The future of pyrogenicity testing: Phasing out the rabbit pyrogen test. A meeting report

The rabbit pyrogen test (RPT) was the benchmark for pyrogenicity testing, but scientific advancements have provided innovative and humane methods, such as the in vitro monocyte-activation test (MAT). However, transitioning from the RPT to the MAT has been challenging. The European Directorate for the Quality of Medicines & HealthCare, the Council of Europe, and the European Partnership for Alternative Approaches to Animal Testing jointly hosted an international conference entitled "The future of pyrogenicity testing: phasing out the rabbit pyrogen test". The conference aimed to show how the European Pharmacopoeia intends to remove the RPT from its texts by 2026, facilitate the use of MAT, and identify gaps in the suppression of RPT. The events contributed to a better understanding of the barriers to RPT replacement and acceptance of in vitro alternatives. Participants comprised stakeholders from Asia, Europe, and North America, including vaccine developers, contract laboratories, and regulators. Participants shared their replacement strategies and experiences with MAT implementation. They emphasised the need for continued cooperation between stakeholders and stressed the importance of international harmonisation of regulatory requirements to help accelerate MAT acceptance outside Europe. Despite the challenges, the willingness to eliminate the unnecessary use of RPT was common across all participants.

3Rs implementation in veterinary vaccine batch-release testing: Current state-of-the-art and future opportunities. A webinar and workshop report

Regulatory authorities require veterinary batch-release testing to confirm vaccine potency and safety, but these tests have traditionally relied on large numbers of laboratory animals. Advances in vaccine research and development offer increasing opportunities to replace in vivo testing, and some stakeholders have made significant progress in incorporating 3Rs elements in quality control strategies. A three-part event series entitled "3Rs Implementation in Veterinary Vaccine Batch-Release Testing: Current state-of-the-art and future opportunities" was jointly organized by the Animal-Free Safety Assessment Collaboration, HealthforAnimals, and the International Alliance of Biological Standardization. Two webinars and a workshop aimed to outline the state-of-the-art non-animal approaches for veterinary batch-release testing. The events included information on the state of the deletion of obsolete safety testing and the current initiatives implemented by European, North American, and Asian-Pacific stakeholders on 3Rs implementation and regulatory acceptance. The events contributed to a better understanding of the barriers to 3Rs implementation. Participants highlighted the need for open communication, continued collaboration between stakeholders, and international harmonization of regulatory requirements to help accelerate acceptance. Despite the challenges, the countries represented at this three-part event have shared their commitments to advancing the acceptance of alternative methods.

Future of TABST and LABST in the Indian Pharmacopoeia Monographs A Humane Society International/India Workshop Report

Humane Society International India (HSI India) organized and facilitated a workshop on the 'Future of Target Animal Batch Safety Test (TABST) and Laboratory Animal Batch Safety Test (LABST) in the Indian Pharmacopoeia (IP) Monographs'. The workshop hosted key Indian regulators from the Indian Pharmacopoeia Commission (IPC) and the Central Drugs Standard Control Organization (CDSCO), industry representatives from the Indian Federation of Animal Health Companies (INFAH), Asian Animal Health Association (AAHA), and international experts representing the European Directorate for the Quality of Medicines (EDQM), the International Cooperation on Harmonization of Technical Requirements for Registration of Veterinary Medicinal Products (VICH), and multinational veterinary products manufacturers. The workshop was organized to encourage a bidirectional flow of information and to discuss the deletion of TABST and LABST from the veterinary vaccine monographs in the IP. This workshop was built from the symposium held by Humane Society International on the 'Global Harmonization of Vaccine Testing Requirements' held in 2019. This report details the outcomes of the workshop with proposed activities to be taken up as part of the next steps for the elimination or waiving of these tests.

The DetectDeviatingCells algorithm was a useful addition to the toolkit for cellwise error detection in observational data

OBJECTIVES

We evaluated the error detection performance of the DetectDeviatingCells (DDC) algorithm which flags data anomalies at observation (casewise) and variable (cellwise) level in continuous variables. We compared its performance to other approaches in a simulated dataset.

STUDY DESIGN AND SETTING

We simulated height and weight data for hypothetical individuals aged 2-20 years. We changed a proportion of height values according to predetermined error patterns. We applied the DDC algorithm and other error-detection approaches (descriptive statistics, plots, fixed-threshold rules, classic, and robust Mahalanobis distance) and we compared error detection performance with sensitivity, specificity, likelihood ratios, predictive values, and receiver operating characteristic (ROC) curves.

