairns A, Caplan D, Chatfield B, Chidekel A, Cho M, Christiani D, Crapo J, Crouch J, Daley D, Dang A, Dang H, De Paula A, DeCelie-Germana J, Drumm A, Dyson M, Emerson J, Emond M, Ferkol T, Fink R, Foster C, Froh D, Gao L, Gershan W, Gibson R, Godwin E, Gondor M, Gutierrez H, Hansel N, Hassoun P, Hiatt P, Hokanson J, Howenstine M, Hummer L, Kanga J, Kim Y, Knowles M, Konstan M, Lahiri T, Laird N, Lange C, Lin L, Lin X, Louie T, Lynch D, Make B, Martin T, Mathai S, Mathias R, McNamara J, McNamara S, Meyers D, Millard S, Mogayzel P, Moss R, Murray T, Nielson D, Noyes B, O’Neal W, Orenstein D, O’Sullivan B, Pace R, Pare P, Parker H, Passero M, Perkett E, Prestridge A, Rafaels N, Ramsey B, Regan E, Ren C, Retsch-Bogart G, Rock M, Rosen A, Rosenfeld M, Ruczinski I, Sanford A, Schaeffer D, Sell C, Sheehan D, Silverman E, Sin D, Spencer T, Stonebraker J, Tabor H, Varlotta L, Vergara C, Weiss R, Wigley F, Wise R, Wright F, Wurfel M, Zanni R, Zou F, Nickerson D, Rieder M, Green P, Shendure J, Akey J, Bustamante C, Crosslin D, Eichler E, Fox P, Fu W, Gordon A, Gravel S, Jarvik G, Johnsen J, Kan M, Kenny E, Kidd J, Lara-Garduno F, Leal S, Liu D, McGee S, O’Connor T, Paeper B, Robertson P, Smith J, Staples J, Tennessen J, Turner E, Wang G, Yi Q, Jackson R, Peters U, Carlson C, Anderson G, Anton-Culver H, Assimes T, Auer P, Beresford S, Bizon C, Black H, Brunner R, Brzyski R, Burwen D, Caan B, Carty C, Chlebowski R, Cummings S, Curb J, Eaton C, Ford L, Franceschini N, Fullerton S, Gass M, Geller N, Heiss G, Howard B, Hsu L, Hutter C, Ioannidis J, Jiao S, Johnson K, Kooperberg C, Kuller L, LaCroix A, Lakshminarayan K, Lane D, Lasser N, LeBlanc E, Li KP, Limacher M, Lin DY, Logsdon B, Ludlam S, Manson J, Margolis K, Martin L, McGowan J, Monda K, Kotchen J, Nathan L, Ockene J, O’Sullivan M, Phillips L, Prentice R, Robbins J, Robinson J, Rossouw J, Sangi-Haghpeykar H, Sarto G, Shumaker S, Simon M, Stefanick M, Stein E, Tang H, Taylor K, Thomson C, Thornton T, Van Horn L, Vitolins M, Wactawski-Wende J, Wallace R, Wassertheil-Smoller S, Zeng D, Applebaum-Bowden D, Feolo M, Gan W, Paltoo D, Sholinsky P, Sturcke A. Whole-exome sequencing identifies rare and low-frequency coding variants associated with LDL cholesterol. Am J Hum Genet 2014; 94:233-45. [PMID: 24507775 DOI: 10.1016/j.ajhg.2014.01.010] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 01/14/2014] [Indexed: 10/25/2022] Open
Abstract
Elevated low-density lipoprotein cholesterol (LDL-C) is a treatable, heritable risk factor for cardiovascular disease. Genome-wide association studies (GWASs) have identified 157 variants associated with lipid levels but are not well suited to assess the impact of rare and low-frequency variants. To determine whether rare or low-frequency coding variants are associated with LDL-C, we exome sequenced 2,005 individuals, including 554 individuals selected for extreme LDL-C (>98(th) or <2(nd) percentile). Follow-up analyses included sequencing of 1,302 additional individuals and genotype-based analysis of 52,221 individuals. We observed significant evidence of association between LDL-C and the burden of rare or low-frequency variants in PNPLA5, encoding a phospholipase-domain-containing protein, and both known and previously unidentified variants in PCSK9, LDLR and APOB, three known lipid-related genes. The effect sizes for the burden of rare variants for each associated gene were substantially higher than those observed for individual SNPs identified from GWASs. We replicated the PNPLA5 signal in an independent large-scale sequencing study of 2,084 individuals. In conclusion, this large whole-exome-sequencing study for LDL-C identified a gene not known to be implicated in LDL-C and provides unique insight into the design and analysis of similar experiments.
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Mayer-Hamblett N, Rosenfeld M, Treggiari MM, Konstan MW, Retsch-Bogart G, Morgan W, Wagener J, Gibson RL, Khan U, Emerson J, Thompson V, Elkin EP, Ramsey BW. Standard care versus protocol based therapy for new onset Pseudomonas aeruginosa in cystic fibrosis. Pediatr Pulmonol 2013; 48:943-53. [PMID: 23818295 PMCID: PMC4059359 DOI: 10.1002/ppul.22693] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [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: 04/09/2012] [Accepted: 06/29/2012] [Indexed: 11/06/2022]
Abstract
RATIONALE The Early Pseudomonal Infection Control (EPIC) randomized trial rigorously evaluated the efficacy of different antibiotic regimens for eradication of newly identified Pseudomonas (Pa) in children with cystic fibrosis (CF). Protocol based therapy in the trial was provided based on culture positivity independent of symptoms. It is unclear whether outcomes observed in the clinical trial were different than those that would have been observed with historical standard of care driven more heavily by respiratory symptoms than culture positivity alone. We hypothesized that the incidence of Pa recurrence and hospitalizations would be significantly reduced among trial participants as compared to historical controls whose standard of care preceded the widespread adoption of tobramycin inhalation solution (TIS) as initial eradication therapy at the time of new isolation of Pa. METHODS Eligibility criteria from the trial were used to derive historical controls from the Epidemiologic Study of CF (ESCF) who received standard of care treatment from 1995 to 1998, before widespread availability of TIS. Pa recurrence and hospitalization outcomes were assessed over a 15-month time period. RESULTS As compared to 100% of the 304 trial participants, only 296/608 (49%) historical controls received antibiotics within an average of 20 weeks after new onset Pa. Pa recurrence occurred among 104/298 (35%) of the trial participants as compared to 295/549 (54%) of historical controls (19% difference, 95% CI: 12%, 26%, P < 0.001). No significant differences in the incidence of hospitalization were observed between cohorts. CONCLUSIONS Protocol-based antimicrobial therapy for newly acquired Pa resulted in a lower rate of Pa recurrence but comparable hospitalization rates as compared to a historical control cohort less aggressively treated with antibiotics for new onset Pa.
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Affiliation(s)
- Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
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Rowe SM, Borowitz DS, Burns JL, Clancy JP, Donaldson SH, Retsch-Bogart G, Sagel SD, Ramsey BW. Progress in cystic fibrosis and the CF Therapeutics Development Network. Thorax 2012; 67:882-90. [PMID: 22960984 PMCID: PMC3787701 DOI: 10.1136/thoraxjnl-2012-202550] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [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] [Indexed: 12/18/2022]
Abstract
Cystic fibrosis (CF), the most common life-shortening genetic disorder in Caucasians, affects approximately 70 000 individuals worldwide. In 1998, the Cystic Fibrosis Foundation (CFF) launched the CF Therapeutics Development Network (CF-TDN) as a central element of its Therapeutics Development Programme. Designed to accelerate the clinical evaluation of new therapies needed to fulfil the CFF mission to control and cure CF, the CF-TDN has conducted 75 clinical trials since its inception, and has contributed to studies as varied as initial safety and proof of concept trials to pivotal programmes required for regulatory approval. This review highlights recent and significant research efforts of the CF-TDN, including a summary of contributions to studies involving CF transmembrane conductance regulator (CFTR) modulators, airway surface liquid hydrators and mucus modifiers, anti-infectives, anti-inflammatories, and nutritional therapies. Efforts to advance CF biomarkers, necessary to accelerate the therapeutic goals of the network, are also summarised.
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Affiliation(s)
- Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham, 1819 University Boulevard (MCLM 768), Birmingham, AL 35294, USA.