RESULTS

At our chosen thresholds error detection specificity was excellent across all scenarios for all methods and sensitivity was higher for multivariable and robust methods. The DDC algorithm performance was similar to other robust multivariable methods. Analysis of ROC curves suggested that all methods had comparable performance for gross errors (e.g., wrong measurement unit), but the DDC algorithm outperformed the others for more complex error patterns (e.g., transcription errors that are still plausible, although extreme).

CONCLUSIONS

The DDC algorithm has the potential to improve error detection processes for observational data.

Investigating the sociodemographic and behavioural factors associated with hepatitis C virus testing amongst people who inject drugs in England, Wales and Northern Ireland: A quantitative cross-sectional analysis

BACKGROUND

Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year).

METHODS

We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression.

RESULTS

Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67).

CONCLUSION

Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

Accelerating Global Deletion of the Abnormal Toxicity Test for vaccines and biologicals. Planning common next steps. A workshop Report

This online workshop Accelerating Global Deletion of the Abnormal Toxicity Test for vaccines and biologicals. Planning common next steps was organized on October 14th, 2021, by the Animal Free Safety Assessment Collaboration (AFSA), the Humane Society International (HSI), the European Federation of Pharmaceutical Industries and Associations (EFPIA), in collaboration with the International Alliance of Biological Standardization (IABS). The workshop saw a participation of over a hundred representatives from international organizations, pharmaceutical industries and associations, and regulatory authorities of 28 countries. Participants reported on country- and region-specific regulatory requirements and, where present, on the perspectives on the waiving and elimination of the Abnormal Toxicity Test. With AFSA, HSI, EFPIA and IABS representatives as facilitators, the participants also discussed specific country/global actions to further secure the deletion of ATT from all regulatory requirements worldwide.

COVID-19 through Adverse Outcome Pathways: Building networks to better understand the disease - 3rd CIAO AOP Design Workshop

On April 28-29, 2021, 50 scientists from different fields of expertise met for the 3rd online CIAO workshop. The CIAO project “Modelling the Pathogenesis of COVID-19 using the Adverse Outcome Pathway (AOP) framework” aims at building a holistic assembly of the available scientific knowledge on COVID-19 using the AOP framework. An individual AOP depicts the disease progression from the initial contact with the SARS-CoV-2 virus through biological key events (KE) toward an adverse outcome such as respiratory distress, anosmia or multiorgan failure. Assembling the individual AOPs into a network highlights shared KEs as central biological nodes involved in multiple outcomes observed in COVID-19 patients. During the workshop, the KEs and AOPs established so far by the CIAO members were presented and posi­tioned on a timeline of the disease course. Modulating factors influencing the progression and severity of the disease were also addressed as well as factors beyond purely biological phenomena. CIAO relies on an interdisciplinary crowd­sourcing effort, therefore, approaches to expand the CIAO network by widening the crowd and reaching stakeholders were also discussed. To conclude the workshop, it was decided that the AOPs/KEs will be further consolidated, inte­grating virus variants and long COVID when relevant, while an outreach campaign will be launched to broaden the CIAO scientific crowd.

Systematic Organization of COVID-19 Data Supported by the Adverse Outcome Pathway Framework

Adverse Outcome Pathways (AOP) provide structured frameworks for the systematic organization of research data and knowledge. The AOP framework follows a set of key principles that allow for broad application across diverse disciplines related to human health, including toxicology, pharmacology, virology and medical research. The COVID-19 pandemic engages a great number of scientists world-wide and data is increasing with exponential speed. Diligent data management strategies are employed but approaches for systematically organizing the data-derived information and knowledge are lacking. We believe AOPs can play an important role in improving interpretation and efficient application of scientific understanding of COVID-19. Here, we outline a newly initiated effort, the CIAO project (https://www.ciao-covid.net/), to streamline collaboration between scientists across the world toward development of AOPs for COVID-19, and describe the overarching aims of the effort, as well as the expected outcomes and research support that they will provide.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Animal testing for vaccines. Implementing replacement, reduction and refinement: challenges and priorities