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Burns J, LiPuma J, Retsch-Bogart G, Bresnik M, Henig N, McKevitt M, Lewis S, Tullis E. 58 No antibiotic cross-resistance after 1 year of continuous aztreonam for inhalation solution (AZLI) in cystic fibrosis (CF) patients (pts) with chronic Burkholderia (BURK) infection. J Cyst Fibros 2012. [DOI: 10.1016/s1569-1993(12)60228-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mayer-Hamblett N, Kronmal RA, Gibson RL, Rosenfeld M, Retsch-Bogart G, Treggiari MM, Burns JL, Khan U, Ramsey BW. Initial Pseudomonas aeruginosa treatment failure is associated with exacerbations in cystic fibrosis. Pediatr Pulmonol 2012; 47:125-34. [PMID: 21830317 PMCID: PMC3214247 DOI: 10.1002/ppul.21525] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [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: 04/15/2011] [Accepted: 06/16/2011] [Indexed: 11/07/2022]
Abstract
RATIONALE The risk of pulmonary exacerbation following Pseudomonas aeruginosa (Pa) acquisition in children with cystic fibrosis (CF) is unknown. OBJECTIVES To determine if failure of antibiotic therapy to eradicate Pa and frequency of Pa recurrence are associated with increased exacerbation risk. METHODS The cohort included 282 children with CF who participated in the EPIC trial ages 1-12 with newly acquired Pa, defined as either a first lifetime Pa positive respiratory culture or positive after two years of negative cultures (past isolation of Pa but >2 years prior to the trial). All received antibiotics to promote initial eradication followed by 15 months of intermittent maintenance antibiotics. Quarterly cultures were used to define initial eradication success and subsequent number of Pa recurrences. A standardized symptom-based definition of exacerbation was utilized. Cox proportional hazards models were used to estimate exacerbation risk. RESULTS Failure to initially eradicate Pa was associated with exacerbation risk (hazard ratio [HR]: 2.49, 95% confidence interval [CI] 1.26, 4.93). In 245/282 with successful initial eradication during the trial, past isolation of Pa >2 years before the trial was the most significant predictor of exacerbation (HR 1.62, 95% CI 1.12, 2.35). In 37/282 who failed initial eradication, persistent Pa during the maintenance phase (1 or more Pa recurrences after failure to initially eradicate) added even greater exacerbation risk (HR 4.13, 95% CI 1.28, 13.32). CONCLUSIONS Children with CF who fail to eradicate after initial antibiotic treatment are at higher risk of subsequent exacerbation, suggesting clinical benefit to successful early eradication of Pa infection.
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Affiliation(s)
- Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington, USA.
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Treggiari MM, Retsch-Bogart G, Mayer-Hamblett N, Khan U, Kulich M, Kronmal R, Williams J, Hiatt P, Gibson RL, Spencer T, Orenstein D, Chatfield BA, Froh DK, Burns JL, Rosenfeld M, Ramsey BW. Comparative efficacy and safety of 4 randomized regimens to treat early Pseudomonas aeruginosa infection in children with cystic fibrosis. Arch Pediatr Adolesc Med 2011; 165:847-56. [PMID: 21893650 PMCID: PMC3991697 DOI: 10.1001/archpediatrics.2011.136] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of 4 antipseudomonal treatments in children with cystic fibrosis with recently acquired Pseudomonas aeruginosa infection. DESIGN Randomized controlled trial. SETTING Multicenter trial in the United States. PARTICIPANTS Three hundred four children with cystic fibrosis aged 1 to 12 years within 6 months of P aeruginosa detection. INTERVENTIONS Participants were randomized to 1 of 4 antibiotic regimens for 18 months (six 12-week quarters) between December 2004 and June 2009. Participants randomized to cycled therapy received tobramycin inhalation solution (300 mg twice a day) for 28 days, with oral ciprofloxacin (15-20 mg/kg twice a day) or oral placebo for 14 days every quarter, while participants randomized to culture-based therapy received the same treatments only during quarters with positive P aeruginosa cultures. MAIN OUTCOME MEASURES The primary end points were time to pulmonary exacerbation requiring intravenous antibiotics and proportion of P aeruginosa -positive cultures. RESULTS The intention-to-treat analysis included 304 participants. There was no interaction between treatments. There were no statistically significant differences in exacerbation rates between cycled and culture-based groups (hazard ratio, 0.95; 95% confidence interval [CI], 0.54-1.66) or ciprofloxacin and placebo (hazard ratio, 1.45; 95% CI, 0.82-2.54). The odds ratios of P aeruginosa- positive culture comparing the cycled vs culture-based group were 0.78 (95% CI, 0.49-1.23) and 1.10 (95% CI, 0.71-1.71) comparing ciprofloxacin vs placebo. Adverse events were similar across groups. CONCLUSIONS No difference in the rate of exacerbation or prevalence of P aeruginosa positivity was detected between cycled and culture-based therapies. Adding ciprofloxacin produced no benefits. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00097773.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, WA 98104, USA.