Transition to in vitro alternative methods from in vivo in vaccine release testing and characterization, the implementation of the consistency approach, and a drive towards international harmonization of regulatory requirements are most pressing needs in the field of vaccines. It is critical for global vaccine community to work together to secure effective progress towards animal welfare and to ensure that vaccines of ever higher quality can reach the populations in need in the shortest possible timeframe. Advancements in the field, case studies, and experiences from Low and Middle Income Countries (LMIC) were the topics discussed by an international gathering of experts during a recent conference titled "Animal Testing for Vaccines - Implementing Replacement, Reduction and Refinement: Challenges and Priorities". This conference was organized by the International Alliance for Biological Standardization (IABS), and held in Bangkok, Thailand on December 3 and 4 2019. Participants comprised stakeholders from many parts of the world, including vaccine developers, manufacturers and regulators from Asia, Europe, North America, Australia and New Zealand. In interactive workshops and vibrant panel discussions, the attendees worked together to identify the remaining barriers to validation, acceptance and implementation of alternative methods, and how harmonization could be promoted, especially for LMICs.

An observational study of the lung clearance index throughout childhood in cystic fibrosis: early years matter

The London Cystic Fibrosis Collaboration (LCFC) has prospectively followed a clinically diagnosed cohort of infants with cystic fibrosis (CF) born in South East England since 1999 [1–4]. Over the past 20 years, the LCFC has obtained comprehensive measures of lung function and structure, including measures of ventilation inhomogeneity (lung clearance index (LCI)) and high-resolution computed tomography (HRCT) scans. By pre-school age, 73% of this cohort had LCI above the limits of normal, compared with 7% with abnormal forced expiratory volume in 0.5 seconds (FEV_0.5) [1]. Children with elevated LCI during pre-school years also had worse lung function at early school age [2]. The aim of this study was to investigate how LCI changes across childhood to better understand to what extent LCI results at pre-school age are an indicator of lung disease severity in adolescence.

Lung clearance index (LCI) in the early years was associated with LCI during adolescence in children with cystic fibrosis. Pre-school LCI may help to identify children in whom treatment could be intensified.https://bit.ly/2yKyMbM

Global harmonization of vaccine testing requirements: Making elimination of the ATT and TABST a concrete global achievement

This one-day symposium organized by Humane Society International (HSI) brought together 18 international experts from Argentina, Brazil, China, Europe, India, Russia, South Africa and the United States to discuss the elimination of the abnormal toxicity test (ATT) from the testing requirements for human vaccines as well as the target animal batch safety test (TABST) and the laboratory animal batch safety test (LABST) for veterinary vaccines. Participants reported on country-specific regulatory requirements and, where present, the perspectives on waiver and elimination of those tests. In addition, the attendees, with HSI in the role of facilitator, moved to define the barriers to the complete elimination or waiving of these tests. This report expounds the outcomes of the symposium, and introduces a proposed roadmap - populated with country specific activities - for the elimination of these tests.

Drivers and barriers in the consistency approach for vaccine batch release testing: Report of an international workshop

Safety and potency assessment for batch release testing of established vaccines still relies partly on animal tests. An important avenue to move to batch release without animal testing is the consistency approach. This approach is based on thorough characterization of the vaccine, and the principle that the quality of subsequent batches is the consequence of the application of consistent production of batches monitored by a GMP quality system. Efforts to implement the consistency approach are supported by several drivers from industry, government, and research, but there are also several barriers that must be overcome. A workshop entitled "Consistency Approach, Drivers and Barriers" was organized, which aimed to discuss and identify drivers and barriers for the implementation of the 3Rs in the consistency approach from three different perspectives/domains (industry, regulatory and science frameworks). The workshop contributed to a better understanding of these drivers and barriers and resulted in recommendations to improve the overall regulatory processes for the consistency approach. With this report, we summarise the outcome of this workshop and intend to offer a constructive contribution to the international discussion on regulatory acceptance of the consistency approach.

Epidemiology of nontuberculous mycobacteria (NTM) amongst individuals with cystic fibrosis (CF)

BACKGROUND

Infection by nontuberculous mycobacteria (NTM) in patients with cystic fibrosis (CF) is often associated with significant morbidity. Limited, conflicting results are published regarding risk factors for pulmonary NTM disease. We analysed factors potentially associated with NTM in a large population of European patients with CF.

METHODS

We investigated associations between presence of NTM and various factors for patients registered in the European Cystic Fibrosis Society Patient Registry.