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Tullis E, Burns J, Retsch-Bogart G, Bresnik M, Lewis S, Montgomery A, LiPuma J. 84 Aztreonam 75 mg powder and solvent for nebuliser solution (AZLI) in cystic fibrosis (CF) patients with chronic Burkholderia species (Burk) infection: baseline demographics and microbiology from a randomized, placebo-controlled trial. J Cyst Fibros 2011. [DOI: 10.1016/s1569-1993(11)60103-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rosenfeld M, Emerson J, McNamara S, Joubran K, Retsch-Bogart G, Graff GR, Gutierrez HH, Kanga JF, Lahiri T, Noyes B, Ramsey B, Ren CL, Schechter M, Morgan W, Gibson RL. Baseline characteristics and factors associated with nutritional and pulmonary status at enrollment in the cystic fibrosis EPIC observational cohort. Pediatr Pulmonol 2010; 45:934-44. [PMID: 20597081 DOI: 10.1002/ppul.21279] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [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] [Indexed: 11/06/2022]
Abstract
SUMMARY BACKGROUND The EPIC Observational Study is an ongoing prospective cohort study investigating risk factors for and clinical outcomes associated with early Pseudomonas aeruginosa (Pa) acquisition in young children with cystic fibrosis (CF). OBJECTIVES AND HYPOTHESIS To describe the baseline characteristics of the cohort and evaluate associations between potential risk factors and nutritional and respiratory characteristics at enrollment. We hypothesized that distinct demographic and environmental risk factors could be identified for poorer nutritional status and lung function at enrollment. METHODS During 2004-2006, 1,700 children with CF were enrolled at 59 US CF centers. Children <or=12 years were eligible if they had no prior Pa infection (Pa-Never) or, if prior isolation of Pa from respiratory cultures, at least a 2-year history of Pa negative cultures (Pa-Past). RESULTS One thousand one hundred seventeen participants (65.7%) were Pa-Never and 583 (34.3%) Pa-Past. Pa-never patients had a lower proportion of CFTR genotypes with both mutations in functional classes I, II, or III), higher lung function and less respiratory symptoms. Diagnosis after newborn or prenatal screening was associated with significantly higher mean weight, height, and FEV(1) at enrollment, while maternal smoking during pregnancy appeared to worsen these parameters. CONCLUSIONS Children in this cohort with a remote history of Pa infection had a higher proportion of CFTR genotypes associated with severely reduced CFTR function as well as lower lung function and more respiratory symptoms than those without prior Pa infection. These observed differences in respiratory indices may reflect the impact of prior Pa airway infection and/or of CFTR genotype or other genetic factors predisposing both to earlier Pa acquisition and more severe lung disease. Key characteristics associated with nutritional and pulmonary status at enrollment included diagnosis after prenatal or neonatal screening (protective) and in utero cigarette exposure (harmful).
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Affiliation(s)
- Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington, USA.
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Treggiari M, Retsch-Bogart G, Mayer-Hamblett N, Khan U, Kronmal R, Ramsey B, Accurso F. Comparative efficacy and safety of four randomized regimens to treat early Pseudomonas aeruginosa infection in children with cystic fibrosis. J Cyst Fibros 2010. [DOI: 10.1016/s1569-1993(10)60210-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
A high prevalence of low bone mineralization is documented in adult patients with cystic fibrosis (CF). Osteopenia is present in up to 85% of adult patients and osteoporosis in 10% to 34%. In children, study results are discordant probably because of comparisons to different control populations and corrections for bone size in growing children. Malnutrition, inflammation, vitamin D and vitamin K deficiency, altered sex hormone production, glucocorticoid therapy, and physical inactivity are well known risk factors for poor bone health. Puberty is a critical period for bone mineralization and requires a careful follow-up to achieve optimal bone peak mass. Strategies for optimizing bone health, such as monitoring bone mineral density (BMD) and providing preventive care are necessary from childhood through adolescence to minimize CF-related bone disease in adult CF patients.