RESULTS

374 (2.75%) of 13,593 patients studied had at least one positive NTM culture within the study year. Age- and FEV1-adjusted odds of NTM infection was more than 2.5 times higher (95%CI: 1.79; 3.60) in patients infected by Stenotrophomonas maltophilia than in patients not infected (p<0.0001), 2.36 times higher (95%CI: 1.80;3.08) in patients with ABPA than without (p<0.0001), 1.79 times higher (95%CI: 1.34; 2.38) in patients who use bronchodilators than in patients who don't (p<0.0001), 1.49 times higher (95%CI: 1.18; 1.89) in patients who use inhaled antibiotics than in patients who don't (p=0.001), and 1.30 times higher (95%CI: 1.02; 1.66) in patients who use rhDNase than in patients who don't (p=0.032).

CONCLUSIONS

NTM-positive cultures in individuals with CF are associated with distinct clinical variables. Improved data collection identifying risk factors for NTM infection will allow more focused screening strategies, and influence therapeutic choices and infection control measures in high-risk patients.

Estimating the Incidence of Acute Infectious Intestinal Disease in the Community in the UK: A Retrospective Telephone Survey

Objectives

To estimate the burden of intestinal infectious disease (IID) in the UK and determine whether disease burden estimations using a retrospective study design differ from those using a prospective study design.

Design/Setting

A retrospective telephone survey undertaken in each of the four countries comprising the United Kingdom. Participants were randomly asked about illness either in the past 7 or 28 days.

Participants

14,813 individuals for all of whom we had a legible recording of their agreement to participate

Outcomes

Self-reported IID, defined as loose stools or clinically significant vomiting lasting less than two weeks, in the absence of a known non-infectious cause.

Results

The rate of self-reported IID varied substantially depending on whether asked for illness in the previous 7 or 28 days. After standardising for age and sex, and adjusting for the number of interviews completed each month and the relative size of each UK country, the estimated rate of IID in the 7-day recall group was 1,530 cases per 1,000 person-years (95% CI: 1135–2113), while in the 28-day recall group it was 533 cases per 1,000 person-years (95% CI: 377–778). There was no significant variation in rates between the four countries. Rates in this study were also higher than in a related prospective study undertaken at the same time.

Conclusions

The estimated burden of disease from IID varied dramatically depending on study design. Retrospective studies of IID give higher estimates of disease burden than prospective studies. Of retrospective studies longer recall periods give lower estimated rates than studies with short recall periods. Caution needs to be exercised when comparing studies of self-reported IID as small changes in study design or case definition can markedly affect estimated rates.

Report of the European Respiratory Society/European Cystic Fibrosis Society task force on the care of adults with cystic fibrosis

The improved survival in people with cystic fibrosis has led to an increasing number of patients reaching adulthood. This trend is likely to be maintained over the next decades, suggesting a need to increase the number of centres with expertise in the management of adult patients with cystic fibrosis. These centres should be capable of delivering multidisciplinary care addressing the complexity of the disease, in addition to addressing the psychological burden on patients and their families. Further issues that require attention are organ transplantation and end of life management.Lung disease in adults with cystic fibrosis drives most of the clinical care requirements, and major life-threatening complications, such as respiratory infection, respiratory failure, pneumothorax and haemoptysis, and the management of lung transplantation require expertise from trained respiratory physicians. The taskforce therefore strongly reccommends that medical leadership in multidisciplinary adult teams should be attributed to a respiratory physician adequately trained in cystic fibrosis management.The task force suggests the implementation of a core curriculum for trainees in adult respiratory medicine and the selection and accreditation of training centres that deliver postgraduate training to the standards of the HERMES programme.

Future trends in cystic fibrosis demography in 34 European countries

Median survival has increased in people with cystic fibrosis (CF) during the past six decades, which has led to an increased number of adults with CF. The future impact of changes in CF demographics has not been evaluated. The aim of this study was to estimate the number of children and adults with CF in 34 European countries by 2025.

Data were obtained from the European Cystic Fibrosis Society Patient Registry. Population forecasts were performed for countries that have extensive CF population coverage and at least 4 years of longitudinal data by modelling future entering and exiting flows in registry cohorts. For the other countries, population projections were performed based on assumptions from knowledge of current CF epidemiology.

Western European countries’ forecasts indicate that an increase in the overall number of CF patients by 2025, by approximately 50%, corresponds to an increase by 20% and by 75% in children and adults, respectively. In Eastern European countries the projections suggest a predominant increase in the CF child population, although the CF adult population would also increase.

It was concluded that a large increase in the adult CF population is expected in the next decade. A significant increase in adult CF services throughout Europe is urgently required.