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Affiliation(s)
- Isabelle Sermet-Gaudelus
- Centre de Référence et de Compétence en Mucoviscidose, Hopital Necker-Enfants Malades, INSERM U 845, Université René Descartes, Paris, France
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Treggiari MM, Rosenfeld M, Mayer-Hamblett N, Retsch-Bogart G, Gibson RL, Williams J, Emerson J, Kronmal RA, Ramsey BW. Early anti-pseudomonal acquisition in young patients with cystic fibrosis: rationale and design of the EPIC clinical trial and observational study'. Contemp Clin Trials 2009; 30:256-68. [PMID: 19470318 PMCID: PMC2783320 DOI: 10.1016/j.cct.2009.01.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 12/27/2008] [Accepted: 01/06/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND The primary cause of morbidity and mortality in patients with cystic fibrosis (CF) is progressive obstructive pulmonary disease due to chronic endobronchial infection, particularly with Pseudomonas aeruginosa (Pa). Risk factors for and clinical impact of early Pa infection in young CF patients are less well understood. PURPOSE The present studies are designed to evaluate risk factors and outcomes associated with early Pa acquisition, and the benefits and harms of four anti-pseudomonal treatment regimens in young CF patients initiated after the first Pa positive respiratory culture. METHODS The Early Pseudomonas Infection Control (EPIC) program consists of two studies, a randomized multicenter trial in CF patients ages 1-12 years at first isolation of Pa from a respiratory culture, and a longitudinal cohort study enrolling Pa-negative patients. Using a factorial design, trial participants are assigned for 18 months to either anti-pseudomonal treatment on a scheduled quarterly basis (cycled therapy) or based on recovery of Pa from quarterly respiratory cultures (culture-based therapy). The study drugs include inhaled tobramycin (300 mg BID) for 28 days, combined with either oral ciprofloxacin (15-20 mg/kg BID) or oral placebo for 14 days. The primary endpoints of the trial are the time to pulmonary exacerbation requiring IV antibiotics or hospitalization for respiratory symptoms, and the proportion of patients with new Pa-positive respiratory cultures during the study. The broad goals of the observational study are to describe the risk factors and outcomes associated with early acquisition of Pa. 306 patients were randomized in the clinical trial and 1787 were enrolled in the cohort study. CONCLUSIONS These companion studies will provide valuable epidemiological and microbiological information on early CF lung disease and Pa acquisition, and safety and clinical efficacy data on anti-pseudomonal treatment strategies for early Pa infections in the airways of young children with CF.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA.
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McCoy K, Retsch-Bogart G, Gibson R, Oermann C, Braff M, Montgomery A. Microbiologic resistance and clinical efficacy of aztreonam lysine for inhalation (AZLI) in cystic fibrosis (CF). J Cyst Fibros 2008. [DOI: 10.1016/s1569-1993(08)60138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Oermann C, McCoy K, Retsch-Bogart G, Gibson R, Quittner A, Montgomery A. Effect of multiple aztreonam lysine for inhalation (AZLI) cycles on disease-related endpoints and safety in patients with cystic fibrosis (CF) and Pseudomonas aeruginosa (PA): Interim analysis of 12 month data. J Cyst Fibros 2008. [DOI: 10.1016/s1569-1993(08)60097-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Treggiari MM, Rosenfeld M, Retsch-Bogart G, Gibson R, Ramsey B. Approach to eradication of initial Pseudomonas aeruginosa infection in children with cystic fibrosis. Pediatr Pulmonol 2007; 42:751-6. [PMID: 17647287 DOI: 10.1002/ppul.20665] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The primary cause of morbidity and mortality in children with cystic fibrosis (CF) is the progression of obstructive lung disease secondary to chronic endobronchial infection, mainly caused by Pseudomonas aeruginosa (Pa). Initial Pa isolates are typically non-mucoid, usually susceptible to most anti-pseudomonal antibiotics, and potentially amenable to eradication. Preliminary studies of early intervention suggest a "window of opportunity" with anti-pseudomonal antibiotics to eradicate Pa from upper and lower airways. Several large trials in young children with CF are currently ongoing with the goals of (1) investigating if early intervention at the time of initial Pa acquisition is effective and safe and (2) identifying the least invasive and safest treatment regimen to achieve both microbiologic and clinical benefits.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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Gibson RL, Emerson J, Mayer-Hamblett N, Burns JL, McNamara S, Accurso FJ, Konstan MW, Chatfield BA, Retsch-Bogart G, Waltz DA, Acton J, Zeitlin P, Hiatt P, Moss R, Williams J, Ramsey BW. Duration of treatment effect after tobramycin solution for inhalation in young children with cystic fibrosis. Pediatr Pulmonol 2007; 42:610-23. [PMID: 17534969 DOI: 10.1002/ppul.20625] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
RATIONALE Among young children with cystic fibrosis (CF), Pseudomonas aeruginosa (Pa) airway infection is associated with increased morbidity and mortality. Early intervention strategies include tobramycin solution for inhalation (TSI), which can eradicate lower airway Pa from cultures obtained at the end of 28 days of treatment in young children. METHODS We conducted an open label, sequential cohort study of TSI in young children with CF to investigate duration of antimicrobial treatment effect. The primary outcome was lower airway Pa eradication per bronchoalveolar lavage (BAL) fluid culture. Sequential treatment cohorts varied by duration of treatment (28 or 56 days) and timing of follow-up BAL (at Days 56, 84, or 112). Subjects (N = 36) were treated with TSI, 300 mg twice daily, for 28 days or 56 days per cohort assignment. RESULTS Among 31 evaluable subjects, culture based, lower airway Pa eradication was observed in the majority of subjects for up to 1-3 months following TSI treatment: 75% in Cohort 28/56 (days of treatment/day of follow-up BAL), 63% in Cohort 28/84, 82% in Cohort 56/112, and 75% in Cohort 28/112. Non-mucoid Pa at baseline and/or exotoxin A seronegativity were associated with higher rates of eradication. There was a less pronounced effect of TSI treatment on Pa eradication from oropharyngeal cultures in all cohorts. TSI treatment was associated with reduced neutrophilic airway inflammation and was not related to any serious adverse events. CONCLUSION TSI monotherapy is safe and can eradicate lower airway Pa for up to 3 months after treatment in young children with CF.