The vaccines consistency approach project: an EPAA initiative

The consistency approach for release testing of established vaccines promotes the use of in vitro, analytical, non-animal based systems allowing the monitoring of quality parameters during the whole production process. By using highly sensitive non-animal methods, the consistency approach has the potential to improve the quality of testing and to foster the 3Rs (replacement, refinement and reduction of animal use) for quality control of established vaccines. This concept offers an alternative to the current quality control strategy which often requires large numbers of laboratory animals. In order to facilitate the introduction of the consistency approach for established human and veterinary vaccine quality control, the European Partnership for Alternatives to Animal Testing (EPAA) initiated a project, the "Vaccines Consistency Approach Project", aiming at developing and validating the consistency approach with stakeholders from academia, regulators, OMCLs, EDQM, European Commission and industry. This report summarises progress since the project's inception.

The European Cystic Fibrosis Society Patient Registry: valuable lessons learned on how to sustain a disease registry

BACKGROUND

Disease registries have the invaluable potential to provide an insight into the natural history of the disease under investigation, to provide useful information (e.g. through health indicators) for planning health care services and to identify suitable groups of patients for clinical trials enrolment. However, the establishment and maintenance of disease registries is a burdensome initiative from economical and organisational points of view and experience sharing on registries management is important to avoid waste of resources. The aim of this paper is to discuss the problems embedded in the institution and management of an international disease registry to warn against common mistakes that can derail the best of intentions: we share the experience of the European Cystic Fibrosis Society Patient Registry, which collects data on almost 30,000 patients from 23 countries.

METHODS

We discuss the major problems that researchers often encounter in the creation and management of disease registries: definition of the aims the registry has to reach, definition of the criteria for patients referral to the registry, definition of the information to record, set up of a data quality process, handling of missing data, maintenance of data confidentiality, regulation of data use and dissemination of research results.

RESULTS

We give examples on how many crucial aspects were solved by the European Cystic Fibrosis Society Patient Registry regarding objectives, inclusion criteria and variables definition, data management, data quality controls, missing data handling, confidentiality maintenance, data use and results dissemination.

CONCLUSIONS

We suggest an extensive literature research and discussions in working groups with different stake holders, including patient representatives, on the objectives, inclusion criteria and the information to record. We propose to pilot the recording of few variables and test the applicability of their definition first. The use of a shared electronic platform for data collection that automatically computes derived variables, and automatically performs basic data quality controls is a good data management practice, that also helps in reducing missing data. We found crucial for success the collaboration with existing national and international registries, cystic fibrosis organisations and patients' associations.

The relative frequency of CFTR mutation classes in European patients with cystic fibrosis

More than 1900 different mutations in the CFTR gene have been reported. These are grouped into classes according to their effect on the synthesis and/or function of the CFTR protein. CFTR repair therapies that are mutation or mutation class specific are under development. To progress efficiently in the clinical phase of drug development, knowledge of the relative frequency of CFTR mutation classes in different populations is useful. Therefore, we describe the mutation class spectrum in 25,394 subjects with CF from 23 European countries. In 18/23 countries, 80% or more of the patients had at least one class II mutation, explained by F508del being by far the most frequent mutation. Overall 16.4% of European patients had at least one class I mutation but this varied from 3 countries with more than 30% to 4 countries with less than 10% of subjects. Overall only respectively 3.9, 3.3 and 3.0% of European subjects had at least one mutation of classes III, IV and V with again great variability: 14% of Irish patients had at least one class III mutation, 7% of Portuguese patients had at least one class IV mutation, and in 6 countries more than 5% of patients had at least one class V mutation.

The second study of infectious intestinal disease (IID2): increased rates of recurrent diarrhoea in individuals aged 65 years and above

Background

Infectious intestinal disease (IID) is a major health and economic burden in high-income countries. In the UK, there are an estimated 17 million IID cases annually, of which 6 million are caused by the 12 most common pathogens. Host factors that influence risk of IID are not well understood.

Methods

We analyzed data from the IID2 Study, a UK cohort that measured IID incidence, to investigate factors associated with recurrent IID. We calculated rates of IID by age group, sex, previous episodes experienced, and socioecomic indicators. We used Cox models to investigate factors associated with recurrent illness.

Results

The rate of IID was five times higher among infants than those aged 65 years and above (hazard ratio, HR = 5.0, 95% CI: 3.1 – 8.0). However, the association between previous IID and a subsequent IID episode was stronger in the elderly. Among those aged 65 years and above, each additional IID episode increased the rate of subsequent IID three-fold (HR = 3.1, 95% CI: 2.5 – 3.7). Among infants, the corresponding increase was 1.7-fold (HR = 1.7, 95% CI: 1.3 – 2.3).

Conclusions

Elderly populations have a high propensity for recurrent IID. More detailed studies are needed to identify vulnerable subgroups and susceptibility factors, and inform adequate control policies among the elderly.

Factors associated with FEV1 decline in cystic fibrosis: analysis of the ECFS patient registry

Pulmonary insufficiency is the main cause of death in cystic fibrosis (CF). We analysed forced expiratory volume in 1 s (FEV1) data of 14,732 patients registered in the European Cystic Fibrosis Society Patient Registry (ECFSPR) database in 2007. We used linear and logistic regressions to investigate associations between FEV1 % predicted and clinical outcomes. Body mass index (BMI), chronic infection by Pseudomonas aeruginosa, pancreatic status and CF-related diabetes (CFRD) showed a statistically significant (all p<0.0001) and clinically relevant effect on FEV1 % pred after adjusting for age. Patients with a lower BMI experience a six-fold increased odds ratio (95% CI 5.0-7.3) of having severe lung disease (FEV1 <40% pred) compared to patients with normal BMI. Being chronically infected with P. aeruginosa increases the odds ratio of severe lung disease by 2.4 (95% CI 2.0-2.7), and patients with pancreatic insufficiency experience a 2.0-fold increased odds ratio (95% CI 1.6-2.5) of severe lung disease compared to pancreatic sufficient patients. Patients with CFRD have a 1.8-fold increased odds ratio (95% CI 1.6-2.2) compared to patients not affected. These potential risk factors for pulmonary disease in patients with CF are to some degree preventable or treatable. We emphasise the importance of their early identification through frequent routine tests, the implementation of infection control measures, and a timely initiation of relevant therapies.

Reference percentiles for FEV(1) and BMI in European children and adults with cystic fibrosis

Background

The clinical course of Cystic Fibrosis (CF) is usually measured using the percent predicted FEV₁ and BMI Z-score referenced against a healthy population, since achieving normality is the ultimate goal of CF care. Referencing against age and sex matched CF peers may provide valuable information for patients and for comparison between CF centers or populations. Here, we used a large database of European CF patients to compute CF specific reference equations for FEV₁ and BMI, derived CF-specific percentile charts and compared these European data to their nearest international equivalents.

Methods

34859 FEV₁ and 40947 BMI observations were used to compute European CF specific percentiles. Quantile regression was applied to raw measurements as a function of sex, age and height. Results were compared with the North American equivalent for FEV₁ and with the WHO 2007 normative values for BMI.

Results

FEV₁ and BMI percentiles illustrated the large variability between CF patients receiving the best current care. The European CF specific percentiles for FEV₁ were significantly different from those in the USA from an earlier era, with higher lung function in Europe. The CF specific percentiles for BMI declined relative to the WHO standard in older children. Lung function and BMI were similar in the two largest contributing European Countries (France and Germany).

Conclusion

The CF specific percentile approach applied to FEV₁ and BMI allows referencing patients with respect to their peers. These data allow peer to peer and population comparisons in CF patients.

Longitudinal study of infectious intestinal disease in the UK (IID2 study): incidence in the community and presenting to general practice

OBJECTIVES

To estimate, overall and by organism, the incidence of infectious intestinal disease (IID) in the community, presenting to general practice (GP) and reported to national surveillance.

DESIGN

Prospective, community cohort study and prospective study of GP presentation conducted between April 2008 and August 2009.

SETTING

Eighty-eight GPs across the UK recruited from the Medical Research Council General Practice Research Framework and the Primary Care Research Networks.

PARTICIPANTS

6836 participants registered with the 88 participating practices in the community study; 991 patients with UK-acquired IID presenting to one of 37 practices taking part in the GP presentation study.

MAIN OUTCOME MEASURES

IID rates in the community, presenting to GP and reported to national surveillance, overall and by organism; annual IID cases and GP consultations by organism.

RESULTS

The overall rate of IID in the community was 274 cases per 1000 person-years (95% CI 254 to 296); the rate of GP consultations was 17.7 per 1000 person-years (95% CI 14.4 to 21.8). There were 147 community cases and 10 GP consultations for every case reported to national surveillance. Norovirus was the most common organism, with incidence rates of 47 community cases per 1000 person-years and 2.1 GP consultations per 1000 person-years. Campylobacter was the most common bacterial pathogen, with a rate of 9.3 cases per 1000 person-years in the community, and 1.3 GP consultations per 1000 person-years. We estimate that there are up to 17 million sporadic, community cases of IID and 1 million GP consultations annually in the UK. Of these, norovirus accounts for 3 million cases and 130,000 GP consultations, and Campylobacter is responsible for 500,000 cases and 80,000 GP consultations.