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Affiliation(s)
- Ronald L Gibson
- Department of Pediatrics, University of Washington/Children's Hospital & Regional Medical Center, Seattle, WA 98105-0371, USA.
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McCoy K, Retsch-Bogart G, Oermann C, Gibson R, Montgomery A. 40* Aztreonam lysine for inhalation (AZLI) for CF patients with P. aeruginosa (PA) infection. J Cyst Fibros 2007. [DOI: 10.1016/s1569-1993(07)60033-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Deterding R, Retsch-Bogart G, Milgram L, Gibson R, Daines C, Zeitlin PL, Milla C, Marshall B, Lavange L, Engels J, Mathews D, Gorden J, Schaberg A, Williams J, Ramsey B. Safety and tolerability of denufosol tetrasodium inhalation solution, a novel P2Y2 receptor agonist: results of a phase 1/phase 2 multicenter study in mild to moderate cystic fibrosis. Pediatr Pulmonol 2005; 39:339-48. [PMID: 15704203 DOI: 10.1002/ppul.20192] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Denufosol tetrasodium (INS37217) is a selective P2Y(2) agonist that stimulates ciliary beat frequency and Cl(-) secretion in normal and cystic fibrosis (CF) airway epithelia, and is being investigated as an inhaled treatment for CF. The Cl(-) secretory response is mediated via a non-CFTR pathway, and the driving force for Cl(-) secretion is enhanced by the effect of P2Y(2) activation to also inhibit epithelial Na(+) transport. Denufosol is metabolically more stable and better tolerated, and may enhance mucociliary clearance for a longer period of time than previously investigated P2Y(2) agonists. The goal of this phase 1/phase 2 study was to assess the safety and tolerability of single and repeated doses of aerosolized denufosol in subjects with CF. The study was a double-blind, placebo-controlled, multicenter comparison of ascending single doses of denufosol (10, 20, 40, and 60 mg, administered by inhalation via the Pari LC Star nebulizer) vs. placebo (normal saline), followed by a comparison of twice-daily administration of the maximum tolerated dose (MTD) of denufosol or placebo for 5 days. Thirty-seven adult (18 years of age or older) and 24 pediatric (5-17 years of age) subjects with CF were evaluated in five cohorts. Subjects were randomized in a 3:1 ratio to receive either denufosol or placebo within each cohort. The percent of subjects experiencing adverse events was similar between the denufosol and placebo groups. The most common adverse event in subjects receiving denufosol was chest tightness in adult subjects (39%) and cough in pediatric subjects (56%). Three (7%) subjects receiving denufosol and one (7%) subject receiving placebo experienced a serious adverse event. Forced expiratory volume in 1 sec (FEV(1)) profiles following dosing were similar across treatment groups, with some acute, reversible decline seen in both groups, most notably in subjects with lower lung function at baseline. In conclusion, doses up to 60 mg of denufosol inhalation solution were well-tolerated in most subjects. Some intolerability was noted among subjects with lower baseline lung function. Based on the results of this phase 1/phase 2 study, the Therapeutics Development Network (TDN) of the Cystic Fibrosis Foundation (CFF) and Inspire Pharmaceuticals, Inc., recently completed a multicenter, 28-day, phase 2 safety and efficacy clinical trial of denufosol inhalation solution in CF subjects with mild lung disease.