CONCLUSIONS

IID poses a substantial community and healthcare burden in the UK. Control efforts must focus particularly on reducing the burden due to Campylobacter and enteric viruses.

Impact of the A (H1N1) pandemic influenza (season 2009-2010) on patients with cystic fibrosis

BACKGROUND

Influenza, like other respiratory viral infections, can cause acute deterioration of lung function in patients with cystic fibrosis (CF). Previous studies on a small number of patients reported that most people with CF infected with A (H1N1) influenza experienced a mild course of disease.

AIM

To characterise the impact of A (H1N1) infection on CF in a large number of patients from different centres and countries.

METHODS

CF centres accessing the web-site of the European Cystic Fibrosis Society (ECFS) were asked to report clinical data on patients with an ascertained diagnosis of influenza caused by the A (H1N1) virus. The study was web-based and data were collected through an electronic data sheet on the ECFS website.

RESULTS

Twenty-five centres from 10 countries caring for 4698 patients with CF reported data on 110 patients (2.3%), median age 13 years (range 1-39 years). The prevalence of infection in each centre ranged from 0% to 9.4%. Only 8.8% of the patients had been vaccinated. The main symptoms were fever and respiratory exacerbation requiring IV antibiotics in 53% of the patients; 48% of the patients were hospitalised for an average of 12.9 days (range 2-56) and 31% required oxygen treatment during the time of the infection. Most of the patients recovered and FEV(1) 1 month after the infection was similar to that before the infection. However, 6 patients were admitted to ICU, 5 with mechanical ventilation. Three patients with severe respiratory disease died.

CONCLUSIONS

A (H1N1) influenza infection caused transient but significant morbidity in most of the patients with CF. However, in a small number of patients with severe lung disease, A (H1N1) influenza was associated with respiratory deterioration, mechanical ventilation and even death.

50 FIRST EQUINE CLONE BORN IN ARGENTINA BY SOMATIC CELL NUCLEAR TRANSFER FROM A POLO ARGENTINO MARE

Births of the first cloned equids were reported in 2003 (Woods et al. 2003 Science 301(5636), 1063; Galli et al. 2003 Nature 424 (6949), 635) but no equine clones have been reported in Latin America. The aim of this work was to inform the birth of the first equine clone in Argentina as a result of interdisciplinary teamwork. Equine oocytes were obtained from slaughterhouse ovaries and were transported at 38°C for 15 h in TCM-199 buffered with 20 mM HEPES and supplemented with 1 mM glutamine, 0.19 mM sodium pyruvate, 2 μg mL–1 LH, 5 μg mL–1 FSH, 100 ng mL–1 EGF, 100 ng mL–1 IGF-I, and 10% FCS. After 16 to 18 h of maturation, oocytes were denuded and enucleated. Frozen–thawed somatic cells from 1 of 2 aged (23 and 20 years old) Polo Argentino breed donor mares were inserted into the perivitelline space of each enucleated oocyte and fusion was induced. Activation was performed by exposure to Ionomycin (5 μM) for 4 min, followed by 4 h culture in a combination of 6-DMAP and cycloheximide in SOFaas culture media (Choi et al. 2001 Reproduction 122, 177–183). Embryos were cultured in 50 μL SOFm droplets for 7 to 8 days and then were transferred non-surgically to anovulatory recipient mares treated with 1.5 mg oestrogen, followed by long acting progesterone (BioRelease P4 300 LA, BET Pharm, KY). The production rates of the first cell line were: fusion 301/553 (54.4%), cleavage 163/218 (53.4%), blastocysts produced 20/163 (12.2%), blastocysts transferred 18/20 (90%), pregnancies 1/18 (5.5%) and no foal born. The production rates of the second cell line were: fusion 252/553 (45.6%), cleavage 55/252 (21.8%), blastocysts produced 8/55 (14.5%), blastocysts transferred 7/8 (87.5%), pregnancies 4/7 (57%) and 1 filly was born. DNA microsatellite analysis confirmed that the filly was a clone from the original donor cell line. The filly, born naturally on Day 329 of gestation, suffered premature placental separation and weighed 12 kg. Despite the intensive care provided, the filly’s respiratory, nervous, and cardiovascular functions deteriorated rapidly and she died 14 h postpartum. Fetal membranes weighed 5.7 kg (47.5% of the filly’s weight) and showed marked oedema of the chorioalantois and umbilical cord (which also showed a torsion of 9 twists). Histopathologically, the chorioalantois showed scant and poorly developed villi and also connective tissue oedema. Death could have been due to marked immaturity, as a consequence of placental insufficiency and umbilical cord torsion.

Evaluation of a home telemonitoring service for adult patients with cystic fibrosis: a pilot study

We have conducted a pilot trial of a home telemonitoring system involving 60 adult patients with cystic fibrosis (CF) enrolled at four Italian CF centres. Thirty randomly selected patients received a home device to perform spirometry and to measure oxygen saturation. The data were transferred to a data centre which forwarded them to the patient's CF clinic. The telemonitoring system was evaluated using questionnaires completed by patients and their doctors. The doctors reported that telemonitoring was useful in monitoring their patients' health status and in decreasing the CF centre workload. The data transfer procedure posed no particular problems for the patients. The major difficulties reported by the patients were night-time saturimetry measurements, and in the first week of the study, data transmission to the data centre. The pilot trial was positive and therefore merits a larger study.

Comparative demographics of the European cystic fibrosis population: a cross-sectional database analysis

BACKGROUND

Country-specific patients' registries are rarely used to make international comparisons because of protocol discrepancies in data collation. We present data from a European cystic fibrosis registry that is dedicated to collection of demographic data, and assess whether the resources available in countries with and without European Union (EU) membership affects care and survival of patients.

METHODS

Data for demographic indicators-age, age at diagnosis, sex, and genotype-for patients with cystic fibrosis from 35 European countries were combined, and used to establish the differences in demographic indicators between EU and non-EU countries. EU membership status in 2003 was used to divide countries. We modelled demographic indicators of EU countries on non-EU countries to estimate the size of the cystic fibrosis population if non-EU countries had had the same resources available for patients as did EU countries.

FINDINGS

Data were gathered for 29 025 patients, who had a median age of 16.3 years (IQR 8.9-24.8), with a difference of 4.9 years (95% CI 4.4-5.1; p<0.0001) between EU (median 17.0 years, IQR 9.5-25.6) and non-EU countries (12.1 years, 6.0-19.2). The proportion of patients older than 40 years was higher in EU countries (1205 [5%]) than in non-EU countries (76 [2%]), with an odds ratio of 2.4 (95% CI 1.9-3.0, p<0.0001). We estimated that the cystic fibrosis population in non-EU countries would increase by 84% if patients had a demographic profile comparable to that of patients in EU countries.

INTERPRETATION

Future studies need to establish the reasons for the lower proportion of patients with cystic fibrosis in non-EU countries than in EU countries, such as underdiagnosis and premature childhood mortality.

FUNDING

European Community's Sixth Framework Programme for Research, and Czech Ministry of Health.

[The Italian registry for cystic fibrosis: what has changed in the last decade]

Cystic Fibrosis is the most common life-shortening autosomal recessive disease of Caucasian population. The clinical expression of the disease is heterogeneous and the treatment of CF patients requires high qualification of medical and paramedical staff. In 1992 and 1993, in Italy, two national laws (104/92 and 548/93) were enacted in favour of people affected by CF. Data gathered in the Italian Registry for CF (started on 1.1.1988) allow us to monitor changes occurred in the age structure of patients and diagnosis methods. This also thanks to the laws mentioned above. Data here presented refer to 4,209 patients, 1,964 of whom were alive on 1.1.1988, and 2,245 were diagnosed afterwards. A remarkable increase in early diagnosis (within the 3rd month of life) was noticed (from 41% to 65%), together with an increasing percentage of subjects who underwent a neonatal screening program (+34%). An increase in late diagnoses is also apparent: the frequency for patients diagnosed after 18 years of life ranged from 8% to 12%. The proportion of adult patients is more than doubled between 1988 (17%) and 2000 (41%) and the number of patients over 30 is now about 400. 512 patients died during the study period. Median age at death increased from 14 (1988) to 22 (2000) years. This trend can be observed also for patients diagnosed within the first year of life. All these changes have contributed in modifying age structure of CF population. In late 80's, the latter was mostly composed by children, while now 50% of patients are adolescents or adults. Therefore, it is now necessary to involve specialists of adult diseases in CF care.