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Affiliation(s)
- Robin Deterding
- Department of Pediatrics, Children's Hospital, Denver, Colorado 80218, USA.
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Moss RB, Mayer-Hamblett N, Wagener J, Daines C, Hale K, Ahrens R, Gibson RL, Anderson P, Retsch-Bogart G, Nasr SZ, Noth I, Waltz D, Zeitlin P, Ramsey B, Starko K. Randomized, double-blind, placebo-controlled, dose-escalating study of aerosolized interferon gamma-1b in patients with mild to moderate cystic fibrosis lung disease. Pediatr Pulmonol 2005; 39:209-18. [PMID: 15573395 DOI: 10.1002/ppul.20152] [Citation(s) in RCA: 49] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interferon gamma-1b (IFN-gamma1b) is a pleiotropic cytokine with immunomodulatory activities that could decrease bacterial burden, inflammation, and obstruction in patients with CF. Patients with CF (> or =12 years old, FEV1 > or =40% predicted) were randomly assigned to sequential dose cohorts inhaling 500 microg IFN-gamma1b, 1,000 microg IFN-gamma1b, or placebo by Respirgard II nebulizer thrice weekly for 12 weeks. Sputum bacterial density and spirometry were measured. Safety, antibiotic use, hospitalization, and sputum neutrophils, elastase, DNA, IL-8, and myeloperoxidase were also evaluated. Sixty-six patients (mean age, 24 years, with mean baseline FEV1 of 74 +/- 20 (SD) percent predicted) were studied. One patient had bronchospasm after the first dose of IFN-gamma1b; the overall withdrawal rate was 15% (5 in the placebo group, 2 in the 500-microg IFN-gamma1b group, and 3 in the 1,000 microg IFN-gamma1b group). The 500-microg IFN-gamma1b dose was well-tolerated, but the 1,000-mug dose cohort, who had a higher baseline bacterial density than placebo patients (mean difference, 1.2 log(10) CFU/g sputum, 95% confidence interval (CI), 0.1,2.8, P=0.04), had 24% more hospitalizations for exacerbation than placebo patients (95% CI, 2,45%, P=0.05). There was a 0.12-l difference between the 500-microg IFN-gamma1b and placebo groups with respect to the 12-week change in FEV1 (active group minus placebo group, 95% CI, -0.03,0.26, P=0.11), as compared to a 0.01-l difference between the 1,000-microg IFN-gamma1b and placebo groups (95% CI, -0.16,0.17, P=0.96). No effects of IFN-gamma1b were seen in sputum bacterial density or inflammatory biomarkers at 12 weeks. Aerosolized IFN-gamma1b did not improve pulmonary function, reduce sputum bacterial density, or affect inflammatory sputum markers in patients with mild-moderate lung disease.
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Affiliation(s)
- Richard B Moss
- Department of Pediatrics, Stanford University Medical Center, Palo Alto, California 94304-5786, USA.
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Gibson RL, Emerson J, McNamara S, Burns JL, Rosenfeld M, Yunker A, Hamblett N, Accurso F, Dovey M, Hiatt P, Konstan MW, Moss R, Retsch-Bogart G, Wagener J, Waltz D, Wilmott R, Zeitlin PL, Ramsey B. Significant microbiological effect of inhaled tobramycin in young children with cystic fibrosis. Am J Respir Crit Care Med 2003; 167:841-9. [PMID: 12480612 DOI: 10.1164/rccm.200208-855oc] [Citation(s) in RCA: 225] [Impact Index Per Article: 10.7] [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] [Indexed: 12/20/2022] Open
Abstract
We conducted a double-blind, placebo-controlled, multicenter, randomized trial to test the hypothesis that 300 mg of tobramycin solution for inhalation administered twice daily for 28 days would be safe and result in a profound decrease in Pseudomonas aeruginosa (Pa) density from the lower airway of young children with cystic fibrosis. Ninety-eight subjects were to be randomized; however, the trial was stopped early because of evidence of a significant microbiological treatment effect. Twenty-one children under age 6 years were randomized (8 active; 13 placebo) and underwent bronchoalveolar lavage at baseline and on Day 28. There was a significant difference between treatment groups in the reduction in Pa density; no Pa was detected on Day 28 in 8 of 8 active group patients compared with 1 of 13 placebo group patients. We observed no differences between treatment groups for clinical indices, markers of inflammation, or incidence of adverse events. No abnormalities in serum creatinine or audiometry and no episodes of significant bronchospasm were observed in association with active treatment. We conclude that 28 days of tobramycin solution for inhalation of 300 mg twice daily is safe and effective for significant reduction of lower airway Pa density in young children with cystic fibrosis.
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Affiliation(s)
- Ronald L Gibson
- Department of Pediatrics, Children's Hospital and Regional Medical Center/University of Washington, Seattle, Washington 98105-0371, USA.
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Egan TM, Detterbeck FC, Mill MR, Bleiweis MS, Aris R, Paradowski L, Retsch-Bogart G, Mueller BS. Long term results of lung transplantation for cystic fibrosis. Eur J Cardiothorac Surg 2002; 22:602-9. [PMID: 12297180 DOI: 10.1016/s1010-7940(02)00376-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES We reviewed our experience with lung transplant for cystic fibrosis (CF) over a 10-year period to identify factors influencing long-term survival. METHODS One hundred and twenty-three patients with CF have undergone 131 lung transplant procedures at our institution; 114 have had bilateral sequential lung transplants (DLTX) and nine have had bilateral lower lobe transplants from living donors. Three patients had retransplant for acute graft failure, and five had late retransplant for bronchiolitis obliterans syndrome (BOS). Kaplan-Meier survival was calculated for the entire cohort and for subsets at higher risk of death to determine factors predicting a better outcome. RESULTS Actuarial survival for the entire group of DLTX CF patients was 81% at 1 year, 59% at 5 years, and 38% at 10 years. Lobar transplant was associated with a poorer survival (37.5% at 1 and 5 years). Among DLTX patients, colonization with Burkholderia cepacia was present in 22 patients and was associated with poorer outcome (1- and 5-year survival 60 and 36% in B. cepacia patients vs. 86 and 64% in non-cepacia patients). DLTX patients younger than age 20 (n=22) had a similar survival to patients age 20 or older (n=90). Being on a ventilator at the time of transplant was not associated with poorer survival (n=8). BOS affects increasing numbers of survivors with time. Five CF patients have been retransplanted due to BOS with one operative death and 1-year survival of 60%. CONCLUSIONS DLTX has acceptable long term survival in CF adults and children with end stage disease. CF patients colonized with B. cepacia have a worse outcome but transplantation is still warranted.
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Affiliation(s)
- T M Egan
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 108 Burnett-Womack Building, UNC, Chapel Hill, NC 27599-7065, USA.
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Rosenfeld M, Gibson R, McNamara S, Emerson J, McCoyd KS, Shell R, Borowitz D, Konstan MW, Retsch-Bogart G, Wilmott RW, Burns JL, Vicini P, Montgomery AB, Ramsey B. Serum and lower respiratory tract drug concentrations after tobramycin inhalation in young children with cystic fibrosis. J Pediatr 2001; 139:572-7. [PMID: 11598606 DOI: 10.1067/mpd.2001.117785] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the serum and lower respiratory tract tobramycin concentrations (C(T)) produced by a single dose of tobramycin for inhalation delivered by a nebulizer and a compressor in patients with cystic fibrosis (CF) 6 months to 6 years of age. STUDY DESIGN We performed a dose escalation study of serum C(T) measured before and 0.5, 1, 2, and 4 hours after a single dose of inhaled tobramycin, either 180 mg (10 patients) or 300 mg (19 patients). In a separate group of 12 patients, epithelial lining fluid (ELF) C(T) was measured by bronchoalveolar lavage 30 to 45 minutes after a 300-mg dose. RESULTS A 180-mg dose of inhaled tobramycin produced a mean peak serum C(T) of 0.5 microg/mL (SD 0.4; range, <0.2 to 1.4 microg/mL). A 300-mg dose produced a mean peak serum C(T) of 0.6 microg/mL (SD 0.5; range, <0.2 to 1.2 microg/mL). These peak values are well below the accepted maximum trough concentration with parenteral dosing (2 microg/mL). The target ELF C(T) was 20 microg/mL, 10-fold greater than the minimal inhibitory concentration for most Pseudomonas aeruginosa isolates from very young patients with CF (2 microg/mL). Mean ELF C(T) was 90 microg/mL (SD 54; range, 16 to 204 microg/mL) and exceeded the target concentration in 11 patients. CONCLUSION In patients with CF ages 6 months to 6 years, a single 300-mg dose of inhaled tobramycin appears to produce safe peak serum concentrations and drug concentrations in the bactericidal range in the lower respiratory tract.
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Affiliation(s)
- M Rosenfeld
- Division of Pulmonary Medicine, Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA
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